Consultation and Presentation of Cases Using Molecular Techniques/Data • Understand and use pedigrees for familial genetic assessments wellbutrin sr 150mg visa anxiety 8 months pregnant. Recommendations for in-house development and operation of molecular diagnostics tests order genuine wellbutrin sr line depression symptoms light headed. Specific Toxicology Learning Objectives: • Be able to answer the following questions: What is the meaning of comprehensive drug screening? What are the most common drugs seen in overdose situations (pediatrics vs adults)? The description of the dermatopathology portion of the rotation is described first followed by the neuropathology portion of the rotation purchase 150 mg wellbutrin sr visa depression symptoms anger. Sets of glass slides organized by pathogenesis for self-study are available for correlation with the required reading. The resident should assist in the preparation of the weekly dermatopathology conference for the dermatology residents and the monthly dermatopathology conference for the pathology residents. Residents are encouraged to pursue a research project that would lead to publication. Learn the following common epidermal neoplasms and cysts: Actinic keratosis Solar lentigo Seborrheic keratosis Squamous-cell carcinoma Acanthoma (clear cell, large cell, epidermolytic, acantholytic, dyskeratotic) Epidermoid cyst Pilar cyst 2. Learn the following adnexal neoplasms: Basal-cell carcinoma Trichofolliculoma Trichoepithelioma Syringoma Cylindroma Spiradenoma Sebaceous hyperplasia Sebaceous carcinoma 3. Learn the following melanocytic neoplasms Acquired benign melanocytic nevus Congenital benign melanocytic nevus Blue nevus Lentigo maligna (melanoma in situ) Superficial spreading melanoma Nodular melanoma Acral lentiginous melanoma 4. Learn the criteria used to separate benign melanocytic nevus from melanoma Learn how to manage melanocytic neoplasms with ambiguous histopathology Learn some of the arguments for and against dysplastic nevus 5. Learn the following mesenchymal neoplasms: Dermatofibroma Cherry angioma Kaposi sarcoma Angiosarcoma Dermatofibrosarcoma protuberans 6. Learn the following hematopoietic neoplasms: Mycosis fungoides Marginal zone lymphoma Follicle-center cell lymphoma Mastocytosis 7. This rotation is office-based and professional attire rather than "scrubs" are encouraged. The resident should help prepare and attend the weekly 3-5 pm Thursday dermatopathology conference for the dermatology residents. The resident should attend the monthly 1-6 pm Kansas City Dermatological Society meeting. If a case report is chosen, it should be completed prior to the end of the rotation. Pathology Resident Manual Page 209 Neuropathology The major purpose of the neuropathology rotation is to review the gross and microscopic anatomy of the nervous system, introduce major categories of disease that affect the human nervous system, and to acquire elementary dissection and diagnostic skills using both autopsy and surgical material. Required Conferences and Seminars Neuro-Oncology Tumor Board Time/Location: Monday, 5:30 p. Pathology Resident Manual Page 212 Primary audience: Neurosurgeons, neuropathologists, radiation oncologists, neuroradiologists, medical oncologists, neurologists, neurosurgery, radiation oncology, neurology, radiology, and pathology residents. Purpose: Weekly review of new patients with central or peripheral nervous system tumors for preoperative and/or postoperative treatment planning. Primary audience: Pathologists, neurologists, neurophysiology fellows, pathology and neurology residents. Primary audience: Pathologists, neurologists, neurosurgeons, pathology, neurology, and neurosurgery residents, medical students. Purpose: Review of classic or unusual cases from current surgical specimens, including consultation cases. Primary audience: Neurosurgeons, neurologists, neuroradiologists, neuropathologists, neurosurgery and neurology residents. Scholarly Activities and Research During Rotation Research within the Division of Neuropathology is an option that residents may choose for research elective activities. Incorporation of residents into experimental neuropathological work ongoing in the Division or selection of projects in clinically related research, e. Residents will be evaluated on their demonstrated ability to provide useful consultation to the clinical service teams, medical knowledge, application of this knowledge to efficient/quality patient care, and gross and microscopic diagnostic, technical and observational skills. Residents are also evaluated on their interpersonal skills, professional attitudes, reliability, and ethics with members of the teaching faculty, peers, laboratory staff, and clinicians. They are further evaluated on their initiative in fostering quality patient care and use of the medical literature, as it relates to their assigned cases. Their timely completion of assigned interpretive reports is another component of the evaluation. Chapters 27-28, Robbins and Cotran Pathologic Basis of th Disease, 7 Edition, Elsevier Saunders, Philadelphia, 2005. Surgical Pathology of the Nervous System and its Coverings, th 4 ed, Churchill Livingstone, New York, 2002. Diagnostic Pathology of Nervous System Tumours, Churchill Livingstone, London, 2002. Tumors of the Peripheral Nervous System, Armed Forces Institute of Pathology, Washington, D. Tumors of the Pituitary Gland, Armed Forces Institute of Pathology, Washington, D. Practice Guidelines for Autopsy Pathology: Autopsy Procedures for Brain, Spinal Cord, and Neuromuscular System, Arch Pathol Lab Med 119:777–783, 1995. Residents must obtain permission from the appropriate faculty member prior to scheduling the elective. Residents must obtain permission from the appropriate faculty member prior to signing up for the elective. A one month rotation can be designed to teach research skills and allow a resident time to begin a clinically related research project that will be carried forward during the rest of the training program. A goal of the rotation is to encourage pathology residents to participate in a research project that will result in formal presentation at national meetings and publication in peer-reviewed journals. Research rotations must have a focused research project and must follow the below described process for formalizing the rotation. A longer period of research training is available as elective time for those who wish to pursue an academic career. Procedure: Listed below are the required procedures for the Research Rotation • The academic year prior to scheduling a research rotation, the resident should identify a faculty sponsor, have the faculty member sign the attached form stating that they will agree to be the mentor and agree to be responsible for the research activity during the scheduled month. The faculty sponsor must submit the progress report along with the standard evaluation of the resident to the resident education committee. He continued to improve his fund of knowledge and diagnostic skills and received positive comments on performance evaluations. Overall, his performance during the last six months of his residency was very good.
Daily therapy and cloa- grown feathers near the cloaca 150mg wellbutrin sr with visa depression symptoms procrastination, dieting overweight cal mattress suture may be necessary to prevent birds or treating birds for localized infections can be recurring prolapses (see Chapter 41) best wellbutrin sr 150mg depression psychology. The diet should be carefully analyzed and biotics should be considered due to the possibility of any deficiencies should be corrected order wellbutrin sr 150 mg otc anxiety disorder treatment. If large areas of ne- deterrents to breeding may be determined by using a crosis are present, then surgery is necessary to de- video camera to observe the pair’s daily behavioral bride the wound. Reproductively active males and females (particu- larly budgerigars and cockatiels) may exhibit mas- Endocrine manipulation for improving reproductive turbatory behavior or excessive regurgitation. These success in birds has been studied with marginal suc- are normal reproductive behaviors that may become cess. The dependence of the avian endocrine system pathologic in birds that are isolated. Cockatiel cocks on environmental stimuli makes clinical manipula- incubate the eggs, and a single male may spend much tion of the avian reproductive system difficult. Spe- of the time on the enclosure floor mimicking incuba- cific behavioral manifestations of endocrine abnor- tion activities. Removing the bird from its enclosure malities have been treated medically, such as for long periods of time (with available food and testosterone injections in timid male Eclectus Par- water sources) or changing the enclosure or enclosure rots, but such therapy is experimental in nature and location may stop this behavior. Contamination tive tract development with accompanying increased can be reduced by fasting the birds and evacuating incidences of egg binding and oviposition on the en- the cloaca before semen collection. Problems with incompatible of semen from males paired with reproductively ac- pairs, poor fertility due to physical or behavioral tive hens did not affect their breeding performance. Electroejaculation was successful in to copulate and deposit semen in or on a suitable 95% of mature pigeons when used in conjunction with 16 a cloacal retractor. Semen volume can the use of dummy mounting devices and artificial 11 be increased by multiple collections in a week. Semen collected with these techniques is sively frequent collection can cause cloacal irritation, usually free from contamination. Adding diluent The massage collection technique requires two peo- to the semen may help preserve sperm viability in low-volume samples. The inner thigh, ventral abdomen, tail, before and after any storage or preservation and vent and synsacral area are stroked. Hispaniolan Amazon Parrot used for insemination immediately following collec- hens begin egg laying when housed separately but tion. Commercially available poul- Non-disease Factors try diluents have been used successfully in non-do- mestic species. Fro- zen-thawed semen has proven to be viable in Sand- Gender hill Cranes, American Kestrels, Peregrine Falcons 20,124,146,152 The most common cause of reproductive failure in and budgerigars. Modifications in cryopre- companion birds is pairing of two birds of the same servation methods and fluids may be necessary when gender. Several techniques for determining the gen- handling semen of other avian species. The appropriate method to use depends on the species, age of the bird Insemination Technique and the information to be derived from the procedure. Cooperative techniques may be used to inseminate Physical Characteristics females that are encouraged to respond to handlers Many species of birds are sexually dimorphic, with allowing semen to be deposited in the cloaca or ovi- 184 visual characteristics that distinguish males from duct. The degree of dimorphism varies with spe- tion, eversion of the cloaca and placement of the cies and may not always be obvious. Even with mono- semen via a tube, straw or catheter through the morphic species, subtle differences may exist that cloaca into the vagina. With most monomor- better visualized using speculums and specially de- 10 phic species, definitive gender differentiation re- signed cloacal retractors. Head size as well as bill dialyzed semen placed by cannula into the oviduct breadth, length and depth are often greater in males. Determining when to in- Differences in beak size are usually obvious in tou- seminate is crucial for fertilization to occur. It is best cans but may require calipers to appreciate in to inseminate every other day after the first egg in a 184 smaller species. The fre- monomorphic although there are many exceptions quency of insemination is governed by the species, (Table 29. Hispaniolan In dimorphic birds, feather color, iris color and bill Amazon Parrots were successfully inseminated be- characteristics typically differentiate hens from fore egg laying started but fertile eggs were not laid cocks. Immature birds typically have Initiating egg laying usually requires behavioral color patterns similar to adult females. Complete mounting is typical of more common in female cockatoos; however, this raptors, waterfowl and Passeriformes. In New World technique is not always reliable, especially in Moluc- Psittaciformes, copulation occurs side by side, and can, Rose-breasted, Bare-eyed, Goffin and immature homosexual pairs have been observed precisely mim- cockatoos. The male usually places one erigars have lavender to dark-blue ceres while fe- foot on the caudal tail region of the female and has males have light-blue to tan or brown ceres. The White-fronted or courtship behavior with inanimate objects, other Amazon is clearly sexually dimorphic. If no numerous red secondary wing coverts while females eggs are produced, it may indicate that the bird is a have few to none. Gender can be determined in most Galliformes, An- seriformes, some game birds, ratites and some spe- Laparoscopic Sexing cies of Cracidae by looking for the phallus on the wall Although subject to error when used in young birds of the cloaca. In Columbiformes and Passeriformes, with undifferentiated gonads, laparoscopic examina- which have prominent papillae of the ductus defer- tion is a definitive method of gender determination ens, gender can be determined if these structures can when performed by an experienced practitioner (see be visualized using general anesthesia and a cloacal Chapter 13). Determining the distance between the pelvic bones (gapped in females, close together in males) has been Laboratory Methods discussed as a method of gender determination. The Genetic determination of gender in birds is consid- distance between the pelvic bones increases in post- ered the most reliable of the available noninvasive ovipositional females but may narrow considerably techniques. After culturing, staining and ine birds, this is an unreliable method of gender careful examination, the gender chromosomes can be determination. The disadvantage of this reliable method for gender determination in mature technique is the difficulty of collecting an adequate lovebirds. Other prob- Behavioral Characteristics lems include overnight mailing and a lag time in Behavioral characteristics generally vary with gen- obtaining results, as only one laboratorya offers this der; however, birds can develop homosexual pair service commercially in the United States. Males are generally more aggressive and Determination of gender can also be accomplished by are responsible for territorial defense. With some free-ranging psittac- cells is necessary for this procedure, and advantages ine species, the hen incubates while the male is include easy and relatively non-traumatic sample perched nearby as a sentry. Depending on the cycle collection and a long sample shelf life without refrig- of incubation and the age of chicks, the hen may join eration. Lag time in obtaining results is a disadvan- the male in inter- and intraspecific territorial con- tage, as only one laboratoryb offers this service in the frontations. Brown to black iris Red to reddish-brown iris Eclectus Parrot Green Red and purple Pesquet’s Parrot Red spot behind eye No red spot Grey-headed Lovebird Grey head, neck and breast Green head, neck and breast Ring-necked Parakeet Colored ring around the neck No ring Mueller’s Parrot Red beak White beak White-fronted Amazon Parrot Red alula and primary covert feathers Slight to no red in primary covert feathers Mountain Parakeet Yellow forehead, lores, cheeks and throat Green forehead, lores, cheeks and throat Mexican Parrotlet Blue lower rump and underwing coverts Yellow-green lower rump and underwing coverts Pileated Parrot Red forehead Green forehead African Grey Parrot Red vent and rump feathers Grey tips on red feathers or mostly grey * Not all members within a genus will portray the listed sexual differences. Sex differ- hormones varies with age and sexual activity and entiation occurs in the developing embryo during the leads to some overlap in the estrogen/testosterone first trimester of development. Commercial laboratoriesc claim high accuracy, characteristics under hormonal control may be obvi- although no blind studies have been performed to ous before functional sexual maturity is achieved. One recent report suggests that The age of sexual maturity varies greatly between fecal sex steroid determination in most parrots is not species.
Seeds with hulls and large chunks of food should be avoided because at this stage the bird may consume them whole buy generic wellbutrin sr anxiety questionnaire. Most birds will pick up and play with food long before they actually consume the material proven 150mg wellbutrin sr 08861 anxiety. To encourage experi- mentation discount wellbutrin sr 150 mg with amex depression symptoms eyes, food bowls should be easily accessible and placed at perch height. The head should be gently supported to prevent injuries during the feeding process baby to a wide variety of formulated diets and fresh (courtesy of Apalachee River Aviary). This will make them more likely to accept the varied diets that they may be offered when they leave the nursery. If birds are Feeding Amounts and Frequency weaned onto a specific diet, it is important that a new Younger birds should be fed more often than older, owner continue feeding the same diet until the bird larger birds. Adequate weight gain and good mor- is accustomed to its new surroundings and the diet phologic development are more important indicators can be safely changed. The amount of food and frequency of feed- When the bird is at the right weight and develop- ing depends on the age and development of the chick ment or consuming some solid food, the midday feed- and the particular diet fed. Birds one to five days old ing should be gradually eliminated, followed by the should be fed six to ten times daily; chicks with eyes morning and then the evening meals. If the bird was closed, four to six times daily; chicks with eyes fed properly to begin with, weight loss in the range of opened, three to four times daily; and birds with 10 to 15% of the peak body weight may be expected feathers emerging, two to three times daily. If the bird was under- less than one week old may benefit from around-the- weight to begin with, any weight loss may be abnor- clock feeding, but it is not necessary to feed older mal. The last feeding can be bacterial infections of the alimentary tract) may be- given between 10:00 p. The crop should be filled include excessive weight loss, slowed crop-emptying to capacity and allowed to nearly empty before the times, depression, diarrhea, regurgitation or simply next meal. If problems are noted, weaning empty at least once each day (usually in the morning should be postponed and the underlying problem following the final night feeding). If the weight loss is severe, it feed young birds the maximum amounts of food early may be necessary to resume hand-feeding two to to stimulate good growth and increase crop capacity. This is especially common in malnour- ished birds that are stunted in growth but of weaning age. It may be necessary to tube-feed these birds, because forcing them to hand-feed increases the risk of aspiration and causes severe stress. Hygiene Careful control of environmental sources of patho- genic bacteria and yeast are essential for maintain- ing healthy chicks. A diligent, thorough, common- sense approach that includes minimum exposure to harmful chemicals works best. The most important sources of microbial contamination include the food, water supply, feeding and food preparation utensils, other birds in the nursery and the hand-feeder. If microbial infections are repeatedly encountered in a nursery, these areas should be cultured in order to identify and eliminate the source of contamination. To avoid these microbes, the compo- of manufactured food when, in fact, the outbreaks were the result nents of the diet should be carefully selected. Most of careless food handling (eg, wet food or food contaminated by rodent droppings) on the part of the aviculturist (courtesy of commercial diets are relatively clean. Yeast and bacterial contamination of any formulated diet can occur if it is improperly stored. Pseudomonas is a frequent con- taminant of water taps and bottled water dispensers. As a guide, the standards for cleanliness in a nursery should be higher than the feeders would maintain for themselves. Opened containers of dry baby formula should be stored in sealed containers in the freezer. Powdered baby formula that has been mixed with water should never be stored and fed to babies in subsequent feedings. A separate syringe should be dry environment, aviculturists must also make certain they do not used for each bird and the syringes should be filled in serve as sources of infection for their neonates. Under no circumstances should a syringe hygiene involves thoroughly washing the hands before handling any neonate. Hands should also be washed when moving from one used to feed a bird be dipped back into the food for a group of neonates to the next. The type of diet, percent solids content, how the periodically removed and scrubbed to avoid a build- diet is prepared, amount and frequency of feed- up of food and pathogens. New Additions Body Weight Charts New additions to the nursery should be placed in One of the most valuable tools for evaluating nestling separate brooders, fed last and monitored carefully birds is a chart recording daily body weight. At most stages of development, juve- potential microbial infections that might spread to nile birds should gain a certain amount of weight other chicks. Failure to gain this amount of weight is cause make certain that the neonates are not shedding for concern. Detecting an infectious agent in a weight gain, and lack of a normal weight gain is often newly introduced chick also indicates that the par- one of the earliest signs of problems. In this be compared to weight charts developed from records manner, chicks can be used to monitor the health of of morphologically normal birds to access normal the adult collection. A clinical workup and brief isola- development; however, it must be stressed that there tion period of all new arrivals to the nursery will help is wide natural variation in the normal growth rates prevent some diseases but will not eliminate all of chicks depending on individual body conformation, risks. Evaluating Nestling Birds Nestling psittacine birds can be evaluated in the same way as adult birds. A complete history, thor- ough physical examination and appropriate labora- tory tests should be completed. The unique features of neonatal psittacine birds are emphasized in the sections below. History Avicultural clients should be asked to prepare a writ- ten summary prior to taking a nestling psittacine chick to the veterinarian. The past breeding and health history of the par- ents and condition of the chick’s siblings. Brooder temperature, substrate, hygiene prac- tices (including exposure to any disinfectants) and condition of other birds in the nursery. During weaning, this extra weight is lost as the bird exercises more and assumes more adult pro- portions. The crop was partially filled with food but peristaltic a generalization, growth charac- activity appeared to be normal. The teristics vary with body size, and bird did not respond to supportive therapy. At necropsy, the heart was enlarged and a ventricular septal defect was identified. Physical Examination A thorough physical examination is as important in nestlings as it is in adults. During the examination, chilling and stress should be avoided by warming hands, warm- ing the room and keeping handling times to a minimum. Birds with food in the crop should be handled carefully to avoid regurgitation and aspiration.
The wings and progresses until about half of the prima- bird was placed on a formulated diet and the newly developing ries are replaced purchase 150mg wellbutrin sr mastercard anxiety for no reason. The body feathers begin to molt after the wing feathers are growth discount wellbutrin sr uk depression us, it might become increasingly sensitive to actively being replaced buy wellbutrin sr now mood disorder nos symptoms. The tail feathers are re- certain secretions (thyroid hormone, sex hormones) placed from the central feathers outward. By having that could then potentiate the growth of a new a progressive molt, birds are able to continue flying feather. In some water- fowl and seabirds, all of the flight and tail feathers The occurrence of a cyclic rather than systemically are replaced at one time, and these birds go through controlled molt seems clinically feasible given that a period of flightlessness. The feathers appear to molt in sections Malnutrition can impact the speed of molt and the starting with the head, neck and thorax, followed by health of the developing feathers. The molt in each anatomic increases a bird’s metabolic rate and demand for location may occur at varying times, and some ptery- protein. Birds that are on diets that contain insuffi- lae may undergo several plumage replacements be- cient energy or protein might undergo a partial molt fore any feathers are molted from another area. The process probably involves nutrition and environmental or disease-related a combination of hormonal, seasonal, nutritional and stress factors. The effects of individ- generation of feathers on the head and neck, with ual hormones on the molt cycle appear to vary widely several generations of old feathers on the wings and among avian genera, and information derived from body (Figure 24. This hormone may affect the shape, struc- General Diagnosis ture, formation of pigment, color patterns and rate of growth of feathers. In fowl, administration of thyroid and Therapy hormone may induce a molt in seven or eight days. If the thyroid is removed, feather formation on the body stops but the molt of wing feathers will continue, suggesting that their replacement is not controlled Investigation of Dermatologic Disease by thyroid hormone. Administration of high concen- Integumentary diseases can be broadly classified as trations of thyroxine will increase the speed of the being caused by infectious or noninfectious agents molt cycle. In many cases, dermatologic lesions are mone is important in initiating a molt; however, secondarily infected with bacterial or fungal agents, other studies indicate that progesterone and pro- and the identification of microbial agents from cul- lactin can induce a molt without a change in circulat- tures of the skin does not necessarily implicate these ing levels of thyroid hormone. In a study of King Penguins, it was found that thy- Using a dermatology examination form is a concise roxine levels rose significantly (five times resting way to consistently evaluate and record integumen- levels) during the molting period, and corticosterone tary lesions. In other5 is an effective method of recording the precise loca- studies, it has been demonstrated that thyroid activity tion and the effects of therapy on skin lesions. By (as measured by thyroidal uptake of radioactive iodine) using a standardized form and evaluation system, did not differ appreciably between molting and non- avian veterinarians and dermatologists can more ef- molting hens. These apparent conflicts in experimental fectively quantify and compare their findings, which findings may suggest that research protocols, no mat- will ultimately lead to improved clinical description, ter how effectively conceived, may not accurately re- diagnosis and treatment of skin and feather diseases. The predilection to develop certain types of integu- Feather formation is prevented by circulating estro- mentary diseases may vary among species (Table gens. The diagnostic evaluation used for avian der- follicles that are already replacing a feather but will matologic diseases is similar regardless of the etiol- not stimulate feather development. The evaluation of feather and skin gish and prolonged in fowl exposed to 12 to 14 hours lesions, particularly in small birds, can be facilitated of light. Inflammation of the companion birds that originate from widely varying skin can occur as a result of trauma, chemical irrita- geographic regions is undetermined. Molting activity can be induced by high doses of medroxyprogesterone, de- Cytology, culture and biopsy are indicated in cases of creased exposure to light or administration of thyrox- dermatitis. Birds that are stressed by handling during Protozoal Irradiation a molt may lose more feathers than birds that are in Metazoal (parasitic) Neoplastic a relaxed atmosphere. Some birds are able to release Immune-mediated Behavioral feathers when being restrained (fear or stress molt). These general therapeutic considera- “Bumblefoot” syndrome tions include: “Wet feather” Vesicular dermatitis and photosensitization Correcting any nutritional deficiencies by admin- Leech infestation istering parenteral multivitamins, minerals (trace Raptors minerals) and placing the bird on a formulated diet Malnutrition supplemented with some fruits and vegetables. Poxvirus “Bumblefoot” syndrome Removing the bird from all exposure to aerosolized Gangrene of wing toxins that may accumulate on the feathers and Tuberculosis “Blain” (bursitis of carpus) skin and cause irritation (eg, cigarette smoke, Damaged nails and beak kerosene fumes, cooking oils). Neoplasia including melanomas Identifying and correcting any behavioral abnor- Ratites Poxvirus malities that are causing over-grooming (feather Malnutrition picking). Skin lesions should be kept clean, and creams, lotions any scabs, moistening the culturette in the sterile or solutions can be used to moisturize and sooth dry, transport media and rolling the tip over the lesion. Moistened swabs will yield better results than dry Any medications placed on a wound should either kill ones, and it is important that the swab be plated as specific target microorganisms or protect healing tis- soon as possible after collection. Ointments and oily compounds interfere with sive diagnostic technique in practice is to apply a normal feather function and should be avoided (Color microscope slide to the affected area and to examine 24. Skin biopsies are iodine compounds for example, are effective in con- most diagnostic if collected from the center and the trolling bacteria, but may also impair healing by periphery of the lesion. A mixture gars and occasionally in large Psittaciformes (see of Penetran and aloe vera may relieve severe pruri- Chapter 32). This therapy should be discontinued or the solution should be “French moult” is a descriptive term used to describe diluted further if a bird becomes depressed or lethar- feather dystrophy in young psittacine birds, primar- ily budgerigars. If a bird does not improve within 48 hours of initiating therapy, the preparation should be consid- premature molting of the wing and tail feathers and ered ineffective and discontinued. Affected young birds are termed “runners” be- If an infectious agent is identified, specific antimicro- cause they are usually incapable of flying. It should be noted that any factor (infectious or however, surgery should not be considered until all noninfectious) that damages the epidermal collar can other therapeutic modalities have failed to resolve result in a gross lesion resembling that induced by the lesions over a six-month treatment period. Techniques that are discussed in the lay literature, including dietary additives and careful selection of Lesions should be evaluated regularly (generally on breeding stock, are probably futile. Good hygiene is a weekly basis) to determine if prescribed therapy is advisable, and birds should be purchased from effective. Poxvirus can cause skin lesions in most avian species and may retard wound healing. Uncomplicated le- sions are characterized by the formation of nodules on the unfeathered skin. Skin lesions should be kept clean and dry to prevent secondary bacterial or fun- Specific Etiologies of gal infections (see Chapter 32). Generalized Dermatopathies Cutaneous papillomas may occur on the head, neck, beak commissure, feet or uropygial glands. Some of these lesions have been associated with papil- Viral Diseases lomavirus or herpesvirus while others are of undeter- mined etiology. Dermatologic lesions may oc- “feather dusters,” and adenoviral folliculitis has been cur with poxvirus, papillomavirus and herpesvirus reported in lovebirds (see Chapter 32). The ally attack birds causing characteristic hyperemic disease progression can be acute or chronic depending swellings (Color 24. The likelihood of a bird being stung can be reduced by removing uneaten soft foods (particularly fruits) from the enclosure and destroying wasp nests found near the aviary.
At this time discount wellbutrin sr 150 mg with amex mood disorder association vancouver, the precise mechanism(s) that override the expression of the v-myc onco- gene product and pull the cells from mitotic cycling are not known buy discount wellbutrin sr 150 mg on-line depression definition science. Alzheimer’s represents the single greatest cause of mental dete- rioration in older people purchase wellbutrin sr with american express depression unusual symptoms, affecting approximately 4 million in the United States and 300,000 in Canada. The German physi- cian Alois Alzheimer ﬁrst described this condition in 1907 as a case presentation of a 51-year-old woman whose symptoms included depression, hallucinations, demen- tia, and, upon postmortem examination, a “paucity of cells in the cerebral cortex. Although the majority of individuals are in their sixties, Alzheimer’s can develop at a younger age. No matter when a person is affected, the condition is always progressive and degenerative. Formerly self-reliant people even- tually become dependent upon others for routine daily activities. Although there are a number of promising clues, the deﬁnitive cause of Alzheimer’s has not been determined. Scientists recognize that there are two forms of Alzheimer’s—familial and sporadic. The familial (sometimes referred to as early- onset Alzheimer’s) stream is known to be entirely inherited. Mutations at all three of these loci lead to increased production of the amyloid polypeptide Ab42. Abnormal phosphorylation events lead to the deposition of Ab42 in the neuropil and blood vessel walls and may be the initiating factor in Alzheimer’s. It progresses faster than the sporadic, late-onset form of the disorder, which generally develops after age 65. In Alzheimer’s, axons and dendrites in the brain neurophil degenerate and disrupt the normal passage of signals between cells. These focal areas of degenera- tion (senile plaques) have speciﬁc cytological characteristics. The plaques are com- posed of degenerating neuronal processes associated with extracellular deposits of amyloid peptides. In addition, changes also occur inside the neurons, leading to cytoskeletal disruption and the accumulation of abnormal ﬁlament proteins in twisted arrays called neuroﬁbrillary tangles. Tangles consist predominantly of abnormal phosphorylated forms of tau—a protein that binds to microtubules as part of the neuronal cytoskeleton. Acetylcholine and somatostatin are the principal neurotransmitters that are depleted in Alzheimer’s. There is strong evidence implicating cholinergic neurons as the mediators of memory loss in Alzheimer’s. The illness results from selective damage of speciﬁc neuronal circuits in the neocortex, hippocampus, and basal forebrain cholinergic system. In fact, the extent of the cholinergic deﬁcit correlates with the degree of memory impairment and the loss of cholinergic function appears to be one of the earliest changes. This chapter describes experiments applying gene therapy to the animal models of Alzheimer’s and Parkinson’s as well as related clinical trials. Parkinson’s In 1817, the British physician James Parkinson published a study entitled An Essay on the Shaking Palsy. In this work, he outlined the major symptoms of the disorder that would later bear his name. Parkinson’s runs a lifetime incidence of about 2% and an estimated one million people in the United States have this neurodegenerative disorder. In fact, many years may pass before early symptoms progress to the point where they interfere with normal activities. The four major hallmarks or symptoms are debilitating rigidity, resting tremor, bradykinesia or akinesia (slow- ness or lack of movement), and postural instability demonstrated by poor balance. Parkinson’s is caused by the progressive deterioration of a small area in the mid- brain called the substantia nigra. Dopamine is transported through the axons that terminate in the striatum—a large structure consisting of the caudate nucleus and the putamen. This structure is part of the basal nuclei and is involved in complex mus- cular activities such as postural adjustments, locomotion, and balance. The striatum may also be viewed as responsible for inhibiting unwanted movements and per- mitting selected actions. As neurons in the substantia nigra die, less dopamine is transported to the striatum. Eventually a low threshold level of dopamine leads to the neurologi- cal symptoms (Fig. There is freezing of movement when the movement is stopped and often the inability to resume motion. There is also a loss of ﬁne motor skills and hand writing takes on distinctive features. A variety of reciprocal connections are made between neurons joining the substantia nigra with the striatum (putamen). Death of substantia nigra neurons results in reduced levels of dopamine transported to the putamen and causes the neurological symptoms of Parkinson’s. A mutation in the a-synuclein gene (a substitution of alanine to threonine at position 53), which codes for a presynaptic nerve terminal protein, was identiﬁed to be at fault in a large Italian family in 1997 by Mihael Polymeropoulos and co- workers at the National Human Genome Research Institute in Bethesda, Maryland. Basic research and gene therapy initiatives are directed at preventing the loss of neurons that synthesize dopamine (possibly by supplying a neurotrophic factor) or by engineering cells to increase the dopamine concentration in the striatum. Magnetic resonance imaging and electrophysiologically monitoring during surgery permits detailed localization within the brain. The presence of high-frequency stim- ulation through electrodes placed deep in the brain appears to produce a functional lesion in the desired target area (deep brain stimulation). Huntington’s In 1872, George Huntington described a disease that he, his father, and his grand- father had observed in several generations of their patients. However, 150,000 individuals are at a 50% risk of inheriting the disease from an affected parent. It usually develops in a subtle fashion in the fourth to ﬁfth decade of life and gradually worsens over a course of 10 to 20 years until death. The motor symptoms develop gradually, initially characterized by involuntary movements. Uncontrolled movements increase until the patient is conﬁned to a bed or wheelchair. The movement symptoms appear in the form of clumsiness, stiffness, and trouble with walking. Aspects of dementia include a decline in memory, concentration, and problem solving. If psychiatric symptoms appear, there are episodes of depression, instability, and even personality changes associated with mood swings.
Hyperosmolar hyponatremia occurs in severe hyperglycemia or after exposure to mannitol buy wellbutrin sr 150 mg free shipping depression in test, ethanol purchase genuine wellbutrin sr line depression cherry, Electrolyte free water clearance generic 150 mg wellbutrin sr mastercard depression symptoms nz, or methanol. Thus, clinical history, physical exam, Ce will be negative with water retention and posi- and consideration of changes in weight are key initial H2O tive with losses of free water. Since there is volume depletion with a tool to assess response to therapy and can guide cerebral salt wasting, assessing other markers such as fluid restriction in hyper or hyponatremia. Urinary include history, and physical examination for signs concentrating defects may lead to dehydration or of dehydration or volume overload such as edema electrolyte imbalance, while ongoing losses (e. Check for presence of a renal to anesthesia, circulatory changes intraoperatively, and concentrating defect and review clinical history for renal water handling. For such as recent cranial surgery or medications such as example, diluting segment dysfunction will result diuretics or lithium. Recent weight changes will pro- from low solute presentation caused by avid proxi- vide additional clues, with the expectation of weight mal reabsorption due to preoperative volume deficits loss with inadequate or delayed replacement of ongo- or unreplaced intraoperative fluid losses. Generally, since the continued loss of free water is likely to lead to this condition is associated with volume depletion and a further increase in serum sodium. With cerebral salt wasting, there from increased salt loading (salt poisoning) results 158 K. Volume depletion, circulatory insufficiency, or marked ongoing water and sodium losses as in inflam- matory bowel disease, fistulae, or prolonged gastric 10. Additional concentrations are low initially and may fall after fluid helpful investigations include serum electrolytes, including serum potassium and calcium to exclude the administration. When this process occurs in the renal tubules, it Rather than yielding an absolute value, renal physiologi- can result in acute kidney injury due to tubular necrosis. Additionally, acute kidney injury may occur secondary to uricosuria and ensuing uric acid nephropathy. The risk of acute kidney injury in tumor lysis syndrome increases when there is preexisting kidney dysfunction or intravascular volume depletion. N Eng J Med 357:797–805 assessment of electrolytes, phosphorus, uric acid, cal- 2. Crit Care Med 35 phate or uric acid crystals may also be visualized in (Suppl):S198–S205 the urine. N Eng J Med 304:373–380 In the face of oliguria with tumor lysis, renal ultrasound 6. Vet Clin N Am Food the assessment of any derangement in fluid or electrolyte Anim Pract 15:447–471 status and in differentiating between expected vs. Pediatr Nephrol 7:268–272 Chapter 10 Tools for the Diagnosis of Renal Disease 161 15. Arch Dis Child 51:875–878 patients after cardiothoracic surgery: a prospective cohort 17. J Am Soc Nephrol 15:1597–1605 assessment of extracellular fluid volume in hyponatremia. J Am Soc Nephrol 11:A0828 Comparison of three different methods of evaluation of meta- 38. Rastegar A (2007) Use of the delta anion gap/delta bicarbo- and tubular disorders. Pediatr Nephrol 9:364–374 ney foundation kidney disease outcomes quality initiative 49. J children and adolescents: evaluation, and classification, Pediatr 123:393–397 and stratification. N hospital induced hyponatremia in children: a physiologic Eng J Med 340:1177–118 approach. Churchill Livingstone, Edinburgh, pp 297–320 ride measurements in critically ill patients. Siggaard-Anderson O, Engel K (1960) A new acid–base nom- interpretation of urinalysis performed by a nephrologist ogram, an improved method for calculation of the relevant versus a hospital based clinical laboratory. Wang Y, Cui Z, Fan M (2007) Hospital acquired and com- acid–base nomogram revised. Scand Clin Lab Invest munity acquired acute renal failure in hospitalized Chinese: 14:598–604 the 10-year review. N Engl J Med 331:250–258 excess or buffer base (strong ion difference) as a measure 68. Treatment was initiated with intravenous not always have renal involvement of their infec- ampicillin and cefotaxime after septic workup was tions . The urine and blood cultures grew Escherichia a hospital originate from the urogenital tract. The spinal fluid examination was unremarkable, half of them can be considered as primary sepsis and culture of the fluid showed no growth. A renal due to the combination of infection and obstruction ultrasound obtained on the day after admission, when within the upper or lower urinary tract, which is due the urine culture result was reported, showed a normal to congenital or acquired causes; however, the other left kidney and a duplicated collecting system on the half may be induced by any urologic intervention right with moderate to severe hydronephrosis. Review of the lit- Infant boys with intact foreskins have a higher risk of erature indicates that secondary bacteremia, or urosep- urosepsis and may not have specific anatomic find- sis, is uncommon, except in young febrile infants and ings. Fungal infections of the urinary tract are Patients with structural or functional obstruction at increasing in frequency , likely due to use of inva- any level of the urinary tract, such as calculi, neuro- sive devices that impair physical host defenses and use genic bladder, spinal cord injury, and other uropathies, of broad-spectrum antimicrobial agents that eliminate as well as those with biomaterials or foreign bodies commensal flora. Posterior urethral valves and in very-low-birth weight, premature infants, and immu- other congenital obstructions of the urethra are par- nocompromised children . These Although retrograde ascending infection is probably anomalies are unique to male children. Occasionally the most common pathway, seeding from systemic girls with bladder outlet obstruction secondary to and nosocomial infection is a significant pathway to ureteroceles or neoplasm may present with a similar infection in infants and immunocompromised chil- clinical picture [22, 28]. There are three mechanisms through which the Pyelonephritis results from ascending bacteriuria urinary tract may become infected: (1) retrograde from the bladder via the ureter to the renal pelvis and ascent of fecal-perineal bacteria, (2) nosocomial or the renal parenchyma. The bacteria third of patients with pyelonephritis there also is bac- associated with retrograde ascent most often come teremia, which can result in urosepsis [17, 33]. The second catheterization, stenting, and aggressive immunosup- mechanism is the introduction of pathogens by way pression. Other risk factors for urosepsis after renal Chapter 11 Urosepsis 165 transplant are anatomic abnormalities and neurogenic (e. There is evidence that acute pyelonephritis in addition, when abnormal voiding with residual urine the early posttransplant period predisposes to acute or bacterial adherence occurs, mechanical clearance rejection . Risk factors for the development of funguria mechanisms, and incite an injurious host inflamma- include long-term antibiotic treatment, use of urinary tory response. P fimbriae also appear to be important drainage catheters, parenteral nutrition, and immunosup- in the pathogenesis of bloodstream invasion from the pression . A multitude of cytokines are pro- are caused by Candida spp followed by Aspergillus spp, duced in response to the presence of certain organ- Cryptococcus spp, and Coccidioides spp . Together, these proinflam- tract is most frequently the primary entry point but also matory mediators trigger the systemic inflammatory may represent the site of disseminated infection.
The fluid is placed in a plastic test tube and centrifuged at 600 G (gravity) for ten minutes cheap 150mg wellbutrin sr mood disorder with depressive features. Unlike urine sediments buy 150mg wellbutrin sr fast delivery depression symptoms teenage males, cytologic sediments from poorly cellular fluids do not have a visible button or pellet at the bottom of a spun tube trusted wellbutrin sr 150 mg depression symptoms bereavement. Therefore, the concentrated cells are usually obtained by aspirating the fluid at the bottom of the tube into a pipette or syringe. The sample is then placed onto a microscope slide and a smear is made in the manner described for concentrating cells in a smear. Special cytocentri- fuge equipmenta is available for concentrating cells on microscope slides while absorbing the fluid onto filter paper. This equipment is expensive and not practical for the average veterinary laboratory. Because centrifugation distorts the appearance of the cells, a cell concentration method that utilizes gravity provides a concentrated sample with normal appearing cells. A simple, inexpensive sedimentation device can be made for use in the veterinary labora- tory. This device consists of a base to support the slide and a clamping mechanism to hold the fluid column onto the microscope slide (Figure 10. The column that holds the fluid is made from a one millimeter tuberculin syringe barrel with the tip removed. The base of the syringe barrel allows for the syringe to be held in place by a clamp (usually made of wood). A piece of filter paper (eg, Whatman #2) is cut to the dimensions of the microscope slide and a standard 2 mm paper hole punch is used to create a hole in the center of the filter paper. Fluid samples having low cellularity require a con- centration procedure for easier examination of the cells. A simple method is to marginate the cells on a smear made by the conven- tional wedge technique used for making blood films. A drop of the fluid sample is placed on a microscope slide and spread slowly using a spreader slide. Just prior to reaching the end of the smear, the spreader slide is quickly backed slightly into the advancing smear, just before lifting it from the surface of the slide containing the smear. This should produce a slide with the marginated cells concentrated at the end of the film. A simple device that uses gravity to concentrate cells provides cytologic samples of better quality than centrifugation (courtesy of Terry Campbell). The clamp is used to secure the aspirated into the tube using a syringe attached to column to the slide. In cases where allowed to stand undisturbed, the fluid is drawn by material cannot be aspirated for examination, a gravity and absorbed into the filter paper. The cells wash sample can be obtained by infusing a small in the fluid fall onto the surface of the slide where amount of sterile isotonic saline into the crop and they adhere. Once the fluid has drained from the aspirating the fluid back into the tube and syringe. After staining, the cells can be Aspiration of the infraorbital sinus of birds suffering found concentrated in the two millimeter circle cre- from sinusitis can provide diagnostic material for ated by the filter paper and column. One technique of sinus aspiration in psittacine birds samples the large Cytologic evaluation of the ingluvies (crop) can be sinus between the eye and the external nares (Figure performed from samples obtained by aspiration. With the head and body properly restrained, a is indicated in birds showing clinical signs of regur- needle (eg, 22 ga one-inch) is passed through the gitation, vomiting, delayed emptying of the crop or fleshy skin at the commissure of the mouth. A crop aspirate is obtained by needle is directed toward a point midway between inserting a sterile plastic, metal or rubber feeding the eye and external nares, keeping parallel with the tube through the mouth and esophagus into the side of the head. The tube should pass matic bone, which lies between the lower corner of freely and not be forced into the crop. Often the tube is facilitated by extending the head and neck to passage of the needle is improved by keeping the straighten the esophagus. This procedure requires some practice and complete restraint to prevent damage to the globe. A caudally misdirected needle could mouth, directing the needle under the zygomatic result in penetration of the ocular orbit; however, bone and ending in the sinus cavity below the eye more commonly, a misdirected needle results in pene- (Figure 10. It is impor- Collection of synovial fluid by arthrocentesis is an- tant to note that in some species (eg, some passerine other example of sample collection by aspiration. Therefore, a surgery, a needle (22 ga or smaller) attached to a bilateral sinusitis may require bilateral aspirations. The cytologic adequate sample, the anesthetized bird may be held sample is prepared by making direct smears using with the head parallel to the floor and the affected the “squash preparation technique. The sinus is flushed from underneath Wash samples are aspiration techniques in which a with the needle directed up; see Chapter 22). This sinus usually yields collect a cytologic sample from locations that may be a smaller sample volume than the previously de- difficult to sample or that provide a poorly cellular scribed sinus. Tracheal washes are commonly performed in inserting the aspiration needle at a perpendicular birds suspected of having respiratory disease of the angle through the skin just below the eye (Figure trachea, syrinx and bronchi. A soft, smooth-tipped, sterile have been blotted with a clean paper towel to remove plastic or rubber tube or catheter small enough to the excess fluid and blood. It is best to lay the slide pass through the trachea is inserted through the against the tissue surface using the weight of the open glottis taking care not to contaminate the tip in slide to make the imprint. The tube is passed to the level of the the slide, too much force is used and the resulting thoracic inlet near the syrinx. The animal is held Contact smears made from tissues that exfoliate parallel to the floor, and sterile saline (0. One method of immediately re-aspirated to complete the wash sam- improving cellular exfoliation is to scrape the tissue ple. Similar wash techniques can be used to collect to be sampled with a scalpel blade and to make the cytologic samples from the air sacs, ingluvies and contact smear from either the scraped surface or the infraorbital sinus. Using a drop of oil on the scalpel blade may improve the ability to detect mites but will interfere with staining Contact Smears for cytologic evaluation. Imprints should be made Cytologic samples can also be obtained by direct from biopsy of internal organs (eg, liver, spleen and contact between the tissue being sampled and the kidney) using the impression technique. Often referred to as contact smears, Scrapings are commonly performed to collect cells these samples are used to evaluate postmortem tis- from the palpebral conjunctiva, cornea, oral cavity or sues or antemortem tissue biopsies. Samples can be ob- tained either from the tip of the endoscope or by Gram’s stain Gram-positive bacteria. Romanowsky stains (Wright’s and Wright-Giemsa) achieve uniformity of staining on the smear. This stain is not used to These stains are commonly used for peripheral blood films and routine evaluate cells. Mycoplasma colonies resemble chlamy- This is a routine cytologic stain used as a wet preparation on dried dia. This stain is not used to evaluate demonstration of fibrin, lipid droplets, fungal hyphae and other struc- cells.