Muzzy Level 2 Torrent
Avery Blaschko
His son, Willie, who coached with him at Valley and Greensburg Central Catholic and with the Pittsburgh Passion and the Renaissance Christian Academy in Penn Hills, wrote a Facebook post further detailing the decision, and hundreds of responses from many of his former players, students, coaches at different levels and others flooded in, taking the normally unemotional Colosimo on a roller-coaster ride.
HYANNIS, MA -- Korey Muzzy, a forward for the Total Athletics Seahawks, has committed to Northland College for the Fall of 2018. The '97 is in his first season in the EHL, and has an even seven goals and seven assists to his name this year.
"We are very excited for Korey and his family," said Seahawks head coach and general manager Bill Zaniboni. "Korey had a very productive summer and it has transferred to the ice. He is also a great person in the community and has won employee of the month on numerous occasions at his work place."
Muzzy brings a certain level of grit with him on every shift, and he has been a key part of a successful inaugural season for the Seahawks. The native of Arden Hills, MN took some time to reflect on his journey and thank all of those who helped him along the way.
"I am proud to announce my commitment to Northland College," said Muzzy. "I would first like to thank my family and friends for showing me all the support to get to the collegiate level. Next I would like to thank all my coaches throughout the years, helping me push to be a better person and player on and off the ice. Lastly I would like to thank the Total Athletics Seahawks, especially Coach Zaniboni for believing and giving me the opportunity to grow and play college hockey. Go Lumberjacks!"
Learn more about the Total Athletics Seahawks on the team's official website, and check out the full list of 2018 NCAA Commitments.
Taking a reputation for broadheads with bone-crushing capabilities, the Muzzy Trocar HB-Ti takes the potential for destruction to a whole new level thanks to a streamlined titanium ferrule, .050-inch-thick one-piece single-bevel serrated fixed blade edge and a pair of expandable .039-inch-thick expandable wing blades to maximize damage. This compact and aerodynamic 100-grain broadhead flies as true as a field point prior to expansion but unleashes total cutting surfaces of 2 5/8-inches for complete devastation upon impact.
One of the currently proposed therapeutic interventions to care for patients with PNALD is the use of a fish oil ILE (Omegaven, Fresenius Kabi, Graz, Austria) and a mixed oil ILE consisting of a mixture of soybean oil, medium-chain triglycerides, olive oil, and fish oil (SMOFlipid, Fresenius Kabi) instead of larger doses of the once-standard soybean oil ILE (Intralipid, Fresenius Kabi). These alternate fat emulsions provide less of the pro-inflammatory omega-6 fatty acids, which is a proposed mechanism of prevention of PNALD. Incidentally, they also contain a higher concentration of vitamin E. The Table provides the alpha-tocopherol concentrations in each lipid emulsion. Vitamin E is a generic term for different tocopherol and tocotrienol homologs. Alpha-tocopherol is one of the most abundant and active homologs, and it is what is tested to determine vitamin E levels in our facility. For these reasons, we only evaluated alpha-tocopherol concentrations in the different lipid emulsions.2
Another complication of prolonged PN use is abnormalities in serum micronutrient concentrations, including vitamin A, selenium, and vitamin E. Vitamin A is an essential micronutrient for the development and function of the respiratory, GI, and immune systems and eyes. Because of its limited transfer across the placenta and, subsequently, low hepatic stores at birth, preterm infants are prone to deficiency in vitamin A.3,4 Selenium is another essential micronutrient, given its role in metabolic functions, the immune system, thyroid hormone metabolism, cardiovascular disease, and more. Many factors may contribute to low levels detected in premature infants, including poor intestinal absorption secondary to immature chorionic villi, lower hepatic stores associated with a shorter gestation, or lower blood concentrations observed with PN or formula feeding versus breastfeeding.5 Vitamin A and selenium are both well-studied micronutrients in this population. Data on vitamin E, however, are not as available. There has been an association between VLBW infants (35 mg/L and an increased risk of sepsis and hemorrhage.4,6 The American Society for Parenteral and Enteral Nutrition (ASPEN) currently recommends monitoring micronutrient levels when pediatric patients require long-term PN for at least 3 months.7 The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN), on the other hand, does not recommend routine monitoring of vitamins A and E unless clinically indicated and recommends regular monitoring of selenium in long-term PN, but does not specifically define a time period.4,8
This case series presents 3 similar patients who were found to have vitamin A and selenium levels measuring below the normal range and above-normal vitamin E serum concentrations after 1 to 2 months of receiving PN and Omegaven as their primary nutrition source. These cases serve as examples that micronutrient monitoring may need to occur earlier. We also will highlight challenges we experienced bringing the micronutrient labs into normal therapeutic range.
On DOL 50, Omegaven was initiated at 1 g/kg/day infused over 12 hours with Intralipid at 0.5 g/kg/day 3 times a week because of her extensive GI history, elevated direct bilirubin of 6 mg/dL, and PNALD. The Intralipid was used to prevent essential fatty acid deficiency. On DOL 61, after administration of continuous PN for 2 months, micronutrient labs were drawn (Figure). Her vitamin A concentration was undetectable, indicating severe deficiency, and vitamin E (alpha-tocopherol) was indicative of hypervitaminosis. Additionally, her selenium level resulted low. Based on these results, it was decided to remove the pediatric multivitamin injection solution from her PN and initiate vitamin A supplementation at 5000 international units administered IM 3 times per week for a course of 4 weeks. Not long after these findings, the patient developed NEC. Because of the acute state of the patient secondary to NEC and the elevated levels of vitamin E, Omegaven and Intralipid were discontinued, and SMOFlipid was restarted at 2.5 g/kg/day. The selenium dose was increased to 3 mcg/kg/day from the standard 2 mcg/kg/day at this time. On DOL 99, the patient's vitamin A level remained below the World Health Organization goal; thus, another course of vitamin A supplementation was started at a dose of 10,000 units administered via a feeding tube 2 times per week. Almost 4 weeks later, the patient's vitamin A level finally returned at a normal level, at which point the supplementation was discontinued.
A former 28 2/7-week GA male was born via cesarean delivery with a birth weight of 625 g. He was transferred to our facility at DOL 13 for evaluation and management of NEC. A bowel resection with ostomy was performed the same day, resulting in 16 cm of viable small intestine and the colon. The patient was started on PN outside of our facility on Day 0, but the start date of lipids is unknown to us. On DOL 13, when the patient transferred to our facility, he was continued on PN and started on SMOFlipid at 3 g/kg/day. However, owing to his elevated direct bilirubin of 6.4 mg/dL and the likelihood of longer PN requirement, Omegaven 1 g/kg/day was initiated in addition to Intralipid 0.5 g/kg 3 times weekly on DOL 14. Enteral feeds were slowly introduced on DOL 30 with maternal milk. Because of the similarities between our patient from Case 1 and this patient, long-term micronutrient levels were checked after 1 month of PN (Figure). Vitamin A was below goal, and supplementation was provided at 5000 units administered IM 3 times per week for 4 weeks. Vitamin E was elevated; however, Omegaven was recommended to be continued at that time, with close monitoring of prothrombin time and international normalized ratio, which were previously slightly elevated. The repeat vitamin E levels resulted within normal limits (Figure). Following 4 weeks of vitamin A supplementation therapy, levels came back still below normal. Supplementation was resumed. The patient was able to tolerate minimal trophic feedings at this time; however, because of concerns for absorption, his vitamin A supplementation was administered IM at a dose of 7500 units 3 times per week. Rechecked levels remained low, and vitamin A supplementation was increased to 10,000 units IM 3 times per week from DOL 113 through 143. Levels at that time were at goal.
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