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Professor, Charles R. Drew University of Medicine and Science College of Medicine

In rabbits, Pasteurellosis, a common clinical finding, can lead to many of the causes mentioned. In addition, Pasteurellosis of the inner ear can initiate nausea associated with the head tilt, and can contribute to anorexia. Lastly, pseudoanorexia, which is a physical inability to eat, rather than the lack of desire to eat, must always be considered with the clinically anorectic patient. Dental disease, more specifically malocclusion of either the incisors or the molars, is a frequent contributing factor in rabbits. A thorough physical examination is warranted for every case, including cases with apparent obvious explanations for the anorexia. Radiographs, laboratory analysis (including complete blood counts, serum chemistry analysis and urinalysis) should be a part of every minimum data base. Anorexia and food deprivation has serious consequences on a patient, especially to those which are convalescing. Rabbits are prone to developing fatty livers if the anorexia is not corrected quickly. Vegetable gruels can be administered via syringe feeding, and when necessary, nasogastric tubes. Pasteurellosis Pasteurella multocida is one of the more common bacteria isolated from rabbit pathology. The bacterium can be found in all organ systems, and can be responsible for several different disease symptoms. As a result, most house rabbits should be considered to at least have been exposed to or are carriers of the organism. It is believed that the organism cannot be eliminated from the host, thus resulting in a permanent carrier state. Symptoms can include "Snuffles" (ocular/nasal discharge, mild respiratory signs), dermatitis, dental disease (tooth abscesses), severe respiratory infections (pneumonia), torticollis and abscesses. These abscesses are usually dermal, and can occur anywhere on the body, or can be internal, commonly arising in organs such as the kidneys, the liver and the lungs. Dermal abscesses can literally arise in a short period of time, with owners often reporting their presence in as little as a couple of days. Although the abscesses can be found anywhere on the body, I have seen them between the mandibles, below or between the ears, and attached to the mandibular or maxillary bone, associated with dental abscesses. In pasteurella conjunctivitis, the periorbital tissue is oftentimes so inflamed as to make the entire orbit/globe appear enlarged. It is not uncommon for the lacrimal glands to be occluded with inflammatory debris, thus exacerbating the pasteurella conjunctivitis. It is a benefit to the patient to gently flush the lacrimal glands prior to initiating ophthalmic antibiotics. Simple draining of the caseous material within the abscess, even with the aid of a penrose drain, will not suffice as it does in feline abscesses. This necessitates anesthesia, and because of the propensity for pasteurella abscessation in the lungs, it is prudent to radiograph the thorax prior to administering any anesthetics. Lesser cases, those involving the As mentioned, it may not be possible to completely eradicate the pasteurellosis from a rabbit. Culture, surgical debulking and appropriate antimicrobial therapy should always be considered. In some instances, animals may require prolonged administration of antimicrobials, sometimes lasting as long as one year. Either drug should be administered for at least 14 to 21 days, or as long as is necessary to control the infection. Tooth Root Abscess It is not uncommon for rabbits to present with abscesses of dental roots. These manifest as simple anorexia, or present with large, firm swellings adhered to the adjacent maxillary or mandibular bone. There may be an associated fluid or purulent pocket associated with the abscess, over the lesion. Proper restraint is in order, and a thorough oral examination is a must when masses are identified around the oral region.

Thus it may diminish, an indication of spontaneous resoIution, or it may enIarge downward. Large cul-de-sac masses may arise out of the pelvis and then become palpable on abdomina1 examination. As suppuration occurs in a pelvic mass, the anal sphincter relaxes and the anus becomes patulous. The recta1 mucosa becomes edematous and succuIent and has a soft, thick, velvety feel. In general, our preference is for abdomina1 drainage and this should be performed in the extraperitoneal manner. Many surgeons, however, more or Iess routinely advise drainage by way of the rectum or vagina. In rectal puncture there is aIways the danger of injury to the great vessels of the pelvis. The bIadder may also be injured during this procedure and Stafford and Sprong report a fatahty due to this accident which was folIowed by a persistent rectovesical hstula and a fatal ascending infection of the urinary tract. In our opinion, rectal drainage should be reserved for those peIvic abscesses which are Iarge and which point low down in the rectum, and in which a large area of softening can be demonstrated. When this is the case, the diagnosis is first confirmed by aspiration of the abscess with a Iarge gauge needle. If pus is obtained on aspiration, drainage of the cavity is established by making a vertica1 incision in the anterior rectal wall at the site of the needle puncture, evacuating the pus and inserting drains. Undrained cul-de-sac abscesses may spontaneously rupture into the rectum and thereby undergo spontaneous cure. Ab- 108 American Journal of Surgery Ransom-Appendicitis hepatic space into right and Ieft spaces of approximately equa1 size. The right suprahepatic space is divided by the IateraI extension of the cardina1 Iigament of the Iiver, i. The infrahepatic space is aIso divided into right and Ieft haIves by the round Iigament and the ligament of the ductus venosus. WhiIe there is but one right inferior space, on the Ieft side and separated by the stomach and gastrohepatic omentum are the Ieft anterior inferior and the Ieft posterior inferior spaces. Thus Ochsner and DeBakey found in a review of 1,461 cases of subphrenic abscess that the right posterior superior space was invoIved in 33. Subphrenic abscesses may be residua1, as in cases of a resoIving genera1 peritonitis, or secondary when infection has extended from the appendix to the peritoneum but when genera1 peritonitis has not occurred. With regard to diagnosis, the condition is suggested by continued evidence of sepsis (fever and Ieucocytosis) in a patient known to have had a IocaI or general appendicea1 peritonitis and in whom evidence of a suppurative process eIsewhere in the abdomen, as we11 as extraabdomina1 causes for fever have been excIuded. Faxon, l4 in a recent communication, reported 124 consecutive operative cases of subphrenic abscess at the Massachusetts Genera1 HospitaI, and found the etioIogy to be a lesion of the appendix in thirty-eight, or 31 per cent. The mechanism whereby infection may reach the subdiaphragmatic spaces from the somewhat distant right iIiac fossa is of interest. The route most often described is that of direct extension aIong the right paracolic gutter. Overholt, l6 by experimentaI studies, has demonstrated the fact that a negative pressure is created in the upper abdomen by respiratory movements, and this wouId tend to cause septic materia1 to be aspirated upward and into this region. ConsiderabIe attention has been given to the possibiIity of extension by way of the Iymphatics by Munro,17 Barnard l8 and TruesdaIe. The main subphrenic space is divided by the Iiver into a suprahepatic and an infrahepatic portion. A, roentgenogram in anteroposterior projection showing the appearance in a late case of subdiaphragmatic abscess. The right diaphragm is elevated and a large gas bubble is seen beneath the diaphragm. The roentgenoIogica1 examination will assist materially in the diagnosis, although the roentgen findings are not pathognomanic unti1 the late stages when a gas bubble and ffuid IeveI can be demonstrated. It is to be remembered that at the time of Iaparotomy or abdominal paracentesis, air may be intro- picture.

This low and declining achievement rate may be connected to a general lack of reading. The general movement, however, should be toward decreasing scaffolding and increasing independence both within and across the text complexity bands defined in the Standards. Although the decline occurred in all demographic groups, the steepest decline by far was among 18-to-24- and 25-to-34-year-olds (28 percent and 23 percent, respectively). In other words, the problem of lack of reading is not only getting worse but doing so at an accelerating rate. Although numerous factors likely contribute to the decline in reading, it is reasonable to conclude from the evidence presented above that the deterioration in overall reading ability, abetted by a decline in K­12 text complexity and a lack of focus on independent reading of complex texts, is a contributing factor. Being able to read complex text independently and proficiently is essential for high achievement in college and the workplace and important in numerous life tasks. Moreover, current trends suggest that if students cannot read challenging texts with understanding-if they have not developed the skill, concentration, and stamina to read such texts-they will read less in general. In particular, if students cannot read complex expository text to gain information, they will likely turn to text-free or text-light sources, such as video, podcasts, and tweets. These sources, while not without value, cannot capture the nuance, subtlety, depth, or breadth of ideas developed through complex text. As Adams (2009) puts it, "There may one day be modes and methods of information delivery that are as efficient and powerful as text, but for now there is no contest. A turning away from complex texts is likely to lead to a general impoverishment of knowledge, which, because knowledge is intimately linked with reading comprehension ability, will accelerate the decline in the ability to comprehend complex texts and the decline in the richness of text itself. This bodes ill for the ability of Americans to meet the demands placed upon them by citizenship in a democratic republic and the challenges of a highly competitive global marketplace of goods, services, and ideas. It should be noted also that the problems with reading achievement are not "equal opportunity" in their effects: students arriving at school from less-educated families are disproportionately represented in many of these statistics (Bettinger & Long, 2009). The consequences of insufficiently high text demands and a lack of accountability for independent reading of complex texts in K­12 schooling are severe for everyone, but they are disproportionately so for those who are already most isolated from text before arriving at the schoolhouse door. In the Standards, qualitative dimensions and qualitative factors refer to those aspects of text complexity best measured or only measurable by an attentive human reader, such as levels of meaning or purpose; structure; language conventionality and clarity; and knowledge demands. The terms quantitative dimensions and quantitative factors refer to those aspects of text complexity, such as word length or frequency, sentence length, and text cohesion, that are difficult if not impossible for a human reader to evaluate efficiently, especially in long texts, and are thus today typically measured by computer software. Such assessments are best made by teachers employing their professional judgment, experience, and knowledge of their students and the subject. The following pages begin with a brief overview of just some of the currently available tools, both qualitative and quantitative, for measuring text complexity, continue with some important considerations for using text complexity with students, and conclude with a series of examples showing how text complexity measures, balanced with reader and task considerations, might be used with a number of different texts. Qualitative and Quantitative Measures of Text Complexity the qualitative and quantitative measures of text complexity described below are representative of the best tools presently available. However, each should be considered only provisional; more precise, more accurate, and easierto-use tools are urgently needed to help make text complexity a vital, everyday part of classroom instruction and curriculum planning. Qualitative Measures of Text Complexity Using qualitative measures of text complexity involves making an informed decision about the difficulty of a text in terms of one or more factors discernible to a human reader applying trained judgment to the task. In the Standards, qualitative measures, along with professional judgment in matching a text to reader and task, serve as a necessary complement and sometimes as a corrective to quantitative measures, which, as discussed below, cannot (at least at present) capture all of the elements that make a text easy or challenging to read and are not equally successful in rating the complexity of all categories of text. Built on prior research, the four qualitative factors described below are offered here as a first step in the development of robust tools for the qualitative analysis of text complexity. These factors are presented as continua of difficulty rather than as a succession of discrete "stages" in text complexity. Additional development and validation would be needed to translate these or other dimensions into, for example, grade-level- or grade-band-specific rubrics. The qualitative factors run from easy (left-hand side) to difficult (right-hand side). Few, if any, authentic texts will be low or high on all of these measures, and some elements of the dimensions are better suited to literary or to informational texts. Similarily, informational texts with an explicitly stated purpose are generally easier to comprehend than informational texts with an implicit, hidden, or obscure purpose.

Horses should either have access to a white non-iodized salt block or have white table salt top dressed on to their daily ration. Salt intake is likely to be highly variable between horses, but most horses will consume an adequate amount of salt daily if applied directly to the daily ration. When selecting an electrolyte supplement, it is important to evaluate the ingredients and guaranteed analysis. Many commercially available electrolytes have large amounts of dextrose and relatively limited levels of electrolytes. Administering electrolytes to an already dehydrated horse is dangerous and may in fact exacerbate dehydration (Holbrook et al. Further, addition of electrolytes directly to water has been shown to decrease voluntary water intake in horses. Commercially available concentrate diets are often fortified appropriately to provide the required levels of vitamins and minerals when fed according to directions. Vitamin E is a fat-soluble vitamin that acts as an important antioxidant to neutralize free radicals produced during exercise. Supplemental energy should be supplied via dietary fat and horses should receive optimal levels of Vitamin E daily. Providing these horses with high quality concentrate diets is critical to ensuring optimal performance. For all these horses, conditioning programs and consistent exercise protocols should be followed. However, understanding the need for precise energy sources to support the specific activity that the horse is doing can help guide the decision-making process. Understanding the physiology of exercise and energy utilization can serve as a guide in determining the optimal concentrate diet for the individual horse. Having a nutrition program that complements a training program is critical as these go hand in hand in ensuring the health and performance of the exercising horse. It is important to remember that successful performances and winning is not the result of feeding a single certain supplement or feed. Rather, it is the combination of knowledge of the physiology of the animal with the diet that they are being provided. However, horses with certain medical conditions may require a unique feeding management protocol. Unfortunately, little published data exists regarding what to feed the "sick" horse, as most studies have focused on meeting the nutritional needs of the "healthy" horse. This paper will serve as a reference for feeding management of horses afflicted with certain clinical cases including: 1) Feeding the starved or severely malnourished horse 2) Feeding horses suffering from chronic colic, and 3) Feeding horses prior to and immediately following surgery. This paper should serve as a starting point when looking for information; however, there are many in-depth references available (Reed et al. Causes of Extreme Weight Loss or Malnutrition Extreme weight loss in horses is often highly emotive. Extreme weight loss, defined as an individual approximately 30% below ideal body weight, may be the result of one or multiple causes. The following list outlines a more comprehensive causative list of emaciation in horses. While the causative factors of emaciation in horses is extensive, typically the pathophysiology of the condition is similar across cases. As the individual horse routinely and consistently experiences nutritional deprivation, body stores of carbohydrates, fat and protein are metabolized and utilized to sustain critical physiological functions. If this process persists, significant stores of adipose tissue and skeletal muscle will be depleted leading to visible muscle wasting as well as harder to detect depletion of cardiac muscle and organ tissue (Witham and Stull, 1998). Dietary insufficiencies of minerals such as calcium and phosphorus may lead to instances of abnormal joint and bone development. Deficiencies of other minerals such as iodine and selenium may cause more noticeable clinical signs including goiter and hair loss respectively.

Polycythaemia vera presents in late middle age (50­60 years), most commonly as a chance haematological finding. If symptomatic, it presents usually with vascular occlusion, arterial or venous or, much less often, with gout, pruritus or a finding of splenomegaly. Prognosis Sickle cell disease carries a high infant and child mortality from thrombosis to a vital organ or infection, with pneumococcus the most common as a result of hyposplenism. Children who survive beyond 4­5 years continue to have chronic ill health with anaemia, haemolytic and thrombotic crises, leg ulcers and infections (which may precipitate crises), and rarely survive beyond 50 years. Pneumococcal vaccine should be given and penicillin prescribed to reduce mortality from pneumococcus. Bone marrow transplantation is curative but limited by availability of well matched donors. Thalassaemia Thalassaemia is found in the Middle and Far East and the Mediterranean and is caused by deficient alphaor beta-chain synthesis. In the latter, gamma-chains continue to be produced in excess into adult life and excess HbF is present. Erythroid hyperplasia occurs in the marrow and chain precipitation appears as inclusion bodies on supravital staining. Infants who survive develop hepatosplenomegaly, bossing of the skull, brittle and overgrown long bones, gallstones and leg ulcers. Treatment consists of transfusion to maintain the haemoglobin at 10 g/dl, but this, combined with increased iron absorption, results in iron overload. Desferrioxamine is given to reduce haemosiderosis with folic acid replacement, and splenectomy may be indicated if hypersplenism supervenes. A diagnosis of polycythaemia vera can also be made if there is a raised haemoglobin and two minor criteria. Secondary causes to be excluded include hypoxaemia and renal disease (ultrasound for polycystic disease and hypernephroma). Treatment is with repeated venesection, low-dose aspirin to reduce the incidence of intravascular coagulation and hydroxyurea in high risk patients who are elderly or have a history of thrombosis. Essential thrombocythaemia, if not found incidentally, presents with small vessel vascular occlusion. Treatment is with low dose aspirin and hydroxyurea in high risk patients who are elderly or have a history of thrombosis. Primary myelofibrosis typically presents with the finding of huge and increasing splenomegaly, and evidence of bone marrow failure: anaemia, infection, bleeding. Hydroxyurea, thalidomide and the thalidomide analogue lenalidomide have been used in therapy. Autoimmune thrombocytopenic purpura, in which circulating antiplatelet antibodies lead to premature platelet destruction. Chemotherapy, lenalidomide and allogenic bone marrow transplantation have all been used in therapy. Myelodysplastic syndromes Myelodysplastic syndromes are a heterogeneous group of disorders that are characterised by clonal and ineffective hematopoiesis in the setting of a dysplastic bone marrow, peripheral blood cytopenias and progressive bone marrow failure. It is usually discovered on a routine peripheral blood film, usually as macrocytosis (with normal B12, folates, liver and thyroid function tests, and g-glutamyl transferase). Less commonly, patients may present with a refractory anaemia, pancytopenia, neutropenia or thrombocytopenia (Table 20. Classification is continuously under review, but there are five major subgroups which tend to have decreasingly satisfactory prognoses: refractory anaemia refractory anaemia with ringed sideroblasts refractory anaemia with excess blasts refractory anaemia with excess blasts in transformation 5 chronic myelomonocytic leukemia. Although hereditary forms of sideroblastic anaemia exist, sideroblasts are most frequently seen in myelodysplastic syndromes. Marrow failure Marrow aplasia Primary aplastic anaemia gives a pancytopenia with reduction in all the formed elements. A peripheral blood film reveals a pancytopenia, although one cell line may be affected more than the others. If it is difficult to aspirate (possible myelofibrosis or malignancy), a trephine biopsy may be necessary to obtain a diagnostic specimen of marrow. The drugs that most Haematology 331 commonly cause marrow suppression include cytotoxic drugs, gold, indometacin and chloramphenicol. Some marrow suppression is associated with uraemia, rheumatoid arthritis and hypothyroidism.