By E. Tyler. Reed College.

This form of niacin has long been used in Europe to lower cholesterol levels and also to improve blood flow in intermittent claudication generic aygestin 5 mg with mastercard. It yields slightly better clinical results than standard niacin and is much better tolerated discount aygestin 5 mg online, in terms of both flushing and purchase aygestin 5mg without prescription, more important, long-term side effects. Niacin should not be used by anyone with pre-existing liver disease or elevation in liver enzymes. For best results niacin should be taken at night, as most cholesterol synthesis occurs during sleep. If pure crystalline niacin is being used, begin with a dose of 100 mg a day and increase carefully over four to six weeks to the full therapeutic dose of 1. If you use an intermediate-release product (do not use any other form of time-release niacin) or inositol hexaniacinate, a 500-mg dosage should be taken at night and increased to 1,500 mg after two weeks. Plant Sterols and Stanols Phytosterols and phytostanols are structurally similar to cholesterol and can act in the intestine to lower cholesterol absorption by displacing cholesterol from intestinal micelles (an aggregate of water- insoluble molecules, such as cholesterol, surrounded by water-soluble molecules that facilitate absorption into the body). Because phytosterols and phytostanols are poorly absorbed themselves, blood cholesterol levels will drop, owing to increased excretion. Phytosterols and phytostanols can be used in addition to diet or drug interventions, as they provide additional benefits. The individuals most likely to respond are those who have been identified as having high cholesterol absorption and low cholesterol biosynthesis. Phytosterols and phytostanols have also shown antiplatelet and antioxidant effects. Pantothenic acid is the most important component of coenzyme A, which is involved in the transport of fats to and from cells as well as to the energy-producing compartments within the cell. Pantethine has significant lipid-lowering activity, while pantothenic acid has little if any effect in lowering cholesterol and triglyceride levels. Garlic Garlic (Allium sativum) appears to be an important protective factor against heart disease and stroke for many reasons. Garlic has been shown to lower blood cholesterol levels even in apparently healthy individuals. However, most trials not using products that can deliver this dosage of allicin fail to produce a lipid-lowering effect. However, the others do have a place in the clinical management of high cholesterol and triglycerides. In particular, the benefits of fish oils extend far beyond their effect on blood lipids. Typically, along with dietary and lifestyle recommendations, niacin (1,000 mg to 3,000 mg at night) reduces total cholesterol by 50 to 75 mg/dl in patients with initial total cholesterol levels above 250 mg/dl within the first two months. In patients with initial cholesterol levels above 300 mg/dl, it may take four to six months before cholesterol levels begin to reach recommended levels. Once cholesterol levels are below 200 mg/dl for two successive blood measurements at least two months apart, the dosage can be reduced to 500 mg three times per day for two months. If the cholesterol levels creep up above 200 mg/dl, then the dosage of niacin should be raised back up to previous levels. If the cholesterol level remains below 200 mg/dl, then the niacin can be withdrawn completely and the cholesterol levels rechecked in two months, with niacin therapy reinstituted if levels have exceeded 200 mg/dl. The same sort of schedule applies to other natural cholesterol-lowering agents as well. Hives (Urticaria) • Hives (urticaria): raised and swollen welts with blanched centers (wheals) that may coalesce to become giant welts. Hives (urticaria) are an allergic reaction in the skin characterized by white or pink welts or large bumps surrounded with redness. These lesions are known as wheal and flare lesions and are caused primarily by the release of histamine (an allergic mediator) in the skin. About 50% of patients with hives develop angioedema—a deeper, more serious form involving the tissue below the surface of the skin. Hives and angioedema are relatively common conditions: it is estimated that 15 to 20% of the general population has had hives at some time. Although persons in any age group may experience acute or chronic hives and/or angioedema, young adults (from the end of adolescence through the third decade of life) are most often affected. Mast cells are widely distributed throughout the body and are found primarily near small blood vessels, particularly in the skin, while basophils circulate in the blood. The classic allergic reaction occurs as a result of complexes of allergic antibodies (IgE) and antigens (foreign molecules) binding to mast cells and basophils and stimulating the release of histamine and other inflammatory compounds. However, other factors appear to be more important in stimulating the release of histamine in hives.

Cysts are believed to be inter- Coccidian parasites include a variety of life styles mittently shed in the feces generic aygestin 5mg with amex, and multiple samples and means of transmission purchase aygestin 5mg otc. Oocysts of most genera must be examined before considering that a bird is are passed unsporulated purchase 5mg aygestin with mastercard. The cysts measure 10-14 µm x 8-10 µm 45 µm in length, contain a granular-appearing and contain four nuclei and fibrillar structures. Keeping the aviary as clean and dry as possible will reduce the viability and number of cysts available for Coccidia are common in mynahs, toucans, pigeons, transmission. By either from endogenous parasites that are not de- comparison, infections are rare in captive Amazon stroyed or from reinfection from exposure to environ- parrots. Contaminated water supplies cause clinical changes unless the birds are main- have been discussed as a method of repeated expo- tained in crowded, unsanitary conditions. Clinical sure of mammals to Giardia and may serve as a disease is occasionally seen in canaries and finches. Giardia cysts survive the Coccidiosis is a major cause of enteritis in Columbi- standard chlorination of water. Eimeria dunsingi oocysts are ated Splendid Grass Parakeets and cockatiels and ovoid, lack a micropyle and are 26-39 x 22-28 µm. Generally, Hexamita is smaller than oocysts of Eimeria are subdivided into four sporocysts Giardia, swims in a smooth linear fashion and may each with two sporozoites, whereas withIsospora, the be associated with chronic diarrhea. Hexamita has oocysts have two sporocysts each with four sporozoi- been described as a cause of disease in lories. In general, some cases of coccidiosis are associated with severe Histomonas: Histomoniasis is common in gallina- clinical disease, while other birds will pass numerous ceous birds. The induced disease is called blackhead oocysts in the feces and remain asymptomatic. In some Isospora is most common in Passeriformes, Psittaci- birds, this parasite is considered a major pathogen formes and Piciformes, and Eimeria is most common while in other birds it is considered an incidental in Galliformes and Columbiformes. When lesions occur, they generally include may be asymptomatic or develop clinical signs of hepatomegaly (with necrosis) and ascites. Adults are gen- ovoid protozoa that infect and may cause disease in erally asymptomatic carriers that shed oocysts in the the mucosal epithelial cells lining the gastrointesti- feces. Prevalence can be high in young birds during nal, respiratory and urinary tracts of birds. Birds less than a year of age are most likely Cryptosporidiosis has been documented in Gallifor- to develop clinical changes. An enlarged liver and dilated bowel loops that cryptosporidial infections may be transmitted can occasionally be observed through the transpar- among closely related species, which should be con- ent skin (see Color 20). With severe infections, zoite sidered when managing this coccidia in a collection. At ne- blood to parenchymal organs where it infects reticu- cropsy, there may be an excessive amount of mucus loendothelial and intestinal epithelial cells. Coccidial oocysts are environmentally stable and are not killed by most disinfectants. Finches x Oocysts were identified in the feces from young and adult birds in the affected group. Suggestive of the opportunis- Toxoplasma: Toxoplasma is a coccidian parasite tic nature of Cryptosporidium was the detection of with an indirect life cycle. In fatal infections in most species, has been documented three birds, the parasite remained localized to the in the Red Lory, Swainson’s Lorikeet, Regent Parrot, Superb Parrot and Crimson Rosella. In the other bird, Cryptosporidium was present throughout the large gondii is considered a ubiquitous organism with a intestines, small intestines and bursa (see Figure broad host range, and probably could infect any mam- 32. Oocysts produced and passed in the feces of infected cats would be the only source Cryptosporidium sp. The number of parasites varied tomegaly, vasculitis and necrotic foci in the lungs, from a few to several million per gram of feces. Cryptosporidium undergoes sexual multiplication in the intestine of a recovered from the ostriches was not infectious to definitive host. None of the restricted to North America and has been associated birds in this study had clinical signs of infection, but with acute deaths in a variety of psittacine species. Adult New World genous sporulation resulting in autoinfection in the Psittaciformes appear to be relatively resistant (Ta- parasitized host. The susceptibility of Old World Psittacifor- severe enteritis and diarrhea in experimentally in- mes and resistance of New World Psittaciformes may fected Bobwhite Quail in the company of reovirus. Infections appear to be more the feces so the frequent cleaning regimes that are common in the winter months and males appear to used to control other coccidia are ineffective in pre- be more susceptible than females.

Suggested therapeutic measures for cloacal papil- lomas have been based on the physical removal of the Attempts to demonstrate papillomavirus in suspect masses through cryotherapy 5mg aygestin visa, radiocautery or surgi- lesions by electron microscopy buy aygestin 5mg low cost, low stringency south- cal excision generic 5mg aygestin visa. These procedures have been performed ern blotting techniques or immunocytochemical pro- alone or in combination with the use of autogenous cedures have all failed. None of the proposed therapies is consis- Amazon parrots, macaws and cockatoos using ho- tently effective, and papillomatous tissue often re- curs. It is suspected that papillomatous lesions from the cloaca (see Color strains from Passeriformes are also different. The proce- clinically healthy broiler chickens in Central Europe dure is repeated at two-week intervals until the le- that were also infected with infectious bursal disease sions have been removed. The role that this immunosuppressive virus played in the pathogenesis of the polyomavirus infec- Epizootiologic evidence has been used to suggest that tion was undetermined. Transmission Mutual preening and sexual contact have been sug- The epizootiology of polyomavirus infections is not gested as methods of transmission. The factors involved in the dura- investigations suggest that the disease is not infec- tion and induction of viral shedding remain unre- tious (Clubb, S unpublished). Some asymptomatic adults produce persist- aviaries have had epizootic outbreaks of the disease ently infected young, while others have neonates following the introduction of a clinically positive that intermittently may develop clinical signs and bird. It has been suggested that persistently infected this disease is available, it is prudent to isolate birds birds may be immunotolerant as a result of being with lesions from the remainder of a collection. Some birds are known to shed virus in the presence of high Polyomavirus antibody titers. Virus can replicate in the epidermal mammalian polyomaviruses indicates that there are cells of the feather follicles resulting in the presence similarities; however, the genomes are not identical. The presence of virus in the renal tubular epi- thelial cells suggests passage of virus in the urine. It has been suggested that the avian strains of Polyomavirus nucleic acid can be detected in cloacal polyomavirus be placed into the subgenus swabs taken from birds during polyomavirus out- avipolyomavirus. These findings, along with the frequent Seronegative young adult birds will seroconvert occurrence of glomerulopathy (immune complex in- when housed adjacent to seropositive breeding birds, duced) have led to the theory that death from avian implicating indirect transmission of the virus. These birds did seroconvert and developed high neutralizing antibody titers Findings in support of vertical transmission include (>1:640) indicating that they were susceptible. The experimentally infected birds remained tions when eggs from parents that consistently pro- asymptomatic a year after infection, suggesting that duce diseased neonates are cross-fostered to parents 38,39,125 other factors may precipitate the formation of im- producing normal young. Further, massive hepatocellular necrosis maternally derived antibodies, virus or both to its (with intranuclear inclusion in hepatocytes) is the young. The clinical status of the chick could then most frequent histologic lesion in larger psittacine depend on the level of maternally derived antibodies birds that die from avian polyomavirus, and an im- and the stage of immunocompetency when viral ex- mune complex theory of avian polyomavirus-induced posure occurs. Chicks that have protective levels of death does not explain the principal histologic lesion. The virus appears to require host cells that with intermittent shedding and vertical transmis- are dividing and temperatures of at least 39°C. Fol- sion are also suspected to occur in finches and result 192,256 lowing the primary viremia, inclusion bodies can in early embryonic death. The highest erigar fledglings show peak mortality rates between virus concentration is usually found in the brain. In larger parrots, death Tissue lesions can be severe and are directly related may occur from 20 to 140 days of age, with most to the level of morbidity and mortality. Infections in adult Estrildi- As a group, polyomaviruses typically reside in a la- dae or Ploceidae have been suggested to be depend- ent on immunosuppression. There has thus far been no association be- factor in the pathogenesis of polyomavirus infections. For example in Europe, a more chronic form of ently infected birds may be those that are infected 105,106,424 the disease is common in budgerigars, while in the before they are immunocompetent. White-bellied Caiques, parrotlets, African Grey Par- Other Psittaciformes: In larger psittacine birds, rots, lovebirds, Ring-necked Parakeets, Eclectus Par- 392 311 polyomavirus infections may cause peracute death rots, Scarlet-chested Parrots, Bourke’s Parrots, 311,363 381,382,440 with no premonitory signs or acute death after devel- cockatoos and finches. Other infected hatch- signs characterized by ataxia, tremors and paralysis lings may develop clinical signs, which include ab- have been described in some Psittaciformes. Infections may occur in both Infections have also been associated with decreased parent-raised and hand-raised neonates. Mortality are thought to result in the formation of subclinical rates are highest in budgerigars less than 15 days of carriers with only occasional development of clinical age. Blue and Gold Macaw neonates experimen- normalities characterized by dystrophic primary and tally infected with budgerigar fledgling disease virus tail feathers, lack of down feathers on the back and (derived from cell culture) did not develop clinical abdomen and lack of filoplumes on the head and neck signs of infection but did seroconvert, indicating that (Color 32. Developing primary and secondary A chronic form of polyomavirus has also been de- feathers may break or fall out, resulting in substan- scribed and is typified by weight loss, intermittent tial blood loss. Affected birds are unable to fly and are anorexia, polyuria, recurrent bacterial or fungal in- often called runners or hoppers. Occult hematuria has been North America and Europe, lesions attributable to suggested as an indication of a polyomavirus infec- French moult are thought to be caused either by the tion in this species. Neonates presented for ne- cropsy are usually in excellent over- all condition and may have full crops and gastrointestinal tracts, indicat- ing the speed of disease progression. Karyomegaly in various tissues and hepatic necrosis are the most consis- tent histologic lesions in larger psit- tacine birds.

For example: ◼=Is it your responsibility to give phenytoin to every patient with a head injury? One way around this is to ask/tell your consultant what your plan is and ask if they have any specifc objections or suggestions cheap 5mg aygestin with mastercard. Bradycardia ◼=Maintain airway order 5mg aygestin with amex, give oxygen ◼=Monitor rhythm generic aygestin 5mg amex, blood pressure, oximetry ◼=Signs of adequate perfusion (good mentation, no chest pain, no hypotension) ▶=Observe/monitor ◼=Signs of poor perfusion (altered mental status, chest pain, hypotension) ▶=Prepare for transcutaneous pacing ▶=Consider atropine 0. One of several drugs that may be used to restore sinus rhythm for atrial fbrilla- tion or atrial futter in patients with preserved ventricular function 3. The amiodarone infusion is best given in a central line but a periph- eral line can be used until a central line is available in an emergency. Magnesium defciency Dose ◼=Torsades with pulses: 1 to 2 g in 50–100 D5W over 5 to 60 minutes, followed by infusion of 0. Stable, narrow-complex, automaticity mechanism tachycardias (junctional, ectopic, multifocal) if rhythm not controlled or converted by adenosine or vagal maneuvers 3. Symptomatic bradycardia after atropine, dopamine, and pacing, or pacing not available 3. Severe hypotension (systolic <70 mm Hg) and low total peripheral resistance Dose: Initially, 0. Severe heart failure and hypertensive emergencies 508 Advanced Cardiac life support review Dose: 0. Calcium channel blocker toxicity Dose: 10% solution of calcium chloride in a dose of 8 to 16 mg/kg (usually 5-10 ml and repeated as necessary at 10-minute intervals). Using this system, medication doses and equipment sizing are color-coded based on the child’s height. Elective cardiover- sion may be used as an alternative to chemical cardioversion in stable patients with these rhythms. Note that pulseless ventricular tachycardia requires defbril- lation, not synchronized cardioversion. Contraindications ◼=No absolute contraindications exist for defbrillation or cardioversion except when the procedure poses an undue risk to healthcare providers (eg, in a wet submersion victim). Equipment ◼=Monophasic or biphasic defbrillator with appropriately-sized pads – infant pad- dles for patients less than 10 kg/1 year of age, adult paddles for all others ◼=Conductive gel, saline-soaked pads, or self-adhesive electrode pads ◼=Procedural sedation agents, if applicable ◼=Advanced airway equipment and antidysrhythmic drugs in the event of compli- cations Technique ◼=Defbrillation ▶=Verify that the defbrillator is not in synchronous/cardioversion mode. Dose for biphasic is unit- specifc and should be indicated on face of unit; if unclear, use 200 J. The “sternum” paddle is placed to the right of the sternum, below the clavicle; the “apex” paddle is placed left of the nipple in the midaxillary line, centered on the ffth intercostal space. Alternatively, anterior-posterior positioning is acceptable – the sternum paddle is placed over the precordium, and the apex paddle to the left of the spine, directly posterior to the heart. Twenty-fve pounds of force are recommended to ensure appropriate contact between the paddle and the chest wall. Atrial fbrillation often requires a higher dose than ventricu- lar and other supraventricular tachycardias, but the general recommendation is to start with 50 J, then 100 J, followed by 200 J for all rhythms, for both monophasic and biphasic machines. Remember to verify that the machine is in synchro- nized mode before each shock – many units will revert to unsynchronized defbrillation after any discharge. Note that a delay often occurs while the defbrillator evaluates the rhythm for synchronization. In that case, change the lead that the monitor is sensing or move the arm leads closer to the chest. Twenty Common Emergency Medicine Procedures 517 ◼=There are several accepted methods for performing cricothyrotomy. The simplest, “Rapid four-step technique,” is described here: ▶=Position yourself at the head of the bed, as if for endotracheal intubation. If the anatomy is ambiguous, make a verti- cal incision through the skin to identify the cricothyroid membrane and then a horizontal incision through the membrane. The anterior pad is placed over the cardiac apex and the posterior pad is placed just medial to the left scapula. Once capture is achieved, brief trains of 10 overdrive beats of asyn- chronous pacing are applied. Complications ◼=Failure to recognize an underlying dangerous rhythm (eg, ventricular fbrillation) that is buried beneath pacer spikes is the most important potential complication. Notes ◼=Chest compressions can be administered directly over the pads while pacing. Contraindications ◼=There are no absolute contraindications to pericardiocentesis. In the case of traumatic pericardial effusion, pericardiocentesis may be performed on Twenty Common Emergency Medicine Procedures 519 the arrested or nearly arrested patient as preparations are made for thoracotomy, but should not delay thoracotomy. Technique ◼=Head of bed is elevated to 45 degrees, if possible, to bring the heart closer to the anterior chest wall. Needle is inserted between the xiphoid process and the left costal margin at a 30-degree angle to the skin and directed toward the left shoulder. Complications ◼=Cardiac injury/tamponade ◼=Chest vessel injury/hemorrhage ◼=Pneumonia ◼=Arterial air embolism Notes ◼=The immediate placement of a chest tube is preferred to needle thoracostomy if possible – advancing a Kelly clamp through the pleura treats the tension pneumo- thorax.