By D. Uruk. Alaska Pacific University.

In addition purchase zenegra pills in toronto, there may be increased protein loss from the gut zenegra 100mg fast delivery, leading to increased fecal nitrogen loss generic zenegra 100 mg online. Finally, specific nutrients may be deficient and cause alterations in certain tissues. In particular, folic acid and vitamin B12 deficiencies may lead to subtotal villous atrophy in association with crypt hypoplasia (Table 4). Effects of depletion of specific nutrients on the intestine Nutrient Effects Protein-energy malnutrition (e. There is growing evidence that mucosal atrophy occurs during total parenteral nutrition with associated increased intestinal permeability, especially in stressed metabolic states, and that atrophy is absent or minimal in patients fed enterally. In this circumstance, partial enteral refeeding with parenteral supplementation is usually given, provided there are no contraindications to enteral feeding (e. There is evidence that the colonic mucosa uses short-chain fatty acids (especially butyrate) as an energy source. In patients who undergo a colostomy, the bowel that is left distally does not have a fecal stream. A major source of the short-chain fatty acids in the colon is fermented dietary fiber, and thus fiber may be considered a nutrient. General Principles A number of specific diets are useful in different gastrointestinal disorders. These may involve diet restriction or supplementation, or alternatively, a change in the consistency or content of specific nutrients. In patients with steatorrhea, for example, luminal fatty acids are present and involved in the pathogenesis of diarrhea. In some patients with steatorrhea, supplementation with medium-chain triglycerides may be useful because these are hydrolyzed more rapidly by pancreatic enzymes, do not require bile acid micelles for absorption, and are primarily directed to the portal rather than the lymphatic circulation. Because medium-chain triglycerides undergo -oxidation to metabolically nonutilizable dicarboxylic acids, the effective caloric content of medium-chain triglycerides is less than expected. Medium-chain triglycerides in a daily dose of 60 mL will provide approximately 460 calories. Low-fat dietary supplements may be provided in the form of a number of commercially available products prepared as complete nutritional supplements. Fat- soluble vitamins can be replaced using oral water-miscible formulations, if steatorrhea is present. Fat-soluble vitamins require bile acid micelles for absorption; thus, if steatorrhea is due to bile acid depletion (as might occur in the short bowel syndrome following surgical resection for extensive Crohn disease), increased amounts of vitamins may be required. Dietary lactose restriction may be indicated in patients if there is a history of lactose intolerance or a positive lactose tolerance test (i. An alternative test is the lactose breath hydrogen test, in which 2 g/kg (up to 25 g) of lactose is ingested and breath hydrogen is measured. An increase in breath hydrogen of greater than 20 ppm is considered diagnostic of lactose intolerance. Lactose may be found in milk, including buttermilk, even if it has been naturally fermented. Commercial yogurt should also be avoided, since this often has milk or cream added First Principles of Gastroenterology and Hepatology A. Shaffer 656 after fermentation to avoid the sour taste produced by fermenting lactose. Cheese or desserts made from milk or milk chocolate as well as sauces or stuffings made from milk, cream or cheese should also be avoided. Calcium supplements may be necessary with dairy product restriction, particularly in postmenopausal women. Liquid dairy products may be used to a limited extent by patients who have lactose intolerance; in these patients, an enzyme preparation (prepared from yeast or bacteria) added to milk at 4C (15 drops/L) can hydrolyze up to 99% of the lactose in 24 hours. Nonliquid dairy products cannot be treated with enzyme preparations, although lactase tablets may be chewed prior to eating solid food. It is believed that the alcohol-soluble gliadin fraction of wheat gluten or similar alcohol-soluble proteins from the other grains (termed prolamins) cause the intestinal damage. Although wheat, rye, barley and possibly oats are important, corn and rice do not appear to activate celiac disease. Rye whiskey, Scotch whiskey and other cereal-derived alcohols can be consumed, since gluten is not present in distilled spirits. Beer and ale are produced from barley; it is not entirely clear if they can activate disease and would best be avoided. Malt made from barley should be avoided, as well as hydrolyzed vegetable proteins used as flavor enhancers in processed foods, since they may be made from soy, wheat and other cereal proteins. Multivitamin supplements are frequently required and specific vitamin, First Principles of Gastroenterology and Hepatology A. Iron and folate supplementation may be needed and poor absorption of oral iron may sometimes necessitate parenteral administration. Supplements of calcium and vitamin D may be required to prevent mobilization of skeletal calcium, and in some patients magnesium may be needed. Inflammatory Bowel Disease Malnutrition in patients with inflammatory bowel disease, especially Crohn disease, is a frequent problem. Weight loss may be seen in over 65% of patients and growth retardation may be observed in up to 40% of children. As shown in Table 6, there are multiple causes for malnutrition, especially in patients with Crohn disease with small bowel involvement. The goal of nutritional management is to ensure adequate nutrient intake with modifications that reduce symptoms. Although only limited studies are available, evidence suggests that energy expenditure in quiescent Crohn disease and ulcerative colitis is no greater than one would predict for a healthy individual. If the disease is quite active, or is accompanied by fever or sepsis, resting energy expenditure increases. There may be increased caloric as well as nutrient requirements, particularly if gastrointestinal losses are substantial and malabsorption is significant. Attention should also be placed on micronutrient deficiencies in these patients, particularly if concomitant malabsorption is present. For example, patients with significant ileal disease or resection require regularly administered parenteral vitamin B12. Malnutrition in inflammatory bowel disease Reduced oral intake o Disease-induced (e. Shaffer 658 Lactose intolerance is no more common in patients with ulcerative colitis than in healthy individuals. Furthermore, lactose intolerance is also probably no more common in patients with Crohn disease. Owing to the problems with malnutrition in Crohn disease, a lactose-restricted diet should not be recommended unless there is clear-cut improvement in diarrhea with lactose restriction. Cholestyramine is the classic example of an agent that interferes with nutrient (especially cations such as zinc) and drug absorption.

Impotence: Organic factors and management Montejo-Gonzalez A L generic 100mg zenegra visa, Llorca G purchase zenegra australia, Izquierdo J A et al order generic zenegra on-line. Partner responses to sildenafil citrate Salvador, northeastern Brazil: a population-based (Viagra) treatment of erectile dysfunction. Sublingual apomorphine for the treatment of randomized double-blind trial of risperidone vs. Improving the streptococcal septicemia following intracavernous accuracy of vascular testing in impotent men: correcting injection therapy for erectile dysfunction in diabetes. Lancet forskolin: Role in management of vasculogenic impotence 1999;353(9155):840 resistant to standard 3-agent pharmacotherapy. A dose- response study of the effect of flutamide on benign Mulhall J P, Levine L A, Junemann K P. The erectile response to erotic stimuli in men with erectile dysfunction, in relation to age and in comparison Nicolosi A, Moreira E D, Shirai M et al. Psychopharmacology (Berl) Epidemiology of erectile dysfunction in four 1994;115(4):471-477. The erectile response to erotic stimuli in Nieschlag E, Swerdloff R, Behre H M et al. Flutamide administration at management of antidepressant-associated erectile 500 mg daily has similar effects on serum testosterone to 750 dysfunction. Journal of Vascular & Depression, antidepressant therapies, and erectile Interventional Radiology 2000;11(8):1053-1057. Erectile Dysfunction and Comorbid year update on the safety of sildenafil citrate (Viagra). Sildenafil in the high plasma catecholamines do not impair pharmaco treatment of sexual dysfunction induced by selective serotonin induced erection of psychogenic erectile dysfunctional reuptake inhibitors: An overview. Mov Disord 1998;13(3):536 erectile dysfunction in married impotent patients: 539. Is Hypogonadism a Risk Factor for Sexual prostatic hyperplasia: results from the proscar long- Dysfunction?. The external of and tolerance to sildenafil in patients with erectile vacuum device in the management of erectile dysfunction. Int J Clin Pract Frequency and determinants of erectile dysfunction in 1999;Supplement. The Scandinavian Prostate Cancer Group Ozdel O, Oguzhanoglu A, Oguzhanoglu N K et al. Sympathetic methylprednisolone on return of sexual function after nerve- activation by sildenafil. The role of endothelial dysfunction in the pathophysiology of erectile Pittler M, Ernst E. Trials have shown yohimbine is dysfunction in diabetes and in determining response to effective for erectile dysfunction [14]. Clinical sildenafil on retinal blood flow and flicker-induced & Laboratory Haematology 2004;26(5):335-340. General quality of life 2 years following treatment for prostate cancer: what influences Pollack Mark H, Reiter Stewart, Hammerness Paul. Sexuality and intimacy following radical prostatectomy: Patient Pomara G, Morelli G, Montorsi F et al. Vardenafil for the treatment of erectile dysfunction: A critical review of Perimenis P, Athanasopoulos A, Papathanasopoulos P et al. Gabapentin in the management of the recurrent, refractory, Eur Urol 2005;47:612-21 (multiple letters). Drug devices for intracavernosal pharmacotherapy: operational Benefit Trends 2002;14(10):33+40 classification and safety considerations. Eau Update Series moclobemide and doxepin in major depression with special 2004;2(2):56-63. Re-dosing of prostaglandin-E1 versus prostaglandin-E1 plus phentolamine in male erectile Philipp M, Tiller J W G, Baier D et al. Int moclobemide with selective serotonin reuptake inhibitors J Impot Res 2000;12(2):134-135. Switching to moclobemide and Safety of Once-a-Day Dosing of Tadalafil 5 mg and 10 mg to reverse fluoxetine-induced sexual dysfunction in in the Treatment of Erectile Dysfunction: Results of a patients with depression. Thalidomide and to reverse fluoxetine-induced sexual dysfunction in sexual dysfunction in men. Aldosterone antagonism: An emerging strategy for effective Reyes J A, Tan D A, Quimpo J A et al. Journal of Psychiatric Practice pituitary magnetic resonance imaging in men with 2004;10(6):375-385. Oral terbutaline in the management of pharmacologically induced prolonged erection. Int J Androl 2001;7(5):302 findings from a prospective, multi-institutional, phase 305. Cardiology and erectile dysfunction receiving intracavernous injection vascular disorders. Quality of therapy in acute promyelocytic leukemia and beyond: From life in patients with erection difficulties: Evaluation of bench to bedside. Overview of phosphodiesterase 5 Dehydroepiandrosterone treatment in the aging male - inhibition in erectile dysfunction. The efficacy of tadalafil in improving sexual satisfaction and overall satisfaction Safarinejad M R. Prevalence and risk factors for in men with mild, moderate, and severe erectile dysfunction: A erectile dysfunction in a population-based study in retrospective pooled analysis of data from randomized, placebo- Iran. A sexually compulsive male with AndroGel (testosterone gel) with sildenafil to treat erectile erectile dysfunction treated with Viagra: Case report. Safety pathophysiology of erection: Consequences for and tolerability of oral erectile dysfunction treatments in the present medical therapy of erectile dysfunction. Sildenafil medical and scientific meeting: From diabetes to mixed preserves intracorporeal smooth muscle after radical hyperlipidaemias. Effect of lifestyle changes on erectile of prostaglandin E1 on erectile dysfunction. From aspiration to achievement: action of neurotropin for penile pain associated with Assessment and noninvasive treatment of erectile intracavernous injection of prostaglandin E1 assessed using the dysfunction in aging men. 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Therapy sessions are divided into three topics or modules that consist of four sessions each cheap 100mg zenegra overnight delivery. The initial session establishes the structure and purpose of the subsequent sessions zenegra 100mg low cost. Also effective 100mg zenegra, the time and day of the sessions will be established as well as rules for therapy and limits of confidentiality. It is important that participants are clear on the limits and scope of confidentiality since this can have an effect on the type and quality of the therapeutic relationship. The first session begins a dialogue on depression: what it is and how the participant experiences it. The therapist also presents the purpose of the first module, which is to understand how our thoughts influence our mood. The next three sessions work with different types of thinking errors and dysfunctional thoughts associated with depression, as well as how they can be debated and modified to improve our mood. The design of the third session meets the purpose of providing the participant with strategies for increasing positive thoughts and decreasing unhealthy or dysfunctional negative thoughts, and thus, decreasing depressive symptoms. There is a discussion on how the presence of depression can limit participation in pleasant activities, which in turn, increases depressive symptoms. During these sessions, pleasant activities are defined and obstacles for engaging in them are identified. This module also works with how learning to establish clear goals can help decrease depression. The main purpose of this module is that the participant increase his/her control over his/her life and learn to identify alternatives that will allow him/her to have more freedom and choices. Together with the therapist, goals and activities are established that will help improve the participants mood. The therapist together with the participant examine how thoughts affect the activities, social support and relationships the participant engages in. Exercises are used to teach assertive communication skills that will help the participant establish healthy satisfying relationships. The therapeutic process ends reconsidering and integrating the main themes of each module. During the final session, an evaluation of the therapy experience is carried out with the participant to identify strengths and successes achieved. Recommendations related to follow up and areas to continue working on are discussed with the participant and his/her parents Instructions for therapists Use this manual as a guide. It will be useful because it presents the fundamental areas you show focus on during sessions. It also provides examples that will serve as guides when the adolescent doesnt provide material to work with in session. Nonetheless, the situations that adolescents bring to therapy are the most useful to work with since they provide information that is relevant to their particular circumstances. On the other hand, it is important to point out that the content worked on in each session should be integrated or built upon in subsequent sessions. We suggest that you become familiar with the manual and use your own personal style so that when you put it into practice you feel comfortable and confident. The names of worksheets are in bold and are placed at the end of each session in which they are used. The first 15 minutes are used to review the Personal Project and the Mood Thermometer, as well as material from the previous session. Then the material for the session is presented and worked through, as well as material brought in by the adolescent. Effects of a rational-emotive mental health program on poorly achieving disruptive high school students. Cognitive- behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: Evidence-based medicine review. A cognitive-behavioral approach to the treatment of conduct disorder children and adolescents. A comparison of Cognitive-Behavioral Therapy, sertraline and their combination for adolescent depression. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 1151-1161. The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Cognitive-behavioral and interpersonal treatments for depressed Puerto Rican adolescents. New Developments in Cognitive-Behavioral and Interpersonal Treatments for Depressed Puerto Rican Adolescents. The use of cognitive self-instruction in the treatment of behaviorally disturbed adolescents. Perceptions and response styles of referred adolescent girls with family problems. Effects of psychotherapy for depression in children and adolescents: A meta-analysis. Explain issues surrounding confidentiality and the nature of communication with parents. If there is information that you understand the parents need to know (whether because it represents a danger for the adolescent or other persons, or because it is necessary for the adolescents treatment), after discussing it with the adolescent you should share that information with the parents. On parents, reinforce the demonstrate interest in the childs well-being and their supporting role in this process. If the adolescent doesnt respond you can share information similar to information you want the adolescent to share by modeling. Encourage the adolescent to share personal information such as: Where he/she was born, information about his/her history or development Things about his/her family The school he/she attends What his/her principal interests are (goals, likes and dislikes, hobbies) Things about him/herself that they consider important 3. Ask about their main problems (for example, you can ask about worries or difficulties). By practicing what you learn in these sessions, you can find out whether these skills can help you control your symptoms of depression. However, its ok if you what to share what youve learned with other people if you want. Try to be as honest as possible, and express yourself just as you are and how you feel. Turn off your phone or put it on vibrate once you come into the therapy so it doesnt interrupt the session. The purpose of this session is to introduce you to the therapy in which you are going to participate. By identifying thoughts and actions that affect our feelings, we can learn to gain more control over them and improve our mood (feel better). Use this diagram How we understand depression to explain Cognitive Behavioral Therapy. There is a copy of this diagram in the participants manual and in Appendix A of this manual which you can reference when you provide the explanation.

Several authors discount 100mg zenegra with amex, indeed order online zenegra, have warned against the use of the have been established cheap zenegra master card. Depression has been examined in various con- burnout label in medical settings in the current context of diagnostic texts, including the occupational context (Adler et al. Burnout seems to be both predicting and predicted by depressive symptoms, ronment and actively neutralizing stressors is a key pathogenic factor in following a circular causal pathway. The extent to which job-specic and generic factors discriminate burnout from depression is unclear. History of clinical depression is a risk factor for both new depression and burnout. Sapolsky (2004) afrmed that it is impossible to understand either the biology or psychology of major depressions without recognizing the critical role played in the disease by stress (p. In the burned out at work and functioning well in another domain, whereas United States, 17% of adults experience at least one episode of major depression would inevitably impregnate every situation of an depression during their life (Kessler et al. This view, which is nearly as old as the burnout construct, has been widely adopted across the main conceptions of burnout (e. Despite its remarkable inuence, however, the idea of a scope- In the present article, the issue of the burnoutdepression overlap is based distinction between burnout and depression is problematic rst addressed from a theoretical viewpoint through an analysis of the in several respects. First, if conceptualizing burnout and depression way the added value of the burnout construct has been presented and on a continuum (one is more or less burned out; one is more or less justied so far (for an overview, see Table 1). In the second part of the depressed), it should be noted that the early stages of the depression paper, ndings from empirical studies that examined the link between process can be domain-specicfor example, job-relatedlike the burnout and depression are synthesized in order to determine whether early stages of the burnout process (e. Throughout the paper, future avenues of inves- and develop as occupational stress unfolds and intensies. Second, if adopting a categorical, all-or-nothing approach to burnout and depres- 2. Method sion (one is burned out or not; one is depressed or not), it is worth observ- ing that clinical burnout is pervasive in nature like clinical depression. A systematic literature search was carried out in PubMed, Indeed, the state associated with clinical burnout (e. The systematic search was accompanied of a hand search based on the literature referenced in the retained articles. A total of 92 studies were included, divided into 67 cross-sectional studies (Table A. Conceptual and theoretical considerations At the heart of the distinction between burnout and depression lies the idea that burnoutat least initiallyis job-related and situation-specic whereas depression is context-free and pervasive (e. Following this line of reasoning, Table 1 Overview of the conceptually-examined overlap between burnout and depression. In a dimensional approach, it is unclear how burnout as a process is conceived to differ from a process of depression. In a categorical approach, it is unclear how burnout as a state is conceived to differ from a state of depression. Associating burnout with a job-related scope does not guarantee its nosological distinctiveness with respect to depression. The largely atheoretical origin of the burnout construct seems to be still an obstacle to its differentiation. The arbitrariness surrounding the eld-dominating denition of burnout is fundamentally problematic. Third, attributing a given condition or disorder to a specic environments (Schonfeld, 1991) or even to afrm that the state of domain (e. Other authors have ad- burnout from depression at a theoretical level was job-relatedness, vanced the view that burnout overlaps with depression at a symptom it could be argued that burnout is an index of workplace depression level but only to a limited extent (e. As an illus- stages of burnout from depression, leaving a key problem unre- tration, Ahola et al. All in all, the scope-based distinction between burnout and displaying severe burnout (n = 78) presented a depressive disorder. In a study that directly compared depressive symptoms in a To summarize, gray areas subsist in the theoretical distinction be- group of burned out workers (n = 46) and a group of clinically de- tween burnout and depression. No burned out participant appeared to be free of de- from a state of depression (categorical approach). The association of burnout with depressive symp- purely scope-based distinction between burnout and depression toms has been conrmed in longitudinal studies (e. The dissipation of this conceptu- approach and relied on both a cross-sectional and a three-wave, al fog should be high on the agenda of burnout researchers. Empirical and practical investigations that the pathophysiological changes underlying burnout may be less pronounced than those observed in major depression, notably with Having examined the burnoutdepression overlap from a strictly regard to executive functioning (Beck et al. However, studies conceptual standpoint, we now turn to empirical levels of analysis. Finally, questions will be successively dealt with: Bianchi and Laurent (2014), in a recenteye-tracking study (n = 54), ob- served that burnout and depression predicted similar patterns of atten- 1. Can burnout and depression be distinguished at somatic and biolog- To date, isolating substantial differences between burnout and de- ical levels? Are job-related versus generic factors discriminating burnout from ducible to the symptoms comprised by its dimensions (e. A dimensional approach to burnout was symptoms are components of a wider depressive syndrome rather adopted in a majority of the reviewed studies (Fig. Evidently, the degree of symp- tom overlap observed between burnout and depression is a function of 4. Pending consensual diagnostic criteria for burnout, we rec- evocative of depression. For instance, Schaufeli and Buunk (2004) indi- ommend that future categorical research privilege cutoff scores that cate that rst and foremost, burnt-out individuals feel helpless, hope- closely reect formal denitions of burnout. It should be noted A positive correlation between burnout and depression has been re- that burnout has been difcult to disentangle from depression when ported in numerous studies. However, two observations should work-like contexts by using different measures of burnout (e. In a longi- the experience of work and generate burnout; this has led to conceive tudinal study of 1964 dentists by Hakanen and Schaufeli (2012),emo- circular inuences between burnout and depression (e. Both hypotheses have been empiri- depersonalization at three different measurement times over a seven- cally supported, by cross-sectional and longitudinal studies. Such results, which have been frequently reported merous cross-sectional studies (e. Crucially, the reason for considering deperson- several longitudinal studies have been carried out, especially during the alization and reduced personal accomplishment more cardinal features of last decade. Only studies in which the baseline levels of the outcome burnout than classical depressive symptoms is unclear. Notwithstanding these apparent similarities, most studies that Five longitudinal studies reported a unidirectional relationship with factor-analyzed burnout and depression scales concluded that burnout burnout predicting depression (Armon et al.

Furthermore order cheap zenegra on-line, disease can affect several parameters used for nutritional assessment independently of nutritional status buy 100mg zenegra with visa. Body composition Several methods can be used to measure various body compartments and most are used within a research protocol generic zenegra 100mg without prescription. The ones most frequently used clinically are based on a two compartment model: body fat and lean body mass (muscle, bones). This method is mostly used in population studies and is less reliable in the individual patient because of inter- and intra-observer variability and the effect of hydration status, age and physical activity. Studies have shown that unintentional weight loss of > 10% is a good predictor of adverse clinical outcome. Normalized for height, the 24-hour creatinine excretion is an index of muscle mass and can be compared to published tables. However, in a hospital environment, this is not used because of frequent underlying renal disease and use of diuretics. Plasma proteins Albumin is one of the most studied proteins and several studies have demonstrated that low serum albumin concentration correlates with an increased incidence of medical complications 1 and mortality. Therefore, hospitalized patients may have lower albumin levels for several reasons: inflammatory disorders First Principles of Gastroenterology and Hepatology A. On the other hand, protein-calorie malnutrition causes a decrease in the rate of albumin synthesis, but a short-term reduction in albumin synthesis will have little impact because of albumins low turnover rate (half-life: 20 days) and large pool size. Even during chronic malnutrition, plasma albumin concentration is often maintained because of compensatory decrease in albumin degradation and transfer of extravascular albumin to the intravascular compartment. Another plasma protein, prealbumin, is more responsive to nutritional changes because its turnover rate is rapid with a half-life of 23 days. However, it is also influenced by underlying diseases such as inflammation, infections, renal and liver failure. Immune competence As measured by delayed cutaneous hypersensitivity is affected by severe malnutrition. However, other diseases and drugs may also influence the measurements making it a poor predictor of malnutrition in sick patients. A prognostic nutritional index depending largely on albumin and transferrin was shown to provide a quantitative estimate of postoperative complication (Blackburn, 1977). It categorizes the patients as being well nourished (A) or as having moderate or suspected malnutrition (B) or severe malnutrition (C) (Table 10). It is important to recognize the multiple facets of malnutrition to detect the patient at risk of nutrition-related complications. Subjective global assessment combined with selective objective parameters defined above is the best clinical way to detect the patients at risk. The nitrogen is excreted predominantly as urea in the urine, but stool and skin losses account for about 23 g daily. In the steady state, ingestion of more nitrogen will merely result in excretion of more nitrogen in the urine, with the excess protein oxidized in the liver and used as an expensive energy source. In growing children or in malnourished adults, the nutritional goal is a positive nitrogen balance, meaning that body tissue is being formed in excess of what is being broken down (i. It is less clear that patients with conditions associated with protein loss, such as nephrotic syndrome and protein-losing enteropathy, benefit from extra protein intake. If energy requirements are met or exceeded, studies have shown that well-nourished adults can maintain nitrogen balance when given as little as 0. In order to allow for biologic variability, the standard recommendation for protein intake is 0. It is important that the protein supplied be of high quality; it should include all essential amino acids and a balanced mix of nonessential amino acids. Malnourished, septic, injured or burned patients will require more protein, in the order of 1. It is not clear that patients with conditions associated with protein loss, such as protein-losing enteropathy, benefit from extra protein intake. Indeed, patients with nephrotic syndrome may even benefit from protein restriction, though this is not firmly established. The Harris-Benedict equation may be less accurate in malnourished or obese individuals. Malnourished patients exhibit resting energy requirements about 10% to 20% below predicted. The resting energy requirements of obese patients will also be below predicted since adipose tissue is less metabolically active than other tissues. In overweight patients, it has been proposed that an adjusted weight be used in the Harris-Benedict equation based on actual and ideal body weight, using the following formula: Adjusted weight = [(actual body wt - ideal wt) 0. Joer (also called Mifflin) formula may be a better choice for calculating resting energy expenditure in the obese patient. The population of subjects upon which the formula is based needs to be understood. Types of Nutritional Intervention The options for refeeding include oral refeeding, tube feeding and total parenteral nutrition. An assessment by a dietitian regarding current food intake and food preferences is essential. It may well be possible by determining food preferences to provide a well-balanced, nutritionally First Principles of Gastroenterology and Hepatology A. In addition, supplements of high-calorie, high-protein foods such as milkshakes or commercially prepared liquid formula diets may allow for adequate intake. If the patient will not or cannot eat, however, nutritional intervention may be indicated. Examples of patients who will not eat include those with anorexia due to tumor or chemotherapy, and those with anorexia nervosa. Such patients generally have a normal or near-normal nonobstructed bowel, and can be fed enterally. Patients who cannot eat because of severe gastrointestinal illness include those with bowel obstruction or ileus. If nutritional intervention is required in these patients, parenteral (intravenous) nutrition will be necessary. These tubes can be placed through the pylorus to feed into the jejunum with only local anesthetic and mild sedation. Despite convincing evidence of efficacy of post-pyloric placement of tubes in reducing pulmonary aspiration, the tube is usually placed in the jejunum if aspiration is a concern. The formulas have been traditionally divided into polymeric, oligomeric, monomeric, modular and disease-specific formulas. Polymeric formulas (also called defined formula diets) provide nitrogen as whole protein, often casein, egg white solids or soy protein. Carbohydrate is often provided as corn syrup, maltodextrins or glucose oligosaccharides, with sucrose added for sweetness in oral formulas. Fat is usually provided as soy oil, although corn oil and safflower oil may be used. Protein may be provided as milk (usually dry or skim), with lactose as a major carbohydrate.

High concentrations of molluscs should be rotated between disinfected tanks as often as practical or kept in seawater that has been disinfected with ozone or chlorine and subsequently neutralized order generic zenegra line, or a Risk management options 59 combination purchase 100 mg zenegra free shipping. Each new batch of molluscs introduced into a facility should be placed in pre-disinfected tanks purchase zenegra 100mg visa. Filtering all the incoming water is advised due to the presence of organic matter that could reduce disinfection capacity. The detergent used must be compatible with the disinfectant used and both must be compatible with the surface on which they will be utilized. Regular air- or heat-drying of pipelines (daily), tanks and other equipment, in addition to disinfection of surfaces, is also recommended. Collect nauplii using a plankton net running sea water for 12 minutes formalin (400 ppm) for 30 seconds to 1 minute iodophor (0. Collect fertilized eggs running seawater for 12 minutes formalin (100 ppm) for 1 minute iodophor (0. Prevention of infection by infectious hypodermal and haematopoietic necrosis virus may be achieved by using specific-pathogen-free crustacean populations. Although this approach has proven effective, it is still at an experimental stage. Spray: 1 litre/10 m2 Leave for 48 hours Sodium hypochlorite(2) Bacteria and viruses on all 30 mg available chlorine/litre. The chemicals must be approved for the prescribed use and used according to the manufacturers specifications. Besides fulfilling the abovementioned regulations, record-keeping is advised for any aquaculture activity and is a critical element in quality assurance programmes. This tool helps producers to keep track of the treatment employed, results obtained and the specific water and land involved. In this way, the treatment status of animals, ponds and other areas are known at all times. Product withdrawal times must be observed to ensure that any product used for aquatic sites or for animals does not exceed legal tolerance levels in the animal tissue. Antibiotics should be stored in their original container with the original label attached, at the temperature recommended on the label. These compounds should be stored away from bright light, because light may cause inactivation or deterioration of the product. Drugs should not be stored where flooding is possible or on sites where they might spill or leak into the environment or be exposed to high temperatures. Proper mixing, diluting and reconstituting are essential for their effectiveness and for safety reasons. Improper dilution may cause inappropriate concentration or dosage, with uneven effects ranging from ineffectiveness to overdose and toxicity. Careful reading of the manufacturers instructions is strongly advised as they provide important information about mixing, diluting, storage and disposal. Unused portions of a regulated product and empty containers must be properly disposed of. Improper disposal can result in toxicity, environmental contamination and reliability problems. Use the product only for those species and indications listed on the label, unless extra-label use is specifically prescribed by a veterinarian. Use the proper dosage, amount or concentration for the species, area and specific condition. Do not use medication for prophylactic purposes unless specifically approved for this purpose. Do not substitute trade-name products that are labelled and approved for aquaculture or aquatic by unlabelled or generic products. Consider the environmental impact of discharging treated water, including possible effects on non-target organisms. Be aware of personal safety measures and proper procedures for farm workers who handle or apply antibiotics. The Directorate of Fisheries receives copies of prescriptions issued by veterinary surgeons, chemists and feed-producing firms for the treatment of cultivated fish. The breeder is obliged to inform the Directorate of 62 Responsible use of antibiotics in aquaculture Fisheries in good time before take-up and slaughter, and information regarding medical treatment during the previous 12 months is also required. This information is stored in a database at the Directorate of Fisheries (Directorate of Fisheries, 2001). This system makes it possible to register the use of medicines at every single fish farm in Norway. Fish that have been treated with antibiotics or chemical therapeutics during the previous 12 months must be monitored prior to slaughter. This also applies to fish destined for slaughter in cases where neighbouring sea cages at the fish farm have been so treated. Fish that have been treated with drugs shall not be slaughtered until drug residues are impossible to detect. Slaughtered fish are controlled anew with particular reference to residue of the drugs in question. Such controls are carried out by means of random selection of samples during unannounced controls or through the monitoring programme for undesirable substances and medicine residues. Control of medicine residues at the Directorate of Fisheries was established in 1988 (Directorate of Fisheries, 2001). Vaccines Aquaculture, as a young industry in the 1970s, placed significant reliance on the use of antibiotics to combat a range of bacterial diseases, such as vibriosis and furunculosis. The industrys rapid expansion and the increasing market size brought about heavier investment in vaccine development, which allowed, by the beginning of the 1990s, for a range of effective vaccines to be available. Vaccination offers aquaculture producers an effective way to lower both the risk of disease in their fish and their cost of production. Vaccines stimulate the immune response of fish to produce antibodies that help protect the fish from disease. Once exposed to the vaccine, the fishs immune system reacts, producing antibodies that bind with the disease-causing bacteria and destroy it. This learned response means that the immune system learns how to defend itself from disease by making bacteria-specific antibodies. When an outbreak occurs, these antibodies will help protect the fish from diseases. Vaccines are not impenetrable shields, and the resistance they impart can be destroyed if other risk factors are not considered. The three common methods to administer a vaccine are: immersion, injection and oral. The decision about which method to use is based upon a combination of actual and perceived risk, age of the fish, farmers own risk aversion and return on investment (Hugh, 1995). It is generally considered that injectable vaccines provide greater protection than immersion and oral vaccines, because they allow better dosage control, which results in greater efficacy and a longer duration of protection (Hugh, 1995). However, injectable vaccines are more expensive, more labour intensive, and can damage the fish if not administered with care. Injectable vaccines cause adhesions in the fish body; these adhesions are required for the immune response, but they should not affect the quality of the fish or interfere with the fishs ability to digest food.