Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
For children and adolescents who are severely malnourished (weigh <70% of their standard body weight) buy generic provigil 200mg on-line insomnia light therapy, cardiac monitor ing order discount provigil sleep aid you can take if you are taking antidepressants, especially at night purchase provigil 100mg on-line insomnia 7 weeks pregnant, may be advisable (120). Some patients are completely unable to recognize their illness, accept the need for treatment, or tolerate the guilt that would accompany eating, even when performed to sustain their lives. On the rare occasions when staff have to take over the responsibilities for providing life preserving care, nasogastric feedings are preferable to intravenous feedings. In some programs, supplemental overnight pediatric nasogastric tube feedings have been used to facilitate weight gain in cooperative patients. This practice is not routinely recommended at present, although it appears to be well tolerated, may slightly decrease hospital stays in children, and may be ex perienced positively by some patients, particularly younger patients, who may feel relieved to Treatment of Patients With Eating Disorders 43 Copyright 2010, American Psychiatric Association. If used, such interventions should never supplant expectations that the patient will resume normal eating patterns on his or her own. Total paren teral feeding is required only rarely and for brief periods in life-threatening situations. Forced nasogastric or parenteral feeding can each be accompanied by substantial dangers. When nasogastric feeding is necessary, clinical experience suggests that continuous feeding. As an alter native to nasogastric feedings, in very difficult situations where patients physically resist and constantly remove their nasogastric tubes, gastrostomy or jejunostomy tubes may be surgically inserted. As described above, rapid refeeding can be associated with the severe refeeding syn drome, and infection is always a risk with parenteral feedings in emaciated and potentially im munocompromised patients with anorexia nervosa. Consequently, these interventions should not be used routinely but should be considered only when patients are unwilling or unable to coop erate with oral feedings or when the patients? health, physical safety, and recovery are being threatened. If using interventions that patients with anorexia nervosa may experience as coercive, the clinician should consider the potential impact on the therapeutic relationship, especially since maintaining a sense of control is often a key dynamic in these patients. During the last few years, there has been considerable debate about the ethics of involun tarily feeding patients with anorexia nervosa (122, 123). There is general agreement that chil dren and adolescents who are severely malnourished and in grave medical danger should be re fed, involuntarily if necessary, but that every effort should be made to gain their cooperation as cognitive function improves. Ethical as well as clinical dilemmas often confront clinicians dealing with adult patients with chronic anorexia nervosa and their families. The general principles to be followed are those di recting good, humane care; respecting the wishes of competent patients; and intervening re spectfully with patients whose judgment is severely impaired by their psychiatric disorders when such interventions are likely to have beneficial results (124, 125). During all phases of treatment, seeing patients? families is also helpful, particularly for children and ado lescents, for whom controlled trials suggest that family treatment is the most effective interven tion (86, 126). For patients who initially lack motivation, their awareness and desire for recovery may be increased by psychotherapeutic techniques based on motivational enhancement, al though solid evidence for this contention is lacking. At the same time, clinical consensus suggests that psychotherapy alone is generally not suf ficient to treat severely malnourished patients with anorexia nervosa. Although the value of es tablishing and maintaining a psychotherapeutically informed relationship is clearly beneficial and psychotherapeutic sessions to enhance patient motivation and further patient weight gain are likely to be helpful, the value of formal psychotherapy during the acute refeeding stage is uncertain (127). Attempts to conduct formal psychotherapy may be ineffective with starving patients, who are often negativistic, obsessional, or mildly cognitively impaired, presumably in relation to the known cortical atrophy seen in nutritionally compromised patients. One study documented the difficulty researchers have had in initiating and sustaining cognitive-behavioral therapies for patients with anorexia nervosa (128). Most nutritional rehabilitation programs incorporate emotional nurturance and one of a va riety of behavioral interventions that link exercise, bed rest, and privileges with target weights, desired behaviors, and informational feedback. Several studies of individual therapy have shown modest success, sometimes in only a small percentage of patients (7, 85). However, 70% of patients either did not complete or made only small gains from the active psychotherapies they received (7). In this study, clinical management included education, care, support, and the fostering of a therapeutic relationship designed to promote adherence to treatment through the use of praise, reassurance, and advice. The accumulated evidence strongly supports the value of family therapy for the acute treat ment of children and adolescents in outpatient settings. Studies show that whether patients and parents are seen together or are treated separately in ongoing treatment, the results are better than when families are not involved at all (86, 126). When families are involved in treatment, sibling subsystems can be engaged to sup port the affected sibling. For some outpa tients, a short-term course of family therapy may be as effective as a long-term course; however, a shorter course of therapy may not be adequate for patients with severe obsessive-compulsive features or nonintact families (129). In these studies (129), inpatient care was used briefly for medical stabilization. For adolescents treated in inpatient settings, participation in family group psychoeducation may help promote weight gain and may be as effective as more intensive forms of family therapy (130). Although there have been few formal studies of its effectiveness (134, 135), psychotherapy is generally thought to help patients understand 1) what they have been through; 2) developmen tal, familial, and cultural antecedents of their illness; 3) how their illness may have been a mal Treatment of Patients With Eating Disorders 45 Copyright 2010, American Psychiatric Association. At present there is no absolute weight or percentage of body fat that indicates when a patient is actually ready to begin formal psychotherapy. In addition, patients often display im proved mood, enhanced cognitive functioning, and clearer thought processes once their nutri tional status has significantly improved and even before they make substantial weight gains. Little evidence from controlled studies exists to guide clinicians in the use of specific thera pies for adults with anorexia nervosa. Many clinicians also use psychodynamically oriented individual or group psychotherapy to address underlying personality disorders that may hamper treatment and help sustain the ill ness and to foster psychological insight and maturation in patients who have made strides to ward weight restoration (141?148). Although studies of psychother apies focus on different interventions as distinctly separate treatments, in practice there is frequent overlap among treatments.
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Warming offuids before administration can dence of low cardiac output with high filling pressures buy discount provigil 200mg on-line insomnia in spanish, avoid this complication discount provigil on line sleep aid in pregnancy. Meta-analyses of studies of heterogenous critically ill For vasodilatory shock when increased vasoconstric? populations comparing crystalloid and colloid resuscita? tion is required to best buy for provigil insomnia quote fight club maintain an adequate perfusion pres? tion (with albumin) indicate no beneft of colloid over sure, alpha-adrenergic catecholamine agonists (such as crystalloid solutions except in trauma patients with trau? norepinephrine and phenylephrine) are generally used. Furthermore, in patients with beta-adrenergic agonist, it preferentially increases mean severe sepsis, the addition of albumin to crystalloid solu? arterial pressure over cardiac output. The initial dose is tions did not alter mortality when compared to the admin? 1-2 meg/min as an intravenous infusion, titrated to main? istration of crystalloid alone. Clinical trials and tain the mean arterial blood pressure at 65 mm Hg or meta-analyses have also found no difference in mortality higher. The usual maintenance dose is 2-4 meg/min intra? between trauma patients receiving hypertonic saline (7. When compared refractory shock may require dosages of 10-30 meg/min to isotonic saline, the use of hypertonic saline plus dextran intravenously. Epinephrine, also with both alpha-adrenergic has been found to increase survival, particularly in patients and beta-adrenergic effects, may be used in severe shock with traumatic brain injury. Early Goal-Directed Therapy min as a continuous intravenous infusion initially and Compensated shock can occur in the setting ofnormalized titrate to hemodynamic response; the usual dosage range is hemodynamic parameters with ongoing global tissue 1-10 meg/min intravenously. Traditional endpoints of resuscitation such as Dopamine has variable effects according to dosage. At blood pressure, heart rate, urinary output, mental status, low doses (2-5 meg/kg/min intravenously), stimulation of and skin perfusion can therefore be misleading. At doses of 5-10meg/kg/min, beta-1-adrenergic effects age range is 2-20 meg/kg/min intravenously. Tachyphy? predominate, resulting in an increase in heart rate and laxis can occur after 48 hours secondary to the cardiac contractility. At higher doses (greater than 10 meg/ down-regulation of beta-adrenergic receptors. Amrinone kg/min), alpha-adrenergic effects predominate, resulting and milrinone are phosphodiesterase inhibitors that can be in peripheral vasoconstriction. Vasodilation is a side effect of from, or the superiority of, a particular vasopressor in sep? both amrinone and milrinone. Norepinephrine is the initial vasopressor of choice in septic shock to maintain the mean arterial pres? 2. Phenylephrine can be used as choice in patients with shock secondary to adrenal insuf? a first-line agent for hyperdynamic septic shock if (l) there fciency but studies do not support their use in patients is low systemic venous resistance but high cardiac output, with shock from sepsis or other etiologies. Trials where which can manifest as hypotension with warm extremities either high or low doses of corticosteroids were adminis? or (2) dysrhythmias or tachycardias prevent the use of tered to patients in septic shock did not show improved agents with beta-adrenergic activity. In meta-analyses, the survival; rather, some worse outcomes were observed from use of dopamine as a first-line vasopressor in septic shock increased rates of secondary infections, even in patients resulted in an increase in 28-day mortality and a higher who had relative adrenal insufficiency, defined by a cortisol incidence of arrhythmic events. Dopamine should only be response of9 mcg/dL or less after one injection of250 meg used as an alternative to norepinephrine in select patients of corticotropin. Meta-analyses ofmultiple smallertrials of with septic shock, including patients with signifcant bra? steroids in septic shock have demonstrated that in patients dycardia or low potential for tachyarrhythmias. Imaging studies may prove pressin in the management of septic shock includes the useful to attempt localization of sources ofinfection. Vasopressin cal management may also be necessary if necrotic tissue or also potentiates the effects ofcatecholamines on the vascu? loculated infections are present (see Table 30-5). Intravenous infusion of vaso? etiology and lactic acidosis, clinical studies have failed to pressin ata lowdose (0. Emergent revascularization by percutaneous angio? patients with septic shock who were being treated with plasty or coronary artery bypass surgery appears to improve catecholamine vasopressors. Urgent hemodialy? suggests that either norepinephrine or dopamine be used sis or continuous venovenous hemofltration may be indi? as a first-line agent. Dobutamine, a predominantly beta? cated for maintenance of fuid and electrolyte balance adrenergic agonist, increases contractility and decreases during acute kidney injury resulting in shock from multi? afterload. High versus low blood? myocardial function (decreased cardiac output and ele? pressure target in patients with septic shock. General Approach toAnemias Anemia is present in adults ifthe hematocrit is below 41% (hemoglobin less than 13. Attention to physical signs of primary hematologic diseases (lymphadenopathy; hepatosplenomegaly; or bone tenderness, especially in the. Iron deficiency is the most common cause of anemia Anemias are classifed according to their pathophysio? worldwide. Aside from logic basis, ie, whether related to diminished production circulating red blood cells, the major location of iron in the (relative or absolute reticulocytopenia) or to increased body is the storage pool as ferritin or as hemosiderin in production due to accelerated loss of red blood cells (retic? macrophages. About 10% ofthis amount is absorbed in the stom? pathophysiologic states: acute blood loss, recent replace? ach, duodenum, and upper jejunum under acidic condi? ment of a missing erythropoietic nutrient, or reduced red tions. Dietary iron present as heme is efficiently absorbed blood cell survival (ie, hemolysis). A phages for delivery to erythroid cells prepared to synthesize bone marrow biopsy is generally needed to complete the hemoglobin. Hepcidin, which is increasingly produced evaluation of anemia when the laboratory evaluation fails during infammation, negatively regulates iron transport to reveal an etiology, when there are additional cytopenias by promoting the degradation of ferroportin. Small present, or when an underlying primary or secondary bone amounts of iron-approximately 1 mg/day-are normally marrow process is suspected. In turn, erythroferrone suppresses hepcidin Immune: warm antibody, cold antibody synthesis leading to ferroportin stability and enhanced iron Microangiopathic: thrombotic thrombocytopenic purpura, transport across the gastrointestinal lumen.
There is no specific treatment buy provigil online from canada insomnia types, although various antidepressant drugs have been Plasma Cell Glossitis used successfully buy provigil 100 mg with mastercard sleep aid 1 year old. Plasma cell glossitis is a rare disorder charac terized by diffuse or localized erythema of the tongue buy genuine provigil online insomnia rest client, which exhibits plasma cell infiltration on histopathologic examination (Fig. The cause of the disease is unknown, although several predisposing factors, such as allergic reac tions, endocrine disorders, and C. Plasma cell glossitis may persist for a prolonged period and may be accompanied by a burning sensation. Similar lesions may appear on the gingiva, lips, and other areas of the oral mucosa. The differential diagnosis includes geographic tongue, allergic reactions, and candidosis. Glossodynia, slight erythema and mild elongation of fungiform papillae at the tip of the tongue. Diseases of the Tongue Crenated Tongue Hypertrophy of Circumvallate Papillae Crenated tongue consists of shallow impressions the circumvallate papillae are located on the pos on the lateral margins of the tongue due to the terior aspect of the dorsum of the tongue. The mucosa is usu are 8 to 12 in number arranged in a V-shaped ally normal in appearance but may occasionally be pattern. Hypertrophy of the circumvallate papil red if there is intense friction or pressure against lae results in red, well-circumscribed raised the teeth. Myxedema, acromegaly, amyloidosis, and lipoid proteinosis are diseases that may cause mac roglossia and subsequently crenated tongue. Hypertrophy of Foliate Papillae the foliate papillae are localized in the posterior lateral borders of the tongue and may be rudimen tary in size or they may appear as large protruding nodules. They may become inflamed and enlarged in response to local chronic irritation or infection (Fig. The patient may complain of a burning sensa tion and frequently be alarmed by the enlarged papillae, fearing a cancer. Diseases of the Tongue Hypertrophy of the Fungiform Papillae Sublingual Varices the fungiform papillae appear as multiple small In persons more than 60 years of age varicosities round red nodules along the anterior portion of of the sublingual veins are common. Sublingual varices are benign and they are usually Excessive smoking, alcohol consumption, hot discovered accidentally by the patient. Diseases of the Lips Median Lip Fissure Characteristically, the lesions do not extend be yond the mucocutaneous border. A burning sen Median lip fissure is a relatively rare disorder that sation and feeling of dryness may occur. Un may appear in both lower and upper lips and is treated, angular cheilitis may last for a long time, more common in males than females. Recently, a hereditary predisposi Actinic cheilitis may occur as an acute or chronic tion has been proposed. Chronic actinic cheilitis is observed in sents as a deep inflammatory, persistent vertical older persons as a result of long-standing exposure fissure at the middle of the lip, usually infected by to sunlight (such as farmers, seamen) and charac bacteria and Candida albicans (Fig. In persis sively, the epithelium becomes thin, atrophic with tent severe cases, surgical excision with plastic small whitish-gray areas intermingled with red reconstruction is recommended. There is an increased risk of development of Angular Cheilitis leukoplakia and squamous cell carcinoma. Angular cheilitis, or perleche, is a disorder of the the differential diagnosis should include lupus lips caused by several factors, such as riboflavin erythematosus, lichen planus, contact cheilitis, deficiency, iron deficiency anemia, Plummer-Vin leukoplakia, and squamous cell carcinoma. Histopathologic examination is many cases are due to loss of proper vertical essential to exclude cancer. In such cases, a fold is formed at the angles fluorouracil, and, in severe cases, surgical excision of the mouth in which saliva continuously mois of the involved areas of the lip. It has been shown that microorganisms, such as Candida albicans, Streptococci, Staphylococci, and others may superimpose or cause angular cheilitis. Clinically, the condition is characterized by maceration, fissuring, erythema with erosions, and crusting at the commissures (Fig. Diseases of the Lips Exfoliative Cheilitis Cheilitis Glandularis Exfoliative cheilitis is a chronic inflammatory dis Cheilitis glandularis is an uncommon chronic order of the vermilion border of the lips, which is inflammatory disorder involving chiefly the lower characterized by the persistent formation of scales lip. Emotional stress women with emotional stress and may coexist with and chronic exposure to sunlight have also been atopy. Clinically, it consists of enlargement may become aggravated by cold or very hot of the lip due to minor salivary gland hyperplasia weather. Clinically, exfoliative cheilitis consists of and chronic inflammatory infiltration (Fig. This pattern is repetitive, resulting in thick openings from which mucus or mucopustular fluid ening, scaling, and crusting of one or both lips may be expressed on pressure. The last two forms are a result of the differential diagnosis includes contact cheilitis microbial infection and the clinical signs and and actinic cheilitis. Topical moistening agents (such as the differential diagnosis includes cheilitis cocoa butter) and topical steroids may be helpful. Histopathologic examination is Contact Cheilitis essential in establishing the diagnosis. The most common causes that have been incriminated are lipsticks, lip salves, dentrifices, mouthwashes, foods, etc. Clinically, contact cheilitis is characterized by mild edema and erythema, followed by irritation and scaling (Fig. The differential diagnosis includes exfoliative cheilitis, and plasma cell cheilitis. Treatment consists of discontinuing all contact with the offending substance and use of topical steroids.
Burning or dumping wastes the advertising industry long before they actu into streams and oceans buy 100mg provigil with visa sleep aid for 8 month old, or creating more land ally wear out cheap provigil generic sleep aid with doxylamine. For example it is estimated that the per capita production of do the inordinate amount of waste that is gener mestic waste is many times higher in a devel ated by consumer-oriented societies around the oped country when compared to buy genuine provigil on-line sleep aid dollar tree a developing world is now a serious environmental issue. Unfortunately, many developing coun human activities are related to production and tries are now working out similar wasteful trends consumption cycles which produce excessive through development, but do not have the same amounts of waste in the form of solid, liquid economic potential to handle the waste this new and gaseous waste products. Large quanti waste management in the urban and rural sec ties of solid, liquid and gaseous waste is pro tors are different. Rural communities that were duced by urban industrial communities in the smaller, once had a limited amount of waste form of plastic, paper, leather, tin cans, bottles, which was recycled as the communities used mineral refuse, and pathological waste from them effectively. Dead animals, agricultural wastes, trial civilization the highly complex technologi fertilizer and pesticide overuse, and human and 190 Environmental Studies for Undergraduate Courses Chapter6. The Bagasse, a waste product of the sugar industry, waste is either discharged into the atmosphere, is used in the paper, ply industries. These wastes are not considered to have any the material left over after extraction of oil from economic value. Fancy packaging of consumer products in the generated waste or discarded material that two or three layers is not necessary. Several technological breakthroughs have re Metal scrap and broken glass is used to make cently been made to recover material from in new metal products. Thus Finally, the waste material generated which can the waste does not remain a waste product any neither be reused or recycled, must be disposed more, but becomes a useful resource. Using kitchen wet waste to make compost that can be used as an organic fertilizer. Use only as much as you need, be it any re be adequately treated and raw materials re source water, food, paper, etc. If it is of no the 3R principle of Reduce, Reuse, Recycle, use to you, could someone else use it? If you are sure the item is not usable in its stretched natural resources is reduced. Segregate your waste into wet and dry gar energy expended to convert it into a new bage. A lot of dry waste means you should go back to the Reduce and Thus by following the Reduce, Reuse, Recycle? Reuse? principles and try to follow them better. Avoid the use of non-biodegradable materi nally by proper disposal of residual waste, we als such as Styrofoam and certain types of plas can cut down or the waste generated and en tics. This principle can be Although most plastics are recyclable, recycling followed by everyone, from an individual or an still takes up energy, which is another precious industry to a whole country. Garbage and litter is a visual contaminant and can cause diseases health problems. Try choosing prod ucts that are made from recycled material or are organically grown. They must set up pri reusing the waste resources so as to reduce over orities concerning waste utilization. Most waste can be converted to re sources which can enhance the economy of the country. This must in the Environment (Protection) Act, 1986 not only clude segregation of wet and dry waste, has important constitutional implications but where the wet waste can be converted also an international background. The spirit of to compost and used and the dry waste the proclamation adopted by the United Nations is recycled. Conference on Human Environment which took 3) Research and developmental programs place in Stockholm in June 1972, was imple to find innovative methods of waste re mented by the Government of India by creating cycling must be encouraged. Pri Although there were several existing laws that vate and public organizations for waste dealt directly or indirectly with environmental recycling and management should be issues it was necessary to have a general legis set up. Plans substances or were indirectly related to the en for appropriate disposal of non-utilizable vironment through laws that control landuse, hazardous waste from chemical indus protect our National Parks and Sanctuaries and tries must be implemented and strictly our wildlife. There were also gaps sive programs on education and dem in areas that were potential environmental haz onstration on the reduction of waste, ards and there were several inadequate linkages and the proper disposal and effective in handling matters of industrial and environ reutilization of waste material. This was essentially related to the should be informed of the need for multiplicity of regulatory agencies. Thus there waste management to protect the qual was a need for an authority which could assume ity of the environment. This should be the lead role for studying, planning and imple included in the curriculum at school and menting long term requirements of environmen college level. This is measured in parts per million or cover and an increasing threat to biodiversity. The particulate matter and gases that are released the presence of excessive concentrations of by industry and by cars, buses and two wheel harmful chemicals in the atmosphere and ers is measured by using air sampling equipment. These are people themselves to appreciate the dangers of symptoms of a rapidly deteriorating environ air pollution and reduce their own potential as ment. The growing risks of environmental acci polluters by seeing that their own vehicles or dents and threats to life support systems now the industry they work in reduces levels of emis looms threateningly over our civilisation. While the need for a the earth which among other things includes wider general legislation to protect our environ the preservation of high quality air and ensures ment is now in place, it has become increas controlling the level of air pollution. We need to implement the main objectives of the Act are as follows: this Act much more aggressively if our environ ment is to be protected.
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The bone chosen for breaking is the sam e one as used for the control bones purchase 100mg provigil with amex insomnia 49, as the femur generic 100 mg provigil with visa insomniax sleep pants, etc buy provigil from india sleep aid best. They are roughly cleaned o f soft tissue, being careful not to nick the bone shaft and to place the bone on the bone sup? port o f angle iron, with each support point being 1/3 the distance from each end o f the bone. The lever attached on the w ood fram e extends over the approxim ate center point o f the bone w hen on its supports, w hich are placed on the platform scales. This lever is the same thickness, 1/8 inch, as the supports and can be 18-30 inches long, but touches only the approxim ate center o f the supported bone. Slow dow nw ard pressure on the lever is then exerted, w ith the in? creasing pressure m easured on the scales and noted w hen it breaks, usual? ly quite suddenly, giving an objective strength for each bone, including bones o f control anim als for com parison purposes. The same type o f controls can be used for any bone strong enough to be m easured conveniently by this technique. The m ore uniform the bones used to establish the control levels, the m ore useful in giving the objective num bers needed to evaluate age or disease states for com parison o f soft bones in nutritional im balances or m etabolic variation in disease states, such as rickets, renal failures, or increased density in hypercalcem ias when m ale anim als are fed lactating animal diets. O f course the m aterials used can be enlarged and strengthened for use o f this technique in larger-boned animals. It is also noted in m any studies using these techniques that the bone strengths recorded increase, in rats, for instance, up to about 15 m onths o f age. Also it should be noted that control levels, for instance, in squirrels or fox in one area, m ay not be the same levels at know n ages in other areas because o f dietary differences. A lt? hough usually close, it m ay be necessary to establish the fact with another com parative study for each geographically different area. Feathers and some other external body coverings m ay have to be rem oved previously. A fter the body is transparent, it is im m ersed in an A lizarin Red S solution for a several-day soaking in w hich all tissues are red (purple)) stained. The entire carcass is then placed in glycerol, at w hich tim e m ost o f the dye stain is re? moved, leaving only the red-stained (purple) bones or m ineralized soft tissues still avidly stained in the rest o f the alm ost invisible body. This will allow for better bone evaluation in cases o f bone m alform ation exam inations in toxicological studies and finding o f early m ineral depositions in pathological studies and norm al early stages o f bone developm ent and other related studies involving bone developm ent. This technique works well for fetal studies or young animal studies that do not have a heavy hair coat that m ay have to be re? m oved before clearing the skeleton. It is good for snakes and about any studies for bone evaluations and even for soft-tissue m inerali? zation, such as the aorta or dura m ater o f the spinal cord. Peter Ossent, U niversitat Zurich, Switzerland It has been a problem over the years to exam ine the inside bones and joints o f feet o f m ost large dom estic anim als because o f the difficul? ty in rem oving the h o o f wall from the feet in order to exam ine the inner structures. As m ost diagnostic facilities have hand-type saws or band saws to cut the wall as well as the bone structures for closer exam ina? tion, it still leaves the attached wall to cover other possible lesions. This technique involves the heating o f the entire foot and distal bones in a container partly filled w ith water. The heating tim e for large anim als, when the w ater reaches 6 0 65?C, is approxim ately 4 0 -6 0 m inutes for cattle and horses, and only 15 -2 0 or few er m inutes for sm aller rum inants and pigs. The tim e o f im m ersion can be varied w ithout damage to the foot, but do not allow the tem perature to rise above 65?C. Holding the hoof wall, after heating as above, in a vice, the m etacarpals and m etatarsals can be jerked suddenly to both sides to separate the horn from the underlying tissue and be rem oved. If some difficulty is encoun? tered, the foot should be reim m ersed in the 60-65?C w ater bath for a longer period. H igher tem peratures should N O T be used, as they will cook and discolor the tissue, hiding the lesions. Also, the hooves should be exam ined as soon as possible to prevent discoloration even without higher tem perature use. O f course, continued exam ination o f involved ligam ents, tendons, bones, joint surfaces, etc. A good exam ple is an accident on the highw ay w ith both hu? mans and anim als at risk, with such injuries as partial evisceration o f the horse. They often shoot them betw een the eyes, but in the long-nosed horses, dogs, and others, even apes in the zoo that m ust be killed, this location will often destroy the olfactory ability o f the anim al but will not result in the instant death which is desired. We have subsequently tried to advise police officers, gam e w ar? dens, and others an alm ost 100% sure way to kill rapidly in such cases. It is to draw a line betw een each eye and the opposite ear, form ing a cross, and hit at the junction, aim ing tow ards the spinal cord (foram en magnum). Even then, some anim als will respond to m ovem ent o f the car? cass m inutes after shooting, but these actions are usually only spinal re? flexes. The pig is one exception to this m ethod o f shooting, as large pigs have greatly enlarged diploe, sinus cavities in the skull that can deflect sm all-caliber am m unition. They can be m ore quickly killed if shot in the back o f the skull, aim ing tow ards the nose. In the event o f not having the chem ical nor a gun for the euthana? sia, a sharp necropsy knife w ith a 6-inch, slightly curved blade is a very efficient instrum ent used with a halter, to hold the head dow n tow ards the front feet, enlarging the dorsal joint space betw een the skull and the first vertebra. H olding the knife crossw ise in the m idline over this joint with one hand and hitting the hilt forcefully with the palm o f the other will instantly transect the spinal cord. The large pig can also be killed with a noose put on the upper snout, from w hich the pig will naturally pull backw ards, exposing its entire throat and allow ing a sudden stab into the thoracic inlet just above the bony sternum, directed caudally and to one side, cutting the anterior vena cava. Panciera, O klahom a State University, Stilllwater, O klahom a Intestinal Villi M ovem ent To better assess the m otility and appearance o f intestinal villi, slowly flow on warm saline, and note also their presence and size. Lym phosarcom a and A dipose Tissue Lymphom atous (tumor) tissue in very fatty locations such as the epidural space can be difficult to visually differentiate from adipose tissue depots. A control sec? tion o f lung for com parison, not treated by bronchial perfusion before final fixation, m ay be very enlightening. Glass Slide Sm ears In preparation o f im prints/sm ears o f necropsy specim ens, warm the un? used slide surface first by placing the slide on the forearm for a few sec? onds.