Once these basic data are produced routinely on a European level purchase cheap super p-force online erectile dysfunction pills at walgreens, this framework can be expanded to address other essential dimensions of the health and care of mothers and babies in Europe generic 160 mg super p-force otc doctor for erectile dysfunction in delhi. Neonatal survival rates in 860 singleton live births at 24 and 25 weeks gestational age. Prediction of survival for preterm births by weight and gestational age: retrospective population based study. The risk of major birth defects after intracytoplasmic sperm injection and in vitro fertilization. Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis. Cesarean section rates in Italy by hospital payment mode: an analysis based on birth certificates. Level of perinatal care of the maternity unit and rate of cesarean in low-risk nulliparas. The reliability of perinatal and neonatal mortality rates: differential under-reporting in linked professional registers vs. Maternal age and the risk of stillbirth throughout pregnancy in the United States. Elevated risks of pregnancy complications and adverse outcomes with increasing maternal age. Effect of age, parity, and smoking on pregnancy outcome: a population-based study. Prospective risk of fetal death in singleton, twin, and triplet gestations: implications for practice. Contemporary risks of maternal morbidity and adverse outcomes with increasing maternal age and plurality. Trends in twin preterm birth subtypes in the United States, 1989 through 2000: impact on perinatal mortality. Twins and triplets: the effect of plurality and growth on neonatal outcome compared with singleton infants. The epidemiology of smoking during pregnancy: smoking prevalence, maternal characteristics, and pregnancy outcomes. Comparative trends in cause-specific fetal and neonatal mortality in twin and singleton births in the North of England, 1982-1994. Perinatal deaths in a Norwegian county 1986-96 classified by the Nordic- Baltic perinatal classification: geographical contrasts as a basis for quality assessment. Perinatal audit on avoidable mortality in a Dutch rural region: a retrospective study. Comparability of published perinatal mortality rates in Western Europe: the quantitative impact of differences in gestational age and birthweight criteria. Algorithms for combining menstrual and ultrasound estimates of gestational age: consequences for rates of preterm and postterm birth. Short-term outcomes of infants born at 35 and 36 weeks gestation: we need to ask more questions. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. Spontaneous preterm delivery in primiparous women at low risk in Denmark: population based study. Maternal deaths and substandard care: the results of a confidential survey in France. Epidmiologie de la mortalit maternelle en France, de 1996 2002 : frquence, facteurs et causes. Substandard care in immigrant versus indigenous maternal deaths in The Netherlands. Trends in cerebral palsy among infants of very low birthweight (<1500 g) or born prematurely (<32 weeks) in 16 European centres: a database study. Self-reported quality of life of 8-12-year-old children with cerebral palsy: a cross- sectional European study. Differences in management and results in term-delivery in nine European referral hospitals: descriptive study. Long-term consequences on postnatal well-being and neurosensorial development in terms of disabilities and quality of life will also be discussed. Moreover, the long-term consequences of extreme prematurity are considerable in terms of compromise of their well-being as children and adults3, causing stress for families4 and economic burden for health systems5. Furthermore, most disabilities of perinatal origin are more frequent in premature than in term infants. One possible cause is the increased number of twin pregnancies, related to increasing maternal age and accessibility to assisted reproduction techniques8. Neonatal mortality reporting systems from civil and birth registers are well established but have traditionally included weight-specific data only for the whole category of Low-Birth- Weight (i. Years ago data from more immature infants was often under-reported because at those low gestational ages and weights mortality was extremely high. In the last few decades, improvements in perinatal and neonatal care have pushed back the limits of viability, so collecting data from those immature infants has become extremely important. This project collects aggregated perinatal data (maternal morbidity and mortality and neonatal mortality), but not data on short-term morbidity and long-term disability outcomes for these very high risk infants. In the medical field, networking has been used to improve the quality of health care provided to patients by means of disseminating information. Existing neonatal networks collect standardised patient data to promote excellence in clinical practice by use of benchmarking and comparisons of outcomes, to promote research, continued education and quality improvement projects. Periodic reports are generated with standardised comparisons of selected outcomes used by participating units to identify opportunities for improving care processes and evaluating effects of improvement efforts. The 24- months follow-up set of indicators to assess health and neurodevelopment status can be considered temporary. To evaluate health programs and develop priorities for planning, promotion and evaluation of short- and long- term care of these infants by health organisations. To document clinical variability of the care process and its outcomes with the aim of developing the optimal application of health care. To push forward consensus in health policies and strategies to improve care of these high-risk premature infants. Morbidity and mortality data from the 2006 EuroNeoStat cohort of immature infants will be used in this report, emphasising the influence of gestational age, birthweight and gender. Table V shows the infant characteristics of the cohort that had a mean birthweight and gestational age of 1152 g and 28. The most important protective factor was prenatal corticosteroid use, being given to 81. The reasons for this are unclear, but imminent delivery is likely to be a major contributing factor. A broader approach to health measurement in follow-up studies should include both long-term objective disability assessed by third-party34,35 and subjective self-reported quality of life36, since neonatal interventions which appear to have minimal effect on mortality and neurodevelopment at an early age may profoundly influence the quality of life in later childhood and adult age37. Even though published follow-up studies did not use comparable outcome measures, developmental disabilities resulting from cognitive, motor or sensorial impairments were more likely at lower gestational age.

Subse- More than 100 cases of human babesiosis have been quently cheap 160 mg super p-force mastercard erectile dysfunction treatment after prostate surgery, it lyses the host red blood cell purchase super p-force paypal herbal erectile dysfunction pills nz. Because multipli- described, many occurring in Massachusetts on the cation is asynchronous, massive hemolysis is not seen. The infection is contracted by humans during the months of About the Babesia Lifecycle May through September when the nymphs are feeding. The small nymph form (2 mm in diameter) of Clinical Presentation the deer tick, Ixodes scapularis, carries Babesia from white deer mice to humans. Multiplication is asynchronous, and therefore fever for the preceding 2 months, associated with inter- hemolysis is never massive. How- patients with babesiosis also had antibodies against the ever, despite appropriate treatment, her fevers did not Lyme spirochete, suggesting that these patients had dual resolve. Treatment with clindamycin and Giemsa stain of thick and thin smears from the periph- quinine caused a rapid resolution of her fever. The classic tetrad is The symptoms of babesiosis are nonspecic, mak- not observed in Plasmodium infection, and the ing the disease difcult to diagnose clinically. Patients often do not give a history of tick bites, having failed to detect the attached nymph because of its small size (the diameter of a small freckle). In the normal host, the disease may cause minimal symptoms and resolve spontaneously. However, in older patients or in those who have undergone splenectomy, infection can be more severe and persistent. Cases of adult respiratory distress syndrome and hypotension have been reported, and on rare occasions, patients have died. In Europe, cases have strictly involved splenectomized patients, and the clinical presentation has been more fulminant, being associated with severe hemolysis and death. Patients with babesiosis may also have symptoms suggestive of Lyme disease, particularly the skin rash of erythema migrans. Often no history of tick bite, because the Ixodes scapularis nymph is mistaken for a small freckle. Treatment should be initiated in splenectomized About Diagnosis and Treatment of Babesiosis patients and in other patients with serious disease. Antiparastic Therapy Dosingh Parasite Preferred therapya Alternative therapya Babesia Intravenous clindamycin 1. Contracted in tropical areas where the phle- Leishmania has caused major epidemics in eastern India, botomine sandy is common;rare in the United Bangladesh, and East Africa. Urban outbreaks have been States Found in South America, India, reported in the cities of northeastern Brazil. Flagellated promastigote introduced by the leishmaniasis during the Persian Gulf War in 1991 and sandy is ingested by macrophages. In the macrophage, Leishmania develops into a been reported occasionally in the United States, but nonflagellated amastigote that lives happily most U. Leishmaniasis can be an opportunistic infection walls of dwellings, in rubbish, and in rodent burrows. Because they are weak iers, sandies remain close to the ground near their breeding sites, resulting in localized pockets of infectious insects. In the digestive Visceral leishmaniasis is a chronic disease that can tract of the insect, the amastigote develops into a agel- cause severe morbidity and death in debilitated lated spindle-shaped promastigote. The pro- mastigote then binds to complement receptors on macrophages and is ingested. Where are lesions of cutaneous leishmaniasis usu- vation of interferon production. Subacute onset presents with increased abdominal swellinig (because of massive and L. After inoculation of pro- splenomegaly and hepatomegaly), intermittent mastigotes into the skin, a small papule may be noticed. Anemia, leukopenia, and hypergammaglobu- In subacute cases, the patient will experience slow linema are common. Increased abdominal girth is showing amastgotes accompanied by intermittent fever, weakness, loss 6. In acute cases, an abrupt onset of high fever and chills mimics malaria or an acute bacterial infection. The skin tends to be dry After a sandy bite, signicant skin lesions gener- and thin, and in light-skinned individuals, it takes on a ally take 2 weeks to several months to develop. This characteristic accounts for the Indian Lesions usually develop on exposed areas. Single or multiple lesions may be The diagnosis is made when a biopsy of lymphatic found, with varying morphology. Lesions may be tissue or bone marrow demonstrates amastigotes on crusted and dry, or moist and exudative. Enzyme-linked immunoab- circular ulcers with sharp, raised borders may develop sorbent assays usually demonstrate high anti-leishmanial and progressively increase in size, becoming pizza- antibody titers. However, this test frequently cross-reacts like in appearance as a result of the beefy red of the with antibodies to other pathogens. Lesions may become secondarily infected with staphy- Splenomegaly may not be present in these patients, and lococci or streptococci. Amastigotes are seen macrophages from bronchoalveolar lavage, pleural on Giemsa stain. Organisms invade mononuclear cells in the tourists in the Middle East and Central and South mucosa. The species most commonly associated with in nasal stufness, discharge, pain, or epistaxis. The lesions can heal raised boarders; pizza-like lesions are com- spontaneously, and so, if there is no mucosal involve- mon. Mucosal disease is rarer, usually involves the metic concern, they can be followed without therapy or nose. Patients with mucosal involvement, progressive lesions, or lesions in The only drug approved in the United States for treat- cosmetically sensitive areas require treatment with intra- ment of leishmaniasis is liposomal amphotericin B. Fluconazole (500 mg twice daily for 6 weeks) has been The course can be repeated if the parasite persists. Miltefosine has the immunocompromised host, the recommended regi- proved successful against some forms of cutaneous leish- men is amphotericin B 4 mg/kg daily administered on maniasis, but other species are refractory. Which insect is responsible for transmitting this disease, and is the disease commonly transmitted 1. Between About 1 week after the parasite enters the skin, an area 16 and 18 million people worldwide are infected with of localized swelling called a chagoma develops, often in T. With improvement of substandard parasite via the conjunctiva causes periorbital edema housing, the incidence of this disease among young (Romaa s sign). At the same time that it bites the Years to decades after the primary infection 10% to host, it also defecates, depositing trypomastigotes on 30% of individuals go on to develop chronic Chagas the skin.

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Characteristics of milk ow from a tures or wind chill predispose to frostbite order 160 mg super p-force mastercard erectile dysfunction treatment lloyds, teat dipping properly prepared cow include a rapid increase to peak with aqueous solutions may be suspended purchase generic super p-force pills erectile dysfunction medications drugs. Suspending ow and maintenance of a relatively uniform peak ow postmilking teat dipping may place the herd at greater risk until the cow is milked out. The initial increase in the for new infections particularly if contagious pathogens milk ow rate and peak ow is strongly inuenced by the (S. In these situations, rapid drying dips are phase of milk ow is largely an individual cow character- best to avoid damage to the teat end. The rst milk to be harvested immediately after polypropylene glycol to teat dips prevents excessive drying the milking unit is attached is cisternal milk. If stimulation of let down is inad- lowing milking to keep them standing until the teat end equate or prep lag time is short, milk ow into the claw dries and the streak canal closes completely. This tech- will decrease substantially or cease for a period after nique helps to avoid environmental contamination of the cisternal milk is harvested (often a minute or more), teat ends immediately after milking. Milk ow graphs below were generated with the dures on milk harvest efciency and udder health have LactoCorder. Studies have shown that premilking A basic understanding of the milking machine and stimulation provided by forestripping, washing, and equipment is essential when evaluating mastitis or milk wiping of teats, and the time interval required to take quality problems on a dairy. Improperly functioning full advantage of oxytocin release and milk let down machines may contribute to the spread of contagious leads to greater peak milk ows and shorter unit on pathogens, create new infections by environmental or- time. It ow of milk at the teat end, thereby predisposing to accounts for approximately 20% of stored milk and is mastitis. Bimodal milk ow results in inefcient milk harvesting by extending machine-on time. The extended machine-on time results in overmilking and excessive trauma to teat ends, which may increase teat end hyperkeratosis and the risk for new mastitis infections. Although slight differences exist, the Reduced milk ow toward the end of milking may be major principles and techniques are very similar. Poorly caused by obstruction of ow from the gland cistern to the functioning or poorly maintained milking systems and teat cistern as the vacuum inside the liner pulls the teat machines may contribute to teat-end injuries, the spread deeper into the liner. Poorly results in teat-end injury because massage is less effective cleaned equipment may contribute to high bulk tank at counteracting the congestion and trauma to the teat end bacterial counts and postpasteurization counts. Vacuum uctuations cyclical vacuum uctuations bore to maintain a snug t along the entire length of the may occur in the claws or liner and often correlate teat and lessen the chances of liner slips, air leaks, or teat with improper pulsator function or inadvertent cups that ride too high on the teat. The Decreased vacuum during the massage phase may inside of the liner is under constant vacuum from the short result in teat end trauma, and subsequent reduction milk tube from the claw. During milking, the liner maintains its normal milking phase may initiate reverse milk ows and shape. The opening of the streak canal that allows milk to droplet jets that spray against the teat ends. Milk ow into the liner is primarily caused by the vacuum that ow reversal may force pathogens into or through is applied at the teat end. When the cavity is vented to atmo- systems with low milk lines and should not ex- spheric pressure, negative pressure at the teat end collapses ceed 15 in Hg for high milk lines. The volume of air displaced at a given vacuum end would produce edema and blood engorgement of the level is expressed in cubic feet per minute walls. Current recommendations for reserve increases the milk ow during the next milking cycle. This may vary slightly with various milk- milkout is less efcient during the latter phase of milking. Pulsator line sizes: Cracked or damaged liners are difcult to clean and 1 to 2 in for up to 6 units disinfect. They act as reservoirs for pathogens and do 2 to 3 in for 7 to 15 units not function properly during milking. When worn or Lines should be sloped toward pump with drains overused liners stretch, their performance changes. Av- at risers and no dead ends erage milking time increases, the frequency of liner slips d. Milk lines condition and liner slips will lead to a higher rate of Sloped 1 to 2 in/10 ft new infections. Special continuing education programs Milk inlet at top third of line and regular consultation with mastitis control profes- Looped with no dead ends sionals are the best means to evaluate a milking system 1 in size 2 units per slope during routine or troubleshooting analysis. Milk hoses should be 9/16-in or 5/8-in inside ponent of dry cow therapy or as an organic alternative diameter and not excessively long (maximum to intramammary infusion of antibiotics at the beginning length 7 ft) of the dry period has become more commonplace. Vacuum to the teats should be shut off before is currently evidence to support a combination of teat removal from the cow. Either the claw or each sealant and intramammary antibiotic infusion at dry off, individual ination should be vented. This is an particularly in cattle that have experienced late lactation extremely important part of milking procedure mastitis in the previous lactation. Furthermore teat seal- to prevent droplet jets to the teat end and expo- ant usage on its own at dry off has been shown to reduce sure to, or inoculation of, pathogens. This offers considerable promise for faster but must be maintained carefully to provide ade- those producers who elect not to use antibiotic therapy at quate time for the rest phase. Natural Resistance Mechanisms of the Udder The pulsation ratio is the amount of time a pulsator Physical Mechanisms. The streak canal (teat canal) creates vacuum to open the lines compared with the provides the most important physical deterrent to the amount of time it admits air to collapse the liner. Keratin in the streak canal not only pulsation ratio of various types of units may vary from serves as a physical barrier that tends to trap bacteria but 50:50 (milk/massage times) to 70:30, with 60:40 or 65:35 also inhibits pathogens through a chemical defense sys- as common compromises. Thinning of the keratin layer predisposes to mas- a 70:30 ratio leaves little room for error. Teat-end injuries titis, as does any relative dysfunction of tight sphincter or chronic damage is propagated by inadequate massage muscle tone. The rate of milking is not greatly different for pul- to 2 hours, management procedures such as feeding sation ratios of 60:40 versus 70:30, thus 60:40 may pro- cows after milking to keep them standing may lessen the vide more room for slight imperfections or deciencies in chances of environmental mastitis. Fear of excessive dilatation of the streak canal during Excessive machine stripping should be avoided be- dry cow treatment has led to research concerning the cause it contributes to liner squawks and claw vacuum advantages of partial insertion of the dry cow infusion uctuations and mechanical injury to the teat end and cannula. Liners should be re- number of new intramammary infections during the placed regularly according to manufacturers recommen- dry period. Despite this high concentration of colostral anti- nal has formed a thick keratin plug but is most resistant bodies at this time, the udder remains susceptible to to new infections during the middle of the dry period. Subclini- along with sloughed alveolar epithelial cells compose the cal mastitis with various pathogens does not seem to majority of somatic cells in milk. Lymphocytes compose generate sufcient immune response to eliminate most a small fraction of these cells as well. Attempts at systemic and local immuniza- the most populous in noninamed glands, but neutro- tion have been attempted for S. Because neutrophils have a relative im- well-managed herds that have minimal incidence of pairment in milk as compared with blood, large numbers contagious pathogens, coliform mastitis may be the pre- of neutrophils are necessary for an effective response to dominant cause of acute mastitis. This altered performance of neutro- numbers of dairy cattle in California during controlled phils in milk is thought to be because of lack of opsonins, studies shows that bacterins signicantly reduce the lack of energy source, and interference with phagocytosis prevalence of coliform mastitis.

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If the suspension type of cell culture is used for production order super p-force 160 mg overnight delivery impotence vitamins supplements, both the stirred tank reactor order generic super p-force pills erectile dysfunction doctor in phoenix, the air lift reac- tor, and the packed bed reactor (133) can be used for large scale. If the adherent type of cell culture is necessary, the fluidized bed reactor is a good choice (134). If the stirred tank reactor is used for animal cells, axial flow impellers with large blades are preferable, as they lead to good mixing with low mechanical shear forces. Both reactor types (the airlift and the stirred tank reactors) have been used for up to 10,000-L working volume in animal cell suspension culture. Although the airlift reactor performance is optimal, with a constant filling volume slight modifications of the inner draft tube also allow its use with variable filling for batch-fed culture (135). In batch culture the aver- 6 age cell densities are in the range of 1 4 10 cells/mL, whereas batch-fed culture allows a slight increase in cell density and maintenance in a productive state for longer time. The batch-fed culture is defined by the increase of osmolarity due to the feed of substrates and by the accumulation of metabolites such as lactate and ammonia (136,137). On the basis of ultrafiltration principles, devices have been developed that give the reac- tor a kind of kidney function to remove low-molecular-weight metabolites and ammonia, while the large biomolecules are retained. Thus cell viability and density are improved and the yield of product is increased. Other possibilities to increase productivity are found with devices that allow continous perfusion with fresh media and cell retention in the reactor. Various unit operations such as ultrasonic devices (138), special filters (139), cartrifuges, or backlooping of cells into the reactor can increase cell retention. Such high-density con- 8 tinuous perfused systems can accumulate cell densities beyond 10 cells/mL (140). Depending on the expression rate of the production cells and the cultivation methods applied, antibody titers above 1 g/L crude culture harvest can be accumulated. Downstream Processing and Purification Antibodies are applied therapeutically in high doses and at high concentrations. The process steps downstream from the bioreactor must therefore establish a product of the highest possible purity. Furthermore, the single process steps must allow safe sanitiza- tion procedures since downstream processing usually cannot be performed under ster- ile conditions. In addition to the purification of the antibody from impurities contained in the matrix of the culture supernatant, the downstream process steps have to be designed and validated to remove and inactivate potential viral contaminations. A typical downstream processing procedure usually starts with removal of the cells and cell debris from the crude culture supernatant. Cell sedimentation combined with filtration or centrifugation are generally applied. The following process steps usually 90 Kunert and Katinger include a series of chromatographic columns containing different matrices, each of which contribute complementary separation principles to the entire purification process. Ideally, purification begins with a high-capacity antibody capture step based on the principle of affinity chromatography. Affinity ligands capable of reversible and specific binding of the antibody such as protein A result in an enormous reduction in volume as well as high concentration and purity of antibody. Last but not least, such procedures result in a robust inactivation and removal of potential virus contaminations achieved by a one-step unit operation (141). As for general safety cautions, the bulk purified antibody should be treated with one of the virus inactivation technologies routinely used in -globulin manufacture. The final drug format usually contains excip- ients useful for the stabilization and shelf life of the antibody. Additional inhibitory effects of intravenous immunoglobu- lins in combination with cyclosporine A on human T lymphocyte alloproliferative response in vitro [see comments]. A system for the separation into fractions of the protein and lipoprotein com- ponents of biological tissues and fluids. Clinical experience with 20 cases of group A strep- tococcus necrotizing fasciitis and myonecrosis: 1995 to 1997. Treatment of childhood acute immune thrombocytopenic purpura with anti-D immune globulin or pooled immune globulin [see comments]. Randomised trial of intravenous immunoglobu- lin as prophylaxis against infection in plateau-phase multiple myeloma. Utilization of intravenous immunoglobulin therapy to treat recurrent pregnancy loss in the antiphospholipid syndrome: a review. Prevention and treatment recommendations for respiratory syncytial virus infection. Respiratory syncytial virus immunoglobulin and monoclonal antibodies in the prevention and treatment of respiratory syncytial virus infection. Use of immune globulin to prevent symptomatic cytomegalovirus disease in transplant recipients a meta-analysis [letter; comment]. Suppressant effect of human or equine rabies immunoglobulins on the immunogenicity of post-exposure rabies vaccination under the 2-1-1 regimen: a field trial in Indonesia. Aggressive treatment of the first acute rejection episode using first- line anti-lymphocytic preparation reduces further acute rejection episodes after human kidney transplantation. Objective regressions of T- and B-cell lymphomas in patients following treatment with anti-thymocyte globulin. Beneficial effect of digoxin-specific Fab antibody fragments in oleander intoxication. Measurement of antibody-dependent infection enhancement of four dengue virus serotypes by monoclonal and polyclonal antibodies. Antibody-dependent enhancement of infection and the pathogenesis of viral disease. Analysis of neutralizing and enhancing antibodies to human immu- nodeficiency virus type 1 primary isolates in plasma of individuals infected with env genetic subtype B and E viruses in Thailand. Double-blind randomised controlled trial of monoclonal antibody to human tumour necrosis factor in treatment of septic shock. The in vivo and in vitro characterisation of an engineered human antibody to E-selectin. Immunoprophylaxis with palivizumab, a humanized respiratory syn- cytial virus monoclonal antibody, for prevention of respiratory syncytial virus infection in high risk infants: a consensus opinion. Development of the anti-gp120 antibody response during seroconversion to human immunodeficiency virus type 1. Temporal association of cellular immune responses with the initial con- trol of viremia in primary human immunodeficiency virus type 1 syndrome. Virologic and immunologic characterization of long-term survivors of human immunodeficiency virus type 1 infection [see comments]. Modulation of primary human immunodeficiency virus type 1 envelope glycoprotein-mediated entry by human antibodies. Sequence of simian immunodeficiency virus and its relationship to the human immunodeficiency viruses.

Gross inspection of the lungs at nec- represents anaphylaxis purchase super p-force 160mg with mastercard erectile dysfunction vacuum, accidental intravascular admin- ropsy reveals diffuse pale 160mg super p-force mastercard erectile dysfunction 37 years old, heavy, rm lungs. Obliteration of alveolar air space fatal outcomes may appear in 10% to 20% of the cases. History and physical signs sufce for histopathologically explain the antemortem dyspnea. No treatment is likely to be successful, severity of disease and consists of drugs such as epi- but antiinammatory drugs may be tried. Signs may be mild, with along with other symptomatic therapy (above) if the urticaria predominating, or severe, with collapse quickly cow shows a serious allergic reaction. Laryngeal edema may occur and be In most cases, one treatment sufces, but in cattle progressive over many hours. Certain biologics have been with severe pulmonary edema or urticaria, several treat- incriminated more than others in this regard. Antibiotic- ments at 8- to 12-hour intervals may be necessary for induced anaphylaxis has been observed as a result complete resolution. Many apparent anaphylactic crises may in fact thology during bovine respiratory syncytial virus infection: explor- be the result of endotoxins in certain biologics and cattle ing the parameters of pathogenesis, J Virol 77:12067-12073, 2003. Dyspnea may be inapparent or obvious, with Munch Tierarztl Wochenschr 118:305-308, 2005. Cecal indigestion may be part of the cecal tympany syndrome; this is discussed later. Individual animals, or a few animals (if it is rumi- nal indigestion), can be affected at any one time. The diagnosis of ruminal or small small intestinal indigestion and bowel distention. The cow developed diarrhea a couple of hours later and was intestinal indigestion is made by using a combination normal the next day. In fact, this form of indigestion Clinical Signs may be the most common cause of true colic in the Simple ruminal indigestion results in signs of an- dairy cow. Colic resulting from small intestinal indi- orexia, decreased milk production, cold extremities, gestion can be difcult to differentiate from a me- and rumen dysfunction. The uid responsible for small bowel gas and uid distention may be present in the right distention results from stasis associated with indi- lower quadrant, representing small intestinal disten- gestion and quickly appears as diarrhea as the cow tion. This hypocalcemia results in the clinical signs of cool peripheral parts and contributes to the already exis- ting gastrointestinal stasis. Magnesium products (sulfate, oxide, or hydroxide) are commonly used as cathartics and/or alka- linizing products; in dehydrated cattle with low urine production, these may cause hypermagnesemia and clinical weakness when used excessively or repeatedly. Cows that demonstrate severe colic associated with small intestinal indigestion may require treatment with unixin meglumine. Potential lameness sequelae including lami- for 2 to 3 days to ensure complete evacuation of caus- nitis, sole ulcers, and toe abscesses may be observed in ative feed material from the rumen. Although the diag- some cases 2 to 6 weeks after a rumen indigestion nosis of simple indigestion often seems like an excuse episode. Hypocalcemia portant differential diagnosis is primary ketosis, and is the only biochemical abnormality anticipated with this should be ruled out by testing for urinary ketones. Hypocalcemia and hypochlo- The two disorders also may coexist in some recently remia are common with small intestinal indigestion. Treatment Moderate to Severe Acute Ruminal Treatment for simple indigestion follows the two major Indigestion principles suggested by Udall: 1. Reestablish normal gastrointestinal motility and Etiology establish normal ora More severe forms of ruminal indigestion may closely 2. Evacuate the gastrointestinal tract with the intent approximate lactic acidosis (lactic acid indigestion, toxic of eliminating a causative agent indigestion) and are difcult to categorize. There is a These two goals are accomplished by administration range of clinical signs possible, depending on the quan- of oral laxative-ruminotoric mixtures and calcium solu- tity and type of feed material ingested by the cow. Many laxative-antacid-ruminotoric history of overingestion of grain or grain silage may ex- mixtures are available, and each practitioner has a favo- ist. If the rumen has some activity, boluses of these feeding, bolus concentrate has historically been a com- mixtures may be acceptable, but the powdered form of mon prelude to ruminal acidosis in cows (especially these products should be mixed with warm water and rst calf heifers). A less common history would be that administered through a stomach tube to ensure distri- the cow had access to an apple orchard where large bution of the product if rumen activity is severely de- numbers of apples dropped from trees after a storm. In cases with ruminal tympany, a stomach tube Thus in cases of severe indigestion, the ingested mate- should be passed routinely to relieve gas distention be- rial often is known as opposed to the usual case of fore administering treatment. Excessive treatment with simple indigestion, in which the causative feed material alkalinizing products should be avoided because these may not be known. Some affected cows are hypo- duction of highly fermentable small grain silage into calcemic enough to be recumbent and unable to rise. Another should be emphasized that these cows have more severe problem that can lead to lactic acidosis in modern signs than simple indigestion cases, including splashy dairy management systems is improper mixing of total rumen, dehydration, and tachycardia. In these cases, equipment fail- of indigestion, clinical signs of lameness (laminitis) may ure or human error can lead to stratication of feed- occur 2 to 6 weeks later. Cattle that acci- Hypocalcemia is a consistent nding, and acid-base- dentally overeat grain by gaining access to the grain electrolyte values vary depending on the degree of lactic room or by getting loose and eating from a grain bin acidosis. Because rumen ment factors often are involved, multiple animals in stasis is more severe, powdered ruminotoric-laxative- the herd tend to show signs. A basic understanding antacid products dissolved in water and 1 lb of activated of the pathophysiology of lactic acidosis is essential charcoal administered through a stomach tube are recom- for one to understand the signs that occur and be able mended. If signs of severe tion, the easily fermentable concentrate is broken indigestion occur within hours of known overingestion of down to lactic acid of both the D and L forms. The L isomer can be utilized make because medical therapy often will sufce and no rapidly, whereas the D isomer persists and results in clear-cut rules exist as to how much of any feed material D-lactic acidosis. As more and should be gradual over 24 to 48 hours, and treatment may more lactic acid and volatile fatty acids are produced, need to be repeated at 24-hour intervals. As gastrointesti- the pH of the rumen contents decreases into the acid nal motility returns, loose manure usually is observed. If sufcient substrate is available, the rumen pH Milk production may be slow to return to previous levels may decrease to 4. Rapid accumulation of lac- tic acid in the rumen osmotically draws water into the Fulminant Acute Lactic Rumen Acidosis rumen, causing the cow to dehydrate. Clinical examples of this may occur in feed- have elevated heart (90 to 120 beats/min) and respira- lots where feeder steers are introduced to total concen- tory rates (50 to 80 breaths/min). They typically have trate diets rather than being gradually changed from a splashy, totally static rumen, cool skin surface, sub- high roughage to high concentrate feeds. Because of dehydration, titration of bicar- type of feed quickly change to another. The rumen is then washed with water and emptied several times to remove as much lactic acid as possible. In Other treatments may be attempted for animals acute cases, obtaining a rumen uid sample through a showing less severe signs and higher rumen pH values stomach tube, percutaneous left ank puncture, or at nec- or when the number of animals affected precludes ru- ropsy examination of acute fatalities will reveal a rumen menotomies.

By Z. Kalan. Northern Kentucky University.