Michael Vincent Boland, M.D., Ph.D.
- Director of Information Technology, Wilmer Eye Institute
- Associate Residency Program Director, Wilmer Eye Institute
- Associate Professor of Ophthalmology
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0020165/michael-boland
Vitamin E is a fat-soluble vitamin that acts as an important antioxidant to neutralize free radicals produced during exercise antiviral bacteria discount 2 mg minipress overnight delivery. Supplemental energy should be supplied via dietary fat and horses should receive optimal levels of Vitamin E daily hiv infection rate spain trusted 1 mg minipress. Providing these horses with high quality concentrate diets is critical to ensuring optimal performance hiv infection uganda discount 2mg minipress fast delivery. For all these horses hiv symptoms urinary tract infection purchase 1mg minipress free shipping, conditioning programs and consistent exercise protocols should be followed. However, understanding the need for precise energy sources to support the specific activity that the horse is doing can help guide the decision-making process. Understanding the physiology of exercise and energy utilization can serve as a guide in determining the optimal concentrate diet for the individual horse. Having a nutrition program that complements a training program is critical as these go hand in hand in ensuring the health and performance of the exercising horse. It is important to remember that successful performances and winning is not the result of feeding a single certain supplement or feed. Rather, it is the combination of knowledge of the physiology of the animal with the diet that they are being provided. However, horses with certain medical conditions may require a unique feeding management protocol. This paper will serve as a reference for feeding management of horses afflicted with certain clinical cases including: 1) Feeding the starved or severely malnourished horse 2) Feeding horses suffering from chronic colic, and 3) Feeding horses prior to and immediately following surgery. This paper should serve as a starting point when looking for information; however, there are many in-depth references available (Reed et al. Causes of Extreme Weight Loss or Malnutrition Extreme weight loss in horses is often highly emotive. Extreme weight loss, defined as an individual approximately 30% below ideal body weight, may be the result of one or multiple causes. The following list outlines a more comprehensive causative list of emaciation in horses. While the causative factors of emaciation in horses is extensive, typically the pathophysiology of the condition is similar across cases. As the individual horse routinely and consistently experiences nutritional deprivation, body stores of carbohydrates, fat and protein are metabolized and utilized to sustain critical physiological functions. If this process persists, significant stores of adipose tissue and skeletal muscle will be depleted leading to visible muscle wasting as well as harder to detect depletion of cardiac muscle and organ tissue (Witham and Stull, 1998). Dietary insufficiencies of minerals such as calcium and phosphorus may lead to instances of abnormal joint and bone development. Deficiencies of other minerals such as iodine and selenium may cause more noticeable clinical signs including goiter and hair loss respectively. Understanding the unique signs of nutritional insufficiency is important in treating the malnourished horse. This section will focus however, on better understanding the physiology of the starved horse and the unique strategies necessary to successfully refeed the individual. Physiology of Starvation Designing and implementing a successful protocol requires an understanding of the unique pathophysiology of the starved horse. Feed deprivation in horses is generally met with a predictable series of metabolic, physiological and behavioral changes. With declining dietary input of critical nutrients comes a reduction in circulating concentrations of these nutrients in the blood. In a relatively short period of time, typically less than 24 hours, endocrine function is altered to conserve blood glucose concentrations. At the same time, mobilization of glycogen from skeletal muscle and liver stores occurs as the primary defense mechanism against starvation. Once glycogen stores are depleted, acute starvation has developed into chronic starvation with significantly more detrimental health effects both in number and in severity. Once glycogen stores are depleted, gluconeogenesis is necessary to maintain blood glucose concentrations, and stored adipose and protein are catabolized to fuel the energy intensive gluconeogenic processes. This catabolism of adipose and skeletal muscle results in the drastic appearance of malnourished horses. However, the unseen damage as a result of malnourishment is typically manifested in damage to the nervous system. Neural tissue has an extremely high glucose requirement, accounting for up to 20% of glucose utilized in the system. The increased catabolism of body stores adipose and protein can lead to conditions such as hyperlipidemia and elevated plasma urea nitrogen respectively. Evaluation of serum triglyceride levels and plasma urea nitrogen are a useful tool in evaluating nutrient deficiency in horses and may in fact be more applicable than measurements of plasma glucose and insulin (Christensen et al. As starvation progresses, visible physical changes as well as unseen changes occur throughout the body of the horse. The body condition of the horse will diminish with much of the bony architecture of the animal visible. Additionally, protein catabolism, not restricted to skeletal muscle breakdown, can significantly alter the architecture of the gastrointestinal tract resulting in decreased absorptive capacity, reduced intestinal mobility and volume and delayed gastric emptying. These changes, resulting in diminished immune function may predispose the horse to systemic infections as the damage to the digesta-blood barrier is compromised. All of these issues must be taken into account as a refeeding protocol is designed on an individual basis. Refeeding Syndrome First described following the Second World War and the discovery of hundreds of thousands of severely malnourished humans, the aptly named refeeding syndrome is a major factor contributing to the high mortality rates during the rehabilitation of emaciated individuals. If a high glycemic feed is abruptly reintroduced into the system, a potentially fatal increase in blood insulin elicited (Tresley and Sheean, 2008). A system that has been metabolizing fat and protein for energy now has a large carbohydrate bolus that it is unprepared to cope with. Horses reintroduced to feeds with high levels of non-structural carbohydrates may in fact succumb even quicker (Witham and Stull, 1998). In addition to the effects of a shift towards glucose metabolism described earlier, a rapid influx of electrolytes may further exacerbate health issues as the organ systems are not primed to deal with this. The resulting electrolyte imbalances may lead to organ failure, red blood cell death and hypoxemia as a depletion in phosphorylated metabolites rapidly occur (Witham and Stull, 1998). It is important that during all stages of a refeeding program, but particularly the early days, serum electrolytes, specifically phosphorus and magnesium, be monitored as a measure of progress and to address any deficiencies or imbalances (Hurley, 2005). Levels of water-soluble vitamins, specifically thiamin should be monitored due to their important role as co factors in carbohydrate metabolism. Providing the proper levels of vitamins to allow for substrate utilization is critical to the success of a refeeding program (Magdesian, 2003). Developing a Refeeding Plan As is the recommendation with any dietary alterations to the equine diet a slow and steady approach is preferred when developing a refeeding program. It is important to understand that the emaciated and malnourished condition that the horse is in did not occur over a short period and the successful rehabilitation may take even longer. As part of a successful refeeding program, the initial step should be a comprehensive physical examination to determine any underlying medical conditions that may complicate the success of the plan. Any aberrations in liver, kidney or gastrointestinal function should be treated in conjunction with the proper refeeding management. Severely malnourished or debilitated horses may no longer be able to support themselves and the use of a sling may be necessary to support the weight of the animal (Lewis, 1995). Especially on the first day, priority should be given to rehydration either by allowing the horse to drink or via nasogastric intubation or intravenous administration. Once the horse has regained a healthy hydration level, free-choice water may be offered.
A localized defect that results from the sloughing of necrotic inflammatory tissue from the surface of an organ c primary hiv infection symptoms rash buy minipress without prescription. A 25-year-old female presents with a history of losing four pregnancies in the past 5 years antiviral properties 2mg minipress with mastercard. She also has a history of recurrent pains in her legs secondary to recurrent thrombosis hiv infection clinical stages best order minipress. Evaluation of a pedigree for a certain abnormality reveals the following information: there are skipped generations with male-to-male transmission; females are affected at the same rate as are males; and the disease is produced in the homozygous state anti viral bronchitis minipress 2mg low price, while heterozygous individuals are carriers. You obtain a detailed family history from this patient and produce the associated pedigree (dark circles or squares indicate affected individuals). A 10-month-old baby is being evaluated for visual problems and motor incoordination. Talking to the family of this visually impaired 10-month-old infant, you find that they are Jewish and their family is from the eastern portion of Europe (Ashkenazi Jews). Based on this specific family history, which one of the following enzymes is most likely to be deficient in this infantfi A 4-year-old male with mental retardation, self-mutilation, and hyperuricemia is likely to have a deficiency of an enzyme involved in the a. A young boy is being evaluated for developmental delay, mild autism, and mental retardation. Physical examination reveals the boy to have large, everted ears and a long face with a large mandible. An 8-month-old male infant is admitted to the hospital because of a bacterial respiratory infection. The infant responds to appropriate antibiotic therapy, but is readmitted several weeks later because of severe otitis media. Over the next several months, the infant is admitted to the hospital multiple times for recurrent bacterial infections. During a routine physical examination, a 45-year-old male is found to have microscopic hematuria. This mass is resected and reveals a tumor composed of a uniform population of cells with clear cytoplasm. Based on all of these findings, which of the following best characterizes this tumorfi Also assume that renal tumors composed of cells with clear cytoplasm that are larger than 2. A 35-year-old male living in a southern region of Africa presents with increasing abdominal pain and jaundice. He has worked as a farmer for many years, and sometimes his grain has become moldy. Physical examination reveals a large mass involving the right side of his liver, and a biopsy specimen from this mass confirms the diagnosis of liver cancer (hepatocellular carcinoma). A biopsy of this mass is diagnosed as a moderately differentiated squamous cell carcinoma. A 22-year-old female presents with the sudden onset of a high fever, a diffuse erythematous skin rash, and shock. Several days after exploring a cave in eastern Kentucky, a 39-year-old female develops shortness of breath and a low-grade fever. Chest x-rays reveal several irregular areas in both upper lung fields along with enlarged hilar and mediastinal lymph nodes. The use of broad-spectrum antibiotics can produce a bleeding diathesis characterized by hematomas, hematuria, melena, and bleeding from the gums by decreasing the normal gut flora and inducing a deficiency of a. Which one of the listed changes will result from decreased function of this membrane ion pumpfi Decreased sodium ions inside Decreased potassium ions outside the cell the cell b. Decreased sodium ions inside Increased potassium ions outside the cell the cell c. Increased sodium ions inside Increased potassium ions outside the cell the cell d. Increased sodium ions outside Increased potassium ions inside the cell the cell. Increased sodium ions outside Decreased potassium ions inside the cell the cell 22. A 54-year-old male develops a thrombus in his left anterior descending coronary artery. The thrombus is destroyed by the infusion of streptokinase, which is a plasminogen activator, and the injured area is reperfused. Which one of the following microscopic associations concerning hepatocytes is correctfi A 48-year-old male who has a long history of excessive drinking presents with signs of alcoholic hepatitis. Histologic sections from this ovarian mass reveal a papillary tumor with multiple, scattered small, round, laminated calcifications. A 49-year-old man develops an acute myocardial infarction because of the sudden occlusion of the left anterior descending coronary artery. The degradation of intracellular organelles through the process in which autosomes combine with primary lysosomes to form autophagolysosomes is called a. Histologic sections of an enlarged tonsil from a 9-year-old female reveal an increased number of reactive follicles containing germinal centers with proliferating B lymphocytes. A patient presents with a large wound to his right forearm that is the result of a chain saw accident. You treat his wound appropriately and follow him in your surgery clinic at routine intervals. Initially his wound is filled with granulation tissue, which is composed of proliferating fibroblasts and proliferating new blood vessels (angiogenesis). A growth factor that is capable of inducing all the steps necessary for angiogenesis is a. During the early stages of the inflammatory response, histamineinduced increased vascular permeability is most likely to occur in a. A 3-year-old boy presents with recurrent bacterial and fungal infections primarily involving his skin and respiratory tract. Examination of a peripheral blood smear reveals large granules within neutrophils, lymphocytes, and monocytes. Further workup reveals ineffective bactericidal capabilities of neutrophils due to defective fusion of phagosomes with lysosomes. Which of the following laboratory findings is most suggestive of activation of the alternate complement system rather than the classic complement systemfi A 19-year-old female is being evaluated for recurrent facial edema, especially around her lips. She also has recurrent bouts of intense abdominal pain and cramps, sometimes associated with vomiting.
Psychosocial impact of the bionic monitoring for the management of insulinglucosemonitoringandfiashglucosemonitoring pancreas during summer camp natural factors antiviral buy minipress online from canada. J Diabetes Sci Tech14 November 2018 with diabetes: a randomized controlled trial hiv process of infection order minipress us. Aerts O latent hiv infection symptoms order genuine minipress line, Herman A hiv infection rate morocco purchase minipress with american express, Bruze M, Goossens A, glucose monitoring test systems for prescription 98. Accessed A new consensus error grid to evaluate the clinusability of a novel glucose monitoring system in 22 October 2018 ical significance of inaccuracies in the measureChinese adults with diabetes. Small studies have demonstrated that in patients with type 2 diabetes and obesity, more extreme dietary energy restriction with very low-calorie diets can reduce A1C to ,6. The goal of this section is to provide evidence-based recommendations for weight-loss therapy, including diet, behavioral, pharmacologic, and surgical interventions, for obesity management as treatment for hyperglycemia in type 2 diabetes. Obesity management for the treatment of type 2 diabetes: Standards of Medical Care in Recommendation Diabetesd2019. S82 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 42, Supplement 1, January 2019 record. Providers feasibility of achieving and maintaining (weekly or more frequently) should advise patients who are overlong-term weight loss in patients with and/or other self-monitoring weight or obese that, in general, higher type 2 diabetes. Participants short-term (3-month) interventherapy, pharmacologic therapy, and randomly assigned to the intensive lifetions that use very low-calorie metabolic surgery (Table 8. B physical and sexual function, and ioral therapy designed to achieve health-related quality of life (28). A tions in blood pressure, improvements events with intensive lifestyle interven8. Medications associated with gressive; more intensive weight-loss weight-loss maintenance program is weight gain include antipsychotics. Potential benefits Intensive behavioral lifestyle intervenin patients at risk (41). Phentermine is must be weighed against the potions should include $16 sessions in indicated as short-term (#12 weeks) tential risks of the medications. Providers should be knowledgequently) and/or other self-monitoring like peptide 1 receptor agonists, and able about the product label and should strategies such as tracking intake, amylin mimetics. Unlike ful weight loss against the potential risks a reduced-calorie diet; and participation in these agents, insulin secretagogues, thiaof the medication for each patient. A recent meta-analysis of 227 randomtential must be counseled regarding the When provided by trained practiized controlled trials of antihyperglyceuseofreliablemethodsofcontraception. S84 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 42, Supplement 1, January 2019 care. Given the high cost, extremely limited insurance coverage, and paucity of data in people with diabetes at this time, these are not considered to be the standard of care for obesity management in people with type 2 diabetes. Mortality rates with them adjust to medical and data suggest an erosion of diabetes remetabolic operations are typically 0. Major complications including partial gastrectomies and ease-free period among such individuals rates. The exact prevalence of sympvascular complications of diabetes, caradditional health benefits in randomized tomatic hypoglycemia is unknown. Patients studies attempting to match surgical microvascular disease (74), and enhancewho undergo metabolic surgery may and nonsurgical subjects suggest that ments in quality of life (66,71,75). Additional potential risks On the basis of this mounting eviof patients with type 1 diabetes and of metabolic surgery that have been dence, several organizations and governmorbid obesity, establishing the role of described include worsening or newment agencies have recommended metabolic surgery in such patients will onset depression and/or anxiety, need expanding the indications for metabolic require larger and longer studies (76). Surgery should be postoperative follow-up ranging from improved significantly over the past postponed in patients with alcohol or care. The importance of weight mental health conditions until these Randomized placebo-controlled clinical trial of management in type 2 diabetes mellitus. Very low-calorie diet and 6 months of Comparison of weight loss among named diet patients. Int J Obes Relat Metab Force on Practice Guidelines and the Obesity an updated systematic review.
Ticagrelor has several known hiv infection symptomatic stage purchase discount minipress on-line, usually self-limited antiviral wipes order minipress 2 mg mastercard, side effects antiviral essential oils buy minipress amex, which likely arise 3 from its interference with adenosine uptake (options A through C are incorrect) hiv infection rates by age minipress 1 mg online. However, major bleeding events were reduced by 48% with fondaparinux, and mortality trended lower in the fondaparinux group at 30 days (2. Major bleeding risk was particularly high among patients treated with weight-adjusted enoxaparin who had a creatinine clearance below 30 mL/min (9. Third, the long half-life of fondaparinux may create logistical problems in centers that perform early cardiac catheterization. Finally, among patients undergoing cardiac catheterization, an excess in catheter-related thrombotic complications was observed, a finding that has also been observed in other trials using fondaparinux (option C is incorrect). For many, conservative management may be quite effective, particularly if flow is present in the coronary artery at the time of diagnostic coronary angiography; spontaneous healing of the dissection may be seen at the time of follow-up angiography. It is thought that coronary spasm is a result of abnormalities in endothelial function and nitric oxide activity at sites of coronary spasm. Patients with variant angina are often difficult to treat because attacks are unpredictable and often occur without an obvious precipitating factor. For example, long-acting nifedipine (90 mg/d), diltiazem (360 mg/d), verapamil (480 mg/d), and amlodipine (20 mg/d) are commonly used. Statin therapy is indicated (option C is incorrect), given beneficial effects on endothelial function and the common presence of atherosclerosis underlying focal spasm. Management of patients with stress cardiomyopathy is typically supportive; patients most often recover rapidly after presentation, though shock at presentation is not uncommon. All of the following electrocardiographic findings can potentially support the diagnosis of a myocardial infarction in the presence of a known old left bundle branch block except: A. A 55-year-old man with a history of coronary artery disease is brought to the emergency room with chest pain by his wife. Patients treated successfully with fibrinolysis do not require follow-up angiography 40-3. Fibrinolysis should generally be considered up to 6 hours following symptoms onset E. Failure of T waves to invert within 48 hours following the administration of fibrinolysis E. Which of the following is true about the epidemiology of cardiogenic shock complicating myocardial infarctionfi No trials have successfully demonstrated improvement in outcomes in patients with cardiogenic shock D. A 52-year-old man presents with myocardial infarction and undergoes placement of a pulmonary artery catheter, which 2 demonstrated a cardiac index of 2. Nitroglycerine is beneficial to relieve symptoms of chest pain and to decrease endogenous catecholamine release B. Atrioventricular synchrony should be achieved, and bradycardia should be corrected C. Inotropic support should be used for hemodynamic instability not responsive to volume challenge 40-10. When papillary muscle rupture occurs, the posteromedial papillary muscle is more often involved than the anterolateral muscle D. Additionally, patients with contraindications to fibrinolysis, including ischemic stroke within 3 months (option D is incorrect), should be transferred, as well as those with cardiogenic shock (option B is incorrect). Fibrinolysis should be considered up to 12 hours following symptoms onset (option D is incorrect). While the R wave may initially increase in height but then soon decrease, this finding is not specific for left main coronary artery disease (option C is incorrect). Failure of the T wave to invert within 24 to 48 hours suggests early postinfarction regional pericarditis (option D is incorrect). There was a trend toward increased in-hospital survival in the midto late 1990s, which correlated with the increased application of reperfusion technologies. In most recent studies, the mortality from cardiogenic shock remains approximately 50% (option D is incorrect). The basic goals of this approach include adjustment of the intravascular volume status to bring the pulmonary artery capillary wedge pressure from 18 to 20 mm Hg and optimization of cardiac output with inotropic and/or vasodilating agents. Severely hypotensive patients can be temporarily aided by intra-aortic balloon pumping or possibly by a ventricular assist device. However, the benefits from these mechanical treatments are often temporary, and there may be a significant risk of complications. In some patients, this alone is sufficient to improve cardiac output and systemic pressure. Patients requiring temporary pacing for heart block may also benefit from arteriovenous sequential pacing rather than lone ventricular pacing. Rupture may be complete or partial, and it usually involves the posteromedial papillary muscle because its blood supply is derived only from the posterior descending artery, whereas the anterolateral papillary muscle has a dual blood supply from both the left anterior descending and the circumflex coronary arteries. Most patients have relatively small areas of infarction with poor collaterals, and up to half of the patients may have single-vessel disease. The clinical presentation of papillary muscle rupture is the acute onset of pulmonary edema, usually within 2 to 7 days after inferior myocardial infarction (option A is incorrect). The characteristics of the murmur vary; as a result of a rapid increase of pressure in the left atrium, no murmur may be audible (option B is incorrect). Thus a high degree of suspicion, especially in patients with inferior wall infarction, is necessary for diagnosis. Two-dimensional echocardiographic examination demonstrates the partially or completely severed papillary muscle head and a flail segment of the mitral valve (option D is incorrect). The cornerstones of successful therapy are prompt diagnosis and emergency surgery (option E is incorrect). The current approach of emergency surgery accrues an overall operative mortality of 0% to 21%, but this appears to be decreasing, and the late results of this approach can be excellent. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography. A 45-year-old man undergoes coronary stent implantation for stable ischemic heart disease. Higher doses of aspirin could be more effective at preventing ischemic events, but at the expense of a higher risk of bleeding C. Clinical trials support a higher dose (ie, 300 to 325 mg daily) of aspirin in patients with ischemic heart disease D. When used with newer-generation oral P2Y12 receptor inhibitors (prasugrel and ticagrelor), no preference to aspirin dosing is given E. When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival C. Fibrin-specific fibrinolytic agents (tenecteplase, reteplase, alteplase) are preferred over streptokinase if available 41-6. Aspirin absorption in the upper gastrointestinal tract occurs within 60 minutes C. Enteric coating of aspirin has negligible effects on absorption pharmacokinetics D. Recent brain or spinal surgery or recent head trauma with fracture or brain injury 41-8. Finally, the introduction into clinical practice of newer-generation oral P2Y12 receptor inhibitors (prasugrel and ticagrelor) that are characterized by greater potency than clopidogrel and are used in combination with aspirin has also led to questions about the optimal dose of aspirin in these patients. Conversely, prostacyclin plays a role in regulating renal blood flow, and it functions as a platelet inhibitor and a vasodilator. The period of withdrawal should be at least 5 days in patients receiving clopidogrel. After loading dose administration, a maintenance dose of 75 mg daily should be initiated. No dosage adjustment is necessary for patients with renal impairment, including patients with end-stage renal disease (option D is incorrect). However, their broad use has been limited because they are associated with an increased risk of bleeding complications.
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