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Giardia cysts survive the Coccidiosis is a major cause of enteritis in Columbi- standard chlorination of water generic neurontin 100mg fast delivery medicine. Eimeria dunsingi oocysts are ated Splendid Grass Parakeets and cockatiels and ovoid discount neurontin 800mg visa atlas genius - symptoms, lack a micropyle and are 26-39 x 22-28 µm cheap neurontin 300 mg on-line medicine dictionary prescription drugs. Generally order neurontin 800mg on line keratin treatment, Hexamita is smaller than oocysts of Eimeria are subdivided into four sporocysts Giardia, swims in a smooth linear fashion and may each with two sporozoites, whereas withIsospora, the be associated with chronic diarrhea. Hexamita has oocysts have two sporocysts each with four sporozoi- been described as a cause of disease in lories. In general, some cases of coccidiosis are associated with severe Histomonas: Histomoniasis is common in gallina- clinical disease, while other birds will pass numerous ceous birds. The induced disease is called blackhead oocysts in the feces and remain asymptomatic. In some Isospora is most common in Passeriformes, Psittaci- birds, this parasite is considered a major pathogen formes and Piciformes, and Eimeria is most common while in other birds it is considered an incidental in Galliformes and Columbiformes. When lesions occur, they generally include may be asymptomatic or develop clinical signs of hepatomegaly (with necrosis) and ascites. Adults are gen- ovoid protozoa that infect and may cause disease in erally asymptomatic carriers that shed oocysts in the the mucosal epithelial cells lining the gastrointesti- feces. Prevalence can be high in young birds during nal, respiratory and urinary tracts of birds. Birds less than a year of age are most likely Cryptosporidiosis has been documented in Gallifor- to develop clinical changes. An enlarged liver and dilated bowel loops that cryptosporidial infections may be transmitted can occasionally be observed through the transpar- among closely related species, which should be con- ent skin (see Color 20). With severe infections, zoite sidered when managing this coccidia in a collection. At ne- blood to parenchymal organs where it infects reticu- cropsy, there may be an excessive amount of mucus loendothelial and intestinal epithelial cells. Coccidial oocysts are environmentally stable and are not killed by most disinfectants. Finches x Oocysts were identified in the feces from young and adult birds in the affected group. Suggestive of the opportunis- Toxoplasma: Toxoplasma is a coccidian parasite tic nature of Cryptosporidium was the detection of with an indirect life cycle. In fatal infections in most species, has been documented three birds, the parasite remained localized to the in the Red Lory, Swainson’s Lorikeet, Regent Parrot, Superb Parrot and Crimson Rosella. In the other bird, Cryptosporidium was present throughout the large gondii is considered a ubiquitous organism with a intestines, small intestines and bursa (see Figure broad host range, and probably could infect any mam- 32. Oocysts produced and passed in the feces of infected cats would be the only source Cryptosporidium sp. The number of parasites varied tomegaly, vasculitis and necrotic foci in the lungs, from a few to several million per gram of feces. Cryptosporidium undergoes sexual multiplication in the intestine of a recovered from the ostriches was not infectious to definitive host. None of the restricted to North America and has been associated birds in this study had clinical signs of infection, but with acute deaths in a variety of psittacine species. Adult New World genous sporulation resulting in autoinfection in the Psittaciformes appear to be relatively resistant (Ta- parasitized host. The susceptibility of Old World Psittacifor- severe enteritis and diarrhea in experimentally in- mes and resistance of New World Psittaciformes may fected Bobwhite Quail in the company of reovirus. Infections appear to be more the feces so the frequent cleaning regimes that are common in the winter months and males appear to used to control other coccidia are ineffective in pre- be more susceptible than females. Crypto- ent age resistance and a bird over 33 years of age died sporidium is resistant to many disinfectants. Blue and Gold Macaw Port Lincoln Parrot Diagnosis can be improved by centrifuging diluted Budgerigar Princess Parrot feces in a high-concentration salt solution or using Cockatiel Red-capped Parrot Cockatoo Red Shining Parrot Sheather’s flotation. With modified acid-fast Great-billed Parrot Tori Parakeet Green Rosella stain, Cryptosporidium stains pink against a blue Lories (Red) background. If clinical signs lowed by infection of numerous tissues and schizo- occur prior to death, they are characterized by severe gony in the reticuloendothelial cells, particularly in dyspnea, yellow-pigmented urates and lethargy. These replication cycles can cause occlusion of the affected vessels resulting Pulmonary edema with hemorrhage is the most con- in the fatal lesions characteristic of infections in Old sistent sign in birds that die acutely (see Color 22). Histopathologic findings include dif- In a normal infectivity cycle, the intermediate host fuse interstitial and exudative pneumonia, reticu- survives schizogony in the vascular endothelium and loendothelial cell hyperplasia and schizonts or mero- mature cysts containing bradyzoites are sub- zoites in the capillary endothelium. The lung is the sequently formed in striated (skeletal or cardiac) tissue of choice for diagnosis where schizonts may be muscles. Schizogony in the vascular endothelium of birds die before sarcocysts develop in the muscles. Old World psittacines that sur- vive schizogony in the endothelium of the lungs have Encephalitozoon sp. This parasite has complex spores measuring lumbiformes, where cockroaches and flies can serve 1. Lovebirds of the genus Agapornis are Psittacine birds in outdoor facilities throughout the frequently infected,93 but an Amazon parrot with a range of the opossum are at risk. Cock- The spores were documented in kidney tubules, lung, roaches can serve as transport hosts by eating in- liver and the lamina propria of the small intestine. One report gave chickens have been suggested as a method of control- the details of a die-off of 140 lovebirds in Great ling cockroaches within a compound (see Chapter 2). Britain in which the birds were moved to a different facility, stopped eating and lost condition. Sarcocystis was responsible for the deaths of 37 Old World Psittaciformes in a zoologic collection over a An infected Amazon parrot developed progressive 15-month period. Lories, cockatoos, Pesquet’s Parrot, anorexia, weight loss, respiratory disease and diar- Port Lincoln Parrot, lorikeets, Princess Parrot and rhea over a one-month period. About included pale, swollen kidneys and an enlarged, mot- half of the birds developed clinical signs prior to tled liver. Kidney tubular epithelial cells were filled death, while the other birds died with no premoni- with tiny spores, as were epithelial cells in the liver tory signs. Histologic changes were charac- cluded anorexia, diarrhea, weakness, tachypnea, terized by multifocal nephritis, hepatitis and enteritis. Some birds had clinical signs that lasted Haemosporidian parasites have been detected in several hours while others had clinical signs that parrots being imported into England and Ja- progressed over a 52-day period. Four of the mitting the species of Haemoproteus or Leucocyto- Eclectus and two of the Amazon parrots died. Clinical signs included reproduction occur in biting flies, resulting in the weakness, dyspnea and blood in the oral cavity. Af- production of sporozoites that localize in the salivary fected birds died one to 36 hours after presentation. Asex- Radiographic findings indicated an increased lung ual reproduction also occurs in an infected bird. Some birds that were only slightly lethargic cies of Haemoproteus are considered nonpathogenic and had no other clinical signs survived following and a few species of Leucocytozoon and Plasmodium treatment with 0.

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In these cases neurontin 800 mg amex treatment tennis elbow, yeast may be pre- sent in the blood cheap 400mg neurontin medications similar to cymbalta, bone marrow and parenchymous organs generic neurontin 300mg treatment 8th march. Nystatin is the most frequently used otic therapy for upper respiratory tract infections medication for initially treating upper gastrointesti- may develop secondary candida infections neurontin 100 mg low price treatment 7. Systemic nal candidiasis in the avian patient, although some candidiasis in a flock of canaries was associated with of the azole antifungals are undoubtedly more effec- central nervous system signs in addition to those tive. Nystatin has few side effects and is not absorbed routinely noted with gastrointestinal infections. Lactophenol cot- Ketoconazole is recommended for severe or refrac- ton blue is recommended for wet mounts. Although more costly and difficult organism, which is often budding, is small (3 to 6µm to administer, it is a very effective systemic antifun- diameter), and has been compared to the size of an gal with a high therapeutic index. Culturing the organism may be helpful, candidiasis,15,20,23 but may offer no real advantage especially in cases involving beak abnormalities or over other azoles. Sabouraud’sb or cornmeal agar effective in treating yeast infections, but few reports are the recommended culture media. Azole antifun- gals may cause depression, anorexia, vomiting and Treatment 38 hepatic toxicity. Aspergillus fumigatus Gallinaceous birds (particularly quail) often become is the most common etiologic agent, followed in fre- infected as chicks following inhalation of spores from quency by A. Established aspergillosis infections are clini- gallinaceous birds, and presumably aviary birds as cally challenging to resolve. Moldy straw is a particularly Transmission and Predisposing Factors common source of numerous fungal pathogens in- Penguins, birds of paradise, pheasants, waterfowl cluding Aspergillus spp. Waterfowl may be infected (especially diving birds and shorebirds), Goshawks by feeding on moldy corn or wheat straw. When the ventral border of the mass was removed, the cranial and middle lobes of the left kidney were also found to be involved. It has been suggested that healthy birds exposed to high concentrations of spores are generally resistant to infections, while immunocompromised hosts exposed to small concen- trations of spores are frequently infected. Factors that influence the susceptibility of a bird to aspergil- losis include shipping, overcrowding, malnutrition, poor ventilation, very young or old age, antibiotic therapy (particularly tetracyclines), corticosteroid administration, respiratory irritants (eg, disinfec- tant fumes, cigarette smoke, ammonia) or concomi- tant disease. Acute cases occur when spores germinate in a par- Tracheoscopy revealed a large proliferative white mass in the ticularly vital area or when multiple lesions germi- syrinx. The bird was breathing through a hole in the center of the mass the size of a 20 ga needle. The bird was A single air sac lesion may have a protracted course on an all-seed diet, which may have resulted in squamous meta- plasia in the syrinx and precipated an infection. The syrinx or tracheal bifurcation is thought to be a common loca- sure to spores (see Color 22). Air sac infections in tion for aspergillosis colonization because air turbu- mature birds may progress for weeks, or can induce lence patterns may cause the spores to drop out of the granulomas that are present for months. Wheezing, and hyperkeratosis may occur, allowing colonization squeaking or stertor and a voice change are also by inhaled aspergillosis spores (Figure 35. A cream- to yellow-colored granuloma or plaque is present with or without gray or white “cot- ton-wool” mycelial masses (see Color 22). Destruction of adjacent tissue, including bone or beak, may be substantial (Figure 35. Nasal asper- gillosis typically presents as a dry, granulomatous, destructive swelling within one nostril. The extent of damage to shows a necrotic foci surrounded by macrophages, the germinative epithelium is demonstrated by a severe defect in heterophils and giant cells, sometimes within a con- the beak. This photograph was taken several weeks after debride- nective tissue capsule (Table 35. Tracheal or ment and treatment of the infected tissues with miconazole (cour- tesy of Louise Bauck). Radio- be recognized as a white exudate within the conjunc- graphic findings can be negative or may show hyper- tival sac. Fun- Monocytosis gal culture, hematology, serology, cytology, radiology Lymphopenia and endoscopy or exploratory surgery are among the Nonregenerative anemia Hyperproteinemia methods used to diagnose infections (Table 35. The presence of branching sep- tate hyphae, sometimes with spores and sporulating areas, is highly suggestive (see Figure 35. If ac- cess to a suggestive lesion is not available, then serology may be helpful. Radiographs indicated a large soft tissue mass that was localized to the right lung and cranial thoracic air sac. A slightly oblique, rather than ventrodorsal, radiograph was made to Latex agglutination and com- better visualize the thoracic mass. An aspergilloma was diagnosed at necropsy (courtesy of plement fixation methods have Marjorie McMillan). Severe dyspnea can also be caused by in- creased abdominal pressure (eg, mass, ascites, hepatomegaly), pneumonia and inhaled foreign bod- ies. Eye lesions, as described in gallinaceous birds, may be caused by hypovitaminosis A. Treatment Treatment of aspergillosis often depends on the loca- tion and extent of the lesion. Resolving advanced cases of aspergillosis is difficult, especially in anatomic areas where surgical removal of affected tissues is not possible. Correction of underlying stress factors is a mandatory component of successful therapy. Surgical debridement of plaques and granu- lomas should be employed when feasible. A severe granu- lomatous sinusitis occurred in an African Grey Par- rot following the accidental use of amphotericin B suspension rather than a solution as a nasal flush. Am- cleansing and disinfection of hatching equipment is photericin B is potentially nephrotoxic. Feed for companion and aviary birds should always be free of fungal growth in order to Flucytosine is also frequently used to treat aspergil- limit exposure to fungal pathogens and mycotoxins losis, especially in combination with amphotericin B (see Chapter 37). The advantage to this drug is that it can mycotin may be effective in reducing aspergillosis in be administered orally; however, bone marrow toxic- susceptible species such as captive penguins and ity has been reported in some cases. Cryptococcosis Some of the azole antifungals have good efficacy Cryptococcus neoformans is an imperfect, sapro- against aspergillosis in mammals and may be admin- phytic yeast that has been reported as a cause of istered orally. Ketoconazole has been used to success- 9,14,43 disease in psittacine birds and pigeons. This transmission and pathogenesis in birds is largely drug preparation has an advantage over other anti- 2,26,42,44,47,53 unknown, but it is isolated frequently from the drop- fungals in having a wide therapeutic index.

The law applies to medical records 100mg neurontin with mastercard treatment jellyfish sting, regardless of whether they are part of a relevant filing system purchase neurontin 400 mg mastercard administering medications 6th edition. As well as the primary legislation (the Act itself) buy generic neurontin 300mg medications and breastfeeding, secondary or subordinate legislation has been enacted generic 100mg neurontin medications side effects prescription drugs, such as the Data Protection (Subject Access Modification) (Health) Order of 2000, which allows information to be withheld if it is likely to cause serious harm to the mental or physical health of any person. Guidance notes about the operation of the legislation are available from professional bodies, such as the medical protection and defense organizations. In the United Kingdom, compliance with the requirements of the data protec- tion legislation requires that the practitioner adhere to the following: • Is properly registered as a data controller. It is important to understand the nature of the request and what is required—a simple report of fact, a report on present condition and prognosis after a medi- Fundamental Principals 53 cal examination, an expert opinion, or a combination of these. Because a doc- tor possesses expertise does not necessarily make him or her an expert witness every time a report is requested. A report may be required for a variety of reasons, and its nature and content must be directed to the purpose for which it is sought. Is it a report of the history and findings on previous examination because there is now a crimi- nal prosecution or civil claim? Is it a request to examine the patient and to prepare a report on present condition and prognosis? Is it a request for an expert opinion on the management of another practitioner for the purposes of a medical negligence claim? The request should be studied carefully to ascertain what is required and clarification sought where necessary in the case of any ambiguity. The fee or at least the basis on which it is to be set should also be agreed in advance of the preparation of the report. If necessary, the appropriate consents should be obtained and issues of confidentiality addressed. A medicolegal re- port may affect an individual’s liberty in a criminal case or compensation in a personal injury or negligence action. A condemnatory report about a profes- sional colleague may cause great distress and a loss of reputation; prosecuting authorities may even rely on it to decide whether to bring homicide charges for murder (“euthanasia”) or manslaughter (by gross negligence). Reports must be fair and balanced; the doctor is not an advocate for a cause but should see his or her role as providing assistance to the lawyers and to the court in their attempt to do justice to the parties. It must always be conisdered that a report may be disclosed in the course of legal proceedings and that the author may be cross-examined about its content, on oath, in court, and in public. A negligently prepared report may lead to proceedings against the author and perhaps even criminal proceedings in exceptional cases. Certainly a civil claim can be brought if a plaintiff’s action is settled on disadvantageous terms as a result of a poorly prepared opinion. The form and content of the report will vary according to circumstances, but it should always be well presented on professional notepaper with relevant dates and details carefully documented in objective terms. Care should be taken to address the questions posed in the letter of instructions from those who commissioned it. If necessary, the report may be submitted in draft before it is finalized, but the doctor must always ensure that the final text represents his or her own professional views and must avoid being persuaded by counsel or solicitors to make amendments with which he or she is not content: it is the 54 Palmer doctor who will have to answer questions in the witness box, and this may be a most harrowing experience if he or she makes claims outside the area of expertise or in any way fails to “come up to proof” (i. In civil proceedings in England and Wales, matters are now governed by the Civil Procedure Rules and by a Code of Practice approved by the head of civil justice. Any practitioner who provides a report in civil proceedings must make a declaration of truth and ensure that his or her report complies with the rules. Additionally, the doctor will encounter the Coroners Court (or the Procurators Fiscal and Sher- iffs in Scotland), which is, exceptionally, inquisitorial and not adversarial in its proceedings. A range of other special courts and tribunals exists, from eccle- siastical courts to social security tribunals; these are not described here. The type of court to which he or she is called is likely to depend on the doctor’s practice, spe- cialty, and seniority. The doctor may be called to give purely factual evidence of the findings when he or she examined a patient, in which case the doctor is simply a professional witness of fact, or to give an opinion on some matter, in which case the doctor is an expert witness. Usually the doctor will receive fair warning that attendance in court is required and he or she may be able to negotiate with those calling him or her concerning suitable dates and times. Many requests to attend court will be made relatively informally, but more commonly a witness summons will be served. A doctor who shows any marked reluctance to attend court may well receive a formal summons, which compels him or her to attend or to face arrest and proceedings for contempt of court if he or she refuses. If the doctor adopts a reasonable and responsible attitude, he or she will usually receive the sympathetic understanding and cooperation of the law- yers and the court in arranging a time to give evidence that least disrupts his or her practice. However, any exhibition of belligerence by the doctor can induce a rigid inflexibility in lawyers and court officials—who always have the ability to “trump” the doctor by the issuance of a summons, so be warned and be reasonable. A doctor will usually be allowed to refer to any notes made contemporaneously to “refresh his memory,” although it is courteous to seek the court’s agreement. Demeanor in Court In the space available, it is not possible to do more than to outline good practice when giving evidence. Court appearances are serious matters; an individual’s liberty may be at risk or large awards of damages and costs may rely on the evidence given. The doctor’s dress and demeanor should be appro- priate to the occasion, and he or she should speak clearly and audibly. As with an oral examination for medical finals or the defense of a writ- ten thesis, listen carefully to the questions posed. Think carefully about the reply before opening your mouth and allowing words to pour forth. Answer the question asked (not the one you would like it to have been) concisely and carefully, and then wait for the next question. There is no need to fill all silences with words; the judge and others will be making notes, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer. Your frankness will be appreciated, whereas an attempt to bluff or obfuscate or overreach yourself will almost certainly be detrimental to your position. Doctors usually seek consensus and try to avoid confrontation (at least in a clinical setting). They should remember that lawyers thrive on the adversarial process and are out to win their case, not to engage on a search for truth.

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Effects of aqueous extracts of onion best neurontin 400mg medications for depression, garlic and ginger on the platelet aggregation and metabolism of arachidonic acid in the blood vascular system cheap neurontin 300mg on line treatments for depression. Sign up for our newsletter and receive special offers purchase neurontin 100 mg online medicine hat weather, access to bonus content order neurontin 100 mg on-line medicine app, and info on the latest new releases and other great eBooks from Atria Books and Simon & Schuster. In anaesthesiology, the debate continues about whether a Sell- ick manoeuvre (backward pressure on the cricoid cartilage) is a necessary component of a rapid-sequence intubation. The question for an author assigned the task of writing the airway chapter in a new edition of a standard textbook is different from that of an investi- gator interested in revisiting the question of whether or not the technique is bene¿cial. For one, it is a matter of adjudicating the technique’s inclusion; for the other, it is a question of hypothesis and result. For the student, the standard text becomes the gold standard; for the experienced practitioner, the hypothesis-driven study may become the foundation of a new reality. The tension is clear and the discriminatory responsibility of author–reader relationship is highlighted. Another dif¿culty for the author is the necessity of catering to multiple reader types in a single manuscript or chapter. It is apparent that readers vary in their attention span and the manner in which they obtain and process information. For some, the text itself is the key; for others, the graphics, ¿gures and tables are the most important area and primary focus. Although most authors perceive their articles to be a consistent whole, the most discerning provide each reader a content and style with a unique experience, ensuring that graphs, ¿g- ures, tables and text tell the story independently yet collaboratively. Figures and tables are felt to be the most effective way to present results, but much of the standard textbook relies on a complete, easily understood explanation of technique or process. All graphic material should be presented in a manner that is easy to interpret, and the captions or titles should be understandable independently of the accompanying text. It is dangerous to suppose that the reader will follow the author’s detailed logic to gain an independent interpretation of the data; rather, the author must sell the message in all locations. This is a dif¿cult task and one that becomes increasingly complex as the subject matter broadens and the available information is more expert opinion than objective data. In this setting, the experienced context expert is able to present a balanced assessment of available information in a man- ner that is both useful and intellectually and practically challenging. There are general rules that authors must consider: The manuscript must establish the subject and context clearly. The reader should not be confused about the article’s purpose or become confused by a poorly constructed argu- ment. The peer reviewers and editor have a responsibility to the author and reader to help re¿ne the manuscript and to make it relevant while avoiding hyperbole. The author must understand that reviewers are likely authors themselves and that personal opinion and experience, linguistic and stylistic preferences and writing mannerisms are prevalent. The responsibility for appropriate and ethical publication rests with the author and editor; the responsibility for disseminating the information rests with the publisher; the responsibility for appropriate utilisation of the information rests with the reader. The partnership is becoming increasingly important, and the reader must take increasing responsibility for discriminatory consump- tion. Electronic systems and open publishing platforms reduce the ability of peer and edi- torial review to re¿ne the ¿nal submission, and the reader must undertake many of these responsibilities personally. The learning–reading cycle comes full circle: from uncritical acceptance of the information presented to scepticism. Ultimately, the reader is responsible for performing not only a critical review of information presented but also for placing the relevant pieces into an appropriate context. It is only in this manner that the question posed can be answered in the af¿rmative. Scolletta Multiple organ failure is a common feature in critically ill patients, and the severity of organ dysfunction is associated with outcome. Multiple mechanisms can be implicated in the development of multiple organ failure, including global and regional haemodynamic alterations and microcirculatory and cellular alterations. Microcirculation may play a cru- cial role in the pathophysiology of multiple organ failure. In addition, the microcirculatory bed represents the largest endothelial surface of the body and takes an important place in the initiation and ampli¿cation of inÀammatory processes and of the coagulation cascade. Accordingly, even though the importance of global and regional vascular alterations should not be minimised, many events implicated in im- pairment in tissue oxygenation and inÀammatory processes occur at the microcirculatory level. Microvascular alterations have been observed in various experimental conditions, in- cluding severe haemorrhage [1], ischaemia–reperfusion injury [2] and sepsis [3–7]. These alterations are characterised by a decrease in capillary density and the presence of stopped- Àow capillaries in close vicinity of well-perfused capillaries (blood Àow heterogeneity) [1, 3, 5]. Similar alterations have been observed in patients with severe sepsis [8, 9] or severe heart failure, as well as in patients submitted to high-risk surgery [10, 11]. The severity and persistence of these alterations is associated with development of organ failure and results in poor outcome [12]. As rarefaction of capillaries and heterogeneity are characterising these microvascular alterations, microvascular recruitment is more likely to improve tissue perfusion than simply increasing microvascular blood Àow in already perfused capillaries. In this chapter, we describe the impact on microvascular perfusion of various interventions typically used in haemodynamic resuscitation, as well as those of other therapies used in critically ill patients. The improvement in microvascular perfusion was associated with a de- crease in lactate levels. The authors failed to notice differences in microcirculatory effects with administration of albumin 4% compared with crystalloids. More interest- ingly, the authors evaluated the effects of Àuids at two different phases of sepsis: 37 patients were investigated within 24 h of diagnosis of sepsis and 23 patients after more than 48 h. Microvascular perfusion improved in all patients investigated early after di- agnosis of sepsis, whereas it was unchanged in patients investigated later (Fig. Importantly, whatever the time at which Àuids were administered, the microvascular effects of Àuids were dissociated from the impact on global haemodynamics, as patients who had improved cardiac output in response to Àuids sometimes failed to show improved microcirculation, whereas patients who failed to show increased cardiac output sometimes demonstrated improvement in microvascular perfusion in response to Àuids. In all patients, microcirculation improved in response to initial Àuid administration, but a second Àuid bolus, which further increased cardiac output, failed to further improve microvascular per- fusion. Hence, Àuids may have a place in microvascular resuscitation at early stages of sepsis but fail to affect the microcirculation at later stages, independent of their global haemody- namic effects. Patients investigated within 24 h of diagnosis of severe sepsis (n = 37) are represented by white rectangles; patients investigated after 48 h of diagnosis (n = 23) by grey rectangles. Even if severe anaemia may weaken microcirculatory oxygenation [20], less severe haemodilution may be bene¿cial so that the effects of red blood cell transfusions should be analysed according to baseline haematocrit. The effect of storage time and the presence or absence of residual leucocytes in the transfused prod- ucts can represent important factors affecting the microvascular response to red blood cell transfusions. Transfusion failed to affect microvascular perfusion, as both capillary density and proportion of perfused vessels remained unchanged. However, this apparent absence of change masked a dichotomous response: patients with markedly al- tered microcirculation at baseline demonstrated improved microcirculation, whereas pa- tients with relatively normal microcirculation showed deteriorated microcirculation during red blood cell transfusions. There was no relationship between microcirculatory changes and age of red blood cells.

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