*Important Notice : Guided tours to the Parliament Chamber are suspended until further notice as a preventative measure in response to Covid-19


Kelly Bookman, MD

  • Assistant Professor
  • Division of Emergency Medicine
  • University of Colorado Denver School of Medicine
  • Aurora, Colorado

They can also sometimes be found in specialized structures of the gut arthritis in dogs back legs symptoms buy piroxicam canada, although the majority of gut bacteria are free living (Dillon and Dillon 2004) arthritis in neck natural remedies order generic piroxicam canada. Endosymbionts housed in specific organs or organelles are frequently vertically transmitted from mother to offspring arthritis medication south africa order 20 mg piroxicam with amex, and hence share part of their evolutionary history with their hosts arthritis management dogs buy piroxicam with mastercard. This association can lead to cospeciation between hosts and their mutualistic endosymbionts (Moran et al arthritis vs gout generic piroxicam 20mg amex. Some organisms become entirely reliant on their endosymbionts for successful reproduction. Females of the parasitic wasp Asobara tabida are unable to develop ovaries in the absence of their obligate endosymbiotic Wolbachia bacteria (Dedeine et al. For example, some populations of the butterfly Hypolimnas bolina harbour male-killing endosymbionts (Wolbachia) that cause population-level female-biased sex ratios. Variation in male killer prevalence in turn affects female mating behaviour, with females evolving to be less choosy, and male ejaculate size is negatively correlated with the frequency of male killers (Charlat et al. In high-frequency populations, females run the risk of not obtaining sufficient sperm to fertilize all their eggs due to a shortage of males. This sperm shortage is exacerbated by males in these populations suffering ejaculate depletion due to high mating rate, further promoting increased female mating to obtain more sperm (Charlat et al. In African Acraea encedon butterflies, in populations harbouring male-killing endosymbionts, there is even evidence of sex role reversal with females adopting lekking behaviour to advertise their presence to the rare males and thereby increase their mating success (Jiggins et al. In contrast, in populations without male killers, lekking is only performed by males, illustrating the impact of sex ratio distorters in indirectly shaping female mating behaviour. Similarly, sex ratio distorters in flies promote female mating strategies that affect male ejaculate evolution. Some populations of Drosophila pseudoobscura flies harbour a selfish gene (an X-linked meiotic driving chromosome) that kills Y-linked sperm (because they do not pass on the selfish gene) resulting in population-level, female-biased sex ratios (Price et al. Male flies that carry the sperm killer suffer reduced paternity in sperm competition due to low sperm number (Price et al. This in turn favours multiple mating by females as a strategy that effectively biases paternity against sex ratio distorting males. Experiments have shown that females in populations that are at risk of sex ratio distorting males rapidly evolve increased remating frequency to promote sperm competition, demonstrating the potency of sex ratio distorters to alter female mating behaviour (Price et al. As a consequence of increased female remating, male ejaculates evolve in response to the higher risk of sperm competition in these populations (Price et al. This male-female coevolution occurs even when the sex ratio distorter is present at low frequency (5%; Price et al. They achieve this through a variety of sophisticated manipulations by targeting neurological pathways, including neural peptides and neurotransmitters. This is also the case for gut bacteria, and there is growing evidence that gut microbiota can communicate directly with the host nervous system (Cryan and Dinan 2012). Their impacts on behaviour are well documented in vertebrates where specific bacterial neurotransmitters can affect anxiety levels (Forsythe and Kunze 2013), and influence behaviours ranging from cognitive performance to sleep (Cryan and Clark 2016). In insects and arthropods, the brain includes the antennal lobes, that receive input from the olfactory sensory neurons, and mushroom bodies, that play a central role in sensory learning and memory, and microbes have been identified that specifically target these brain regions (Temple and Richard 2015; Strunov et al. In vertebrates, viruses such as rabies, herpes, and measles enter neurons through cell surface receptors, and once inside the neuron, use synapses to spread from cell to cell (Mothes et al. Similarly, the endosymbiont Wolbachia has been recorded in the central nervous system of flies, butterflies, mosquitoes, springtails, and terrestrial isopod hosts (Strunov et al. Gut microbiota can also directly affect the development and function of the nervous system by influencing neurogenesis, neurotransmitter signalling and neurodevelopment and thereby also influence the behaviour of animals (Diaz Heijtz et al. There is even evidence that the host can make use of their endosymbionts to reduce the risk of additional infection. Fungus-growing ants employ a specific behaviour whereby they use antibiotics produced by actinomycetous bacteria housed in specialized structures (infrabuccal pockets) to kill spores of a virulent parasite (Escovopsis) attacking their fungal gardens (Little et al. Many insects, nematodes, and arachnids harbour maternally transmitted endosymbionts, with more than >50% of all insects infected with Wolbachia (Hilgenboecker et al. However, since endosymbionts can only be passed on via females to eggs, the interest of females and the endosymbiont are likely to align over time. Interestingly, this spread in frequency has been accompanied by a shift from parasitic to mutualistic associations with the host. A variety of mutualistic endosymbiotic microbes aid their hosts by providing nutrients or defence against pathogens. Bumblebees and honeybees harbour distinct bacterial communities in their guts that are not shared with related solitary bee species. These microbiota protect bee hosts against a natural trypanosomatid gut parasite, and hence provide an additional benefit of group living to these social insects (Koch and Schmid-Hempel 2011). It has been suggested that one overlooked benefit of group living and sociality is that this serves to facilitate the transmission of beneficial microbes (Lombardo 2008). Microbes that manipulate their hosts to act altruistically in certain situations may be favoured by selection and may therefore also play a role in the evolution of co-operation. Co-operation could favour the microbes as they can be transferred horizontally between hosts during social interactions. Altruistic behaviour could also be favoured by bacteria that are vertically transmitted between mother and offspring, as helping behaviour will increase host survival and reproduction and hence transmission of the microbes (Lewin-Epstein et al. The flip side of social interactions is that they can of course potentially lead to increased risk of disease transmission, and both processes (transmission of pathogenic and protective microbes) are likely to have shaped social behaviour of hosts. Micro-organisms were the first life forms on our planet and therefore have a long history of associating with later emerging multicellular life forms. So it comes as no surprise that microbes have shaped host evolution, and may directly influence the nervous system of their hosts to alter their behaviour (Archie and Tung 2015; Eisthen and Theis 2015). Odour-based signals are 162 8 the Effect of Non-Self Genes on the Behaviour of Hosts also key components in most animal communication. Since these are traits known to shape mate preferences, odour also plays a large role in mate choice. Wolbachia infections are associated with changes in responses to olfactory cues (Peng and Wang 2009; Rohrscheib et al. In Drosophila simulans flies, the wRi strain of Wolbachia increases the responsiveness of flies to food cues, whereas the Wolbachia strains wMel and wMelPop in D. There is a growing realization that microbes can also regulate behaviours between individuals in a social context, and that microbe-based chemical communication commonly occurs between species, as discussed below. Furthermore, these interactions are not restricted to communication between animals. Plants also release volatiles when being consumed by herbivorous insects that in turn can attract parasitoid wasps that attack the herbivores and thereby provide some protection to the plant (Moraes et al. The bacterial pathogen Candidatus modifies the odours released by its citrus tree plant host to attract its vector, the psyllid Diaphorina citri, and thereby facilitate its own proliferation (Martini et al. In humans, the bacterial composition of armpit odours functions as a reliable individual recognition cue as it shows stability over time and conveys distinctive odour profiles (Penn et al. For instance, humans are able to match the scent of monozygotic twins even if they do not live together (Roberts et al. Similar findings have also been shown in a range of mammals where gut microbiota shape the odour cues used in kin recognition (Archie and Tung 2015). There is therefore scope for a complex interaction between diet, the gut microbiota, and resulting individual odours (also see below). In birds, feather-degrading bacteria can affect plumage coloration and therefore influence mate choice. This has been shown in house finches where females prefer redder males that have fewer feather-degrading bacteria than dull males (Shawkey et al. Currently, the precise mechanisms underlying these different results are unclear, but it is possible the former is a case of parasite-mediated sexual selection, with birds of higher quality having lower bacterial loads. In the latter case, brighter males may spend less time preening their feathers and socially dominant males may pay a health cost for dominance, and/or higher bacterial loads are in fact beneficial, but bright birds are better at acquiring these bacteria than their dull male counterparts (Archie and Theis 2011). Internal gut microbiota can also affect odours of animals that directly regulate their sexual behaviours (Sharon et al. Evidence that endosymbionts such as Wolbachia are present in the central nervous system of certain insects and terrestrial isopod hosts suggests that they could act to affect mate preferences (Strunov et al. Intriguingly, in mate choice assays, female mate preferences are dependent on their own Wolbachia variant, with females preferring to mate with males that carry the same compatible Wolbachia strain as themselves. This mate preference disappears after partial depletion of Wolbachia (Miller et al. It is therefore possible that the restriction of Wolbachia to brain areas involved in processing cues relating to sexual behaviour may have evolved to reduce any fitness costs of unrestricted Wolbachia presence in the brain (Strunov et al. The difference in localization of Wolbachia in brain tissue between fly species has been proposed to be the outcome of the age of the association and therefore the potential for coevolution between the host and the endosymbiont. The Wolbachia strain wPau is considered an obligate mutualist that has had a long association with its host and clearing of Wolbachia in D. In other Drosophila species, findings are mixed for the role of Wolbachia-mediated mate preferences. Removal of species-specific Wolbachia infection removes assortative mating preferences. Mating preferences in combination between untreated and treated heterogametic pairs. Grey bars indicate untreated controls; black bars indicate assays with antibiotic-treated flies. However, it is also possible that the different findings could be due to the presence of other agents such as viruses that may also influence mate preferences (Ritschof et al. In the terrestrial isopod Armadillidium vulgare, feminizing Wolbachia influences mate attraction by altering the cuticular compounds and therefore female odours. Males prefer Wolbachia-free females that have different odour profiles, and this preference will result in increased fitness through the production of both sons and daughters (Richard 2017). Sex-specific effects seem likely for maternally inherited endosymbionts that cannot be passed on through males. In mice populations that carry an autosomal segregation distorter (the t-complex), heterozygous females discriminate against heterozygous males using odour cues (Lenington 1991). Females that preferentially mate with males with large eye-stalks enjoy the production of both sons and daughters, and sons in turn enjoy a higher mating success as they will also have large eye-stalks and a mating advantage (Wilkinson et al. Females are just as likely to mate with males whether they carry the sex ratio distorter or not (Price et al. In general, the modest evidence of mate preferences based on selfish genetic elements (Price and Wedell 2008; Wedell 2013) may be due to a lack of linkage between the selfish gene and the female preference gene due to recombination (Nicholls and Butlin 1998). When a virus is transmitted sexually, the host may exhibit increased sexual activity, which can increase virus transmission (Knell and Webberley 2004). Female Helicoverpa zea moths infected with a parasitic virus (Hz-2V) have increased pheromone production and calling frequencies. Virus-infected females are therefore more attractive to males than uninfected females, resulting in increased mating activity and higher reproductive success. This seems to be due to virus-infected females producing six- to sevenfold more pheromone than uninfected females (Burand et al. The Hz-2V virus is both vertically transmitted by infected females to eggs, and horizontally transmitted during mating (Hamm et al. Similarly, Wolbachia infection appears to be associated with differences in male mating activity in flies. This could be a strategy whereby males try to increase their reproductive success by increasing the likelihood of mating with infected and reproductively compatible females, since crosses with uninfected females result in poor offspring production caused by Wolbachia-induced reproductive incompatibility. Mating at higher rates also restores male reproductive compatibility with uninfected females by depleting his Wolbachia-modified sperm (Awrahman et al. This reduction appears to be largely due to reduced effectiveness in courting females, as a higher proportion of initiated courtship attempts are aborted by resistant males. For example, one particular strain of Wolbachia (wMelPop) influences male aggression levels in D. Aggression is critically important in mate competition, and is hence a key fitness-related male trait. Aggressive behaviour in many insect species is influenced by the neurotransmitter octopamine (Hoyer et al. Transcriptional analysis of the octopamine biosynthesis pathway in male flies revealed that two essential genes (tyrosine decarboxylase and tyramine hydroxylase) were significantly downregulated in Wolbachia-infected flies. Quantitative chemical analysis also showed that total octopamine levels were significantly reduced in adult heads (Rohrscheib et al. It is not clear whether low levels of octopamine are caused by Wolbachia directly modifying neural pathways and thereby influencing transcription and/or high infection densities of wMelPop resulting in consumption of host metabolites important to neurotransmitter production, or are simply due to brain damage. Microbiota can similarly affect level of aggression, and can even have sex-specific effects. In Siberian hamsters (Phodopus sungorus), a broad-spectrum antibiotic was used to explore the consequences of an altered gut flora on subsequent social behaviour. In males, antibiotic treatment reduced the level of aggression, but this effect was transient and aggression returned to normal levels following recovery. In females, on the other hand, antibiotic treatment rapidly reduced aggression levels, and these did not return to normal levels following recovery (Sylvia et al. The different effect on aggression levels observed in males treated with antibiotics may be because males are under strong selection to maintain aggression via alternative mechanisms since this is a trait that is associated with high reproductive fitness in many rodent species. In social insects, a link has also been shown between gut microbiota and aggressiveness, with changes in both inter- and intraspecific aggression levels after antibiotic treatment (Wei et al. In termites, changes in aggression following alterations to the bacterial communities with antibiotic treatment appear to be mediated by disruption of faecal odour cues that are used in nest-mate recognition (Matsuura 2001). The impact of the gut microbiota on aggression levels can also have implications for the establishment success of invasives.

purchase 20 mg piroxicam mastercard

Proinflammatory and anti-inflammatory cytokine responses in preterm infants with systemic infections arthritis diet the best foods to eat generic piroxicam 20mg with mastercard. Neonatal infection and long-term neurodevelopmental outcome in the preterm infant i have arthritis in my fingers what can i do discount piroxicam 20 mg mastercard. Neurodevelopmental and growth impairment among extremely low-birth weight infants with neonatal infection arthritis diet citrus buy piroxicam 20 mg without a prescription. Adverse neurodevelopment in preterm infants with postnatal sepsis or necrotizing enterocolitis is mediated by white matter abnormalities on magnetic resonance imaging at term zyflamend arthritis pain buy 20 mg piroxicam free shipping. Recurrent postnatal infections are associated with progressive white matter injury in premature infants arthritis pain when pregnant order piroxicam overnight delivery. Human milk intake and retinopathy of prematurity in extremely low birth weight infants. Gangliosides protect bowel in an infant model of necrotizing enterocolitis by suppressing proinflammatory signals. Innate lymphoid cells: emerging insights in development, lineage relationships, and function. Neurodevelopment of extremely preterm infants who had necrotizing enterocolitis with or without late bacteremia. As old and intuitive as this concept may be, it has re-entered the consciousness of the research community only in the last 20 years. As a result, the overall interest in the specific experiences and mechanisms through which different perinatal nutritional environments lead to adult-onset diseases has grown exponentially. This interest is an important research priority because it is an avenue for preventing adult diseases, such as diabetes, obesity, and hypertension, before they exact a direct toll. The continuum of early nutrition experienced by humans varies greatly within a single population, let alone between different populations. As a result, the majority of epidemiologic studies interested in understanding the adult consequences of fetal and neonatal nutrition have used poor growth, both in utero and in the early postnatal period, as a marker of poor nutrition. Therefore an important assumption of this chapter is that poor nutrition leads to poor growth in both the fetus and the neonate. Infants included in this group may be small for multiple reasons, including normal genetic variation. Generally, these studies include maternal and fetal parameters that contribute to poor growth, such as maternal uteroplacental insufficiency. Despite these limitations, the epidemiology in this field has been vitally important and often elegant, which is certainly true of the three cohorts (and their respective studies) that have set the standard for understanding the adult consequences of neonatal and fetal nutrition. These cohorts involve the (1) Dutch famine of 1944 to 173 174 Gastroenterology and Nutrition Table 11. This famine occurred as a result of German reprisal for a general railway strike intended to disrupt the transport of German reinforcements against Allied liberation movements. Daily rations in Amsterdam dropped from 1800 kcal/day in December 1943 to 400 to 800 kcal/day in April 1945. Although a goal was set for children under age 1 year and for pregnant or lactating women to receive supplemental rations, this was not possible at the height of the famine. The effects of the famine on the Dutch population have been examined via multiple sources, including population-based cohorts, military induction records, psychiatric registries, and self-reports. One of the more comprehensive studies is the Dutch famine birth cohort study, through which the investigators interviewed 912 individuals who were born at term between November 1, 1943, and February 28, 1947, and assessed socioeconomic factors, lifestyles, and medical histories. Although not quite statistically significant, the adults with coronary heart disease were also more likely to have had lower birth weights and smaller head circumferences. Babies exposed to the famine in late gestation were also more likely to exhibit impaired glucose tolerance compared with those who had not experienced the famine conditions in utero. Group-specific mortality at age 50 years for early, mid-, or late gestation exposure was 11. As early Adult Consequences of Neonatal and Fetal Nutrition: Mechanisms 175 as 1986, Barker and Osmond noted, in an article in the Lancet, a geographic association between ischemic heart disease in 1968 to 1978 and infant mortality in 1921 to 1925. An initial focus of these studies was a cohort of 5654 men born between 1911 and 1930 in Hertfordshire, England. A subset of these men was further used to evaluate the relationship between insulin sensitivity and birth weight. Specifically, 468 men born, raised, and living in east Hertfordshire were studied after ingesting a 75-g glucose drink. Furthermore, the percentage of men with impaired insulin sensitivity decreased as weight increased at age 1 year; this progression was statistically significant and independent of the adult body mass. This concept-that reduced growth in early life leads to impaired glucose tolerance-has impacted the way numerous clinicians and investigators now approach perinatal metabolism and nutrition. The study has continued through follow-up questionnaires every 2 years, thus eliciting updated histories and medical information. No significant effects on relative risk were noted after adjustment for prematurity, multiple births, maternal age at birth, participant breastfeeding, ethnicity, parental occupation at age 16 years, paternal diabetes, participant height, parity, cigarette smoking, and physical activity. Nonfatal myocardial infarctions were included as an endpoint of the study if the criteria of the World Health Organization were met. Nonfatal strokes were included as another endpoint if the criteria of the national survey of stroke were met. For every 454-g increase in birth weight, a 5% decrease in the risk of nonfatal myocardial infarction was noted, as was an 11% decrease in the risk of nonfatal stroke. They have provided an impetus to further studies that identify possible physiologic and molecular mechanisms, which may lead to either in utero interventions or postnatal therapies to moderate the impending risks. The following section will focus on recently identified important biologic targets. Developmental Biology of the Adult Consequences of Neonatal and Fetal Nutrition A this section is presented in two parts. The first part discusses recent insights into how fetal growth restriction affects phenotype in humans, and animal studies used to investigate possible mechanisms. The discussion is not meant to be all inclusive but focuses on some of the most recent and thought-provoking observations. The second part discusses recent insights into how growth restriction in the premature infant potentially leads to later morbidities and how dietary interventions may either contribute to or moderate these effects. Fetus/Intrauterine Growth Restriction Multiple studies from different regions of the world containing racially distinct cohorts have associated fetal growth restriction with adult morbidities, as previously discussed. One of the more recent trends is the realization that the lasting effects of fetal growth restriction are evident in both early life and adulthood. These findings pertain to issues involving glucose homeostasis, lipid biology, and hypertension; however, an important central theme to this literature, as well as the literature focusing on adult phenotype, is that cohorts differ, whether as a result of fetal growth restriction or postnatal consequences. Consequently, the findings of these studies differ slightly, which has led to the conundrum that multiple mechanisms may be involved. At 48 hours of life, glucose and insulin levels were measured in these infants, and at 1 and 3 years of life an intravenous glucose tolerance test was administered after an overnight fast. A calculation of insulin resistance was determined by using the homeostasis model. Interestingly, lipid oxidation was increased nearly twofold, although not significantly based on variation. The resulting molecular alterations cause changes in the structure and function of various organs. Among the most important functions of leptin is the regulation of hypothalamic centers that determine, at least in part, whole-body energy expenditure and fat mass. As a result, humans and rodents lacking either leptin or the leptin receptor develop severe obesity and hyperphagia. The failure of increased levels of leptin in regulating weight loss suggests a potential state of leptin resistance in many cases of obesity. In utero ultrasonography identified fetal growth restriction by an abdominal circumference 178 Gastroenterology and Nutrition A below the 10th percentile, which was confirmed at birth if the birth weight was similarly below the 10th percentile. No significant differences were noted between male and female infants in either group. As expected, umbilical cord serum leptin levels correlated with neonatal birth weight. In most animal studies, the animals develop components of the morbidities afflicting growth-restricted humans, including insulin resistance, dyslipidemia, and hypertension. In adulthood, the pups that suffered intrauterine low-protein undernutrition developed diabetes, hyperinsulinemia, and tissue insulin resistance in adulthood. The low-protein diet increased maternal serum leptin levels at day 17 of gestation (term 21 days) and decreased maternal serum leptin levels at term. No significant differences in perinatal serum leptin levels were noted between the pups suffering the low-protein maternal diet and the control pups. To begin the process of defining leptin homeostasis in the postnatal growthrestricted rat, Krechowec et al. Regardless, such studies suggest that leptin biology plays a significant role in the effects of early nutrition on the adult phenotype. Future studies will delve further into "chicken and egg" issues to more clearly differentiate the relative importance of leptin and other molecules produced by adipocytes. Adiponectin Adiponectin is also produced by adipocytes, and its receptors adiponectin receptor-1 and adiponectin receptor-2 are found in skeletal muscle and liver, respectively. In humans, serum levels of adiponectin correlate directly with insulin sensitivity, but not with serum lipid profiles or obesity. In growth-restricted humans, the impact of the early malnutrition appears to vary with age. In contrast to leptin, adiponectin levels were unrelated to insulin levels, and multiple regression analysis found that adiponectin related only to postnatal age. If postnatal age was excluded from the analysis, then determinants of adiponectin levels included lower postnatal body weight (P < 0. Although the findings on adiponectin levels are not as immediately satisfying as the leptin data in this study, those findings are thought provoking because of the many gender-specific effects of early growth restriction that have been noted. Adult Consequences of Neonatal and Fetal Nutrition: Mechanisms 179 In contrast to the study by Iniguez et al. In general, early malnutrition and subsequent growth restriction appear to affect serum adiponectin levels. Little has been done at this point using specific rodent models to analyze adiponectin biology within the context of growth restriction. As in the case of leptin, we are still at the point of trying to figure out "chicken and egg" type issues. Whether this is a marker for, or cause of, impending morbidity remains to be seen. The key question will be which comes first, the poor growth or the altered homeostasis, and the likely answer is that both are possible along the spectrum of the human environmental continuum. In adulthood, the relationship becomes even more complicated, and again, genetic and environmental diversities enter the picture, as does the impact of puberty. Early life events have been shown to affect hippocampal neurogenesis and increase age-related learning impairments in the rat. These authors exposed pregnant dams from day 14 of pregnancy until term (approximately 21. Females whose dams had been stressed during pregnancy exhibited learning impairment in the water maze task. One of the debates in the field is whether the adult consequences of early life events are a nonspecific response to early injury or is, in some way, teleologically protective, an evolutionary response, if you will. There is a possibility that the benefits of early programming have not been appreciated, but the cost is evident, particularly as humans, as a species, have become more sedentary. Investigators have used maternal malnutrition in the rat or bilateral uterine artery ligation of the pregnant rat to define this toll. Interestingly, serum fetal glucose concentrations correlated positively with liver (P < 0. Interestingly, baseline growth hormone levels were significantly decreased (P < 0. Zinc is one of the most abundant divalent ions in living organisms and performs multiple functions secondary to its unique physiochemical properties. On the basis of the type of malnutrition (marasmus versus kwashiorkor), the presence of diarrhea, and the numbers of days after recruitment, each child was placed in a standardized feeding regimen, which included vitamin supplementation. The diet increased ponderal catch-up growth rapidly, although linear growth was only moderately improved. The authors of this study noted that their inability to demonstrate a clearer effect of zinc in this particular study may be secondary to (1) the lower supplementation providing sufficient zinc or (2) the full nutritional supplementation masking the effects of the higher zinc dosing. On all levels-molecular, endocrinologic, and physiologic- there is a lot of information that has yet to be elicited (Table 11. Multiple mechanisms probably play a role with this grouping of morbidity, so the mechanisms that we have focused on are neither exclusive nor exhaustive. The two mechanisms discussed here, renal morphogenesis and endothelial dysfunction, are based on emerging evidence in both human and animal research. Nephrogenesis increases markedly during the third trimester, and is completed by 34 to 36 weeks, with 60% of the normal complement of nephrons in the human kidney formed during the third trimester. As a result, the kidney is particularly vulnerable to nutritional insults during this period. Histomorphometric analysis was performed by a renal pathologist, who was blinded to the origin of the biopsy.

purchase piroxicam 20mg with visa

Profound changes in the brain occur during this time of development arthritis in feet how to treat discount 20 mg piroxicam with visa, in which high-order cognitive functions such as logical and abstract thinking and executiveplanning capacities rheumatoid arthritis hair loss generic 20 mg piroxicam mastercard, especially in the prefrontal cortex arthritis knuckles piroxicam 20 mg visa, achieve maturation (165) arthritis in fingers and hands pictures purchase piroxicam us. During development arthritis in fingers what to do quality piroxicam 20 mg, frequently used synaptic connections are strengthened and infrequently used connections are attenuated, and at adolescence the weak connections are removed by synaptic pruning of synapses, dendrites, and axons (110, 165). Gray matter of the prefrontal, parietal, and temporal cortex, as demonstrated in imagining studies, undergoes significant attrition through this critical period from late adolescence to early adulthood (165). Disturbances of inhibitory neurons containing the calcium-binding protein parvalbumin have been implicated in initiation of abnormal synaptic pruning processes, and these inhibitory neurons may be damaged by oxidative stress (110, 165). Aberrant pruning compromises the integrity, stability, and fidelity of connectional architecture of excitatory glutamate synapses in the prefrontal cortex in particular that are responsible for reliable and predictable information processing (110, 165). These types of developmental synaptic plasticity abnormalities are hypothesized to be instrumental in the onset of schizophrenia (165). Epigenetic modulations during brain development may initiate pathological processes leading to schizophrenia (4, 31). Abnormalities in microglial functioning are considered important contributors to the pathogenesis of schizophrenia (31), likely related to their essential role in normal dendritic spine pruning and maintenance (110). Synaptic pruning activities of microglia-the main immunocompetent cells in the developing brain (72)-involve immune inflammatory processes (110). Abnormal immune and inflammatory processes in brain development have been demonstrated to contribute risk for schizophrenia, involving multiple immune mediators, including cytokines (72, 110, 156). Maternal infections during pregnancy (reflected in an overrepresentation of births during late winter and spring in individuals who develop schizophrenia) (156) may increase risk for schizophrenia through immunological mechanisms. Other prenatal stressors increasing risk for schizophrenia include gestational and obstetric complications and famines during pregnancy (22, 118, 137, 144). Postnatal environmental stressors found to represent potential epigenetic contributors to risk for schizophrenia include urban residence, immigration, especially among minority groups, childhood trauma and neglect, and cannabis use (110, 117, 118, 165). The biological studies of the brain in schizophrenia reviewed here collectively indicate that the disorder is unlikely to be explained by any lesion in a single structure. Rather, the disorder appears to involve widespread abnormalities in structures and connections throughout the brain supporting many different cognitive, emotional, and behavioral regulatory processes (41, 110, 165). These limitations have precluded clinical applications of biological measures for differential diagnosis (147, 164). Some researchers have observed, however, that longitudinal studies can detect biological differences in brain development trajectories between schizophrenia and bipolar illness that cross-sectional studies alone are inadequate to differentiate (58, 89). Concerted efforts to differentiate psychotic disorders (schizophrenia, schizoaffective disorder, and bipolar psychosis) from one another on biological measures have failed (17, 113, 146). Thus, attempts to map biological data to clinical diagnoses in search of biological validation of the existing diagnostic categorization have not proven feasible. This situation has prompted researchers to try to reorganize diagnostic classification by mapping psychiatric disorders according to biological data in a new framework that is agnostic to existing diagnostic systems (112). This new psychosis research trajectory represents a major departure from phenomenologically based syndromes in a search for purely neurobiological definitions of psychotic illness (113). Findings from these early exploratory studies will require replication, investigation of additional biomarkers, and examination of the findings in longitudinal studies. An accompanying means of detecting biologically defined disorders through clinical examination will be needed before such biologically based categories can be used in psychiatric practice (32). Some researchers have concluded that the boundaries between psychotic disorders have not been established by brain morphology research, and that current progress in neurobiology is not yet compelling enough to justify a transition to a more biologically determined model of classification (34, 63). In retrospect, many patients, if not most, evidence certain prepsychotic personality abnormalities: excessive shyness, social awkwardness, withdrawal from personal relationships, and inability to form close relationships-that is, schizoid personality features. In childhood and adolescence, long before the diagnostic symptoms of schizophrenia are evident, signs of neurodevelopmental problems may be evident among individuals who later develop schizophrenia. These prepsychotic abnormalities may be manifestations of the increased frequency of pregnancy and birth complications in the records of individuals who later developed schizophrenia (4, 22, 110). Prospective studies have provided considerable evidence that individuals at risk for schizophrenia may manifest early abnormalities. Compared to siblings and other controls, they exhibit more neuromotor developmental delays in infancy, delayed speech milestones, lower cognitive and motor performance, difficulties in reading and spelling, problems with sustaining attention, academic difficulties, poor premorbid adjustment and abnormal social interactions, and various traits identified in association with development of schizophrenia in childhood and early adolescence (55, 68, 101, 118, 159). In studies of videotapes made long before the onset of schizophrenia, raters blind to the diagnosis of schizophrenia in the children identified more negative emotional expressions, thought disorder, and negative symptoms in the children destined to develop schizophrenia than in their unaffected siblings (109, 160). Neurocognitive difficulties are thought to constitute core deficits that may manifest early in the course of the illness or even before the onset of symptoms (72, 110, 118, 156). Delusions, hallucinations, and strange behavior usually become apparent in the late teens or 20s. At first, these aberrations may be brief and vague, leaving families uncertain of their significance. Gradually, the symptoms become more obvious and disturbing, usually leading to psychiatric consultation. When a patient is seen for the first time, it may be difficult to predict what the course and prognosis will be. Good-prognosis cases generally begin more abruptly than poor-prognosis cases, without a history of longstanding personality abnormalities (71). Other factors associated with better outcomes include female gender, older age at onset of illness, educational attainment, employment history, better premorbid functioning, positive social support, and association of stressors with the onset of the illness. Factors associated with worse outcomes include insidious onset of illness, prominent negative symptoms, lack of insight, never-married status, and family history of schizophrenia (37, 71, 102, 152). Both greater duration of illness and duration of untreated psychosis have been associated with less favorable outcomes of illness (37, 71, 102, 114, 152, 157). Today, most patients with schizophrenia live independently outside hospitals, although many require extensive support from relatives and from outpatient case management services (110). Even when not hospitalized, many people with this illness lead disturbed lives: They fail to form satisfactory personal relationships, are less likely to marry than their contemporaries, have poor job histories, and seldom achieve positions of responsibility. They may become neighborhood eccentrics or socially isolated residents in urban areas, doing irregular unskilled work or being supported by welfare. Those who lack insight into their illness and who have comorbid substance abuse are particularly vulnerable to homelessness. Schizophrenia is overrepresented in homeless populations by a factor of about 10, yet it is present only in a minority (about 10%) of homeless individuals (48). Historically, the benchmark for determining schizophrenia outcomes has been achievement of remission-defined as substantial symptomatic improvement to levels no longer representing an active diagnosis (52, 152). The advent of modern antipsychotic medications has allowed up to one-half of patients to experience remission of psychotic symptoms. Schizophrenia outcomes have recently been reconceptualized in terms of recovery-defined as re-establishment of functioning in domains of work, school, community, and home (52). Only one in seven patients have been found to achieve complete recovery as defined by normalization of social and vocational functioning and symptom remission lasting at least 2 years (52). The potential for recovery as an achievable goal for a substantial minority of patients (152), however, can provide a source of hope for patients undergoing treatment (52). More than one-half of patients have a chronic course of illness, and the majority of the remainder have an episodic-remitting course (58). Relapse is especially frequent in patients who discontinue their antipsychotic medication, and medication discontinuation is the biggest risk factor for relapse of schizophrenia (44). It has been hypothesized that relapse exerts neurotoxic effects on the brain through glutamatergic and dopaminergic transmitter systems (44, 116). Frequent relapses are associated with progressive functional deterioration, cognitive impairment, reduced treatment response, and worse clinical prognosis (116). A deteriorating course in symptom levels and executive functioning has been demonstrated to be associated with progressive changes in the frontal cortex and cognitive impairment (58). It is thus recommended that psychotic illness be identified early and adequate treatment be provided as soon as possible to prevent further deterioration that may result from continuing active illness. Clinicians and investigators have long noted high rates of drug and alcohol use disorders among individuals with schizophrenia, demonstrated in recent research studies to occur in approximately one-half of all patients with schizophrenia (148). Self-medication of emotional distress may be a compelling explanation for the associated substance abuse, but there is considerable evidence that people with schizophrenia use substances for the same reasons and in the same manner as the general population, with additional contributions of impaired judgment and impulse control that psychosis may confer (6). Comorbid substance abuse makes the care of patients with psychotic illness much more difficult, as these patients have more positive symptoms, less treatment adherence, more frequent relapse requiring inpatient care, and more frequent homelessness and legal, medical, and social complications (35, 116, 124). Two historic developments have dramatically altered the general clinical course in the treatment of schizophrenia: the introduction of antipsychotics and the shift away from prolonged hospitalization. With antipsychotics, significant control of hallucinations, delusions, and bizarre behavior is possible for many patients. As a result, and also because of substantial reductions in hospital admissions and the duration of inpatient stays, patients spend far less time in psychiatric hospitals than was the case in earlier years. The advent of the newer second-generation antipsychotic medications has allowed many patients with previously incapacitating functional deficits based on amotivation and apathy to achieve new levels of occupational and social functioning. Clozapine in particular targets negative symptoms not substantially affected by traditional antipsychotics, leading to significant clinical improvement in many patients who have been refractory to other antipsychotic medications. For example, difficulties in school or at work are common features of schizophrenia. Suspicious, fearful, and deluded individuals may not perform well in school or at work because of preoccupation with abnormal thoughts; at the same time, withdrawn, preoccupied, and unresponsive students may draw criticism and other adverse responses from teachers and supervisors. The definition of the disorder encompasses its natural history and at the same time specifies the complications. These include impaired education, poor work history and job achievement, celibacy, and prolonged or repeated psychiatric hospitalization. Early school difficulties have been noted, but even among those who do well in elementary school, difficulties may arise in high school or college. These changes, coupled with the need to leave school at the onset of more dramatic symptoms, may eventually lead to dropping out of school. If the illness peaks after the completion of formal education, the same clinical features may lead to marked reduction of effectiveness at work, demotions, being fired, frequent job changes, and financial dependency. Despite great reductions in chronic psychiatric hospitalization of patients with schizophrenia in recent decades, no other illness results in more time spent in psychiatric hospitals. Hospitalization is usually for repeated, relatively brief periods, but a few patients spend many years in hospitals. A common misconception about schizophrenia is that people with this illness are likely to act on psychotic delusions and commit violent crimes such as murder. Available data suggest, however, that there is only a modestly greater risk of significant crimes committed by individuals with this illness than in general populations (103, 158). Risk for violent crime by individuals with schizophrenia is highly associated with substance abuse and increases with treatment discontinuation (158, 163). Individuals with schizophrenia are far more likely to be arrested for vagrancy, disturbing the peace, and other misdemeanors than for violent crimes and are only rarely involved in serious or violent felonies. Approximately 1 out of 20 people with schizophrenia will eventually commit suicide (60, 110, 111, 115, 157). The most vulnerable time is near the beginning of illness onset, often following discharge from an inpatient hospital stay (115, 157). Suicide risk in schizophrenia is related to psychotic symptoms such as paranoia and command hallucinations, depressive symptoms and hopelessness, agitation and motor restlessness, and awareness of effects of the illness on cognitive functioning (57, 157). Additionally, previous suicide attempts, recent loss, poor treatment adherence, and substance abuse have been identified as suicide risk factors in schizophrenia (157). Social support, positive coping skills, life satisfaction, and engagement in treatment appear to be protective against suicide risk in schizophrenia (99, 157). Patients with schizophrenia have remarkable rates of morbidity and mortality from all causes, resulting in a reduced life expectancy by 20 years compared to the general population (88, 110). Lifestyle factors such as smoking, excessive alcohol and drug use, unhealthy diet, and lack of exercise likely contribute to medical complications in these patients (105). Underutilization of prevention and treatment for medical illness may also contribute, as well as the known adverse metabolic side effects of antipsychotic medications (110). There is a 10-fold elevated risk of schizophrenia in the close relatives of patients with schizophrenia (73). The specific lifetime risk for developing schizophrenia is 9% for individuals with an affected sibling, 13% for individuals with one affected parent, and 46% for individuals with two affected parents (55, 137). Studies of the offspring of twins have shed additional light on hereditary disposition to schizophrenia. A study of monozygotic twins discordant for schizophrenia found no different rates of schizophrenia in the children of unaffected and affected twins (17% each) (46, 50). In contrast, a study of dizygotic twin pairs discordant for schizophrenia found higher rates of schizophrenia among offspring of affected (17%) compared to unaffected (2%) twins (50). These findings suggest that at least some schizophrenic illnesses have a hereditary predisposition, and that a schizophrenic genotype or diathesis may not be expressed unless it is accompanied by critical nonfamilial, environmental factors. Adoption studies provide more specific evidence to untangle genetic from environmental factors (26). These studies have found that children separated early in life from parents with schizophrenia and raised by unrelated adoptive parents are far more likely to have schizophrenia as adults than are adopted-away offspring of parents without the disorder (26). A more recent and much larger study using a Swedish population registry has further substantiated the results of these earlier studies (90). Family studies have investigated the concept of a familial schizophrenia spectrum, which dates to observations by Kraepelin and Bleuler that many family members of patients with schizophrenia who do not have schizophrenia appear to have long-standing, schizophrenia-like characteristics (36). Studies have shown a familial and even a genetic relationship between schizophrenia and schizotypal personality, thus supporting the validity of a familial schizophrenia- spectrum concept (36).

Purchase 20 mg piroxicam mastercard. Options for Front Leg Support.

The intestine in patients with omphalocele (other than being abnormally rotated) is functionally normal arthritis vs carpal tunnel cost of piroxicam. As such arthritis pain generic piroxicam 20 mg with visa, feeding advancement is infrequently delayed except in the immediate perioperative period of abdominal wall closure arthritis medication cream purchase piroxicam 20mg line. In contrast arthritis pain on hand cheap piroxicam 20mg with mastercard, the intestine of patients with gastroschisis is frequently damaged because of amniotic fluid exposure as well as ischemia induced by the small opening in the abdominal wall arthritis in fingers cure discount 20mg piroxicam with amex, resulting in constriction of the blood supply. Patients with gastroschisis are typically slow to reach full enteral feeding volumes because of intestinal dysmotility or the presence of intestinal atresia or short gut. These patients should be monitored closely for signs of malnutrition and dehydration. Cholestasis may result in hepatic steatosis, fibrosis, or failure that may necessitate liver transplantation or may result in death. Lipids have been implicated as a potential cause of cholestasis, as previously described. These patients should be monitored closely for signs of cholestasis and adjustments in parenteral nutrition should be made as tolerated. This, in part, results from variable clinical courses and timing of surgical repair. Adequate nutrition in the newborn period is crucial to prevent these deficiencies and to promote appropriate growth during early life. Although many advancements have been made over time to help support these patients during the perioperative period and beyond, further studies are needed to guide the care of these neonates. Many of the studies performed to identify protein, carbohydrate, and fat requirements in surgical neonates included only small numbers of patients several years ago and therefore should be repeated to accurately reflect current clinical management strategies and nutritional support. No studies have been recently performed to identify the appropriate composition of amino acid solutions; and although it has been proven that 2. Overall, nutritional support remains challenging in this population, and attention to both short-term and long-term growth, including weight and length, in these infants is important. Recently more attention has been paid to the effects of linear growth failure and the potential association between impaired neurodevelopmental outcomes and linear stunting. Long-term outcomes, such as linear growth, body composition, and neurodevelopment, need to be evaluated in the surgical subpopulation to help guide the nutritional management of these infants. Long-term nutritional morbidity for congenital diaphragmatic hernia survivors: failure to thrive extends well into childhood and adolescence. Growth in children with congenital diaphragmatic hernia during the first year of life. Growth and developmental outcomes of infants with gastroschisis at one year of age: a retrospective study. The effects of anesthesia and surgery on metabolic homeostasis in infancy and childhood. Early postoperative alterations in infant energy use increase the risk of overfeeding. Nutritional considerations for infants and children during critical illness and surgery. Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: effects on the stress response. Effect of nutritional support on clinical outcomes in perioperative malnourished patients: a meta-analysis. Energy expenditure: how much does it matter in infant and pediatric chronic disorders Effect of body position on energy expenditure of preterm infants as determined by simultaneous direct and indirect calorimetry. Cumulative energy imbalance in the pediatric intensive care unit: role of targeted indirect calorimetry. Effect of major abdominal operations on energy and protein metabolism in infants and children. Protein turnover, lipolysis, and endogenous hormonal secretion in critically ill children. Stable isotopic quantitation of protein metabolism and energy expenditure in neonates on- and post-extracorporeal life support. Energy metabolism, nitrogen balance, and substrate utilization in critically ill children. Achieving positive protein balance in the immediate postoperative period in neonates undergoing abdominal surgery. Effect of low versus high intravenous amino acid intake on very low birth weight infants in the early neonatal period. Hyperglycemia is associated with increased morbidity and mortality rates in neonates with necrotizing enterocolitis. Glucose utilization in the surgical newborn infant receiving total parenteral nutrition. Effect of replacing glucose with lipid on the energy metabolism of newborn infants. Energy substrate utilization in infants receiving total parenteral nutrition with different glucose to fat ratios. Free radical formation in infants: the effect of critical illness, parenteral nutrition, and enteral feeding. Oxidation of intravenous lipid in infants and children with systemic inflammatory response syndrome and sepsis. Incidence, prevention, and treatment of parenteral nutrition-associated cholestasis and intestinal failure-associated liver disease in infants and children: a systematic review. Identifying patients, on the first day of life, at high-risk of developing parenteral nutrition-associated liver disease. Mechanisms for the effects of fish oil lipid emulsions in the management of parenteral nutrition-associated liver disease. Phytosterolemia in parenteral nutrition patients: implications for liver disease development. Short-term use of parenteral nutrition with a lipid emulsion containing a mixture of soybean oil, medium chain triglycerides, and fish oil: a randomized double-blind study in preterm infants. Elimination of soybean lipid emulsion in parenteral nutrition and supplementation with enteral fish oil improve cholestasis in infants with short bowel syndrome. Resolution of parenteral nutrition-associated jaundice on changing from a soybean oil emulsion to a complex mixed-lipid emulsion. The effect of zinc supplementation on linear growth, body composition, and growth factors in preterm infants. Acute electrolyte and acid-base disorders in patients with ileostomies: a case series. Sodium deficit causing decreased weight gain and metabolic acidosis in infants with ileostomy. Gut hormones in preterm infants with necrotizing enterocolitis during starvation and reintroduction of enteral nutrition. Gall bladder contractility in neonates: effects of parenteral and enteral feeding. Central venous catheter-related complications in newborns and infants: a 587-case survey. Randomized controlled trial of early enteral fat supplement and fish oil to promote intestinal adaptation in premature infants with an enterostomy. Nutritional and other postoperative management of neonates with short bowel syndrome correlates with clinical outcomes. Pathophysiology of short bowel syndrome: considerations of resected and residual anatomy. Gastroschisis in the United States 1988-2003: analysis and risk categorization of 4344 patients. Prenatal intraabdominal bowel dilation is associated with postnatal gastrointestinal complications in fetuses with gastroschisis. Treatment strategies for small bowel bacterial overgrowth in short bowel syndrome. Predictors of low weight and tube feedings in children with congenital diaphragmatic hernia at 1 year of age. Enteral nutrition in neonatal and pediatric extracorporeal life support: a survey of current practice. The incidence of septic complications in newborns on extracorporeal membrane oxygenation is not affected by feeding route. Parenteral Nutrition and Epithelial Integrity Microbial Ingress: Mechanisms and Clinical Evidence Bacterial Profiling Controversy 3: What Is Wrong with the Intestinal Microbiota in Short Bowel Syndrome Abnormal Microbial Colonization Metabolic Impact of the Altered Microbiota in Short Bowel Syndrome Controversy 4: Should Small Bowel Bacterial Overgrowth Prophylaxis Be Given Controversy 7: How Does One Predict Whether Full Intestinal Adaptation Will Occur The approaches to care, however, are very similar and are termed intestinal rehabilitation. This article attempts to deal with some of the leading controversies of the present decade affecting the management of this challenging population of patients by neonatologists, pediatric surgeons, pediatric gastroenterologists, nurses, dietitians, therapists, and others. Controversy 1: Lipid Minimization versus Lipid Modification Before the development of parenteral lipid formulations 50 years ago, patients had essential fatty acid deficiency, hepatic steatosis, and hyperglycemia. The use of parenteral lipids has been associated with development of severe and often life-threatening liver disease. A higher incidence of cholestasis and liver fibrosis has been reported in patients receiving high doses of parenteral lipids (>2 g/kg/day). Evidence points toward phytosterols, which are plant-derived sterols similar in structure to cholesterol. Furthermore, phytosterol levels appear to be elevated in children with cholestasis, although it is not clear whether this elevation is the cause or the result of liver disease. The -6 fatty acids are generally proinflammatory, and experts speculate that these fatty acids promote hepatic inflammation and injury. Lipid minimization is one such approach that may result in prevention of liver disease. A significant negative trend in bilirubin was observed in the lipid reduction group compared with a similar recent historical cohort. One fourth (8 of 31) of these neonates developed biochemical evidence of mild essential fatty acid deficiency (triene-to-tetraene ratio of 0. With this strategy of lipid reduction, a higher glucose infusion rate is required for adequate calorie provision in neonates. There has been Controversies in Short Bowel Syndrome 115 concern that there could be some neurodevelopmental sequelae even at this level of lipid restriction. There was no difference in neurodevelopment and growth outcomes except for a higher 12-month cognitive scaled score in the 1 g/kg group. Improvement in this fish oil cohort with liver disease may therefore be the result of lipid reduction as well. Many studies have now demonstrated improvement in infants with cholestasis with use of Omegaven, a 10% lipid solution administered over 12 hours at 1 g/kg/day. Two reports described infants with persistent portal fibrosis on liver biopsy despite resolution in cholestasis after treatment with -3 fatty acid lipid. Department of Agriculture, the Institutional Review Board, and an order to the company in Hamburg, Germany. The medication costs $50 to $100 per day per child, and unless special permission is granted for use as an experimental drug, the cost of the drug cannot be billed to the patient, and the institution has to bear the cost. A Microbial Ingress: Mechanisms and Clinical Evidence the role of the intestinal tract as a central organ in systemic infections and multiorgan failure was proposed more than 20 years ago. These include burns, intestinal transplantation, hemorrhagic pancreatitis, malignancy, cardiopulmonary bypass, and obstructive jaundice. Moreover, the intestinal endotoxin pool may increase in infants without an ileocecal valve. The reasons for this are unclear, but atrophy of gut-associated lymphoid tissue may play some role. Alterations in lymphocyte function may also play a role in susceptibility to translocation. Bacterial Profiling A link between bacterial overgrowth (of aerobic gram-negative bacilli) and septicemia in infants has been shown in some studies. Thus the carriage of abnormal flora increased the risk for septicemia and sepsis, whereas the incidence of septicemia in the infants with normal flora was significantly lower. The types of bacteria that translocate are mainly aerobic (gram-positive and gram-negative) bacteria. The most common gram-negative isolates were Klebsiella (13%), Enterobacter (11%), Escherichia coli (10%), and Pseudomonas (5%). Many institutions are using ethanol locks, but not yet for infants under 6 months of age. Enteral feeding appears to be the single most important factor in restoring gut-related immunity,46 reducing the incidence of infection,47 improving intestinal permeability,48 and enhancing macrophage function. A unique gut microbiota signature deficient in Firmicutes (anti-inflammatory Clostridia and Lactobacillus spp. They observed relative abundance of species from the phyla Proteobacteria and the class Gammoproteobacteria as well as the class Bacilla, with Escherichia Shigella and Streptococcus being the most notable. Stool cultures indicated a major shift from anaerobes (with virtually undetectable levels of Bacteroides and Clostridium) to high levels of aerotolerant enterobacteria.

buy piroxicam 20mg without prescription


  • Katz AM. Maladaptive growth in the failing heart: The cardiomyopathy of overload. Cardiovasc Drugs Ther. 2002;16(3): 245-249.
  • Osborn TM, Bell RB, Qaisi W, Long WB. Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the neck: a reduction in the need for operative exploration. J Trauma 2008;64:1466-1471.
  • Tan HP, Razzouk A, Gundry SR, et al. Pulmonary Rhizopus rhizopodiformis cavitary abscess in a cardiac allograft recipient. J Cardiovasc Surg (Torino). 1999;40(2):223-226.
  • Hruda J, Hazekamp MG, Sobotka-Plojhar MA, et al. Repair of aorto-right ventricular tunnel with pulmonary stenosis and an anomalous origin of left coronary artery. Eur J Cardiothorac Surg. 2002;21:1123-5.
  • Kurman RJ: Blausteinis Pathology of the Female Genital Tract, 5th ed. New York, Springer-Verlag, 2002.
  • Xu KC, Niu LZ, Zhou Q, et al. Sequential use of transarterial chemoembolization and percutaneous cryosurgery for hepatocellular carcinoma. World J Gastroenterol. 2009;15(29):3664-3669.