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Key services for this demographic include anti-ageing skin treatments, therapies aimed at relieving pain and arthritis, and massages to Wellness programmes for reduce stiffness and joint/muscle pain. Cleveland Clinic’s Wellness Institute in Ohio is an example of how medical centres are using patient history As the elder population is exposed to a knowledge to create customised wellness programmes, integrating acupuncture, myriad of age-related health issues, spas massage, reiki and even Chinese herbal can serve as relief for common ailments therapy to relieve symptoms. As the elder population is exposed to a myriad of at Equinox Resort in Vermont, people age-related health issues, spas can serve are booking longer and more expensive as relief for common ailments. In realising the importance of self-care and addition, spas are implementing add-ons how spas tie into everyday wellness. At the Spa tional services provide customers with a non-labour-intensive de-stressing experience. Wellness is key in reducing stress, Guests over 65 have the time and and no matter one’s age, consumers are money to spend on travel and spa looking for various ways to relieve stress and maintain a balance in everyday life. Further, each treatment important that spas are able to keep up based world, it’s important now more starts off with honey to awaken the with consumer demand without sacrificing than ever to provide one-of-a-kind expesenses. It’s unique practices like these service standards and individual guest riences to not only attract new demand, that help attract new customers and attention. At Mohonk Mountain House therapists and aestheticians are key to and emphasise a true balanced wellness in New York, a Mindfulness in Motion the successful implementation of unique experience at their facility will continue to walk guides guests around wooded trails, and personalised services in spas. O cliff edges and a crystal-clear lake, while As digital technologies become its Signature Elements of Nature facial ever-more prevalent, human interaction Q About the author: incorporates witch hazel grown on-site. The report features 14 key metrics Dubai spas saw a marginal fall in the been an increasing willingness to spend designed to track spa operational perforaverage treatment rates (by 1 per cent), money on wellness, making the wellness mance, and is based on data received owing to an increased number of industry one of the fastest growing indusfrom a spa panel representing a stock of price-sensitive customers and pressure tries in the world. According to the Global 272 and 92 treatment rooms from Dubai from new entrants in the market. Moreover, with more promotions, Graph 1: Retail revenue contribution* 16% Resorts 14% City hotels 12% 10% 8% 6% 4% 2% 14. Additionally, the average demand, increasing in share from fallen by 11 per cent, dropping the overall number of treatments sold per day in 40 per cent to 46 per cent from 2016 spa revenue among Dubai hotel spas. City hotel spas saw the reverse A closer analysis of the data reveals per day, resulting in a decrease in trend, with resident walk-in demand going that the spa revenue has dropped by both therapist and treatment room from 51 per cent of total demand in 2016 20 per cent among Dubai’s resort spas, utilisation by 17 per cent and 28 per cent, to 45 per cent in 2017. On the other hand, city hotels have by Dubai spas increased by nearly the demand for spas has also shown been able to maintain a steady customer 3 per cent, especially among the a slight dip (4 per cent) among Dubai’s base, as indicated by the slight increase city hotel spas, which increased to resort spas, while the city hotel spas in number of treatments sold per day, 3. Nequo hours has fallen in both city and resort spas in 2017ellabor epernam volorrovitio doll pore volenitatur, aut rae nistrum spas than in resort spas, dropping by Decreasing therapist productivity About Colliers International 5 per cent in 2017. Therapist utilisation in city hotel Increasing female spa guests the consultants provide strategic advice spas decreased from 36 per cent Dubai spas also witnessed a significant on everything from market feasibility and to 33 per cent in 2017, despite an increase in the number of female operator searches to budget analysis increase in treatments sold, suggesting spa guests over the last three years, and asset management. The figures also suggest of several new spas in 2017, including New versus established spas that the efficiency of spas in Abu Dhabi When analysing the data by age, has reduced as utilisation of therapist established spas in Dubai (open more hours has fallen by almost 18 per cent. Several new spas are anticipated to New spas have a lower capture rate open in 2018, including the Zen Spa at (2 per cent vs. Finding the right talent predict an increase in spa revenues was the next-biggest challenge. Increasing competition due Q About the authors: the top three challenges faced in 2017 to the new entrants was the next-biggest Christopher Lund and their outlook for the coming year. However, Annie Fernandez 2017 was the increase in price-sensitive there is a significant variance in 2018 is a senior analyst in the same division. Twenty-four per cent also outlook, which means that the market Email: christopher. There is almost an equal Tel: +971 4 453 7400 and therefore had trouble retaining their distribution between respondents who Several spa and welland upscale facilities, but the Gen X (26 per cent, compared to 25 per ness centres report the number of male Tgrowth in the market will come cent globally). In the rest of the world, and female guests is equal, and a few from young and first-time visitors who are Baby Boomers may lead the charge when reported more male than female guests. This has important implications for international visitors, with most of those cooperation with Resources for Leisure both spa design and programming. Assets, published its 5th benchmarking Data also show that although the report on the role of spa and wellness female segment is still the typically What motivates guestsfi The survey results reveal that the spa market is still dominated by Table 1: Top 3 market segments for spas luxury/upmarket facilities in the AsiaPacific region, and 65 per cent of the market considers itself a luxury operator, Global data German-speaking Asia-Pacific compared to 55 per cent of spa and markets markets 1. Global marketing and branding a long list of likely motivation triggers It should be noted that demand does not seem to be working anymore. The data we received appears to be more and more fragmented both in the pilot and in the follow-up as we compare different regions around What treatments do guests wantfi Operators need to define In terms of popularity of services and or price play little role in foreign guests’ relevant market segments differently, treatments, we asked operators to motivation in selecting a spa or wellness facility – important information, since investors tend to spend a significant amount on spa design and technology. Table 2: Amount spent per day on spa services Operators also confirmed the growing trend of social consumption – when GermanSpanishGlobal Asia-Pacific treatments and services are consumed speaking speaking data Market in small groups, rather than individually. Whereas the global data show the holistic treatments in Asia importance of natural resources-based therapies and treatments as well as services based on local resources, the differ greatly from that of the global data. Spas and wellness facilities must Asia-Pacific market shows a somewhat Foreign guests are estimated to spend apply special marketing and management different path. The current and forecasted therapies and holistic treatments in prospects, developers and operators demand from these major groups shows Asia, which refiects the rich spiritual need to look at their respective markets limited overlap, and this provides chaland holistic resources and traditions. This is actually not that different from trends and forecasts depending on which the operators in the Asia-Pacific region the global data, however; holistic market we look at. This Q the amount of domestic visitors changed these are to be marketed – either as interest may not turn these guests into by less than 5 per cent, whereas holistic, complementary services or local wellness tourists, but clearly shows the Q the number of foreign tourists resources. The research, which is built on operational benchmark data and forecasts, defines market intelligence on a global scale. The recurring survey’s objective is to identify the key changes in the market learning from operators’ experiences. What is very exciting is the growth of cially when it comes to international He is the (co-)author of numerous specialfirst-time guests. The candid dialogue Merchandising — defined as the activity from Contento Marketing’s first underscored that there needs to be an of promoting the sale of goods at retail — Tretail study, published in the open dialogue between buyer and seller. Respondents reported a range of this year’s survey focused on both sides accounts do not share their professional merchandising and display fiaws, from of the spa/supplier relationship, to sell-through percentages. Yet suppliers improper lighting and fixtures, to lack of uncover challenges and best practices need information to help spas improve sales support tools such as shelf-talkers, while digging deeper into specific issues service to retail sales ratios, which have displays, samples and testers. The majority Lack of signage and collateral for (67 per cent) of spa directors report consumer education was chosen as the retail revenues as a percentage of gross biggest fiaw by several suppliers. This suggests that current 4% question “What is the biggest fiaw you collateral is failing to reach the target 13% 17% see in a spa retail settingfi Many spa directors find themselves without the proper resources, Staf training & incentives or work with corporate buyers who are not Staff training and incentives was a close 25% always on the same page. Spa retail often second in this year’s survey as the bigtakes a backseat to services. There are a number 42% of staffing issues to manage, including the top 5 fiaws cited were: selection, training and incentives. Wrong product mix/saturation of amount of time visiting accounts for prod* Source: Contento Marketing 2018 Spa Retail Study products uct knowledge and treatment trainings. Q Retail sales are 15 per cent higher per therapist if a professional license is displayed: the ‘credible authority’ syndrome Q Employees need to be able to buy at a deep discount. Very often the least paid “Whoever sells the most gets to keep the people are selling retail. Sales increased by 35 percent in shift,” says Ann Patton, principal of Savvy when you do not have a retail the first week. If you are carrying more than three months worth of inventory, get rid of what you can’t sell. Grab-and-go items such as travel Consulting, noted excess back stock to a carefully curated group of products to sizes be a burden in nearly all his consulting free-up valuable space. Items that address common do not want to bring in new lines because Q Interactive-iPads in lounges for shopping concerns (ex.
Reliable typing of systemic amyloidoses through proteomic analysis of subcutaneous adipose tissue impotence unani treatment in india buy cheap himcolin 30gm on-line. Independent predictors of survival in primary systemic (Al) amyloidosis impotence hypertension discount himcolin online american express, including cardiac biomarkers and left ventricular strain imaging: an observational cohort study impotence vacuum treatment purchase generic himcolin on-line. A 35-year-old man experiences a sudden-onset syncope while playing soccer erectile dysfunction with diabetes purchase himcolin in india, and you are consulted by the emergency department. Inverted T waves in leads V1 and V2 in the absence of complete right bundle branch block C. Intercalated disks are the units of electromechanical continuity between cardiac myocytes B. A 30-year-old man presents to your clinic with bilateral lower extremity edema that has been progressive over the last few months. A 45-year-old woman has a diagnosis of nonischemic cardiomyopathy, with signs and symptoms of predominantly rightsided heart failure. The diagnostic yield may be improved by using electroanatomic voltage mapping to guide biopsy 62-8. The predominant inheritance pattern is autosomal recessive with variable penetrance and expressivity, although an autosomal dominant pattern has been described B. Class I recommendation for mutation-specific screening of family members following the identification of a pathogenic mutation in the proband C. The Task Force document formally introduced the 1 biventricular variant and the left dominant variant. Options A and C through E represent major criteria from the updated Task Force criteria. A definite diagnosis requires two major, or one major and two minor, or four minor criteria from different categories to be fulfilled. The prevalence of clinical manifestations of the disease 7-8 is higher in males than in females (3:1). The disease usually manifests in young adults; of 439 index patients described 7 by Groeneweg et al, only 4 presented before the age of 13 years, while none presented before the age of 10 years. The reason could be related to the completion of intercalated disk maturation or the need for prolonged exposure to exercise 7 before the disease becomes manifest. In dilated cardiomyopathy, genetic abnormalities in the sarcomere may be causal for disease (option B). Gap junctions (nexus, communicating junctions) are located in the lateral parts of the intercalated disks and mediate ionic traffic between the adjacent cells and provide the basis for functional cell coupling. Key structural proteins are connexins; the connexins predominantly expressed by cardiac myocytes are Cx43, Cx40, and Cx45. Adherens junctions (fasciae adhaerentes) are located in the transverse parts of the intercalated disks where the actin filaments of the sarcomeres are anchored and connected with the plasma membrane. This anchorage provides the intercellular “mechanical continuity” between the myocytes supporting the transmission of force between cells and synchronous contraction and relaxation. Desmosomes (maculae adhaerentes) are located in both the transverse and lateral parts of the intercalated disks: they reinforce the adherens junctions and fix adjacent cells. Desmosomes bind desmin on the intracellular side, span the cell membrane, and bind adjacent desmosomes on the extracellular side. Symptoms are heterogeneous but most commonly reflect the presence of ventricular arrhythmias, which can range from isolated premature ventricular contractions to sustained ventricular tachycardia. In a study of 129 probands, symptoms on presentation included palpitations in 56%, dizziness in 29%, syncope in 26%, chest pain in 19%, 12 13 and cardiac arrest in 22%. Catecholaminergic polymorphic ventricular tachycardia (option D) is another inherited arrhythmia characterized by episodic syncope that occurs during exercise or acute emotion in individuals without structural cardiac abnormalities; the underlying cause is the onset of fast ventricular tachycardia (bidirectional or polymorphic). Diagnostic yield may be improved by using electroanatomic voltage 24 mapping to guide biopsy (option E). The Heart Rhythm Society and European Heart Rhythm Association expert consensus guidelines give this 25 indication a Class I recommendation. The clinical genetic and molecular workup in the proband and his or her family should be performed as in other familial cardiomyopathies and include clinical and genetic screening of firstdegree relatives. Also, the presence of symptoms or the occurrence of more than one genetic variant in family 7,26,28 members increases the likelihood of Task Force criteria–confirmed disease. The role of electrophysiology 31,33,38,39 study for risk stratification is unclear because studies provide conflicting evidence. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the Task Force Criteria. Arrhythmogenic right ventricular cardiomyopathy, clinical manifestations, and diagnosis. Arrhythmogenic right ventricular cardiomyopathy/dysplasia clinical presentation and diagnostic evaluation: results from the North American Multidisciplinary Study. Prevalence of right ventricular dysplasia-cardiomyopathy in a non-referral hospital. Clinical presentation, long-term follow-up, and outcomes of 1001 arrhythmogenic right ventricular dysplasia/cardiomyopathy patients and family members. Arrhythmogenic right ventricular dysplasia/cardiomyopathy—three decades of progress. Prevalence of atrial arrhythmias in arrhythmogenic right ventricular dysplasia/cardiomyopathy. The Canadian Arrhythmogenic Right Ventricular Cardiomyopathy Registry: rationale, design, and preliminary recruitment. Clinical and genetic characterization of families with arrhythmogenic right ventricular dysplasia/cardiomyopathy provides novel insights into patterns of disease expression. Naxos disease and Carvajal syndrome: cardiocutaneous disorders that highlight the pathogenesis and broaden the spectrum of arrhythmogenic right ventricular cardiomyopathy. Mutation-positive arrhythmogenic right ventricular dysplasia/cardiomyopathy: the triangle of dysplasia displaced. Quantitative assessment of endomyocardial biopsy in arrhythmogenic right ventricular cardiomyopathy/dysplasia: an in vitro validation of diagnostic criteria. Diagnostic value of endomyocardial biopsy guided by electroanatomic voltage mapping in arrhythmogenic right ventricular cardiomyopathy/dysplasia. Approach to family screening in arrhythmogenic right ventricular dysplasia/cardiomyopathy. Prospective evaluation of relatives for familial arrhythmogenic right ventricular cardiomyopathy/dysplasia reveals a need to broaden diagnostic criteria. Familial evaluation in arrhythmogenic right ventricular cardiomyopathy: impact of genetics and revised task force criteria. Natural history and risk stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy. Arrhythmogenic right ventricular dysplasia: clinical results with implantable cardioverter defibrillators. Implantable cardioverter-defibrillators in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy. Prophylactic implantable defibrillator in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia and no prior ventricular fibrillation or sustained ventricular tachycardia. Prognostic predictors in arrhythmogenic right ventricular cardiomyopathy: results from a 10-year registry. Different prognostic value of functional right ventricular parameters in arrhythmogenic right ventricular cardiomyopathy/dysplasia. Long-term follow-up and risk assessment of arrhythmogenic right ventricular dysplasia/cardiomyopathy: personal experience from different primary and tertiary centres. Predictors of adverse outcome in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy: long term experience of a tertiary care centre. Incidence and predictors of implantable cardioverter-defibrillator therapy in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy undergoing implantable cardioverter-defibrillator implantation for primary prevention. Three-dimensional electroanatomical voltage mapping and histologic evaluation of myocardial substrate in right ventricular outflow tract tachycardia. Outflow tract premature ventricular contractions and ventricular tachycardia: the typical and the challenging.
B vitamin plasma levels and the risk of ischemic stroke and transient ischemic attack in a German cohort causes of erectile dysfunction in 60s purchase 30 gm himcolin visa. Nutrients involved in one-carbon metabolism and risk of breast cancer among premenopausal women erectile dysfunction caused by lisinopril buy generic himcolin 30 gm on-line. Folate erectile dysfunction caused by surgery cheap himcolin, vitamin B12 and postmenopausal breast cancer in a prospective study of French women erectile dysfunction support group cheap himcolin 30 gm overnight delivery. Plasma levels of B vitamins and colorectal cancer risk: the multiethnic cohort study. Plasma vitamin B12 concentrations and the risk of colorectal cancer: a nested case-referent study. Circulating folate, vitamin B12, homocysteine, vitamin B12 transport proteins, and risk of prostate cancer: a case-control study, systematic review, and meta-analysis. Dietary folate and vitamin B12 intake and cognitive decline among community-dwelling older persons. Biochemical indicators of vitamin B12 and folate insuffciency and cognitive decline. Dietary folate and vitamins B-12 and B-6 not associated with incident Alzheimer’s disease. Homocysteine, vitamin B-12, and folic acid and the risk of cognitive decline in old age: the Leiden 85-Plus study. Prospective study of plasma folate, vitamin B12, and cognitive function and decline. Signifcant correlations of plasma homocysteine and serum methylmalonic acid with movement and cognitive performance in elderly subjects but no improvement from short-term vitamin therapy: a placebo-controlled randomized study. A daily intake of approximately 6 microg vitamin B-12 appears to saturate all the vitamin B-12-related variables in Danish postmenopausal women. Daily intake of 4 to 7 microg dietary vitamin B-12 is associated with steady concentrations of vitamin B-12-related biomarkers in a healthy young population. Opinion of the Scientifc Committee on Food on the Tolerable Upper Intake Level of Vitamin B12: Scientifc Committee in Food 2000. Biotin is essential to all known organisms and is synthesized by plants and microorganisms, but animals, including man, lack the ability to synthesize biotin (1). Ofal meats such as liver and kidney, egg yolks, rolled oats, and wheat bran are rich sources (2). The average intake in Danish adults is estimated at 40 µg per day and approximately 70% of this intake is provided by bread and other cereal products, dairy products, and eggs (2). Physiology and metabolism Protein-bound biotin is digested in the gut prior to absorption and requires the enzyme biotinidase (1) to cleave the covalent bond between the biotin and the protein (1). Bioavailability of biotin in diferent foods varies from very low to almost complete utilisation. Raw egg white contains the glycoprotein avidin that binds to biotin and prevents its absorption, but the biotin binding capacity of egg white is lost upon cooking. A potential source of biotin is microbial synthesis in the large intestine, but the quantitative contribution of this source to biotin metabolism is unclear (4). These reactions are important in fatty acid synthesis, in the conversion of pyruvate into oxaloacetate (an intermediate in the citric acid cycle), and in degradation of branched amino acids and odd-chain fatty acids. Dietary defciency of biotin is rare and has only been conclusively demonstrated in individuals on parenteral nutrition without biotin or on diets with chronic ingestion of raw egg white. Biotin defciency has also been demonstrated in cases of inherited biotinidase defciency (1). However, no untoward efects of a marginally reduced biotin status in pregnancy have been documented (7). This reference intake is based upon the intake of biotin in breast-fed infants and is extrapolated to adults by body weight. Increased urinary excretion of 3-hydroxyisovaleric acid and decreased urinary excretion of biotin are sensitive early indicators of decreased biotin status in experimental biotin defciency. Opinion of the Scientifc Committee on Food on the Tolerable Upper Intake Level of Biotin: European Comission. The vitamin is watersoluble and has an important role in intermediary metabolism as part of coenzyme A (1, 2). Pantothenic acid is widely distributed in nature as its name implies (from the Greek pantos meaning “everywhere”). Rich sources of pantothenic acid are ofal, dried legumes, and wholegrain products. The majority (~ 75%) of this amount comes from milk and cheese, cereal products (including bread), meats, and vegetables (3). Physiology and metabolism As a constituent part of coenzyme A and acyl-carrier protein, pantothenic acid plays a central role in both catabolism and anabolism as a carrier of acyl groups. Defciency of pantothenic acid is rare because of the widespread nature of the vitamin, and defciency has only been observed in individuals on a diet free of pantothenic acid or given an antagonist to pantothenic acid (4). Defciency-induced greying of the hair in mice can be reversed by administration of pantothenic acid, but the once popular idea that pantothenic acid might restore hair colour in humans proved fruitless (5, 6). Upper intake levels and toxicity the toxicity of pantothenic acid is very low, and due to a lack of systematic oral intake dose-response studies no upper intake level can be derived. The evidence available from clinical studies using high doses of pantothenic acid indicates that intakes considerably in excess of current levels of intake from all sources do not represent a health risk for the general population (7). Mitochondrial function and toxicity: role of the B vitamin family on mitochondrial energy metabolism. The effect of pantothenic acid defciency on keratinocyte proliferation and the synthesis of keratinocyte growth factor and collagen in fbroblasts. Opinion of the Scientifc Committee on Food on the Tolerable Upper Intake Level of Pantothenic Acid. Although the classical vitamin C defciency, scurvy, is prevented by small daily intakes (about 10 mg/d) (1), current knowledge of the antioxidant functions of vitamin C has recently had a great infuence on the research into daily vitamin C allowances. Dietary sources and intake the concentration of vitamin C is high in many vegetables, berries, and fruits (especially citrus fruits). The plasma level of vitamin C is a biomarker of fruit and vegetable consumption (1), and the observed associations between plasma (and dietary) vitamin C and health might at least partly refect other health-enhancing components in fruit and vegetables or even other lifestyle variables. In all these functions, the efects of ascorbic acid are based on its ability to be an electron donor. The vitamin is also involved in the biosynthesis of corticosteroids and aldosterone and in the microsomal hydroxylation of cholesterol in the conversion of cholesterol to bile acids. Due to its reducing power, ascorbic acid also improves absorption of non-haem iron. The vitamin readily scavenges reactive oxygen species and reactive nitrogen species in addition to singlet oxygen and hypochlorite. It is evident that ascorbic acid provides meaningful antioxidant protection in neutrophils, semen, and plasma. As a reducing agent, ascorbic acid can also inactivate carcinogenic substances such as nitrosamines. Ascorbic acid is absorbed from the intestine by a sodium-dependent, active process that is saturable and dose-dependent. The bioavailability (the efciency of gastrointestinal tract absorption) is at least 80% for doses of 100 mg or less, 60–70% for doses of 200–500 mg, and less than 50% for doses exceeding 1,000 mg (3). Unabsorbed ascorbate is degraded in the intestine and this process can lead to diarrhoea and intestinal discomfort that are sometimes reported by persons ingesting very large doses from supplements (4). When the transport protein reaches saturation, the remaining vitamin C is excreted in the urine. For doses up to 60 mg no ascorbic acid is excreted (3), for doses of 100 mg about 25% is excreted, for doses of 200 mg about 50% is excreted, and for doses of 500 mg about 80–90% is excreted. The estimated threshold for excretion is about 80 mg/d meaning that essentially no vitamin C is excreted in the urine if the daily intake is lower than the threshold (5). The body pool of ascorbic acid increases up to a daily intake of approximately 100 mg (6) at which point neutrophils, monocytes, and lymphocytes become saturated (3, 7). When white blood cells become saturated, the plasma ascorbic acid concentration is approximately 50–60 mmol/L but very large doses (2,500 mg/d) are capable of increasing plasma levels 466 up to 80 mmol/L (3, 7). However, above a daily intake of about 100 mg ascorbic acid, further increases in vitamin C intake lead to gradually smaller increases in plasma vitamin C levels (9). Plasma ascorbic acid concentrations below 23 mmol/L are indicative of marginal vitamin C status (8). This level is reached with an estimated daily intake of 41 mg, but this exact value depends on body size (8).
Feline gastrointestinal parasitism in Greece: emergent zoonotic species and associated risk factors erectile dysfunction rates age purchase himcolin 30gm on-line. Dog and cat bites: Epidemiologic analyses suggest different prevention strategies erectile dysfunction underlying causes himcolin 30 gm line. Concurrent cellular infiltrates frequently include neutrophils erectile dysfunction in females buy genuine himcolin on-line, lymphocytes and plasma cells impotence cures purchase himcolin online now. If the dog is systemically unwell or large bowel diarrhea is severe or chronic, a biochemical profile, urinalysis, and complete blood count are also submitted to screen for evidence of multiorgan involvement. Abdominal radiographs usually yield minimal information about primary colonic disease but can be performed to screen for masses or foreign bodies and to evaluate the relationship of the colon to other viscera and the pelvic canal. Ultrasonography can be useful for detecting ileocecocolic lesions and masses, as well as assessing mural thickness and regional lymph nodes. Thoracic radiographs and cytology of a rectal scrape may identify local and disseminated infections such as histoplasmosis. Bacterial cultures (blood, urine, fecal) should be considered, particularly for febrile dogs that are systemically unwell. The next step in the investigation of chronic and/or severe colitis is endoscopic examination of the rectum, colon, cecum, and terminal ileum. At least 8 to 10 endoscopic biopsies of normal and abnormal mucosa should be acquired, as lesions can be patchy. Biopsies may be placed in sterile transport media but must be ground with a sterile mortar and pestle or tissue homogenizer prior to plating. Rigid proctoscopy is an alternative to flexible endoscopy for evaluating and biopsying the distal colon and rectum. Other fungal antigen and antibody tests should be considered based on geographic prevalence. These dogs most often present with a lifelong history of diarrhea and/or hematochezia. This has typically been accomplished with 6 to 8 weeks of oral fluoroquinolone administration. As treatment successes are predicated on the judicious selection of appropriate antimicrobial drugs, the authors caution against empirical use of antimicrobial polypharmacy in dogs suspected to have E. In addition to antimicrobial therapy, adjunctive therapies directed at modifying the luminal environment and colonic epithelium may also help dogs with E. Dogs that achieve clinical remission may experience a clinical cure and live normal lives. Infection results in disseminated disease in dogs, most commonly affecting the colon, nervous system, and eyes. Urine culture is a reliable means of detecting disseminated protothecosis (Stenner et al 2007). Amphotericin B as well as azole antifungals have been employed, but the optimal treatment regimen is not known. Since many of these are infectious, it is imperative not to immunosuppress patients with granulomatous or neutrophilic intestinal infiltrates until infectious etiologies have been excluded to the best of one’s ability. The prognosis for granulomatous or neutrophilic enteropathies is guarded to poor if an underlying cause is not identified. In rare cases, autoimmune and neoplastic diseases, as well as foreign-body reactions can promote granulomatous enterocolitis. Alterations of the Ileal and Colonic Mucosal Microbiota in Canine Chronic Enteropathies. Antimicrobial resistance impacts clinical outcome of granulomatous colitis in boxer dogs. Inflammation-associated adherent-invasive Escherichia coli are enriched in pathways for use of propanediol and iron and M-cell translocation. Host–microbe interactions have shaped the genetic architecture of inflammatory bowel disease. Association between granulomatous colitis in French Bulldogs and invasive Escherichia coli and response to fluoroquinolone antimicrobials. Adherent and invasive Escherichia coli is associated with granulomatous colitis in boxer dogs. This presentation will discuss common causes, diagnostics, and treatments for equine joint disease. Case studies will be used to highlight the value of objective gait analysis for monitoring response to treatment. Lameness Evaluation and Objective Gait Analysis Lameness examination in the horse typically involves evaluation at a walk and trot in hand. Induced lameness is lameness that becomes apparent as a result of manipulation, such as a flexion test or applied pressure. In cases of subtle lameness, horses are best evaluated under a variety of conditions, including in hand, on soft and firm footing, lungeing in both directions, and under saddle examination performing discipline-specific maneuvers. The Equinosis Q is not the only objective gait analysis system available; however, the nature of the inertial sensor-based system and laptop offers the advantage of mobile, ambulatory use. Other objective gait analysis systems include the EquiGait inertial sensor-based system and Qualisys Gait Analysis, which is an optical-based system for locomotion assessment with high precision and accuracy; however, the optical system is not mobile and only accessible on a referral basis. In addition to being able to quantitate lameness more precisely, objective gait analysis offers the ability to more objectively evaluate response to diagnostic analgesia or, more importantly, the response to treatment over longer time scales. Objective analysis also helps to eliminate bias, conscious or unconscious, by the veterinary practitioner. The most common sites for osteochondral fragmentation in the carpus are the distal and proximal intermediate carpal bone and distal radial carpal bone. Flexed lateromedial radiographs of the carpus and elevated angle oblique (20 degrees above horizontal and 15-20 degrees dorsal to a standard lateromedial projection) radiographs of the fetlock joints help delineate the sites of osteochondral fragmentation. In addition to osteochondral fragmentation, osteochondral fracture, soft tissue injuries, subchondral cystic 2 lesions and osteochondrosis can all precipitate joint disease in the racehorse. Diagnosis of subtle injuries, especially involving subchondral bone, can be challenging and may require volumetric imaging. Diagnosis of Joint Disease in the Non-Racehorse Predispositions for specific joint disease will depend upon breed, conformation and discipline. Likewise, horses with sickle-hocked conformation will be predisposed to distal tarsal joint disease, while carpal and fetlock angular limb deformities or offset knees can predispose to joint disease secondary to uneven mechanical loading and stresses on these joints. However, although it is helpful for the equine practitioner to be aware of certain breed and discipline predispositions to joint disease, it is also important to keep an open mind. For example, although metacarpal/tarsal condylar fractures are far more common in racehorses, they do occasionally occur in non-racehorses. Treatment of High-motion Joint Disease Treatments for high-motion joint disease typically involve pharmaceutical and biological therapies that will be discussed in depth, along with emerging experimental therapies, in a subsequent session, “Frontiers in Management of Joint Disease. In young, growing foals, the veterinarian may be able to intervene to help correct angular deformities, flexural deformities or other conformational faults. Arthrodesis may allow affected animals to go on to their intended purpose, with a better prognosis for hindlimb pastern arthrodesis than forelimb. Although non-surgical methods for facilitated ankylosis of the pastern joint have been described, non-surgical methods have a lower success rate and typically take longer for the joint to fuse than surgical arthrodesis. For this reason, non-surgical methods should be offered as an alternative option where clients are reluctant to perform surgery and where radiographic evidence of arthritis is already moderately advanced. In a retrospective study on facilitated pastern ankylosis using intra-articular ethanol injections in 34 horses, 50% of horses were sound at 6 months follow-up, 38% of horses were improved but not sound, one horse showed 3,4 no improvement in lameness, and 3 horses were lost to follow-up. The median time to return to work was 8 months (range 0-15 months), and the median age of horses was 13 years (range: 3 1-24 years). As such, surgical arthrodesis is the technique of choice to achieve more rapid joint fusion, decrease periosteal callus and improve comfort and return to function. Pastern 4 arthrodesis with a combination of a plate and screws is the most stable fixation, followed by 5–7 screw fixation with 2-3 parallel screws. Many surgeons will also opt to apply cast or bandage 5,6,8 cast coaptation for the first few days to weeks post-operatively. A combination of diode laser-facilitated pastern arthrodesis with parallel screws has been reported to increase fusion 5 and reduce immediate post-operative lameness. Proper trimming and shoeing, especially increasing breakover and keeping horses in regular work can also help manage the clinical signs associated with distal tarsal arthritis. Injections of 3 mL of 70% ethyl alcohol in 20 horses 11 with distal tarsal arthritis resolved lameness in 85% of horses by 3 months post-injection. In another study, improvement in lameness was reported in 60% of cases (21/35); however, 4 horses 12 (19%) deteriorated and 2 developed significant complications. Surgical arthrodesis is probably the most reliable and effective method to induce distal hock fusion; however, it is more expensive.
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