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By: Daniel James George, MD

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The effect of a calorie deficit on weight body weight are all important concepts when builddoes not depend on how the deficit is produced—by ing an eating pattern that promotes calorie balance reducing calorie intake jon gomm hypertension zip purchase generic cardura from india, increasing expenditure blood pressure medication with little side effects cardura 1 mg visa, or and weight management hypertension symptoms high blood pressure order cardura american express. Data are drawn from analyses of usual dietary intakes conducted by the National Cancer Institute blood pressure chart to keep track order discount cardura. Additional information on the top calorie contributors for various age groups, as well as by gender and race/ethnicity, are available at riskfactor. Sodas, energy drinks, sports drinks, and sweetened bottled water including vitamin water. Similarly, fiber can be naturally occurring in foods (such Carbohydrate, protein, fat, and alcohol as in beans and whole grains) or added to foods. Most Carbohydrate, protein, and fat are the main sources carbohydrate is consumed in the form of starches, of calories in the diet. Most foods and beverages which are found in foods such as grains, potatoes, and contain combinations of these macronutrients in other starchy vegetables. Added Carbohydrates provide 4 calories per gram and are sugars and added starches generally provide calories the primary source of calories for most Americans. Although most people Carbohydrates are classified as simple, including consume an adequate amount of total carbohydrates, sugars, or complex, including starches and fibers. Some many people consume too much added sugar and sugars are found naturally in foods (such as lactose in refined grain and not enough fiber. Estimated Calorie Needs per Day by Age, Gender, and Physical Activity Levela Estimated amounts of calories needed to maintain calorie balance for various gender and age groups at three different levels of physical activity. An individual’s calorie needs may be higher or lower than these average estimates. Physical Activity Levelb Gender Age (years) Sedentary Moderately Active Active Child (female and male) 2–3 1,000–1,200c 1,000–1,400c 1,000–1,400c Femaled 4–8 1,200–1,400 1,400–1,600 1,400–1,800 9–13 1,400–1,600 1,600–2,000 1,800–2,200 14–18 1,800 2,000 2,400 19–30 1,800–2,000 2,000–2,200 2,400 31–50 1,800 2,000 2,200 51+ 1,600 1,800 2,000–2,200 Male 4–8 1,200–1,400 1,400–1,600 1,600–2,000 9–13 1,600–2,000 1,800–2,200 2,000–2,600 14–18 2,000–2,400 2,400–2,800 2,800–3,200 19–30 2,400–2,600 2,600–2,800 3,000 31–50 2,200–2,400 2,400–2,600 2,800–3,000 51+ 2,000–2,200 2,200–2,400 2,400–2,800 a. Sedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life. The calorie ranges shown are to accommodate needs of different ages within the group. In addition To manage body weight, Americans should consume to calories, protein provides amino acids that assist a diet that has an appropriate total number of calories in building and preserving body muscle and tissues. Strong evidence shows Protein is found in a wide variety of animal and plant that there is no optimal proportion of macronutrients foods. Animal-based protein foods include seafood, that can facilitate weight loss or assist with maintainmeat, poultry, eggs, and milk and milk products. Although diets with a wide range of Plant sources of protein include beans and peas, macronutrient proportions have been documented nuts, seeds, and soy products. Inadequate protein to promote weight loss and prevent weight regain intake in the United States is rare. Types of fat in calories and the individual is able to maintain a include saturated, trans, monounsaturated, and polyreduced-calorie intake over time. Some fat is found naturally in of calories consumed is the essential dietary factor foods, and fat is often added to foods during prepararelevant to body weight. Similar to protein, inadequate intake of total fat suggests that diets that are less than 45 percent of is not a common concern in the United States. Most total calories as carbohydrate or more than 35 percent Americans consume too much saturated and trans of total calories as protein are generally no more effecfatty acids and not enough unsaturated fatty acids. Therefore, Alcohol contributes 7 calories per gram, and the individuals who wish to lose weight or maintain number of calories in an alcoholic beverage varies weight loss can select eating patterns that maintain widely depending on the type of beverage consumed. Recommended Macronutrient Proportions by Age Carbohydrate Protein Fat Young children (1–3 years) 45–65% 5–20% 30–40% Older children and adolescents (4–18 years) 45–65% 10–30% 25–35% Adults (19 years and older) 45–65% 10–35% 20–35% Source: Institute of Medicine. The followship between the intake for recommendations for ing guidance may help individuals control their total of meat and poultry individual food groups and calorie intake and manage body weight: or beans and peas, components. Although not independently related to body fruits: Moderate evidence shows that adults who eat weight, these foods are important sources of nutrients more whole grains, particularly those higher in dietary in healthy eating patterns. Moderate evidence in Placing individual food choices into an overall adults and limited evidence in children and adoleseating pattern cents suggests that increased intake of vegetables Because people consume a variety of foods and and/or fruits may protect against weight gain. Strong evidence shows that children and these patterns that has been researched is the adolescents who consume more sugar-sweetened concept of calorie density, or the amount of calobeverages have higher body weight compared ries provided per unit of food weight. Foods high to those who drink less, and moderate evidence in water and/or dietary fiber typically have fewer also supports this relationship in adults. Sugarcalories per gram and are lower in calorie density, sweetened beverages provide excess calories and while foods higher in fat are generally higher in few essential nutrients to the diet and should only calorie density. A dietary pattern low in calorie be consumed when nutrient needs have been met density is characterized by a relatively high intake and without exceeding daily calorie limits. Strong evidence shows that eating patterns and adolescents, especially those who are overthat are low in calorie density improve weight loss weight or obese: For most children and adolesand weight maintenance, and also may be associcents, intake of 100% fruit juice is not associated ated with a lower risk of type 2 diabetes in adults. However, heavier than moderate ful properties of food and beverages, as well as their consumption of alcohol over time is associated with calories, when selecting an eating pattern for optimal weight gain. When choosing carbohydrates, Americans mixtures with other beverages, the calorie content should emphasize naturally occurring carbohydrates, of accompanying mixers should be considered when such as those found in whole grains, beans and peas, calculating the calorie content of alcoholic beverages. Glycemic index and glycemic load have been developed as measures of the Strong evidence in adults and moderate evidence effects of carbohydrate-containing foods and beverin children and adolescents demonstrates that conages on blood sugar levels. Strong evidence shows that sumption of milk and milk products does not play glycemic index and/or glycemic load are not associated a special role in weight management. Moderate alcohol consumption is the consumption of up to one drink per day for women and up to two drinks per day for men. Substituting active pursuits for plant-based sources and/or animal-based sources can sedentary time can help people manage their weight be incorporated into a healthy eating pattern. Fat intake should provides guidance to help Americans improve their emphasize monounsaturated and polyunsaturated fats, health, including weight management, through such as those found in seafood, nuts, seeds, and oils. To achieve and maintain a healthy tional discussion of eating as long as foods and body weight, adults should do the equivalent40 of patterns that meet nutrient beverages consumed 150 minutes of moderate-intensity aerobic activity needs within calorie limits. If necessary, adults should increase their and calorie intake is weekly minutes of aerobic physical activity gradually appropriate, individuals can select an eating patover time and decrease calorie intake to a point where tern that they enjoy and can maintain over time. Individuals should consider the calories from all Some adults will need a higher level of physical activfoods and beverages they consume, regardless of ity than others to achieve and maintain a healthy body when and where they eat or drink. Some may need more than the equivalent of 300 minutes per week of moderate-intensity activity. Although the Physical Activity Guidelines Physical activity is the other side of the calorie balance do not include a specific quantitative recommendation equation and should be considered when addressing for children ages 2 to 5 years, young children should weight management. Children and Health and Human Services released a comprehensive adolescents are often active in short bursts of time set of physical activity recommendations for Americans rather than for sustained periods of time, and these ages 6 years and older. Weight management along short bursts can add up to meet physical activity with health outcomes, including premature (early) needs. Physical activities for children and adolescents death, diseases (such as coronary heart disease, type of all ages should be developmentally appropriate and 2 diabetes, and osteoporosis), and risk factors for enjoyable, and should offer variety. To address the current calorie imbalance in the United States, individuals are encouraged to become more Strong evidence supports that regular participation in conscious of what they eat and what they do. This physical activity also helps people maintain a healthy means increasing awareness of what, when, why, and weight and prevent excess weight gain. Further, physihow much they eat, deliberately making better choices cal activity, particularly when combined with reduced regarding what and how much they consume, and calorie intake, may aid weight loss and maintenance of seeking ways to be more physically active. Decreasing time spent in sedentary behavbehaviors and practices have been shown to help iors also is important as well. Strong evidence shows people manage their food and beverage intake and that more screen time, particularly television viewing, calorie expenditure and ultimately manage body 39. One minute of vigorous-intensity physical activity counts as two minutes of moderate-intensity physical activity toward meeting the recommendations. Some physical activity is better than none, and adults who participate in any amount of physical activity gain some health benefits. Aerobic activity should be performed in episodes of at least 10 minutes, and preferably, it should be spread throughout the week. Additional health benefits are gained by engaging in physical activity beyond this amount. When older adults cannot meet the adult guideolder lines, they should be as physically active as their abilities and conditions will allow. Moderate-intensity physical activity: Aerobic activity that increases a person’s heart rate and breathing to some extent. On a scale relative to a person’s capacity, moderate-intensity activity is usually a 5 or 6 on a 0 to 10 scale. Vigorous-intensity physical activity: Aerobic activity that greatly increases a person’s heart rate and breathing.

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After Biopsy deeply enough to blood pressure and pulse rates generic 1 mg cardura with visa penetrate any overlying normal or referral arteria spinalis anterior order 4mg cardura free shipping, it is important to blood pressure levels of athletes purchase cardura with amex establish a treatment plan for ongoing reactive tissue blood pressure 20090 buy cardura 2mg on line. Place samples in an adequate amount of formalin (10 parts formalin to 1 part tissue). Diagnosis of Tumor Type To avoid seeding adjacent normal tissue with cancer cells, Once the possibility of a neoplastic process is suspected, place the biopsy incision so that it can easily be excised at the determination of the tumor type serves as the basis for all time of definitive tumor removal. No confirmed diagnosis can be made by if (1) principles of appropriate surgical excision of tumors are palpation alone. A biopsy is the basic tool that allows removal and followed; and (2) staging procedures that might influence the examination of cells from the body to determine the presence, owner’s decision to have an excision performed have been cause, or extent of a disease process. Nodal metastasis seen more commonly and earlier than systemic (liver, bone, pelvis, lung). Often slowly progressive unless diffusely metastatic at diagnosis or compromised renal function due to hypercalcemia. Mast cell tumor Skin and subcutaneous Locally invasive; invasiveness increases with Pretreatment staging is optional for known tissues grade. Grade 1: metastases are rare Biopsy for determination of histologic grade is Grade 2:;20% advisable for any non-resectable, large or Grade 3:;100% rapidly growing tumor. Impact of local and nodal disease impacts quality of Primary radiation therapy (palliative or curative intent) life early in the disease process. A significant proportion of malignant tumors do not Lymph node metastases Consider complete mastectomy for dogs presenting metastasize and can be cured with appropriate High histologic grade with multiple tumors or developing multiple tumors surgery. When margins are histologically incomplete, local Mucous membrane locations Scar excision may be considered if margins are recurrence rates are;20–30%. C-kit mutation be provided or margins are histologically Metastases Histologically incomplete surgical margins incomplete. Most patients with metastases eventually die Previous local recurrence Systemic treatment regardless of treatment. Survival periods are highly Systemic illness Vinblastine-based chemotherapy variable. Resection of;1/3 lack melanin and may be confused with medial retro-pharyngeal, parotid and a sarcomas histologically. Liver A significant proportion Survival times are highly correlated with metastases cannot be definitively of splenic masses are clinical stage: distinguished from hyperplastic nodules. Optional definitively Stage 2: Hemoabdomen, no clinically Echocardiography for concurrent right atrial distinguished from detectable metastases. Ancillary tests can provide or confirm a diagnosis when how they might be beneficial. Knowledge of the lymphocyte routine histopathology does not yield definitive results. For example, as immunohistochemistry, proliferation markers, special tissue identification of a T-cell phenotype lymphoma generally indicates a stains, polymerase chain reaction, polymerase chain reaction for poor or guarded prognosis, making the patient a candidate for any antigen receptor rearrangement (in this case for lymphoma), and of several therapies that may differ from those typically used for a flow cytometry can provide additional prognostic information or B-cell lymphoma. Immunohistochemistry, polymerase chain reacidentify potential therapeutic targets. Carboplatin produces responses in measurable disease; studies regarding prolongation of survival are conflicting. Recurrence rates are Incomplete histologic margins Amputation may be considered if adequate margins likely higher for high grade tumors. Data regarding Metronomic chemotherapy may improve duration of treatment of micro-metastases with conventional or local control. However, which test to known behavior of the individual tumor type combined with the choose depends on the individual case. Evaluation of local disease starts with the physical exam to Diagnostic Staging determine the size, appearance, and mobility or fixation of the Diagnostic staging is a mainstay of oncology case management. Documentation of metastases to lymph nodes cannot blood count, chemistry panel, and urinalysis. The scope of the reliably be made by palpation for size and other physical parameters, diagnostic workup for staging purposes is dependent upon the but requirescytologyorhistopathology. Regional lymph node aspirate (even if normal size) Maxilla Oral tends to be extremely aggressive. Oropharynx Trachea Cutaneous Nasal planum Ear pinna Multifocal cutaneous in situ (Bowens) Soft tissue sarcomas Cutaneous and Locally aggressive, especially injection site with 3-view chest radiographs 6 chest radiographs (including injectionsubcutaneous tissue high (. Lymphatic invasion Unilateral or bilateral modified mastectomy with node removal Higher clinical stage if positive. Primary radiation therapy (palliative or curative intent) provides Bulky invasive lesions often cannot be poor local control for non-resectable disease even if surgically removed, rendering radiation combined with chemotherapy. Primary tumor Injection site sarcoma Injection-site location Surgery if possible for non-injection site. If a lymph node aspirate is non-diagnostic or if of the bone marrow and gastrointestinal tract. Although this the lymph node cannot be accessed for aspiration, it is a candidate for approach maximizes tumor cell death and is associated with a low excisional biopsy. For internal lymph nodes, imaging to assess and chance of serious side effects, the periods between treatments may potentially guide aspiration is recommended. The presence of confirmed tumors known to be sensitive to drug therapy, such as hematologic metastases generally implies a worse prognosis and may drastically malignancies (lymphoma, multiple myeloma), and for highly affect therapeutic decisions. Complete staging can vary depending metastatic malignancies, such as osteosarcoma, hemangiosarcoma, on the particular tumor type, but distant metastasis may be and high-grade mast cell tumors. When conventional chemotherrevealed by a thorough physical examination, abdominal and threeapy is used against solid tumors, such as osteosarcoma, it is often view thoracic radiographs, abdominal ultrasound, nuclear scintigused in an adjuvant setting after primary tumor treatment to slow progression of occult micrometastatic disease. The two Therapeutic Modalities main objectives of conventional chemotherapy are tumor control Perhaps no disease entity is more dependent on a multiand maintenance or improvement of the patient’s quality of life. Understanding Table 3 lists chemotherapeutic agents with anti-neoplastic activity how these various therapeutic modalities complement each 2 that are commonly used in veterinary medicine. For example, Metronomic Chemotherapy knowing when to initiate multiple treatment options Metronomic chemotherapy is defined as the uninterrupted adminconcurrently or sequentially is important for therapeutic istration of low doses of cytotoxic drugs at regular and frequent efficacy and ensuring the patient’s safety. Recent studies suggest that this approach may be at least as effective as conventional chemotherapy and is associated with less toxicity and expense. The endothelial cells recruited Immunotherapy to support tumor growth are exquisitely sensitive to low and Chemotherapy is now a commonly used treatment modality in 5 uninterrupted doses of chemotherapy drugs. Conventional chemotherapy, metrostability of endothelial cells makes them inherently less susceptible to nomic chemotherapy, and targeted chemotherapy using tyrosine 6 the development of drug resistance compared to tumor cells. Therefore, in order to be successfully used in practice, the clinician Despite the promise of metronomic chemotherapy, this must be aware of some of the basic principles of each approach. The potential side effects of the drugs to be used is also essential and types of cancer best suited to metronomic therapy and appropriate will be covered in later sections. The most common side effects seen with these (osteosarcoma, melanoma, and assorted carcinomas) but in a chemotherapeutics are gastrointestinal, including diarrhea, loss of much smaller number of patients. These 12 oral chemotherapeutics were often combined with a nonsteroidal pancreatitis. Immunotherapy In contrast to conventional chemotherapy, the desired Capturing the ability of the immune system to fight cancer holds endpoint for metronomic chemotherapy is often stabilization of significant promise for the treatment of highly aggressive disease rather than an overall reduction in the tumor burden. There are a number of other chemotherapy protocol has failed or has been declined by the immunotherapies currently being investigated in clinical trials patient’s owner. Side effects may occur, but are typically mild and including monoclonal antibodies for dogs with B-cell and T-cell transient. Because sterile hemorrhagic cystitis is a risk with lymphoma and an anti-nerve growth factor antibody that may cyclophosphamide chemotherapy administered in either a metropalliate the pain associated with canine osteosarcoma. Initial metronomic chemotherapy studies have shown positive tumor Therapeutic Modalities: Adjunctive Therapy responses and the protocols are generally well tolerated in Adjunctive therapies have long been used as a means of improving veterinary patients. Inhibitors A variety of adjunctive therapies are employed in controlling Tyrosine kinases are enzymes that are responsible for the activation the clinical signs encountered in dogs and cats that are treated for of proteins involved in the signaling pathways that regulate normal cancer. A treatment goal for any oncology patient is to maintain cell proliferation and survival. Because many of these pathways are quality of life by limiting treatment side effects, pain, and discomfort. Although nausea and vomiting are often self-limiting in targeted to specific signal transduction pathways, each drug can oncology patients, in some cases they are severe enough to require induce toxicities to rapidly dividing normal cells that also rely on medical intervention. Itmaybebeneficialtoconsultaveterinary veterinary medicine and is an effective anti-emetic.

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Pulseless electrical activity is electrical activity without mechanical contraction heart attack death buy cardura 1mg fast delivery. Fill in the blanks below with the particular characteristics of the strip and then check your answers with ours supine blood pressure normal value order cardura 1 mg amex. The clinical effect of the block depends on how many impulses are completely blocked blood pressure medication safe for pregnancy buy cheapest cardura, how slow the ventricular rate is as a result blood pressure chart seniors generic cardura 1 mg online, and how the block ultimately affects the heart. A slow ventricular rate can decrease cardiac output, possibly causing lightheadedness, hypotension, and confusion. Damage is most likely presence of aortic valve to occur in surgery involving the mitral or tricuspid valve or in the calcification. If a portion of the conduction system itself is severed, a permanent block results. Radio blackout Similar disruption of the conduction system can occur from a procedure called radiofrequency ablation. In this invasive procedure, a transvenous catheter is used to locate the area within the heart that participates in initiating or perpetuating certain tachyarrhythmias. Radiofrequency energy is then delivered to the myocardium through this catheter to produce a small area of necrosis. That severity is measured according to how well the node conducts impulses and is separated by degrees—first, second, and third. It’s as if people are walking in a line through a doorway, but each person hesitates before crossing the threshold. The condition may also be caused by medications, such as digoxin, calcium channel blockers, and betaadrenergic blockers. For example, if a medication is causing the block, the dosage may be reduced or the medication may be discontinued. Administer digoxin, calcium channel blockers, or beta-adrenergic blockers cautiously. That pattern continues until an impulse fails to be conducted to the ventricles, and the cycle then repeats. It’s like a line of people trying to get through a doorway, each one taking longer and longer until finally one can’t get through. It may also be due to cardiac medications, such as beta-adrenergic blockers, digoxin, and calcium channel blockers. Almost always temporary, this type of block resolves when the underlying condition is corrected. The symbols below represent some of the patterns you might see as you study rhythm strips. A temporary pacemaker may be required for long-term relief of symptoms until the rhythm resolves. When caring for a patient with this block, assess his tolerance for the rhythm and the need for treatment to improve cardiac output. Evaluate the patient for possible causes of the block, including the use of certain medications or the presence of ischemia. This block is like a line of people passing through a doorway at the same speed, except that, periodically, one of them just can’t get through. The arrhythmia indicates a problem at the level of the bundle of His or bundle branches. It’s also more likely to cause symptoms, particularly if the sinus rhythm is slow and the ratio of conducted beats to dropped beats is low such as 2:1. Expressed as a ratio of atrial-to-ventricular beats, this block will be at least 3:1. With the prolonged refractory period of this block, latent pacemakers can discharge. For instance, decreased cardiac output and reduced heart rate can combine to cause Stokes-Adams syncopal attacks. Most patients who experience a few dropped beats remain asymptomatic as long as cardiac output is maintained. As the number of dropped beats increases, patients may experience palpitations, fatigue, dyspnea, chest pain, or light-headedness. On physical examination, you may note hypotension, and the pulse may be slow and regular or irregular. How you intervene If the dropped beats are infrequent and the patient shows no symptoms of decreased cardiac output, the practitioner may choose only to observe the rhythm, particularly if the cause is thought to be reversible. If the patient is hypotensive, treatment aims to improve cardiac output by increasing the heart rate. Maintaining our doorway analogy, this form of block is like a line of people waiting to go through a doorway, but no one can go through. Most typically, it originates from the Purkinje system in the ventricles and maintains a rate of 20 to 40 beats/minute. In addition, the patient loses his potentially atrial kick—that extra 30% of blood flow pushed into the venlife-theatening tricles by atrial contraction. The P and R waves can be “walked out” across the strip, meaning that they appear to march across the strip in rhythm. Usually, the duration and configuration after congenital are normal; however, with an idioventricular escape rhythm (an escape rhythm originating in the ventricles), the duration is greatheart repair er than 0. This arrhythmia symptoms, including severe fatigue, dyspnea, chest pain, lightmay develop from interheadedness, changes in mental status, and loss of consciousness. The severity of symptoms depends to a great extent on the resulting ventricular rate. How you intervene If cardiac output isn’t adequate or the patient’s condition seems to be deteriorating, therapy aims to improve the ventricular rate. Atropine may be given, or a temporary pacemaker may be used to restore adequate cardiac output. Temporary pacing may be required until the cause of the block resolves or until a permanent pacemaker can be inserted. If the underlying rhythm decreases cardiac output, the patient will need treatment to correct the arrhythmia. Depending on the underlying cause, the patient may be treated with an antiarrhythmic, such as atropine and isoproterenol, to restore synchrony. Alternatively, the patient may be given a pacemaker to support a slow ventricular rate. If drug toxicity caused the original disturbance, the drug should be discontinued. Placement of Can your patients tolerate a permanent pacemaker is usually delayed in such cases to evaluthis rhythmfi When caring for a patient with third-degree heart block, immediately assess the patient’s tolerance of the rhythm and the need for treatment to support cardiac output and relieve symptoms. Evaluate for possible correctable causes of the arrhythmia, such as medications or ischemia. Temporary pacing may be required for this rhythm disturbance until the cause of the block resolves or until a permanent pacemaker can be implanted. Using the 8-step method for interpretation, fill in the blanks below with the particular characteristics of the strip. No real intervention is necessary; we’ll just continue to monitor your progress. A pacemaker is an artificial device that electrically stimulates the myocardium to depolarize, which begins a contraction. Pacemakers are commonly necessary following myocardial infarction or cardiac surgery. And the beat goes on Pacemakers work by generating an impulse from a power source and transmitting that impulse to the heart muscle. The impulse flows throughout the heart and causes the heart muscle to depolarize. Pacemakers consist of three components: the pulse generator, the pacing leads, and the electrode tip.

These cells are resistant to blood pressure medication starting with b purchase 4 mg cardura amex the thrombogenic influence of platelets and coagulation proteins heart attack sam tsui chrissy costanza of atc order cardura 1mg without a prescription. Intact endothelial cells act to heart attack in sleep cost of cardura modulate several aspects of hemostasis and oppose coagulation after injury by thromboresistance you purchase generic cardura online. This simplified conceptualization is useful for laboratory testing, but the division into extrinsic and intrinsic pathways is somewhat artificial. Contact activation is important in in vitro clotting in glass containers and in laboratory testing, but its physiologic role has been questioned because a deficiency of the contact factors is not associated with abnormal bleeding. It can also be activated by the platelet phospholipid complex, which becomes available through conformational changes in the platelet membrane. It restores blood flow in vessels occluded by a thrombus and facilitates healing after inflammation and injury. Thrombotic disorders can be antithrombotic (hemorrhagic), leading to pathologic bleeding states such as hemophilia and von Willebrand disease. They can also be prothrombotic, leading to hypercoagulability with pathologic thrombosis. Hereditary thrombophilia is a prothrombotic familial syndrome occurring most often in adolescents or young women. Prothrombin 20210a transition (1) this is the second most common cause of hereditary thrombophilia (as of this writing). The increased homocysteine can be reduced by dietary supplementation with folic acid and vitamins B6 (pyridoxine) and B12 (cobalamin). This prothrombotic disorder is characterized by autoantibodies directed against a number of protein antigens complexed to phospholipids. It is further characterized by recurrent venous and arterial thromboembolism, fetal loss, thrombocytopenia, and a variety of neurologic manifestations. This syndrome is characterized by heparin-induced thrombocytopenia (and thrombosis) and is a consequence of therapy with high-molecular-weight heparin. It occurs in about 5% of heparinized platelets and can appear within a day of heparinization. It usually manifests 5 to 10 days after heparin therapy and occurs in fi1% of heparinized patients. It is thought to be caused by antibodies to the complex of heparin and platelet factor 4 (Pf4). When mature, they demonstrate alternate dark gray layers of platelets interspersed with lighter layers of fibrin. Eventually they liquefy and disappear or are organized with fibrous tissue formation. These thrombi are formed in areas of less active blood flow, most often in the veins of the lower extremities and in the periprostatic or other pelvic veins. They are predisposed by venous stasis, with a high incidence occurring in hospitalized patients on bed rest. Settling of red cells results in a two-layered appearance: currant jelly appearance in the red cell-rich lower layer and a chicken fat appearance in the cell-poor upper layer. Portions of the friable thrombus break away, travel through the venous circulation, and lodge in branches of the pulmonary artery. Pulmonary emboli vary in size from saddle emboli obstructing the bifurcation of the pulmonary artery, which can produce sudden death, to less clinically significant small emboli. Obstruction of the pulmonary artery leads to pulmonary infarction, a term often used interchangeably with pulmonary embolism. Arterial emboli usually arise from a mural thrombus, a thrombus that adheres to one wall of a heart chamber or major artery. This large venous embolus obstructing both main branches of the pulmonary artery is known as a saddle embolus. Paradoxical emboli are left-sided emboli that originate in the venous circulation but gain access to the arterial circulation through a right-to-left shunt, most often a patent foramen ovale or an atrial septal defect. These emboli are particles of bone marrow and other fatty intraosseous tissue that enter the circulation as a result of severe (often multiple) fractures. These emboli result from the introduction of air into the circulation, most often by a penetrating chest injury or as a consequence of a clumsily performed criminal abortion. They can occur as decompression sickness, observed in deep-sea divers who return to the surface too rapidly. Bubbles of relatively insoluble nitrogen come out of solution and obstruct the circulation, producing musculoskeletal pain (“the bends”) and small infarcts (caisson disease) in the central nervous system, bones, and other tissues. Because nitrogen has an affinity for adipose tissue, obese persons are at increased risk for this disorder. These emboli are caused by escape of amniotic fluid into the maternal circulation. Increased capillary permeability occurs in inflammation or with injury to capillary endothelium, as may occur in burn injury. Hydroperitoneum (ascites) is an abnormal accumulation of fluid in the peritoneal cavity. This noninflammatory edema fluid results from altered intravascular hydrostatic or osmotic pressure. This edema fluid results from increased vascular permeability caused by inflammation. Because the metabolically active leukocytes consume glucose, the glucose content is often greatly reduced. Decreased cardiac output, as occurs in hemorrhage or severe left ventricular failure 2. Widespread peripheral vasodilation, as occurs in sepsis or severe trauma, with hypotension often being a prominent feature B. Hypovolemic shock is circulatory collapse resulting from the acute reduction in circulating blood volume caused by: a. Loss of fluid from the gastrointestinal tract, through severe vomiting or diarrhea 2. Cardiogenic shock is circulatory collapse resulting from pump failure of the left ventricle, most often caused by massive myocardial infarction. Initially, vasodilation may result in an overall increase in blood flow; however, significant peripheral pooling of blood from peripheral vasodilation results in relative hypovolemia and impaired perfusion. Lipopolysaccharide (endotoxin from the outer membrane of gram-negative bacteria) and other bacterial products appear to induce a cascade of cytokines. The release of these molecules occurs in the “toxic shock syndrome,” which is most often associated with Staphylococcus aureus infection. This constellation of findings may also be caused by a number of other mechanisms such as infection, ischemia, trauma, and so on. Compensatory mechanisms, including increased heart rate and increased peripheral resistance, maintain perfusion of vital organs. Pulmonary edema Review Test Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. The cut surface of the liver as it appears at autopsy is shown in the first panel. Which of the fol(B) Diabetes mellitus lowing is the most likely cause of the effusionfi A 70-year-old man seeks medical atten(e) Tuberculosis tion because of shortness of breath on minimal exertion. A 26-year-old woman dies after a short radiograph reveals blunting of the right illness beginning in the late stages of labor. The protein convernix, mucin), as did other vessels of centration is low, and the specific gravity is multiple organs. Microscopic examination reveals an tory reveals that she had become acutely ill 43 44 Brs Pathology with dyspnea, hypotension, and seizures, 7. A 60-year-old man with unstable angina and a chest radiograph had demonstrated (a form of acute coronary syndrome) is evidence of pulmonary edema. The vagina and generalized bleeding from multimechanism of action of this agent is the ple other sites. The changes that were found ability to within multiple blood vessels most likely are (a) dilate coronary arteries. Two days following a cholecystectomy, a for fractures of the pelvis and left femur 32-year-old hospitalized woman has sudden resulting from a high-speed motor vehicle onset of dyspnea, pleural pain, and cough accident. If it were possible of embolism is the likely cause of these to examine a portion of the affected lung, findingsfi A 56-year-old man is surgically treated (e) Hemorrhagic (red) infarct by a four-vessel coronary artery bypass graft procedure and placed on prophylac5.

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