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Topic:Gastrointestinal Health

Gastrointestinal health in horses encompasses the study of the structure, function, and disorders of the equine digestive system. The equine gastrointestinal tract is complex, consisting of the stomach, small intestine, cecum, and large intestine, each playing a specific role in digestion and nutrient absorption. Research in this area often focuses on common disorders such as colic, gastric ulcers, and parasitic infections, which can impact a horse's overall health and performance. Investigations examine factors affecting gastrointestinal health, including diet, management practices, and the microbiome. This page compiles peer-reviewed research studies and scholarly articles that explore the physiology, pathology, and management of gastrointestinal health in horses.
Cardiorespiratory, gastrointestinal, and analgesic effects of morphine sulfate in conscious healthy horses.
American journal of veterinary research    May 25, 2012   Volume 73, Issue 6 799-808 doi: 10.2460/ajvr.73.6.799
Figueiredo JP, Muir WW, Sams R.To compare the cardiorespiratory, gastrointestinal, analgesic, and behavioral effects between IV and IM administration of morphine in conscious horses with no signs of pain. Methods: 6 healthy adult horses. Methods: Horses received saline (0.9% NaCl) solution (IM or IV) or morphine sulfate (0.05 and 0.1 mg/kg, IM or IV) in a randomized, masked crossover study design. The following variables were measured before and for 360 minutes after drug administration: heart and respiratory rates; systolic, diastolic, and mean arterial blood pressures; rectal temperature; arterial pH and blood gas variabl...
Prevalence of gastric and duodenal ulceration in 691 nonsurviving foals (1995-2006).
Equine veterinary journal. Supplement    May 19, 2012   Issue 41 76-79 doi: 10.1111/j.2042-3306.2011.00449.x
Elfenbein JR, Sanchez LC.Gastric ulcer disease is reported to be a significant cause of morbidity in foals, but the prevalence of ulcers in this population has not recently been evaluated. Objective: To determine the prevalence of gastric and duodenal ulceration in nonsurviving foals, and the association of ulceration with the body system of primary diagnosis. Secondary objectives were to evaluate a potential association between age and ulcer prevalence and to evaluate the use of antacid medication in the neonatal hospital population during the study years. Methods: Necropsy records were searched for all equine access...
The importance of ultrasonographic pneumatosis intestinalis in equine neonatal gastrointestinal disease.
Equine veterinary journal. Supplement    May 19, 2012   Issue 41 64-68 doi: 10.1111/j.2042-3306.2011.00478.x
de Solis CN, Palmer JE, Boston RC, Reef VB.Recognising the presence of a necrotising component of the gastrointestinal disease may be clinically useful in ill equine neonates. Objective: To study the importance of abdominal sonograms in neonatal foals suffering from gastrointestinal conditions and to describe the clinical features of necrotising gastrointestinal disease. Objective: There is a subgroup of neonates with sonographically detectable pneumatosis intestinalis (PI), reflecting a necrotising disease. Methods: Records of foals aged < or = 7 days hospitalised from 2005 to 2009 with signs of gastrointestinal disease were evalua...
Gastric emptying, intestinal absorption of electrolytes and exercise performance in electrolyte-supplemented horses.
Experimental physiology    May 11, 2012   Volume 98, Issue 1 193-206 doi: 10.1113/expphysiol.2012.065185
Lindinger MI, Ecker GL.Horses lose considerably more electrolytes through sweating during prolonged exercise than can be readily replaced through feeds. The present study tested an oral electrolyte supplement (ES) designed to replace sweat electrolyte losses. We measured gastric emptying of 3 litres of ES (using gamma imaging of (99)Tc-sulfide colloid), the absorption of Na(+) and K(+) from the gastrointestinal tract using (24)Na(+) and (42)K(+), and the distribution of these ions in the body by measuring radioactivity within plasma and sweat during exercise. Three litres of ES emptied from the stomach as fast as wa...
Expression of sweet receptor components in equine small intestine: relevance to intestinal glucose transport.
American journal of physiology. Regulatory, integrative and comparative physiology    May 2, 2012   Volume 303, Issue 2 R199-R208 doi: 10.1152/ajpregu.00031.2012
Daly K, Al-Rammahi M, Arora DK, Moran AW, Proudman CJ, Ninomiya Y, Shirazi-Beechey SP.The heteromeric sweet taste receptor T1R2-T1R3 is expressed on the luminal membrane of certain populations of enteroendocrine cells. Sensing of sugars and other sweet compounds by this receptor activates a pathway in enteroendocrine cells, resulting in secretion of a number of gut hormones, including glucagon-like peptide 2 (GLP-2). This subsequently leads to upregulation in the expression of intestinal Na(+)/glucose cotransporter, SGLT1, and increased intestinal glucose absorption. On the basis of the current information available on the horse genome sequence, it has been proposed that the ge...
Lactobacillus equigenerosi strain Le1 invades equine epithelial cells.
Applied and environmental microbiology    April 13, 2012   Volume 78, Issue 12 4248-4255 doi: 10.1128/AEM.00552-12
Botha M, Botes M, Loos B, Smith C, Dicks LM.Lactobacillus equigenerosi strain Le1, a natural inhabitant of the equine gastrointestinal tract, survived pH 3.0 and incubation in the presence of 1.5% (wt/vol) bile salts for at least 2 h. Strain Le1 showed 8% cell surface hydrophobicity, 60% auto-aggregation, and 47% coaggregation with Clostridium difficile C6. Only 1% of the cells adhered to viable buccal epithelial cells and invaded the cells within 20 min after contact. Preincubation of strain Le1 in a buffer containing pronase prevented adhesion to viable epithelial cells. Preincubation in a pepsin buffer delayed invasion from 20 min to...
Efficacy of omeprazole paste in the prevention of gastric ulcers in 2 years old Thoroughbreds.
The Journal of veterinary medical science    April 13, 2012   Volume 74, Issue 8 1079-1081 doi: 10.1292/jvms.11-0545
Endo Y, Tsuchiya T, Sato F, Murase H, Omura T, Korosue K, Nambo Y, Ishimaru M, Wakui Y.Prevalence of equine gastric ulcer syndrome in 85 young Thoroughbreds was investigated. The presence of gastric ulcers was confirmed in 27.1% (23/85) of the horses by endoscopic examination. Sixty-two horses without gastric ulcers were allocated randomly to either the treated group (31 horses) or sham-dosed control group (31 horses) in order to investigate the efficacy of omeprazole oral paste in the prevention of gastric ulcers. At the second endoscopic examination conducted after 28 days of administration, only 1 horse in the treated group developed gastric ulcers, while 12 horses developed ...
Case report: Left dorsal displacement of the large colon manifested as increased y-glutamyl transferase activity in a horse.
Compendium (Yardley, PA)    April 11, 2012   Volume 34, Issue 2 E3 
Banse HE, Tennent-Brown BS, Mueller PO.No abstract available
Gluten-dependent antibodies in horses with inflammatory small bowel disease (ISBD).
The veterinary quarterly    April 10, 2012   Volume 32, Issue 1 3-11 doi: 10.1080/01652176.2012.675636
van der Kolk JH, van Putten LA, Mulder CJ, Grinwis GC, Reijm M, Butler CM, von Blomberg BM.Equine inflammatory small bowel disease (ISBD) is an idiopathic pathologic condition seeming to increase in prevalence. Objective: To investigate the potential role of gluten in equine ISBD. Methods: Antibodies known to be important in the diagnosis of human coeliac disease (CD): IgA antibodies to human recombinant and guinea pig tissue-transglutaminase (TGA), native gliadin (AGA), deamidated-gliadin-peptides (DGPA), and primate and equine endomysium (EMA) were assessed in blood samples from three different groups of horses: ISBD affected (n = 12) on a gluten-rich diet and controls either ...
Mid-gestation pregnancy is not disrupted by a 5-day gastrointestinal mucosal cytoprotectant oral regimen of misoprostol.
Equine veterinary journal    April 9, 2012   Volume 45, Issue 1 91-93 doi: 10.1111/j.2042-3306.2012.00572.x
Jacobson CC, Sertich PL, Mc Donnell SM.To investigate effects of a 5-day oral misoprostol regimen recommended for use in horses as a gastrointestinal mucosal cytoprotectant during colic on mid-gestation pregnancies. Objective: To monitor cervical tone, ultrasonographic characteristics of the uterus, cervix and conceptus, as well as serum progesterone and oestrone sulphate concentrations, and observations of general health, behaviour and comfort of mid-gestation mares given a 5-day course of misoprostol or control treatment. Methods: Eleven light horse and pony mares with known breeding dates were administered 5 µg/kg bwt misoprost...
Electromyographic evaluation of masseter muscle activity in horses fed (i) different types of roughage and (ii) maize after different hay allocations.
Journal of animal physiology and animal nutrition    March 29, 2012   Volume 97, Issue 3 515-521 doi: 10.1111/j.1439-0396.2012.01292.x
Vervuert I, Brüssow N, Bochnia M, Cí·¯ord D, Coenen M.The aims of this study were to monitor electromyographic (EMG) activity of masseter muscle in healthy horses fed (i) different types of roughage and (ii) maize after different hay allocations. Four horses were offered the following three diets ad libitum: hay, haylage or straw/alfalfa chaff (SAC). In a second trial, four horses were fed cracked maize (CM) and hay in three different orders: (i) CM after a 12-h overnight fast; (ii) CM immediately after restricted hay intake (0.6 kg hay/100 kg BW); or 3) CM after hay intake ad libitum. The activity of the masseter muscle was determined by EMG...
Intestinal barrier function in neonatal foals: options for improvement.
Veterinary journal (London, England : 1997)    February 28, 2012   Volume 193, Issue 1 32-37 doi: 10.1016/j.tvjl.2012.01.032
Vendrig JC, Fink-Gremmels J.Gastrointestinal defence in the new-born is limited in comparison to adults, due to an immature epithelial barrier function and deficits in both innate and adaptive immune responses. Consequently, neonates (including foals) are at increased risk of disturbance to mucosal homeostasis during initial intestinal colonisation that may lead to excessive inflammation and bacterial translocation into the bloodstream, resulting in septicaemia. Bacterial recognition by Pattern Recognition Receptors (PRRs) and their downstream regulation of cytokine release have been shown to be pivotal for gastrointesti...
Equine stomachs harbor an abundant and diverse mucosal microbiota.
Applied and environmental microbiology    February 3, 2012   Volume 78, Issue 8 2522-2532 doi: 10.1128/AEM.06252-11
Perkins GA, den Bakker HC, Burton AJ, Erb HN, McDonough SP, McDonough PL, Parker J, Rosenthal RL, Wiedmann M, Dowd SE, Simpson KW.Little is known about the gastric mucosal microbiota in healthy horses, and its role in gastric disease has not been critically examined. The present study used a combination of 16S rRNA bacterial tag-encoded pyrosequencing (bTEFAP) and fluorescence in situ hybridization (FISH) to characterize the composition and spatial distribution of selected gastric mucosal microbiota of healthy horses. Biopsy specimens of the squamous, glandular, antral, and any ulcerated mucosa were obtained from 6 healthy horses by gastroscopy and from 3 horses immediately postmortem. Pyrosequencing was performed on bio...
Evaluation of a wireless ambulatory capsule (SmartPill®) to measure gastrointestinal tract pH, luminal pressure and temperature, and transit time in ponies.
Equine veterinary journal    February 2, 2012   Volume 44, Issue 4 482-486 doi: 10.1111/j.2042-3306.2011.00533.x
Stokes AM, Lavie NL, Keowen ML, Gaschen L, Gaschen FP, Barthel D, Andrews FM.This study investigated the use of a wireless ambulatory capsule (WAC; SmartPill(®) pH.p GI Monitoring System) to determine WAC-gastric emptying time (GET) in ponies. Objective: To measure WAC-GET and compare it to those findings with GET assessed by nuclear scintigraphy (S-GET). Objective: WAC-GET will be slower than S-GET, but will be significantly correlated. Methods: Seven healthy adult mixed-breed pony mares were used in this study. Feed was withheld for 12 h prior to the WAC administration. After administration, a complete-feed diet was fed to allow the WAC to pass into the stomach. Lum...
Ileal impaction in 245 horses: 1995-2007.
The Canadian veterinary journal = La revue veterinaire canadienne    January 3, 2012   Volume 52, Issue 7 759-763 
Fleming K, Mueller PO.The objective of this study was to identify parameters that would assist in determining the probability of a successful outcome with medical management versus surgical intervention in horses with ileal impaction. Medical records of 245 horses admitted for ileal impaction were reviewed and placed into 2 groups: medical (med) and surgical (sx) treatment. Persistence of abdominal pain, gastric reflux, frequency of analgesic administration, and 1-year survival were evaluated. There were no differences in signalment, abdominal pain, or heart rate among groups; however, significantly more sx horses ...
Prevalence and intensity of gastro-intestinal helminths in horses in the Sudano-Guinean climatic zone of Cameroon.
Tropical parasitology    January 1, 2012   Volume 2, Issue 1 45-48 doi: 10.4103/2229-5070.97239
Lem MF, Vincent KP, Pone JW, Joseph T.It is important to understand the biology and health impact of parasites affecting horses in the Western highlands of Cameroon. Objective: to evaluate the prevalence and intensity of infection of gastrointestinal helminths in these animals. Methods: A total of 894 horses (367 males and 527 females), and aged ≤1 to ≥7 years old were examined. A parasitological investigation of faeces was carried out using two techniques: concentration method of Full Born Willis (flotation in saturated solution of sodium chloride) and Mc Master Technique. Conclusions: From the results the overall prevalence ...
Effects of phenylbutazone on gene expression of cyclooxygenase-1 and -2 in the oral, glandular gastric, and bladder mucosae of healthy horses.
American journal of veterinary research    December 30, 2011   Volume 73, Issue 1 98-104 doi: 10.2460/ajvr.73.1.98
Nieto JE, Aleman M, Anderson JD, Fiack C, Snyder JR.To assess gene expressions of cyclooxygenase-1 and -2 in oral, glandular gastric, and urinary bladder mucosae and determine the effect of oral administration of phenylbutazone on those gene expressions in horses. Methods: 12 healthy horses. Methods: Horses were allocated to receive phenylbutazone or placebo (6 horses/group); 1 placebo-treated horse with a cystic calculus was subsequently removed from the study, and those data were not analyzed. In each horse, the stomach and urinary bladder were evaluated for ulceration via endoscopy before and after experimental treatment. Oral, glandular gas...
In vitro comparison of three suture techniques for anastomosis of the equine small intestine.
Equine veterinary journal. Supplement    December 7, 2011   Issue 40 46-50 doi: 10.1111/j.2042-3306.2011.00494.x
Auletta L, Lamagna F, Uccello V, Lamagna B, Pasolini MP.The equine small intestine can be affected by a variety of disorders that may require some form of bypass or anastomosis. Many suture patterns have been used in equine anastomoses to minimise post operative complications, which include leakage from the anastomosis site, stenosis and adhesions. Because of the critical condition of horses undergoing colic surgery, it is imperative this is performed as quickly as possible. Objective: To evaluate, in vitro, differences in the time of execution and leakage pressure between the Lembert single layer, Gambee and Lembert double layer suture patterns fo...
Attempted medical management of suspected ascending colon displacement in horses.
Veterinary surgery : VS    November 21, 2011   Volume 41, Issue 3 399-403 doi: 10.1111/j.1532-950X.2011.00915.x
McGovern KF, Bladon BM, Fraser BS, Boston RC.To determine the success of medical management of suspected displacement of the ascending (large) colon in horses. Methods: Retrospective case series. Methods: Horses (n = 127) with suspected large colon displacement. Methods: Medical records (January 1998-September 2008) of horses admitted for colic were reviewed. Suspected large colon displacement was diagnosed from clinical examination and in some cases, subsequent surgical examination. Medically managed horses were exercised and administered intravenous fluids and analgesia. Horses with suspected left dorsal displacement (LDD) of the large...
Abdominal computed radiography for the diagnosis of enterolithiasis in horses: 142 cases (2003?2007).
Journal of the American Veterinary Medical Association    November 18, 2011   Volume 239, Issue 11 1483-1485 doi: 10.2460/javma.239.11.1483
Maher O, Puchalski SM, Drake C, le Jeune SS.To evaluate the sensitivity and specificity of abdominal computed radiography (CR) for the diagnosis of enterolithiasis in horses and to examine how these parameters are affected by the number and anatomic location of enteroliths and by gas distension of the gastrointestinal tract. Methods: Retrospective case series. Methods: Horses ? 1 year old that underwent abdominal CR and subsequent exploratory laparotomy or postmortem examination. Methods: 3 reviewers blinded to signalment, history, clinical signs, and diagnoses separately evaluated abdominal computed radiographs of horses included in th...
In vitro studies on intestinal calcium and phosphate transport in horses.
Comparative biochemistry and physiology. Part A, Molecular & integrative physiology    November 16, 2011   Volume 161, Issue 2 259-264 doi: 10.1016/j.cbpa.2011.11.005
Cehak A, Wilkens MR, Guschlbauer M, Mrochen N, Schröder B, Feige K, Breves G.Transepithelial transport mechanisms play a key role in regulating the absorption and secretion of calcium (Ca(2+)) and inorganic phosphate (P(i)) in the gastrointestinal tract. Although intestinal disorders with imbalances in macromineral homeostasis are frequently observed in horses, available data on intestinal Ca(2+) and P(i) transport are limited. The aim of the present study was to characterize the intestinal Ca(2+) and P(i) transport functionally by using the in vitro radioisotope tracer technique with Ussing chambers and to identify components involved in Ca(2+) transport at both mRNA ...
Characterization of L-lysine transport across equine and porcine jejunal and colonic brush border membrane.
Journal of animal science    November 7, 2011   Volume 90, Issue 3 853-862 doi: 10.2527/jas.2011-4210
Woodward AD, Fan MZ, Geor RJ, McCutcheon LJ, Taylor NP, Trottier NL.In nonruminant herbivores, microbially derived AA could contribute to whole-body AA homeostasis and thus decrease predicted AA requirements. However, postileal capacity of AA uptake is currently unknown. Therefore, to test the hypothesis that Lys is transported across the large colon mucosal apical membrane with capacity similar to that of the small intestinal mucosa in the pony and pig, we examined Lys transport in vitro using brush border membrane vesicles (BBMV). Mucosa was collected from the distal jejunum (DJ) and proximal large colon (PLC) of growing pigs (n = 3) and ponies (n = 4), flas...
Gastric and enteric phytobezoars caused by ingestion of persimmon in equids.
Journal of the American Veterinary Medical Association    October 12, 2011   Volume 239, Issue 8 1110-1116 doi: 10.2460/javma.239.8.1110
Banse HE, Gilliam LL, House AM, McKenzie HC, Johnson PJ, Lopes MA, Carmichael RJ, Groover ES, Lacarrubba AM, Breshears MA, Brosnahan MM, Funk R....CASE DESCRIPTION-13 equids (10 horses, 2 donkeys, and 1 pony) were examined for signs of colic (n = 7), weight loss (6), anorexia (3), and diarrhea (2). Ten equids were evaluated in the fall (September to November). Seven equids had a history of persimmon ingestion. CLINICAL FINDINGS-A diagnosis of phytobezoar caused by persimmon ingestion was made for all equids. Eight equids had gastric persimmon phytobezoars; 5 had enteric persimmon phytobezoars. Gastroscopy or gastroduodenoscopy revealed evidence of persimmon ingestion in 8 of 10 equids in which these procedures were performed. TREATMENT A...
Histological and immunohistochemical studies of changes in myenteric plexuses and in interstitial cells of Cajal associated with equine colic.
Research in veterinary science    August 27, 2011   Volume 93, Issue 1 350-359 doi: 10.1016/j.rvsc.2011.07.019
Pavone S, Gialletti R, Pepe M, Onofri A, Mandara MT.In this study we investigated the histological changes of the myenteric plexuses and interstitial cells of Cajal (ICC) in gut samples from horses with colic to try to find results useful in the prognostic evaluation of enteric lesions. A morphologic and quantitative study of myenteric ganglia, ganglion cells and neuronal chromatolytic and necrotic changes of 24 horses with colic was performed. For ganglion cells, enteroglial cells and ICC immunolabeling was also performed to identify cell functional disorders. A significant increase of neuronal chromatolysis and necrosis occurred in horses suf...
Inhibition of motility in isolated horse small intestine is mediated by κ but not µ opioid receptors.
Equine veterinary journal    August 23, 2011   Volume 44, Issue 3 368-370 doi: 10.1111/j.2042-3306.2011.00426.x
Menozzi A, Pozzoli C, Zullian C, Poli E, Serventi P, Bertini S.The effects of preferential µ (morphine), selective µ (fentanyl), selective κ (compound U69593) opioid receptor agonists, and nonselective (naloxone) and selective µ (naloxonazine) antagonists on equine small intestinal motility were evaluated in vitro. Samples of circular muscle from equine jejunum were placed in isolated organ baths and drug-induced modifications of both spontaneous and electrically evoked contractile activity were measured. None of the opioid agonists induced a significant change in spontaneous contractions. Fentanyl and U69593 reduced electrically induced contractions,...
Detection of calprotectin and apoptotic activity within the equine colon from horses with black walnut extract-induced laminitis.
Veterinary immunology and immunopathology    August 17, 2011   Volume 144, Issue 3-4 366-373 doi: 10.1016/j.vetimm.2011.08.006
Chiavaccini L, Hassel DM, Shoemaker ML, Charles JB, Belknap JK, Ehrhart EJ.The black walnut extract (BWE) model of equine laminitis is associated with a systemic inflammatory response manifest by increased expression of inflammatory cytokines in the lungs and liver as well as the laminae. The specific role of the gastrointestinal tract in development of this response is unclear and is of utmost importance, as gastrointestinal disease and laminitis are intimately related. We investigated calprotectin expression and epithelial and endothelial apoptosis in the colon of horses exposed to orally administered BWE. Sections of colon from 19 horses including 7 controls not e...
Alterations in microbiota and fermentation products in equine large intestine in response to dietary variation and intestinal disease.
The British journal of nutrition    August 5, 2011   Volume 107, Issue 7 989-995 doi: 10.1017/S0007114511003825
Daly K, Proudman CJ, Duncan SH, Flint HJ, Dyer J, Shirazi-Beechey SP.We aimed to determine the effects of variations in dietary composition on equine gut microbiota and their fermentation products, and proposed that dietary modifications profoundly affect microbial ecosystems and their metabolites. Bacterial communities within the large intestine of three groups of horses were compared using oligonucleotide-RNA hybridisation methodology. Each group consisting of six horses was maintained on (1) a grass-only diet, (2) a concentrate diet (i.e. supplemented with hydrolysable carbohydrates) and (3) a concentrate diet but horses were affected by simple colonic obstr...
Application of the lactose 13C-ureide breath test for measurement of equine orocaecal transit time.
Equine veterinary journal. Supplement    August 4, 2011   Issue 39 49-55 doi: 10.1111/j.2042-3306.2011.00407.x
Sutton DG, Preston T, Love S.Application of the lactose (13) C-ureide breath test (LUBT) for measurement of equine orocaecal transit time (OCTT) has not been reported previously. The ability to assess OCTT noninvasively, and to investigate its relationship to gastric emptying rate and small intestinal transit, would be of both clinical and research value. Objective: 1) Assessment of the LUBT in healthy horses, with comparison of induced versus noninduced test protocols. 2) Application of a new dual stable isotope breath test (lactose (13) C-ureide and (13) C-octanoic acid) for gastrointestinal transit measurement. Objecti...
In vitro electrical activity of the equine pelvic flexure.
Equine veterinary journal. Supplement    August 4, 2011   Issue 39 145-148 doi: 10.1111/j.2042-3306.2011.00396.x
Fintl C, Pearson GT, Mayhew IG, Hudson NP.The generation and maintenance of intestinal motility patterns involve the complex interactions of several components including the gastrointestinal pacemaker cells (interstitial cells of Cajal, ICC). Central to ICC function is the generation of rhythmic pacemaker currents, namely slow waves, which represent the rate limiting step for intestinal smooth muscle contractions. Currently, intracellular slow wave activity has not been demonstrated in the equine colon. Objective: To characterise the in vitro myoelectrical activity of the equine pelvic flexure using intracellular recording techniques....
The effect of nonsteroidal anti-inflammatory drugs on the equine intestine.
Equine veterinary journal. Supplement    August 4, 2011   Issue 39 140-144 doi: 10.1111/j.2042-3306.2011.00398.x
Marshall JF, Blikslager AT.Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the management of pain and endotoxaemia associated with colic in the horse. While NSAIDs effectively treat the symptoms of colic, there is evidence to suggest that their administration is associated with adverse gastrointestinal effects including right dorsal colitis and inhibition of mucosal barrier healing. Several studies have examined the pathophysiology of NSAID associated effects on the large and small intestine in an effort to avoid these complications and identify effective alternative medications. Differences in the re...
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