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Lísa actos 15 mg mastercard diabetic edema, Recent developments in liquid chromatography–mass spectrometry and related techniques buy actos 15mg diabetes type 1 headaches, J buy discount actos 15mg on line blood glucose exercise. Eiceman cheap actos 45mg what causes diabetes type 2 yahoo, Ion mobility spectrometry: Arriving on site and moving beyond low profile, Appl. Vogt, A review of recent advances in mass spectrometric methods for gas- phase chiral analysis of pharmaceutical and biological compounds, J. Cooper, Separation of Peptide Isomers with Variant Modified Sites by High-Resolution Differential Ion Mobility Spectrometry, Anal. Li, Analysis of antibiotics from liquid sample using electrospray ionization-ion mobility spectrometry, Anal. Zarei, Determination of veterinary drug residues in chicken meat using corona discharge ion mobility spectrometry, Anal. Creaser, Enhanced Analyte Detection Using In- Source Fragmentation of Field Asymmetric Waveform Ion Mobility Spectrometry-Selected Ions in Combination with Time-of-Flight Mass Spectrometry, Anal. Reimann, Terbutaline Enantiomer Separation and Quantification by Complexation and Field Asymmetric Ion Mobility Spectrometry−Tandem Mass Spectrometry, Anal. Claereboudt, Product ion mobility as a promising tool for assignment of positional isomers of drug metabolites, Rapid Commun. Mester, Separation and Quantitation of the Stereoisomers of Ephedra Alkaloids in Natural Health Products Using Flow Injection-Electrospray Ionization-High Field Asymmetric Waveform Ion Mobility Spectrometry-Mass Spectrometry, Analytical Chemistry 75 (2003) 2538-2542. Kim, Structural Characterization of Drug-like Compounds by Ion Mobility Mass Spectrometry: Comparison of Theoretical and Experimentally Derived Nitrogen Collision Cross Sections, Anal. McLean, Chiral and structural analysis of biomolecules using mass spectrometry and ion mobility-mass spectrometry, Chirality 21 (2009) E253-E264. Reimann, Enantiomer Separation of Amino Acids by Complexation with Chiral Reference Compounds and High-Field Asymmetric Waveform Ion Mobility Spectrometry: Preliminary Results and Possible Limitations, Anal. Stoll, Selective comprehensive multi- dimensional separation for resolution enhancement in high performance liquid chromatography. Mondello, Mass spectrometry detection in comprehensive liquid chromatography: Basic concepts, instrumental aspects, applications and trends, Mass Spectrom. Sandra, Comprehensive two- dimensional liquid chromatography applying two parallel columns in the second dimension, J. Barbas, Ultra rapid liquid chromatography as second dimension in a comprehensive two-dimensional method for the screening of pharmaceutical samples in stability and stress studies, J. Holčapek, Lipidomic profiling of biological tissues using off-line two- dimensional high-performance liquid chromatography–mass spectrometry, J. Weigel, Quantitative trace analysis of a broad range of antiviral drugs in poultry muscle using column-switch liquid chromatography coupled to tandem mass spectrometry, Anal. Carr, Fast, comprehensive online two-dimensional high performance liquid chromatography through the use of high temperature ultra-fast gradient elution reversed-phase liquid chromatography, J. Nakashima, Comprehensive Two-Dimensional Liquid Chromatography of nd Triglycerides, in: A. Mondello, Comprehensive Two-Dimensional Normal-Phase (Adsorption)−Reversed-Phase Liquid Chromatography, Anal. Vander Heyden, Supercritical fluid chromatography for the enantioseparation of pharmaceuticals, J. Berger, Separation of polar solutes by packed column supercritical fluid chromatography, J. Smith, Supercritical fluids in separation science – the dreams, the reality and the future, J. Lesellier, Overview of the retention in subcritical fluid chromatography with varied polarity stationary phases, J. Vander Heyden, Chiral separations in sub- and supercritical fluid chromatography, J. Lynen, Design and evaluation of various methods for the construction of kinetic performance limit plots for supercritical fluid chromatography, J. Wise, Comparison of liquid and supercritical fluid chromatography using naphthylethylcarbamoylated-β-cyclodextrin chiral stationary phases, J. McManigill, Supercritical fluid chromatography with small particle diameter packed columns, Anal. Guillarme, Comparison of ultra-high performance supercritical fluid chromatography and ultra-high performance liquid chromatography for the analysis of pharmaceutical compounds, J. Clifford, Imprinted polymers for chiral resolution of (±)-ephedrine, 4: Packed column supercritical fluid chromatography using molecularly imprinted chiral stationary phases, J. Jiménez, Separation of albendazole sulfoxide enantiomers by chiral supercritical-fluid chromatography, J. Jiménez, Enantiomeric separation of chiral sulfoxides by supercritical fluid chromatography, J. Nieto, Use of semipreparative supercritical fluid chromatography to obtain small quantities of the albendazole sulfoxide enantiomers, J. Eichhold, Comparison of Packed- Column Supercritical Fluid Chromatography−Tandem Mass Spectrometry with Liquid Chromatography−Tandem Mass Spectrometry for Bioanalytical Determination of (R)- and (S)-Ketoprofen in Human Plasma Following Automated 96-Well Solid-Phase Extraction, Anal. Johannsen, Separation of enantiomers of ibuprofen on chiral stationary phases by packed column supercritical fluid chromatography, J. Armstrong, Super/Subcritical Fluid Chromatography Separations with Four Synthetic Polymeric Chiral Stationary Phases, Chromatographia 65 (2007) 381-400. Hamdan, Supercritical fluid chromatography coupled to electrospray mass spectrometry: a powerful tool for the analysis of chiral mixtures, J. Kassel, Two-dimensional supercritical fluid chromatography/mass spectrometry for the enantiomeric analysis and purification of pharmaceutical samples, J. Pikkemaat, Microbial screening methods for detection of antibiotic residues in slaughter animals, Anal. Vreeken, Fragmentation trees for the structural characterisation of metabolites, Rap. Ashcroft, Considerations in experimental and theoretical collision cross-section measurements of small molecules using travelling wave ion mobility spectrometry-mass spectrometry, Int. Jayarai, Impact of antibiotic use in adult dairy cows on antimicrobial resistance of veterinary and human pathogens: a comprehensive review, Foodborne Pathog. Morlock, Determination of drugs and drug-like compounds in different samples with direct analysis in real time mass spectrometry, Mass Spectrom. Yogo, Rapid and Simple Analysis of Pesticides Persisting on Green Pepper Surfaces Swabbing with Solvent-Moistened Cotton, J. Marco, A label- free and portable multichannel surface plasmon resonance immunosensor for on site analysis of antibiotics in milk samples, Biosensors and Bioelectronics 26 (2010) 1231-1238. Marco, Portable Surface Plasmon Resonance Immunosensor for the Detection of Fluoroquinolone Antibiotic Residues in Milk, J. Norde, Label-Free and Multiplex Detection of Antibiotic Residues in Milk Using Imaging Surface Plasmon Resonance-Based Immunosensor, Anal. Delahaut, Development of an optical surface plasmon resonance biosensor assay for (fluoro)quinolones in egg, fish, and poultry meat, Anal. Higson, Label-free immunochemistry approach to detect and identity antibiotics in milk, Pedriatr. Homola, Surface Plasmon Resonance Sensors for Detection of Chemical and Biological Species, Chemical Rev. 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Antibiotics are used to treat bacterially infected animals but are also administered as a preventive measure cheap 15mg actos with visa diabetes medications supplement. From an animal and human health perspective discount 45mg actos amex diabetes medications hypoglycemia, responsible use of antibiotics is of importance buy actos 15mg lowest price diabetes type 1 zelftest. In residue analysis of antibiotics in products of animal origin actos 15 mg online diabetes symptoms type 2 treatment, quantitative and qualitative aspects are involved in declaring a sample non-compliant (positive). The quantitative aspect regards the determination of the amount of the compound present in the sample. The qualitative aspect regards the confirmation of the identity of the compound present. In this, selectivity is the main parameter of importance which is defined as the ability of a method to distinguish the analyte being measured from other substances. In chapter 1, the background on antibiotics usage in animal breeding and the legal framework of antibiotic analysis are discussed. To be able to simultaneously analyse compounds having different physical and chemical properties, generic sample preparation procedures are applied. These multi-analyte methods - sometimes including over 150 different compounds – are of much interest for analytical laboratories due to the reduction of costs. A clear drawback of generic sample preparation procedures is the occurrence of abundant matrix effects which compromise detection limits, quantitative aspects, maintenance frequency and method selectivity. Validation procedures are available to determine the uncertainty of the quantitative result, which is taken into account in the decision making process. Procedures to determine the uncertainty of the qualitative aspect of a method of analysis are lacking and, as a result, whether or not a method is adequately selective is a matter of experts’ judgment. A measure for the (un)certainty of the selectivity is the probability of any compound showing the same precursor ion, product ions and retention time as the compound of interest. In the developed procedure this is calculated based upon empirical models constructed from three large compound databases. Based upon the final probability estimation, additional measures to assure unambiguous identification can be taken, like the selection of different or additional product ions. To demonstrate the importance of selectivity, in this thesis two analytical challenges are presented in which selectivity plays an important role. One in which selectivity is extreme to be able to discriminate between a banned antibiotic and its antimicrobially inactive isomers. Second a method in which selectivity is deliberately compromised to obtain an effective monitoring strategy in which not only the parent drugs are detected, but also their protein bound metabolites. The separation of the isomers on the analytical column, the selectivity of the monitored product ions and the clean-up of urine turned out to be critical parameters. To obtain reproducible retention times, isocratic elution on a chiral α-acid glycoprotein column was applied. For urine samples, matrix compounds present in the final extract caused decreased retention of the isomers on the chiral stationary phase and a lack of chromatographic resolution. Therefore an extensive clean-up procedure that combines solid phase extraction and liquid- liquid extraction had to be developed. Especially penicillins are frequently applied in animal breeding and human medicine. Also resistance against cephalosporins and even carbapenems has been reported, which is a major threat to human health. The main challenges in ß-lactam analysis are (1) the instability of some of the analytes and (2) the fast metabolism ceftiofur and cefapirin and the protein binding of ceftiofur residues. A slight instability of cefapirin and desfuroylceftiofur was observed at elevated temperatures. Ceftiofur and cefapirin degraded immediately and completely in an alkaline environment, resulting in antimicrobially inactive degradation products. Ceftiofur and cefapirin also degraded immediately and completely in kidney extract resulting in both formerly reported metabolites as well as not previously reported products. It is shown that conditions often occurring during the analysis of ceftiofur or cefapirin can result in rapid degradation of both compounds. From this, on a theoretical basis, it is concluded that underestimation of the determined amounts of ceftiofur and cefapirin is likely to occur when using conventional methods for the quantitative analysis of these compounds in tissue, and that a new approach is needed that takes the metabolism and degradation into account. To effectively detect off-label ceftiofur usage an analytical method is needed that, besides the native compound, also detects its active metabolites. It was found that approach A is not suited for quantitative analysis of total ceftiofur concentration nor for effectively detecting off-label use of ceftiofur. Approach B resulted in adequate quantitative results, but is considered to be a single compound method. Approach C showed adequate quantitative results as well, but in contrast to approach B, this approach is applicable to a range of cephalosporin antibiotics and therefore applicable as a broad quantitative analysis method for cephalosporin compounds in poultry tissue samples. It was shown that this method is suitable for the quantitative analysis of 21 out of 22 compounds included and that it is effective for the detection of off-label ceftiofur use, because protein bound metabolites are included. A study comparable to the work described in chapter 3 is needed to assess the selectivity of that technique. Other methods have become available to further enhance the selectivity of a method. Research is needed to determine optimal and compatible conditions for both dimensions and to effectively couple the two chromatographic systems. Due to the fast diffusion rate and the limited back pressure, fast separation at high resolution can be obtained. The national monitoring plan will become more risk based and therefore, a more generic and flexible approach is needed. The most efficient would be to use generic screening methods that include a broad range of compounds in combination with highly selective confirmatory methods. Also, due to the increasing bacterial resistance, the focus of regulatory control will be more on antibiotic usage in general next to the control of food products itself. In this, detection limits should be as low as reasonably possible and the use of other matrices should be investigated, e. Based on the outcome of these studies, the banned status of the drug should be reconsidered. Based on the findings in this thesis we can now answer the question: “What selectivity is adequate? Usually there is a trade-off between selectivity and the number of compounds that can be included in a method. For a screening method a low selectivity is acceptable (as long as the number of false positives remains limited), whereas selectivity should be high for a confirmatory method. Furthermore, the selectivity needed depends on the interferences that can be expected. To conclude, whenever developing or validating a method, it is of extreme importance to consider the parameter selectivity in detail. Antibiotica worden gebruikt om bacterie-infecties te behandelen, maar worden ook toegepast als preventief middel. Het verantwoordelijk gebruik van antibiotica is van belang vanuit het oogpunt van dierlijk welzijn en humane gezondheid. Om antibioticumgebruik in de veehouderij te controleren bestaan er wettelijke monitoringsprogramma’s. In de residuanalyse van antibiotica in producten van dierlijke oorsprong spelen kwantitatieve en kwalitatieve aspecten een rol in het bepalen of een monster conform de regelgeving is. Het kwantitatieve aspect betreft de bepaling van de hoeveelheid van het aanwezig antibioticum en het kwalitatieve aspect betreft het vaststellen van de identiteit van het antibioticum.

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Red blood cells and include pain discount 45 mg actos mastercard diabetic diet and eggs, discharge buy actos 30 mg fast delivery diabetes mellitus renal failure, or lesions as well as a vague protein pass through the glomerulus and enter the feeling of fullness or discomfort in the perineal or tubule order actos 30mg on-line diabetes symptoms in women. buy actos 45 mg free shipping diabetes mellitus type 2 fatty liver. A complete evaluation of the genitalia, nephron tubules and forms solid masses that take reproductive history, and past and present geni- the shape of the tubules in which they develop. They commonly pass identify disorders associated with male reproduc- out of the kidney by way of the urine and may be tive structures. For diagnosis, treatment, and management of The clinical picture for glomerulonephritis genitourinary disorders, the medical services of a includes blood and protein in the urine (hema- specialist may be warranted. The physician who specializes in diagnoses and with acute glomerulonephritis associated with a treatment of genitourinary disorders is known as a streptococcal infection recover with no lasting kid- urologist. Stones (calculi) may form in any part of the uri- nary tract (urolithiasis), but most arise in the kid- Pyelonephritis ney, a condition called nephrolithiasis. These stones may is pyelonephritis, (also called kidney infection or increase in size and obstruct urinary structures. In this disor- they lodge in the ureters, they cause intense throb- der, bacteria invade the renal pelvis and kidney tis- bing pain called colic. Because urine is hindered sue, commonly as a result of a bladder infection that from passing into the bladder, it flows backward has ascended to the kidney via the ureters. When (refluxes) into the renal pelvis and the tubules, the infection is severe, lesions form in the renal causing them to dilate. If the stone is large, an ultrason- ic or electrohydraulic probe is used to break the stone into smaller fragments, which are then more easily removed. For stones that have descended into the ureters, it may be pos- Kidney stones sible to remove them using a specialized uretero- scope fitted with a small basket. The ureteroscope is passed through the urethra and bladder and into the ureter where the basket collects the stone. For larger stones, it may be necessary to break them into smaller pieces using an endoscope fitted with a laser beam before the fragments are removed. This procedure is called ureteroscopic stone removal, and no incision is required. Bladder infection (cystitis) and, ultimate- this procedure, a small incision is made in the skin, ly, kidney infection (nephritis) may result. Pathology 321 the entire prostate may be done through the per- disorder involves surgical suspension of the testes ineum (perineal prostatectomy) or an abdominal (orchiopexy) in the scrotum. This procedure is opening above the pubis and directly over the usually done before the child reaches age 2. These pro- Because an inguinal hernia commonly accompa- cedures are invasive and are performed when the nies cryptorchidism, the hernia may be sutured entire prostate must be removed, such as when (herniorrhaphy) at the same time. At the conclusion of the surgery, the urethra may occur because of circulatory collapse, severe and bladder are irrigated to remove the small hypotension, hemorrhage, dehydration, or other chips. In many mental apathy, nausea, vomiting, and increased infants born with this condition, the testes blood levels of calcium (hypercalcemia). When descend spontaneously by the end of the first tubular damage is not severe, the disorder is usually year. Urinary bladder Resectocope in urethra Testis Benign prostatic hyperplasia Rectum Figure 11-6. Two The most common form of cancer in men is carci- forms of radiation oncology include brachytherapy noma of the prostate. In brachytherapy ease is rarely found in men younger than age 50; (also called internal radiation therapy), radioactive however, the incidence dramatically increases with “seeds” are placed directly in the malignant tissue. Symptoms include difficulty starting urina- They remain in place for long or short periods of tion (hesitancy) and stopping the urinary stream, time depending on the type of malignancy, its loca- dysuria, urinary frequency, and hematuria. Early pre- directed at the tumor from outside the body to symptomatic tests include a blood test for destroy prostate tissue. Surgery and apy) has been effective in treatment at the early radiation therapy are usual treatment modalities, stages of the disease. Because prostatic cancer is but other forms of treatment may also be em- stimulated by testosterone, surgical removal of the ployed. Surgical treatment includes the removal of testes (bilateral orchiectomy) may be necessary. Prostate with nodule Urinary bladder Digital rectal examination Rectum Figure 11-7. Pathology 323 Urethra Urethral catheter Needle that transmits Bladder seeds into prostate Ultrasound probe Template to aid accurate Prostate for needle guidance placement of needles Rectum delivering radioactive seeds Figure 11-8. Urethral catheter Ice balls forming Bladder Cryoprobe needles Prostate Ultrasound probe Rectum for needle guidance Figure 11-9. Term Definition Urinary System anuria Absence of urine production or urinary output an-U-r¯˘ ¯ e-˘a Anuria may be obstructive, in which there is blockage proximal to the bladder, or an-: without, not unobstructive, which is caused by severe damage to the nephrons of the kidneys. Its causes include previous pelvic surgery such as hysterectomy, diff icult and prolonged labor, or reduced blood supply to the area. The pressure impairs, and increase (used primarily may eventually interrupt, kidney function. The tumor is well encapsulated in the early stage but may metastasize to other sites, such as lymph nodes and lungs, at later stages. Diagnostic and Therapeutic Procedures This section introduces procedures used to diagnose and treat genitourinary system disorders. Descriptions are provided as well as pronunciations and word analyses for selected terms. The level is elevated in prostatitis, benign prostatic hyperplasia, and tumors of the prostate. Nitrogenous waste products are collected in a solu- loosening tion called dialysate, which is discarded at the end of the procedure. Dialyzing fluid remains in the peritoneal cavity for 1 to 2 hours and then is removed. Because the prostate gland is not completely removed, remaining -al: pertaining to tissue eventually grows back and may cause obstruction again at a later time. Vas deferens Skin incision Vas deferens pulled through incision and cut Vasectomy reversal Each end tied off with ends of with suture before vas deferens incision is closed sutured together Figure 11-14. Pharmacology 333 rently with many diuretics to counteract potassi- Pharmacology um depletion. Table 11-1 Drugs Used to Treat Genitourinary Disorders This table lists common drug classifications used to treat urinary and male reproductive disorders, their therapeutic actions, and selected generic and trade names. Ditropan Bladder spasms can result from such conditions as urinary tract infections and catheterization. Viagra Anti-impotence drugs should not be used by patients vardenafil with coronary artery disease or hypertension. Complete each activity and review your answers to evaluate your understand- ing of the chapter. Learning Activity 11-1 Identifying Urinary Structures Label the following illustration using the terms listed below. Learning Activities 337 Learning Activity 11-2 Identifying Male Reproductive Structures Label the following illustration using the terms listed below. Enhance your study and reinforcement of word elements with the power of DavisPlus. We recommend you complete the flash-card activity before completing Activity 11–3 below.

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Cell Membrane and Cytoplasm • Connective tissue supports and connects The cell membrane acts as a barrier that encloses other tissues and organs buy cheap actos 45 mg diabetic muffins. It controls the transport of many diverse cell types generic 30 mg actos with amex ketosis-prone diabetes mellitus type 2, including fibroblasts order 30 mg actos diabetes mellitus question and answer, fat substances to and from the cell cheap actos 45mg online diabetes diet what can you eat. Nucleus The nucleus is responsible for metabolism, growth, Organ and reproduction. This blueprint is found in Organs are body structures that perform special- a complex molecule called deoxyribonucleic acid ized functions. When the cell is ready to divide, made up of connective tissue, muscle tissue, chromatin forms chromosomes, which carry thou- epithelial tissue, and nervous tissue. In the human, there are about 31,000 genes that Epithelial and connective tissue cover the inner determine unique human characteristics. Abdominopelvic Divisions 43 penetrates the epithelial lining of the stomach and Table 4-1 Planes of the Body its muscular wall to stimulate the release chemicals for digestion and contraction for peristalsis. System Plane Anatomical Division A body system is composed of varying numbers of Midsagittal (median) Right and left halves organs and accessory structures that have similar or Coronal (frontal) Anterior (ventral) and related functions. For example, organs of the gas- posterior (dorsal) trointestinal system include the esophagus, stom- aspects ach, small intestine, and bowel. Some of its accesso- ry structures include the liver, gallbladder, and Transverse Superior (upper) and pancreas. The purpose of this system is to digest (horizontal) inferior (lower) aspects food, remove and use its nutrients, and expel waste products. Other body systems include the reproduc- tive, respiratory, urinary, and cardiovascular systems. Thus, structural abnormalities and body The highest level of organization is the organism. All complex organisms, scanning devices that show images taken in sever- including humans, are made up of several body al body planes. Body Cavities Anatomical Position Medical professionals locate structures or abnor- The anatomical position is a body posture used to malities by referring to the body cavity in which locate anatomical parts in relation to each other. The lower • dorsal (posterior), including the cranial and limbs are parallel, with toes pointing straight spinal cavities ahead. No matter how the body is actually • ventral (anterior), including the thoracic and positioned—standing or lying down, facing for- abdominopelvic cavities. Divisions The abdominopelvic area of the body lies beneath Planes of the Body the diaphragm. It holds the organs of digestion (abdominal area) and the organs of reproduction To identify the different sections of the body, and excretion (pelvic area). Two anatomical meth- anatomists use an imaginary flat surface called a ods are used to divide this area of the body for plane. The most commonly used planes are mid- medical purposes: sagittal (median), coronal (frontal), and trans- verse (horizontal). Current imaging a means of locating specific sites for descriptive procedures, such as magnetic resonance imaging and diagnostic purposes. Pain, lesions, abrasions, Spine punctures, and burns are commonly described as The spine is divided into sections corresponding to located in a specific quadrant. These also identified by using body quadrants as the divisions are: method of location. For example, the stomach is located in the left example, the kidneys are superior to the urinary hypochondriac and epigastric region; the appen- bladder. The directional phrase superior to denotes dix is located in the hypogastric region. Table 4-2 Body Cavities This table lists the body cavities and some of the major organs found within them. The thoracic cavity is separated from the abdominopelvic cavity by a muscular wall called the diaphragm. Cavity Major Organ(s) in the Cavity Dorsal Cranial Brain Spinal Spinal cord Ventral Thoracic Heart, lungs, and associated structures Abdominopelvic Digestive, excretory, and reproductive organs and structures Table 4-3 Body Quadrants This table lists the quadrants of the body, their corresponding abbreviations, and their major structures. Right Left hypochondriac Epigastric hypochondriac region region region Right upper Left upper quadrant quadrant Right lumbar Umbilical Left lumbar region region region Right lower Left lower quadrant quadrant Right inguinal Hypogastric Left inguinal (iliac) region region (iliac) region Figure 4-4. Table 4-4 Abdominopelvic Regions This table lists the names of the abdominopelvic regions and their location. Region Location Left hypochondriac Upper left region beneath the ribs Epigastric Region above the stomach Right hypochondriac Upper right region beneath the ribs Left lumbar Left middle lateral region Umbilical Region of the navel Right lumbar Right middle lateral region Left inguinal (iliac) Left lower lateral region Hypogastric Lower middle region beneath the navel Right inguinal (iliac) Right lower lateral region It is time to review the planes of the body and quadrants and regions of the abdominopelvic area by completing Learning Activities 4–1 and 4–2. Table 4-5 Directional Terms This table lists directional terms along with their definitions. Term Definition Abduction Movement away from the midsagittal (median) plane of the body or one of its parts Adduction Movement toward the midsagittal (median) plane of the body Directional Terms 47 Table 4-5 Directional Terms—cont’d Term Definition Medial Pertaining to the midline of the body or structure Lateral Pertaining to a side Superior (cephalad) Toward the head or upper portion of a structure Inferior (caudal) Away from the head, or toward the tail or lower part of a structure Proximal Nearer to the center (trunk of the body) or to the point of attachment to the body Distal Further from the center (trunk of the body) or from the point of attachment to the body Anterior (ventral) Front of the body Posterior (dorsal) Back of the body Parietal Pertaining to the outer wall of the body cavity Visceral Pertaining to the viscera, or internal organs, especially the abdominal organs Prone Lying on the abdomen, face down Supine Lying horizontally on the back, face up Inversion Turning inward or inside out Eversion Turning outward Palmar Pertaining to the palm of the hand Plantar Pertaining to the sole of the foot Superficial Toward the surface of the body (external) Deep Away from the surface of the body (internal) It is time to review body cavity, spine, and directional terms by completing Learning Activity 4–3. Medical Word Elements This section introduces combining forms, suffixes, and prefixes related to body structure. Thus, the individual with heterochromia may have one brown iris and one blue iris. Cirrhosis of the liver is usually associated with alcoholism or chronic hepatitis. Pathology 53 Pathology diseases include: • metabolic (such as diabetes) All body cells require oxygen and nutrients for sur- • infectious (such as measles and mumps) vival. They also need a stable internal environment • congenital (such as cleft lip) that provides a narrow range of temperature, water, • hereditary (such as hemophilia) acidity, and salt concentration. This stable internal • environmental (such as burns and trauma) environment is called homeostasis. When home- • neoplastic (such as cancer) ostasis is disrupted and cells, tissues, organs, or sys- tems are unable to function effectively, the condition Establishing the cause and nature of a disease is is called disease. Determining a diagnosis ease is a pathological or morbid condition that helps in the selection of a treatment. A prognosis is presents a group of signs, symptoms, and clinical the prediction of the course of a disease and its findings. A symptom is subjective and is A variety of diagnostic procedures are used to experienced only by the patient. Dizziness, pain, and identify diseases and determine their extent or malaise are examples of symptoms. Diagnostic tests can be simple, such as are the results of radiologic, laboratory, and other listening to chest sounds with a stethoscope, or medical procedures performed on the patient or complex, such as a biopsy. Abbreviations Diagnostic, Symptomatic, and Related Terms This section introduces diagnostic, symptomatic, and related terms and their meanings. Descriptions are provided as well as pro- nunciations and word analyses for selected terms. The endoscope is usually named for the organ, cavity, or canal being exam- ined, such as gastroscope and sigmoidoscope. Rather than being directed into the body, radiation comes from inside the body and is then detected by a specialized camera to produce an image. It is especially useful to visu- -graphy: process of recording alize blood flow through arteries and veins in the brain. A computer analyzes the reflected echoes and converts them into an image on a video monitor. Because this procedure does not use ionizing radiation (x-ray), it is used for visualizing fetuses as well as the neck, abdomen, pelvis, brain, and heart. The evaluation by the pathologist helps determine if and how aggressively the surgeon will treat the patient. Abbreviations This section introduces body structure abbreviations and their meanings. Complete each activity and review your answers to evaluate your understanding of the chapter. Learning Activity 4-1 Identifying Body Planes Label the following illustration using the terms below.

If you truly can’t take the time to meditate daily then make an attempt to meditate as often as you can cheap actos 45mg without prescription diabetes test nz. If you miss a day order actos 45 mg overnight delivery blood glucose conversion chart, don’t worry; just form the intention in your mind to make this a part of your daily routine cheap 45 mg actos free shipping diabetic dietcoza. Making it a Priority We all lead very busy lives and in order to find time to practice you may have to be creative with the time you have buy 30 mg actos mastercard blood glucose levels. Let your family and friends know not to interrupt you and that this time is your quiet time. Take a few minutes to meditate on especially hectic days, wherever and whenever you can, but don’t forget that it takes time to develop a new and healthy habit. There are great health benefits in just coming to your meditation place no matter what you experience in that particular session. It can be frustrating when it seems that your mind is 108 • Mindfulness Medication always wandering and always thinking. There will be times when you can’t seem to concentrate on the object of your meditation. Can you remember when you first started to learn something new like how to play a musical instrument or a new sport, or when you first learned to drive? Just know that if you spend enough time practicing, your concentration will improve. If you find yourself feeling frustration, anger, happiness, or sadness during the course of your meditation session, then just acknowledge, or recognize what you’re feeling without trying to grab onto the emotion or engage it. Be aware of thoughts and feelings as they try to pull you into the past, or entice you into thoughts of the future. Perfection You should not be concerned about whether the meditation practice that you’re doing is ‘perfect’ or if you’re doing it ‘the right way’. Try not to have unrealistic expectations about the way you think the meditation session should be going. The meditation that you’re experiencing, at that point, is what exists for you in that moment. You’re benefiting from the routine of meditating no matter what you experience in any given session. Sometimes it will be what you may perceive as a “good” meditation, other times it will be a more challenging experience. Try not to come to your meditation with an expectation that it will be ‘good’ like the last time. Meditation: Sitting in Stillness • 109 Promise I promise you that the benefits you will get from meditation are invaluable. If you can make meditation a priority, then it will become so important to you and your well-being, that you will always make time for it in your life. In the beginning, you may just have to trust that these benefits, which may not be so obvious to you initially, will gradually reveal themselves. Over time, if you’re generally choosing a sitting posture, your flexibility may increase and you can try other postures that you might have found to be uncomfortable when you first started. The list on the following pages will familiarize you with some of the phrases common to meditation, but pretzel-like contortions are not important. As long as you’re maintaining a position that is stable and comfortable, you’re on the right track. Sitting on the Floor When sitting on the floor you should feel grounded and stable. Try sitting on a cushion, to elevate your buttocks and allow your pelvis to tilt forward, creating a more comfortable curve in your lower back. Sit on the edge of the cushion, rather than in the middle of it, to encourage this forward pelvic tilt. Elevating the pelvis allows for greater stability as there are multiple points of contact between your legs and the floor. This will take pressure off of your knees and legs and allow you to sit more comfortably. If you’re sitting on a chair, or on a sofa, remember to assume the sitting position that you use when you’re doing your meditation. The more often you sit in this position the more your ease and flexibility will increase, and you’ll find the position to be more comfortable and less distracting during your meditation. The Butterfy Exercise There are also hip exercises that you can do to increase your flexibility. The Butterfly exercise involves sitting on the floor with the knees bent sideways and the soles of the feet touching each other. Remember that the motion should be gentle without overstretching or causing any pain. Sitting Postures • Cross-legged posture The sides of both feet touch the floor and the legs are comfortably crossed. The left foot is on the floor under the right leg and the right foot is on top of the left thigh. Meditation: Sitting in Stillness • 111 • Bench There is a special meditation bench that supports the weight of your body and allows your feet to be curled underneath. If your feet don’t reach the floor comfortably you can fold a blanket for your feet to rest upon. Lying Down If, for some reason, you have physical limitations such that the only comfortable posture for you is lying down, this can be done as well. However, this posture is not recommended for those who are physically able because of the tendency to fall asleep. In this posture, make sure to be comfortable but extra aware of the need to stay alert. Standing Standing up to meditate can be very helpful when fatigue is becoming a problem in a sitting posture. What you may find is that, by simply assuming the meditation posture, the posture itself starts to bring about a calming effect on your body. At first you may experiment with different postures to find the one that’s right for you, but I recommend that, after a while, you settle on the one that you find the most comfortable. Sometimes drawing the head back slightly will keep the spine in the right alignment. However, some people recommend that your eyes be slightly open with your gaze directed downward. Another option is that the tip of your tongue may touch the roof of your mouth just behind the upper teeth. If you find this difficult, like when you have a cold, then breathe through your mouth. The right palm should be sitting over the left palm and the thumbs can be touching. Keeping the arms in this position creates some body tension that may be a reminder to keep your spine straight. Meditation: Sitting in Stillness • 113 An alternative is for each hand to rest on your thighs just above your knees with your palms facing downward. Shrug your shoulders a few times before you begin to see if they are tensed upward or fully relaxed. Weak muscle groups will announce themselves and try to get you to move around or to even stop meditating entirely. However, if you move, do so slowly and with careful attention to what you’re doing. With every meditation that you do, your body and mind will grow more accustomed to it and you’ll feel less distracted and more and more comfortable. Having a shawl or light blanket with you that you can put over your shoulders if you get cold may be helpful. If you find that you get cold often when you meditate, it may be better to wear a sweater, or shawl from the start.

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In junctional nevi generic actos 30mg overnight delivery diabetes type 2 with erectile dysfunction, nevus cells are clus- tered at the dermal–epidermal junction above the basement membrane discount actos 30 mg without a prescription diabetic socks. These are dark brown to black generic actos 30 mg visa diabetes type 1.5, macular to slightly raised lesions that appear in young children after age 2 discount actos 30 mg managing diabetes guideline. Compound nevi are composed of nevus cells both at the dermal–epidermal junction and within the dermis. They also are brown to black in color, are usually slightly raised, and are frequently hairy, with sharply defined but often irregular borders and smooth to slightly papillary surfaces. A compound nevus sur- rounded by an area of hypopigmentation is called a halo nevus. Intra- dermal nevi are made up of nevus cells primarily occupying the dermis, sometimes extending into subcutaneous fat. These are flesh- colored to brown, raised, fleshy papules that distort normal skin anatomy, with hairs and dark flecks sometimes present on the surface. Malignant transformation of any of these nevi is rare when they are small in size (<6mm), stable in appearance over time, and lacking suspicious characteristics, including ulceration, bleeding, or pruritis. No intervention is indicated for this patient’s lesions at this time, although she should be instructed to monitor their appearance and to follow up with her physician for periodic screening exams. Atypical and Dysplastic Nevi Case 4 describes a specific lesion on the same young woman as in Case 3. Unlike the many pigmented lesions on her arms and trunk that easily are classified as benign, this particular lesion should come to the physi- cian’s attention because of its size and irregular shape and surface texture. This lesion is termed atypical on the basis of its gross clinical characteristics. While often referred to as dys- plastic nevi, atypical nevi may or may not demonstrate histologic dysplasia. A single atypical nevus can be found in 5% of whites in the United States, and, in the absence of family history of melanoma, this finding is associated with a 6% lifetime risk of developing melanoma. In persons with one or more atypical nevi and a strong family history, the risk of developing melanoma may be as high as 80%. In these persons, the atypical nevus itself may undergo malignant transforma- tion, or disease may develop de novo elsewhere; hence, annual skin screening exams by a physician strongly are recommended. In all patients with a single atypical nevus or nevi, education regarding melanoma risk and self-examination is essential. Intermittent but intense exposure to sunlight Blistering sunburns in childhood Tendency to sunburn rather than tan Living in sunny climates close to the equator Positive family history of melanoma Positive personal history of melanoma or other skin cancer History of atypical nevi Recent changes in mole(s) are associated with increased risk of developing melanoma, full- thickness biopsy of this patient’s lesion should be performed. Melanoma The lesion of the patient described in Case 5 is worrisome for several reasons. He has a significant history of sun exposure and sunburn, which is a strong risk factor in fair-complexioned individuals. Inter- mittent but intense sunlight exposure in particular appears to increase risk. Additionally, melanoma in a first-degree relative, in this case his father, increases risk by at least eight times. The patient also reports a recent history of rapid change in the size and texture of the lesion, which should alert the physician to the likelihood of a malignant process. Other suspicious changes not seen in this patient include changes in color, ulceration, bleeding, or pruritis. Given the high like- lihood of malignant melanoma in this patient, one also should ques- tion him about recent weight loss or other constitutional symptoms that may be indicative of metastatic disease. On exam, this patient’s lesion possesses many characteristics typical of malignant melanoma, including heterogeneous color and nodular- ity and relatively large (1. A: Asymmetry B: Border irregularity C: Color variation or variegation D: Diameter greater than 6mm E: Elevated area or palpable nodule within a formerly flat lesion Also: ulceration, inflammation, bleeding, satellite nodules, local lymphadenopathy 30. Nonetheless, not all melanomas are clinically obvious, as different histologic types present very differently. Amelanotic melanoma, for instance, is a dangerous, albeit rare entity, because of its tendency to go unrecognized, and hence, it tends to be diagnosed at a later stage when therapy becomes more problematic. Besides a complete history and examination of the suspect lesion, a thorough examination of the skin over the entire body is essential to the initial evaluation and follow-up of this high-risk patient. While 60% of melanomas arise de novo from epidermal melanocytes, 40% arise from malignant degeneration of a preexisting atypical or dys- plastic nevus. Identification and monitoring of atypical nevi permits early detection and intervention, which are critical, since the depth of melanoma invasion at the time of diagnosis is the most accurate pre- dictor of survival. Regional lymph node basins also should be pal- pated for clinical evidence of nodal involvement. Given the highly suggestive appearance and suspect history of the presenting lesion, further evaluation is mandatory. The management of this patient would begin with excisional biopsy, to include a 1- to 2-mm margin of grossly normal skin and subcutaneous tissue. Inci- sional or punch biopsy also would be an acceptable approach and would be indicated for larger lesions or those in cosmetically sensitive areas. Full-thickness biopsy techniques are absolutely necessary to provide adequate tissue for pathologic assessment and staging, while allowing for reexcision at the site should the malignancy be confirmed. Shave biopsy, cryosurgery, and electrodesiccation should not be used, since they compromise histologic assessment and primary staging of disease, which are the cornerstones of establishing progno- sis and defining treatment. The biopsy results showed superficial spreading melanoma of intermediate thickness at 2. Superficial spreading melanoma is the most common type of melanoma, accounting for approximately 70% of all cases. It begins as a brown, slightly elevated lesion, progressing to have irregular, raised borders, a variegated brown to black color pattern, and a diam- eter of 2 to 3cm, sometimes with central pigment loss. It exhibits a pro- longed radial growth phase, with lateral extension confined to the epidermis and papillary dermis. Wey last as long as a decade, and, as a result, it generally is associated with a good prognosis. In this patient’s case, however, increasing nodular- ity may be indicative of vertical growth into deeper layers of skin and increased likelihood of metastasis. There are three other distinct histologic types of melanoma, each exhibiting its own characteristic features, growth patterns, and prog- noses. Nodular melanoma represents 8% to 10% of all melanomas, with characteristically uniform gray-blue to brown or black color, although they also can be nonpigmented. These demonstrate almost immediate vertical growth, and hence, they are associated with early metastasis and poor prognosis. They are typically flat, tan macules of up to 3cm or more in diameter that grow slowly and radially within the upper dermis. Elevated nodules and irregular areas of dark brown or black pigmentation arising within these lesions may represent invasive melanoma. Acral-lentiginous melanoma represents only 1% of melanoma cases and occurs exclusively on the palms, soles, and nail beds. Unlike the other subtypes, it occurs with equal frequency among Caucasians and dark-skinned persons. Lesions generally are flat with irregular borders, variably pigmented brown-black to black, but they also may be amelanotic. Depth of tumor invasion as measured in millimeters (Breslow depth) is the defining variable in determining the next appropriate step in this patient’s management. Lesion thickness has been found to be inversely related to survival, and it is a good predictor of prognosis in node-negative patients. While these levels correlate reasonably well with Breslow depth, the basis of the Clark system is flawed, in that no true barriers to tumor invasion exist in the subepidermal layers and, in that dermal thickness varies greatly in different parts of the body. Chest x-ray, serum alkaline phosphatase, and lactate dehydrogenase are recommended as screening measures for pul- monary and liver metastasis in patients with melanoma greater than 1mm thick.

Second- Oncology degree (partial-thickness) burns are deep burns that damage both the epidermis and part of the Neoplasms are abnormal growths of new tissue dermis generic actos 45mg on line diabetes treatment journal. Symptoms neoplasms are noncancerous growths composed mimic those of first-degree burns discount actos 15 mg mastercard diabetes prevention with diet, but fluid-filled of the same type of cells as the tissue in which they blisters (vesicles or bullae) form and the burn may are growing discount actos 30 mg with visa misdiagnosed diabetes in dogs. If In third-degree (full-thickness) burns buy actos 45 mg without prescription blood sugar solution diet, the the benign neoplasm remains small and places no epidermis and dermis are destroyed and some of pressure on adjacent structures, it commonly is not the underlying connective tissue is damaged, leav- removed. When it becomes excessively large, causes ing the skin waxy and charred with insensitivity to pain, or places pressure on other organs or struc- touch. These burns may be caused are composed of cells that are invasive and spread to by corrosive chemicals, flames, electricity, or remote regions of the body. These cells show altered extremely hot objects; immersion of the body in function, altered appearance, and uncontrolled extremely hot water, or clothing that catches fire. They invade surrounding tissue and, ulti- Because of the extensiveness of tissue destruction, mately, some of the malignant cells from the Figure 5-4. From Goldsmith, Lazarus, & Tharp: Adult and Pediatric Dermatology:A Color Guide to Diagnosis and Treatment. Pathology 81 9% Head and neck 18% (Back) 18% 18% Head and neck 9% 9% 18% (Back) 1% 18% 18% 18% 9% 9% 1% 13. Grading and Staging Systems The presence of a malignant growth (tumor), is the disease called cancer. The ability to invade sur- Pathologists grade and stage tumors for diagnos- rounding tissues and spread to remote regions tic and therapeutic purposes. If system is used to evaluate the appearance and left untreated, cancer is usually progressive and maturity of malignant cells in a tumor. It is an invasive tumor with • T—size and invasiveness of the primary potential for metastasis and occurs most common- tumor ly in fair-skinned white men over age 60. Repeated • N—nodal involvement overexposure to the sun’s ultraviolet rays greatly • M—spreading of the primary tumor to increases the risk of squamous cell carcinoma. Other predisposing factors associated with this Numbers are used to indicate size or spread of type of cancer include radiation therapy, chronic the tumor. The higher the number, the greater the skin irritation and inflammation, exposure to can- extent or spread of the malignancy. For example, cer causing agents (carcinogens), including tar T2 designates a small tumor; M0 designates no and oil, hereditary diseases (such as xeroderma evidence of metastasis. Basal cell carcinoma, the most common type of There are two types of squamous cell carcinoma: skin cancer, is a malignancy of the basal layer of the those that are confined to the original site (in situ) epidermis, or hair follicles. This type of cancer is and those that penetrate the surrounding tissue commonly caused by overexposure to sunlight. Basal cell carcinoma is most vide good cosmetic results for smaller lesions; radi- prevalent in blond, fair-skinned men and is the ation therapy, usually for older or debilitated most common malignant tumor affecting white patients; and chemotherapy, depending on the loca- people. Although these tumors grow slowly, they tion, size, shape, degree of invasion, and condition of commonly ulcerate as they increase in size and underlying tissue. Metastases are uncommon with this type of cancer; however, the disease can invade the tissue Malignant Melanoma sufficiently to destroy an ear, nose, or eyelid. M alignant melanoma is a neoplasm composed Depending on the location, size, and depth of the of abnormal melanocytes that commonly begin lesion, treatment may include curettage and elec- in a darkly pigmented mole. Although malignant trodesiccation, chemotherapy, surgical excision, melanoma is relatively rare, the incidence is irradiation, or chemosurgery. It is the most lethal of the skin cancers and and using sunscreen have proved effective in pre- can metastasize extensively to the liver, lungs, venting the disease. Melanomas are diagnosed by biopsy along with Several factors may influence the development histological examination. Treatment requires sur- of melanoma, but persons at greatest risk have fair gery to remove the primary cancer, along with complexions, blue eyes, red or blonde hair, and adjuvant therapies to reduce the risk of metastasis. Excessive exposure to sunlight and severe The extent of surgery depends on the size and sunburn during childhood are believed to increase location of the primary tumor and is determined the risk of melanoma in later life. A cluster of furuncles in the subcutaneous tissue results in the formation of a carbuncle. They may be found in any location but commonly on the scalp, knees, elbows, umbilicus, and genitalia. Treatment includes topical application of various medications, keratolytics, pho- totherapy, and ultraviolet light therapy in an attempt to slow hyperkeratosis. From Goldsmith, Lazarus, & Tharp: Adult and Pediatric Dermatology:A Color Guide to Diagnosis and Treatment. The axillae, genitalia, inner aspect of the thighs, and areas between the f ingers are most commonly affected. From Goldsmith, Lazarus, & Tharp: Adult and Pediatric Dermatology:A Color Guide to Diagnosis and Treatment. From Goldsmith, Lazarus, & Tharp: Adult and Pediatric Dermatology:A Color Guide to Diagnosis and Treatment. Descriptions are pro- vided as well as pronunciations and word analyses for selected terms. The intensity of the response is determined by the wheal- and-flare reaction after the suspected allergen is applied. Positive and negative controls are used to verify normal skin reactivity (See Figure 5-12. Any lesion suspected of malignancy is removed and sent to the pathology laboratory for evaluation. Therapeutic Procedures chemical peel Chemical removal of the outer layers of skin to treat acne scarring and general keratoses; also called chemabrasion Chemical peels are also commonly used for cosmetic purposes to remove f ine wrinkles on the face. This type of skin graft is temporary and is used to protect the patient against infection and fluid loss. Pharmacology Widespread or particularly severe dermatologi- Various medications are available to treat skin disor- cal disorders may require systemic treatment. Such mild, localized topical medication and may require a prescription- skin disorders as contact dermatitis, acne, poison ivy, strength drug. In such a case, an oral steroid or and diaper rash can be effectively treated with topi- antihistamine might be prescribed to relieve cal agents available as over-the-counter products. Table 5-3 Drugs Used to Treat Skin Disorders This table lists common drug classifications used to treat skin disorders, their therapeutic actions, and selected generic and trade names. Table 5-3 Drugs Used to Treat Skin Disorders—cont’d This table lists common drug classifications used to treat skin disorders, their therapeutic actions, and selected generic and trade names. As a group, these drugs are also known loratadine as antipruritics (pruritus means itching). Oral corticosteroids may be prescribed for Azmacort, Kenalog systemic treatment of severe or widespread inflamma- tion or itching. Milder keratolytics promote shedding of scales and crusts in eczema, psoriasis, seborrheic dermatitis, and other dry, scaly conditions. Weak keratolytics irritate inflamed skin, acting as a tonic to accelerate healing. The drug is applied as a cream Kwell,Thion or lotion to the body and as a shampoo to treat permethrin the scalp. Cetaphil moisturizing lotion Rather, they allow the natural healing process to ointments occur by forming a long-lasting film that protects Vaseline the skin from air, water, and clothing. It is time to review diagnostic, symptomatic, procedure, and pharmacology terms by completing Learning Activity 5–5. Complete each activity and review your answers to evaluate your understand- ing of the chapter. Learning Activity 5-1 Identifying Integumentary Structures Label the following illustration using the terms listed below.

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