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By D. Ben. University of Tennessee Health Science Center.

Then discount cialis 5mg free shipping erectile dysfunction fatigue, during the pre-maintenance and maintenance phases cheap 2.5mg cialis mastercard erectile dysfunction treatment methods, dieters determine the level of carbohydrate consumption that allows them to maintain their weight order cialis 20mg amex encore erectile dysfunction pump. To prevent regaining weight, dieters must stick to this level of carbohydrate consumption, perhaps for the rest of their lives. Although we agree with the underlying principle of the Atkins Diet, that diets high in sugar and refined carbohydrates cause weight gain and ultimately lead to obesity, we disagree with several aspects of the solution. One of the big reasons why the Atkins Diet is so attractive to dieters who have tried unsuccessfully to lose weight on low-fat, low-calorie diets is that while on the Atkins Diet, they can eat as many calories as desired from protein and fat, as long as carbohydrate consumption is restricted. As a result, many Atkins dieters are spared the feelings of hunger and deprivation that accompany other weight loss regimens. However, we simply do not agree that such a diet is conducive to long-term health. Despite its enormous popularity, the Atkins program was not evaluated in a proper clinical trial until 2003. In this initial study, although people following the Atkins Diet did experience initial weight loss (probably as a result of water loss rather than true fat loss), in the long run they gained it all back plus more. In the study, 63 obese men and women were randomly assigned to the Atkins Diet or a low-calorie, high-carbohydrate, low-fat diet. Although at 6 months subjects on the Atkins Diet had lost more weight than subjects on the conventional diet, the difference at 12 months was not significant. Although the Atkins Diet did promote weight loss during the first 6-month period, this effect began to disappear during the second 6-month period. At 12 months, the difference in average weight loss in the groups was no longer statistically significant (11 lb in the Atkins group vs. In this study, 120 overweight but otherwise healthy adult subjects with elevated lipid levels followed either the Atkins Diet or a diet containing fewer than 30% calories from fat, 10% or fewer calories from saturated fat, less than 300 mg cholesterol, and a deficit of 500 to 1,000 calories. The main criticism of this dietary study was that the so-called low-fat group received almost 30% of its caloric intake from fat, and the dieticians administering the dietary recommendations made no clear attempt to significantly restrict sugar and refined carbohydrate sources. Thus, the control diet with which the Atkins Diet was compared was significantly less than ideal. Although the low-carbohydrate diet was associated with a greater improvement in some risk factors, on the basis of the current evidence we do not recommend the Atkins Diet. Furthermore, since the high protein content of the Atkins Diet stresses the liver and kidneys, we do not recommend it for anyone with impaired liver or kidney function. Our final concern is that on the Atkins Diet there is not much differentiation between high-quality proteins and fats and those of lower quality. For example, a person eating an Atkins-type diet can consume excessive amounts of carcinogens from meats and omega-6 fatty acids from corn-fed animals that can result in silent inflammation (see the chapter “Silent Inflammation” for a more complete discussion). Natural Weight Loss Aids Several natural weight loss aids can help to either reduce appetite or enhance metabolism. When taken with water before meals, these fiber sources bind to the water in the stomach to form a gelatinous mass that induces a sense of satiety. Fiber supplements have been shown to enhance blood sugar control, decrease insulin levels, and reduce the number of calories absorbed by the body. In some of the clinical studies demonstrating weight loss, fiber supplements were shown to reduce the number of calories absorbed by 30 to 180 per day. Although modest, this reduction in calories would, over the course of a year, result in a 3- to 18-lb weight loss. Be sure to drink adequate amounts of water when taking any fiber supplement, especially if it is in pill form. Several studies have used guar gum, a soluble fiber obtained from the Indian cluster bean (Cyamopsis tetragonoloba), glucomannan from konjac root (Amorphophallus konjac), and pectin, with good results. For instance, this ability to bind water and form a viscous mass is why oat bran lowers cholesterol and controls blood sugar better gram for gram than wheat bran. Meal Replacement Formulas Meal replacement formulas are a popular weight-loss strategy. The Medifast plan included five meal replacement drinks (90–110 calories each), 5–7 oz lean protein, 11/2 cups nonstarchy vegetables, and up to two fat servings per day, providing a total of 800–1,000 calories. The meal replacements used in this study were low-fat, low-glycemic, and low-sugar; provided a balanced ratio of carbohydrates to proteins; and were based on either soy and/or whey protein. The food-based plan included 3 oz grains, 1 cup vegetables, 1 cup fruit, 16 fl oz milk, 5–7 oz lean protein, and 3 tsp fat per day, providing a total of about 1,000 calories per day. Significantly more of the Medifast participants had lost 5% or more of their initial weight at week 16 (93% vs. At week 40, mean body fat had dropped among the subjects in the Medifast group by 2. Blood pressure also dropped: at week 40, the Medifast group saw a reduction in systolic blood pressure of 6. Chromium has recently gained a great deal of attention as an aid to weight loss, as it plays a key role in cellular sensitivity to insulin. The importance of this trace mineral in human nutrition was not discovered until 1957, when it was shown that it was essential to proper blood sugar control. Chromium levels can be depleted by refined sugars, white flour products, and lack of exercise. In one study, eight female patients with hypoglycemia given 200 mg per day for three months demonstrated alleviation of their symptoms. Chromium supplementation has been demonstrated to lower body weight yet increase lean body mass, presumably as a result of increased insulin sensitivity. The men taking chromium picolinate lost more than seven times as much body fat as those taking the placebo (7. Particularly interesting is the fact that in these initial studies, chromium picolinate promoted an increase in lean body weight percentage, as it led to fat loss but also to muscle gain. However, two clinical trials with women involved in an exercise program did not find any significant changes in body composition. Chromium picolinate, chromium polynicotinate, chromium chloride, and chromium-enriched yeast are each touted by their respective suppliers as providing the greatest benefit. No firm evidence indicates that one is a significantly better choice than another. In other words, these rats are fat as a result of a genetically determined low level of activity of the enzyme that starts the manufacture of serotonin from tryptophan. These rats don’t get the message to stop eating until they have consumed far greater amounts of food than normal rats. Circumstantial evidence indicates that many humans are genetically predisposed to obesity. This predisposition may involve the same mechanism as that in these genetically predisposed rats (i. For the first 6 weeks there were no dietary recommendations, and for the second 6 weeks the women were placed on a 1,200-calorie diet. The lack of weight loss during the second 6-week period in the placebo group obviously reflects the fact that the women had difficulty adhering to the diet.

Activa- tion causes macrophages to increase in size order cialis 20 mg mastercard doctor of erectile dysfunction, mobility and metabolic activ- ity order 2.5mg cialis fast delivery erectile dysfunction doctor singapore. They are che- motactically attracted to the site of microbial invasion where they help to eliminate the intruder cheap 10mg cialis erectile dysfunction pills available in stores. The macrophage then activates the immune response by stimulating the propagation of B-cells tion, they secrete factors such as and T-cells. If a pathogen persists in the macrophage, then a bird’s immune system will complement factors C2, C3, C4 and not be stimulated to destroy the invading pathogen. Macro- absorb antibody into their cytoplasmic filaments in phages also activate fibroblasts and stimulate wound such a way that antigens can be trapped. The ability of a host to survive an infection that are bound to dendritic cells are very powerful is usually dependent on the functional capacity of the immunostimulants that may play a major role in macrophages (Figure 5. Immune Modulators Not all foreign material is totally ingested or de- Several immune modulators, including adjuvants stroyed in macrophages. Some antigen molecules re- and paramunity inducers, function principally at the main on the cell surface for long periods of time. Adjuvants function in various surface of this macrophage subpopulation expresses ways to enhance the immune response to antigens. Adju- tion between the antigen-presenting macrophage vants are usually insoluble and provoke local inflam- and the antigen-recognizing cells (lymphocytes). The tissue inflam- an antigen evades the macrophages and reaches the mation (severe inflammation is an undesirable ad- antigen-sensitive cells, then the host either will verse response) increases the number of antibody- manifest a poor immune response or will be tolerant producing cells in the affected tissues. Some adjuvants cause increased Macrophage-like cells (called dendritic cells) are phagocytosis activity; in particular, Freund’s adju- characterized by long, filamentous cytoplasmic proc- vant can activate the alternative complement path- esses and are distributed throughout the spleen and way, leading to undesirable results. Paramunity inducers, especially those consisting of Antigens are the trigger for stimulating the specific inactivated components from various poxviridae, can defense response. Several epitopes may exist in each anti- virus infections and virus-induced tumor cells. With such a defined antigenic site, the main to play a distinct role in “genetic” resistance to virus- portion of foreign macromolecule is nonantigenic, induced neoplasms. The type of reaction is mainly controlled by immune re- Antibiotics, especially some tetracycline prepara- sponse genes, which code for regulatory proteins lo- tions, inhibit the immune system to varying degrees. An indirect effect is a transient increase in the serum Epitopes may also stimulate a varying response de- corticosterone level, which depresses macrophage ac- pending on the manner in which the antigen is pre- tivity. Be- induce antibody production, cell-mediated reactions, cause of their potential side effects, antibiotics tolerance or immunosuppression. The immune re- should be used only when absolutely necessary, par- sponse that follows natural infection is thus a mix- ticularly when treating secondary bacterial infec- ture of responses (ie, polyclonal). Antibiotics specifically defined and occupy rather small areas on should not be used prophylactically, but only when an antigen, an antibody produced against one anti- specifically indicated. This cross-reaction between totally different antigens can create diagnostic prob- lems in some serologic tests. It has been experimen- tally suggested that approximately ten million epi- topes exist that can stimulate an immune response. Specific Defense In addition to macromolecules, small molecules (called haptens) that are linked to a carrier may also provoke an immune response. Haptens of particular Nonspecific defense mechanisms function to destroy interest to the clinician are small, metabolized mole- foreign material the moment it touches or enters the cules of drugs, which may bind to serum (or other) host. These molecules are recognized as foreign defending the host against ubiquitous microorgan- and often induce hypersensitivity responses. The specific defense cal examples of hapten-induced reactions in mam- mechanism relies mainly on antigen-sensitive cells, mals are reactions to penicillins and cephalosporins. B- and T-lymphocytes, to recognize each antigenic Hypersensitivity responses appear to be less common epitope (antigenic determinant) and to produce or- in birds but have been linked to some antimicrobial ganism-specific antibodies (humoral immune sys- sulfonamides. Responses to hapten-carrier molecules tem), or to provoke cell-mediated reactions (cellular indicate that production of antibodies to epitopes of immune system). Depending on whether the host has the haptens is possibly independent of the carrier been exposed to the particular antigen before or if it molecule itself. Nevertheless, cell-mediated response is an initial encounter, specific defense responses to may be initiated against the hapten-carrier as such, and is therefore called “carrier-specific. Humoral System Immunoglobulins The primary function of the humoral immune system is the production of antibodies directed mainly against extracellular phases of antigens. Antibodies are immunoglobulins, with the major part of the molecule containing ligands for membrane receptors, complement activation and isotype-specific (an- tigenically unique) structures. Immunoglobins can be differentiated into isotypes (IgM, IgG, IgA and, in mammals, also IgD and IgE). In some cases, improper hatching will prevent the egg-yolk from being absorbed and it must be surgically re- biochemical differences between mammalian and moved. Avian immunoglobulins ag- considered to be immunologically naive and are more susceptible gregate in a 8% NaCl solution. It can ment is fixed by immune complexes, it is not affected agglutinate particulate antigens and neutralize vi- by complement from the guinea pig. Its major task is to prevent antigens from the routine complement fixation test cannot be car- adhering to the mucosal surfaces of the body. Antibody Production IgG: (synonym IgY because of its structural and Although antibody production is the main feature of weight difference from mammalian IgG) is the most the humoral defense system, the concentrations of common antibody in the serum, and due to its small IgM and IgG in the serum are generally not indica- size (7 S), it can penetrate into tissue spaces and tors of immunity. IgG can opsonize, agglutinate titers against a certain infection are better protected and precipitate antigen. However, there are many IgM: is the major isotype produced following the in- exceptions to this generality, particularly with re- itial contact with an antigen. In S), IgM is normally confined to the peripheral blood- many instances, an effective response requires the stream and is more active than IgG in opsonization, interaction of antibodies and components of the cell- agglutination, virus neutralization and complement mediated immune system. In the and when coupled with a secretory component, is case of phagocytosis, the immunoglobulins can be excreted onto the mucosal surfaces of the respiratory, recycled by virtue of the noncovalent complex bonds. In the chicken, IgA also occurs in the bloodstream and in pigeons, The humoral immune system requires time to re- this immunoglobulin is found in high concentrations spond to a pathogen and the respective lymphocytes in the crop milk. The new- The cellular basis of humoral immunity is the B-lym- born chick is, therefore, ill prepared to respond to all phocyte, which is the antigen-sensitive cell. For compensation, the sor cells colonize and develop in the cloacal bursa newly hatched chicks receive maternally derived an- during embryonic life. Vaccination (plus a booster) of the breeder hens lymphoid precursor cells through the secretion of with the appropriate antigens is carried out four to bursin (and maybe other mediators from the bursal six weeks prior to the beginning of egg production in epithelial cells). The first antigen that is localized on order to ensure significant levels of IgG in the yolk. The half-life of the Between the 14th and 16th days of incubation, the maternally transmitted antibodies is four to six days. Here antigen and, at the same time, depleting the chick’s the Harderian gland is particularly important, and natural protection. Early vaccination successfully in- parts of the cloacal bursa, which act as a secondary hibits the production of immunoglobulins.

If the bird was wild-caught discount cialis 10 mg without prescription erectile dysfunction diabetes cure, it is wise to other birds should not re-enter the nursery order cialis 20 mg with mastercard erectile dysfunction pump surgery. If the bird has changed owners several times generic cialis 20 mg with visa erectile dysfunction red 7, it is best Quarantine Facilities to determine why. For captive-bred birds, it is advis- Facilities used for quarantine will vary among able to determine where the bird was produced, when aviculturists. In many instances there is no opportu- it was hatched and if the bird was parent-raised or nity for strict segregation of new arrivals, and in hand-fed. If the bird is represented as captive-bred these cases it is prudent not to add new birds to a but is not closed banded, it is useful to know why. Ideally, birds in quarantine should be housed Determining the genealogical history of the bird, separately from the remainder of the collection for a determining if any previous health problems have minimum of sixty days. Birds in quarantine should occurred and evaluating as much information as pos- be attended by an individual who has no contact with sible about the flock of origin can guide the avicultur- the established collection, who takes care of estab- ist in making a wise choice in adding birds. A copy of lished birds prior to servicing the quarantine facility all medical and reproductive records should be re- or who showers and changes clothes after servicing quested. Know- aviary property (eg, a neighbor’s home) is a practical ing when and how the gender was determined in a means of providing an effective quarantine period. Male cockatoos are frequently available for sale Birds placed in separate rooms within a home pro- after they have killed their mate. If a seller isunwill- vide a minimum amount of separation between new ing to freely provide any requested information, the and established residents. Birds that are maintained buyer should be concerned about the validity of any in any enclosure (home or building) with the same air claims that are made concerning a pair of birds. The bowls and all handling equipment used for birds Evaluating a Prospective Purchase in quarantine should not come in contact with the The addition of new birds to an established aviary remainder of the birds in a collection. Additionally, new birds that are misrepre- New Bird Examination sented (inaccurately sexed or sold, due to previous Birds should be examined at the beginning of quar- reproductive failure) represent a loss to the avicul- antine to establish any pre-existing problems and turist by occupying space and requiring care that again at the end of quarantine to detect any clinical could be used for productive pairs. The bird’s quarantine is only a “safety valve” in the prevention gender and the visual health of the reproductive tract of infectious disease and does not ensure that a new should be confirmed by laparoscopy. Diagnostic test- bird is not an asymptomatic carrier of parasitic, bac- ing should be based on the client’s needs, species of terial or viral pathogens. The new bird exam and quarantine testing program should be tailored to the needs and resources of the Quarantine aviculturist and the species of bird. Suggested screening techniques would include a thorough A routine quarantine program for new birds is vital physical examination, Gram’s stain of feces and to protect an established avicultural collection from evaluation of a blood smear. The type of blood chemistry profile and cultures are useful to examinations performed, length of the quarantine detect birds that require more extensive evaluation. In essence, this testing allows the veterinarian to establish a “point- in-time” medical fingerprint for the individual bird. Direct and flotation examination of feces for internal para- sites should also be considered in birds that were recently imported or that are in flights with access to the ground (see Chapter 36). Any thin birds, espe- cially species susceptible to neuropathic gastric dila- tation (formerly proventricular dilatation syndrome) should be examined radiographically. Alternatively, a bird that was captive produced in another country and imported into the United Identification States could have a closed band and an open import band. Such Each new bird should be permanently identified dur- was the case in this macaw. Implantable transponders provide the least alterable identifica- Open bands are the least desirable but are none the tion with minimal risk to the bird. An alternative to removal of these bands is to fitting closed bands are an indication (not proof) that close them as tightly as possible, thereby reducing a bird was bred in captivity. Metal bands must be nately, the numbers often wear off closed bands and removed from the legs of birds exposed to sub-freez- large birds may collapse them, resulting in leg or foot ing temperatures, as they contribute to frostbite. In addition, bands can catch on loose enclo- importance of individual identification was graphi- sure wires. These disadvantages should not dissuade cally demonstrated in the aftermath of Hurricane the serious aviculturist from closed banding nor Andrew’s assault on South Florida in August 1992. The veterinarian can help the aviculturist establish a record system that is best for a particular facility, assist in developing and implementing effective iden- tification systems and evaluate production records. Records that include all available medical informa- tion should be established at the time the bird enters the aviary. Trends indicate an increasing interest in the estab- lishment of stud books and cooperative breeding pro- grams involving private aviculturists. Infected groups can then be Acclimation screened on an individual basis and treated as Birds should be acclimated to their new surround- needed. Birds may refuse food for several days (small birds) or up to a week (larger Annual prophylactic treatment for chlamydiosis is species), especially if the bird was a previous pet. Gavage feeding should outdoors and exposed to free-ranging birds, espe- be used only if the weight loss is dramatic (15% of cially pigeons. In most cases, the indiscriminate use initial weight) in order to avoid unnecessary stress. Exposing birds in bird that is reluctant to eat can be maintained on the a flock to unnecessary or sub-therapeutic levels of diet to which it is accustomed and slowly changed to antibiotics will create “super” strains of bacteria that the diet used by the aviculturist. If quality of water may cause temporary intestinal up- birds are medicated, treatment should be delayed set. A species that will be housed outdoors must be until the non-breeding season (the fall for most spe- slowly acclimated to its new climatic conditions. Egg production will typically decrease during Tropical birds can tolerate northern temperate cli- treatment, and chicks that hatch from eggs laid dur- mates if acclimated for several months before being ing treatment may have developmental abnormalities. Exposure to direct Commercially available oil emulsion adjuvant vac- sunlight can cause burns on the unfeathered portions cines for Pacheco’s virus disease, pox and salmonella of the face. These vac- exposed skin in feather-plucked birds will eventually cines were developed for use in wild-caught imported “tan” and show color changes indicative of melaniza- birds to prevent catastrophic disease outbreaks. Housing of affected birds indoors until the sever- ity of such reactions subsides may be helpful. The Feeding Aviary Birds possibility of birds becoming sensitized (allergic) to Proper nutrition is vital to avicultural success. The goals in formulating diets for Preventive Husbandry Practices captive breeding birds include meeting the known or perceived nutritional requirements, maintaining The level of husbandry advice provided by the veteri- good food hygiene, providing psychological enrich- narian must be adjusted to compensate for the expe- ment by offering variety, and having a diet that is rience of the aviculturist. Successful aviculturists easy to prepare and minimizes labor, waste and ex- frequently have vast experience in animal husbandry pense. In general, breeding birds should receive a and carefully evaluate the behavior and condition of formulated diet, a variety of fresh fruits and vegeta- their birds on a daily basis. In-the-shell peanuts intuitively when problems are occurring that require should be avoided because of their potential for ex- veterinary assistance to identify, correct and prevent. Establishing a species in If a veterinarian expects client compliance, recom- captivity requires an understanding of the feeding mended therapeutic programs must be designed to habits of free-ranging conspecifics. Knowing what address the daily problems faced by the breeder and free-ranging birds consume will define dietary pref- require minimum input of time, labor and resources. In captivity, birds are usually offered the same diet A routine preventive medicine program should be year-round.