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PubMed2004

Options for patients with irritable bowel syndrome: contrasting traditional and novel serotonergic therapies.

This article reviews the efficacy and tolerability of traditional therapies for irritable bowel syndrome (IBS) and concludes that they are limited by both poor efficacy and adverse effects. Serotonin, a neurotransmitter found mainly in the gut, appears to represent a link in IBS pathophysiological processes -- altered gut motility, abnormal intestinal secretion and visceral hypersensitivity. Recently, available treatments for IBS have targeted serotonin receptors that are involved in motor, sensory and secretory functions of the gut. Serotonergic agents, such as alosetron (a 5-HT3 receptor antagonist) and tegaserod (a selective 5-HT4 receptor partial agonist), provide global relief of the multiple symptoms of IBS with diarrhoea and IBS with constipation, respectively, and represent important additions to the IBS treatment armamentarium.

Animals↗
PubMed1996

Mechanism and treatment of diarrhoea due to Vibrio cholerae and Escherichia coli: roles of drugs and prostaglandins.

The primary objectives of these studies were to determine the clinical efficacy and safety of the potential antisecretory and antimicrobial drugs in the treatment of diarrhoea due to Vibrio cholerae and enterotoxigenic Escherichia coli (ETEC). The drugs evaluated were chlorpromazine (CPZ), nicotinic acid, berberine, indomethacin, chloroquine, tetracycline, furazolidone, and bioflorin. Additionally, the role of prostaglandins (PGs) in the pathogenesis of cholera diarrhoea has been studied. The drug studies were carried out as placebo-controlled, randomized clinical trials in patients with active diarrhoea due to vibrio cholerae and ETEC. All patients received intravenous (i.v.) or oral rehydration solutions (ORS), but no other medications except the study drugs. Results indicate that CPZ (1 mg/kg or 4 mg/kg), berberine (200 mg), and nicotinic acid (2 g) all reduced stool volumes from 30% to more than 50% in diarrhoeal patients without significant side effects. It appeared that berberine was more effective in ETEC diarrhoea than in cholera. However, chloroquine, indomethacin, clonidine, and bioflorin had no clinically useful effects. Among the antimicrobial agents, a single dose of tetracycline was found to be effective in cholera, because the drug significantly (p < 0.05) reduced the total stool volume from 20.9 +/- 15.9 to 10.5 +/- 8.6 (liters in 6-days, mean +/- SD) compared to furazolidone. Drugs other than antimicrobial and antisecretory agents were also evaluated in the treatment of cholera. It has been shown that treatment with bioflorin, which is a bacterial preparation of lyophilized Streptococcus faecium, did not significantly (p > 0.05) reduce fluid-loss in cholera. Additional studies in animals indicated that treatment with short chain glucose polymers, alone or in combination with a chloride blocking agent, anthracene-9-carboxylic acid (A9C), significantly reduced intestinal secretion in a rat model of secretory diarrhoea. For the first time it was demonstrated that jejunal prostaglandin (PG) E2 concentrations were significantly increased during acute cholera and correlated with the volumes of stool and duration of diarrhoea. Furthermore, it was shown that treatment with indomethacin, a potent inhibitor of PG synthesis, significantly reduced jejunal PGE2 output in adults with acute cholera, in addition to net secretion of water and electrolytes. In summarizing the results, it is concluded that: (1) CPZ, berberine, and nicotinic acid are potential antidiarrhoeal agents, (2) PGs are involved in the pathogenesis of cholera, (3) tetracycline and furazolidone are effective antimicrobial agents in cholera, (4) and glucose short-chain polymers (used with the chloride blocking agent, anthracene-9-carboxylic acid) are better sources of carbohydrates in oral rehydration solutions.

Animals↗
PubMed2001

[Comparative effects of oral rehydratation solutions in experimental cholera in the rat].

UNLABELLED: The composition of the World Health Organisation (WHO) solution in oral rehydration therapy has remained controversial because of its total osmolarity (303 mosm/L) and higher sodium concentration (90 mEq/L), increasing the risk of hypernatraemia. AIM OF THE STUDY: To compare the efficacy of two reduced-osmolarity oral rehydration solutions (S1: 268 mosm/L and 50 mEq/L Na(+); S2: 240 mosm/L and 60 mEq/L Na(+) ) with the WHO recommended formula taken as the reference solution. Water, electrolytes and glucose fluxes were directly measured in vivo, in isolated ligated loops of rat jejunum (n=12). Intestinal secretion was induced by exposing jejunum to cholera toxin (CT=20 microg/loop). RESULTS: All three test solutions similarly reversed cholera toxin-induced net water absorption (3.37 +/- 1.35; 3.31 +/- 0.43 and 3.13 +/- 0.66 microL/min.cm(2) for S1, S2 and WHO solutions respectively). However, net Na secretion induced by cholera toxin was observed with S1 and S2 while Na absorption occurred with the WHO solution. CONCLUSION: For a same amount of water absorbed, Na absorption from reduced - osmolarity rehydration solutions is lower than with the WHO solution. Our data may contribute to a better rationale for the use of orally administered hydration solutions in man.

Animals↗
PubMed1988

[Endotoxinemia and bacteremia in manual oral decompression of ileus].

In the framework of the present clinical prospective study using a randomly selected patient collective, the question was pursued whether manual oral decompression (MOD), done in connection with surgical intervention in severely ill patients with ileus of the large and small intestine, leads to detectable bacteremia or higher concentrations of endotoxin in serum. From October, 1985 to March, 1987, bacteriological tests were conducted and the endotoxin concentrations in serum were measured in a total of 31 patients. 71% of the patients were female and 29% were male, aged 18-89. The endotoxin measurement was conducted with the aid of the limulus-amoebocyte-lysate (LAL) test, modified according to Piotrowicz. Additionally, bacteriological tests were done of the operation sites and the decompressed gastro-intestinal secretions. Simultaneously, cultures from the central blood stream were prepared. The tests showed that bacteremia and endotoxinemia occur in connection with manual oral decompression (MOD). Neither of the two, however, has any clinically relevant influence on the further post-operative course. Thus, manual oral decompression continues to represent an indispensable maneuver in the surgical management of an ileus.

Adolescent↗
PubMed2000

Uroguanylin treatment suppresses polyp formation in the Apc(Min/+) mouse and induces apoptosis in human colon adenocarcinoma cells via cyclic GMP.

The enteric peptides, guanylin and uroguanylin, are local regulators of intestinal secretion by activation of receptor-guanylate cyclase (R-GC) signaling molecules that produce cyclic GMP (cGMP) and stimulate the cystic fibrosis transmembrane conductance regulator-dependent secretion of Cl- and HCO3-. Our experiments demonstrate that mRNA transcripts for guanylin and uroguanylin are markedly reduced in colon polyps and adenocarcinomas. In contrast, a specific uroguanylin-R-GC, R-GCC, is expressed in polyps and adenocarcinomas at levels comparable with normal colon mucosa. Activation of R-GCC by uroguanylin in vitro inhibits the proliferation of T84 colon cells and elicits profound apoptosis in human colon cancer cells, T84. Therefore, down-regulation of gene expression and loss of the peptides may interfere with renewal and/or removal of the epithelial cells resulting in the formation of polyps, which can progress to malignant cancers of the colon and rectum. Oral replacement therapy with human uroguanylin was used to evaluate its effects on the formation of intestinal polyps in the Min/+ mouse model for colorectal cancer. Uroguanylin significantly reduces the number of polyps found in the intestine of Min/+ mice by approximately 50% of control. Our findings suggest that uroguanylin and guanylin regulate the turnover of epithelial cells within the intestinal mucosa via activation of a cGMP signaling mechanism that elicits apoptosis of target enterocytes. The intestinal R-GC signaling molecules for guanylin regulatory peptides are promising targets for prevention and/or therapeutic treatment of intestinal polyps and cancers by oral administration of human uroguanylin.

Adenocarcinoma↗
PubMed1981

Are oral cathartics of value in optimizing the gallium scan? Concise communication.

The normal intestinal secretion of 9-15% of an administered dose of gallium-67 may prevent early detection of intra-abdominal disease. We randomized 50 patients to receive either no bowel preparation or 30 cc of milk of magnesia plus 5 cc of cascara. No significant difference was found between the two groups in frequency with which gallium interfered with readings or time to complete the study.

Abdomen↗
PubMed1989

The effect of opiates on the intestinal immune response to cholera toxin in mice.

We studied the effect of opiates on the intestinal immunoglobulin A response in mice. C57BL mice were orally immunized by two doses of 10 micrograms of cholera toxin, 2 weeks apart. Experimental groups received subcutaneous injections of morphine, either 10 or 20 mg/kg/day, in two divided doses. Morphine was given for 4 days, starting 1 day prior to each cholera toxin dose. Intestinal secretions were collected by lavage 1 week after the last cholera toxin dose, and assayed for specific anticholera toxin antibody and total immunoglobulin A. Results were expressed as units of anticholera toxin per nanogram immunoglobulin A. It was found that morphine, 20 mg/kg/day, reduced the response from 30.9 +/- 3.11 to 9.78 +2- 1.42 units/ng (M +/- SEM; p less than 0.0001). 10 mg/kg/day of morphine slightly reduced the immune response to 21.38 +/- 3.51 units/ng (M +/- SEM), but failed to achieve statistical significance. Naloxone administration prior to morphine injections abolished the inhibitory effects of morphine. Morphine administration had no effect on the response to a booster dose of cholera toxin 3 months after the initial cholera toxin immunization and morphine administration. It is concluded that morphine has a significant inhibitory effect on the intestinal immune response, but does not effect long-term mucosal immunological memory. The effect is probably mediated by a specific opiate receptor, as it is blocked by naloxone. This effect may have clinical implications.

Animals↗
PubMed1987

Intestinal permeation of nonquaternary amines: a study with telenzepine and pirenzepine in the isolated mucosa of guinea pig jejunum and colon.

Previous studies which demonstrated an intestinal secretion of quaternary ammonium compounds in the jejunum were extended to nonquaternary amines. Telenzepine and pirenzepine, two structurally similar compounds differing in lipid solubility, were administered either to the lumen or blood side of isolated mucosae of guinea pig jejunum and colon mounted in a flux chamber. Transepithelial permeation of both drugs from blood to lumen side was 3.2 to 18 times higher than in the reverse, absorptive direction. The indicated net secretion was highest with telenzepine in the colon. At 7 degrees C transepithelial permeation was restricted to paracellular shunt fluxes. In the colon, the highest cellular concentrations were observed after blood side administration of telenzepine and pirenzepine (500 and 150% of that of the incubation solution). At 7 degrees C these values were reduced to 1 of 5 and 1 of 8 of the values at 37 degrees C. At pH 6.6, 7.4 or 8.2, no differences in the colonic secretion of telenzepine were seen; cellular concentration increased with increasing pH only after luminal administration. Under all conditions, the colon acidified the luminal solution by roughly 0.4 pH units. Phenoxybenzamine, shown previously to inhibit the jejunal secretion of quaternary ammonium compounds, inhibited the secretion of pirenzepine and telenzepine in both gut segments, but did not affect blood-to-lumen permeation of N-methylscopolamine in the colon. In addition, phenoxybenzamine reduced the cellular content in the colon but had little or no effect on pirenzepine or telenzepine content in the jejunum. The results are consistent with a model in which the nonquaternary amines are secreted in the jejunum by two serial transport steps specific for the base cations; an additional diffusion of the free bases is of importance in the basolateral membrane. In the colon, carrier-mediated influx increases with lipophilicity of the base cations, whereas efflux across the brush border is limited to diffusion of the free bases; concomitant luminal acidification and formation of base cations maintains the diffusion gradient.

Animals↗
PubMed1999

Characterization of binding properties to human P-glycoprotein: development of a [3H]verapamil radioligand-binding assay.

Interaction with the exsorptive transporter P-glycoprotein (P-gp) is a possible source of peculiarities in drug pharmacokinetics, including dose-dependent absorption, drug-drug interactions, intestinal secretion, and limited permeability of the blood-brain barrier. Among the established in vitro methods of the analysis of drug interactions with P-gp, none directly quantifies the affinity of ligands with P-gp. Instead, they measure the result of a membrane permeation and a receptor-binding process; this may lead to difficulties in the interpretation of results. An assay for quantification of drug affinity to the transporter is presented on the basis of the radioligand-binding assay principle. This has the advantage of directly quantifying the interaction between drugs and P-gp. Because of the reversible and competitive interaction of numerous substrates with P-gp, a radioligand-binding assay was developed by taking [3H]verapamil and [3H]vinblastine as radioligands and the human intestinal Caco-2 cells, overexpressed with P-gp by culturing in the presence of vinblastine or transfecting with multidrug resistance gene MDR-1 as receptor preparation. The assay was performed in 96-well plates and has the potential to be used as a high-throughput method. A clear induction of the expression of P-gp was demonstrated in the Caco-2 cells grown in the presence of vinblastine, as well as in the transfected cells, although to a lesser extent. Both radioligands were shown to bind to P-gp. Verapamil was the radioligand of choice for further investigations due to its lower nonspecific binding to the transporter preparation. Kinetics as well as specificity of the binding of verapamil to the P-gp preparation were demonstrated. A two-affinity model was found to adequately describe the data derived from saturation as well as from competition experiments, in accordance with previous findings on two exsorption sites for P-gp. The binding properties of [3H]verapamil and [3H]vinblastine to a P-gp preparation derived from induced Caco-2 cells are described. The concentration-dependent displacement of the radioligand by nonlabeled substrates for P-gp should be a suitable principle for the determination of drug affinity to the respective binding sites at the human intestinal multidrug transporter P-gp.

ATP Binding Cassette Transporter, Subfamily B, Mem↗
PubMed2003

Octreotide for enterocutaneous fistulas of Crohn's disease.

UNLABELLED: Crohn's disease is a chronic, life-long disease and has many troublesome complications. Fistulas are a part of Crohn's disease, and although there are many therapeutic modalities used in treating these fistulas they are only partially successful. As we are still very far from being able to cure it, the aim is to improve the patients' quality of life and to reduce the iatrogenic harm that may be caused by various treatment modalities. Somatostatin is an inhibitor of intestinal secretion and has been used to treat pancreatic and surgical fistulas. Therefore, we decided to treat enterocutaneous fistulas using somatostatin. METHODS: Five patients with Crohn's disease were treated with four daily injections of 300 microg octreotide. The total period of treatment was eight weeks. RESULTS: Closure of fistulas was achieved in four of the five patients. CONCLUSION: Somatostatin may have a role in treating Crohn's disease enterocutaneous fistulas and may prevent surgery or prolonged immunosuppressive therapy.

Adolescent↗
PubMed1996

Immunological and trophical effects of Saccharomyces boulardii on the small intestine in healthy human volunteers.

Saccharomyces boulardii (S.b.) is used for the prevention and treatment of diarrhea of different etiologies. We prospectively investigated the effects of S.b. on lymphocytes and duodenal mucosa. Before and after oral administration of S.b. for 3 weeks, circulating and intestinal lymphocytes were isolated and characterized by flow cytometry. Trophic effects on duodenal mucosa were investigated by morphometry and determination of brush border enzyme activity. Results were compared intraindividually before and after S.b. In intestinal lymphocytes no phenotypic changes were observed. CD4+ cells of the peripheral blood had a significantly increased expression of CD25 (p < 0.02). None of twelve volunteers had an increase in villous surface area (n.s.). Immunoglobulin A content in small intestine secretion was unaltered. An increase in brush border enzyme activity of lactase, alpha-glucosidase, and alkaline phosphatase was observed (p < 0.01). Our findings indicate that S.b. has a positive effect on the maturation of enterocytes and only a minor influence on lymphocytes.

Administration, Oral↗
PubMed1994

Effects of interleukin 12 on immune responses and host protection in mice infected with intestinal nematode parasites.

The cytokine interleukin (IL) 12 stimulates T cell and natural killer cell production of interferon (IFN) gamma and inhibits T cell production of IL-4. We investigated the effects of IL-12 on cytokine gene expression, immunoglobulin (Ig)E, mucosal mast cell, and eosinophil responses, and the course of infection in mice inoculated with the nematode parasite Nippostrongylus brasiliensis, as well as the IFN-gamma dependence of these effects. IL-12 stimulated IFN-gamma and IL-10 gene expression during primary and secondary N. brasiliensis infections and inhibited IL-3, IL-4, IL-5, and IL-9 gene expression during primary infections but had little inhibitory effect during secondary infections. IL-12 inhibited IgE, mucosal mast cell, and blood and tissue eosinophil responses during primary infections, but only eosinophil responses during secondary infections. IL-12 enhanced adult worm survival and egg production during primary, but not secondary infections. IL-12 needed to be administered by day 4 of a primary infection to inhibit IgE and mucosal mast cell responses, and by day 6 to strongly inhibit eosinophil responses and to enhance worm survival and fecundity. Anti-IFN-gamma mAb inhibited the effects of IL-12 on IgE secretion, intestinal mucosal mastocytosis, and parasite survival and fecundity, but did not affect IL-12 inhibition of eosinophilia. These observations indicate that IL-12, if administered during the initiation of eosinophilia. These observations indicate that IL-12, if administered during the initiation of an immune response, can change the response from one that is characterized by the production of T helper (Th)2-associated cytokines to one characterized by the production of Th-1 associated cytokines. However, IL-12 treatment has less of an effect once the production of Th2-associated cytokines has become established. In addition, our results provide evidence that Th2-associated responses protect against, and/or Th1-associated responses exacerbate, nematode infections.

Animals↗
PubMed1992

[Measures for the acceleration of toxin excretion via liver, bile and intestines].

It is possible to enhance elimination of already absorbed xenobiotics through the gastrointestinal tract by influencing distribution, by specifically inducing metabolism, by interrupting the enterohepatic circulation, and by increasing intestinal secretion, respectively. Case reports of clinical experiences, however, are not sufficient support for a rational and comprehensive concept of secondary decontamination (i.e. all measures to enhance elimination of substances that have been absorbed). This is especially true during and after either subacute or chronic exposure to harmful xenobiotics. Further scientific work in the laboratory is needed to provide the necessary background for controlled clinical studies. Highly lipophilic compounds with a long terminal half-life, as for example amiodarone or persistent environmental pollutants, will challenge such a concept.

Bile↗
PubMed1987

Cardiovascular effects of vasoactive intestinal peptide in healthy subjects.

Hypotension and flushing are occasionally observed in patients with pancreatic cholera syndrome. Similar effects are produced when vasoactive intestinal polypeptide (VIP) is administered to healthy subjects. To characterize further these responses, serial measurements of heart rate, blood pressure, cardiac output and forearm blood flow were made in 6 healthy subjects during constant VIP infusion (400 pmol/kg/hr for 100 minutes). VIP infusion caused sustained vasodilatation and decreased total peripheral resistance and mean arterial pressure by 30 and 12%, respectively. Forearm resistance decreased by 65%. The effects on cardiac output and stroke volume were biphasic. During the early phase of VIP infusion (0 to 70 minutes), heart rate and cardiac output increased with only minor changes in stroke volume. Later (71 to 100 minutes) the tachycardia persisted, but cardiac output decreased toward control levels due to decreased stroke volume. Echocardiograms during the infusion demonstrated increased left ventricular contractility as defined by the relation between end-systolic wall stress and shortening fraction. These data document potent vasodilatory and inotropic actions of VIP. It is likely that intravascular volume losses from increased intestinal secretion account for the decreased stroke volume seen late in the VIP infusion period and immediately thereafter. The tachycardia appears to be an appropriate compensatory mechanism to maintain blood pressure in the presence of vasodilatation and loss of intervascular volume. These observations provide an explanation for the cardiovascular findings in patients with sudden release of VIP from tumors.

Adult↗
PubMed1994

Mucosal immune responses in calves orally vaccinated with a live auxotrophic aroA Salmonella dublin strain.

The mucosal immune responses were studied in two calves orally vaccinated with the live aroA mutant strain, Salmonella dublin SL5631, and in two non-vaccinated control calves. Intestinal secretions were collected through a permanent fistula in place during a 5-week period. Vaccinated calves responded with high IgM and IgA titres against the S. dublin lipopolysaccharide. Both IgA and the IgM titres appeared already after 3 days and IgM somewhat earlier than the IgA titres. Both antibody titres remained high for 2 weeks after the third and final vaccine dose. The calves also showed marked T-cell responses in lymphocytes collected from mesenterial lymph nodes and the spleen.

Animals↗
PubMed1985

Lipid transport systems: some recent aspects in swine, cattle and trout during development.

Lipids such as triacylglycerols, free and esterified cholesterol and phospholipids are essentially insoluble in water; lipoproteins, which are complex macromolecules of pseudomicellar structure, have evolved to ensure their efficient transport in the vascular system of vertebrates. Plasma lipoproteins are operationally classified according to their relative lipid and protein contents and thus according to density. The protein components, i.e. apolipoproteins, have a highly specialized structure contributing to particle stability and metabolism. The chemistry and structure of plasma lipoproteins and apoproteins is discussed and their biosynthesis, intravascular metabolism and cellular degradation briefly considered. Circulating concentrations of lipoproteins are under complex control, involving hormonal, nutritional and genetic factors; changes occurring in lipoprotein levels in pigs (Sus domesticus), cattle (Bos sp.) and rainbow trout (Salmo gairdnerii) during development are discussed. In pigs and calves, LDL predominate at the fetal stage and VLDL are absent. During suckling, this pattern is rapidly modified with HDL becoming the major class and low levels of VLDL appearing. These changes in part reflect high levels of exogenous triglyceride lipolysis consequent to the ingestion of fat-rich, maternal milk. With further growth, HDL predominate in both adult pigs and steers, although the LDL:HDL ratio is considerably lower in the latter (0.5-0.8 and approximately 0.2, respectively). Our studies in pigs suggest that the intestinal secretion of lipoproteins commences rapidly after birth since proteins akin to human apo-B48 and apo-B100 are detectable in plasma VLDL some 2-3 h after parturition. Although the trout is an oviparous vertebrate, LDL is also preponderate at the juvenile stage. With sexual maturity, LDL and VLDL levels diminish progressively, plasma HDL attaining concentrations as high as 1,500 mg/dl in adults. Our knowledge of the biochemical mechanisms at the origin of these developmental changes in lipid transport in both mammals and fish remains largely incomplete.

Animals↗
PubMed2000

P-glycoprotein inhibitor erythromycin increases oral bioavailability of talinolol in humans.

OBJECTIVE: Increased bioavailability of the P-glycoprotein (Pgp) substrates digoxin and cyclosporin due to erythromycin has been observed in vivo. The aim of the present study was to investigate the effect of orally administered erythromycin on the oral bioavailability of the beta-blocker talinolol. Talinolol is a suitable model compound for Pgp drug-drug interaction studies due to its Pgp-related active intestinal secretion and lack of any significant metabolism. METHODS: In a randomized crossover study, the oral pharmacokinetics of talinolol (50 mg) after a concomitant single oral dose of erythromycin (2 g) or placebo were investigated in 9 healthy men. Concentrations of talinolol were measured in serum and urine by HPLC. RESULTS: The area under the curve of talinolol serum concentrations from 0 to 24 h (AUC(0-24)) and the maximum serum concentrations (Cmax) were significantly increased after administration of erythromycin compared to placebo. t(max) values were significantly reduced. The renal clearance (CLR) of talinolol was unchanged after co-administration of erythromycin and there was a small but statistically significant decrease in elimination half-life (t1/2). Serum pharmacokinetics correlate with the results derived from urine concentration measurement. One subject suffered from moderate diarrhea after erythromycin and was excluded from the analysis. CONCLUSION: We suggest that the increase in oral bioavailability of talinolol after concomitant erythromycin is caused by increased intestinal net absorption due to Pgp inhibition by erythromycin.

Administration, Oral↗
PubMed1983

Effect of parenteral immunization on the local immunoglobulin A response of the intestine to Shigella flexneri antigens.

Most traditional methods of immunization involve parenteral vaccines. Using a chronically isolated ileal loop model as the probe, we examined the effect of a primary parenteral immunization on the local immune response of the intestine. Secretions from isolated ileal loops of rabbits given a primary parenteral immunization with Shigella flexneri without adjuvant showed a small, but definite, specific immunoglobulin A (IgA) response locally, whereas a vigorous serum antigen-specific IgG response was elicited. Also, stronger antigen-specific IgG activity was detected in secretions of parenterally immunized animals than from animals given shigella only by oral immunization. No local IgA or IgG memory response could be elicited by prior parenteral priming with S. flexneri antigens. Lastly, no increase in the primary local IgA response was found in secretions from animals given an oral dosage regimen previously shown to prime for mucosal memory and then challenged with a single parenteral dose of the same antigen. These studies demonstrate that without adjuvant, parenteral doses of S. flexneri antigens elicit both specific serum and local immune responses, but they are not able to prime for a mucosal memory response upon subsequent mucosal challenge. The implications of these findings for programs that use parenteral vaccination to protect against mucosal diseases are discussed.

Animals↗