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By: Jennifer Lynn Garst, MD

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Comparison of pancreatic tissue revealed a greater quantity impotence home remedies tadalafil 2.5mg overnight delivery, and larger size erectile dysfunction young order tadalafil 20mg without a prescription, of insulin-containing cell clusters in fetuses which appear to impotence jelly purchase tadalafil 20mg without prescription separate as the animal matures erectile dysfunction treatment electrical generic tadalafil 20 mg mastercard. Kendall Swanson, for giving me the opportunity to obtain my doctoral degree in Animal Science and for his continual leadership, encouragement, and patience as I worked to complete this goal. Thank you to the other faculty members that I have had the opportunity to work with (Dr. The passion and expertise that these professors show for teaching and research was truly an inspiration to me and I am forever grateful to you for your contribution to my education and future. Some special thanks go to James Kirsch, Marsha Kapphahn, Wanda Keller, Laurie Geyer, the staff at the Animal Nutrition and Physiology Center, Jennifer Young, and my fellow graduate students for their willingness to assist me in laboratory analysis, animal care and handling, and comfort during the stress of graduate school. I would also like to thank my parents and siblings (Kristina, David, and Theodore) for always being there to listen, reassuring me and pushing me to continue in my pursuit of an advanced degree. Finally, I would like to thank my husband, Jamie Keomanivong, for your ability to make me smile even in the most stressful of situations and your dedication to stand by my side and take hold of my hand through it all. Distiller’s Inclusion Rate and Feed Processing Methods to Enhance Enzymatic Activity and Improve Nutrient Utilization. Influence of nutrient restriction and melatonin supplementation on insulin concentration and measurements of insulin containing clusters in maternal pancreas at 130 days of gestation. Influence of nutrient restriction and melatonin supplementation on insulin concentration and measurements of insulin containing clusters in fetal pancreas at 130 days of gestation. Influence of realimentation after nutrient restriction during mid to late gestation on maternal pancreatic digestive enzymes. Influence of realimentation after nutrient restriction during mid to late gestation on maternal serum and pancreatic insulin concentration and measurements of insulin containing cell clusters. Influence of realimentation after nutrient restriction during mid to late gestation on fetal pancreatic digestive enzymes. Influence of realimentation after nutrient restriction during mid to late gestation on fetal serum and pancreatic insulin concentration and measurements of insulin containing cell clusters. Comparison of maternal vs fetal pancreatic digestive enzymes during mid to late gestation. Comparison of fetal vs maternal serum and pancreatic insulin concentration and measurements of insulin-containing cell clusters. Rumen enzyme activity of steers consuming corn vs barley-based diets with variable distiller’s oil concentration. Influence of nutrient restriction and melatonin supplementation on insulin-positive staining. Sections represent the maternal and corresponding fetal pancreatic tissues of representative ewes fed 5 mg/d melatonin and receiving 100% of nutrient requirements (a and b) and 60% of nutrient requirements (c and d). The Importance of the Ruminant Animal the world’s population is predicted to increase to 11 billion people by 2100. While many are lead to believe that only undeveloped countries are enduring such suffering this has proven to be untrue. The tragedy of undergoing such malnutrition is consequently one of the leading causes of death and disability. Therefore, the need to increase the food supply is significantly related to future health. This includes not only physical and mental health but also plays a strong role in future academic achievement and financial productivity impacting the nations as a whole (Seligman et al. Due to such an effect, researchers are quickly working to increase the efficiency of livestock production to provide food and economic growth to the world (Thorton, 2010). In regards to livestock, some of the greatest nutritional resources obtained by the population are provided by ruminants due to their ability to utilize cellulosic feed sources which would otherwise be indigestible by humans. In order to produce significant meat and milk products, 1 however, it is important to consider the efficiency of their digestive tracts and determine the value of the products generated and also to factor in the environmental impact of the animal. Overview of Digestive Enzymes the anatomy of the ruminant digestive system includes the mouth, esophagus, four compartment stomach (rumen, reticulum, omasum, and abomasum), pancreas, gall bladder, liver, small intestine (duodenum, jejunum, and ileum), and large intestine (cecum, colon, and rectum). The impact of these organs on nutrient utilization is highly variable depending on the feed source provided and maturity of the animal (Church, 1988). Therefore, in order to gain a further understanding, extensive research must be continued. One area of focus that has gained considerable interest is on the subject of enzymatic activity. An enzyme can be defined as an organic catalyst that facilitates a chemical reaction without being affected. Within the ruminant animal, enzymatic secretions are found throughout the digestive tract. For example, the mouth of the ruminant contains salivary glands which secrete the enzyme known as salivary lipase to begin the breakdown of fat (Van Soest, 1982). These glands are also responsible for the secretion of salivary buffers such as phosphate and bicarbonate in an effort to keep the pH of the rumen and reticulum within 5. After ingestion, the feed travels down the esophagus and into the rumen and reticulum. Little separation exists between these organs as food and water easily pass between the two. Due to this, feed is predominantly exposed to similar microorganisms responsible for the synthesis of digestive enzymes such as amylase, glucanase, maltase, lipase, cellulase, pectinase, protease, xylanase, and tannase (Jenkins, 1993; Wang and McAllister, 2002). Amylase is predominantly 2 responsible for the breakdown of starch into the components of glucans and maltose (Swanson et al. The fats ingested by the animal undergo breakdown by lipase (Bauchart, 1993) while the enzymes responsible for digestion of the plant cell wall polymers include cellulase, pectinase, protease and xylanase. Tannase is also an important enzyme as it is responsible for the degradation of specific plant toxins (Wang and McAllister, 2002). While these enzymes are capable of breaking down many nutrients some feed components continue traveling along the digestive tract for further degradation. The folds of the omasum begin to absorb fluid contained in the digesta (Prins et al. Within the abomasum, protein is further broken down by enzymes such as pepsin and rennin (Guilloteau et al. Lysozyme is also produced to break down the cell walls of the bacteria passing through the abomasum helping to provide microbial protein (Kisia, 2010). Despite an alkaline secretion by chief cells, the pH in the abomasum is typically 2 to 4 (Jackson and Cockcroft, 2002). The pH is reduced largely as a + result of H that is being secreted and used to continue the digestion of feed particles. Once leaving the abomasum, digesta enters the first compartment of the small intestine known as the duodenum. Although the pH in the abomasum was low it is quickly neutralized in the duodenum as digesta is being subjected to an alkaline bile secretion from the gall bladder and bicarbonate released by the pancreas (Noble, 1978). Enzymes secreted by the pancreas are also important for the breakdown of nutrients. Those most commonly recognized in pancreatic secretions include amylases, lipases and proteases. As discussed before, amylases are responsible 3 for the breakdown of carbohydrates such as starch into dextrins, maltose and isomaltose. Next the enzymes known as maltase and isomaltase become active and continue to digest the maltose and isomaltose into glucose (Croom et al. The enzyme lipase works with bile salts and colipase to break down triglycerides, into monoglycerides and finally free fatty acids. Proteins also face further breakdown in this area by proteases such as elastase, gelatinase, chymotrypsin and trypsin. Chymotrypsin and trypsin first appear as inactive proenzymes called chymotrypsinogen and trypsinogen. Once these proenzymes are secreted into the duodenum they are activated by enterokinase (also known as enteropeptidase) secreted from intestinal glands called the crypts of Lieberkuhn (Pizauro et al. Further activity of these enzymes continues within the brush border of the intestine. Aminopeptidase and dipeptidase help to further the denaturing of proteins into amino acids. Nutrients incapable of further degradation in the small intestine continue to move into the large intestine where microbial fermentation occurs. Finally, undigested components (as well as endogenous components) are excreted from the body through the rectum.

Syndromes

  • Blood vessel disorders with bleeding (hemorrhage), clots, or atherosclerosis of the blood supply of the ear
  • Pulmonary flow murmurs
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  • Use low-fat toppings, sauces, and dressings.
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  • Kidney failure
  • Vitamin D is needed to help the body use calcium. Milk is fortified with vitamin D for this reason.
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However erectile dysfunction doctor boca raton generic tadalafil 2.5mg mastercard, if clinical judgment indi cates that nasal congestion might impede delivery of the vaccine to erectile dysfunction treatment in egypt generic tadalafil 10mg with visa the nasopharyngeal mucosa neurogenic erectile dysfunction causes generic tadalafil 10 mg with amex, vaccine deferral should be considered until resolution of the illness impotence from steroids order 10 mg tadalafil. Data do not warrant recommendation of a single preferred site for all injections, and product recommendations of many manufacturers allow fexibility in the site of injection. Recommended routes of administration are included in package inserts of vaccines and are listed in Table 1. The recommended route is based on studies designed to demonstrate maximum safety and immunogenicity. To minimize untoward local or systemic effects and ensure optimal effcacy of the immunizing procedure, vaccines should be given by the recommended route. In children younger than 1 year of age (ie, infants), the anterolateral aspect of the thigh provides the larg est muscle and is the preferred site. Ordinarily, the upper, outer aspect of the buttocks should not be used for active immunization, because the gluteal region is covered by a signifcant layer of subcutaneous fat and because of the possibility of damaging the sciatic nerve. Because of diminished immunogenicity, hepatitis B and rabies vaccines should not be given in the buttocks at any age. People, especially adults, who were given hepatitis B vaccine in the buttocks should be tested for immunity and reimmunized if antibody concentrations are inadequate (see Hepatitis B, p 369). The site selected should be well 1 For a review on intramuscular injections, see Centers for Disease Control and Prevention. This site is the center of a triangle for which the boundaries are the anterior superior iliac spine, the tubercle of the iliac crest, and the upper border of the greater trochanter. These vaccines should not be administered subcutaneously or intracutaneously, because they can cause local irritation, infammation, granuloma formation, and tissue necrosis. Reported adverse events include broken needles, muscle contracture, nerve injury, bacterial (staphylococcal, streptococcal, and clostridial) abscesses, sterile abscesses, skin pigmentation, hemorrhage, cellulitis, tissue necrosis, gangrene, local atrophy, periostitis, cyst or scar formation, and inadvertent injection into a joint space. Site and Needle Length by Age for Intramuscular Immunization Needle Length, Age Group inches (mm)a Suggested Injection Site Newborns (preterm and term) and 5 (16)b Anterolateral thigh muscle 8 infants <1 mo of age Term infants, 1–12 mo of age 1 (25) Anterolateral thigh muscle Toddlers and children 5 –1 (16–25)b Deltoid muscle of the arm 8 1–1 (25–32) Anterolateral thigh muscle Adults Female and male, weight <60 kg 1 (25)c Deltoid muscle of the arm Female and male, weight 60–70 kg 1 (25) Deltoid muscle of the arm Female, weight 70–90 kg 1 (25)–1 (38) Deltoid muscle of the arm Male, weight 70–118 kg 1 (25)–1 (38) Deltoid muscle of the arm Female, weight >90 kg 1 (38) Deltoid muscle of the arm Male, weight >118 kg 1 (38) Deltoid muscle of the arm a Assumes that needle is inserted fully. Such events can be minimized by administration immediately after the patient’s receipt of replacement factor if relevant, by utilization of a fner needle (23-gauge or less of appropriate length), and by applying frm pressure at the immuni zation site for at least 2 minutes. Because of the decreased antigenic mass administered with intradermal injections, attention to technique is essential to ensure that material is not injected subcutaneously. When neces sary, 2 or more vaccines can be given in the same limb at a single visit. The distance separating the injections is arbitrary but should be at least 1 inch, if possible, so that local reactions are unlikely to overlap. Multiple vaccines should not be mixed in a single syringe unless specifcally licensed and labeled for admin istration in 1 syringe. Aspiration before injection of vaccines or toxoids (ie, pulling back on the syringe plunger after needle insertion, before injection) is not recommended, because no large blood vessels are located at the preferred injection sites, and the process of aspiration has been demonstrated to increase pain. A brief period of bleeding at the injection site is common and usually can be controlled by applying gentle pressure. Managing Injection Pain A planned approach to managing the child before, during, and after immunization is helpful for children of any age. Parents should be educated about techniques for 1 reducing injection pain or distress. Truthful and empathetic preparation for injections is benefcial, using words that are explanatory without evoking anxiety—for example, “pressure,” “squeezing,” and “poking” rather than “pain,” “hurt,” and “shot. Parents should be advised not to threaten children with injections or use them as a punishment for inappropriate behavior. Techniques for minimizing pain can be divided into physical, psychological, and pharmacologic. Pain reduction during pediatric immunizations: evidence-based review and recommendations. In addition, breastfeeding is a potent analgesic intervention in newborn infants during blood collection. Infants may exhibit less pain behavior when held on the lap of a parent or other caregiver. Older children may be more comfortable sitting on a parent’s lap or examination table edge and hugging their parent chest to chest, while an immunization is administered. Stroking or rocking a child after an injection decreases crying and other pain behaviors. A rapid plunge of the needle through the skin without aspirating and rapid injection may decrease discomfort. If multiple injections are to be given, having different health care professionals administer them simultaneously at multiple sites (eg, right and left anterolateral thighs) may lessen anticipation of the next injection. It may be helpful to give older children a degree of control by allowing some choice in selecting the injection site. Humor and distraction techniques tend to decrease distress, whereas excessive parental reassurance, concern, or apology tends to increase distress. Breathing and distraction techniques, such as “blowing the pain away,” use of pinwheels or soap bubbles, telling children stories, reading books, or use of music, are effective. Techniques that involve the child in a fantasy or reframe the experi ence with the use of suggestion (“magic love” or “pain switch”) also are effective but may require training. Topical anesthetics (eg, lido caine/pilocaine) have been evaluated in placebo-controlled, randomized clinical trials and have been demonstrated to provide pain relief. Because currently available topical anesthetics require 30 to 60 minutes to provide adequate anesthesia, planning is necessary, such as applying the cream before an offce visit or immediately on arrival. Oral admin istration of a small volume of a 25% to 75% sucrose solution (eg, dissolving 1 packet of sugar in 10 mL water) or dipping a pacifer into a sucrose solution just before the injection reduces crying time in infants younger than 6 months of age. However, optimal immunologic response for the person must be balanced against the need to achieve timely protection against disease. For example, pertussis-containing vaccines may be less immunogenic in early infancy than in later infancy, but the beneft of conferring protection in young infants—who experience the highest morbidity and mortality from pertussis—mandates that immunization should be given early, despite a lessened serum antibody response. For this reason, in some developing countries, oral polio vaccine is given at birth, in accordance with recommendations of the World Health Organization. With parenterally administered live-virus vaccines, the inhibitory effect of residual specifc maternal antibody determines the optimal age of administration. For example, live-virus measles-containing vaccine in use in the United States provides suboptimal rates of seroconversion during the frst year of life, mainly because of interference by transplacentally acquired maternal antibody. If a measles-containing vaccine is admin istered before 12 months of age, the child should receive 2 additional doses of measles containing vaccine at the recommended ages and interval (see Fig 1. An additional factor in selecting an immunization schedule is the need to achieve a uniform and regular response. For example, live-virus rubella vaccine evokes a predictable response at high rates after a single dose. With many inactivated or component vaccines, a primary series of doses is necessary to achieve an optimal initial response in recipients. For example, some people respond only to 1 or 2 types of poliovirus after a single dose of poliovirus vaccine, so multiple doses are given to produce antibody against all 3 types, thereby ensuring complete protection for the person and maximum response rates for the population. For some vaccines, periodic booster doses (eg, with tetanus and diphtheria toxoids and acellular pertussis antigen) are administered to maintain protection. This information is particularly important for scheduling immunizations for children with lapsed or missed immunizations and for people preparing for international travel (see Simultaneous Administration of Multiple Vaccines, p 33). Data indicate possible impaired immune responses when 2 or more parenterally administered live-virus vaccines are not given simultaneously but within 28 days of each other; therefore, live-virus vaccines not admin istered on the same day should be given at least 28 days (4 weeks) apart whenever possi ble. No minimum interval is required between administration of different inactivated vaccines. The recommended childhood (0 through 6 years of age), adolescent (7 through 18 years of age), and catch-up immunization schedules in Fig 1. These schedules are reviewed regularly, and updated national schedules are issued annually in February; schedules are available at Special attention should be given to footnotes on the sched ule, which summarize major recommendations for routine childhood immunizations. The use of a combination vaccine generally is preferred over separate injec tions of its equivalent component vaccines.

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Patients with Chagas cardiomyopathy may die suddenly from ventricular arrhythmias erectile dysfunction causes emotional effective 10 mg tadalafil, complete heart block erectile dysfunction exam what to expect cheap tadalafil 20 mg online, or emboli phenomena; death also may occur from intractable congestive heart failure laptop causes erectile dysfunction order tadalafil 10 mg with mastercard. Congenital Chagas dis ease may be characterized by low birth weight impotence 25 purchase tadalafil 5 mg without prescription, hepatosplenomegaly, myocarditis, and/or meningoencephalitis with seizures and tremors, but most infants with congenital T cruzi infection have no signs or symptoms of disease. Reactivation of chronic T cruzi infection may occur in immunocompromised people, including people infected with human immu nodefciency virus and those who are immunosuppressed after transplantation. The bitten person is inoculated through inadver tently rubbing the insect feces containing the parasite into the site of the bite or mucous membranes of the eye or the mouth. The parasite also can be transmitted congenitally, during solid organ transplantation, through blood transfusion, and by ingestion of food or drink contaminated by the vector’s excreta. Accidental laboratory infections can result from handling parasite cultures or blood from infected people or laboratory animals, usu ally through needlestick injuries. Vectorborne transmission of the disease is limited to the Western hemisphere, predominantly Mexico and Central and South America. The south ern United States has established enzootic cycles of T cruzi involving several triatomine vector species and mammalian hosts, such as raccoons, opossums, rodents, and domestic dogs. Nevertheless, most T cruzi-infected individuals in the United States are immigrants from areas of Latin America with endemic infection. The disease is an important cause of morbidity and death in Latin America, where an estimated 8 to 10 million people are infected, of whom 30% to 40% either have or will develop cardiomyopathy. Diagnosis in the chronic phase relies on serologic tests to demonstrate immunoglobulin (Ig) G antibodies against T cruzi. Serologic tests to detect anti-T cruzi IgG antibodies include indirect immunofuorescent and enzyme immunosorbent assays. The Pan American Health Organization and the World Health Organization recommend that samples be tested in 2 assays based on different formats before diagnostic decisions are made. The diagnosis of congenital Chagas disease can be made during the frst 3 months of life by identifcation of motile trypomastigotes by direct microscopy of fresh antico agulated blood specimens. All infants born to seropositive mothers should be screened using conventional serologic testing after 9 months of age, when IgG measurements refect infant response. Treatment of chronic T cruzi infection in adults without advanced cardiomyopathy also generally is recommended. The only drugs with proven effcacy are benznidazole and nifurtimox (see Drugs for Parasitic Infections, p 848). Travelers to areas with endemic infection should avoid contact with triatomine bugs by avoiding habitation in buildings vulnerable to infestation, particularly those constructed of mud, palm thatch, or adobe brick. Camping or sleeping outdoors in areas with endemic transmission is not recommended. Diagnostic testing should be performed on members of households with an infected patient if they have had exposure to the vector similar to that of the patient. Homes should be examined for the presence of the vectors, and if found, measures to eliminate the vector should be taken. The American Red Cross and Blood Systems Inc voluntarily began screening all blood donations in January 2007. M africanum is rare in the United States, and clinical laboratories do not distinguish it routinely. M bovis can be distinguished routinely from M tuberculosis, and although the spectrum of illness that is caused by M bovis is similar to that of M tuberculosis, the epidemiology, treatment, and prevention are distinct. Most infections caused by M tuberculosis complex in children and adolescents are asymptom atic. When tuberculosis disease does occur, clinical manifestations most often appear 1 to 6 months after infection and include fever, weight loss, or poor weight gain and possibly growth delay, cough, night sweats, and chills. Chest radiographic fndings after infection range from normal to diverse abnormalities, such as lymphadenopathy of the hilar, subcarinal, paratracheal, or mediastinal nodes; atelectasis or infltrate of a segment or lobe; pleural effusion; cavitary lesions; or miliary disease. Extrapulmonary manifestations include meningitis and granulomatous infammation of the lymph nodes, bones, joints, skin, and middle ear and mastoid. Renal tuberculosis and progression to disease from latent tuberculosis infec tion (“adult-type pulmonary tuberculosis”) are unusual in younger children but can occur in adolescents. In addition, chronic abdominal pain with intermittent partial intestinal obstruction can be present in disease caused by M bovis. Clinical fndings in patients with drug-resistant tuberculosis disease are indistinguishable from manifestations in patients with drug-susceptible disease. Tuberculin reactivity appears 2 to 10 weeks after initial infection; the median interval is 3 to 4 weeks (see Tuberculin Testing, p 740). Infectious tuberculosis refers to tuberculosis disease of the lungs or larynx in a person who has the potential to transmit the infection to other people. It is defned as infection or disease caused by a strain of M tuberculosis complex that is resistant to isoniazid and rifampin, at least 1 fuoroquinolone, and at least 1 of the fol lowing parenteral drugs: amikacin, kanamycin, or capreomycin. In recent years, foreign-born children have accounted for more than one quarter of newly diagnosed cases in children age 14 years or younger. Transmission of M tuberculosis complex is airborne, with inhalation of droplet nuclei usually produced by an adult or adolescent with contagious pulmonary or laryngeal tuberculosis dis ease. M bovis is transmitted most often by unpasteurized dairy products, but airborne transmission can occur. The duration of contagiousness of an adult receiving effective treatment depends on drug susceptibilities of the organism, the number of organisms in sputum, and frequency of cough. Although contagiousness usually lasts only a few days to weeks after initiation of effective drug therapy, it can last longer, especially when the adult patient has cavitary disease, does not adhere to medical therapy, or is infected with a drug-resistant strain. Unusual cases of adult-form pul monary disease in young children and cases of congenital tuberculosis can be highly contagious. The risk of developing tuberculosis disease is highest during the 6 months after infection and remains high for 2 years; however, many years can elapse between initial tuberculosis infection and tuberculosis disease. Children older than 5 years of age and adolescents frequently can produce sputum spon taneously or by induction with aerosolized hypertonic saline. Studies have demonstrated successful collections of induced sputum from infants with pulmonary tuberculosis, but this requires special expertise. The best specimen for diagnosis of pulmonary tuberculosis in any child or adolescent in whom the cough is absent or nonproductive and sputum cannot be induced is an early-morning gastric aspirate. Gastric aspirate specimens should be obtained with a nasogastric tube on awakening the child and before ambulation or feeding. Gastric aspirates have the highest culture yield in young children on the frst day of collection. Because M tuberculosis complex organisms are slow growing, detection of these organ isms may take as long as 10 weeks using solid media; use of liquid media allows detection within 1 to 6 weeks and usually within 3 weeks. Even with optimal culture techniques, M tuberculosis complex organisms are isolated from fewer than 50% of children and 75% of infants with pulmonary tuberculosis diagnosed by other clinical criteria. The differentiation between M tuberculosis and M bovis usually is based on pyrazinamide resistance, which is characteristic of almost all M bovis isolates. The Mantoux method consists of 5 tuberculin units of purifed protein derivative (0. Creation of a palpable indura tion 6 to 10 mm in diameter is crucial to accurate testing. Multiple puncture tests are not recommended, because they lack adequate sensitivity and specifcity. Without recent exposure, these people are not at increased risk of acquir ing tuberculosis infection. Underlying immune defciencies associated with these conditions theoretically would enhance the possibility for progression to severe disease. Initial histories of potential exposure to tuberculosis should be included for all of these patients. Risk assessment for tuberculosis should be performed at frst contact with a child and every 6 months thereafter for the frst year of life (eg, 2 weeks and 6 and 12 months of age). After 1 year of age, risk assessment for tuberculosis should be performed annually, if possible. Tuberculin testing at any age is not required before administration of live-virus vaccines. Measles vaccine temporarily can suppress tuberculin reactivity for at least 4 to 6 weeks. However, induration that develops at the site of administration more than 72 hours later should be measured, and some experts advise that this should be considered the result. The diameter of induration in millimeters is measured transversely to the long axis of the forearm.

Diseases

  • Brachydactyly type C
  • Autoimmune peripheral neuropathy
  • Idiopathic alveolar hypoventilation syndrome
  • Chondrocalcinosis familial articular
  • Glutaricaciduria II
  • Bronchiolotis obliterans organizing pneumonia (BOOP)
  • Hereditary ataxia
  • Thymic renal anal lung dysplasia
  • Hemophobia
  • Heparane sulfamidase deficiency

References:

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  • http://nciom.org/wp-content/uploads/2017/07/Patient-FamilyEngage_Report-FINAL.pdf
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