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Professor, University of South Florida College of Medicine

The role of nafamostat mesylate in continuous renal replacement therapy among patients at high risk of bleeding. Pediatric convective hemofiltration: normocarb replacement fluid and citrate anticoagulation. Biochemical effects of phosphate-containing replacement fluid for continuous venovenous hemofiltration. Effluent volume in continuous renal replacement therapy overestimates the delivered dose of dialysis. Is there a role for continuous renal replacement therapies in patients with liver and renal failure? A comparison of two citrate anticoagulation regimens for continuous veno-venous hemofiltration. The acid-base effect of changing citrate solution for regional anticoagulation during continuous veno-venous hemofiltration. Recombinant hirudin (lepirudin) as anticoagulant in intensive care patients treated with continuous hemodialysis. Update on drug sieving coefficients and dosing adjustments during continuous renal replacement therapies. Middle-molecule clearance at 20 and 35 ml/kg/h in continuous venovenous hemodiafiltration. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Peripherally inserted veno-venous ultrafiltration for rapid treatment of volume overloaded patients. Insertion side, body position and circuit life during continuous renal replacement therapy with femoral vein access. Extended daily dialysis: a new approach to renal replacement for acute renal failure in the intensive care unit. Dialyzer fiber bundle volume and kinetics of solute removal in continuous venovenous hemodialysis. Intermittent versus continuous renal replacement therapy for acute kidney injury patients admitted to the intensive care unit: results of a randomized clinical trial. Interrelation of humoral factors, hemodynamics, and fluid and salt metabolism in congestive heart failure: effects of extracorporeal ultrafiltration. Mortality rate comparison after switching from continuous to prolonged intermittent renal replacement for acute kidney injury in three intensive care units from different countries. Unexpected severe hypocalcemia during continuous venovenous hemodialysis with regional citrate anticoagulation. Increased total to ionized calcium ratio during continuous venovenous hemodialysis with regional citrate anticoagulation. A randomized trial of catheters of different lengths to achieve right atrium versus superior vena cava placement for continuous renal replacement therapy. Long-term outcomes in acute renal failure patients treated with continuous renal replacement therapies. Blood warming during hemofiltration can improve hemodynamics and outcome in ovine septic shock. Effects of continuous venovenous haemofiltration-induced cooling on global haemodynamics, splanchnic oxygen and energy balance in critically ill patients. Low molecular weight heparins as thromboprophylaxis in patients undergoing hemodialysis/hemofiltration or continuous renal replacement therapies. The use of regional citrate anticoagulation continuous venovenous haemofiltration in extracorporeal membrane oxygenation. Continuous renal replacement therapy and charcoal plasmaperfusion in treatment of amanita mushroom poisoning. In vitro glucose kinetics during continuous renal replacement therapy: implications for caloric balance in critically ill patients. Automated regional citrate anticoagulation: technological barriers and possible solutions. Machine generated bicarbonate dialysate for continuous therapy: a 10-year experience. Phosphate addition to hemodiafiltration solutions during continuous renal replacement therapy. Outcome of acute kidney injury with different treatment options: long-term follow-up.

Viral-specific nucleic acid probes are more sensitive than other techniques and allow the detection of small concentrations of virus as well as the ability to detect the presence of viral nucleic acid before substantial histologic changes may have occurred. There are over 8,700 avian species, which probably have an equally large number of specifically host-adapted viruses. Primary cell cultures from fibroblasts, kidney or liver cells collected from embryos of the test species normally provide the best chance of isolating a host-adapted virus. Unfortunately, such embryos (which should ideally be free of specific pathogens) are rarely available for the bird species seen in private practice. Cell cultures derived from chickens, ducks and geese are most often used as an alternative choice because of their wide availability; however, these sources of cells have inherent problems. Not every newly prepared cell culture is identical to its predecessor, which may affect virus propagation. In addition to tissue cultures, embryonated eggs have been used to recover avian viruses. In contrast to tissue culture, they offer a complete biologic system with cells of endo-, meso- and ectodermal origin. The flocks from which these eggs are obtained should be free of viruses and virus antibodies in order to allow a particular virus to grow. Virus Identification Direct identification of a virus by electron microscopy is possible only with a relatively high concentration of the virus (generally >106 particles/ml). As a rapid but insensitive survey, fresh tissue samples fixed on grids (stained with osmium or another appropriate stain) can be examined by electron microscopy for the presence of viruses. Viral-specific nucleic acid probes allow the detection of very small concentrations of a virus in infected tissues or contaminated samples (crop washing, feces, respiratory excretions). Analytic methods such as electrophoresis without blot systems (Ab-dependent with blots), chromatography and nucleic acid probes are the most sensitive methods of demonstrating virus. The recent advances in genetic engineering will certainly have profound effects on virus detection in the future. The initial precipitating antibody changes induced by the virus, such as histologically titer was 0. The presence of a precipitation line at 1/80 (arrow) discernible inclusion bodies. Depending on the test objective, either polyclonal or monoclonal antibodies can be used. Monoclonal antibodies are normally used for identifying specific antigen structures and to differentiate between serotypes, subtypes, variants and mutants. A rise or fall in Ab concentrations or a switch from IgM to IgG are indicative of an active infection. Egg yolk (containing IgG) can be used in place of serum for some diagnostic tests. Serologic cross-reactions caused by closely related antigens or epitopes with an identical structure can cause false-positive results when using indirect virus identification techniques. The immunodiffusion test; therefore, is useful in diagnosing an actively occurring antibody response. Test Material the proper test material for diagnosing viral infections depends on whether antemortem or postmortem samples are available and which viral disease is suspected. Antemortem samples may include feces, skin, organ or feather biopsy, blood or serum, or mucosal swabs from the trachea, cloaca, pharynx or conjunctiva. Samples for culture should be transported quickly and well cooled in a transport medium containing antibiotics. A relevant anamnestic report is valuable to help guide the laboratory diagnostic efforts. Avipoxvirus Members of the Poxviridae family (Avipoxvirus genus) cause a variety of diseases in birds. These inclusion bodies may be identified in affected epithelial cells of the integument, respiratory tract and oral cavity. Many bird species are considered to be susceptible to some strain of poxvirus, and isolates from different bird species have been classified into taxons. Biologic and serologic-immunologic properties for many avian poxviruses have not been determined, and the currently described taxons are probably incomplete. Most of the members of the genus seem to be speciesspecific, but some taxons appear to be able to pass the species, genus or even family barrier.

Feeding a liquid formula to granivorous birds can induce crop stasis, possibly as a result of a lack of mechanical stimulation. In turkeys, there is thought to be a hereditary predisposition to developing a pendulous crop after increased liquid intake during the first wave of seasonal hot weather. The majority of affected birds do not recover, but continue to have pendulous crops. It has been shown that feeding cerelose as a substitute for starch increases the incidence of pendulous crop in gallinaceous birds. Affected birds had large quantities of the gas-producing yeast Saccharomyces tellustris. Lead poisoning, acute fowl cholera and ventricular worm infections can cause similar clinical signs. Food substances that are difficult to digest, such as raw potatoes, beets, apple skins, sausage skins and large pieces of animal tissues, may also cause crop impaction. In captive raptors, ingluvial impaction may occur when roughage is suddenly added to a low roughage diet, or when the moisture content of the diet is inadequate. Crop impaction may be complicated by secondary Clostridium perfringens infection in the European Kestrel. However, an ingluviotomy will generally be the method of choice for removing impacted material. Expressing the ingluvial contents through the mouth by turning the bird upside down is a dangerous procedure that may lead to irritation of the nasal mucosa, sinusitis or aspiration pneumonia. Packing the choana with cotton and intubating with an endotracheal tube will help eliminate this problem. Other ingluvioliths have been found to contain potassium phosphate, oxalate and cystine, and were not considered to have occurred secondary to urate ingestion (Color 19. Crop and Esophageal Lacerations and Fistula Penetration of the pharynx or esophagus by feeding cannulas, or esophageal-ingluvial burns caused by ingestion of overheated feeding formulas or caustic materials can result in deposition of food subcutaneously and lead to extensive foreign body reactions. In birds of prey, sharp bones from prey animals may cause an esophageal or ingluvial fistula. A bird with a crop fistula may be presented with weight loss despite a ravenous appetite. A feeding tube can be passed from the esophagus directly into the proventriculus to allow enteral feeding while the esophagus and crop heal (see Chapters 15, 16 and 41). Endoscopic examination through an ingluvial incision revealed an annular ring of exudate and hyperplastic tissue. The bird was maintained in an earthen-floored flight enclosure and was fed wild bird seeds. In addition, an excessive number of mineral densities (small rocks, grit) were present in the ventriculus and intestinal tract. The metallic densities (pieces of wire) were removed using an endoscope and forceps. The bird was given corn oil by crop tube three times a day for three days, and rocks were noted in the stool on the day after the first corn oil treatment. The Proventriculus and Ventriculus Anatomy and Physiology55,101 the avian stomach consists of a cranial glandular part (proventriculus) and a caudal muscular part (ventriculus). The proventriculus in birds is situated in the left dorsal and left ventral regions of the thoraco-abdominal cavity, and is covered ventrally by the fat-laden posthepatic septum (see Color 14). The pyloric part of the ventriculus joins the duodenum and is located on the right side of the midline. In granivorous, insectivorous and herbivorous birds, the muscular wall of the ventriculus is highly developed and is clearly distinct from the proventriculus. The two organs are divided by an intermediate zone, or isthmus, which can be seen grossly as a constrictive band (Figure 19. The ventriculus can be palpated in granivorous birds on the left ventral side of the abdomen just caudal to the sternum. Mucus-producing, columnar epithelial cells line the proventricular mucosa and the lumina of the ducts from the proventricular glands. These cells have ultrastructural features similar to both the parietal (acid-secreting) and the peptic (enzyme-secreting) cells of the mammalian stomach, and secrete both pepsinogen and hydrochloric acid.

Pupillary light reflexes do occur in birds but their interpretation is complicated by the fact that voluntary constriction and dilation of the pupil is possible, even in the absence of retinal stimulation. Clinically, the complete separation of the optic nerves prevents the elicitation of a consensual pupillary light reflex. The iridocorneal angle is well developed in all birds and drains the aqueous fluid, as in mammals. The lens is soft and is almost spherical in nocturnal birds, or has a flattened anterior face in diurnal species including companion birds. An annular pad lies under the lens capsule in the equatorial region, and can be separated from the center of the lens during cataract surgery. Recent work has shown that small, regular torsional movements of the eye sweep the pecten through the relatively fluid vitreous. Blood vessels in the pecten disperse a serum filtrate that extends to the peripheral retina. Macaws have a particularly distinct foveal area that can be evaluated fundoscopically. It is suggested that in bi-foveate birds, one fovea serves for near vision and the other accommodates long-range vision. Ophthalmic Disorders Lids and Periorbita One of the most common ocular presentations in large psittacine birds is periorbital disease secondary to upper respiratory infection, particularly chronic rhinitis and sinusitis (Figure 26. As stated above, the close proximity of the infraorbital sinus to the orbit predisposes it to physical displacement when the sinus diverticulum is enlarged. In some cases, cellulitis or abscessation occur from spread of organisms from the sinus cavity. Antibiotics alone are rarely efficacious in these cases; flushing the sinus and, in some cases, more aggressive surgical debridement is required (see Chapter 41). This condition has been most frequently reported in macaws but may also occur with sinusitis in other avian species. Poxvirus Avian poxvirus may cause lesions in or around the eyes in a number of species (see Chapter 32). The initial changes include a mild, predominantly unilateral blepharitis with eyelid edema and serous discharge starting about 10 to 14 days post-infection (Color 26. As the disease progresses, ulcerative lesions on the lid margins and at the medial or lateral canthus develop; these can become secondarily infected, giving rise to a mucopurulent discharge and transient ankyloblepharon (Color 26. An infection can be confirmed through histopathologic identification of eosinophilic intracytoplasmic inclusion bodies (Bollinger bodies) in scabs or scrapings of periocular ulcers. The keratitis can be mild with corneal clouding or severe with ulceration that progresses to panophthalmitis and rupture of the globe. Cicatricial changes in the lid margins can lead to entropion, ankyloblepharon or deformities of the lid edge, resulting in keratitis from corneal abrasion or environmental exposure. These patients may need corrective surgery (lid retraction) or can be placed on life-long therapy with ocular lubricants. Many affected psittacine birds, particularly Amazons, pionus parrots and mynah birds, have residual problems that cause more important pathology than the primary ocular and periocular lesions. In one study, 46% of the Amazon parrots and pionus parrots with poxvirus had post-infection ocular abnormalities. Treatment of poxvirus lesions should include topical antibiotic ophthalmic ointments to reduce the incidence of these sequelae. It may be beneficial to soften scabs with hot or cold compresses soaked in nonirritating baby shampoo. It has been reported that prophylactic vitamin A supplementation of exposed birds decreases the severity of infection36 (see Chapter 18). The importance of subclinical hypovitaminosis A in the progression of the disease has not been determined. Hypovitaminosis A Hypovitaminosis A is less prevalent today than a decade ago; however, it may still be seen as a complicating factor in ocular diseases.