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Eleven different ages were single age premises and 46 had flocks of multiple statistically evaluated to determine the percentage of ages on site at the time of infection buy cheap zocor 10 mg on-line cholesterol levels high risk. The median age of patients with pandemic characteristics of pandemic influenza H1N1 2009 and influenza H1N1 is reported as 20-25 years from seasonal influenza infection zocor 40 mg online cholesterol in foods guide. Several physicians and scientists from Europe sponsors for voluntarily aligning product use have questioned the scientific basis for the ban of the conditions with guide for industry # 209 (9) buy zocor 40mg with amex definition of cholesterol molecule. It was felt that this action the potential impact of antibiotic use in poultry on was required to accommodate the transition from human health (7). In fact, there is growing use of medically important antimicrobial drugs in admission that the main cause of the antibiotic- food-producing animals should be limited to those resistance problems confronted by the medical uses that are considered necessary to assure animal profession is antibiotic use in humans rather than health, and the second one indicated that the use of animals (12, 13). Even though gentamicin has been widely and Others have expressed concern that the use of a massively administered for many years in ovo to streptogramin antibiotic like virginiamycin can foster chicks, resistance in Salmonella isolates from the development of streptogramin-resistant chickens remains relatively low at 5. The the latter includes people with clinical infections as ban was imposed on fears that resistance increases well as people with colonization. Nevertheless, even seen on human isolates of Campylobacter jejuni when colonized cases are removed infections have could be related to enrofloxacin use in poultry. A critical bloodstream infections and only two resulted in review of published data. Journal of Antimicrobial deaths, in both cases the patients had additional Chemotherapy, 53:28-52, 2004. Journal of Antimicrobial resistance in zoonotic and indicator bacteria from Chemotherapy, 53:28-52, 2007. An members stated that bacteria in humans, food and assessment of the impact of antibiotic resistance in animals continue to show resistance to the most different bacterial species and of contribution of widely used antimicrobials and warns that animal sources to resistance in human infections. Antibiotic usage in poultry: from the European Food Safety Authority and the assessing the effects on antibiotic resistance and European Center for Disease Prevention and Control human health. Federal policy and starting in 2017 will eliminate the use of Register: 77 (72), 22328-22329, 2012. It drinking water of food-producing animals: remains to be seen if the removal of the lower use Recommendations for drug sponsors for voluntarily levels of antibiotics in feed will result in an increased aligning product use conditions with guide for incidence of disease in food-producing animals and a industry # 209. Federal Register: 78 (239), 75570- higher use of antibiotics at therapeutic doses but 75571, 2013. Antibiotic th 43 65 Western Poultry Disease Conference 2016 prescribing and antibiotic resistance in community 17. British Medical Administration, Center for Veterinary Medicine Journal 319: 1239-1240, 1999. Quinupristin-Dalfopristin-resistant occurrence of antimicrobial resistance in bacteria Enterococcus faecium on chicken and in human stool from food animals, foods and humans in Denmark, specimens. European Food Safety Authority, European Synercid) tested against over 28,000 recent clinical Center for Disease Prevention and Control. Scientific isolates from 200 medical centers in the United States Report: The European Union summary report on and Canada. Diagnostic Microbiology and Infectious antimicrobial resistance in zoonotic and indicator Diseases, 30:437-451, 1998. Equation 9 was modified by The use of air filtration to prevent aerosol adding a reducing factor to take into account the transmission in commercial poultry production was effect of filtration (6). The probability of infection of explored in the late 60s and early 70s but never a flock as a function of time was calculated given resulted in widespread adoption. Equations were aerosols of Porcine Reproductive and Respiratory programmed in the Julia (3) programming language. Overall the use of produced over the last year data demonstrating the filtration would have reduced the probability of efficiency of their 15 layer, 10 layer and a 6 layer infection to very low levels, preventing pleated filter in blocking aerosolized low pathogenic contamination in most cases. We first evaluated the effect that filtration would have had on Overall, applying the filter reducing factors laboratory data by applying the reduction factors to measured under laboratory conditions to laboratory the data of previous studies (1) on H5N1 virus, (4), experiments involving exposure of chickens to Avian and H9N2 (7). Secondly, we evaluated the potential Influenza virus would have theoretically prevented risk reduction using the model of Ssematimba et al. Theoretical effect of air filtration on laboratory studies of aerosolized avian influenza infection. Publication Ru Probability of infection n No filtration 15 layer filter 10 layer filter 6 layer pleated filter Agranovski 7 0. Theoretical effect of air filtration on the probability of a flock breaking with avian influenza under the assumption of the model of Ssematimba et al. Cecure was the most the consumption of Foster Farms brand chicken bactericidal, but is concentration-dependent and products from three processing facilities in ineffective against S. This raises the question: if the Salmonella enterica consists of six subspecies prevalence of Salmonella from these facilities is and over 2500 serovars belonging to five serogroups, relatively low, why did this outbreak occur, and how many of which are zoonotic pathogens (1). When disinfectants, and sanitizers to validate vendor claims Salmonella biofilms become established in food and maintain quality assurance (9). Biofilm pegs were sonicated to create biofilm, which studies have concluded to be more a suspension. The chiller and dipping stations offer extended This approach allows for a more comprehensive exposure of poultry carcasses to disinfectants prior to understanding of the differences between planktonic packaging, while bringing the temperature down to and biofilm S. Stock solutions of Cecure was most effective in a concentration- disinfectants were stored at 100X concentration, and and time-dependent manner, but was not reflective of diluted as needed. Disinfectants were tested at serial present poultry processing conditions due to current dilutions and at the average concentrations used by regulations. Based on our results, Cultures of bacterial isolates were incubated at current contact times and concentrations used in overnight at 37C. Planktonic cultures were grown to practice by poultry processors, the application of mid-log phase (3. For each might be important for controlling other pathogens in replicate, 20 L were serially diluted and spread- a processing environment, mitigation of Salmonella th 49 65 Western Poultry Disease Conference 2016 must essentially focus on preventing contamination and surface material. Food Research multidrug resistant strains, and an increase in disease International. Letters in difficulty of eradication of established biofilm serves Applied Microbiology. Variations in motility and biofilm ubiquitous than planktonic bacteria in many formation of Salmonella enterica serovar Typhi. Applied and environmental to more fully characterize disinfectant efficacy, and microbiology. Biofilm bacteria: formation and comparative susceptibility to (The full-length article will be published in the antibiotics. Survival of Salmonella strains of Multidrug-Resistant Salmonella Heidelberg differing in their biofilm-formation capability upon Infections Linked to Foster Farms Brand Chicken. Senftenberg field P Static** Ineffective Cidal strain 65 B Ineffective Ineffective Cidal Static** P Static* Ineffective Static P.

A larger than expected number of mortalities On day four discount zocor 20mg amex cholesterol chart tracker, one chick was found dead in Room was experienced in five to 12-day-old broiler chicks A and was diagnosed with sudden death syndrome on housed at a research institute cheap zocor 40mg on-line cholesterol test. An adjacent room diagnosis of intestinal accident was made and no housing chicks of the same age and from the same further diagnostic tests were performed cheap zocor 40mg visa cholesterol test superdrug. A cursory gross examination identical in both rooms, and no experimental revealed the presence of food in the crops and procedures had yet been performed on any of the gizzards and no obvious lesions to explain the cause birds. Seventy-four Ross broiler chicks were picked One chick found dead in Room A was discarded up from a local hatchery on day of hatch (Day 0) for before it could be examined. Routine treatment at the Four more chicks were found dead acutely in hatchery included in ovo vaccination for Mareks and Room B the next day. One was diagnosed with infectious bursal disease, and spray vaccination for sudden death syndrome, and the other three had infectious bronchitis virus at hatch. One chick had white plaques with examined, neck tagged, and divided between two depressed centers visible through the serosa biocontainment rooms (Rooms A and B) in a throughout the small intestine, and fibrino-necrotic th 273 65 Western Poultry Disease Conference 2016 debris was found associated with these areas. The lesions were seen in any of the gizzards and intestines second chick had a walled-off area of peritonitis examined at the end of the trial (14 birds at 18 days surrounding an obvious intestinal rupture, and of age and 21 birds at 28 days). Necrotic enteritis primarily affects two to On day 11, one more chick was found dead in six week-old broiler chickens raised on litter although Room B. Food was present in the gizzard, however outbreaks in older birds have also been reported (1, there were urate crystals in the ureters indicating 2). The intestinal mucosa from the which is a normal inhabitant of the intestines of jejunum to the cecae was coated with a fibrino- healthy chickens (1). Microscopic Predisposing factors are thought to include a drastic examination of tissues from all three chicks showed change in intestinal microflora, high dietary levels of lesions of extensive coagulation necrosis of the villi fishmeal or grains, or any condition that results in which were lined by rod shaped bacterial. Larger damage to the intestinal mucosa, such as coccidiosis numbers of short rod bacteria were also present in the or mycotoxicosis (1, 2, 3). Colonization of the intestinal epithelium by Eimeria On day 12, two more birds were found dead in spp. No further testing was feed particle size, nutritional deficiencies, adenoviral done on these two birds. One additional runted bird infections, and toxic substances such as mycotoxins was euthanized. Gizzard On day 14 a decision was made to euthanize the erosions have also been associated with high numbers remaining 24 birds in Room B since we could not be of C. In a case dating back to confident they would be useful for the intended 1981, an increased frequency of gizzard erosions research. The remaining 10 birds were sent to a perfringens isolated from the koilin layer of the diagnostic laboratory for complete post mortem gizzard. In No other significant gross abnormalities were retrospect, the cecal intussusception that occurred in observed. A summary of post mortem findings is the five-day-old chick may have been related to the presented in Table 1. Overview of necrotic enteritis rinsing of feed or water containers, or exposure to in poultry. Rethinking our understanding of feed and more extensive contamination may have the pathogenesis of necrotic enteritis in chickens. Gizzard erosions as a cause of mortality in white Despite this, it is important to remember to perform a leghorn chickens. Dupont Material Safety Data Sheet Virkon systems even in young chicks, so lesions are not S. Days of Age Lesions Seen in Room A Lesions Seen in Room B 4 sudden death syndrome 5 cecae intussuscepted into rectum 6 unknown - not fully examined 7 unknown - not fully examined 8 did not examine necrotic enteritis 9 necrotic enteritis 10 necrotic enteritis (2); intestinal perforation (1); sudden death syndrome (1) 11 necrotic enteritis 12 colibaccillosis (2); runt (1) 14 gizzard erosions/ulcers (7) Summary Sudden Death Syndrome 1/37 Gizzard Erosion 7/37 Unknown 1/37 Necrotic Enteritis 5/37 No Apparent Lesions 35/37 Intestinal Accident 2/37 Unknown 2/37 Colibacillosis 2/37 Sudden Death Syndrome 1/37 Runt 1/37 No Apparent Lesions 17/37 (gizzard not examined in 14 of these birds) Table 2. Mycotoxin Amount Detected in Room A Feed Amount Detected in Room B Feed 3-acetyl-deoxynivalenol 29. Just after hatching (Sept 15, 2015 for both eggs), the adult female was presented with acute left A three- year-old adult female roller pigeon limb lameness. She was able to ambulate in the cage used as part of a breeding pair for an ongoing but would not brood her recent hatchlings, which research study was presented with acute left limb subsequently died. Palpation of the leg revealed a large lump large lump that felt near the hip joint. Sections of affected organs were Microscopic examination of the various organs fixed in 10% buffered formalin, routinely processed, revealed neoplastic proliferation of round cells sectioned and stained with hematoxylin and eosin. Osteopenia or osteoporosis is more A three-year-old adult female roller pigeon used likely to occur in adult birds and results in a as a part of a breeding pair for an ongoing research reduction in bone mass. Typical causes include study was housed with her mate at the Poultry starvation, calcium, copper, phosphorus or vitamin D Diagnostic and Research Center animal facilities. Females in production that lack housing consisted of a large wire cage with perches, sufficient dietary calcium can experience bone water and feed. A cardboard nesting box was present resorption due to a high calcium requirement during for laying eggs and brooding hatchlings. Common examples of trauma include foot o study animals comfortable at around 25 C. The entrapment in caging material, flying into objects, breeding pair had produced two eggs laid a couple of improper handling etc. In the present clinical case, days apart (Aug 26 and 28, 2015) and were brooding we perceived that the bird had caught her foot in the th 277 65 Western Poultry Disease Conference 2016 wire caging and dislocated the femur from the hip choice of chemotherapeutic regimes. Nutritional diseases none of the previously cited reports characterized the were ruled out as the diet supplied was balanced for cell origin of the lymphosarcoma. One types of tumors in a pigeon research colony at Perdue possibility is that some of neoplastic cells were University (5). Eighty-three birds were submitted for immature or anaplastic and thus, not able to exhibit necropsy and 28 (33. Seminoma and thyroid veterinary patients is largely dependent on the staging adenoma were the most common tumors diagnosed and pathological grade of the tumor, none of the over an 11 year period. Lymphosarcoma was these diagnostic parameters exist nor have any documented in four birds and grossly had multiple chemotherapeutic agents or protocols been approved nodules in multiple organs. In our (A case report manuscript will be submitted to clinical case, with the exception of the spleen similar Avian Diseases or Journal of Veterinary Diagnostic organs were affected in a 3 year-old bird. Journal of Avian Medicine and suspected respiratory infections, euthanasia was Surgery 9:3-7. Journal of left kidney was most likely applying pressure to the American Veterinary Medical Association 179:1266- sciatic nerve, resulting in lameness. Naturally occurring neoplasms in Immunohistochemistry is typically performed pigeons in a research colony: a retrospective study. Many of these of interest to the industry including additional salmonellas do not pose any risk to human health and Salmonella serovars (Gallisepticum and Enteritidis), are not of significant health concern for the host pathogenic mycoplasmas, and avian influenza. Some usually as a consequence of subclinical infection in laboratories may need to send isolates to a reference food animals leading to contamination of meat, eggs, laboratory to confirm the full serological identity and and milk or secondary contamination of fruits and to determine the phage type and genotype of the vegetables that have been fertilized or irrigated by strain, where applicable. An important initial factor animal feedstuffs, causing subclinical gastro- to consider in the determination of the diagnostic intestinal carriage or infectious disease in animals, method of choice is whether the goal is to detect particularly poultry and swine. The poultry industry antigen presence (the bacteria is present) or antibody works vigilantly to minimize and prevent the detection (evidence of previous exposure or infection introduction of these pathogenic strains from entering to the bacteria).

Nutritional compounds influence tis sue factor expression and inflammation of chronic kidney disease patients in vitro proven zocor 20mg cholesterol score of 5.3. Docosahexaenoic acid enhan ces the antioxidant response of human fibroblasts by upregulating gamma-glutamyl- cysteinyl ligase and glutathione reductase zocor 40 mg on line cholesterol levels daily allowance. Antioxidative and anti-inflammatory actions of docosahexaenoic acid and eicosapentaenoic acid in renal epithelial cells and macrophages purchase zocor 20mg visa foods for high cholesterol diet. Short- time infusion of fish oil-based lipid emulsions, approved for parenteral nutrition, re duces monocyte proinflammatory cytokine generation and adhesive interaction with endothelium in humans. Dietary omega-3 polyunsaturated fatty acids inhibit phosphoinositide formation and chemo taxis in neutrophils. Omega-3 fatty acid supplementation attenuates oxidative stress, inflammation, and tubulointerstitial fibrosis in the remnant kidney. The effects of dietary fish oil on inflam mation, fibrosis and oxidative stress associated with obstructive renal injury in rats. The use of ome ga-3 poly-unsaturated fatty acids in heart failure: a preferential role in patients with diabetes. Effects of omega-3 polyunsaturated fatty-acid supplementation on redox status in chronic re nal failure patients with dyslipidemia. In sights into the inhibition of platelet activation by omega-3 polyunsaturated fatty acids: Beyond aspirin and clopidogrel. Effects of purified eicosapentaenoic and docosahexaenoic acids on glycemic control, blood pressure, and serum lipids in type 2 diabetic patients with treated hypertension. Eicosapentaenoic acid improves imbalance between vasodilator and vasoconstrictor actions of endo thelium-derived factors in mesenteric arteries from rats at chronic stage of type 2 dia betes. Effect of hypouricaemic and hyperuricaemic drugs on the renal urate efflux transporter, multidrug resistance protein 4. Role of xanthine oxidase inhibitor as free radical scavenger: a novel mechanism of action of allopuri nol and oxypurinol in myocardial salvage. Effect of allopurinol in chronic kidney disease progression and cardiovascular risk. Effect of treatment of hyperuricemia with allopurinol on blood pressure, creatinine clearence, and pro teinuria in patients with normal renal functions. The effects of lower ing uric acid levels using allopurinol on markers of metabolic syndrome in end-stage renal disease patients: a pilot study. Relationship between serum carnitine, acylcarnitines, and renal function in pa tients with chronic renal disease. Practice recommendations for the use of L-carni tine in dialysis-related carnitine disorder. L-carni tine supplementation decreases the left ventricular mass in patients undergoing he modialysis. Effects of L- carnitine supplementation on cardiac morbidity in hemodialyzed patients. Propion yl-L-carnitine therapy: effects on endothelin-1 and homocysteine levels in patients with peripheral arterial disease and end-stage renal disease. Accumulation of circulating ad vanced oxidation protein products is an independent risk factor for ischemic heart disease in maintenance hemodialysis patients. Ure mia, atherothrombosis and malnutrition: the role of L-arginine-nitric oxide pathway. Abnormalities in L-arginine trans port and nitric oxide biosynthesis in chronic renal and heart failure. Activation of L-arginine transport in undialysed chronic renal failure and continuous ambulato ry peritoneal dialysis patients. Enhanced nitric oxide synthesis in uremia: implications for platelet dysfunction and dialysis hypotension. Evidence that renal arginine transport is impaired in spontaneously hypertensive rats. Potential ergogenic effects of L-arginine against oxida tive and inflammatory stress induced by acute exercise in aging rats. Mod ulation of apoptosis and improved redox metabolism with the use of a new antioxi dant formula. Long-term dietary antioxidant cocktail supplementation effectively reduces renal inflammation in diabetic mice. Effect of long-term treatment with antioxidants (vitamin C, vitamin E, coenzyme Q10 and selenium) on arterial compliance, humoral factors and inflammatory markers in patients with multiple cardiovascular risk factors. Introduction Calcific Aortic Stenosis is the most common cause of aortic valve disease in developed coun tries. Aortic valve replacement is the number one indication for sur gical valve replacement in the United States and in Europe. The natural history of severe symptomatic aortic stenosis is associated with 50% mortality within 5 years [2]. Bicuspid aortic valve disease is the most common congenital heart abnormality and it is the most common phenotype of calcific aortic stenosis. Understanding the cellular mechanisms of tricuspid versus bicuspid aortic valve lesions will provide further understanding the mechanisms of this disease. Previously, the Wnt/Lrp5 signaling pathway has been identified as a signaling mechanism for cardiovascu lar calcification [5, 16, 17]. The corollaries necessary to define a tissue stem cell niche: 1) physical architecture of the endothelial cells signaling to the adjacent subendothelial cells: the valve interstitial cell along the valve fibrosa. Re cently, the mechanisms of oxidative stress have been identified in the development of calcif ic aortic valve disease. This chapter will outline the factors important in the role of calcific aortic valve disease. The role of lipids in vascular and valvular disease The role of lipids in vascular atherosclerosis has been defined in the literature for years. The acti vation of these cellular processes is regulated by a number of pathways. Integrins pro vide an important role in the regulation of cellular adhesion in atherosclerosis [26]. In this inflammato ry environment, growth factors and cytokines are secreted to induce vascular smooth cell proliferation and recruitment of macrophage cells [32-37] which are important in the de velopment of the atherosclerotic plaque lesion. Patients who have the diagnosis of familial hyper cholesterolemia develop aggressive peripheral vascular disease, coronary artery disease, as well as aortic valve lesions which calcify with age [10, 42]. Rajamannan et al, have shown that the development of atherosclerosis occurs in the aortic valve in a patient with Familial Hypercholesterolemia with the Low density lipoprotein receptor mutation [10]. The athero sclerosis develops along the aortic surface of the aortic valve and in the lumen of the left cir cumflex artery [10]. This provides the first index case of atherosclerotic aortic valve disease in this patient population. Studies have confirmed in experimental hypercholesterolemia that both atherosclerosis and osteoblast markers are present in the aortic valves [4, 6, 13]. This background provides the foundation for studying valve calcification in an experimental atherosclerotic in vivo model.

There should be an infrared light over the The brightness and width of the endometrium varies with examination table and the room should be as quiet as her menstruation cycle purchase zocor 20 mg fast delivery cholesterol update 2015. Ask the parent to have the child fed about 1hr you will only detect a bright reflex whereas after ovulation before and to bring some toys which the baby is interested the central reflex has disappeared and the endometrium in cheap zocor 20mg cholesterol levels 23 year old. Although you will start the examination with the sector appears hyperechoic throughout order cheap zocor on line cholesterol levels in kfc. Common but benign transducer you will probably wish to switch to the linear findings are fibroids which usually display the same or less transducer in between, in order to use its better near-field brightness as the myometrium. In these cases a follow The neonatal skull offers the unique opportunity to scan up is necessary as they sometimes become sarcomas. Measure the size of a fibroid accurately to exclude rapid The anterior fontanelle serves as your acoustic window progression on her next visit and be sure that the fibroid is until its closure at the age of 18months. Method: On the laterally tilted sagittal section you will get The most common findings are ovarian cysts which can lots of information at once. However, rapid recognize the lateral ventricle as an anechoic curved growth, solid parts or septations within the cyst might be a fringe. Attached to the sign of teratoma or malignancy and need further caudal parts of the lateral ventricle you will find brighter examination. The plexus should An adnexal mass with solid and cystic components is have a regular bright echogenicity, a smooth outline likely to be an ectopic gestation; if it is more solid, without any bulging. Acute intracerebral haemorrhage presents hyperechoic usually located near the ventricles which makes it K. Approach + Method: in much abdominal pathology you will find fluid in the abdominal cavity. Between the 24th & 32nd gestational weeks, the ependymal Place the transducer on the right anterior axillary line as matrix, which covers the inside of the ventricles, you would do to scan the right kidney. During these weeks, the premature neonate is patient to hold his breath in inspiration. Common bile duct: transverse diameter (wall to wall) <8mm (but increases with age In the mid-coronal plane you will easily find the 01mm/yr) connection between the 3rd ventricle and the lateral N. After a cholecystectomy, ventricles across the foramen of Munro: this structure <10mm looks like the letter Y in which the 3rd ventricle Common hepatic duct: transverse diameter <5mm resembles the shaft of the Y. Also in this plane the Portal vein; diameter 13-15mm choroid plexus is displayed as a hyperechoic structure with Aorta: diameter <3cm a smooth outline best seen in the lateral ventricles. In this Kidney: maximal size 12x6 cm plane you can measure the width of the 3rd ventricle which cortical width >13mm should be <10mm in the neonate. Prostate: normal size 2x2x2cm(young man), If you suspect a non-communicating hydrocephalus you do growing with age. Apply the transducer on the anterior fontanelle in the mid-coronal plane and determine the cranio-cortical Ultrasound is easily the most useful and reliable diagnostic distance which should be <4mm and the inter-hemispheric tool in pregnancy, and you must learn to use it (38. You can readily discern the position of the placenta (a thickening on the amniotic N. Multiple pregnancy and intra-uterine death are easy If you can press on the cystic structure and elicit pain, diagnoses. You can readily diagnose certain foetal malformations, A dilated vessel: scan the structure in both planes and viz. A uterine rupture presents as a collapsed amniotic space and free fluid in the abdomen. It is particularly adapted for those whose surgical experience is basic or minimal. Importantly, it has extensive advice about pitfalls to avoid, and what to do if things go wrong. It is written in simple style, particularly for those whose mother tongue is not English. It is not a text which discusses the latest up- to-date technology, but it is not out-of-date being a synthesis of the best advice from a myriad of surgeons practicing for many years in low- and middle-income countries. This new edition builds and expands on the success of Maurice Kings seminal frst edition. Front Cover: depicts, very approximately, the inequality of access to surgery globally. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. The team would like to thank the administration of university of Gondar University, Jimma University, Alemaya University and Debub University for extending support to authors whenever it was needed. It is a descriptive term based on the symptoms and signs secondary to one or more of a wide range of problems. If not recognized and corrected as early as possible, shock may rapidly progress to an irreversible state with subsequent multi-organ failure and death. Distributive shock Distributive shock is further subdivided into three subgroups: a. Anaphylactic shock Hypovolemic shock is present when marked reduction in oxygen delivery results from diminished cardiac output secondary to inadequate vascular volume. In general, it results from loss of fluid from circulation, either directly or indirectly. Septic Shock (vasogenic shock) develops as a result of the systemic effect of infection. It is the result of a septicemia with endotoxin and exotoxin release by gram-negative and gram-positive bacteria. Despite normal or increased cardiac output and oxygen delivery, cellular oxygen consumption is less than normal due to impaired extraction as a result of impaired metabolism. Neurogenic shock results primarily from the disruption of the sympathetic nervous system which may be due to pain or loss of sympathetic tone, as in spinal cord injuries. This circulatory response to hypotension is to conserve perfusion to the vital organs (heart and brain) at the expense of other tissues. Progressive vasoconstriction of skin, splanchnic and renal vessels leads to renal cortical necrosis and acute renal failure. If not corrected in time, shock leads to organ failure and sets up a vicious circle with hypoxia and acidosis.