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By Y. Fedor. Williams College.

This is best accomplished by Esophagus (if present) nerve opening the thoracoabdominal cavity purchase hydroxyzine 10 mg overnight delivery, gently separat- Selection of additional tissues will depend upon gross lesions observed at ing the viscera and fixing the entire carcass in for- necropsy generic 25 mg hydroxyzine free shipping. Exces- sively thick (one cm thickness) tissue slices or tissues that float (gas-filled intestine purchase generic hydroxyzine on line, fatty liver, lung) when immersed in formalin solution often do not fix and Specimen Collection become autolytic. Representative tissue specimens from all organ systems should be collected (Table for Ancillary Testing 14. When specific lesions are observed at necropsy, the tissue specimen collected should include a small margin of normal tissue adjacent to the lesion. Ancillary testing often is essential to confirm or es- Specimens should be shipped to the laboratory in tablish a definitive diagnosis. To de- should be collected routinely for histopathologic crease shipping weight, tissues that have been fixed evaluation; however, additional specimens (eg, swabs in formalin solution for at least 24 hours can be for bacterial culture, fresh tissues for bacterial cul- wrapped in a formalin-soaked gauze square that is ture and virus isolation, crop contents for toxicologic placed into a sealable plastic bag for shipment. In the analysis) are obtained as necessary based upon his- authors’ experience, a complete set of necropsy tis- torical, clinical and necropsy findings. Because specimens can be submitted along with the formalin- cost is often a consideration when submitting his- fixed tissues if the need for additional laboratory topathologic specimens to the laboratory, the practi- testing is obvious or they may be held under appro- tioner should consult a veterinary pathologist con- priate conditions for later submission if required. It cerning the tissues to be submitted in a particular is better to have taken specimens for ancillary testing case. The remaining fixed tissues can be held for and not need them, than to need the specimens and additional study if needed. The following information is designed to expedite specimen procurement and han- Hematologic and Cytologic Specimens dling to maximize the results obtained. A telephone call to the diagnostic laboratory prior to performing Preparation of blood and cytology specimens for mi- the necropsy is a prudent measure to ensure correct croscopic examination is detailed in Chapters 9 and specimen collection, preparation and handling. Tissue Histopathology scrapings may be smeared onto a clean glass slide, or squash preparations may be made if particles of Tissue specimens for histopathology should be pre- tissue are present. Tissue imprints are prepared by served in neutral-buffered ten percent formalin solu- blotting the tissue specimen on an absorbent surface tion. Buffered formalin is necessary to prevent acid (filter paper or paper towel) to remove excess blood hematin formation, which can obscure microscopic and tissue fluid. Furthermore, adequate preservation of touched to a clean glass slide several times or vice tissues requires rapid and complete penetration of versa. Tissue specimens may be antibody staining for chlamydiosis or herpesvirus placed in sealable plastic bags and frozen prior to infection). Swab specimens the laboratory immediately, they may be stored in are properly prepared by gently rolling the swab the the freezer until needed for diagnostic testing. Three such passes may be the definitive diagnosis has been made, remaining made on a single slide from top to bottom. If they are not stained before examination or submission to the diagnostic labora- Tissue specimens for fungal culture and identifica- tory, they should be protected from excessive mois- tion may be collected, placed in sealable plastic bags ture or formalin fumes, which could cause cellular and refrigerated or frozen until analyzed. Microbiology Parasitology Microbiology includes culture and identification of bacteria, viruses and fungi as well as certain sero- Fecal flotation for detection of parasite ova is per- logic assays to detect the presence of or exposure to formed frequently as a portion of the minimum data- these pathogens. Additional may include culture swabs, fresh tissues, body fluids fecal specimens may be taken for analysis at ne- or exudates, cytologic smears and imprints (eg, fluo- cropsy, especially in those patients with diarrhea, rescent antibody staining for chlamydia and herpes- where protozoal infection is a consideration. These specimens are perishable intact parasites such as cestodes, trematodes, nema- and should be shipped to the laboratory without todes or arthropods may be taken for specific identi- delay. Proper fixation of these para- Fresh tissues submitted for bacterial culture should sites is essential for successful identification by a be at least two cubic centimeters to yield accurate veterinary parasitologist. At the laboratory the surface of the tissue is preservation of fecal material and parasites are de- seared with a heated spatula to sterilize it, and a loop tailed in Tables 14. If the tissue Wet mounts of feces or a feces-saline slurry should be is too small, the entire specimen (including bacteria) examined within minutes of death to detect organ- is destroyed during the searing step, and a false- isms such as Giardia sp. Following in- tine bacterial culture can be placed in sterile, seal- itial examination, a small drop of Lugol’s iodine can able plastic bags and submitted immediately or be added to kill and stain protozoa and their cysts for frozen if a delay of more than 12 to 24 hours before more detailed examination. If unusual pathogens are sus- perishable and generally will not survive shipment to pected, the diagnostic laboratory should be consulted the diagnostic laboratory. Intestinal scrapings or im- regarding the best means of handling the tissue to prints, which may be air-dried, stained and exam- optimize culture results. Products such as Cul- turettes® are preferred because they are self-con- Toxicology tained, minimize the possibility of specimen con- tamination and contain a transport medium that Toxicologic analysis is generally labor-intensive, re- maintains organism viability while preventing sap- quires sophisticated analytical equipment and is rophytic bacterial overgrowth. The clinician should have some sus- picion of the substance involved before toxicologic Fresh tissues (especially liver, spleen, kidney, lung analysis is requested, because tissue handling and and brain) are collected for viral isolation. A veterinary toxicologist Aflatoxins or diagnostic laboratory should be contacted to en- Aflatoxins B1, B2, G1 and G2 are metabolites of Asper- sure that the proper samples are collected and sub- gillus flavus. In addition, a particular labora- erly stored feed and act as potent hepatotoxins. They tory may not perform a desired test or may not be may be identified in feed or tissue specimens using equipped for analysis of small tissue specimens. Identification of afla- and aviary bird practice are heavy metals (eg, zinc, toxin in foodstuffs requires submission of 50 to 100 g lead), aflatoxin-contaminated feeds and various or- of feed. The most commonly inhaled sampling errors, and should be derived from the toxins include the fumes of polytetrafluoroethylene same lot of material fed before the onset of disease. Samples for analysis following discussion briefly covers sample submis- should be placed in sealable plastic bags. Although sion for toxicologic analysis, especially for identifica- not ideal, tissues from several dead birds can be tion of certain heavy metals and aflatoxins (see pooled for analysis if necessary. Poisonous Plants and Chemicals Heavy Metals Suggestion of plant-induced toxicosis may be based Heavy metal toxicosis is most frequently associated upon the medical history and observation of crop with ingestion of zinc by companion or aviary birds contents. Sources of excess plants have been published, recent publications indi- zinc include ingestion of particulate material from cate that development of toxicosis is dependent on homemade galvanized wire mesh enclosures and in- the species of bird, portion of plant ingested and gestion of pennies thrown into captive bird dis- 1,8,28 season of plant growth. A veterinary toxicologist soning is usually due to ingestion of lead shot by should be consulted concerning appropriate speci- waterfowl during normal feeding activities. Using this tech- Proper fixation requires a ratio of one part tissue to 10-20 parts fixative nique, quantitation of lead requires submission of solution. Blood and serum Carson’s modified Millong’s phosphate-buffered formalin:This solu- should be submitted in screw-cap plastic containers tion may be used for routine preservation of tissue specimens for both or stoppered test tubes.

In physical medicine and rehabilitation it is important to have more specific tools responding to metrological criteria of validity hydroxyzine 10 mg mastercard, sensitivity and reproducibility cheap hydroxyzine line. For motor deficit (hemiplegia) purchase 10 mg hydroxyzine with amex, three assessment tools tend to be used: The Fugl-Meyer scale (8). The reproducibility is excellent but its application is demanding and it takes a long time to administer. Faster and easier to administer than the previous one, it was inspired by specific rehabilitation con- cepts (“motor relearning program”). It consists of eight motor tasks performed during therapy and evaluates spasticity in an overall man- ner but this item has poor interobserver and intraobserver repro- ducibility. In therapeutic trials, the modified Ashworth Scale is applic- able in cases of cerebral and spinal cord spasticity (11). Cognitive impairment after stroke is evaluated using numerous spe- cific tests and batteries of tests including the Boston Diagnostic Aphasia Examination for speech impairment, visual graphic evaluations and oth- er tests for unilateral neglect, and anosognosia scales for awareness of im- pairment. The same re- mark applies to the Blessed Dementia Rating Scale (13), used in some cas- es of post-stroke assessment (14). The evaluation of depression after stroke poses a major practical problem, because frequent depressive states play a considerable role in the process of adaptation during the rehabilitation period, then at home. For this population, the General Health Questionnaire appears to be more sen- sitive and successful than the Hamilton Anxiety and Depression Rating Scales (15). Assessment of disabilities Independence regarding activities of daily living after stroke, during the course of rehabilitation, or at the stage of sequelae is usually assessed using generic scales. The Barthel index is the oldest and was initially conceived specifi- cally for this population (16). It is currently widely used to evaluate the care load of patients with physical impairments of various na- tures in hospitals. Correlated to neurological scores, the scores of the Barthel Index established early after stroke are predictive of the mor- tality, functional recovery, and duration of stay in rehabilitation units, and orientation at discharge from units of Physical and Rehabilita- tion Medicine (17). It is noteworthy that the Barthel Index, available in several languages, evaluates ten simple activities of daily living: feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers, mobility, and stairs. The score extends from 0 to 100; to each category corresponds specific maximum scores of vari- able value. However this tool shows poor sensitivity to change, be- cause of the system of attributing value and the limited number of ac- tivities evaluated. Above all, in case of stroke, this score fails to take cognitive disability into account. The Frenchay Activities Index (20) was specifically elaborated for post-stroke hemiplegia. It contains fifteen items, which investigate personal hygiene, mobility and activities using an ordinal scale of 1 to 4 for every item according to the degree of independence. Easy to use and fast (5 minutes on the average), certain au- thors also consider it as a quality-of-life scale (21). The Rankin Handicap Scale (22) was designed for the overall evalu- ation of outcome after stroke. Extensively used with the Barthel index in therapeutic trials, it is short, simple and consists of six levels ac- cording to outcome. It is used in the form of a self assessment form investigating mobility, personal hygiene, leisure activities, family role, social activities, per- sonal relationships, and self image in eleven categories. Values are at- tributed using a visual analog scale or a three-level ordinal scale. In cerebral vas- cular disease, comparison of scores obtained by telephone or by di- rect interview and the responses of the patients or by close friends or family are generally consistent (24). This is true in all stages, from coma to physical therapy and psychosocial rehabilitation. Nonetheless, more or less complex associated neuromotor syndromes, and, above all, psychoemotional and behavioral disorders also occur. The evaluation plays a major role in guiding therapeutic choices during the phase of re- covery and in organizing cognitive and physical rehabilitation. In general, all instruments based upon questionnaires or subjective analyses raise questions concerning the reli- ability of measurements. In this respect, neuro-psychometric tools are limited in cases of persistent memory disorders or anosognosia. The cur- rent tendency is to opt for evaluation in a specific “real-life” situation (27). This scale, which is useful to compare popula- tions of patients with head injuries, nevertheless has poor repro- ducibility and only tenuous validation (31). Three domains receive particu- lar attention: motor capacities, cognitive capacities and social interactions. Fifty-eight items are listed and classified (Six- ty-two items in the French version) according to a specified se- quence of recovery. These items are grouped into four cate- gories: – Items 1 to 15: basic behavior corresponding to reflex and more or less appropriate activity; – Items 16 to 29: essentially investigating visual behavior, de- signed to detect recovery of social interactions, communica- tion and signs of emotional behavior directed toward family and friends. They combine a frontal executive deficit, including predominantly disorders of attention and speed of processing information, a durable or, in some cases, even definitive memory disorder, as well as complex disorders of communicating ca- pacities, judgment, decision making, and self awareness (anosog- nosia). For every dysfunction, there are reference psychometric as- sessment tools (see chapter on Assessment of cognitive impairments). However, as already mentioned, there are numerous methodological limits in assessments of patients with the most severe head injuries. This is why more general assessment tools adapted to this population have been proposed. The scale contains twenty-sev- en items, in seven quantified levels (from 0 for no disorder to 6 for most severe disorder). Sig- nificant correlations have been demonstrated with convention- al prognostic factors of head injury: age, educational level, depth and duration of the coma. Five factors can be identified using factorial analysis including disorders of memory and mo- tivated behavior, modification of emotional states, emotional and behavioral hyperactivation, impairment of awareness and attention, and speech disorders. Interobserver agreement is high and determining the five factors is useful to establish a profile of cognitive impairment (38).

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In patients who deteriorate despite usual therapeutic efforts discount hydroxyzine 25mg free shipping, evidence supports a trial of positive-pressure mask ventilation before intubation 25mg hydroxyzine with mastercard. Hypercapnia is usually a late fnding that refects increasing airfow obstruction and fatigue because of the increased work of breathing best hydroxyzine 10mg. Indications for intubation include cardiac or respiratory arrest, severe hypoxia, exhaustion, or deterioration of mental status. Note that intubation alone does not correct the underlying pathology of the exacerbation (airfow obstruction). Ventilator settings on intubated asthmatic patients are very diffcult to manage, and hypotension after intubation commonly occurs. This is due to decreased preload from high intrathoracic pressures in these patients. Vent settings should include low tidal volumes and prolonged expiratory times to avoid barotrauma. She noted a red rash last night to upper chest and neck area, now spreading to abdomen and arms. Social: smoker (1 pack per day for 10 years), occasional alcohol use, denies drugs, monogamous with husband g. Urogenital: small red erosions near introitus of vagina, no crusting or vesicles noted h. Skin: symmetric red, purpuric mildly tender macules and plaques over neck and chest, extensor surfaces of arms (~10%) with vesicles and bullae, some with sloughing and necrosis of larger plaques, bullae spread with pressure, some appear like target lesions H. Critical actions == Obtain history of recent antibiotic use == Skin examination Figure 30. This is a case of Erythema multiforme major or Stevens–Johnson syndrome, an acute infammatory reaction in the skin. Although the exact pathophysiology is not well known, this syndrome is often associated with medication reactions and infections. Important actions include making the diagnosis on the basis of history and physical examination, contacting dermatology, and admitting the patient to a burn unit. Among those implicated include antibiotics (penicillins, sulfonamides, and cephalosporins), antiepileptics, non- steriodal antiinfammatory agents, antipsychotics, and antigout medications. He also complains of progressive shortness of breath, dry cough, dyspnea on exertion, dizziness, and parasthesias of his hands and feet. He notes recent diarrhea, now improving; denies, fever, headache, vision changes, diffculty speaking or swallowing; denies pain, no known tick bites, no recent travel. Abdomen: soft, distended suprapubic area with associated mild pain with pal- pation, normal bowel sounds g. Place nonrebreather mask, prepare equipment for intubation Case 31: weakness 149 c. After discussion with patient and family, perform intubation for declining respiratory status, airway protection d. In this case, it is important to distinguish the symptoms from stroke, metabolic dis- orders, or other causes of weakness. The candidate must recognize that the patient’s symptoms have worsened, and intubation based on clinical assess- ment (worsening respiratory status) or pulmonary function (respiratory testing) should be initiated. If the patient is intubated using succinylcholine as a paralytic, he will lose his pulse and demonstrate a wide-complex tachycardia (consistent with severe hyperkalemia) on the monitor. Predictors of respiratory failure include inability to cough, stand, lift the elbows or head, and elevated liver enzymes. As with any demyelinating disorder, acetyl cholinesterase receptors are upregu- lated. This can cause severe, prolonged hyperkalemia when a depolarizing neu- romuscular blocker is used. The pain is intermittent, feels tight and squeezing and has been increasing in severity. She denies diarrhea, fever, dysuria, chest pain, vaginal bleeding, or shortness of breath. Abdomen: bilateral lower quadrant tenderness with guarding; bowel sounds normal, mild distension, no masses, no hernias, nontender at McBurney’s point, negative Murphy sign g. Patient: continues to have signifcant pain (until a total of 6 mg of morphine or equivalent is administered) 152 Case 32: Abdominal Pain and Vomiting H. The patient is at increased risk of obstruction because of her prior abdominal surgeries, which can lead to scar- ring and adhesions that may block proper fow of intestinal contents. If fuids are not administered, the patient may become tachycardic and hypotensive. Her pain will continue to increase until an opioid medication (such as morphine) is administered. If a nasogastric tube is not placed after diagnosis, the patient may continue vomiting and aspirate. The x-rays may reveal distended loops of small bowel and the upright abdominal flm may show a pattern of intestinal air-fuid arranged similarly to a stepladder proximal to the obstruction. Middle-aged and elderly patients with epigastric pain should be evaluated for coronary ischemia. Nonchest pain presentations are common in this age group, especially upper abdominal pain and/or shortness of breath. If an immediate operation is advocated or if the patient has signs of peritonitis or ischemia, the patient should be given broad-spectrum antibiotics. Surgical intervention is often needed to correct obstruction although a trial of medical management initially can be pursued for obstruction that has not been complicated by ischemia, peritonitis, or bowel perforation. The pain is in the left chest and is accompanied by left arm tingling but no radiation of pain to the back, arm, or jaw. General: alert and oriented, slightly agitated and uncomfortable due to chest pain b. Abdomen: minimally tender in umbilical region; no masses, bowel sounds normal, no distension g. The patient’s symp- toms of chest pain were likely due to cocaine-induced vasoconstriction of the coronary arteries. If benzodiazapines are not administered, the patient will become more tachycardic and hypertensive. Chest pain in the context of cocaine use may be caused by etiologies that are cardiac (such as myocardial ischemia/infarction, aortic dissection, or endocar- ditis with septic pulmonary emboli) or noncardiac (such as those from inha- lation-related barotraumas including pneumomediastinum, pneumothorax, pneumopericardium, pulmonary hemorrhage/infarction). Benzodiazapines (eg, lorazapam or diazepam) are useful to treat hypertension and tachycardia and thus reduce myocardial oxygen demand.

Following mor type generic hydroxyzine 10 mg with mastercard, testicular neoplasias can involve one or the correct environmental stimuli generic hydroxyzine 10 mg line, the testicles can both testes order hydroxyzine 25 mg fast delivery. Unilateral paresis, progressive weight undergo hypertrophy in preparation for breeding. Affected birds may have reduced secondary sex pathologic cases of atrophy can be difficult to diag- characteristics and become more feminine in nature nose (see Color 25). Serial laparotomies may be indi- (cere of the male budgerigar turning from a blue to cated to evaluate changes in testicular size. Metastasis from testicular tumors usu- lar atrophy can be caused by orchitis as a result of ally affects the liver. Therapy is limited to addressing infectious or behav- Phallic Prolapse ioral problems. If fibrotic or infiltrative changes have occurred, spermatogenesis may be permanently altered. Birds with large phalli may develop partial or com- plete prolapses, which are frequently secondary to Testes can be abnormally joined at their anterior 69 trauma, infection or extreme weather fluctuations. The phallus may become enlarged and may occur, causing parts of the genital tract to be ulcerated. In severe cases of phal- A variety of bacteria can cause orchitis in birds, lic prolapse, the birds may be severely depressed, including E. In ostriches, lapsed or ulcerated phalli, renal obstruction, cloacitis frostbite and necrotizing dermatitis may occur secon- and septicemia. Antibiotics may be helpful in resolving the active infection but Exposed tissue should be thoroughly cleaned with a may not prevent or reverse infertility. In these cases, the male is often “imprinted” on humans and cannot complete the re- productive cycle with its own species. Exchanging mates may prove helpful, but usually these males should be removed from the breeding program. Hu- man imprinting can also occur in females, and in both genders behavioral abnormalities due to im- proper imprinting may not be obvious. Indeed, lack of pair-bonding, lack of egg production or infertility may be the only signs associated with the use of hand-raised imprinted birds in a breeding program. The interaction of a chick with its parents and nest- ing conditions may be critical for successful reproduc- tion in some species (see Chapter 4). Under-production Establishing the existing level of production is the first step to managing a breeding pair. This includes calculating levels of fertility, hatchability and chick fledging rates. The design and location of the nest box, with endangered species where maximum produc- enclosure and aviary are all critical factors to consider. Sulphur-crested Cockatoo with fertile eggs was eliciting proper nest box defense behavior in response to an intruder. If production from a breeding pair does not approach the average, then medical, physical or behavior prob- ered with antibiotic cream. Correction of any medical reduce swelling, making replacement of the phallus or physical abnormalities, such as clipping over- easier and more permanent. Daily therapy and cloa- grown feathers near the cloaca, dieting overweight cal mattress suture may be necessary to prevent birds or treating birds for localized infections can be recurring prolapses (see Chapter 41). The diet should be carefully analyzed and biotics should be considered due to the possibility of any deficiencies should be corrected. 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.