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Retention A quarter that continues to produce grossly abnormal of milk for any reason can stimulate the immediate hy- milk order lyrica without a prescription, has frequent clinical areups that require treat- persensitivity order lyrica canada. The mediator release results in variable ment buy lyrica 75 mg free shipping, or has a chronic active necrotizing inammation degrees of urticaria and dyspnea. The condition is characterized ously requires the teat to be functional to hold in what- by urticarial swellings of the eyelids, lips, vulva, and skin. Therefore amputation of the teat Other instigating causes of milk allergy include delayed cannot be performed in conjunction with chemical de- milking or bagging a cow for a show, sale, or photogra- struction. The physiologic mechanisms that initiate used for chronic problems that are not life-threatening to the attack are unknown because these same cows that the patient but require treatment, make the cow slightly developed allergic disease after several hours of dry off ill, or risk spread to other cows by contagion. Glands seem to tolerate routine 12-hour milking intervals with- chronically infected with A. A cow may have only one episode or may constitute the majority of cases that undergo chemical develop repeated episodes so that drying off is impossi- destruction. Corticosteroids may considered in peracute or acute mastitis because it tends only be used in nonpregnant cows; any pregnant ani- to worsen toxemia and illness associated with the pri- mals being dried off routinely should not be treated mary inammation. All are injected into the quarter in sufcient volume to penetrate the Teat Amputation entire gland thus a sizeable volume of chemical or Teat amputation is indicated when the teat presents a chemical plus diluent may be necessary. The solution is barrier to effective drainage of a severely infected mam- left in the udder and, if possible, never milked out. Typically, severe solutions cause inammatory swelling, edema, and dis- toxic or necrotizing mastitis has caused thick clots or comfort within 24 to 48 hours. However, unless the pa- toothpaste-like secretions that cannot be milked out of tient acts ill (inappetence, fever), the solution should not the teat in an efcient manner. Clostridial mas- stripped out at 24 to 48 hours following instillation of titis may necessitate amputation as well. Successful destruction of a gland will be teats that have suffered repeated trauma and allowed indicated by progressive atrophy of the gland following secondary mastitis sometimes are amputated to allow the initial acute inammatory reaction. Infuse as quarter seems essential and milkout is incomplete be- much as the quarter will hold by gravity ow. Acriavine 1 g/500 ml in sterile water: administer lost or the gland threatens the cow s life. There is no transference of the teat (unless it is gangrenous) by rst clamping a chlorhexidine into nontreated quarters; however, Burdizzo at the base of the teat. The proximal udder the disinfectant is present in infused quarter sam- should not be damaged because of the large venous ples for as long as 42 days. After clamping with the very effective in killing the gland and may require Burdizzo, the teat is excised with heavy serrated scissors multiple infusions to be effective. In one study, this was a produced by hydrolysis of the fatty acids from the glyc- preferable method to chlorhexidine infusion. The release of the fatty Intramammary administration of any of the listed acids produces a goat acid or rancid taste to the con- compounds does not conform to the existing Food and sumer. The test is recommended for use on individual these compounds is unknown, and several of the chem- farm samples rather than in tanker truck or composited icals are proved carcinogens. Intact protein membranes normally encap- of bovine Staphylococcus aureus mastitis, J Dairy Sci 89:1877-1895, sulate milk fat molecules and protect the fat from en- 2006. Lack of adequate protein in the cows diet copy: 52 cases (2000-2002), J Am Vet Med Assoc 226:1119-1123, 2. Air leaks in pipeline milkers dairy heifers, J Am Vet Med Assoc 180:164-165, 1982. Holding raw milk more than 48 hours after tis in a dairy herd, J Am Vet Med Assoc 189:913-915, 1986. Partial or less than every-other-day collection of cows, J Dairy Sci 85:1881-1886, 2002. Failure to empty and wash raw milk storage tanks tis is mainly determined by cow factors, Vet Res 34, 521-564, on every processing day 2003. Ingestion of onions and Helenium (sneezeweed) or coplasma mastitis milk used to feed calves: thermal effects on Hymenoxys by lactating cows various Mycoplasma, J Dairy Sci 83:2285-2288, 2000. Low dietary vitamin E, feeding high levels of vege- dairy cattle, J Dairy Sci 87:3322-3329, 2004. High iron or copper content in the drinking water crobial susceptibility proles for treatment decisions, Vet Clin 15. Diets that have strong odors, such as butyrous feed North Am Food Anim Pract 19:139-155, 2003. Surgical procedures and classication of lesions, infection and clinical mastitis over a 5 year period in a closely Can Vet J 28:757-762, 1987. Gilbert The scope of theriogenology is beyond simple summa- may occur due to accumulation of cerebrospinal uid tion within a single chapter of a general textbook. There- (hydrocephalus) or from ascites (usually in Ayrshire fore no effort will be made to cover all gynecologic and calves). Standard theriogenology text- The major outward sign of hydrops is progressive ab- books should be consulted for more in-depth reading dominal distention during the last trimester that wors- and discussions of infertility, endocrinology, dystocia, ens to such a degree as to decrease appetite and cause and abortion. The distended uterus Hydrops Etiology Uterine dropsy or hydrops is a sporadic condition usu- ally occurring during the last trimester of pregnancy. Hy- drops of the amnion results from fetal anomalies that prevent fetal swallowing or intestinal transport of amni- otic uid and is responsible for approximately 10% of the cases of hydrops. Hydrops of the allantois is the more common condition and is usually accompanied by abnormal placentation characterized by reduced num- bers of placentomes and adventitious placentation (mul- tiple areas of adhesion between the endometrium and allantochorion, appearing as miniature placentomes). Therefore hydrallantois usually is considered a maternal abnormality of placentation, whereas hydramnios is considered more likely a fetal problem. Hydrallantois tends to cause rapid (days to weeks) abdominal disten- tion that results in a rounded abdominal appearance as the patient is viewed from the rear, whereas hydramnios usually results in a slow progressive enlargement with eventual pear-shaped appearance. It is possible for nutritional Hydrops allantois in a Holstein cow that was 8 months deciencies to cause hydrops allantois. Weakness results both from reduced feed consum- unable to rise or that already have severe musculoskel- ption and from the increased weight of uterine uids. Secondary ketosis and other metabolic conditions are When treatment is elected, several options exist. In- possible complications as a result of decreased feed in- duction of parturition is preferable if the uterus has not take and fetal nutritional needs especially if twins are already been stretched beyond physiological limits, which present in cows with hydrallantois. This prevents the rapid hydrallantois, the distended uterine horns appear to ll onset of shock, which may result from venous uid shift- the abdomen, but palpation of the fetus and placent- ing into the splanchnic pool with abdominal decompres- omes may not be possible because the uterus is stretched sion. Although some authors have not found hydrops tightly by the increased uid content. Rectal or transab- patients to be markedly dehydrated, our experience dif- dominal ultrasound examination is helpful in making a fers and supports the comments of Roberts that those diagnosis. Cervical relax- ture of the prepubic tendon and ventral hernias also ation may also be attempted by the manual application may occur. Because hydrallantois tends to cause more of synthetic prostaglandin E in the external os and cervi- rapid uid accumulation, musculoskeletal injuries ap- cal canal. Specic human gynecologic preparations of pear to be more common with this condition than in prostaglandin E are very expensive, but I have had success the slowly enlarging hydramnios patients. Pregnant women should not handle this also can help differentiate this condition from the wa- product!

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Serial injections of Bacillus Calmette Gurin are usually avoided as a treatment op- tion in dairy cattle because these injections could sensi- tize the cow to tuberculin and cause a false-positive result on a tuberculin test discount 75mg lyrica. Swelling and discharge are appar- or lymphoid follicles are found on the vulvar mucous ent at the vulva buy discount lyrica 75mg on line, and affected animals may be uncom- membrane especially near the clitoris generic lyrica 150mg free shipping. Mild lesions also can be observed in ization of signs to the caudal reproductive tract. Lactating cattle or those lence in a herd experiencing reproductive problems and under stress for other reasons are more likely to show vaginal or vulvar discharges should be considered ab- systemic signs than heifers. The organism resides primarily in the vagina nomonic and include white plaques, erosions, and ulcers and vulva but can gain entrance to the uterus during in the vulvar and vaginal mucous membranes. If lesions are older of the organism into the uterus of susceptible cows pro- than 7 to 10 days, virus may no longer be present in the duced endometritis and salpingitis. Therefore cattle that subsequently abort are usually purulent discharge, swelling of the vulva, and pus-lled seropositive and may not show an increase in titer with white nodules several millimeters in diameter on the paired samples. Young organism to cows through natural service or via fresh or stock should be vaccinated after maternal antibodies frozen semen. Cloudy or mucopurulent discharges on the vulva, including a cloudy or mucopurulent discharge, appear tail, and perineum signal the condition. Many of the af- chronically or intermittently; infertility or repeat ser- fected cows have not been observed to have endometritis vices recur as an epidemic or endemic problem; and during the early postpartum period and may have had typical vulvar lesions that are raised nodules, granules, clean early postpartum reproductive examinations. Some have histories of reproductive failure or granular vulvitis cows may not show obvious discharge until a few days lesions. Examination of affected cattle usu- than caudal reproductive tract infection, and some strains ally reveals typical lesions of granular vulvitis or atypical, of M. One study found that heifers bred to an infected bull regular or irregular (suggestive of early embryonic death) developed purulent infections and had biopsy-conrmed intervals and early abortions frequently accompany clin- evidence of endometritis. Because of this, antibiotic mix- productive problems usually are dismissed as cases of tures of gentamicin, tylosin, and lincocin-spectinomycin chronic endometritis or chronic vaginitis. A single isolate is less than con- are found in conjunction with isolation of the organ- clusive because the organism has often been found as an ism. Control measures may be similar to those for apparent commensal in the reproductive tract of cows U. Improve management to minimize crowding, clean of infected cattle with tetracycline appears effective. Avoid natural service if it is currently practiced in the isolated with great regularity from the cervicovaginal herd. Assess selenium levels in feed and spiratory tract infections, septicemia, and reproductive blood when the disease occurs in unsupplemented conditions have been attributed to the organism. Some strains may cause neuro- coplasma can infect the reproductive tract to cause infertility. Septicemia is thought ships, data on experimental infections, and signicance of to follow infection regardless of entry site. Isolation of the organism from the reproductive tract cattle and could be introduced to dairy cows or dairy heif- of healthy, fertile cattle raises questions as to pathogenic- ers if infected bulls or heifers are purchased. Following infection of the Klavano worked with eld outbreaks of infertility as- vagina, the organism quickly establishes an endometritis sociated with H. The major consequences of the disease are early em- animals was capable of causing vaginitis with acute muco- bryonic death, fetal death, and infertility. Immunity slowly purulent discharge and persistent isolation of the organ- develops following infection, and most cows subsequently ism for almost 2 months. Therefore vaginitis certainly is a conceive after two or more repeat services even when the possible consequence of H. Such infections may represent postpartum as- act as mechanical carriers of the infection from infected to cending infections from the caudal reproductive tract or susceptible heifers and cattle during natural service. Abortion and early embryonic bulls ( 5 years) more commonly are found to be chroni- death also have been attributed to H. Evidence of purulent tion of the reproductive tract or accessory glands is possi- discharge is unusual. Immunoglobulins of the IgG type ble, but the organism frequently is isolated from bulls with eventually are produced and found in the uterus in recov- no evidence of macroscopic or histologic lesions. Infected ered animals, whereas IgA antibodies are found in the bulls can have reduced semen quality and certainly could vagina. Infertility in infected cows may be apparent as transmit the disease through natural breeding or semen. Irregular Semen usually is treated with antibiotics to minimize this intervals are associated with embryonic death. Animals should be vaccinated twice within 2 to Diagnostic laboratories should be contacted before sam- 4 weeks or according to manufacturer s recommendations ple collection to determine appropriate handling, trans- and then given booster shots annually or semiannually port media, and temperature for shipment. Little is known regarding immunity collect vaginal mucus also have been used to assess anti- to the organism, but vaccines generally are considered body levels in the mucus via agglutination tests. Vaccines may such agglutination tests are chosen, sampled cows should be improved signicantly in the future if distinct strains of be suspected to have infection for more than 30 days, and H. Some manufacturers currently at- recently fresh because antibody levels may be diluted by tempt to address this issue by formulating bacterins from large quantities of mucus at those times. Vaccination should month of gestation, and those that occur before 90 days be performed according to manufacturer s instructions seldom are observed. Some cattle show postcoital discharge several days fol- lowing breeding, and mild vulvovaginitis and cervicitis Trichomoniasis are possible. Although but the uterine infection lingers for 3 to 4 months, after herds using semen from commercial Al stud services as which time immunity or resistance is established. The disease is much more prevalent in Clinical signs other than infertility may be minimal. Postcoital discharges, pyometra, and abortion are help- Older bulls are more likely to be infected chronically ful signs but are far less common than simple return to because T. Diagnosis requires identication and isolation of These crypts become more numerous as bulls age, T. It is recommended that bulls be sampled by thereby causing greater risk for older bulls. These are collected young bulls are infected less commonly, they certainly using a dry pipette inserted into the preputial fornix, can be, and they also may be chronic carriers. Heavy breeding, as occurs during seasonal it is desirable to induce mild irritation or even bleeding breeding in beef animals, tends to dilute or reduce the while collecting the sample. The pipette also may be number of organisms shed during coitus, thereby some- introduced through a dry straw, and preparation of the what reducing infectivity. Cows farms and bred year-round would likely be more infec- may be sampled by collection of cranial vaginal mucus tive at all breedings.

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When Etiology thoracic or lumbar vertebrae are involved discount lyrica 75 mg with visa, the animal as- Although most common in calves purchase lyrica 150mg otc, epidural abscesses oc- sumes an arched stance order lyrica 150 mg online. These abscesses may and contracted exor tendons may be present if polyar- originate either within vertebrae as areas of osteomyelitis thritis coexists or if prolonged recumbency has been ob- or adjacent to the vertebrae in the epidural space. Palpation of the vertebrae may cause a painful re- with acute or chronic septicemia secondary to umbilical sponse when pressure is exerted on the affected bone. Radiographic studies are more easily accomplished in calves than adult cattle because of their size difference. Cervical vertebral abscess that was in the vertebral body Epidural and vertebral body abscesses must be differ- of C4. Occasionally the infection in- selenium values provide ancillary data when necessary. Abscesses identies the site of the lesion when the abscess has cre- located in the lumbosacral region, which seems to be the ated detectable swelling ventral to an affected vertebral most common location in calves, or sacrum may cause body. This is most likely to be helpful if the neurologic difculty in urination, defecation, tail paresis, and pro- examination suggests a lumbosacral lesion. Peracute spinal cord signs may occur associated with a fracture of the in- fected vertebral body (see video clip 44). Cauda equina neuritis following tail docking often results in a rapidly progressive ascending disease. The calf had no tail tone, dribbled urine, and was severe pelvic limb paresis and a dog-sitting position. Appropriate antibiotics and analgesics constitute the therapy for vertebral abscesses. Tetracycline (11 mg/ kg twice daily) is a good choice because this antibiotic maintains good tissue penetration in bony tissues. Treat- ment needs to be long term (minimum of 2 to 4 weeks) and should be directed by cultures where possible. Anal- gesics such as unixin or other nonsteroidal antiinam- matories in standard dosages encourage patient mobility and appetite. Clinical signs of improvement in- clude resolution of fever, improved appetite, and in- creased range of mobility (cervical lesions) or lessening of the arched stance (thoracolumbar lesions). Acute lesions lumbar spinal cord compression caused by lymphosar- obviously carry a better prognosis that chronic ones. Extradural compression of the spinal cord by neo- Lesions from C6 to T2 lead to greater paresis in the plasms is one cause of focal or multifocal spinal cord forelimbs, and the forelimbs may lose tone and reexes, injury that may result in spinal cord signs in the pelvic whereas the pelvic limbs remain normal or exaggerated limbs or all four limbs. Recently a Holstein cow with sub- common neoplasm identied, but nerve sheath neo- acute to chronic bloat and bilateral forelimb weakness plasms occasionally cause similar spinal cord compres- and muscle atrophy that was progressive was found to sion. Lymphosarcoma is usually located in the epidural have massive neurobromatosis of the brachial plex- space at any level of the vertebral canal, although in- uses, heart, and other spinal nerves. A large lesion in the volvement of the lumbosacrocaudal spinal cord and thoracic inlet interfered with effective eructation. Lymphosarcoma sions from C1 to C5 cause spastic paresis and ataxia in lesions usually, but not always, can be identied in all four limbs. Rarely lymphosarcoma may occur dif- other target organs in cattle affected with spinal cord fusely in the subarachnoid space. As mentioned, the history may indicate great variation in the duration of clinical signs. Owners often notice the cow developing progressive weakness or difculty in Clinical Signs rising; she may require manual assistance to rise. Neurologic examination fre- spinal cord that have acute histories must be differenti- quently allows neuroanatomic location of the mass or ated from cattle with injuries from bulling or riding ac- masses (see introductory description of spinal cord tivities, metabolic diseases such as hypocalcemia, Hypo- signs). Lesions from T3 to L3 cause spastic paresis and derma larvae migration, and chute injuries. If no other target organ inltration is identied during the physical examination, ancillary data will be helpful. Elevated protein levels ( 40 mg/dl) were found in 5 of 10, whereas only 1 of 10 had elevated nucleated cells. On these oc- casions, aspiration with a syringe attached to the spinal needle allowed neoplastic cells to be recovered that were made into smears on microscopic slides, stained, and conrmed a diagnosis of lymphosarcoma. Serum globulin values are usually normal in cattle affected with tumors, as opposed to cattle with epidural or vertebral abscesses in which serum globulin may be elevated. Similarly fever and neutrophilia in the periph- eral blood usually are absent in tumor patients. The iliac lymph nodes should be care- fully palpated because these are frequently enlarged if the lymphoma involves the caudal spinal cord. Peripheral nerve injuries must do develop clinical tumors), but a positive result raises be ruled out. Most cows with lymphosarcoma palpable per rectum should be assessed for enlargement masses causing extradural compression will test positive consistent with lymphosarcoma. Palpation of the uterus may reveal masses consistent with lymphosarcoma, and unilateral No effective treatment exists for these patients, and nec- or bilateral exophthalmus may indicate retrobulbar in- ropsy frequently reveals multifocal masses in the epidural ltration with this neoplasm. This treatment is usually reserved for nonpreg- nant cattle, and the owner has a short-term goal such as embryo transfer from an extremely valuable patient. We have used isoupredone in late pregnant cows to im- prove the clinical signs long enough to allow delivery of the calf. L-asparaginase has also been used successfully as short- term therapy but is expensive. Several or internal from compressive lesions such as a tumor other calves in this group suffered long bone or verte- or abscess causing a compressive myelopathy, as just bral fractures over a period of 4 weeks. Nutritional factors must be considered in vertebral body abscess may develop acute spinal cord calves and growing heifers when vertebral fractures or signs if the diseased bone acutely fractures. Riding injuries either Clinical Signs caused by great weight discrepancy between mounted Clinical signs are sudden in onset and not obviously and mounting cows or the mounted cow slipping on a progressive unless the patient struggles excessively or is slippery surface may predispose to thoracolumbar verte- handled too vigorously (i. The clinical signs will reect the that fall while caught in chutes or even stanchions may fracture site and the neuroanatomic diagnosis (see fracture cervical vertebrae. The latter is more likely if the introductory section on spinal cord signs) (see video head is restrained in the chute or stanchion when the clip 45). Cattle trapped under divider bars in tie recumbency, have an anxious expression, and be unable stalls or free stall barns may struggle excessively and frac- to right themselves into sternal recumbency. Mature bulls with anky- examination may raise suspicion of the fracture loca- losing spondylosis eventually may fracture a vertebral tion based on observation and palpation of dorsoven- body if forced to mount after showing early signs of tral or lateral deviation of the vertebral spines. In severe cases, caudal vertebrae are usually caused by cows being nociception and the cutaneous trunci reex may be re- mounted during estrus activity or because of cystic ova- duced caudal to the site of the fracture and these are ries. Dystocia also may be a cause of sacral and caudal easily performed tests during the neurologic examina- vertebral injury or fracture.

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Muscle wasting also affects functional status and mobility buy lyrica paypal, which may impair food shopping order lyrica american express, meal preparation buy 75 mg lyrica with mastercard, and cleanup. As a result of the chronic inflammation, anemia of chronic disease is often present (10,11,34). Medication-related effects on biochemical indices of folic acid and iron status are also common. Some medications such as methotrexate also affect calcium and vitamin D status (17 19). Dietary and functional assessments should include attention to energy intake and problems related to obtaining, preparing, and eating food. Patients with social support may have a better quality of life, potentially moderating the impact of pain, depression, and physical disability (33). The disease is chronic and characterized by an age of onset before 16 years of joint swelling, heat, and pain and stiffness of unknown origin (10, 11) that occurs for 6 weeks or more (11). Disease characteristics often include inflammation, fever, damage/deformity of joints, and altered bone growth (10). In abnormal bone growth, one bone may be longer than another at times of accelerated growth and later become stunted. If the abnormal bone growth occurs in the leg, the child may compensate by bending the longer leg until the hips are level. Either arm-span or knee-height measurements are appropriate depending on the location of contractures and range in motion of joints. Growth charts for stature for age, weight for age, and weight for stature are important tools for monitoring growth retardation and body composition changes. Biochemical indices for iron-deficiency anemia should be monitored and assessed to determine the cause and intervention for the anemia. Side effects that affect nutritional status include mouth sores, bone marrow damage and altered iron status (10,34), and blood and protein loss in urine (34). Dietary intake and status may be influenced by many manifestations of the disease, and therefore dietary intake is important to obtain. Energy and protein malnutrition may be found in 10 to 50% of children with this disease (11). Jaw function is compromised in the 20 to 30% of children who have abnormal jaw development (10), and a small jaw or teeth misalignment can result in dysphagia (difficulty swallowing) (10,11). Patients may be depressed and embarrassed, negatively impacting their social life (10,11). Gout is more prevalent in men than women (18,19) with an age of onset after 40 years (18,35,36). Women are more likely to develop gout later in life (after menopause) than men, and the upper extremities are more often affected (35,37). Large tophi on the heels may make it difficult to accurately measure a standing height. Alternative methods of estimating height may be required depending on the manifestations of the disease. Central fat distribution may be measured using waist circumference and risk is increased with a waist circumference of more than 100 cm for men 88 cm for women (39). Patients with gout are often prescribed medications for inflammation and uric acid control. Other anti-inflammatory drugs prescribed for gout include colchicine and corticosteroids. About 80% of patients experience side effects of nausea, vomiting, and diarrhea when taking colchicine (35). Nutritional deficiency of vitamin B12, sodium, and potassium are also related to colchicine (18). Central obesity and serum uric acid levels are associated with insulin resistance, hypertension, high serum lipids, and renal failure. When gathering dietary intake data, it is important to determine intake of alcohol, nonalcoholic beverages, and purine- rich foods. Adequate hydration is important if the patient is at risk for renal calculi (18,19). Dietary intake of purine- rich foods may contribute to as much as one-third of the serum uric acid (18,19, 36,39). However, dietary intake of purine-rich foods and the impact on serum uric acid is controversial. Elevated serum uric acid is caused by inadequate renal excretion (90% of the serum level) and excess synthesis (10% (18,19,36,39)). Dietary intake contributes to excess synthesis; thus, dietary intake of purine-rich foods will have relatively little impact on serum uric acid levels. It may still be important to determine intake of purine-rich foods because individuals may be more sensitive to these foods and have a greater reaction, or they may be able to take lower drug doses. These patients may not be able to prepare meals, grip utensils to eat, or even write. Systemic Sclerosis Within the United States, the prevalence of systemic sclerosis is estimated at 240 cases per 1 million adults (40). Both involve fibrosis of the skin but limited scleroderma only includes thickening of the skin in the face and neck and below the elbows and knees. Disease manifestations make it difficult to obtain anthropometric measurements in some patients, particularly those with diffuse disease. It may be difficult to obtain accurate stature measurements if the patient is unable to stand upright. Biochemical indices are also affected by drugs that alter nutritional status of some nutrients, particularly folic acid, the fat-soluble vitamins, and calcium. Enteral or parenteral nutrition may be required if a patient is unable to maintain weight or if a patient has significant intestinal dysfunction (41). Skin fibrosis of the fingers may make it difficult to eat and write or to handle objects in shopping or cooking. Raynaud s phenomenon involves vasoconstriction with resulting symptoms of cold hands and feet and changes in skin color on the fingers and toes (25). The patients with moderate to severe Raynaud s phenomenon had greater difficulty in performing activities that involved hand use (i. Reduced grip may increase difficulty in preparing food and fibrosis in the face may limit movement of the lips and mouth (25). Hand disability may result from tight skin (43), swelling, hand contractures (25) or ulcerations (25,43); eating dysfunction seems to be the most closely associated hand disability (43). Fecal incontinence (25,41) or urgency (41) may be a sign or symptom of dysfunction in the lower gut. Estimates of its prevalence are unknown (45), but it is estimated to be up to 10 cases per 1 million people (46). The disease manifests with proximal muscle weakness developing in a few weeks or months (45 47). The muscle weakness is symmetrical and the pelvis and shoulder muscles are most commonly affected in these patients, but the neck muscles, primarily the flexor muscles, can also become weak and this is found in about 50% of the patients (46). Degraded muscle fibers may be replaced with fibrous connective tissue, fat, or simply atrophy (46).