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The traditional medical approach to chronic disease is to accom- plish a diagnostic classication that is as precise as possible order 800mg renagel with visa gastritis mayo clinic, based on symptoms order renagel 800 mg without a prescription gastritis child, signs order renagel with a visa symptoms of gastritis flare up, clinical tests and other clinical elements. A correct and precise diagnosis allows access to the wealth of experience acquired in clinical medicine, including prognosis, and effective disease-modifying and symptomatic treatment of a specic disease. Physicians tend to work backwards in the etiologic pathway from making a disease diagnosis based on external clinical elements to generating hypotheses about patho- 40 L. Treatments aimed at prevention and cure are then administered that work forward in the etiologic pathway, thereby cor- recting the clinical manifestation of diseases. A corollary of this method is the assump- tion that each syndromic manifestation has an underlying specic pathophysiology. The traditional medical approach to human diseases has been quite successful in the care of young and middle-aged patients and prevention in these age groups. However, it has substantial limitations in the care of older patients for several rea- sons. For example, in older persons episodes of hypogly- cemia are often asymptomatic and signs of a previous acute myocardial infarction are often found in people with no history of symptoms. Second, the high likelihood of geriatric conditions and multimorbidity in older ages blurs diagnostic boundaries between diseases and complicates treatment choices. Third, in many older adults, the manifestations and clinical course of diseases are strongly affected by the under- lying status of the host as well as by other coexisting diseases. Because of these reasons, considering aging as a confounder in the study of chronic diseases ignores the complexity of the interactions between aging, disease and frailty. We now know that aging plays a central role in the pathogenesis, clinical presentation and response to treatment of many chronic diseases. Therefore, the patient s age (both biological and chronological) should be a primary clinical element that should affect choices of diagnostic, preventing and therapeutic interventions. Emerging evidence on multi-morbidity and the frailty syndrome lays out the basis for making substantial progress in translating these concepts into improved care of older patients. Promising developments are coming, as well, from the rising interest in Geroscience and Precision Medicine [4]. The convergence of these scientic disci- plines can be transformative in our understanding of the interplay between aging, frailty and disease, with the potential of producing dramatic improvements in public health. In this chapter, we explore the evolution and current state of the science pertain- ing to possible links between aging and chronic disease(s), with a specic focus on the epidemiological evidence that such association is robust and not exclusively explained or sustained by a stochastic process. We seek to link together the mount- ing evidence that biological mechanisms that underlie aging lead to dysregulation of multiple physiological systems, loss of homeostatic capabilities and increased sus- ceptibility to stress, and that these changes facilitate the emergence of both multi- morbidity and clinically apparent frailty. Then, we consider whether the epidemiological literature is consistent with the stated hypothesis. Finally, we examine our current understanding of the biology of frailty as a basis for generating hypotheses about the biological mechanisms that link aging and chronic diseases. This approach led to the development of a number of classication systems, some relatively simple (such as Etiological Role of Aging in Chronic Diseases: From Epidemiological Evidence 41 the now disproven distinction between inammatory and degenerative diseases) and some extremely precise and sophisticated (such as classication of lymphomas based on histological characteristics). While the ability to recognize specic dis- eases and to treat them successfully has increased tremendously, the limitations of these approaches have also become apparent. Biomarker studies perhaps better than any other scientic approaches have offered evidence that, in many cases, diseases that are driven by different mecha- nisms converge into the same pathological and clinical manifestations. For example, it is now widely accepted that under the label of Alzheimer s disease exist a num- ber of conditions with different underlying mechanisms [5]. Conversely, diseases that appear quite different from the perspective of phenotypic and end-organ mani- festations are now known to have shared etiologic biomarkers (e. Interestingly, such biomarkers are often also related to aging itself and predict the development of frailty, a major adverse health outcome associated with aging. This is consistent with evidence that the biology of aging is associated with chronic dis- ease development through mechanisms beyond the length of time for exposure and cumulative risk from external risk factors; rather, the evidence actually points to aging as playing a powerful causal role in development of chronic diseases. With the increase in longevity due to the demographic transition, chronic diseases have become the dominant causes of morbidity and mortality in the devel- oped world, and are rapidly reaching that dominance globally. However, we should not assume that the relationship between aging and disease is monotonic; in fact, it is quite complex. Some chronic diseases, such as those due to genetic defects, exposures during gestation, or environmental perturbation may become clinically evi- dent early in life and are unlikely to emerge after a certain age. Some other diseases have a typical age of emergence and only rarely occur outside a certain time window (e. Ferrucci Given the extreme variability of human pathology, making a generalization is difcult. However, it is plausible that biological aging plays an important patho- physiologic role in diseases whose incidence and prevalence increase with aging. To offer the counterarguments rst, there are basically two objections to this theory. In both cases, objections can be easily overcome by hypothesizing that the clinical emergence of disease results from a tradeoff between organ or tissue-specic susceptibility, the rate of progression by which subclinical processes become clinical, and the overall dys- regulation induced by the aging process. As an example of the latter, aging can facilitate an imbalance in cholesterol metabolism, but such imbalance may never emerge clinically in individuals who do not have a certain genetic susceptibility and maintain a healthy diet and weight. Further, the clinical presentation of disease may be delayed by behavioral compensations, such as walking more slowly in patients with pulmonary diseases so as not to experience the symptoms or increased walking to improve muscle efciency in utilizing oxygen in patients with peripheral artery disease and thus decreasing the symptoms. Unfortunately, modern medicine, public health and much of science has focused almost exclusively on mechanisms that create susceptibility to a single disease, and have substantially ignored the clues as to the potential direct contribution of aging and related biology to health as well as to chronic diseases. In this context, it is understandable why age has been considered merely a confounder. In surveying the literature on chronic disease, the attributable fraction of the burden of chronic diseases to the health burden of aging appears quite high across diseases, even when the effect of powerful risk factors such as hypertension or smoking are factored out. However, such analyses have rarely been conducted comprehensively, because most studies have focused on one disease outcome and ignored the effect of competing risk or aggregate impact. Future studies are needed to estimate in large, representa- tive cohorts the population-attributable fraction to aging and health of multiple chronic diseases after adjusting for known risk factors and using a multivariate approach that addresses competing risk and selective mortality. Such studies would help to estimate the extent to which the burden of morbidity in older persons is attributable to aging per se. An interpretation of the epidemiologic literature strongly suggests that aging con- tributes independently to the pathogenesis of many chronic diseases, and there are truly very few exceptions, largely in the form of rare diseases. Almost counterintui- tively, the only diseases that have been interrogated to reveal aging effects are the Etiological Role of Aging in Chronic Diseases: From Epidemiological Evidence 43 differential mechanisms for congestive heart failure by age [7], and the progeroid syndromes. Whether progeroid syndromes truly recapitulate the effect of aging in their early emergence of the aging phenotypes is unclear [8]. In general, very few of the ndings of these studies have been translated into better understanding of the interface between aging and disease in people who have an average lifespan. To go beyond age as a confounder or aging as a process independent of and unrelated to chronic diseases in the study of human pathology requires a shift in perspective. Technology is currently available or in an advanced stage of development that should allow the testing of some of these theories in humans. Fully developing and testing such technology and then the theories themselves is clearly an important priority in aging research. Criteria for disease diagnosis and multimorbidity classication should be devel- oped that are not exclusively based on clinical manifestations and that do not ignore the role of the aging process or novel insights about causal pathways [9 ].

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Chest radiograph shows symmetric inltrates of the lower lobes similar in appearance to pulmonary edema renagel 800mg line chronic gastritis for years. Sample of bronchoalveolar lavage stained with toluene blue buy renagel 400mg gastritis symptoms right side, showing multiple organisms order renagel pills in toronto gastritis diet 2 days. In many cases, this initial diagnosis may necessitate a transbronchial biopsy deterioration necessitated intubation or caused death. If signs of grave disease are absent, and if the nisone should be given before or simultaneously with patient is not nauseated, outpatient treatment is possible. The risk of relapse famethoxazole 400 mg and trimethoprim 80 mg daily 3 after a rst episode is even higher: 40% after 6 months. Trimethoprim sulfamethoxazole has numerous side effects, of which drug rash is the most frequent. Treatment of Pneumocystis jiroveci involvement is evident), if leukopenia and thrombocy- pneumonia: trimethoprim sulfamethoxazole and topenia are severe, or if renal or hepatic toxicity or serious alternatives vomiting occurs, alternative treatment is necessary. However, almost 50% of a) Interstitial involvement patients will develop signs of cutaneous intolerance. The mechanisms of trimethoprim sul- is associated with >50% and extensively resis- famethoxazole intolerance are not well understood. Some patients, particularly stain of the sputum; however, this test is frequently neg- smokers, cannot tolerate inhaled pentamidine ative in disseminated (miliary) tuberculosis. Preventive use of a liquid media are recommended because results are more bronchodilator may be helpful. By far the most frequent cause is 300 mg daily (plus vitamin B6), rifampicin 600 mg daily, S. This quadruple therapy should be continued and Rhodococcus equi may also be implicated. Bacteremia during the rst 2 months, followed by isoniazid and and relapses are frequent. In cases of isoni- azid or rifampicin resistance (or both), consultation with a Tuberculosis specialist is advised. Classical antituberculous drugs such as isoniazid, rifampicin, and ethambutol are efcacious. Pulmonary Kaposi s Sarcoma In patients with obvious cutaneous Kaposi s sarcoma, involvement of the mucosal surfaces is frequent (30% to 50% of cases) and, in general, asymptomatic. Treatment with radiotherapy or chemotherapy is indicated for relief of cough or dyspnea. In general, lung lesions, like other manifestations of Kaposi s sarcoma, improve on antiretroviral combination therapy. Treatment accompanied by anemia, enlargement of liver and relies on amphotericin B or uconazole. The dis- ease is diagnosed by direct stain of the sputum, where delicate, gram-labile, branched laments are detected. Treatment relies on prolonged administration of high doses of trimethoprim-sulfamethoxazole; alternatives are imipenem and the newer uoroquinolones. Candidiasis of the tongue candidiasis presents with yellowish-white plaques on the (Pictures A and B courtesy of J. Options for Often, Candida stomatitis is associated with subsequent management vary. Typically seen as white plaques that detach tudinal ulcers and viral inclusions on biopsy. They can be associated a relapse, which they then re-treat; others favor preven- with xerostomia. The clinical picture is similar to that in tive therapy for instance, uconazole 50 mg daily or Sjgren s syndrome. Such cases may present difcult As noted earlier, the most frequent cause of esophagitis problems of management. However, when itraconazole solution, voriconazole, or ketoconazole esophageal symptoms occur in a patient who does not may remain effective. In other cases, intravenous ther- have clear evidence of Candida stomatitis, other causes apy with amphotericin B at doses of 20 to 30 mg daily, must be sought. Lesions are typi- a biopsy with viral culture or immunouorescence is cally small. Oral hairy leukoplakia, a whitish lesion with an irregular border located along the lateral part of the tongue, is caused by Epstein Barr virus. The differ- produces painless macules or nodules with characteristic ential diagnosis is vast. Cytomegalovirus is also implicated in Clostridium difcile must often be considered, and the some cases of cholangitis and pancreatitis. Oocysts can be found in tion, bacteremia is extremely frequent, particularly as a the feces. Infections with mycobacteria other than in cases of diarrhea: tuberculosis are often caused by M. Albendazole (400 mg twice daily) is useful in cases of Encephalitozoon intestinalis infection. Antiretroviral drugs and antibiotics can cause diarrhea (with Clostridium difcile, for example). Infecting protozoa include Cryptosporidium, sion to hospital and parenteral therapy with high-dose Microsporidia, and Isospora belli. Resistance to acyclovir may develop; the oocysts,and use trichrome stain for Microsporidia. Ulcer on the buttocks resulting from infection with herpes simplex virus 2 (diameter: 5 cm). See color image on color plate 4 Anal and rectal carcinoma are particularly frequent in frequent in intravenous drug abusers and patients with homosexual patients. Co-infected patients tend to have unfavor- well as vaccination of adolescents have been considered, able prognostic indices for hepatitis C: higher incidence but are not yet part of routine clinical practice. Experience with interferon treatment of When patients with cutaneous Kaposi s sarcoma undergo endoscopy, gastric or intestinal involvement is found in about one half of cases. Co-infection is frequent in intravenous drug the gastrointestinal tract (and the brain), causing diar- abusers and people with hemophilia. Neuroradiologic investigation Au:lig years of therapy, however, the risk of development of usually shows cerebral atrophy. However, tenofovir subcortical white matter, preferentially in the parasagittal remains effective. This side effect of subtle symptoms, such as forgetfulness and difcul- is more frequent with stavudine than with other ties with concentration. Dementia symptoms are accompanied by apa- About half of patients with the acute retroviral syn- thy and withdrawal that can be mistaken for drome complain of headaches, and in 5% to 20%, depression. Encephalitis, with symp- increased T2 signal in the subcortical white mat- toms ranging from confusion to coma, is rare. Insert: Toxoplasma gondii tissue cyst contains thousands of bradyzoites (100 to 300 mm). Such About Central Nervous System Toxoplasmosis latent infection is present in 10% (in the United States) to more than 90% (in developing countries) of 1.

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The active exercise of living faith in Christ is the one great essential to obtaining and maintaining an experience in the Lord that will bring increasing satisfaction in this life and ultimate deliverance from this world when Christ comes buy 800mg renagel with visa gastritis diet peanut butter. Faith is a gift of God to every man rich and poor renagel 400mg free shipping gastritis in pregnancy, high and low discount renagel 800mg fast delivery gastritis healing, free and bond, wise and simple. Though it be as small as a grain of mustard seed, it can grow and be used to move mountains of evil and build temples of righteousness. However, it is not merely faith, but primarily the object of true faith that counts most. If you will read the story of the Pharisee and the publican in Luke 18:9-14, you will note that the publican sought forgiveness of sin. The great store of righteousness upon which God draws, when imputing (counting) this undeserved credit, is the righteous life of our Lord Jesus Christ. Since the divine law is as sacred as God Himself, only one equal with God could make atonement for its transgression. Thus do we exercise faith in the blood of a righteous Christ whose righteous life answers for our unrighteous and unjust past. We are forgiven that we might from henceforth be obedient children, walking in all the commandments of the Lord blameless. Without reservation the follower of Christ will say to Christ, as Thomas did, "My Lord and my God. Too many hear the good news of escape from hell and of a way to heaven, and "with joy" receive it. They want to escape trial and suffering; they have visions of beautiful mansions on high that they will occupy by and by. But they are not concerned with relating themselves to Christ as followers and disciples. He who would accept this sacrifice intelligently and wholeheartedly will give up this world in order to follow the Saviour (see Philippians 2:5). If we hear and obey, we shall be built upon the solid rock, Christ Jesus, not otherwise. Between these two extremes lie all the shades and colors of professed Christianity. We must believe that Christ is a risen, all-powerful Saviour, who can and will bring victory over sin into the life through His indwelling Spirit. In this way, we receive spiritual power for an abiding life of conquest in the Saviour! But it is so easy to keep on trying to live while neglecting to feed upon this heavenly food. In the wilderness of temptation, Jesus wielded the "sword of the Spirit" with swift and telling strokes "It is written. So it is clear that God has made prayer the means for receiving spiritual blessings that we would not otherwise receive unless we asked. The promise is made that "they that wait upon the Lord shall renew their strength. Pray morning, noon, and night as David and Daniel did, and learn the sweetness of communion with God in the Secret place of power. We feed on the Word of God and pray for this and that, but we must surrender, not only to do the will of God as between ourselves and Him, but to do His will toward others. God needs you to help spread abroad the story of the saving gospel and the speedy return of Jesus. Only "faith which worketh by love" (Galatians 5:6) will purify the soul and keep the channel of blessing open. The true Christian will have a special care for the widows, the fatherless, and the poor. These words of commendation are spoken to Servants faithful servants who have worked for Christ. These soul-winning Christians are the ones whom He will take to heaven with Him when He comes again. They have exercised the faculties of the soul and become strong even as the muscles of the body become strong by exertion. There s no disappointment in Heaven, No weariness, sorrow or pain; No hearts that are bleeding and broken, No song with a minor refrain. The clouds of our earthly horizon Will never appear in the sky, For all will be sunshine and gladness, With never a sob or a sigh. I m bound for that beautiful city, My Lord has prepared for His own; Where all the redeemed of all ages Sing Glory! There ll never be crepe on the doorknob, No funeral train in the sky; No graves on the hillsides of glory, For there we shall nevermore die. The old will be young there forever, Transformed in a moment of time; Immortal we ll stand in His likeness, The stars and the sun to outshine. For this corruptible must put on incorruption, and this mortal must put on immortality. And the devil said unto Him, All this power will I give Thee, and the glory of them: for that is delivered unto me; and to whomsoever I will I give it. They shall not build, and another inhabit; they shall not plant, and another eat: for as the days of a tree are the days of My people, and Mine elect shall long enjoy the work of their hands. They shall not labour in vain, nor bring forth for trouble; for they are the seed of the blessed of the Lord, and their offspring with them. And when the new heavens and the new earth have appeared, and the holy city, New Jerusalem, has descended from God and become the metropolis of the new creation, what announcement will then be made? And the cow and the bear shall feed; their young ones shall lie down together: and the lion shall eat straw like the ox. They shall not hurt not destroy in all My holy mountain: for the earth shall be full of the knowledge of the Lord, as the waters cover the sea. Only there will we find the truths which can save the soul, bring the power of Christ into the life, and enable each of us to triumph over all the power of Satan. Those who do so, may feel weaker for a few days, but afterwards will generally feel much better and stronger. Place the liquid back in the pot and simmer uncovered for one hour or until it is reduced to one cup. He is watching over you, and if you are willing to be guided by Him, He will throw around you influences for good that will enable you to accomplish all His will for you. Such stress weakens the functions of the body organs (such as the stomach and liver). Do everything with an attitude of thankfulness toward and trust in God, believing that He will work everything out for the best.

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The nal blatant signs than others order renagel uk chronic gastritis forum, but most within the group will fth stage is reached after the larvae arrive in the bronchi- be affected buy renagel 400mg cheap gastritis diet 1200. The prepatent period is approximately 4 weeks be- been placed on pasture recently or conned by group cause this period is required for the larvae to mature to housing (heifers) to pens having a base consisting of egg-laying adults renagel 400mg low price gastritis symptoms heart attack. Signs of primary infection include varying degrees of Baermann s technique performed on fresh manure dyspnea, a characteristic deep and moist cough, and is indicated for specic diagnosis but is of limited moist rales or crackles heard over the entire lung eld. Therefore Coughing is more severe than with most other bovine Baermann s technique and tracheal washes should be pneumonias. If larvae are found us- the anterior ventral lung elds are an important sign ing Baermann s technique, the diagnosis is conrmed that differentiates lungworm from bacterial pneumo- as a patent infection. Severely affected calves or cows will show heave - wash samples may identify parasites, rule out other like breathing with visible expiratory and inspiratory causes of pneumonia, and allow cytologic conrma- effort. In some cases, emphysema is present when heavy tion of eosinophilic inammation typical of parasitic airway exudate results in extreme mechanical respira- bronchitis/pneumonia. Fever also may be present simply from exertion in- Necropsy ndings in fatal infections vary with the stage volved in breathing during warm weather or in poorly of infection. Usually several animals in a group or examination of bronchial exudate may be necessary to the entire herd will show signs. Affected cattle will con- identify larvae, whereas in later prepatent infections, the tinue to eat unless severe dyspnea or coughing interferes larvae are obvious if the airways are properly opened and with their ability to ingest feed. Eosinophilic bronchitis may be conrmed by vere dyspnea, frequent coughing, marked expiratory ef- histopathology. Secondary anterior veterinarians should be aware of the reinfection or acute ventral bacterial bronchopneumonia may be present, and larval migration syndrome that occurs in adult cattle with interstitial emphysema is observed in occasional severe endemic D. Levamisole has been very effective in our clinic but is no longer approved for use in dairy cattle, so fenbendazole would now be the rst choice of treatment. Affected cattle should not be allowed back on infected pastures, and conned cattle should be re- moved from infected manure packs until the pens can be cleaned completely of manure and bedding. Secondary bacterial pneumonia may mask the Wright-Giemsa stain of tracheal wash from a cow presence of lungworms in calves or heifers. Such animals representative of a herd problem of chronic cough and frequently appear to improve temporarily while on anti- decreased production. Antibiotic therapy in these instances may of eosinophils on this 40 slide is highly suggestive of cause resolution of fever and improved attitude but will lungworm infection. Only when further diagnostics are pursued in live patients or necrop- sies are performed in fatal cases will the true diagnosis be obtained and effective treatment instituted. Although the reinfection syndrome appears to be an immune-mediated disorder, affected cattle appear to respond rapidly to levamisole injections according to Breeze. Without treatment, continued coughing and production losses persist in the affected animals for weeks. Because infective larvae have been shown to sur- vive winter conditions, pastures should not be grazed in the early spring. High- lighting this fact, clinical lungworm infections in the The reinfection syndrome is characterized by clinical northeastern United States are observed primarily dur- signs of severe coughing in the majority of cattle follow- ing wet summers. Tracheal additional anthelmintic treatment are indicated during wash samples will reveal eosinophilic inammation. Auscultation of the lungs may reect interstitial changes of pulmo- nary edema and emphysema. Therefore initial increased bronchovesicular sounds may be replaced by decreased sounds as further interstitial pathology and emphysema ensue. The clinical course lasts 10 to 14 days in most cases and occasionally may be fatal. One experimental infection suggested that initial ex- posure to ascarid larvae resulted in very mild signs, whereas reexposure resulted in pronounced signs. This may imply an immune-mediated cause or component to the severe interstitial pneumonia. A tracheal wash sample may Multiple hepatic abscesses that were an incidental nd- demonstrate an eosinophilic inammatory pattern. Abscesses, al- nitive diagnosis requires identication of the parasite though multiple, were small and located well away from or histopathology to study the larvae and associated the hilus. Treatment is nonspecic and supportive in the hope that the normal life cycle of the parasite will eliminate the larvae. Caudal Vena Caval Thrombosis This disease occurs sporadically in heifers and adult cattle Etiology and Signs. This may be the result of calves being results in a variety of clinical respiratory syndromes in fed less intensive diets than heifers or lactating animals. Septic thromboemboli originating from an ab- In caudal vena caval thrombosis, erosion of a liver ab- scess at the hilus of the liver shower the caudal vena scess into the vena cava with formation of a septic venous cava, right heart, and pulmonary arterial circulation. Those cattle that have inap- may result in massive thromboemboli to the right heart parent seeding of the pulmonary arteries or survive an and pulmonary artery thrombosis, pulmonary infarc- acute respiratory distress episode caused by thrombo- tion, exotoxemia or endotoxemia, and anoxia. Sudden emboli may eventually develop dyspnea, hemoptysis, death may result, and this syndrome represents one of and anemia. Epistaxis is the most common clinical sign the more common causes of acute death in adult dairy observed in those cows with hemoptysis. This sudden death may represent a hypersensitiv- The pathogenesis of caudal vena caval thrombosis ity reaction following a previous clinically inapparent starts in the forestomach or abomasum and involves thromboembolic episode; however, sudden rupture of a inammatory or ulcerative mucosal lesions that allow large hilar abscess into the caudal vena cava or embolic bacterial seeding of the portal circulation with subse- movement of an existing large septic thrombus may quent formation of liver abscesses. Therefore rumenitis, cause enough direct pulmonary infarction to cause ruminal acidosis, abomasal ulcers, and similar disorders death without the need for a previous sensitizing epi- predispose to the condition. The location is much more important than the Acute Respiratory Distress Syndrome number of abscesses, however, because only those at the This syndrome appears in one animal within a group or hilus of the liver or adjacent to the post cava represent herd. Auscultation of the thorax generally reveals reduced airway sounds resulting from pulmonary edema, pulmonary infarction, and bullous emphysema brought on by exertional respiratory efforts. Rales may be ausculted in some instances, but in general, the lungs are quieter than expected given the obviously labored respirations. The key to diagnosis is the fact that only one animal is affected with severe lower airway disease, and to the owner s knowledge, this cow has had no unique stress or previous problems. Septic thromboemboli create pulmonary abscesses at their endpoint in pulmonary arteries, and aneurysms develop proximal to each of the suddenness of death precludes physical examina- these abscesses within the affected pulmonary arteries. Sudden dis- pulmonary edema, pulmonary infarction, and pulmo- charge of purulent material into the airway creates sep- nary arterial thrombosis. This hemor- Distress Syndrome rhage may be sufcient to result in hemoptysis and Sudden onset of respiratory distress in a single cow subsequent epistaxis. Affected cattle are unthrifty and within a herd raises an index of suspicion of acute frequently have been treated for recurrent broncho- caudal vena caval thrombosis. Some affected cattle develop endocarditis caused by the septic thrombus in the caudal vena cava remain- ing as a source of chronic bacteremia through the right heart and pulmonary arteries. Epistaxis associated with coughing and chronic bronchopneumonia in dairy cattle indicates an extremely guarded prognosis because of the irreversible nature of the pathology in caudal vena caval thrombosis. Other signs such as ascites, generalized visceral edema, and diarrhea are possible if the thrombosis occludes the caudal vena cava and results in portal hypertension. Right heart failure and a chronic passive congestion of the liver may also develop in some chronic cases.