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The scheme was first started in February prehypertension buy 0.25 mg digoxin otc, 1952 in the industrial towns of Not more than 5 hours work at a stretch followed by Delhi and Kanpur and now it covers most of the industrial rest for at least half an hour heart attack exo xoxo cheap digoxin 0.25 mg with mastercard. No child to work for more than four and the following: a half hours a day and not at night from 10 pm to 6 • Nonpower using factories employing 20 or more am (Section 71) blood pressure medication how quickly does it work discount digoxin line. At present the Certain accidents to be notified by the manager of the employees drawing wages up to Rs how quickly should blood pressure medication work order 0.25 mg digoxin with mastercard. An employee who is covered specified in the third schedule of the Act blood pressure zippy digoxin 0.25 mg purchase with visa, the manager at the beginning of a contribution period shall continue shall send notice therefore to the prescribed authorities. An industrial worker is • Minister for Labor-Chairman exposed to ‘employment injury’ which includes • Secretary, ministry of labor-Vice Chairman accidents and diseases related to his occupation. During • 5 representatives of Central Government 95 illness or employment injury, a worker faces fear of • One representative each from the States and one economic, physical or even social ruin. Social insurance representatives of Union Territories • 5 representatives of employees and 5 of employers, • Maternity-benefits 2 of medical profession and 3 Members of • Disablement benefit Parliament. The medical benefit also includes • Director General of Health Services; ambulance services, domiciliary treatment facility and • Deputy Director General of Health Services; provisions of drugs, dressings and some appliances. A dispensary with full time medical assisted by 4 Principal Officers: (1) Medical Commis- officer and paramedical staff serves an area having sioner, (2) Financial Adviser and Chief Accounts Officer, 1000 or more ‘employees family units’; but part (3) Insurance Commissioner, (4) Actuary. Indirect system or Panel system: In this system Regional and Local Medical Benefit Councils. It empanelled private medical practitioners called delegates them powers to administer the scheme in the ‘Insurance Medical Practitioner’ provide care to the States. It also appoints Inspectors to inspect factories workers and their dependent family members. The scheme is primarily funded by contribution raised from insured employees and their employers as Extended sickness benefit (cash): For some specified a small but specified percentage of wages payable to long-term diseases like paralytic disorders, tuberculosis, such employees. The covered employees contribute leprosy, coronary artery disease, psychosis, chronic 1. Employers earning less than fifty rupees a day absence from work on medical advice are entitled for as daily wage are exempted from payment of their share the cash benefit for longer period of two years. The state government as per the payable in cash as extended sickness benefit is equal to provision of the act bears one-eight share of about 70 percent of the daily wages. The Benefit to employee: Various benefits under the act that duration of benefit for miscarriage is 6 weeks. The rate the insured employees and their dependants are entitled of payment of the benefit is equal to wage. The payment is made according to labor enactments such as Workmen’s Compensation the plan prescribed. Worker Absenteeism Other benefits: Absenteeism is a major factor affecting work productivity • Free supply of physical aids and appliances such as and is closely related to a worker’s health as well as his crutches, wheelchairs, spectacles and other such personal, domestic and social life. The causes of • Rijiv Ghandhi Shramik Kalyan Yojana: Under this absenteeism are: scheme the insured person who are rendered • Sociocultural causes related to domestic and social unemployed involuntarily due to retrenchment / factors such as joint family system, harvesting season, closure of factory is entitled for unemployment fairs and festivals, quarrels, etc. Rehabilitation benefit: Workers entitled to receive an It should be apparent from the above that the first artificial limb are awarded a rehabilitation allowance, for two causes are not directly related to disease or each day of their admission at the artificial limb center, occupational hazard at all, while the third cause has only for provision or replacement of an artificial limb. It is thus implicit, and several other Acts that have been framed to ensure amply borne out by facts, that only a small proportion worker’s rights, safety, health and welfare. The Government of India will bear the Some New Initiatives employer’s share of provident Fund contribution on 14 wages upto Rs. Delhi: National certify skills of youth population in the country to Book Trust 17, 1984. Directorate General • Courses are available for persons having completed of Employment and Training. Ministry of • Persons with skills acquired through years of work Labour and Employment. Employees’ State Insurance but without any formal certificate can get their skills Corporation. Its major the earth fuels (coal and oil), synthesis and use of source is automobile exhaust. It is produced Well-known environmental tradegies, like the cases by combustion of sulfur bearing fossil fuels and coal. Sulfur dioxide is readily and a wide range of other natural resources was being absorbed by soil, plants and water surfaces. Municipal workers entering large sewers have died of hydrogen sulfide Air Pollution poisoning. Air pollutants are the materials that exist in the air in such concentrations as to cause unwanted effects. We are concerned here mainly with the facturing nitric acid, sulfuric acid and nylon intermediates. The chief culprit is These are substances that are gaseous at normal tempe- automobile exhaust. Substances with boiling point below during petroleum combustion yield ozone in the 200°C are also included in this category. This is sozone levels in atmosphere have not decreased in spite because of the low particulate content and minimal of substained efforts. Particulate Pollutants Transportation These comprise both solid and liquid particles varying Example is fuel combustion in vehicular engines. The particulate pollutants may be Industrial Processes described as follows: Cement and steel industries are particularly polluting. Dust Solid W aste Disposal It consists of solid particles, usually 1 to 100 microns in Burning of solid waste also causes air pollution. Effects of Air Pollution Fum es These will be described separately in relation to man, These are particles below one micron, generally formed 1 animals, plants, materials and the atmosphere. The harmful effects of air pollution are most noticeable on the respiratory system. Mist These are liquid particles below 10 microns produced Gaseous Pollutants by condensation of vapor. An example is conversion Carbon monoxide is well known to cause death through of sulfur trioxide from gas to liquid (mist) form at 22°C. It may be mentioned that the affinity of carbon monoxide to hemo- Spray globin is 240 times stronger than that of oxygen. Sulfur These are liquid particles produced from parent liquid dioxide is a very serious pollutant. At lower levels, it causes by mechanical disintegration processes, such as atomi- bronchiolar smooth muscle spasm. The effect of sulfur dioxide is much greater in the presence of an inert aerosol, such as sodium chloride. It may be mentioned that though undesirable compounds to produce sulfuric acid droplets incomplete combustion produces gaseous hydrocarbons which, when inhaled, cause lung damage. Sulfur dioxide and oxides of sulfur and nitrogen also, only the solid can also cause respiratory allergy. It can cause pulmonary edema and hemorrhage Particulate contaminants comprise about 22 metallic at very low concentrations. Among oxides of nitrogen, elements, the most common of which are calcium, nitric oxide is non-irritant while nitrogen dioxide is a sodium, iron, aluminum and silicon. An important source of lead in pollutants are bronchitis, emphysema, asthma and lung atmosphere is the vehicle exhaust because lead tetra- cancer. The relation between lung cancer and pollution can be explained by the following: Source of Pollution • Polluted air contains carcinogens such as hydrocarbons. Compounds extracted from polluted 100 It is convenient to classify the sources of air pollution air have produced cancer in experimental animals. As a result, cooling mentioned that there is still lack of absolute evidence of earth by radiation is decreased and global warming may that air pollution causes lung cancer. It thus produces what is called a greenhouse effect (A green house is a glass house used in cold countries for Particulate Pollutants plants. The harmful effects of particulate matter depend upon In atmosphere, these gases allow the sunlight in but trap particle size. Particles above five microns in diameter the resultant heat, causing the greenhouse effect and global cannot penetrate respiratory mucosa. During last one and a half centuries, after the micron and less penetrate the alveoli easily. Soluble aero- advent of industrialization, the levels of carbon dioxide, sols are directly absorbed into blood from the alveoli, nitrous oxide and methane have increased by 25 percent, while insoluble ones are carried in the lymphatic system. In addition, Important particulate pollutants include lead, beryllium, another class of synthetic chemicals, the chlorofluoro- cobalt, asbestos, silica and some forms of carbon. Proper selection and utilization of fuels: Burning of addition, fluorosis can occur in animals when they coal produces more smoke while burning of oil consume forage contaminated with fluoride containing produces more sulfur dioxide. At the international level most countries three air pollutants of main agricultural concern. These in the West are gradually encouraging the use of cause reduction in photosynthesis and plant respiration. This is aimed at decreasing the oil necrosis, leaf damage can result in depigmented patches, consumption by road vehicles. Change of equipment of processes: An example is the and apple are particularly sensitive to sulfur dioxide injury. Sulfur dioxide oxidisable gases produced in petrochemical, fertilizer is the worst pollutant because it gets converted to and paint industries, but the cost is high. Absorption sulfurous and sulfuric acid in the presence of moisture is achieved by transfer of gas molecules into a liquid and causes corrosion. The damage Adsorption has to be used when other methods are caused is not serious, but is a big nuisance from an not applicable. Site selection: This involves proper location of 101 Fossil fuel consumption increases the carbon dioxide industrial plants away from places of habitation with concentration in air. Excess presence of free chlorine in river water destroys fish and other The main pollutants is motor vehicle exhaust are aquatic life, corrodes metals and can cause mucous hydrocarbons, carbon monoxide and oxides of nitrogen. The techniques of control- fertilizers not taken up by the crops are washed over ling motor vehicle emissions include tuning, engine from land into rivers and lakes where the nitrates modification and catalytic reactors. Engine mentioned that a cow and a pig produce sixteen and modification is aimed at more efficient burning of fuel. This fecal matter largely consists of dioxide while nitrogen oxides are converted to nitrogen. The combined excess of nitrates and phosphates can cause nuisance over large stretches of Water Pollution water through eutrophication. Sea water is contaminated through discharge of Water pollution refers to adverse changes in the compo- pollutants via rivers as also by oil spills from oil tankers. Synthetic detergents are now commonly used in Sources of Water Pollution homes and industries. They are usually nonbiodegra- dable, mainly because of the presence of alkyl benzene Three main sources of water pollution are industry, sulphonate. The foaming action retards usually discharged directly into rivers, adding toxic aeration of river water causing damage to aquatic flora chemicals to water that are harmful for health. Primary The result is that the ‘treated’ sewage causes pollution pollutants are the ones directly attributed to man’s activi- when discharged into rivers. It contains pollutants are those, which are not directly attributable decomposable organic matter and microorganisms, to human endeavor. Agricultural Bacteria and viruses may be pathogenic or nonpatho- sources of water pollution include insecticides, plant genic. The important pathogenic bacteria in water are materials and fertilizers which are applied to crops and Salmonella, Shigella, Vibrio cholerae, Leptospira and find their way into water systems. It is Types of Water Pollutants important to remember that viruses are not attacked by combined chlorine (in the form of chloramines and Water pollutants can be of two types. Organic acids are present in The harmful effects of water pollution have been effluents of rayon, leather and dying industry as also mentioned earlier. For Industrial wastes arise mainly from coal and metal mines example, magenta can impart red color at 0. Examples of inorganic substances are iron and Urban dry wastes include commercial and domestic chromium, which impart red color. Tannery waste wastes as also municipal waste in the form of dried discharged into streams with high iron content causes sewage sludge. Garbage dumps constitute This is caused by colloidal particles, which do not settle breeding ground for vermin and insects. It is estimated down, and fine particles which remain suspended and that 70,000 flies can breed in one cubic foot garbage. Sometimes, the chemical ferti- The primary reason for foam in river water and sewage lizers are contaminated with other chemicals, which works in widespread use of syndets (synthetic deter- pollute the soil where fertilizers are applied. Foaming tendency is more in relatively clean water and decreases as pollution increases. Even the Pesticides final effluent from sewage treatment plants contains considerable amounts of syndet. Others are manganese, syndets, Other Soil Chem icals oils, petroleum products and hydrocarbons. The main types of smells in water are putrid (due to hydrogen sulfide), fishy (due to organic amines), wormy Farm ing (due to phosphorus compounds) and earthy (due to humus). Both odor and taste can be removed by aeration Cattle farming and poultries produce large amount of and active charcoal. In this is not suitably disposed and is merely dumped as garbage, it causes nuisance of smell and sight in addition to public health problems.


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Here arrhythmias effective digoxin 0.25 mg, general themes and principles that underpin the functionality of the endocrine system as a whole will be presented arteria vertebralis discount digoxin 0.25 mg with visa. Hormones function as homeostatic blood-borne chemicals to regulate and coordinate various biologic functions blood pressure 8555 cheap 0.25 mg digoxin with mastercard. They are highly potent hypertension impact factor digoxin 0.25 mg purchase line, specialized heart attack 86 years old order digoxin with paypal, organic molecules produced by endocrine cells in response to specific stimuli and exert their actions on specific target cells. These target cells are equipped with receptors that bind hormones with high affinity and specificity; when bound, they initiate characteristic biologic responses by the target cells. Although the effects of hormones are many and varied, their actions are involved in (1) regulating ion and water balance; (2) responding to adverse conditions, such as infection, trauma, and emotional stress; (3) sequentially integrating features of growth and development; (4) contributing to basic processes of reproduction, including gamete production, fertilization, nourishment of the embryo and fetus, delivery, and nourishment of the newborn; and (5) digesting, using, and storing nutrients. In the past, definitions or descriptions of hormones usually included a phrase indicating that these substances were secreted into the bloodstream and carried by the blood to a distant target tissue. Although many hormones travel by this mechanism, we now realize that there are many hormones or hormone-like substances that play important roles in cell-to-cell communication that are not secreted directly into the bloodstream. Instead, these substances reach their target cells by diffusion through the interstitial fluid. In the endocrine system, a hormone molecule secreted into the blood is free to circulate and contact almost any cell in the body. However, only target cells, those cells that possess specific receptors for the hormone, will respond to that hormone. As presented in Chapter 2, a hormone receptor is the molecular entity (usually a protein or glycoprotein) either outside or within a cell that recognizes and binds a particular hormone. When a hormone binds to its receptor, characteristic biologic effects of that hormone are initiated. Therefore, in the endocrine system, the basis for specificity in cell-to-cell communication rests at the level of the receptor. The restricted distribution of some hormones ensures a certain degree of specificity. For example, several hormones produced by the hypothalamus regulate hormone secretion by the anterior pituitary. These hormones are carried via small blood vessels directly from the hypothalamus to the anterior pituitary, prior to entering the general systemic circulation. The anterior pituitary is, therefore, exposed to considerably higher concentrations of these hypothalamic hormones than the rest of the body; as a result, the actions of these hormones focus on cells of the anterior pituitary. Another mechanism that restricts the distribution of active hormone is the local transformation of a hormone within its target tissue from a less active to a more active form. An example is the formation of dihydrotestosterone from testosterone, occurring in such androgen target tissues as the prostate gland. Because the enzyme that catalyzes this conversion is found only in certain locations, its cell or tissue distribution partly localizes the actions of the androgens to these sites. Therefore, although receptor distribution is the primary factor in determining the target tissues for a specific hormone, other factors may also focus the actions of a hormone on a particular tissue. Feedback mechanisms regulate the endocrine system, just as in many other physiologic systems. The mechanism is usually negative feedback, although a few positive feedback mechanisms are known. Both types of feedback control occur because the endocrine cell, in addition to synthesizing and secreting its own hormone product, has the ability to sense the biologic consequences of secretion of that hormone. This enables the endocrine cell to adjust its rate of hormone secretion to produce the desired level of effect, ensuring the maintenance of homeostasis. In the simplest form, negative feedback is a closed loop in which hormone A stimulates the production of hormone B, which in turn acts on the cells producing A to decrease its rate of secretion (Fig. In the less common positive feedback system, hormone B further stimulates the production of A instead of diminishing it (Fig. Many examples of negative feedback regulation exist and are discussed throughout the endocrine chapters. Endocrine control systems also have feedforward loops, which can be negative or positive and which direct the flow of hormonal information. Unlike negative feedback, which promotes stability, feedforward control anticipates change. Red lines indicate stimulatory effects; blue lines indicate inhibitory, negative feedback effects. More commonly, feedback regulation in the endocrine system is complex, involving second-order or third-order feedback loops. For example, multiple levels of feedback regulation may be involved in regulating hormone production by various endocrine glands under the control of the anterior pituitary (Fig. The regulation of the secretion of target gland hormones, such as adrenal steroids or thyroid hormones, begins with the production of a releasing hormone by the hypothalamus. The releasing hormone stimulates the production of a trophic hormone by the anterior pituitary, which in turn stimulates the production of the target endocrine cell hormone by the target gland. In addition, the trophic hormone may inhibit releasing hormone secretion from the hypothalamus, and in some cases, the releasing hormone may inhibit its own secretion by the hypothalamus. The more complex multilevel form of regulation appears to provide certain advantages compared with the simpler system. Theoretically, it permits a greater degree of fine-tuning of hormone secretion, and the multiplicity of regulatory steps minimizes changes in hormone secretion in the event that one component of the system is not functioning normally. Normal feedback relationships that control the secretion of each individual hormone are discussed in the chapters that follow. Clinical diagnoses are often made based on the evaluation of hormone–effector pairs relative to normal feedback relationships. For example, in the case of anterior pituitary hormones, measuring both the trophic hormone and the target gland hormone concentration provides important information to help determine whether a defect in hormone production exists at the level of the pituitary or at the level of the target gland. Furthermore, most dynamic tests of endocrine function performed clinically are based on our knowledge of these feedback relationships. The range of response in a healthy person is well established, whereas a response outside the normal range is indicative of abnormal function at some level and greatly enhances information gained from static measurements of hormone concentrations. Another important feature of the endocrine system is signal amplification, a mechanism that increases the amplitude of the signal. For example, blood concentrations of hormones are exceedingly low, generally −9 −12 −9 10 to 10 mol/L. Even at the higher concentration of 10 mol/L, only one hormone molecule is present for roughly every 50 billion water molecules. Therefore, for hormones to be effective regulators of biologic processes, amplification must be part of the overall mechanism of hormone action. As presented in Chapter 2, amplification generally results from the activation of a series of enzymatic steps involved in hormone action. At each step, many times more signal molecules are generated than were present at the prior step, leading to a cascade of ever-increasing numbers of signal molecules. The self-multiplying nature of the hormone action pathways provides the molecular basis for amplification in the endocrine system. Most hormones have multiple actions in their target tissues and are, therefore, said to have pleiotropic effects. This phenomenon occurs when a single hormone regulates several functions in a target tissue. For example, in skeletal muscle, insulin stimulates glucose uptake, stimulates glycolysis, stimulates glycogenesis, inhibits glycogenolysis, stimulates amino acid uptake, stimulates protein synthesis, and inhibits protein degradation. In addition, some hormones are known to have different effects in several different target tissues. For example, testosterone, the male sex steroid, promotes normal sperm formation in the testes, stimulates growth of the accessory sex glands, such as the prostate and seminal vesicles, and promotes the development of several secondary sex characteristics, such as beard growth and deepening of the voice. The ability of several different hormones to regulate a single biological function is referred to as multiplicity of regulation. The input of information from several sources allows a highly integrated response, which is of ultimate benefit to the whole animal. For example, several different hormones, including insulin, glucagon, epinephrine, thyroxine, and cortisol, regulate liver glycogen metabolism. For example, they may be pulsatile, episodic spikes in secretion lasting just a few minutes, or they may follow a daily, monthly, or seasonal change in overall pattern. For these reasons, a single randomly drawn blood sample for determining a certain hormone concentration may be of little or no diagnostic value. A dynamic test of endocrine function in which a known agent specifically stimulates hormone secretion often provides much more meaningful information (Clinical Focus 30. Measurements of circulating growth hormone levels are, therefore, desirable in children whose growth rate is not appropriate for their age. To obtain reliable information about growth hormone secretion, insertion of a continuous withdrawal pump or patent indwelling catheter with unrestricted food intake and physical activity is required. Increasing sampling frequencies from every 20-minute to 5-minute or 30-second sampling intervals enhances the threshold for detecting more pulses per hour. By perturbing the system in a well-prescribed fashion, the endocrinologist is able to gain important information about growth hormone secretion that would not be possible if a random blood sample were used. Grouping them by chemical structure is convenient, because in many cases hormones with similar structures also use similar mechanisms to produce their biologic effects. In addition, tissues with similar embryonic origins usually produce hormones with similar chemical structures. The three chemical classes include (1) amine-derived, (2) polypeptide- derived, and (3) cholesterol-derived hormones. Hormones derived from one or two amino acids are small in size and often hydrophilic. These hormones are formed by conversion from a commonly occurring amino acid; norepinephrine and thyroxine, for example, are derived from tyrosine (Fig. Each of these hormones is synthesized by a particular sequence of enzymes that are primarily localized in the endocrine gland involved in its production. Many environmental or pharmacologic agents can influence the synthesis of amino acid–derived hormones in a relatively specific fashion. The steps involved in the synthesis of these hormones are discussed in detail in later chapters. Within the polypeptide class of hormones are many families of hormones, some of which are listed in Table 30. Hormones can be grouped into these families as a result of considerable homology with regard to amino acid sequence and structure. Presumably, the similarity of structure in these families resulted from the evolution of a single ancestral hormone into each of the separate and distinct hormones. In many cases, there is also considerable homology among receptors for the hormones within a family. Moreover, most, if not all, polypeptide hormones are synthesized as part of an even larger precursor or preprohormone. Because the prohormone is processed through the Golgi apparatus and packaged into secretory vesicles, it is proteolytically cleaved at one or more sites to yield active hormone. In many cases, preprohormones may contain the sequences for several different biologically active molecules. Inactive spacer segments of peptide, in some cases, may separate these active elements. Specific mechanisms of polypeptide hormone synthesis, storage, and processing are discussed in later chapters. Examples include aldosterone, cortisol, and androgen, secreted by the cortex (outer zone) of the adrenal glands; testosterone, secreted by the testes; and estrogen and progesterone, secreted by the ovaries. These adrenal and gonadal steroid hormones contain an intact steroid nucleus, as illustrated for cortisol in Figure 30. In contrast, other hormone derivatives of cholesterol, such as vitamin D and its metabolites, have a broken steroid nucleus (the B ring) (see Fig. Steroid hormones are synthesized and secreted on demand (specific mechanisms are discussed in later chapters). As with other secretory peptides, the prepeptide or signal peptide is cleaved off early in the biosynthetic process, yielding proinsulin. Proinsulin is an 86-amino acid protein that is subsequently cleaved at two sites to yield insulin and a 31-amino acid peptide known as C-peptide. Insulin and C-peptide are, therefore, localized within the same secretory vesicle and are cosecreted into the bloodstream. For these reasons, measurements of circulating C-peptide levels can provide a valuable indirect assessment of β-cell insulin secretory capacity. In diabetic patients who are receiving exogenous insulin injections, the measurement of circulating insulin levels would not provide any useful information about their own pancreatic function because it would primarily be the injected insulin that would be measured. However, an evaluation of C-peptide levels in such patients would provide an indirect measure of how well the β cells were functioning with regard to insulin production and secretion. For example, in the bloodstream, the binding of a plasma protein to a hormone has many effects including inactivation. Most amine- and polypeptide-derived hormones dissolve readily in the plasma, and thus, no special mechanisms are required for their transport. Mechanisms are present to promote their solubility in the aqueous phase of the blood and their ultimate delivery to a target cell. In most cases, 90% or more of steroid and thyroid hormones in the blood are bound to plasma proteins. Some of the plasma proteins that bind hormones are specialized, in that they have a considerably higher affinity for one hormone over another, whereas others, such as serum albumin, bind many hydrophobic hormones. The extent to which a hormone is protein bound and the extent to which it binds to specific versus nonspecific transport proteins vary from one hormone to another. The principal binding proteins involved in specific and nonspecific transport of steroid and thyroid hormones are listed in Table 30. The liver synthesizes and secretes these proteins, and changes in various nutritional and endocrine factors influence their production.

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After creases prehypertension workout cheap digoxin 0.25 mg buy, or decreases arterial blood gas values order digoxin cheap online, in direct proportion all arteria zarzad cheap digoxin 0.25 mg line, we have an intense red laser light and to the amount of x-ray exposure the phos­ a somewhat feeble greenish light in the phor receives prehypertension american heart association 0.25 mg digoxin buy overnight delivery. The actual exposure range same vicinity arteria umbilical unica 2012 0.25 mg digoxin overnight delivery, and we would like to detect over which this linear response is seen cov­ the greenish light as the image signal. One ers a range of about 5 microroentgens (5 way to do this is to use a flter that will x 10-3 mR) to about 50 milliroentgens (5 absorb the red light but be transparent to X 101 mR), yielding an exposure range of the greenish light. Figure 9-14 is a rough use an optical fber, we can conduct the graphic representation of this concept. No­ signal light to a photomultiplier tube at a tice that as the exposure increases from 5 remote position so that the photomultiplier X 10-3 mR to 50 mR (horizontal axis of tube and the laser light do not interact. The entire plate can be to take a glance ahead to Figure 11-5 and read, a scan at a time, by moving the image notice that flm has a more narrow dynamic plate perpendicular to the scan line of the range, and a non-linear response to ex­ laser beam. This concept of dy­ tube, we have a continuous point-by-point namic range (we will often call this "ex­ scan of the image. The output is an elec­ posure latitude") will be re-examined in trical analog signal corresponding to ab­ much more detail in Chapter 11. This signal What is the advantage of a system with must be amplifed, converted to a digital a large, linear dynamic range? That is, the exposure that : i w ( causes the flm to be developed as very a 0 I 100 black is about 100 times greater than the 3 2 1 ° 1 2 � 10- 10- 10- 10 10 10 exposure that causes such a faint gray that c. The A major problem in radiology departments newer fast phosphors exhibit a higher con­ results from the need for repeat exami­ version effciency. A rays in the diagnostic range is a function wide latitude system will decrease the need of the matching of the K-absorption edge for repeat exposures. The spectral emis­: necessary to process photostimulable phos­ siOn of some phosphors requires that an phor �mages in two steps. System noise becomes important alyzed to compute the exposure level and when the fastest flm-screen systems are exposure range of the stored image. This pre-reading activated banum fuorohalide, which is thus allows examinations made with a wide coated on an imaging plate. The latent image is con­ underexposed and overexposed as well as verted to a light image using laser stimu­ correctly exposed examinations will be lated luminescence. Digital tube conve ts the: light image intoan analog processing of these images can produce a. This analog signal is am­ vanety of other image changes which we plifed, converted to a digital sig�al, and will consider in another chapter. Also, the lower expo­ method for the evaluatwn of the conversion ef­ sures required (less mAs) allow the shorter fciency of fluoroscopic screens. Until about 1971, calcium mtens1fymg screens which influence the effcacy tungstate was the phosphor used in most of a film-screen combmatwn. Chicago, Year Physical properties of calcium tungstate x-ray Book Medical Publishers, 1960. This is represented by vari­ tected from mechanical damage by layers ation in the number of x-ray photons in known as the supercoating (Fig. We are unable to make direct use of the infor­ Film Base mation in this form, however, and must The only function of the flm base is to transfer it to a medium suitable for viewing provide a support for the fragile photo­ by the eye. Three characteristics of involve a magnetic tape or disc, a fuoro­ the base must be considered. The most im­ not produce a visible pattern or absorb too portant material used to "decode" the in­ much light when the radiograph is viewed. In reviewing x-ray flm, we must examine both the film and those factors that infuence the amount of information lost in the transfer process. In must not change during the developing 1960 the first medical radiographic flm us­ process or during the stored life of the flm. Poly­ Figure 10-2 illustrates a radiograph in ester as a film base offers the advantage of which the base has slowly diminished in size improved dimensional stability, even when over a period of 22 years. Notice how stored under conditions of varying humid­ shrinking of the base has thrown the un­ ity, and it is much stronger than acetate. It is no longer possible to make a "fat under conditions of low pressure and high plate of the abdomen," because x-ray plates temperature to form a molten polymer that are not available. The onset of World War is then literally stretched into sheets of ap­ I cut off the supply of photographic glass propriate size and thickness to form flm from Belgium and created a demand for a base. Cellulose nitrate is Triacetate and polyester bases are clear quite fammable, however, and several fres and colorless. In 1933 the frst commer­ were caused by improper handling and cialized blue tint was added to x-ray flm in storage of the flm. Because of this fre haz­ an effort to produce a flm that was "easier" ard a new "safety base" flm was urgently to look at, causing less eyestrain. The slightly thinner polyester base has handling properties approximately equal to those of the thicker acetate. Therefore, a thin layer of adhesive sub­ stance is applied to the base to ensure per­ fect union between base and emulsion. Emulsion The two most important ingredients of a photographic emulsion are gelatin and silver halide. The exact composition of the various emulsions is a closely guarded in­ dustrial secret. Most x-ray flm is made for use with intensifying screens, and has emulsion coated on both sides of the base. Emulsion thickness varies with flm type, Figure 10-2 Wrinkled emulsion resulting *Dacron and Cronex are trademarks of E. A thicker emulsion would not be useful be­ cause of the inability of light to penetrate to the deeper layers. Photographic gelatin for x-ray film is made from bone, mostly cattle bone from India and Argentina. It keeps the silver hal­ ide grains well dispersed and prevents the clumping of grains. Processing (developing and fxing) solutions can penetrate gelatin rapidly without destroying its strength or permanence, and gelatin is available in a reasonably large quantity and uniform quality. The hal­ ide in medical x-ray film is about 90 to 99% silver bromide and about 1 to 10% silver iodide (the presence of Agi produces an emulsion of much higher sensitivity than a pure AgBr emulsion). The silver iodo­ Figure 10-3 The silver iodobromide crystal lattice bromide crystals are precipitated and emulsifed in the gelatin under exacting conditions of concentration and tempera­ ture, as well as the sequence and the rate emulsions. In general, the precipitation and each grain contains an average of reaction involves the addition of silver ni­ 1,000,000 to 10,000,000 silver ions. A point The silver halide in a photographic defect consists of a silver ion that has emulsion is in the form of small crystals moved out of its normal position in the suspended in the gelatin. The crystal is crystal lattice; these interstitial silver ions formed from ions of silver (Ag+), ions of may move in the crystal (Fig. A dis­ bromine (Br-), and ions of iodine (I-) ar­ location is a line imperfection in the crystal, ranged in a cubic lattice (Fig. These and may be thought of as a brick wall that grains, or crystals, in a medical x-ray film contains one row in which the bricks are emulsion are small but still relatively large not the same size as all the other bricks, compared to fne-grain photographic thus causing a strain in the wall structure. The electron gives the sensitivity speck a negative charge, and this attracts the mo­ bile interstitial Ag+ ions in the crystal. Growth of silver atoms at the Figure 10-4 A point defect site of the original sensitivity speck con­ tinues by repeated trapping of electrons, This may be the way in which the iodine followed by their neutralization with inter­ ion strains the crystal. The negative bromine Chemical sensitization of a crystal takes ions that have lost electrons are converted several forms. It is commonly produced by into neutral bromine atoms, which leave adding a sulfur-containing compound, the crystal and are taken up by the gelatin such as allylthiourea, to the emulsion, of the emulsion. Figure 10-5 diagrams the which reacts with silver halide to form sil­ development of a two-atom latent image ver sulfide. It is one or many of these centers in which the sensitivity speck that traps electrons to atomic silver atoms are concentrated. The begin formation of the latent image cen­ presence of atomic silver is a direct result ters. These small clumps of silver can, however, be seen with electron mi­ Metallic silver is black. These clumps of silver atoms are produces the dark areas seen on a devel­ termed latent image centers, and are the oped radiograph. We must explain how ex­ sites at which the developing process will posure of the sensitized silver iodobromide cause visible amounts of metallic silver to grains in the film emulsion to light (from be deposited. The difference between an x-ray intensifying screens), or to the direct emulsion grain that will react with the de­ action of x rays, initiates the formation of veloping solution and thus become a visible atomic silver to form a pattern. The energy silver deposit and a grain that will not be absorbed from a light photon gives an elec­ "developed" is the presence of one or more tron in the bromine ion enough energy to latent image centers in the exposed grain. The electron can move in the crys­ At least two atoms of silver must be present tal for relatively large distances as long as at a latent image center to make a grain it does not encounter a region of impurity developable (i. The more photoelectric absorption or Compton scat­ silver atoms that exist at a latent image cen­ tering, and have rather long ranges in the ter, the greater the probability that the emulsion. Some centers will this way may react with many grains in an contain several hundred silver atoms. The manner in which the energy der the usual conditions, the absorption of of the electrons is imparted to the photo­ one quantum of light by a silver halide graphic emulsion is complex and will not grain will produce one atom of silver and be considered in detail. The sorption of x rays by the emulsion is not energy of one absorbed x-ray photon can caused by electromagnetic radiation itself produce thousands of silver atoms at latent but by electrons emitted when the x-ray image sites in one or several grains. Even photon interacts with the silver halide in this large number of silver atoms is low, the emulsion. Most of the energy of the absorbed veloped film may be used as an indication photon is lost in processes that do not pro­ of how much x-ray exposure (i. Only 3 to 10% of the pho­ Because the sensitivity of the flm varies ton energy is used to produce photolytic greatly with the energy (kVp) of the x rays, silver. The photographic effect of direct however, blackening of a piece of flm does x-ray exposure on an emulsion can be in­ not give an accurate estimation of the ex­ creased by a factor of almost 100 by proper posure to which the flm has been sub­ chemical sensitization of the emulsion. For example, a flm subjected to an The sensitivity of film to direct x-ray ex­ exposure of 50 mR at an x-ray energy of posure varies signifcantly (by a factor of 50 kVp will, after development, exhibit a 20 to 50) with the energy (kVp) of the x-ray much higher density (amount of blacken­ beam. This x-ray spectral sensitivity is most ing) than an identical flm subjected to an important when considering use of flm to exposure of 50 mR by 200-kVp x rays. Above 50 kVp, the ef­ radiation energy is partially solved by plac­ fciency with which absorbed x-ray photons ing various metal flters in front of the flm are utilized to produce a photographic ef­ in an attempt to control the energy (kVp) fect decreases significantly with increasing of the x rays that reach different areas of photon energy. The accuracy of flm badge mon­ age keV of the x rays produced will be close itoring of x-ray exposure is about ± 20%. This will posure offers several advantages over cause the film to exhibit maximum pho­ other methods, such as ionization cham­ toelectric absorption of 50-kVp x rays. The film badge provides a permanent ure 10-6 shows, in a rough graphic form, record, and is small in size and weight, rug­ the way in which the x-ray sensitivity of film ged, and inexpensive. Supercoating The sensitivity also varies greatly with the way in which the film is developed. The Covering the emulsion is a thin layer, amount of blackening (density) on the de- commonly gelatin, that serves to protect the emulsion from mechanical damage. In special types of film this supercoat, or anti­ � 1 abrasive coating, may contain substances 90 > that make the film surface smooth and 1 slick. This is a desirable quality in flm that ( z must be transported through a cut flm w C 60 rapid film changer. De­ and inactivation of the developing agent velopment is generally an all-or-none phe­ and the liberation of hydrogen ions. Note nomenon, because an entire grain is de­ that the reaction must proceed in an al­ veloped (reduced) once the process begins. When hydroquinone is ox­ The process is usually initiated at the site idized to quinone, two electrons are liber­ of a latent image speck (commonly on the ated to combine with the two silver ions to surface of the grain). The re­ action of the silver atoms in the latent action of phenidone is similar (Fig. The silver in a grain this initially microscopic black spot into a that does not contain a latent image can be single visible black speck of silver in the reduced by the developer, but at a much emulsion. Thus, time is a fundamental In addition to developing agents, the de­ factor in the developing process. Devel­ veloping solution contains ( 1) an alkali to opment should be discontinued when the adjust the pH, (2) a preservative (sodium differential between exposed developed sulfte), and (3) restrainers, or antifog­ grains and unexposed undeveloped grains gants. Hydroquinone was tion, the alkali serves as a buffer to control discovered to be a developing agent in the hydrogen ions liberated during the de­ 1880. Developers made of hy­ velopers function at a pH range of 10 to droquinone are characterized by high con­ 11. Metol developers became available in droxide, sodium carbonate, and borates 1891, and are characterized by high speed, (sodium metaborate and sodium tetrabor­ low contrast, and fine grain. Both metol and phenidone are used mainly The oxidation products of the developing in combination with hydroquinone. This agents decompose in alkaline solution and statement is usually expressed the other form colored materials that can stain the way around by stating that hydroquinone emulsion. These products react rapidly is used mainly in combination with metol with sodium sulfite to form colorless solu­ or phenidone. In addition, sodium sulfte cause of the phenomenon of synergism, or acts as a preservative. The mixture results in a the developing agent will react with oxygen development rate greater than the sum of from the air. The sulfite acts as a preser­ the developing rate of each developing vative by decreasing the rate of oxidation, agent. Sulfite re­ ergism are complex and not fully under­ moves oxygen from the air dissolved in the stood, so we will not explore the details.

To create “suicide genes” that enter cancer Recent trials suggest that immuno- used in colon cancer blood pressure medication addiction purchase digoxin 0.25 mg without prescription. How to best select within the tumor causing it starved to patients for this approach and how to Other Forms of Cancer Therapy death heart attack 720p discount 0.25 mg digoxin visa, called antiangiogenesis blood pressure chart emt 0.25 mg digoxin buy with amex. To use genes to protect healthy cells from pies are not well-understood for most Hormone Therapy the side-efects of therapy hypertension blurred vision proven 0.25 mg digoxin, allowing higher cancer types heart attack pain in arm cost of digoxin. Cancers of the breast, prostate, endometrium doses of radiation therapy and chemo- are hormone sensitive. Biologic Therapy mone sensitive bear appropriate hormone Common cold viruses are used as vectors The basic concept of biologic therapy is to receptors and these are ofen over expressed. At present gene therapy is exploit the molecular diferences between not curative and is given along with other normal cells and cancer cells. Ablative therapy-Tis type of ther- properties and many other protein kinases apy was used previously and included Immunotherapy have been shown to be aberrantly activated oophorectomy and adrenalectomy in the The aim of immunotherapy is to induce or in cancer cells. Terefore, protein kinases treatment of breast cancer and orchidec- potentiate antitumor immunity that can involving these aberrantly activated pathways tomy in the treatment of cancer prostate. Some of the kinase inhibitors occasionally nowadays has given way to Antitumor Strategies in clinical development include inhibitors of drug treatment. It is thought to activate the antitu- Most biologic agents are cytostatic and not used in breast cancer. Tus rational combination therapy cytoproterone acetate which completes with cells and macrophages. For the diagnosis of intestinal obstruc- oarthritis, cervical spondylosis, vertebral 3. Special radiological techniques using con- tion-It is the most important proce- disk protrusion or prolapse. In trauma patients, there may be evi- • Contrast studies using iodine contain- sis. Multiple gas–fuid levels are the dences of rib fracture, pelvic or long ing agents, e. The natural contrasts in diferent body tissues has not had a chest X-ray in the last 12 congenital dislocation of hip, talipes due to their contained liquids and air can be months. Chapter 17  Imaging in Surgery Route of administration-Oral or parenteral Both the above tests cannot be performed doppler scan can detect site of occlusion by which the radiopaque materials are secreted in patients with Jaundice because of impaired in a vessel due to thrombus or embolism. Ba–meal X-ray of stomach and duode- the biliary tree following endoscopic cannu- growth num. Ba meal follow through-Barium is fol- • Abscess or tumor Principle lowed down the small intestine. It is indi- • Postsurgical collection cated in cases of suspected ileocecal tuber- Ultrasonography uses high frequency sound • Acute swelling or infarction. Double contrast Barium X–ray-In this Tus fuid in a simple cyst does not sensitive). Posttraumatic organ scanning – It is Ba–studies are contraindicated if there are obtained. Posttransplant organ scanning to or perforation as there is dense adhe- Advantages see whether the organ is functioning sions when it escapes into the peritoneal • It is noninvasive and carries no radiation properly from the vascular status. It can detect the presence of intrac- Tis is used for the contrast radiology of hol- sedation. Kidney Iodine containing water soluble compounds, Disadvantages – Stone showing the shadowing efect. Gallbladder and biliary tract-Diagnosis – Sol (space occuping lesion) orally to outline the gall bladder (oral chole- of gallstone, pancreatic calculi dilatation – Cystitis. Less useful scans are done in case of suspected pul- kidney lesions like renal trauma, monary embolism. It is relatively expensive, time • In ventilation scan, 133xe is inhaled to requires less time consuming and cannot be used in outline the bronchi and alveoli. Liver scan-The isotope used in 99mTc – tic activity surrounding bone metastases modalities but it is an important adjuvant. Tere are three pairs of major salivary glands Disposition of parotid fascia (sheath) - Presenting Parts (Fig. Besides these main salivary glands, splits at the lower pole of the parotid gland terior belly of digastric and appears in the small accessory glands are found scattered and invest the gland, forming the false cap- carotid triangle. Base is concave and related to the external Tese glands are occasional sites for devel- attached to the zygomatic arch above and acoustic meatus. Superfcial surface is covered by the skin seter muscle to form the tough parotidomas- and superfcial fascia. Anteromedial surface is deeply grooved It is the largest of the three paired salivary The deep layer is thin and is attached to by the ramus of the mandible. The mould presents the the temporal bone and is thickened to form mastoid process, sternomastoid muscle, the following boundaries (Fig. Some parts of the gland extend beyond the mould and produce various processes of the gland, e. Approximately 80 percent of neoplasms of and its branches, (2) Retromandibular vein salivary glands occur in the parotid glands. The remaining 20 percent are parotid gland into two parts – the superfcial eferent vessels from these nodes terminate malignant. The facial nerve emerges from the stylo- 60 percent of which are benign (95% pleo- mastoid foramen about 2. The sym- vary glands including sublingual gland – 50 Within the gland, the nerve runs forward pathetic fbers provide vasomotor supply to percent benign (almost all are pleomor- for another 1 cm superfcial to the retro- the gland. Classifcation into benign, low grade, high The cervicofacial passes downward and grade and nonsalivary tumors is convenient forward and subdivides into buccal (upper Peculiarities for prognostic purpose. Papillary cystadenoma lymphomato- union of superfcial temporal and maxillary of the mandible. Metastatic carcinoma from carcinoma Parotid Duct cle-Fibroma, Lipoma, Rhabdomyoma breast, kidney, lungs, etc. The duct emerges through the anterior border Diagnostic Point of the gland and passes at frst forward on the The swelling becomes fxed and hard mixed Parotid tumor masseter muscle between the upper and lower beneath the fngers when the masseter is introduction buccal nerves. At the anterior border of the contracted by clinching the teeth and free masseter it abruptly turns medially and pierces but relatively sof when the masseter is It is the most common tumor of the parotid the buccinator muscle. Swelling in relation to the overlying skin phic salivary adenoma because there is pleo- 124 site the crown of upper second molar tooth. Multicentric growth potentiality of the • Lymph nodes- Cervical lymph nodes leave behind these extensions resulting in tumor. So treat- spot in case of adenolymphoma unlike • The usual complaint is a painless, slow ment of choice is surgery. The operation other neoplasms including mixed parotid growing tumor over the angle of the jaw. Enlarged cervical is situated below the • The tumor has a predilection to develop at lymph nodes angle of the mandibule the lower part of the gland. Adenolymphoma is not a lymphoma, hence, a treatment • Mobility - The tumor can be moved little misnomer. Origin: During development some parotid carcinoma of Parotid gland • Facial nerve - It is not involved as it is a tissue gets included, within lymph nodes History benign tumor. The cysts usually contain glairy brown • Rapidly growing swelling on the side of 3. Cervical lymphadenopathy due to tuber- • The swelling may be painful, pain may culosis, metastasis or lymphoma Microscopic Appearance radiate to the ear, to the face or to the neck. Lipoma • It is quite diferent from any other tumor • Pain is more felt if there is involvement of 6. Malignant change-Afer a few years, stroma, lymph follicles (hence the name) ing skin may be somewhat warm. When the pleomorphic adenoma shows features of is characteristic of adenolymphoma. It should be suspected when : clinical Features Surface – Irregular, • Sudden or rapid increase in the swell- Age - Commonly afer 40 yrs. Diagnosis History ParotiD FiStula Age – Most common in young and middle- aged adults. Such fstula may be Presentation internal or external when it opens to the exterior. Following incision and drainage of parotid food classically by sucking a lemon (Fig. Penetrating injury particularly by glass Initially the swelling used to disappear in Types of malignant tumor see page 126 in splinters. As a complication of superfcial persistent and gets aggravated during intake parotidectomy. The tumor is almost radioresistant, so treat- on Examination ment of choice is surgery (Fig. Duct fstula - When there is a fstula is usually smooth, all the margins are extent. A malignant lesion such as actinic cell Main complaint is an opening on the cheek stone in the submandibular duct is palpa- tumor, mucoepidermoid carcinoma, etc. Tere may be excoriation of the neigh- lesion, one may try to save the facial nerve borhood skin. Tis operation is investigation sal view) is taken to look for any radioopaque called conservative total parotidectomy). Fistulogram is performed with watery solution calculus in the line of submandibular duct. Local recurrences should be treated by of lipiodol to know whether the fstula is in rela- Sometimes the stone may be nonopaque due radiotherapy. When complete removal is not possible, superfcial parotidectomy along with treatment radium implantation should be the treat- 1. When the lesion is completely fxed and mide Tab, (Probanthine 15 mg Tab) – ½ irremovable only palliative deep X-ray Tab twice daily is given to reduce salivary therapy may be advised. Incision - A curved incision, 5 cm long carcinoma oF SuBmanDiBular in the line of the skin crease (Langer’s SaliVary glanD Stone in the Submandibular Duct line) is made 2 cm below and in front of The stone is removed by making an incision the angle of the mandible to avoid injury History directly over it through the mucous mem- to the cervical branch of the facial nerve. The lingual nerve and the hypoglossal ing in the upper part of lateral side of neck. Tere is no are grasped by the forceps which surface of the gland and mylohyoid mus- alteration in the size of the swelling dur- steady the stone and thus prevent it, cle and hyoglossus muscle - should be ing meals. An incision is made on the mucous mem- lized to raise it from the mylohyoid • Tere is swelling in the submandibular brane and duct directly over the stone in muscle. The deep part of the gland is dissected • The swelling is nontender, surface - irregular. The cut ends of the mucous membrane and removed by ligating and dividing the skin and underlying structures. Hemostasis secured and the wound closed Stone in the Submandibular Gland with a drain. Mixed tumor involving the submandibu- Ques: What are other indications for gland are incision, mobilization and excision. General anesthesia with endotracheal deeper plane and then at superfcial intubation. Divide 2 muscles - Superfcial – platysma, Total excision of the submandibular gland extended and sand - bag placed beneath deep – fbers of myelohyoid. In case of large tumors radical excision of It is the most common of all varieties of epu- the bone should be performed requiring Classification lis. The graf may be Tumors arising from the jaw are of three of an incisor or premolar tooth. Tose arising from the tooth germ called Clinical Features For an understanding of the origin of the odontomes. The tooth germ consists of the • It presents as a frm nodule at the junction odontogenic cysts and also the rarer odon- enamel organ and the dental papilla, consti- of the gum and tooth. It is a slow grow- togenic tumors of the jaws, a brief outline of tuting the developing tooth (See below) and ing tumor and not tender. The rest of the tooth Definition Giant Cell or Myeloid Epulis (pulp, dentine and cement) forming the crown Epulis is a nonspecifc term applied to a local- • It is an osteoclastoma arising from the and root embedded in the tooth socket in the ized swelling of the gum. Granulomatous or false epulis-Tis is a tumor consists of fbrous tissue with abun- from the underlying mesodermal connective heaped up mass of granulation tissue in dant vascularity and giant cells of foreign tissue. The diferent varieties of odontomes are: or at the site of irritation by a false tooth. Epithelial odontomes arising from the peculiarly occurs in pregnancy following • X-ray may be performed to show typical epithelial elements minor trauma and chronic infection. Composite odontomes arising from the association of such a tooth in relation to a approach. Afer excision of the epithelium epithelial and connective tissue elements localized swelling in a jaw gives the diagnosis the cyst wall is curetted and the sof tissue viz. Compound follicular • Most commonly it develops in relation odontome to the incisors or canines of the maxilla. Composite odontome When it attains large size, it extends into rare arising from the whole the maxillary air sinus and causes bulging • It is a squamous epithelial lined cyst con- tooth germ. Usually it occurs in adult life taining the unerupted crown of a tooth and is painless. The its epithelial lining through intraoral the cells resulting in a dentigerous cyst. Within the cyst, the tooth lies obliquely or sometimes, embedded in the wall of the cyst. Large cysts are man- more expansion of the outer cortex of the Benign Tumors aged by marsupialization. Hence it is also called X-ray shows a large cyst or small multiple • Osteosarcoma. It may amount to segmental exci- eration, hence called multilocular cystic sion of the mandible or hemimandibulectomy. Incomplete-When the clef has not At about the 6th week of intrauterine life, the the nasal septum.

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Grim, 29 years: In organs other than the kidney, capillary hydrostatic pressure declines from the arterial to the venule end of the capillary.

Kadok, 28 years: The dog would have been dead long before this could happen, which underscores the importance of glomerulotubular balance.

Runak, 38 years: Preliminary measures mandibulectomy is done in addition to side of the median raphe and may run • To maintain oral hygiene with regular glossectomy.

Xardas, 59 years: Varicella-zoster virus epidemiology - vesicular or without fluid) lasting for more than three days and a changing scene?

Roy, 25 years: Diuretics are also employed to create large urine volumes to reduce the concentration of other performance enhancing drugs in the urine.

Kasim, 27 years: Endoscopy is usually indicated to rule out the presence of an obstructive neoplasm.

Stejnar, 52 years: A patient with malignant disease may be cachec- tic (Chapter 4, p59) and have a palpable epigastric Recent weight loss This suggests malignancy.

Renwik, 57 years: This is known to affect wound is changed regularly or through a long-term central healing and to suppress the immune response, but catheter.

Cyrus, 33 years: Ethnology is the comparative feels that its vital or organic essense is in danger due to study of cultures.

Aidan, 43 years: Effect of a quality improvement • Septic patients may have warm shock or cold shock with or intervention to decrease delays in antibiotic delivery in pediatric febrile without respiratory distress neutropenia: A pilot study.

Jorn, 60 years: Several fortunate coincidences set the outline of his skeleton appeared on the the stage for the discovery.

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