Genotypes Symptoms and signs eration of the intrahepatic bile duct of hepatitis B and C viruses have been General malaise arrhythmia kids purchase clonidine 0.1 mg with mastercard, mild abdominal pain epithelium heart attack anlam clonidine 0.1 mg. When the carcinoma infil Hepatolithiasis trates the hilar region hypertension heart disease buy clonidine with visa, jaundice and Hepatolithiasis (recurrent pyogenic Deposition of Thorotrast cholangitis become manifest prehypertension workout buy clonidine 0.1 mg mastercard. It is frequently observed in opaque intra-arterial contrast medium have attained a large size arrhythmias in children purchase clonidine with paypal. Most of these cases are associ recorded in many patients with prior is less common prehypertension quiz order genuine clonidine line, and signs of portal ated with calcium bilirubinate stones; a exposure to Thorotrast hypertension nursing teaching discount clonidine 0.1mg on line. Endoscopic retrograde hypertension emedicine buy 0.1 mg clonidine overnight delivery, transhepatic or magnetic resonance cholangiography is a useful adjunct for the identification of the level of biliary obstruction and sec ondary bile duct dilatation. A the right lobe contains a mass and shows peripheral bile duct are evaluable by imaging studies, can be dilation. B White, scar-like mass in a normal liver (mass forming types) together with dilated peripheral bile ducts. The density tumour with peripheral ring-like iary tract, due to polypoid tumours and liver lobe or segments containing stones increased density. Intrahepatic a small cancerous enlargement of the show intraductal growth, sometimes with metastases develop in nearly all cases at portal pedicle, or a mass central to the polyp formation. The anatomical of variably sized nodules, usually coales Vascular invasion is a frequent histologi location of the involved ducts can be cent. The rigidity of the bile duct on high-quality and mucin may be visible on the cut sur incidence of metastases in regional cholangiographic images. These tumours are confined within show cholestasis, biliary fibrosis, and bone, adrenals, kidneys, spleen, and the dilated part of an intrahepatic large cholangitis with abscess formation. The tumour hepatic parenchyma and portal pedicle lary carcinoma and in situ like spread cells can also infiltrate into the peribiliary reveals a significant heterogeneity of his along the biliary lumen. Once there is glands of the intrahepatic large bile tological features and degree of differen invasion through the periductal tissue, ducts and their conduits. At an early stage, a tubular pat the lesion may be well, moderately, or cult to distinguish this lesion from reac tern with a relatively uniform histological poorly differentiated adenocarcinoma, tive proliferated peribiliary glands histo picture is frequent. The stenosis or obliteration of the bile duct cells are small or large, cuboidal or lumen. Activated perisinusoidal cells (myofibroblasts) are incorporated into the tumour, producing extracellular matrix proteins that lead to fibrosis . Usually, the central parts of the tumour are more sclerotic and hypocellular, while the peripheral parts show more actively proliferating carcino ma cells. On rare occasions, the tumour cells are lost in a massive hyaline stroma, which may be focally calcified. Carcinoma cell nests with small tubular or cord-like patterns extend by com pressing the hepatocytes or infiltrating along the sinusoids. As a result, the portal tracts are incorporated within the tumour and appear as tracts of elastic fibre-rich con nective tissue. Infiltrating, well-differentiated tubular car cinoma must be differentiated from the non-neoplastic pre-existing small bile ducts. This variant Adenosquamous and squamous carcino cases of undifferentiated lymphoepithe resembles the tumour arising in salivary ma. A predominant component of extracellular mucus (mucus lakes), usually visible to the naked eye, is present in the stroma. A malignant tumour in which there is a predominance of discrete cells distended with mucus. A cholangiocarcino ma with spindle cell areas resembling spindle cell sarcoma or fibrosarcoma or with features of malignant fibrous histio cytoma. B Cytokeratin 7 immunohistochemistry demonstrates tumour cells spreading along bile ducts and infiltrating liver tissue. The hepatocyte anti ly, and poorly differentiated adenocarci goblet cell metaplasia {2008, 913}. In hepatolithiasis, the findings static adenocarcinoma of biliary tract or lary structures, moderately differentiated are those of cholangitis, with proliferation pancreatic origin. Occasionally, dysplas tumours show moderately distorted tubu of the biliary epithelial lining and peri tic changes in neighbouring bile ducts lar patterns with cribriform formations biliary glandular cells, and multiple foci suggest intrahepatic origin. In addition, and/or a cord-like pattern, while the poor of biliary intraepithelial neoplasia . Some peribiliary Dilated intrahepatic and extrahepatic bile glands may also be dysplastic. They are usually multiple and 178 Tumours of the liver and intrahepatic bile ducts A Fig. Within a biliary anomalies, and also in normal liv nosis of a well-differentiated cholangio fibrous or hyalinized stroma, they present ers, multiple cysts may be seen around carcinoma. It occurs in apparently nor as irregular or round ductal structures the intrahepatic large bile ducts {1319, mal livers and also in acquired liver dis that appear somewhat dilated and have 1320}. These cysts are derived from peribil lumina contain proteinaceous or bile iary glands and should be differentiated Molecular genetics and genetic sus stained secretion. Some ducts may be cysti and Korean patients show an intermedi ducts with cuboidal cells that have regu cally dilated. Their fibrous stroma shows varying degrees of chronic inflam mation and collagenization. Biliary adenofibroma is characterized by a com plex tubulocystic biliary epithelium with out mucin production, together with abundant fibroblastic stromal compo nents . Its expansive growth, and foci of epithelial tufting, cellular atypia and mitoses favor a neoplastic process. Small, normal appearing proliferating bile ducts associated with a small con In chronic advanced liver disease and nective tissue component and lymphocytic infiltration. Biliary gesting a somewhat more favourable mutations and less frequently nonsense epithelial cells are continuously exposed prognosis . One study found the ly detectable as a small nodule during fol Overexpression of c-erbB-2 occurs in one 5-year survival rate was 39% in patients low-up of hepatitis virus-related cirrhosis, fourth to about two thirds of carcinoma of with mass-forming tumours and 69% for and is treatable with hepatectomy . Ponchon and cholangiocarcinoma Definition Epidemiology noexpression is sufficient for the diagno A rare tumour containing unequivocal this tumour type comprises less than 1% sis of a hepatocellular carcinomatous elements of both hepatocellular and of all liver carcinomas. Gross inspection does not show signifi cantly different morphology compared to hepatocellular carcinoma. In tumours with a major cholangiocarcinomatous component with fibrous stroma, the cut surface is firm. Histopathology Combined hepatocellular and cholangio carcinoma is the term preferred for a A tumour containing both hepatocellular A and distinct or separate cholangiocarci noma. This category should not be used for tumours in which either form of growth is insufficiently differentiated for positive identification. Hepatocytes preferentially express cytok eratins 8 and 18 and, like duct epithelial B cells, cytokeratins 7 and 19. Ponchon and cystadenocarcinoma Definition solid areas of grey-white tumour in a females and has been likened to ovarian A cystic tumour either benign (cystade thickened wall. The stromal cells express noma) or malignant (cystadenocarcino vimentin, and there are many cells that ma), lined by epithelium with papillary Tumour spread and staging express smooth muscle actin. A xan infoldings that may be mucus-secreting Cystadenocarcinomas show intrahepatic or, less frequently, serous. Lesions arise spread and metastasis to regional lymph from ducts proximal to the hilum of the nodes in the hepatoduodenal ligament. They differ from tumours that arise Distant metastases occur most frequent in in cystic congenital malformation and in the lungs, the pleura and the peritoneum. Epidemiology Bile duct cystadenoma and cystadeno Histopathology carcinoma are rare . Cystadenoma Cystadenomas are usually multilocular is seen almost exclusively in females, and are well defined by a fibrous cap with cystadenocarcinoma appearing sule, which may contain smooth muscle equally in males and females. Patients often present with abdominal the mucinous type is more common and pain and mass. Imaging resting on a basement membrane; poly techniques show multilocular cystic poid or papillary projections may be pres tumour(s), occasionally with tiny papillary ent. Subjacent to the base the cysts are usually multilocular and ment membrane is a cellular, compacted typically range from 5 to 15 cm diameter mesenchymal stroma, which in turn is Fig. This intrahepatic large bile duct in a case of hepatolithi papillary mass may occur as well as mesenchymal component is seen only in asis. A Large peribiliary cysts in the connective tissue of the hilus; the background liver shows advanced cirrhosis. Differenti cells, cholesterol clefts and pigmented ation from intrahepatic bile duct cystade lipofuscin-containing macrophages, may noma depends on the demonstration of be present in the cyst wall. The serous cytological (particularly nuclear) atypia, type consists of multiple, small locules mitosis, and invasion of the underlying lined by a single layer of cuboidal cells stroma. The cells rest on a basement mem may be misdiagnosed as bile duct cys brane but are not surrounded by the tadenomas because insufficient sam mesenchymal stroma typical of the muci pling results in tumour morphology nous variety. Malig nant change may not involve all of the Prognostic factors epithelium lining the cyst; it is usually mul the prognosis of patients with biliary course of patients with unresectable tifocal. The tumours are so well defined duct cystadenocarcinomas is good if a tumours seems to be better than of that complete removal can usually be curative resection is possible. A malignant embryonal tumour with Less frequently nausea, vomiting, and divergent patterns of differentiation, abdominal pain are present. Rarely, tumour cells thelial hepatocytes, to embryonal cells, may produce human chorionic gona and differentiated tissues including dotrophin, leading to precocious puberty osteoid-like material, fibrous connective with pubic hair, genital enlargement and tissue and striated muscle fibers. Epidemiology Hepatoblastoma is accompanied by ane Hepatoblastoma is the most frequent mia in 70% of cases and by thrombocy Fig. Only 3% are seen in ed in about 90% of patients at the time of patients over 15 years of age. Other laboratory abnormalities can Macroscopy Multiple masses, seen in the other 20% include elevated levels of serum choles Hepatoblastomas vary in size from 5 to of cases, may occur in either or both terol, bilirubin, alkaline phosphatase, and 22 cm in diameter and from 150 to 1,400 lobes. Areas of necrosis and haemorrhage are usually present and Birth to Birth to may appear as soft or gelatinous, brown 2 years (%) 20 years (%) Type of Tumour (285 cases) (716 cases) to red tissue . These cells contain a by more abundant cytoplasm and larger small round nucleus with fine nuclear nuclei. Cana only those cases in which macrotrabecu liculi may be seen between hepatocytes lae are a prominent feature of the lesion. In biopsies large, well demarcated lesion with central haemor taken before preoperative chemothera rhage. Hepatoblastomas also spread to the focal staining of the sinusoidal Beckwith-Wiedemann syndrome bone, brain, ovaries, and the eye {179, endothelial cells of normal liver . The cells display little cohesive dysplasia, absence of portal vein melanin pigment. While often inter Hypoglycemia resembling the hepatocytes of the devel mixed with the fetal epithelial cells, the Inguinal hernia foci of embryonal cells, which are devoid Isosexual precocity of glycogen and lipid, can be identified Maternal clomiphene citrate and Pergonal Table 8. Variable concentrations of glycogen and lipid within tumour cells create dark and light areas. This primitive mesenchyme and mesenchy Hepatoblastomas composed entirely of type is believed to represent the least dif mally derived tissues. Of these mixed noncohesive sheets of small cells resem ferentiated form of hepatoblastoma tumours, 80% have only immature and . While often difficult to identify as hepatic in origin, the presence of small amounts of glycogen, lipid and bile pigment, along with cytoplasmic cytokeratin, helps separate this lesion from metastatic small cell tumours. The cells are arranged as solid masses with areas of cellular pyknosis and necrosis and high mitotic activity. Sinusoids are present but decreased in amount compared to the fetal epithelial pattern, and there is pro Fig. Fetal epithelial cells with a high cytoplasmic nounced intracellular expression of lipid concentration are separated by a band of extracellular matrix proteins and large Fig. The primitive mesenchymal tissue consists of a light myxomatous stroma containing large numbers of spindle shaped cells with elongate nuclei. The cells may display a parallel orientation with collagen fibers and cells resembling young fibroblasts. More mature fibrous septa with well differentiated fibroblasts and collagen may also be seen. Islands of osteoid-like tissue composed of a smooth eosinophilic matrix containing lacunae filled with one or more cells are the hallmark of the mixed lesion. Infantile alpha fetoprotein, carcinoembryonic anti patients are considered inoperable at the haemangioendothelioma, the most com gen, chromogranin A, epithelial mem time they are first seen and 10-20% have monly occurring benign tumour of the brane antigen, vimentin and S-100 pro pulmonary metastases, preoperative liver, is seen almost exclusively in the first tein, suggesting an origin from epithelial chemotherapy and transplantation for the year of life and presents as an asympto cells {10, 2058, 1629}. It is important to differentiate these teratoid features from a true ter atoma, which does not contain fetal and embryonal epithelial hepatoblastoma areas. There is, however, a single case report of a discrete cystic teratoma con tiguous to a hepatoblastoma . The one to two-cell thick trabeculae of fetal epithelial hepa mesenchymal tissue and foci of osteoid-like material are present, together with toblastoma pattern are seen on the right. Hepatocellular adenoma is Hepatoblastoma and familial adenoma nal origin for chromosome arm 1q . Alterations D1 genes have been described in a case approximately 5% of patients (Table 8. The presence of oval cell antigen has duplicated ureters, gastrointestinal mal been demonstrated in hepatoblastomas, formations such as Meckel diverticulum, Molecular genetics which supports the stem cell origin of inguinal hernia and diaphragmatic her Cytogenetic abnormalities include tri these tumours . This area resembling fetal hepatoblastoma contains black melanin pig of osteoid-like material. Prognosis and predictive factors Survival in Stage I is nearly 100% and > 1,000,000ng/mL. Wotherspoon Lymphoma of the liver Definition discrete mass, simulating hepatic inflam Hepatosplenic T-cell lymphoma Primary lymphoma of the liver is defined mation . This is characterized by infiltration of the as an extranodal lymphoma arising in the Hepatosplenic T-cell lymphomas present sinusoids by a monomorphic population liver with the bulk of the disease localized with hepatosplenomegaly, usually without of medium sized cells with a moderate to this site. Contiguous lymph node peripheral lymphadenopathy and without amount of eosinophilic cytoplasm. There is almost always nuclei are round or slightly indented with seen but the primary clinical presentation thrombocytopenia and most patients are moderately dispersed chromatin and is in the liver, with therapy directed to this anaemic. There may be mild sinusoidal dilation els of transaminases and alkaline phos and there are occasional pseudo-peliotic Epidemiology phatase. Perisinusoidal fibrosis may be Primary lymphoma of the liver is rare level may be very high . It is mainly a disease of white mid similar sinusoidal pattern of infiltration is dle aged males {1043, 1217} although an Histopathology seen in the spleen and bone marrow occasional case has been reported in B-cell lymphoma both of which are usually involved by the childhood . Most are B-cell lym the majority of primary hepatic lym lymphoma at diagnosis {486, 334}. Primary hepatosplenic T-cell phomas are of diffuse large B-cell type the cells are usually immunoreactive for lymphomas have a different distribution. These rearrangement of the T-cell receptor A proportion of cases are associated are characterized by a dense lymphoid gene. Cytogenetic studies without mixed cryoglobulinaemia {390, ical lymphoid cells have centrocyte-like have shown isochromosome 7q in a 56, 1257, 90, 371, 1625, 311}. Other lym cell morphology and surround reactive number of cases and in some this has phomas have been reported arising with germinal centres. Nodules of the prognosis of primary hepatic lym normal liver may be entrapped within the phoma is generally poor. There is no ties, including surgery in resectable pain or discomfort, weight loss and fever expression of cyclinD1 {797, 1143, 923}. Some cases have been reported triads although nodular infiltration may with a slightly longer survival . Nakanuma Definition Benign and malignant tumours arising in the liver, with vascular, fibrous, adipose and other mesenchymal tissue differenti ation. A B Imaging Imaging studies establish the presence of a space-occupying lesion or lesions in the liver, and may provide a diagnosis or differential diagnosis . B Mixture of bile ducts, accounts for 8% of all liver tumours and mesenchymal tissue and blood vessels. C Bile ducts display a ductal plate malformation; the primitive mes pseudotumours from birth to 21 years of enchymal tissue consists of loosely arranged stellate cells. In addition to blood vessels, the tumour also con age, but during the first two years of life tains liver cells (top). D Fluid accumulation in the mesenchyme mimics lymphangioma, but the spaces lack it represents 12% of all hepatic tumours an endothelial lining. Lesions involve the right lobe in 75% of Mode of Presentation Examples cases, the left lobe in 22% and both lobes in 3%. Asymptomatic (incidental finding) Any Presentation is typically with abdominal Upper abdominal mass +/ hepatomegaly Any swelling, but rapid accumulation of fluid Sudden increase in size of tumour Mesenchymal hamartoma, in the tumour can cause sudden enlarge cavernous haemangioma ment of the abdomen . Macrosco Febrile illness with weight loss Inflammatory pseudotumour, pically, it is usually a single mass that can embryonal sarcoma, angiosarcoma Acute abdominal crisis from rupture Cavernous haemangioma, angiosarcoma, attain a large size (up to 30 cm or more). The fate of Congestive heart failure Infantile haemangioendothelioma untreated lesions is not known but there Cardiac tumour syndrome Embryonal sarcoma is no convincing evidence of malignant Consumption coagulopathy Cavernous haemangioma, transformation. This tumour-like lesion is Hypoglycaemia Solitary fibrous tumour composed of loose connective tissue and Portal hypertension Epithelioid haemangioendothelioma, epithelial ductal elements in varying pro inflammatory pseudotumour portions. Grossly, the cut surfaces exhib Liver failure Epithelioid haemangioendothelioma, angiosarcoma it solid, pink-tan areas and cysts contain Obstructive jaundice Inflammatory pseudotumour ing a clear fluid. Histologically, the con Lung metastases Epithelioid haemangioendothelioma, nective tissue is typically loose and oede angiosarcoma matous with a matrix of acid mucopoly Mesenchymal tumours 191 lined by plump endothelial cells usually arranged in a single layer, but multilayer ing and tufting can occur. The vessels are supported by a scanty fibrous stroma that may be loose or compact. Larger cavernous vessels with a single layer of flat endothelial cells are often present in the centre of the larger lesions; these vessels may undergo thrombosis with A B infarction, secondary fibrosis and calcifi cation. Other characteristic features of infantile haemangioendothelioma are small bile ducts scattered between the vessels, and foci of extramedullary haematopoiesis.
This review discusses them according to this attention has been paid to the impact of temperature arrhythmia dizziness generic 0.1 mg clonidine, sequence blood pressure garlic order clonidine with a visa. The potential importance of environmental and endogenous rhythms and transient conditions on food Fish larvae receive information from their environment via uptake and feeding physiology is recognized but not well their sensory organs pre hypertension vs hypertension purchase clonidine with mastercard. The type and intensity of their understood arteria en ingles cheap clonidine 0.1 mg amex, as are even less so their implications for responses depend on the nature of the stimulus arteria epigastrica superior purchase cheap clonidine, the stage nutritional composition heart attack 2014 order clonidine in united states online, growth rates and survival blood pressure chart lower number discount clonidine line. Food is detected via a wide Another important aspect that should be taken into range of chemical (olfaction and taste buds) arteriosclerosis vs atherosclerosis buy clonidine 0.1 mg low cost, visual (eyes) account is the variety in ontogeny, feeding physiology and mechanical (free neuromasts and lateral line) stimuli. Thus, spe Olfaction detects the most distant stimuli while touch and cies-specic ndings for a process or function in a gustation detect the closest ones (Pavlov & Kasumyan model species cannot be extrapolated directly to other 1990). Vision plays the most prominent role in prey detec teleosts and specic validation studies are essential. However, some species are capable of eating and behaviour and digestive physiology will contribute to the growing independent of light, at low light intensities, in optimization of diets and feeding protocols and will turbid waters or in the dark (Chesney 1989; Downing & eventually improve growth rates and survival, even in Litvak 2001; Mukai et al. An integrated under food with the help of the olfactory epithelium and taste standing of the various factors and events interacting in buds (chemical stimuli), neuromasts and lateral line food acquisition and digestion is necessary for the design (mechanical) and/or electroreceptive ampullary (electrical) of diets that meet the requirements for optimal inges organs. Not least, better knowl among species and developmental stages and changes in edge in this area would mean reductions in the costs of the light spectrum may affect activity, feeding behaviour fry production. In most sh, the rearing that relate to feeding and digestion and on recom rudimentary sensory organs develop rapidly in the course mending future research strategies in the area. Successful food nation, high spatial acuity, motion detection and both sco consumption depends, on the one hand, on a series of topic (low light intensity) and photopic (high light anatomical characteristics and physiological functions intensity) vision, but each species has its peculiar attributes. Given that the main activities of sh larvae are (Evans & Browman 2004) and what we report here cannot to eat and avoid being eaten, the differentiation of sen be extended to all sh larvae. The sh larval eye is usually sory organs, mouth and digestive elements and the functional at the onset of feeding and in Atlantic halibut capacity for locomotion is of primary importance (Osse (Hippoglossus hippoglossus) (Helvik et al. This structure provides rela Feeding behaviour comprises several activities that take tively good vision and object detection under bright light. In a Double and mosaic cone structures and rod photoreceptors hatchery scenario they can be summarized in terms of generally appear later in development. With the structure detection, capture and ingestion, and digestion and assimi of the retina complete the larvae can see at low light Reviews in Aquaculture (2013) 5 (Suppl. As development progresses (according and olfactory epithelium (Noakes & Godin 1988; Tanaka to species), the diameter of the eye increases, providing a et al. As wider angle of vision and longer-distance perception (Hunt olfaction takes place in water, sh primarily perceive small von Herbing & Gallager 2000; Chesney 2008). Most of the substances that stimu Visual disorders and pathologies related to nutritional late olfactory and gustatory sensory cells are characterized deciencies have been described in several sh species by low molecular weight (<1000 Da) non-volatility; they (Hughes 1985): the importance of retinoic acid for retinal tend to be nitrogenous and amphoteric (Hara 1993). All development in larval sh was demonstrated by Marsh these characteristics apply to amino acids, betaines, nucleo Armstrong et al. The of docosahexanoic acid affects rod formation (Bell & Dick amino acids that stimulate the chemical senses of sh, even 1993; Shields et al. Fish may be grouped according to the sensitivity of sea bass (Dicentrarchus labrax) (Bell et al. The rst olfactory sensory cells generally differentiate at the other chemoreceptors involved in feeding behaviour, hatching, and olfaction plays an active role in prey detec the taste bud system, are extremely sensitive to a smaller tion in most larvae from rst feeding (Dempsey 1978; number of chemical stimuli. Olfaction, in combi palatability; the external taste buds play a role in the preli nation with the detection of current direction by the lateral minary determination of the suitability of food, intervening line system, enables the odour source to be located: olfac in the decision whether to seize or reject an item. The taste tory stimuli trigger a feeding excitatory state that starts and receptors located in the mouth are more sensitive (Kasum maintains klinotactic swimming activity until the food is yan & Kazhlayev 1993) and detect a wider range of sub located (Valentincic 2005). This is particularly relevant stances than the inner buds, which are involved in the nal when live prey characteristics are to be mimicked in micro verication of the quality of the prey seized (swallow or diets. Although taste buds acids from inert food particles after rehydration can may be present at the opening of the mouth in some spe improve their acceptability to larvae (Kolkovski et al. The rainbow trout taste system is narrowly ferentiate later in larval development, and only when they tuned, as it detects only a small number of amino acid are connected with olfactory receptors do larvae acquire stimuli and alone does not release feeding excitation, since the ability to detect chemical stimuli. At present, data are either a visual or an olfactory input is also necessary Reviews in Aquaculture (2013) 5 (Suppl. The selection of prey is mainly done by choosing Mechanical stimuli such as touching or water move sizes that can be swallowed as well as prey organisms that ments are detected by neuromasts, which may be either display inadequate escape behaviour. In lar oesophagus diameter are therefore dening factors in food val sh, a few free neuromasts are already present at hatch particle preferences during development (Busch 1996; ing, and these proliferate during growth and development Yufera & Darias 2007a; Russo et al. Originating cally, the prey size/mouth gape ratio determines the accessi from the neural crest, they early differentiate near the audi bility of a given prey. Thus, although sh larvae may ingest tory capsules in the lateral cephalic region soon after hatch preys that are similar in size to the mouth gape (Russo ing, and then develop and migrate to the trunk and the et al. Both the ratio of supercial neuromasts to those sunk been reported as positively selected in several species (Shi in canals or in single pores and the pattern of the canal sys rota 1970; Fernandez-Daz et al. When food items are considered as 3-D objects, it is rst, they differentiate as free supercial neuromasts with a found that width and depth tend to differ, and that depth mucopolysaccharidic cupula that covers the stereo (non is the usually smallest dimension. They are involved not ingested whose depth corresponds to the width of the only in schooling, in the timing of responses to a predator mouth. This hypothesis is consistent with those of Ham stimulus, in detecting currents, in obstacle avoidance and bright (1991) regarding largemouth bass (Micropterus sal in controlling swimming movements (Blaxter et al. However, the ingested prey also needs to supply organisms in the surrounding water: swimming and feeding mass and energy. In cultured larvae, suitable prey size is obtained by sup As the larvae develop, most of the free neuromasts move plying progressively larger strains of rotifers, followed by deeper into the derma, at rst forming a groove and then Artemia nauplii and metanauplii (Polo et al. The canalization extends the sensi zooplankton species have been tested at rst feeding, tivity of this system to a wider range of frequencies and although not at industrial scale (Strottrup & Norsker 1997; velocities. This is not a prob deciencies on olfactory epithelium, taste bud and neuro lem with microdiets, since a wide range of particle diame mast development have yet to be explored. Locomotory capacity during the early larval stages depends largely on the length and development of anatomi Capture and ingestion cal features such as the notochord (which becomes the ver Both the mouth apparatus and swimming ability are tebral column), ns and muscular system of the trunk. In most these structures gradually develop; total length increases, cultured species, teeth and the ability to bite appear during notochord exion occurs, then the primordial nfold pres the later stages of the larval phase (Kohno et al. Day/nightcyclesthusmarkfeeding highly dependent on hydrodynamic conditions and larval rhythmicity in larval sh. The relationship between inertial and viscous tions have indicated that larval sh feed preferentially at forces in the water, characterized by the Reynolds number, sunrise and sunset (Kane 1984; McLaren & Avendano depends on the size and shape of the growing larvae (Webb 1995) and also show the highest digestive enzyme capacity & Weihs 1986). This may be attributed to the total length of marine sh larvae ranges between 2 and particular light intensity of these crepuscular hours and to 4 mm, frictional forces dominate (Webb & Weihs 1986; nycthemeral migration of zooplankton. An adequate com Batty & Blaxter 1992) and the speed and duration of swim bination of the appropriate irradiance for the visual search ming episodes are limited (Hunt von Herbing & Gallager and prey encounter rate has been suggested as a determi 2000). The inertial forces become more relevant after noto nant of feeding success in larval Atlantic cod (Gadus mor chord exion and caudal n development, usually occurring hua) (Fiksen & Jorgensen 2011). After these develop also revealed a daily feeding pattern in spite of the continu mental events swimming resistance notably increases. During the rst week of life, most sh species During the rst days of feeding with limited locomotory feed during the day, while feeding ceases during the hours capacity, the detection and capture of prey is highly depen of darkness. As swimming capacity the early hours of morning, at sunset or at both of these improves, the larvae can actively search for food and pursue times of day (Shoji et al. This rhythmic feeding activity may be distance covered in burst pursuit of the prey (Blaxter 1986; maintained even under continuous 24 h illumination (Yo Hunt von Herbing & Gallager 2000; Chesney 2008). Feeding may thus be continuous, diur tively affect several of these structures, reducing nal, nocturnal or preferentially crepuscular. The negative effects on pattern may change in the course of development and some ossication lead to abnormal bone development. Malfor species exhibit different pre-metamorphosis and post mations in the spinal column and n rays have been metamorphosis patterns. Finally, the larvae may have endo observed in several species fed on inadequate amounts of genous rhythms that are strongly inuenced by exogenous certain classes of lipids (Cahu et al. Neuroendocrine control of appetite and ingestion Nutritional effects on skeletal anomalies have been covered in recent reviews by Boglione (2012) and Hamre et al. Likewise, myotome structure is immediately involves a complex integration of peripheral and central affected by feeding restrictions: stunting can easily be signals by the brain. As in mammals, the centre that observed in larvae kept without food after the opening of regulates ingestion and energy homeostasis in sh seems the mouth or poorly fed during growth (Margulies 1993; to be located in the hypothalamus (Demski & Northcutt Yufera et al. The appetite-regulating hormones described in decient lipid nutrition also appears to induce functional sh so far have been reviewed in several papers (Lin disorders in the swim-bladder (Kitajima et al. Many of the mammalian neuropeptides and hor to remain at the desired level in the water column, leading mones involved in the central regulation of appetite to higher energy expenditure and seriously interfering with have homologues in sh, and several neuropeptides in feeding. Feeding protocols together with neural pathways in this satiety feedback tend to maintain a permanent, or at least a better than min mechanism. Furthermore, the central regulator of appetite imum, prey density by supplying food twice or more often also receives afferent signals regarding the energy stored in per day. It has been suggested that leptin produced in the issues that have not been sufciently studied. Protocols for liver and fat plays an important role in this signalling func supplying live planktonic prey tend to be adapted to work tion in sh (Murashita et al. This protocol works for most There are almost no studies of how neuropeptides and species although obviously it can be optimized. Atlantic cod, one study describes gene expression at the An inappropriate feeding schedule may limit ingestion, whole-larva level during ontogeny as well as the effects of either because the larvae do not eat or do not detect the the dietary regime (Kortner et al. In adult both cases, the prey will spend hours in the tanks before sh, the list of appetite-regulating endocrine factors cur being eaten, with a consequent drop in nutritional quality rently includes orexigenic factors such as neuropeptide (Romero-Romero & Yufera 2012). The precise physiological role of each factor is not efciently digested (for details see section Gut transit rate yet properly understood, and has been explored in only a vs dietary protein utilization). What we know of mammalian systems suggests that the list of endocrine factors that affect appetite and Digestive physiology energy homeostasis in sh will be signicantly extended and that it will include both central and peripheral signal Once larvae have captured and ingested their food, the role ling pathways. Adding to the complexity are the integration of the digestive system is to reduce it to very simple mole and interactions of the various factors involved. However, cules (absorbable units) that are transported across the one of the key questions in larval stages is when these intestinal epithelium into the blood. The fact that larvae functions and limitations in processing capacity of the continue to feed in spite of having a full gut suggests that digestive system during early life stages continues to be a satiety factors may play a relatively minor role, at least in key area for aquaculture-related research on sh larvae. Under natural feeding conditions, these larvae may never encounter prey densities that are Ontogeny and plasticity of the digestive system high enough to permit ingestion rates equal to those in intensive culture. It is not yet known whether altricial sh An ample literature describes the gross morphological larvae possess a system that regulates appetite and to what ontogeny of the sh digestive tract. In recent years, these extent it depends on feedback from the digestive tract (for descriptions have gradually gone into more detail as new satiety) and/or from the body (nutrients/energy stored/ tools become available to describe the embryogenesis of the adiposity). Recently, 3D models of the digestive tract at various developmental stages have started to become available (Fig. Fish larvae are often Adaptation of feeding protocols to the feeding behaviour categorized on the basis of the presence of a stomach: agas Larval feeding activity and digestion capacity dene food tric sh will not develop a stomach, even in the adult stage, preferences, daily ration and daily feeding rhythm. Good precocial sh have a functional stomach at the onset of rst knowledge of all these processes, which are changing during feeding, while altricial larvae develop a functional stomach Reviews in Aquaculture (2013) 5 (Suppl. Most research on feeding-related the shape of the midgut may differ from a narrow tube. This feature probably increases from a short and straight tube, often closed at both the the residence time of food and enables good mixing with mouth and anal ends in yolk-sac larvae, into a segmented secretions from the pancreas and bile that enter close to the and histologically differentiated tract in juvenile sh. Systematic studies linking morphology with onset of exogenous feeding the digestive tract has histologi functional studies of the digestion could provide valuable cally and functionally distinct regions, the bucco-pharynx, insight into the process, particularly at a general level. Some During the transition period from larva to juvenile, the authors use a different terminology and group these differ stomach epithelium becomes structurally differentiated, ent regions into the foregut, midgut and hindgut. At the glands develop and by the end of this period gastric diges onset of exogenous feeding, the gut length is often less than tion has been established. The midgut is individually separated Japanese ounder (Paralichthys olivaceus) for instance, from the foregut and hindgut by muscular sphincters. With seems to be functional before the onset of metamorphosis few exceptions, the gut is coiled into a loop before exoge (Ronnestad et al. In the subsequent phase of develop may start to function as a short-term reservoir before ment, the digestive tract increases its absorptive capacity assuming its role as an acid proteolytic chamber. The wall of the been suggested that the appearance of gastric glands acts as tract also increases in thickness due to a thicker gut epithe a marker to indicate the juvenile stage (Tanaka 1973). The caeca increase the volume of the anterior midgut and also Accessory digestive organs the absorptive area of the digestive tract and may be impor the liver, pancreas and gallbladder with their outlets are tant for protein and fat absorption. In some species, differentiated as early as the embryo and yolk-sac stages, changes in enterocytes during ontogeny include enhanced and are functional at the onset of exogenous feeding, which brush border digestive capacity, due to increased activity of normally occurs some time before the yolk-sac has been membrane-associated enzymes that contribute to a change absorbed completely (Sarasquete et al. Dur digestive tract during the larval stages, and this seems to ing ontogeny, the pancreas develops from a compact organ continue for some species after metamorphosis. There are to an elongated and branched (but still not diffuse) organ small changes in gut morphology after metamorphosis and along the posterior midgut (Fig. Most of the pancreas these may include further increases in its relative length tissue is exocrine, but endocrine tissue can also be identi and, possibly, adaptation to changes in diet. The rst islet of Langerhans can usually be observed the anatomical and functional ontogeny of the digestive from rst feeding (Tanaka 1969; Sarasquete et al. Additional islets appear later, although differences between precocious and altricial, and gastric with a high interspecic variability. However, there banded seabream (Pagrus auriga) the start of proliferation are important inter-species variations in the sequence of was detected at 21 days post-hatch (dph) (Sanchez-Amaya appearance of some tissues and enzymatic activities. The point at which the rst gastric glands As in adult sh, the liver plays a role as an energy appear ranges from a few days to several months after rst reservoir in sh larvae. This event mulation of glycogen and protein granules in the cyto marks the beginning of the end of the larval mode of diges plasm have been observed in the liver of several species tion. After the appearance of gastric glands and pepsin from rst feeding (Tanaka 1969; Guyot et al. As development progresses and body digestion capacity takes some weeks or months, depending size increases, the hepatic sinusoids and vacuolization on the species. Glycogen is progressively stored in the liver senegalensis) in spite of the presence of gastric glands, the with a species-specic time sequence (Hoehne-Reitan & acidication process has not been detected in either juve Kjorsvik 2004). In Senegalese sole liver glycogen deposi niles or adults (Yufera & Darias 2007b). However, cellular changes, the differentiation is recovered from the hindgut in the entero-hepatic and the turnover of intestinal cells as well as the underlying pathway in larvae. More enzymes, particularly trypsin and how enzyme activities Reviews in Aquaculture (2013) 5 (Suppl. There is little in-depth knowledge of the as observed for sh larvae (Zambonino-Infante et al. On the other Likewise, we possess very little knowledge of the endocrine hand, reduced proliferative capacity of the intestinal epithe pancreas in early life or of the role of pancreatic hormones lium has been observed in Vimba bream larvae (Vimba on post absorptive metabolism. The identication of the intestinal epithelium is capable of continuous self factors affecting the epithelium proliferation and intestinal renewal, providing the intestine with the plasticity it needs maturation is therefore a task of primary importance for to adapt to changing feeding conditions and playing an the prevention of developmental delays and future malfor essential role in organ homeostasis, tissue repair and mations and improvement of the quality of the produced regeneration (Henning 1979; Buddington et al. Intestinal development is mediated by pre In other vertebrates, such as mammals and especially programmed intrinsic factors and external cues. However, anurans, this is a research area of intense activity, due to its inadequate dietary and environmental conditions may importance for the treatment of human diseases and mal interfere with the complex regulation mechanisms involved formations (van der Flier & Clevers 2009; Heimeier et al. Weaning onto inert diets with inadequate dietary Remodelling demands a continuous coordination of prolif composition when gastrointestinal motility, digestion and eration, differentiation and apoptosis. Mammalian intesti absorption are not yet fully developed will usually result in nal stem cells are able to differentiate into the four types of epithelial disorders that depress growth and survival rates, cells present in the intestinal epithelium: enterocytes, Reviews in Aquaculture (2013) 5 (Suppl. Proliferative cells are located in the crypts of and this small teleost (Holtta-Vuori et al. The infor Lieberkuhn, which are epithelial invasions into the underly- mation available on the zebrash digestive tract shows ing connective tissue (van der Flier & Clevers 2009). The some differences in the sequence of events of digestive tract denitive intestine in mammals and adult amphibians is morphogenesis, but that it is similar to that of mammals in normally attained after intense, or even drastic, morphoge terms of its development, organization and function, indi netic transformations that are associated with a drastic cating conserved cellular mechanisms (Ng et al. The rst signs of from herbivorous to carnivorous in amphibian (Henning digestive tract morphogenesis in the zebrash were 1979; Buddington 1994; Ramalho-Santos et al. Complex molecular pathways polarization of the columnar epithelium occurred (Wallace coordinate and regulate intestinal remodelling in mammals & Pack 2003). The gut was fully functional by day 5 post high during amphibian metamorphosis and around birth fertilization (dpf), a regular pattern of spontaneous motility in mammals (Shi et al. This pattern of gastrointestinal layer of rapidly renewing cells, in which cellular prolifera development is identical to what is described for marine tion and apoptosis are coordinated and regulated by cell sh larvae (this review). In mammals, indicates the existence of physiological differences between the number of proliferative cells falls during embryonic species (Sharma et al. Some hours later these authors adult stem cells (Ishizuya-Oka & Shi 2005) are the progeni observed expression in the intestinal bulb (36 hpf) and in tors of the adult epithelium. Studies in larval stages of the the liver and the pancreas primordium cells (48 hpf). These authors showed ever, these cells tend to be restricted to small bundles at the that genes involved in mammal gut morphogenesis, such as base of the epithelial folds (Rombout et al. No such cell agglomerations were observed in the and remodelling in the gut of developing sh is important intestine of larval lampreys (Petromyzon marinus) during for the design of appropriate feeds and feeding protocols.
Veins carry muscular blood pressure normal low high clonidine 0.1 mg amex, circulatory arrhythmia murmur order clonidine in united states online, respiratory hypertension over 55 buy 0.1 mg clonidine free shipping, nervous arteria urethralis buy clonidine 0.1 mg line, urinary heart attack on plane order clonidine american express, blood back to the heart blood pressure monitor chart printable purchase generic clonidine on line. Skeletal System Circulatory System the skeletal system consists of bones and cartilage that give the body shape pulse pressure range elderly cheap 0.1mg clonidine with amex. It protects Heart Kidneys internal organs and provides support for the Lungs body quitting high blood pressure medication purchase generic clonidine canada. Bone is the major component of the Arteries skeletal system, which consists partially of calcium and phosphate. Circulatory System the main components of the circulatory Liver system are the heart, arteries, capillaries, and veins. The circulatory system delivers food and oxygen to the cells of the body and eliminates waste products. It contains blood, which consists of red blood cells, white blood cells, and platelets. Urinary System Skeletal System the urinary system, also known as Vertebrae the excretory system, consists of the Scapula kidneys, bladder, urethra, and ureters. The urinary system flters waste Femur products and some water through the Fibula kidneys. The urine then goes through the Humerus Radius ureters to the bladder where it is emptied Tibia Ulna through the urethra. The nervous system can be divided into two parts: Muscles consist largely of protein and are the the central nervous system and the peripheral lean meat of an animal that is used as food for nervous system. Voluntary muscles are those that can for receiving information from nerves that pass be controlled. When an animal walks or chews it is through the spinal cord and others that control the using voluntary muscles. Nervous System Respiratory System Spinal Cord the major parts of the respiratory system are the nostrils, nasal cavity, pharynx, larynx, trachea, and lungs. When using the respiratory system, animals breathe in needed oxygen and breathe out carbon dioxide. Muscular System the peripheral nervous system Tensor Latissimus Fasciae Latae connects the central nervous system Trapezius Dorsi to the rest of the body. The peripheral nervous system is the system that is responsible for voluntary muscle Gleutals control. The autonomic nervous system is a part of the peripheral nervous system and controls automatic body activities, such as the heart muscle. Tricep Pectoral 4 Agriscience Principles and Applications s Urinary System Digestive System Kidneys What happens to food after it is eaten Ureters Reproductive and Mammary Systems Bladder Have you ever seen a newborn foal or calf In Endocrine System female animals, the ovaries produce eggs, which the endocrine system consists of endocrine glands are usually released on a regular cycle through that release hormones into the body. Eggs can become fertilized when mating chemicals necessary for the regulation of many occurs during a certain period of the ovulation cycle. The nutrient requirements of animals differ because of factors such as age and pregnancy. Animals that need nutrients to sustain the body condition they are in (no weight loss or gain) need nutrients for maintenance. Animals that require maintenance levels of nutrients are not pregnant, lactating, or producing products such as wool. Nursing mothers require a larger amount of nutrients in Young, growing animals require nutrients to meet order to feed their young. Young Jupiter Images animals need the proper nutrition for growth and development of bones, muscles, and organs. The male reproductive system provides the sperm Some agricultural animals, such as chickens, grow necessary for a female to become pregnant through rapidly. Animals must reach a certain age change, and as they mature, their diets become before they are able to reproduce safely. Older animals may have health problems related to aging, which could Milk is produced through the mammary system of require different nutritional needs such as vitamin females. In many mammals, Animals that are pregnant or lactating have specifc the mammary system initially produces colostrum, and increased nutritional needs. Some agricultural animals young animals in fghting off infections due to the commonly give birth to only one offspring (cattle and introduced antibodies. Animals that are lactating or nursing their young also need specifc nutrients to provide nourishing milk to their offspring. What could happen if animals do not as working animals, need additional nutrients. What is the purpose of the endocrine wool came from sheep that needed the proper system What do male and female animals agricultural animals are raised for meat and provide for reproduction to occur In order to produce products or have the quality of meat consumers will purchase, proper nutrition is essential. There are blocks of protein and are used for the formation of six major classes of nutrients: water, protein, tissues and muscle production. Common sources of nutrients for agricultural Protein can be obtained from both plant and animal animals include roughages and concentrates. Plant proteins are more common in livestock Roughages include feed that is high in fber and feeds and include soybean, cottonseed, linseed, peanut, and sunfower seed meals. Concentrates include feed that is high in energy Legumes are plants that produce or fx their own and low in fber, such as grains. Sources of animal protein include tankage, fsh meal, meat scraps, and milk products. Crude protein refers to the total amount of protein in a feed while digestible protein is the protein that can be digested and used by an animal. Carbohydrates Carbohydrates are nutrients that provide the main source of energy for activities the body performs. Carbohydrates provide energy for growth, Jupiter Images maintenance, and reproduction. It forms the basis of fuids in the body and is essential for processes such as digestion, blood circulation, and waste elimination. Water helps dissolve nutrients and also regulates body temperature through perspiration and evaporation. During hot weather or when working hard, horses can require 20 or more gallons of Carbohydrates give animals the energy they need for water per day. One may not think of fats as being essential, Selenium toxicity in horses can cause appetite loss, but they are. Fats of some minerals may also interfere with the provide energy and store excess energy. For example, sulfur produce body heat and carry fat-soluble vitamins in toxicity in cattle can interfere with the metabolism the body. Many sources of proteins are also sources of selenium, copper, molybdenum, and thiamin. Plant fats include oils that are within seeds, which are the main source of fats in agricultural feeds. Minerals also help in muscular activities, reproduction, tissue repair, and body heat. Although mineral intake may account for a small portion of the total diet, it is essential. Macrominerals are needed in larger amounts by the body, and microminerals are needed in smaller amounts. Macrominerals include calcium, chlorine, magnesium, phosphorus, potassium, sodium, and sulfur. Microminerals include chromium, cobalt, copper, fuorine, iron, iodine, manganese, molybdenum, nickel, selenium, silicon, and zinc. Minerals are often added to animal feed or fed free choice, which means animals are able to access at any time. For example, salt and mineral blocks are fed free choice where animals are able to lick them anytime they want. Animals may be able to tolerate minerals in excess of recommended quantities; however, excess minerals in some species can cause toxicity, even leading to death. Producers should always ensure that minerals are given in the appropriate amount to animals. Symptoms of copper toxicity in sheep include lethargy, anemia, pale membranes, thirst, and jaundice. Excess of some minerals can cause weight loss and slower rates of gain in some animals. The B-complex vitamins such as digestion, cell metabolism, growth, and include thiamine, ribofavin, niacin, pyridoxine, reproduction. Like minerals, they are also needed pantothenic acid, biotin, folic acid, benzoic acid, in relatively small quantities. The B-complex vitamins tooth and bone formation, assist the body in help many body functions such as red blood cell fghting stress, and prevent infection in the body. Just as in minerals, it is important for the producer to provide the appropriate vitamins. Symptoms of nutrient defciencies range from a variety of diseases and health problems to fatality. The symptoms of water defciency include weakness, reduced feed intake, weight loss, eyes that appear sunken in, and lack of saliva production. Water defciency can ultimately cause death if the animal does not receive adequate amounts of water. Other symptoms of Vitamins are found in a variety of carbohydrate defciency include weight loss, feed sources. In order to produce vitamin D, the animal must be in sunlight for a portion of the day. Some of the main benefts of the other fat-soluble vitamins include blood clotting (vitamin K), reproduction and muscle development (vitamin E), healthy eyes, and preventing infection (vitamin A). Vitamin C is needed for teeth and Nutrient defcient animals can quickly become sick. Symptoms in range of problems from rickets and deformed poultry include reduced growth and reproductive bones (lack of calcium) to joint stiffness (lack of performance. Symptoms of protein defciency include decreased growth and development, reduced feed intake, Like mineral defciencies, vitamin defciencies in body tissue loss, poor hair coat, poor hoof growth, animals can cause a wide range of problems, as well. Mineral Defciencies Vitamin Defciencies Abnormal bone growth Abnormal bone growth Anemia Decreased milk production Decreased growth Decreased appetite Decreased milk or wool production Diarrhea Deformed bones Digestive disturbances Enlarged thyroid gland Excessive watering of the eyes Heart failure Impaired vision Lameness Increased susceptibility to infections Loss of hair Loss of hair Milk fever Poor blood clotting Paralysis Poor coordination Poor feed efciency Poor growth Poor hair coat Poor hair coat Reduced feed intake Poor hoof growth Reproductive problems Reproductive problems Rickets Respiratory illness Skin disorders Rickets Stifness in the joints Scurvy Unthrifty appearance Unthrifty appearance Weakening of the bones Weakness Knowledge Check 1. Feed Additives Anthelmintics, also known as dewormers, are Agricultural producers must be effcient and used to control various types of worms. Other uses produce a marketable product while maintaining of feed additives include bloat control in ruminant costs. One method agricultural producers use animals, stress reduction by adding tranquilizers, to help them achieve these goals is the use of pH level regulation, and fy control. Growth regulators Controversy surrounds the use of feed additives, are hormones that increase growth rates and feed and there is consumer concern about feed additives effciency. In some cases, for the prevention and treatment of diseases and the feed additives are removed before the animals infections such as scours, coccidiosis, and foot rot. Some agricultural producers market Antibiotics may be used at low levels to improve their products as not containing any feed additives. However, alfalfa hay will almost always contain more crude protein than grass hay. Thus, if you feed alfalfa exclusively to mature cows, you could theoretically feed them too much protein. Alfalfa is higher in digestible energy than is grass hay, but the fber of grass hay is more digestible than is the fber of most legumes. Good quality grass hay is usually much less expensive than good quality alfalfa hay. One of the most common methods Producers must balance rations to be effcient and of balancing rations is by using the Pearson Square. The Pearson Square method can be used to determine There are various methods of balancing rations the portions of two feedstuffs required to obtain a such as using computer software or hand desired nutrient composition for a ration. Write the two numbers on the left that represent the feedstufs (ingredients) used to make the ration. To determine the amount of each feed ingredient, multiply the percentage of 2,000 x. Examples of the digestive process of ruminants and monogastrics with a functional cecum include monogastrics differs. Examples of nonruminants with a nonfunctional Because the rumen can store large quantities cecum include pigs, dogs, and humans. Another of roughages, ruminants have a greater ability subdivision of nonruminants is the avian digestive to process and utilize large quantities of bulky system. Examples of ruminants are cattle, special organs (crop, gizzard) soften, crush, and sheep, and goats. Monogastrics, also known as nonruminants, are animals with relatively small, simple, one compartment stomachs containing limited mircroorganisms. Nonruminants are better adapted to processing and utilizing concentrated feeds such as grains. Ruminants the frst step in the digestive process occurs when feed is taken into the mouth and chewed just enough to make swallowing possible. The feed then moves down the esophagus to the rumen, where it is acted on by millions of microorganisms. A portion of this feed, in the form of a bolus (cud), Jupiter Images is forced from the rumen back into the mouth the digestive process for monogastrics with both where it is rechewed and reswallowed. The feed then moves is squeezed from the food and then on to the into the small intestine where most of the digestible abomasum (true stomach) where it is mixed with portion is absorbed. In animals with a functional to the small intestine where the digestible portion cecum, additional digestion and absorption takes of the feed is absorbed. In animals with a nonfunctional cecum, feed of the feed moves on to the large intestine and is moves on through the digestive system. The feces is stored in the rectum moves through the cecum, the undigested portion and expelled through the anus. The feces is stored in the rectum until it is Knowledge Check expelled through the anus. Describe the two major categories of the digestive process of the avian system begins feed additives. What is the frst step to digestion for intestine where it is absorbed or formed into feces. If the beetles are present in a hay feld at harvesting time, they can be trapped and crushed in the hay during baling. Horses and other animals can become deathly ill if they consume the beetles in the hay. Feed additives are used to Animal nutrition is important for the health and improve performance in an area and are generally productivity of agricultural animals. The major types of proper nutrition is much more than purchasing a bag feed additives are growth regulators and antibiotics. The producer should be knowledgeable about the basics of animal Producers must provide animals with balanced physiology. The digestive systems of animals are Nutrients are important to animals so all systems divided into two main categories: ruminants and function properly. The digestive process for each according to factors such as age, pregnancy, and differs. The six major classes of nutrients include animal, as well as how the digestive system works, water, protein, carbohydrates, fats, minerals, and will enable the producer to provide a balanced vitamins. It was revealed that the digestive system of waders at the anatomical level has a universal structure typical for representatives of class Aves. As a result of histological studies of the structure of the digestive tract, it was found that the feature of the wall of the waders small intestine is the dense location of the crypt in its own plate of the mucous membrane throughout its length. High proliferative capacity of cambial crypt cells and their multilayered location provide high secretory and regenerative activity of enterocytes, which helps to restore the mucous membrane and intensify the digestive processes, especially during the active feeding of the waders at the migration stopover points. At this time, the length and mass of the intestine, the mass of the stomach and the liver increase, what is considered as a reaction to a large number of feeds in the intensive feeding of birds and indicates the plasticity of their digestive system.
Thrombosis of deep cere the venous drainage of the brain is susceptible bral veins blood pressure 6 year old buy cheap clonidine 0.1mg, such as the internal cerebral veins to thrombosis in the same way as other venous or vein of Galen blood pressure medication make you cough order cheap clonidine on line, or even in the straight sinus 208 circulations blood pressure medication weight loss cheap clonidine 0.1 mg on line. Most often hypertension in pregnancy cheap clonidine online master card, this occurs during a generally presents as a rapidly progressive syn hypercoagulable state prehypertension levels discount clonidine online visa, related either to dehy drome with headache hypertension emergency treatment generic clonidine 0.1mg overnight delivery, nausea and vomiting heart attack kid quality clonidine 0.1 mg, dration heart attack warnings order clonidine 0.1 mg free shipping, infection, or childbirth, or associated and then impaired consciousness progressing 209,210 212,213 with a systemic neoplasm. Impaired blood ow in the thal bosis may begin in a draining cerebral vein, or amus and upper midbrain may lead to venous it may involve mainly one or more of the dural infarction, hemorrhage, and coma. The most common of these conditions thrombosis associated with coma generally has 210 is thrombosis of the superior sagittal sinus. There is of venous sinus thrombosis, there will be little, also an increase in venous back-pressure in the if any, evidence of focal brain injury. This Sometimes lack of blood ow in the venous causes local edema and sometimes frank in sinus system will be apparent even on routine farction. The treatment depends on the cause of Vasculitis vasculitis; most of the disorders are immune mediated and are treated by immunosuppres Vasculitis affecting the brain either can occur sion, usually with corticosteroids and cyclo 216 218 as part of a systemic disorder. The organisms destroy tissue both netic resonance angiography may demonstrate by direct invasion and as a result of the im multifocal narrowing of small blood vessels or mune response to the infectious agent. The destruction taglandins in response to the presence of the or can initially be unilateral but usually rapidly ganisms may interfere with neuronal function. The differential diagnosis Although many different organisms can cause includes other forms of encephalitis including encephalitis, including a number of mosquito bacteria and viruses, and even low-grade as borne viruses with regional variations in preva trocytomas of the medial temporal lobe, which lence (eastern and western equine, St. Louis, may present with seizures and a subtle low Japanese, and West Nile viruses), by far the density lesion. A pair of magnetic resonance images from the brain of a patient with herpes simplex 1 encephalitis. Note the preferential involvement of the medial temporal lobe and orbitofrontal cortex (arrows in A) and insular cortex (arrow in B). Although there has been no ran elevation of protein, but may show no changes at domized, controlled series, in our experience all; oligoclonal bands are often absent. These is A 42-year-old secretary had pharyngitis, fever, sues have been discussed in Chapter 3. An nausea, and vomiting, followed 3 days later by additional consideration is that trauma suf confusion and progressive leg weakness. She came cient to cause head injury may also involve the to the emergency department, where she was found neck, with dissection of a carotid or vertebral to have a stiff neck, left abducens palsy, and mod artery. These considerations are covered in the erate leg weakness, with a sensory level at around sections on vascular occlusions. She rapidly became stuporous, then co that follows will focus primarily on the injuries matose, with accid quadriplegia. This shock wave can be treated with corticosteroids and over a period of 3 particularly intense when the skull is struck a months, recovered, nished rehabilitation, and was glancing blow by a high-speed projectile, such able to resume her career and playing tennis. The initial blow causes there is a history or external signs of head in the skull to accelerate against the underlying jury at the time of presentation. This coup-contrecoup injury that produces impairment of consciousness re model was rst described by Courville (1950) quires rapid evaluation, as compressive pro and then documented in the pioneering studies cesses such as epidural or subdural hematoma 224 by Gurdjian, who used high-speed motion may need immediate surgical intervention. She was initially alert and confused, but rapidly slipped into coma, which progressed to complete loss of brainstem reexes by the time she arrived at the hospital. The cerebellar and frontal contusions could be seen from the surface of the brain at autopsy to demonstrate a coup (oc cipital injury) and contrecoup (frontal contusion from impact against the inside of the skull) injury pattern (arrows in D). The absence of parenchymal brain damage, move hemorrhage itself is typically not large enough ment of the brain may shear off the delicate to cause brain injury or dysfunction. However, olfactory nerve bers exiting the skull through the blood may incite seizure activity. Nevertheless, seizures themselves and the Specic Causes of Structural Coma 161 following postictal state may complicate the lism, all of which impair neuronal and axonal 231 evaluation of the degree of brain injury. A third mechanism of brain injury is due to Longer term loss of consciousness may be shearing force on long axonal tracts. Because due to mechanical injury to the brain, a con the long axis of the brainstem is located at about dition that Adams and colleagues termed dif 225 an 80-degree angle with respect to the long axis fuse axonal injury. Examination of the brains of the forebrain, the long tracts connecting the of animals with prolonged unconsciousness in forebrain with the brainstem and spinal cord the Gennarelli experiments was associated with take an abrupt turn at the mesodiencephalic diffuse axonal injury (axonal retraction balls junction. In addition, because the head is teth and microglial clusters in the white matter, in ered to the neck, which is not displaced by a dicating a site of injury) and with hemorrhagic blow to the head, there is an additional rota injury to the corpus callosum and to the dorsal tional displacement of the head, depending on surface of the mesopontine junction. These movements of the sites underlie the free edge of the falx and the forebrain with respect to the brainstem produce tentorium, respectively. Similar pathology was seen in 45 human cases of traumatic closed head injury, all of whom Mechanism of Loss of 225,226 died without awakening after the injury. The mechanism of loss of consciousness with a blow to the head is not completely un Delayed Encephalopathy derstood. Physiologically, the concussion only minimal injury at the time of initial pre causes abrupt neuronal depolarization and sentation. However, with the evolution of brain promotes release of excitatory neurotransmit edema over the next few hours and days, the ters. There is an efux of potassium from cells mass effect may reach a critical level at which with calcium inux into cells and sequestra it impairs cerebral perfusion or causes brain tion in mitochondria leading to impaired oxi herniation. Primary brainstem injury also that even minimal swelling may put the brain is unlike the secondary brainstem dysfunction at risk of injury. Elderly individuals, in whom that follows supratentorial herniation, in which there has been some cerebral atrophy, may all functions above a given brainstem level tend have enough excess intracranial capacity to to be lost as the process descends from rostral avoid reaching this crossroad. Hence, any patient with deteriora level, centrally placed brainstem lesions inter tion of wakefulness in the days following head rupt the pathway for the pupillary light reex injury requires repeat and urgent scanning, and often damage the oculomotor nuclei as well. The resulting deep coma commonly is accom More common is the so-called postconcus panied by pupils that are xed at midposition or sion syndrome. This disorder is characterized slightly wider, by abnormalities of eye move by headache, dizziness, irritability, and dif ments due to damage to the third or fourth culty with memory and attention after mild nerves or their nuclei, and by long-tract motor concussion and particularly after repeated con signs. Because it often follows mild head involvement of the cerebral peduncles and com injury, psychologic factors have been imputed monly are bilateral, although asymmetric. Although hemorrhage Severe midpontine destruction can cause a into tumors, infections, or masses also compress functional transection with physiologic effects normal tissue, they appear to have their major that may be difcult to differentiate from met effect in the brainstem through direct destruc abolic coma. Reex lateral eye movements are sciousness immediately, and the ensuing coma absent because the pontine structures for lat is accompanied by distinctive patterns of re eral conjugate eye movements are destroyed. The brainstem arousal system lies so and vertical movement clearly identies pon close to nuclei and pathways inuencing the tine destruction. Ocular bobbing sometimes pupils, eye movements, and other major func accompanies such acute destructive lesions and tions that primary brainstem destructive le when present usually, but not always, indicates sions that cause coma characteristically cause primaryposteriorfossadisease. Themotorsigns focal neurologic signs that can precisely local of severe pontine destruction are not the same ize the lesion anatomically. This restricted, in every patient and can include accid quad discrete localization is unlike metabolic lesions riplegia, less often extensor posturing, or oc causing coma, where the signs commonly indi casionally extensor posturing responses in the cate incomplete but symmetric dysfunction and arms with exor responses or accidity in the few, if any, focal signs of brainstem dysfunction legs. One of our patients was only structive lesions conned to the lower pons 34 years old. The onset can be sudden coma or or medulla do not show loss of consciousness, progressive neurologic symptoms culminating although they may be locked in, in which case in coma. In some patients, characteristic tran only the preservation of voluntary vertical eye sient symptoms and signs owing to brief is and eyelid movements may indicate the wake chemia of the brainstem precede coma by days 242 ful state. Although lesions conned of consciousness and with complete recovery to the lower brainstem do not cause coma, im in seconds). The attacks usually last for as short pairment of blood ow in the vertebral or low a period as 10 seconds or as long as several basilar arteries may reduce blood ow distally minutes. Seldom are they more prolonged, al in the basilar artery to a level that is below the though we have seen recurrent transient at critical minimum necessary to maintain normal tacks of otherwise unexplained akinetic coma function. The classic presentation of ischemic lasting 20 to 30 minutes in a patient who later coma of brainstem origin is produced by oc died from pontine infarction caused by basi clusion of the basilar artery. Except in patients who addi acutely into a comatose state, and the pupils tionally have recurrent asystole or other se may initially be large, usually indicating intense vere cardiac arrhythmias, transient ischemic adrenal outow at the time of the initial onset, attacks caused by vertebrobasilar artery in but eventually become either miotic (pontine sufciency nearly always occur in the erect or level occlusion) or xed and midposition (mid sitting position. Oculovestibular eye move stenosis may have positional symptoms, which ments may be absent, asymmetric, or skewed are present while sitting but improve when (pontine level), or vertical and adduction move lying down. Occlusion of the basilar artery either by A 78-year-old architect with hypertension and thrombosis or embolism is a relatively com diabetes was returning on an airplane from Europe mon cause of coma. The occlusions are usually to the United States when he complained of diz the result of atherosclerotic or hypertensive dis ziness, double vision, and nausea, then collapsed ease. His seat was laid from valvular heart disease or artery-to-artery back and he gradually regained consciousness. Cranial arteritis involving the A neurologist was present on the airplane and was vertebral arteries in the neck also can lead to called to his side. Limited neurologic examination secondary basilar artery ischemia with brain found that he was drowsy, with small but reactive 239 stem infarction and coma. Most unconscious patients kept at bedrest with the head of the bed initially have respiratory abnormalities, which may in down, but gradually raised to 30 degrees while in clude periodic breathing, or various types of the hospital, and then discharged when he could irregular or ataxic respiration. His chair back was kept as almost always abnormal and may be small (pon low as possible for the remainder of the ight, and tine), midposition (midbrain), or dilated (third he was taken from the airplane to a tertiary care nerve outow in midbrain). Most patients have hospital where he was treated with anticoagulants divergent or skewed eyes reecting direct nu and gradual readjustment to an upright posture. Patients with basilar occlusion who become co matose have a nearly uniformly fatal outcome In some cases, segmental thrombi can oc in the absence of thrombolytic or endovascu 243 clude the vertebral or basilar arteries while lar intervention. In one se basis of clinical signs alone, and eye movement ries, only 31 of 85 patients with angiograph signs are particularly helpful in determining ically proved basilar or bilateral vertebral artery the brainstem level of the dysfunction (Table 242 occlusion were stuporous or comatose. However, the nature of the problem degree of impairment of consciousness pre must be conrmed by imaging. Early diagnosis may allow times resemble brainstem infarction in their 246 effective treatment with thrombolysis, an manifestations. With pertensive patients and often are more likely brainstem infarction, the fact that signs of mid to cause occipital headache (which is unusual brain or pontine damage accompany the onset with infarction). Supratentorial ischemic vascular le sions, by contrast, with rare exceptions pointed A 56-year-old woman was admitted in coma. She out on page 152, are not likely to cause coma had been an accountant and in good health, ex at onset, and they do not begin with pupillary cept for known hypertension treated with hydro abnormalities or other signs of direct brain chlorothiazide. The pupils were a midbrain level almost never occurs in patients 4 mm in diameter and unreactive to light. Finally, the neurologic signs of mid noxious stimuli with extensor posturing and oc brain damage in this patient remained nearly con casionally was wracked by spontaneous waves of stant from onset, whereas transtentorial herniation extensor rigidity. Two days later, the Brainstem Hemorrhage patient continued in coma with extensor responses to noxious stimulation; the pupils remained xed Relatively discrete brainstem hemorrhage can 249 250 in midposition, and there was no ocular response affect the midbrain, the pons, or the me 251 to cold caloric irrigation. The basilar brainstem hemorrhages tend to lie deep within artery was occluded in its midportion by a recent the brainstem substance, are rather diffuse, fre thrombus 1 cm in length. There was extensive in quently rupture into the fourth ventricle, occur farction of the rostral portion of the base of the in elderly persons, and have a poor prognosis pons, as well as the medial pontine and midbrain for recovery. The lower portion of the pons and the by vascular malformations occur in younger in medulla were intact. Surgery generally does not have a place in infarct at the midbrain level based on her clinical treating brainstem hypertensive hemorrhages, picture. Other considerations included a thalamic but it is sometimes possible to remove a vascular hemorrhage with sudden acute transtentorial her malformation, particularly a cavernous angioma. Specic Causes of Structural Coma 167 Primary midbrain hemorrhages, which may of decerebrate rigidity. The to plantar stimulation, a reex combination char diagnosis is obvious on imaging. Most patients acteristic of acute low brainstem damage when recover completely from bleeds from cavern it accompanies acute coma. Nearly all patients ous angiomas; some remain with mild neuro with pontine hemorrhage who survive more than logic decits. Rupture into the with secondary dissection into the brainstem, fourth ventricle is frequent, but dissection into produces sudden coma with periodic or ataxic the medulla is rare. Although most patients breathing, pinpoint pupils, absence of oculo lose consciousness immediately, in a few cases vestibular responses, and quadriplegia. However, there is any question in an ambiguous case, such patients often have other focal signs. When the onset is witnessed, Level of Consciousness only a few patients complain of symptoms such Alert 15 (0) as sudden occipital headache, vomiting, dys Drowsy 21 (3) coordination, or slurred speech before losing Stuporous 4 (3) 255 consciousness. Yes 34 (23) In patients who present in coma, the pupils are nearly always abnormal and usually pin Hyperthermia point. The pupils are often thought to be xed Yes 32 (30) to light on initial examination, but close exam ination with a magnifying glass usually demon Pupils strates further constriction. If the hemorrhage extends Anisocoria 29 (11) into the midbrain, pupils may become asym Pinpoint 23 (17) metric or dilate to midposition. About one Mydriasis 9 (9) third of patients suffer from oculomotor ab Motor Disturbance normalities such as skewed or lateral ocular Hemiplegia 34 (4) deviations or ocular bobbing (or one of its var Tetraplegia 22 (17) iants), and the oculocephalic responses disap Decerebrate posture* 16 (14) pear. The blood pressure was 170/ Alterations in consciousness often last longer 90 mm Hg; the pulse was 84 per minute; respi than the usual sensorimotor auras seen with mi rations were Cheyne-Stokes in character and 16 graine. The pupils were pinpoint but reacted occur in patients with familial hemiplegic mi equally to light; eyes were slightly dysconjugate graine associated with mutations in a calcium with no spontaneous movement, and vestibulo 261 channel and in patients with the disorder ocular responses were absent. The former often have xed cer scan showed a hemorrhage into the pontine teg ebellar signs and the latter multiple hyperin mentum. Shortly thereafter, breathing became ir toms in basilar migraine; however, some clini regular and he died. A 3-cm primary hemorrhage cal lesions suggestive of infarction can be found destroying the central pons and its tegmentum was in patients with migraine signicantly more of found at autopsy. They range in content from quiet 259 4 mL, hemorrhage in a ventral location, disorientation through agitated delirium to un evidence of extension into the midbrain and responsiveness in which the patient is barely thalamus, or hydrocephalus on admission, the arousable. Respira have found few somatic neurologic abnormali tory and cardiovascular area may occur, leav ties, although occasional patients are reported ing the patient paralyzed and unable to breathe, as having oculomotor palsies, pupillary dilation, but not unconscious. Basilar Migraine Altered states of consciousness are an uncom Posterior Reversible mon but distinct aspect of what Bickerstaff Leukoencephalopathy Syndrome 260 calledbasilararterymigraine, associatedwith prodromal symptoms that suggest brainstem Once believed to be associated only with ma dysfunction. Among the illnesses other than nesium sulfate followed by delivery of the fe hypertension, pre-eclampsia and immunosup tus has a similar effect. Vasculitis, porphyria, and thrombotic followed by treatment for several weeks with thrombocytopenic purpura are also reported verapamil is often effective, in our experience. Brainstem and cerebellum may also be af rebral hemispheres can also affect the brain fected. Encephalitis, meningi hypertension or discontinuing drugs), symp tis, and abscess formation may either be part toms resolve.
The hospital social worker who is part of the multidisciplinary team will be able to provide more information blood pressure xls buy generic clonidine 0.1 mg on line. In most cases pulse pressure and icp generic 0.1 mg clonidine with visa, there is a clear set of steps to work out who can make decisions for the person blood pressure 50 over 70 buy 0.1mg clonidine fast delivery. In some situations blood pressure medication young order clonidine without a prescription, a guardian is appointed by the guardianship board in that state or territory blood pressure 7843 0.1 mg clonidine, to make treatment decisions heart attack high discount clonidine 0.1mg line. Making a will is another important practical issue to attend to while the person is well enough hypertension with stage v renal disease purchase 0.1 mg clonidine free shipping. If a person with a brain tumour becomes very unwell suddenly and they have not made a will blood pressure low pulse high 0.1mg clonidine fast delivery, the situation for their family can be much more distressing and complicated. People living with brain tumours should discuss their concerns with the health professionals who are treating them. When a person with a brain tumour has personality changes or problems with cognitive function, their family and friends can experience worse quality of life as well as the person. Treatments that help people cope Effective treatments or ways of coping can help in many situations. It involves helping the person identify unhelpful thought patterns and changing them to more helpful thought habits. The psychologist might help the person explore their evidence for this belief and find evidence that they are not useless. The person is trained in getting into the habit of more realistic and positive beliefs. Supportive psychotherapy Many people with brain tumours describe feeling anxious about the future, feelings of guilt about what might have caused the brain tumour, or fear that their family will not cope. They often feel that they cannot tell their family about these feelings without causing more suffering. This kind of therapy can be provided by psychologists, psychiatrists, general practitioners, social workers, or by specially trained nurses in some cancer clinics. Group support Hearing about other people who have had a brain tumour and sharing tips for coping can be can be enormously reassuring. Attending a support group or participating in an online community can make people feel that they have been heard and that their experience is validated. People also benefit from feeling that they are contributing something to the group and are helping other people. The choice to meet other people with cancer should be up to the person and depends on their own preferences. The latest evidence does not show that people with cancer live longer if they participate in group support. Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers 91 Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers 9189 13. Background People with brain tumours commonly experience problems with physical function and quality of life. After treatment for a glioma, a patient whose medical condition is stable should be referred to a rehabilitation service if they have ongoing problems affecting everyday life. There is increasing evidence that for people with brain tumours who have symptoms of abnormal brain function, such as muscle weakness, rehabilitation in the earlier phases of their disease is as effective as it is for patients after a stroke or accidental brain injury. Driving People who expect to start driving again after treatment for a brain tumour should be referred to a rehabilitation service for full assessment of their ability to drive safely. The licensing authority will make a decision about whether the person is permitted to drive. For those who can return to driving, regular ongoing follow-up by the rehabilitation service is needed, to review and manage any on-going risk associated with driving. If someone continues to drive unsafely and disobeys any restrictions of the driver licensing authority, their license may be cancelled. In some states and territories, doctors may be legally responsible to notify the authorities. Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers 93 Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers 9391 14. The time between visits will differ between people and the treating team of health professionals should decide how often an individual needs to visit. Coordinated care is now the standard approach for caring for people with brain tumours, because they have complex needs involving several different specialists. The patient may need to be assessed or treated by the treating specialists (neurosurgeon, radiation oncologist and medical oncologist), neurologists, social workers, nurses, radiologists, physiotherapy, occupational therapy rehabilitation and palliative care specialists, and psychologists or psychiatrists as necessary. Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers 94 9492 Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers the team should make sure the person knows which team member to contact at any time between visits. Having someone coordinate care between all the different providers is likely to make it easier for patients and their families to cope with follow-up. Adjusting medicines Dexamethasone the dose of dexamethasone should be gradually reduced and stopped when possible. It should never be stopped suddenly, because severe sudden swelling (oedema) could occur in the brain. Oedema can have the same symptoms and appearance on brain scans as a tumour that is growing and worsening, but the symptoms can be rapidly controlled by increasing the dose of dexamethasone. If the dose is too low, it can take a week for oedema to develop, so doctors may need to keep checking the person and fine-tuning the dose of dexamethasone to keep symptoms under control. While taking dexamethasone, patients need regular checkups to look for common side effects such as high blood glucose (diabetes), thinning of bones (osteoporosis), muscle weakness (myopathy) or stomach ulcers or damage to stomach lining. Anticonvulsants should not be stopped suddenly because there is a risk of causing a seizure. All patients should be assessed by a rehabilitation physician and occupational therapist before being certified as safe to drive. Even if they seem fit to drive in a normal consultation, they may have brain changes that could make driving very unsafe. It focuses on the whole person within their social and emotional context, not just the cancer. Background Despite advances in the diagnosis and treatment of brain tumours, primary malignant brain tumours are usually not curable. Towards the end of life, patients can have significant symptoms and concerns, and family and carers may be under considerable stress. Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers 96 9694 Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers What is palliative care Palliative care is a coordinated approach to care provided by doctors, nurses and allied health professionals. The aim is to improve life as much as possible for a person who has a medical condition that will eventually end their life. It focuses on the whole person within their social and emotional context, not just the tumour. It involves planning ahead to minimise distress, rather than just intervening when there is a crisis. The emphasis of care is changed to that of support and symptom control rather than cure. As death approaches, the palliative care team takes a greater role, although the cancer doctors will usually maintain contact with the patient. Specialist palliative care services should be available for all patients who would benefit. Most metropolitan hospitals have a palliative care team consisting of doctors, specialist nurses and allied health workers who can review patients in hospital. This may be the place where the person is living, such as their own home, the home of a relative or carer, or a nursing home or hostel. The local palliative care service will usually have specialist palliative care nurses and a specialist palliative care physician as well as counsellors, pastoral care workers and volunteers. Physiotherapy, nutritional support, occupational therapy and home help may also be available through other community services linked to the palliative care service. Several studies have found that many patients say they would prefer to die at home. Carers and relatives of terminally ill patients need support when caring for patients at home, particularly for activities of daily living and domestic chores. This can be stressful and can cause more social disruption when compared to those patients who are cared for in institutions. Hospitals Patients being cared for at home or somewhere else may need to be admitted to a normal (acute) hospital, even if they are no longer receiving treatment for the cancer. This may happen if the person has seizures that cannot be controlled, infections, or symptoms that are difficult to control, or if their carer can no longer cope with all the tasks required. People with brain tumours have often had frequent contact with hospital staff and feel safe and secure there. Sometimes a person being treated for cancer in an acute hospital will be admitted directly to a hospice instead of going home. This may happen if the person has symptoms that need specialised skills to control, and going home is not feasible. A family caring for a patient at home may need to organise temporary care by health professionals for many reasons. Services that provide temporary care for a seriously ill person when their usual carer needs a break are called respite care services. Respite care can be provided in the community, at home, in special palliative care facilities or hospices. Referral to palliative care should not be delayed until the last few months of life. People with symptoms that are difficult to control or who are having trouble coping will benefit from specialist palliative care service earlier in their illness. Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers 98 9896 Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers Because the palliative approach pays attention to symptom control and the psychological, social and spiritual wellbeing of the patient and their family, it is helpful at all stages of the cancer, particularly at the end of life. Doctors should offer people with cancer referral to palliative care early in their illness so that the palliative care team can collaborate with the medical team. Specialist neuro-oncology nurses are now becoming involved in providing support for patients who have just been diagnosed with a brain tumour as well as those with advanced cancer. Planning ahead All patients with advanced disease that will end their life should be given the opportunity to discuss prognosis and end-of-life issues before they are too ill to be involved in making decisions. Most patients prefer to be given some information about prognosis when they are first diagnosed with a life-limiting illness. The amount of information given and the distress that this causes will vary from patient to patient. It is often very difficult to predict how long a patient has to live and many doctors speak generally in terms of weeks or months or years rather than specific dates. Palliative care experts have developed checklists for patients with advanced cancer and their families or carers, to help them ask appropriate questions about what is likely to happen to the person in future and what to expect from treatment. More information A booklet containing helpful checklists (Asking questions can help)xxiv is available from Palliative Care Australia. The person should also be given the opportunity to say where they want to die and who should be present at the time of death. This is partly because looking after a dying person is often more difficult than carers imagine, and towards the end they need professional help. A person is more likely to have their wish of dying at home if a community palliative care service is involved and there is strong family support. Occasionally a dying person or their relatives or carers will ask for medical staff to help make death happen sooner. Patients who ask for euthanasia are often asking for an end of their suffering, rather than for an end of their life. Often the person does not ask again after distressing symptoms have been controlled. It can be due to various medical causes including anaemia, uncontrolled pain, anxiety, depression, weight loss, infection, lack of sleep, side effects of medicines and loss of fitness from decreased physical activity. Management of fatigue can involve treatment of a specific cause, such as a blood transfusion for anaemia or special pain management techniques for difficult-to-treat pain. General management for fatigue can involve teaching the person ways to conserve their energy, tailored exercise programs, help with organising everyday activities, and psychological help such as stress management, relaxation techniques and support groups. If simple painkillers do not stop the headache, stronger painkillers such as morphine and morphine-like drugs may be needed. If the person has significant side effects from dexamethasone, morphine should be started early instead of trying simple painkillers first. If the person is unable to communicate, it may be difficult to tell whether they have a headache.
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