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Environmental enrichment techniques cheap norpace 150mg without a prescription, and occasionally the use of psychotropic drugs and pheromones order norpace 100mg line, are the main techniques to prevent and correct behaviour problems in captive wild felids purchase 150 mg norpace. The main objective of environmental enrichment is to facilitate the expression of the normal behaviour of the species norpace 100 mg fast delivery, especially exploratory behaviour and social interaction. Facial pheromones and appeasing pheromones produced by lactating females can be particularly useful to prevent or correct behavioural abnormalities caused by stress. More recently, Rushen and Mason (2006) have described them as repetitive behaviours resulting from illness or repeated attempts at adapting to a diffcult environment. Stereotypic behaviour has seldom been described in animals in the wild 129 (carlstead, 1996). However, it is seen relatively frequently in wild animals in captivity, such as farm, companion and laboratory animals. Only stereotypies which occur in response to environmental conditions will be considered in this article. T The stereotypy most frequently exhibited by wild carnivores in captivity is known as pacing. It involves the animal making repetitive movements along an unchanging path, often incorporating a fixed sequence of movements in a specific place. This stereotypy makes up 97% of those described in captive carnivores (clubb and Mason, 2003). The causes of environmental stereotypies have been, and continue to be, the subject of many investigations, and a detailed revision of the neurophysiological mechanisms responsible for such behaviours is beyond the objectives of this article. Briefy, however, it appears that environmental stereotypies tend to be exhibited in situations where expression of normal behaviour is obstructed or made diffcult. In particular, they can appear when the environment prevents the expression of feeding, locomotory or exploratory behaviours. Likewise, some stereotypies seem to derive from an animals attempts to escape the environment in which it is confned; in which case, the behaviour would be a consequence of the aversion caused by the environment (Rushen et al. Finally, stereotypies can also be triggered by the general activation of the central nervous system as a response to unspecifc stimuli (Rushen et al. It is often stated that stereotypies are a consequence of the animal being confned to a very limited space, and can be reduced or even eliminated by simply increasing the space available to the animal. The tendency to perform stereotypies varies considerably between species, and between individuals of the same species. The differences between species can be at least partly related to some aspects of their natural history. Interestingly, neonatal mortality in captivity also tends to be greater in these species than in those which use smaller areas. This would indicate differences between species in terms of the ease in which they are able to adapt to their captive conditions. The differences between individuals within a species can have genetic and environmental origins. Thus, during early stages of development, a complex environment that is rich in stimuli may help prevent the development of stereotypies in later stages, due to greater behavioural flexibility and decreased sensitivity to stressful situations. This could explain the differences, described in some species, between individuals born in captivity and individuals captured in the wild in terms of their tendency to carry out stereotypical behaviours (Jones and Pillay, 2006). Therefore, environmental stereotypies appear in animals with a certain individual or species predisposition, when they fnd themselves in environments that do not allow the expression of certain behaviours. Individual predisposition to perform stereotypies in suboptimal environments would result from a combination of genetic and environmental factors. Stereotypies change over time, and stereotypies that have been performed over a long period, are often more diffcult to stop and are also less responsive to management techniques such as environmental enrichment. Such techniques may be more useful to correct more recently acquired stereotypies (Mason, 1993). However, it is important to bear in mind that stereotypies are not synonymous with a lack of welfare. Indeed, some animals can be found in a state of considerably bad welfare, yet still not develop stereotypic behaviours (Jones and Pillay, 2006). In fact, while environments that are conducive to the development of stereotypies are often inadequate from a welfare point of view, animals in such environments that do not perform stereotypies can have an inferior state of welfare to those who do develop them (Mason and Latham, 2004). Moreover, the importance of stereotypical behaviour from a welfare point of view will vary between long-standing and more recently acquired stereotypies. Si t u a t i o n S o F S t r e S S m a y inhibit t h e e x p r e S S i o n o F maternal b e h a v i o r. Immediately after giving birth there is a sensitive period in which the female is especially receptive to any stimulus from the young. During this time, contact between the female and her young is crucial for maternal behaviour to become independent from hormonal stimuli and be maintained until the young are weaned and independent. One of the most important causes of neonatal mortality in domestic cats is the inadequate expression of maternal behaviour, which can cause up to 19% of all kitten deaths (Young, 1973). A similar situation is highly likely in other felid species, such as the Iberian lynx, where maternal neglect occurs in more than half of frst- time mothers (Vargas et al. As has been previously commented, there are differences between species in terms of survival of young in captivity; species that use larger areas in the wild usually suffer a higher percentage of neonatal mortality in captivity (clubb and Mason, 2003). Stress also has a very important effect on maternal behaviour, sometimes inhibiting its expression, or even leading to flial cannibalism. Furthermore, stress can interrupt or prolong parturition, which in turn can cause offspring cerebral hypoxia, reducing their strength and mobility. As the females maternal behaviour is stimulated by movements of the young, the hypoxia caused by an excessively long labour can inhibit maternal behaviour and lead to offspring abandonment. The frst of the two responses is relatively common in carnivores held in facili- ties that lack any form of enrichment and is characterised by the animal showing inactivity and lack of interest in anything that happens around it. On the other hand, these animals may have an abnormally intense response to a sudden stimulus. For example, christian and Radcliffe (1952) describe the case of various captive wild animals, after being kept in extremely small cages, which died suddenly on being moved to a new installation. In all of the cases, there were signs of adrenal cortex atrophy, which indicates an inability to adapt to a new and potentially stressful situation. It has been found in the domestic cat that a change in behaviour caused by a situation of stress following a change in the animals environment, can lead to anorexia, immobility and general inhibition of behaviour. In some cases it can lead to death from liver failure due to the process of lipidosis (Fatj et al. Therefore, an attempt must be made to classify the types of aggressive animal behaviour. The most objective system of classifcation is probably one based on the nervous structures involved in the control of aggressive behaviour. This classifcation distinguishes only three types of aggression: offensive, defensive and predatory. They are distinguished not only by the nervous structures that control them, but also by the context in which they appear, and by the relatively invariable motor sequences that characterize them (Moyer, 1968). Such sequences have been described in great detail in the domestic cat (Leyhausen, 1979). Some of the enrichment techniques used for wild felids in captivity include hiding food so that the animal must dedicate time to searching for it; giving a supply of toys and installing platforms that provide the animals with a three dimensional space (Martos, this book). The effects of environmental enrichment are variable and depend on the technique used and the characteristics of every species and individual. It is important to take into account that, occasionally, environmental enrichment programmes can have negative effects on the animals welfare. For example, in animals housed in groups enrichment can cause an increase in aggression by stimulating competition for resources that did not previously exist. However, this problem usually disappears following an increase in the number of objects or feeding points used for the enrichment, so that the animals have no need to compete with one another (Bloomsmith et al. Furthermore, in order to assess the effect of enrichment upon physiological parameters indicative of chronic stress, it can be useful to analyse the concentration of metabolites of cortisol in the faeces before and after carrying out the programme. Ps y c h o a c t i v e d R u g s Psychoactive drugs can be useful to alleviate specific situations of stress. It is important to take into account, however, that under no circumstance should they be used over a prolonged period of time in order to mask the effects of inadequate housing or husbandry. It is important to note, however, that there is very little information about the use of such pharmaceuticals in non-ungulate mammals, so they must be used with caution. Some species of artiodactyls have been known to perform aggressive behaviours towards people following the administration of long-acting neuroleptics (Ebedes, 1993).
National rates of inpatient and ambulatory surgery visits for urolithiasis by age group buy discount norpace 150mg on-line, 2000 purchase 150mg norpace fast delivery. Admission group than in the <65 age group discount norpace 150mg mastercard, peaking in the 75- to rates for Hispanics were one-half to two-thirds those 84-year group in each year of study buy generic norpace 100 mg on-line. Age-adjustment did not affect regional age-unadjusted and the age-adjusted data, the male- differences in admission rates, but it did slightly to-female ratios also fell slightly over time. Although the total number of procedures increased from 1994 to 1998, the rate decreased (from 14 15 Urologic Diseases in America Urolithiasis Table 9. In all years of study, the rates highest in the 85+ age group, although they increased of procedures increased with age to a maximum in the substantially after age 64by 2. Beyond that age, procedure refecting the higher prevalence of bladder stones counts in this database were too small to be reliable. Inpatient procedures for individuals having commercial health insurance with urolithiasis listed as primary diagnosis, counta, rateb 1994 1996 1998 2000 Count Rate Count Rate Count Rate Count Rate Total 272 25 375 24 539 22 682 25 Age < 3 1 * 1 * 3 * 4 * 310 2 * 0 0. Geographic steadily over time, decreasing by 15% from a mean variation was also evident, with rates highest in the of 3. National trends in mean length of stay (days) for Outpatient Care individuals hospitalized with lower tract urolithiasis listed An individual may be seen in the outpatient as primary diagnosis setting as part of the diagnosis of urolithiasis, during Length of Stay urologic treatment (pre- and/or post-procedure), 1994 1996 1998 2000 or for medical evaluation and prevention. Overall, the absolute Asian/Pacifc Islander * * * * number of hospital outpatient visits during this Hispanic 3. Other * * * * Information on hospital outpatient visits is also Region available from Medicare data for 1992, 1995, and 1998 Midwest 3. There were also regional differences, with the from National Ambulatory Medical Care Survey highest rates occurring in the South. The visit visit rate for a primary diagnosis of bladder stones rate was 43% higher in 2000 than it was in 1992. The rates peaked in the 65-to 74-year nearly 2 million visits in 2000 by patients with age group and then declined. In 1995 and 1998, the rates were higher for translates into a rate of 731 per 100,000 population. Thus, the vast majority offce visit rates slightly widened in all three years of of visits for urolithiasis (74%) are for urolithiasis as study, but the relative differences in geographic and the primary diagnosis (Tables 15 and 17). However, the data do not represent all decreased between 1999 and 2001 (Table 19). This outpatient procedures performed in a population, 24 25 Urologic Diseases in America Urolithiasis 24 25 Urologic Diseases in America Urolithiasis Table 19. The available data regarding ambulatory surgery During the years studied, the male-to-female for urolithiasis in children are too scant to provide ratio varied from 1. Regional differences were apparent: the highest rates were consistently seen in the Southeast; 28 29 Urologic Diseases in America Urolithiasis Table 22. Ureteroscopy of the Holmium laser in 1995 rendered virtually all remained stable over time and comprised 40% to stones amenable to fragmentation if they could be 42% of the procedures. Open stone surgery made up accessed endoscopically (14); however, this new only 2% of the total procedures in 1994 and dropped technology may have not yet reached widespread use to less than 1% in 2000. In database of commercially insured patients (Table both 1995 and 1998, the rates were highest among 24). Each inpatient or outpatient encounter determine whether this represented a sharp increase involves a variety of cost sources, including physician or simply year-to-year variability. In general, the professional fees, radiographic studies, room and rate for males was twice that for females. It is noted board, laboratory, pharmacy, and operating room that the confdence intervals for these estimates are costs. Among Medicare benefciaries, the rate always be easily arrived at or consistently applied. There were clear regional variations, for those without a claim relating to urolithiasis (Table with rates highest in the South. Hence, a $4,472 difference per covered individual 32 33 Urologic Diseases in America Urolithiasis 32 33 Urologic Diseases in America Urolithiasis Table 27. Expenditures for urolithiasis and share of costs, by type of service (in millions of $) Year 1994 1996 1998 2000 Totala 1,373. Average drug spending for urolithiasis-related conditions is estimated at $4 million to $14 million annually for the period 1996 to 1998. Evaluation 100% of regional differences in medical expenditures 90% suggests that overall higher expenditures for the 80% group without urolithiasis-related claims were found 70% in the South and West, whereas in the urolithiasis 60% group, expenditures were highest in the Midwest 50% and South. As prescription drug costs showed 40% little regional variation, the geographic differences 30% 20% in expenditures are likely related to direct medical 10% expenditures or possibly due to differences in the age 0% distributions of the regions. Percent share of costs for urolithiasis by type was spent on treating urolithiasis in 2000, based solely of service, 19942000. That these fgures are somewhat should be accounted for by expenditures either lower than the $1. Total expenditures (excluding as primary hyperparathyroidism, chronic diarrheal outpatient prescription drug costs) increased by syndrome due to bowel disease, etc. During that time period, non-inpatient differences (such as comorbidities) between those services (including physician offce visits, emergency with and without stone disease. When stratifed by of total expenditures for emergency room services age, the expenditures of those without a urolithiasis- also increased, from 15% in 1992 to 24% in 2000. In contrast, the peak total Medicare population also increased signifcantly over medical expenditure for the group with a urolithiasis- time. However, given the higher incidence of stone on outpatient prescription drugs for the treatment disease in men (a factor of 2 to 3), one might expect of urolithiasis in 19961998 ranged from $4 million a greater impact of gender in the group with stones. Expenditures for Medicare benefciaries age 65 and over for treatment of urolithiasis (in millions of $) Year 1992 1995 1998 Total 613. Expenditures In addition to the direct medical costs of in 2001 were nearly twice as high among infants (0 treatment, the economic effects of urolithiasis include to 2 years of age) as they were among children ages labor market outcomes such as absenteeism and work 3 to 10 or 11 to 17 and twice as high among African limitations. The setting for urolithiasis are diffcult to estimate, largely because of both the acute care and the surgical management of the paucity of data. However, some data are available patients with stones has changed over time: inpatient in the medical and fnancial records of the National admissions and length of stay have decreased as Table 30. Annual use of outpatient prescription drugs for the treatment of urolithiasis, 19961998 All Persons with Urolithiasis Conditional on Rx Use Number with % with Rx Claim Mean Number of Mean Rx Gender Urolithiasis for Urolithiasis Prescriptions Expenditures (in $) Male 676,144 29. Work loss is based on reported absences contiguous to the admission and discharge dates of each hospitalization or the date of the outpatient visit. The trends medical evaluation to determine the etiology of in distribution of surgical treatment modalities stone formation? How frequently are preventive measures however, shock wave lithotripsy remains the most recommended? What is the rate of adherence to medical stones, followed by ureteroscopy and percutaneous recommendations, and how does this change over nephrostolithotomy. What are the national recurrence rates, and how the use of open surgery, which is now less than 2% of are they affected by demographic factors? The cost of urolithiasis is estimated at nearly $2 billion annually and appears to be Imaging modalities in the diagnosis and follow-up of increasing over time, despite the shift from inpatient patients with upper tract urolithiasis to outpatient procedures and the shorter length of 1. What is the optimal imaging modality for hospital stays, perhaps because the prevalence of monitoring patients with a history of stone disease is increasing. What is the optimal urological management of the associated procedures, it would be helpful to acute renal colic? How have practice patterns evolved in the upon the site of pathology in the ureter. How have practice patterns evolved in the From a clinical perspective, prevention is balance between ureteroscopy vs percutaneous essential to reduce costs and morbidity. Primary nephrostomy in the management of upper prevention is not practical at this time, but aggressive ureteral stones? Is upper tract urolithiasis a risk factor for other expended a great deal of time and effort to obtain conditions (e. We propose the following topics for investigation to improve the understanding of urolithiasis. How frequently are metabolic evaluations performed for patients with urolithiasis?
A population-based study on the effort (an undue hardship) on the part of the incidence of dementia disorders between 85 and 88 years of age cheap norpace 150 mg line. Individuals lacking insight are least equally effective level of service as that provided frequently brought to professional attention by a family to the nondisabled generic 100mg norpace with visa. Psychiatric comor- nation of good nutritional rehabilitation purchase norpace 100mg amex, psychotherapy norpace 150mg mastercard, bidities include depressive symptoms like sadness, and medications. Aims of treat- cal sequelae of semistarvation and resolve only after ment are to restore the patients nutritional status partial or complete weight restoration. Estimates of specific reuptake inhibitors, for example, fluoxetine male-to-female ratio range from 1:6 to 1:10. Long-term follow-up frequent in industrialized societies, where there is an shows recovery rates ranging from 44% to 76% with abundance of food and being thin, especially for mortality of up to 20% primarily from cardiac arrest or females, is considered attractive. Treatment guidelines are readily available with eating disorders are common in young Hispanic, Native an abridged, up-to-date version at www. Starvation results in many biochemical changes such as American Psychiatric Association. Practice guideline for the treatment of patients with eating and children of patients as well as low levels of nurtur- disorders (revision). Philadelphia: Lippincott, Williams Test, Eating Disorders Inventory, or Body Shape and Wilkins. Generalized weakness, dehydration, electrolyte and cardiac rhythm abnormalities, and amenorrhea are common. Bleeding 89 Anxiety Disorders Panic attacks or panic-like symptoms can be either Anxiety Disorders The term Anxiety Disorders unexpected, situationally bound, or situationally predis- refers to a category of psychiatric illnesses that are gen- posed. The first type occurs unpredictably whereas the erally more chronic than substance use or affective situationally bound type occurs in the presence of a (mood) disorders. Situationally predisposed can be in response to tion have had some type of anxiety disorder in their life- some stimulus but at other times attacks do not occur time. The fourth edition of the Diagnostic and Statistical with that stimulus at all (e. Panic disorder without ago- condition, substance-induced anxiety disorder, and anxi- raphobia has the same criteria for diagnosis except that ety disorder not otherwise specified. On The two most common anxiety disorders are social the other hand, a diagnosis of agoraphobia without his- phobia (13% lifetime prevalence) and simple phobia tory of panic disorder is made when agoraphobia symp- (11% lifetime prevalence). Risk factors for anxiety toms are related to fears of developing the panic-like disorders include lower socioeconomic status, female symptoms without a history of full-fledged panic gender, and living in the Northeast region of the United attacks. Women are twice as likely to have any anxiety Specific phobia and social phobia are similar in that diagnosis, except social phobia, where the women- the increased anxiety is situationally bound to a specific to-men ratio is 3:2. In specific phobia, this can be anything from 34 have the highest prevalence rates. Individuals with anxiety triggers can be easily avoided, functioning is rarely disorders are highly likely to have another coexisting impaired (e. In social phobia, the anxiety arousal is linked to level of anxiety begins to interfere with functioning or social interactions and feared negative evaluations cause considerable emotional distress, it is important to by others. Since anyone can speak to you at any time, evaluate for the presence of an anxiety disorder. In individuals may experience more of a general anxiety most of the disorders outlined here, the level of anxiety arousal than those with other anxiety disorders. Panic attacks are a central feature of Individuals with obsessivecompulsive disorder several of the anxiety disorders. Attempts are symptoms are fewer in number than is required for a made to ignore these thoughts or to neutralize them full-fledged panic attack, but can also include other with some repeated action (e. At times this may also take the form of men- ments include exposure-based therapies, behavioral tal acts (e. Diagnostic and statistical actual or threatened death or injury or threat to physical manual of mental disorders (4th ed. Anxiety disorders reminiscent of the original event including similar and phobias: A cognitive perspective. Journal of Symptoms include a feeling that one is reexperiencing Consulting and Clinical Psychology, 60, 835844. New York: body symptoms include feeling restless, irritable, and Oxford University Press. The focus of worry is usually everyday things like work, school, or family finances but it is severe enough to cause impairment in functioning or cause significant distress. A diagnosis of anxiety disorder not it is vital that the correct diagnosis is made. Various interventions have been used to joints, leading to progressive thinning of that cushion. A positive rheumatoid factor can be sug- Cartilage undergoes constant recycling of removing old gestive of rheumatoid arthritis but it is not absolutely nec- cartilage and replacing it with new. The presence of a positive recycling process breaks down and osteoarthritis then rheumatoid factor means that a more aggressive form of begins to form. To control pain, nonsteroidal anti-inflammatory include: obesity, aging, and situations that put one at risk medications or sometimes prednisone can be used to at certain joints. How- climbing are associated with an increased frequency of ever, these medications cannot stop the abnormal knee osteoarthritis. Initially, the pain is only intermit- The mainstay of rheumatoid arthritis treatment has tent, typically associated with the use of the joint. With inactivity, the joint stiffens and can give been shown to significantly improve the symptoms of the sensation of locking up when trying to move it rheumatoid arthritis in most patients. Morning stiffness, after a full night of inactivity, system altering medications are used if methotrexate is usually lasts about 1530 minutes. The mainstay of treatment for osteoarthritis is researchers to create medications that specifically target nonsteroidal anti-inflammatory drugs. Osteoarthritis is immune molecules that are known to be the cause of discussed in greater detail elsewhere. Both of these medications risk factors for rheumatoid arthritis include age have revolutionized how rheumatoid arthritis is treated. Because this is an immune system process, medications, can increase the risk of infections. The most All patients who use these drugs should be closely common joints include the hands, wrists, knees, and monitored by their physicians. The disease is usu- We now approach rheumatoid arthritis much ally symmetrical, in that the same joint is affected on like we treat cancer, by attempting to put the disease both sides of the body. Of course, aggres- develop rheumatoid nodules, which are bumps on their sive therapy is associated with more potentially elbows. Act of 1964, legal bans on interracial marriage, existent Philadelphia: Williams & Wilkins. During much of the 1990s, Maxine Hong Kingston was the most widely taught Asian and Pacific Islander The women of living American author. Elaine Chao currently serves as Asia and the Pacific Islands are the worlds largest the U. Nevertheless, Asian and demographic group, comprising over one quarter of Pacific Islander women often endure negative stereo- humankind. They inhabit regions as diverse as cos- types of submissiveness and of being accepting of mopolitan Taipei and Tokyo, snowy Himalayan peaks, sexual exploitation, as put forth by media images and the tropical isles of the Philippines. In 1988, play- years ago, Asians journeyed across land bridges and wright David Henry Hwang won a Tony Award for the ocean to become the first inhabitants of what is M. Many Asian and Pacific Islander cultures have In 1965, immigration quotas favoring those of European highly evolved health practices. Examples include national origins were replaced by those favoring acupuncture, Chinese herbal remedies, yoga, medita- skilled professionals. Whereas 19th century Asian tion, and Ayurvedic medicine, all of which are gaining immigrants were mostly Chinese and Japanese male increasing acceptance into mainstream America and agricultural and railroad laborers, the post-1965 Asian being incorporated into Western medical practices. With the fall of Saigon well informed about the offerings of Western medicine, to communist forces in 1975, Southeast Asians many elderly and recent immigrants may not under- sought refuge in the United States. Initially comprised stand Western medical concepts, or find them confus- of the Vietnamese upper class fleeing political perse- ing. For example, a study of Southeast Asians in Ohio cution, later waves consisted of rural populations from found that 94% did not know what blood pressure is.