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The remaining patients only appeared to have improvements in quality; in reality discount artane 2mg fast delivery, many improvements were simply due to improved documentation buy 2 mg artane. Much depends on the details of the plan purchase artane 2 mg fast delivery, as all pay-for-performance plans present structural questions that must be correctly addressed prior to implementation order artane 2 mg on-line. Several questions remain unsolved: should bene¿ts be given to individual physicians or to organisations that will then distribute the bene¿ts collectively? Who should be rewarded for performance: all high performers or only the top performers [56]? To date, there are no decisive answers as to whether pay-for-performance programmes work de¿nitively respecting professionalism recommendations; the linking of physician reimbursement to measures of clinical performance is growing in popularity among pay- ers, including local health authorities and manager, including national and federal govern- ments. Although a body of literature is developing on the anticipated positive results of such programmes – and we applaud innovations that improve care – little evidence exists on the effectiveness of such programmes [57–59]. Pay for performance focuses attention on ethical conÀicts because it rewards good quality care by improving the physician’s in- come, but conÀict of interest exists with non¿nancial incentives to improve quality – only the incentives differ. Similarly, ¿nancial conÀicts exist in every payment system, such as incentives in fee-for-service payment to increase care or the incentive under capitation to do less rather than more. In all of these conÀict-of-interest situations, the ethical impera- tive is the same: clinicians must ensure that provision of medically appropriate levels of care take precedence over personal considerations [60, 61]. According to Snyder and Neu- bauer, pay for performance programmes and other strong incentives can increase the qual- ity of care if they purposely promote the ethical obligation of the physician to deliver the best-quality care for their patients [59]. Proposed methods for assuring quality processes 30 Professionalism, Quality of Care and Pay-for-Performance Services 359 Table 30. Lagasse and Johnstone – in a thoughtful review – de¿ne pay for performance, or value purchasing, as “the use of incentives to encourage and reinforce the delivery of evidence- based practice and health care systems’ transformation that promotes better outcomes as ef¿ciently possible” [61]. This de¿nition provides some insight into the current status of pay for performance by describing its driving force more clearly than it does any particular incentives. In other words, the driving forces pay for performance are quality improvement and cost reduction. Gullo A (2005) Professionalism, ethics and curricula for the renewal of the health system. Gullo A, Santonocito C, Astuto M (2010) Professionalism as a pendulum to pay for performance in the changing world. World Health Organization (2000) World health report 2000 – Health systems: improving performance. Regional overview of social health insurance in south-east Asia, World Health Organization and overview of health care ¿nancing (2006) Retrieved August 18. Kohn L, Corrigan J, Donaldson M, eds (2000) To Err Is Human: Building a Safer Health System. Commonwealth Fund International survey (2005) Taking the pulse of health care systems. New Zealand Ministry of Health (2001) Adverse events in New Zealand public hospital: principal ¿ndings from a national survey. World Health As- 30 Professionalism, Quality of Care and Pay-for-Performance Services 361 sembly. Agency for Healthcare research and Quality: The National Guidelines Clearing- house http://www. Fiorentini G, Iezzi E, Lippi Bruni M et al (2010) Incentives in primary care and their impact on potentially avoidable hospital admissions. Grumback K, Osmond D, Vranizan K et al (1998) Primary care physicians experi- ences of ¿nancial incentives in managed-care systems. Coleman K, Hamblin R (2007) Can pay-for-performance improve quality and re- 362 A. Spooner A, Chapple A, Roland M (2001) What makes British general practitioners take part in a quality improvement scheme? Campbell A, Steiner A, Robinson J et al (2005) Do personal medical services con- tracts improve quality of care? Peterson L, Woodard L et al (2006) Does pay-for-performance improve the quality of health care? Snyder L, Neubauer R, for the American College of Physicians Ethics, Profession- alism and Human Rights Committee (2007) Pay for performance principles that promote patient-centered care: an ethics manifesto. Ethics in practice: managed care and the changing health care environment medicine as a profession managed care ethics working group statement. American College of Physicians (2007) Linking physicians payment to quality of care. American College of Physicians (2007) The use of performance measurements to improve physician quality of care. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the prod- uct information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Associate Professor Department of Pathology Quillen College of Medicine Johnson City, Tennessee Student Reviewers Sara M. Nesler University of Iowa College of Medicine Iowa City, Iowa Class of 2002 Misha F. Haque Baylor College of Medicine Houston, Texas Class of 2001 Joseph Cummings University of Iowa College of Medicine Iowa City, Iowa Class of 2002 Harvey Castro University of Texas—Galveston School of Medicine Galveston, Texas Class of 2002 McGraw-Hill Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto McGraw-Hill Copyright © 2002 by The McGraw-Hill Companies. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be repro- duced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Rather than put a trademark symbol after every occur- rence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. 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With the highly infectious nature of avian polyomavirus discount artane 2 mg free shipping, particularly to young Psittaciformes 2 mg artane, closed breeding operations that do not allow visitors should be encouraged generic 2 mg artane. A cloacal swab of any bird that is being added to a collection should be analyzed Circoviridae during the quarantine period to determine whether a bird is shedding polyomavirus artane 2 mg generic. A chronic disease characterized by symmetric feather Birds also should be tested for viral shedding during dystrophy and loss, development of beak deformities the post-purchase examination. The disease polyomavirus should be separated from the remainder has been diagnosed in numerous Psittaciforme spe- of the collection, and offspring from these birds should cies in addition to cockatoos. The currently used be raised separately from birds that are not shedding name, coined by Perry in 1981, is “psittacine beak the virus. The applicability of killed and recombinant This disease has been experimentally reproduced in polyomavirus vaccines is being evaluated. The virus hemaggluti- Hooded Parrot Meyer’s Parrot nates erythrocytes from cockatoos and some guinea Malee Ring-necked Parakeet Black Palm Cockatoo pigs (see Figure 32. However, the disease has been documented in several black cockatoos and New World psittacine birds including Amazon parrots, macaws and pionus parrots (Table 32. The incidence of source as a major vehicle for the environmental per- the disease in other commonly maintained captive sistence and natural transmission of the virus. Because vire- toos, Rose-breasted Cockatoos, Little Corellas, Major mia has been shown to occur in infected birds, verti- Mitchell’s Cockatoos, Crimson Rosellas, budgerigars cal transmission would be suspected. One flock of Sulfur-crested Cockatoos decreased suggest a carrier state may exist with vertical or from 120 individuals to 20 over a nine-month period. During the test companion birds are subjected may influence regular period, 26% (8 of 31) of the birds screened were found molting periods or the lack of them. Virus that was recovered Most infected birds survive less than six months to from the crop may have originated from infected cells one year after the onset of clinical signs, though some located in the crop or esophageal epithelium, or may birds have been known to live over ten years in a have been deposited in the crop after swallowing of featherless state. Death usually occurs either from exfoliated epithelium from beak or oral mucosal le- changes induced by secondary bacterial, chlamydial, sions. High concentrations of the virus also can be fungal or other viral agents, or from terminal changes that necessitate euthanasia. The factors that determine whether a bird mounts an immune response or is fatally in- fected could depend on the age at the time of expo- sure, the presence and levels of maternal antibodies, the route of viral exposure and the titer of the infect- ing virus. Neonatal budgerigars infected at less than seven tended from the small intestine to the cloaca. In general, crypto- days of age were found to develop severe disease, sporidiosis occurs only in animals that are immunosuppressed (courtesy of Kenneth Latimer). Following experi- (usually birds with severe beak necrosis or other mental infection, the minimum incubation period is 21 to 25 days. Umbrella is critical for the initial processing and presentation Cockatoo chicks infected at three to eight days of age of viral antigen to the immune system, it can be became depressed by 40 days old and developed pro- postulated that the determining factor in whether an gressive feather dystrophy from 42 to 47 days old. Older birds that develop clinical signs later in life may have been infected at a young age and remained latently infected. This is particularly true in African Grey Parrots, where affected feathers may be red instead of grey. The lane 2 chick (below), shown here with the lane 1 chick, did not develop clinical signs enced by the age of the bird when of disease until 80 days of age. Because all three of these chicks were presumably infected clinical signs first appear. Another observation is the irregular necrosis of the reticular cells in the lympho- cytically depleted spleen, which would suggest per- manent immunosuppression. Experimentally infected Rose-breasted Cockatoo neonates became acutely depressed and anorectic approximately four weeks post-infection. Twenty- four hours later, the feathers appeared to lose their luster and became pale and brittle. Subsequently, dystrophic feathers began to appear as the neonates developed their adult plumage. These birds may appear totally normal Birds with long-term infections frequently appear bald as feather one day and exhibit 80 to 100% feather dystrophy pathology progresses through successive molts. Gross changes include reten- necropsy and thorough histologic exam are not per- tion of feather sheaths, hemorrhage within the pulp formed on young of susceptible species that die sud- cavity, fractures of the proximal rachis and failure of denly. Free-ranging birds with severe feather Acute infections are characterized by several days of pathology may have an accompanying brownish dis- depression followed by sudden changes in developing coloration of the skin that is thought to occur from feathers, including necrosis, fractures, bending, exposure of normally sheltered skin to sunlight. This clinical picture feathers with dystrophic, necrotic, non-viable feath- is particularly common in young Sulphur-crested ers that stop growing shortly after emerging from the Cockatoos and lovebirds. In contrast to the classic presen- tation just described, some birds have substantial involvement of the flight, tail and crest feathers, with only minimal changes in the powder down feath- ers. Necrosis of the upper beak progresses fractures of the proximal rachis and failure of the developing proximally to the palatine area and may involve the feather to exsheath; however, it must be stressed that any damage premaxilla in severe cases. The distal end of the to the follicular epithelium can cause a similar appearing gross 187 lesion. Polyomaviral, adenoviral, bacterial down feathers in cockatoos are dystrophic, the beak and fungal folliculitis can cause similar lesions. The beak may elongate or show the feather shaft, where necrosis and ballooning de- transverse delamination or fractures, with or with- generation of epithelial cells in the epidermal collar out bacterial or fungal infections in the clefts (see and epidermal, basal and intermediate zones of the Figure 19. The follicu- Likewise, deformities, fractures, necrosis and 230 lar epithelium may also be necrotic, but this lesion is sloughing of the nails can be seen occasionally. In one study involving 22 cocka- to severe bursal or thymic necrosis with the presence toos of mixed Asian origin, birds older than one year of viral-induced inclusion bodies. Feather pathology of age had a lower incidence of beak lesions than did in these cases may not occur, or may be limited to birds that were under one year of age. In of viral antigen within macrophages in the bone mar- young birds, the cloacal bursa may be small with row and within circulating monocytes suggests that poorly developed folds and the thymus may reveal these cells may be directly infected (Color 32. In mature birds the spleen is frequently small and depleted of lym- Diagnosis phocytes, and occasionally necrosis of the reticular Feather lesions that appear grossly similar can be cells can be observed. In the intestinal tract inclusion bodies were fectious causes of similarly appearing feather lesions mainly found in epithelial cells. Precipitat- viral-specific antibody staining in the beak, hard ing antibodies can be demonstrated using an agar-gel palate, bursa, thymus, tongue, parathyroid gland, immunodiffusion test (see Figure 32. Recoveries have been and has no feather abnormalities must be retested in reported principally in birds with only intranuclear 90 days. A negative test 90 ated as long as the animal is kept in a controlled days later would indicate that the viral nucleic acid environment, beak lesions (also nail lesions) can be was no longer detected in the blood and that the bird painful, particularly when secondarily infected. These birds should be restricted from contact with other Control susceptible birds, particularly neonates. Infected birds should be removed and infectivity remains unchanged when the virus is from the breeding collection and nursery immedi- heated to 60°C for one hour and following treatment ately (see Figure 30. This maternally derived antibodies to their chicks that is particularly true with respect to breeding birds, offer at least temporary immunity to the virus (Color birds being sent to pet shops and birds being evalu- 32. Virions are icosa- African Grey Parrot Adult 320/0 5120/80 hedral and are composed of 252 capsomeres arranged Moluccan Cockatoo Adult 160/1 1280/10 in triangular facets with six capsomeres along each Umbrella Cockatoo Adult 80/0 1280/80 edge. There are 240 nonvertex capsomeres (hexons) Umbrella Cockatoo Adult 320/1 2560/80 and 12 vertex capsomeres (penton bases). The latter Umbrella Cockatoo Adult 80/1 2560/10 contain projections (called fibers).

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Chest: needle or tube thoracostomy in right chest; breath sounds are still slightly diminished on the right; no crackles or rales discount 2 mg artane otc, symmetric excursion; deep 6 cm Case 4: Chest Trauma 43 laceration present along the right anterior chest wall purchase artane 2mg with mastercard, near fourth to ffth rib space discount 2mg artane mastercard. Extremities: moving all four extremities well purchase 2mg artane with visa, normal pulses bilaterally, slightly pale, good tone and 5/5 strength j. Critical actions == Needle thoracostomy (If the examinee performed a tube thoracostomy frst, no need for needle thoracostomy. Air has become trapped outside the lung within this patient’s chest, making breathing diffcult and causing obstruction of normal fow of blood through the chest. It is a diagnosis that should be made during the primary survey before any radiologic or labo- ratory results and on the basis of physical examination alone. Signs include diffculty in breathing, low blood pressure, and poor perfusion due to dimin- ished venous return, distended neck veins, tracheal deviation to the unaffected side, diminished or absent breath sounds, and hyperresonace on the affected side. The most important early action is immediate placement of needle or tube thoracostomy to decompress the pneumothorax. The patient’s vital signs will deteriorate (oxygen saturation and blood pressure will drop, heart rate will rise, and the patient will lose consciousness) until needle or tube thoracostomy is performed. The patient should be kept on supplemental oxygen and monitored while a tube thoracostomy is placed. Other early actions include fuids, continuous cardiac monitoring and pulse oximetry, labs, and early surgical consult. Although this fnding is often used as a pathognomonic sign for tension pneu- mothorax, its absence certainly does not exclude the diagnosis. Monitor patients closely for signs of shock; adequate tissue perfusion should be maintained with crystalloids or blood products. Patient appears stated age, overweight, lying in stretcher holding abdomen, uncomfortable due to pain, in mild distress. She states that her pain is constant, sharp, and worst in the right upper quad- rant, occasionally radiating to the right shoulder. She has had several similar episodes over the past 2 years that have either resolved spontaneously or with pain medications after about 1 to 2 hours. She complains of a subjective fever and chills for 1 day and nausea and three episodes of nonbilious, nonbloody vomiting. She denies diarrhea, constipation, chest pain, shortness of breath, sick contacts, recent travel history, unusual food intake, trauma, or urinary symptoms. Social: lives with her husband and two children, denies smoking, alcohol, drug use, sexually active with her husband only g. Abdomen: normal bowel sounds, soft, severe tenderness in the right upper quadrant with voluntary guarding, positive Murphy’s sign, nontender at McBurney’s point, no pulsatile masses, no hepatosplenomegaly, no hernia, no rebound or guarding g. Discussion with patient regarding need for admission and possible cholecystectomy K. Since the gallblad- der stores bile, used to digest fatty foods, symptoms are often worst after eating fatty meals. The patient will continue to complain of fever until acetamino- phen or other antipyretic is administered, and will continue to complain of pain until an analgesic is given. It is important that the candidate administers antibiotics early, and describes their concern for cholecystitis adequately to the surgical consultant (fever, Murphy’s sign, elevated white blood cell count, vomiting, etc). Presence of gallstones, thickened gallbladder wall, and pericholecystic fuid have a posi- tive predictive value greater than 90%. Differential diagnosis includes hepatitis, hepatic abscess, pyelonephritis, right lower lobe pneumonia or pleurisy, pleural effusion, pancreatitis, peptic acid disease of the duodenum with perforation or penetration, and appendicitis. Consider atypical myocardial infarction, particularly in elderly or diabetic patients that present with similar symptoms. In pregnant patients and young women, consider doing a pelvic examina- tion and eliciting a sexual history to rule out Fitz-Hugh-Curtis syndrome (perihepatitis). Patients with diabetes have an increased risk for bacterial invasion into the gallbladder wall and the development of emphysematous cholecystitis. Acalculous and emphysematous cholecystitis usually indicate an increased risk for gangrene and perforation and require emergent cholecystectomy. Was doing well until past 2 days, initial fussiness, sleep- iness, poor feeding, followed by “really high” tactile fever and lethargy today. This is a case of an infant in septic shock likely from bacteremia (bacteria in the blood). Early and generous fEarly and generous fuid support is essential to maintain blood pres-uid support is essential to maintain blood pres- sure and cardiac output. If the infant is very lethargic, intubation should be performed for airway protection. In a stable child, a full workup is needed including lumbar puncture; in an unstable child, blood and urinalysis can be obtained but lumbar puncture could be deferred as it would be diffcult to tolerate. This patient will need to quickly be placed in an intensive care setting as blood pressure, fuid support, and monitoring will be needed. Sepsis should be considered and prophylactically treated in any newborn in extremis. Circulation: skin diaphoretic, pulses are full in the peripheral extremities 54 Case 7: Chest Pain E. He reports binging on alcohol last night, and had multiple episodes of nonbloody, nonbilious vomiting through the night. Neck: full range of motion, no jugular vein distension, palpable crepitus bilat- erally (must ask) e. This is a case of Boerhaave syndrome (tear of the esophagus) due to episodes of vomiting. Keys include recognition of this etiology as an extremely deadly cause of chest pain, especially in the setting of vomiting and very uncomfort- able appearing patient. Aggressive fuid resuscitation should begin early, or the patient’s vital signs will deteriorate (heart rate will rise, blood pressure will fall, skin will become more clammy and mental status will deteriorate). However, spontane- ous esophageal ruptures, or Boerhaave syndrome, is associated with acts that increase intraluminal pressures, including vomiting, coughing, straining, seizures. No cough, shortness of breath, headache or stiffness of neck, no diarrhea, no new weakness or numbness, and no recent trauma noted. Abdomen: normal bowel sounds, soft, nontender, nondistended, slight decrease in rectal tone f. Critical actions == Consider this diagnosis in an individual with back pain and fever == Obtain a rectal temperature == Obtain stat imaging == Neurosurgery consult for possible operative intervention == Determine cause – urinary tract infection L. This is a case of epidural abscess, an infection surrounding the spinal cord which can compress the cord, causing neurologic complications. If a urinalysis is not ordered, the patient could recall that the urine has looked cloudier recently. Note that the rectal temperature was elevated in this case; this method is more accurate than other types of triage temperature assessment. Epidural abscess is a rare entity, but associated with high morbidity if not diag- nosed promptly. Meds: furosemide, isosorbide nitrate, omeprazole, carvedilol, aspirin, gabapentin 62 Case 9: leg swelling Figure 9.

In chickens buy artane 2 mg visa, penetrated by a trocar and cannula or by blunt sepa- there are three paired air sacs (cranial thoracic cheap artane 2 mg online, cau- ration buy discount artane 2mg on-line. In Psittaciformes order artane 2mg free shipping, this entry site has been dal thoracic, abdominal) and two single, median air demonstrated to occur between the seventh and sacs (cervical, clavicular). With this approach, the tip of the endoscope enters the mid to There is one published examination of air sac mor- caudal portion of the caudal thoracic air sac in most phology in a psittacine bird (budgerigar). The caudal thoracic As an alternative approach to the caudal thoracic air air sacs of the pigeon extend farther caudally than in sac, the bird is restrained in lateral recumbency most Psittaciformes. This is assumed to be an adaption to increased upper part of the triangle formed by the proximal air requirements while diving underwater. For endoscopic purposes, it is preferable to consider A similar approach to the caudal thoracic air sacs the cranial and caudal thoracic and the abdominal that is based upon precise landmarks has been devel- air sac pairs together. The entry site is located by finding the located ventral and cranial to the caudal thoracic air point where the semimembranosus muscle (M. The ventrolateral thoracic wall using the approach first ventral fascia of the semimembranosus muscle is described by Bush,2 who suggested an entry site bluntly separated from the underlying body wall and caudal to the last sternal rib in the area of the lateral the muscle is reflected dorsally. A blunt entry is made notch (a “V”-shaped depression palpable between the just caudal to the last rib, beneath the reflected sternum and the last rib). Except in individuals with moderately to markedly increased fat reserves, The patient is placed in lateral recumbency with the the landmarks are located easily. The wings may be taped to reproducible in members from a wide variety of or- a restraint surface or they may be affixed with a ders including Psittaciformes, Passeriformes, Co- short loop of non-adhesive, self-adhering tapef lumbiformes, Gruiformes, Falconiformes and Strigi- passed between the primary feathers and around the formes. The landmarks are located and a small skin is that the lateral body wall can be more easily incision is made. The musculature of the body wall is approached without the interference of the femoral bluntly separated and the endoscope is inserted in a musculature. From this approach the peri- birds with heavily muscled upper thighs (eg, many cardial sac and heart can be seen as well as the lobe Psittaciformes). With either of these approaches the endoscope enters the caudal thoracic air sac at or near its caudal The traditional left lateral surgical approach takes border. From the two then passing into the abdominal air sac through a to three o’clock position is the transparent membrane small incision (see Figure 13. This approach is formed by the confluent walls of the caudal thoracic similar to the early laparotomy techniques of field air sac and the abdominal air sac. At four to six o’clock is the ventrolat- The patient is placed in true lateral recumbency with eral border of the proventriculus. The upper leg is ex- the left lobe of the liver may be seen at the seven to tended and held caudally. This one is com- appropriate hormonal stimulation, a hierarchy of posed of the walls of the confluent caudal thoracic air follicles develops and matures giving the ovary the sac and cranial thoracic air sacs. A this membrane would place the tip of the endoscope follicle enlarges as it matures; simultaneously, the in the cranial thoracic air sac. A large The abdominal air sacs of most birds are the largest ovum can be mistaken for a testicle, especially in an air sacs. They extend from the caudal surface of the obese bird where other structures are difficult to see lung to the craniolateral borders of the cloaca. Entry or where the surgeon fails to check related anatomic into the abdominal air sacs may be gained through reference points. In juvenile birds, gonadal tis- pubic approach to the caudal portion of the abdomi- sue is less obvious and differentiation is more diffi- nal air sac. It is possible to endoscopically identify the cor- pubic bone and caudal to the ischium (see Figure rect gender of most species of birds at a young age if 13. The endoscope generally first enters the most good optical equipment is used and a careful exami- caudal portion of the intestinal peritoneal cavity and nation of the gonads and associated structures is must be penetrated through this thin membrane to performed. The endoscope can then In one study of juvenile macaws,29 differentiation of be moved cranially up the length of the abdominal air sac. From the left approach a large number of struc- the sexes was uniformly possible as young as six tures may be examined including the kidney, adre- weeks of age when gonadal and oviductal or ductus nal, gonad and associated structures, spleen, proven- deferens morphology were considered together. The ticles were tubular to ellipsoidal with distinct, abdominal air sac may also be approached from a rounded cranial and caudal poles. The entry site is located directly ven- testicle could usually be seen through the dorsal tral to the acetabulum and just dorsal to the ventral mesentery (Color 13. Reproductive Organs The juvenile ovary was comma-shaped, dorsoven- In most avian species, only the left ovary and oviduct 14,16 trally flattened and closely applied to the adrenal develop. The surface texture of normally arrested in a testis-like stage and can fre- the ovary was dependent on the age of the bird. Very quently be visualized near the right adrenal gland, young ovaries had a faintly granular surface with along the caudal vena cava (Color 13. As the birds aged, the sulci reason, endoscopy to examine gonadal structures is deepened, giving the ovary a furrowed, brain-like performed through the left side of the abdomen. With the maturation of the The testicle of the adult male bird is ellipsoidal to primary oocytes, the ovary began to take on a dis- bean-shaped. In most species it is creamy white al- tinctly granular texture with a more three-dimen- though it may be more or less pigmented (gray to sional shape, and the sulci disappeared (Color 13. Under the seasonal influence of hor- substantial appearance than the vas deferens. The mones, the mass of the testicle may increase from 10 oviduct was generally two to four times the thickness up to 500 times. These epididymis enlarges, and the ductus deferens be- may have represented the developing spiral folds of comes very tortuous in preparation for storage and the mature oviductal mucosa. They are the only order with intrinsic lingual quired to confirm the presence of abnormalities re- muscles17 that allow a great variety of movement and lated to the remnant ovary or the right testicle such flexibility. During the non- Salivary glands are most prominent in species that breeding times of the year, the adult gonads return to eat primarily a dry diet (cereal grains) and may be a quiescent state similar to those of the late adoles- absent in those that eat a moist, lubricated diet cent bird. In the parrot, salivary glands are found along teens had very small testicles, yet went on to breed the roof and the floor of the mouth and on the tongue. A mature African Grey The oropharynx is lined with stratified squamous Parrot showed no evidence of follicular development epithelium and may be keratinized in areas of wear. It normally has a smooth, unblemished sur- During the endoscopic examination for gender deter- face except in areas where spike-like sensory papillae mination, the endoscopist is able to evaluate the air are present (Color 13. The mucosa should be sacs, liver, lung, spleen, kidney, adrenal gland, pro- examined for adherent exudate, debris or ulcers, as ventriculus, ventriculus and the visual portions of may be seen in certain protozoal (eg, Trichomonas the intestines. This information is not available using cytogenetic or molecular biologi- The choanal slit is visible as a median “V”-shaped cal techniques of gender determination. In The external auditory meatus is hidden by special- the parrot the borders are more widely spaced, form- ized covert feathers that lack barbules. The opening is usually rounded but can vary anal slit are lined with sensory papillae. Just caudal to and on the midline of the panum can usually be visualized clearly (Color choana is the small slit-like infundibular cleft.

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