Eric W. Schneeberger, MD

• Cardiothoracic Surgeon
• Atrial Fibrillation Center
• Deaconess Hospital
• Cincinnati, Ohio

The number of cell cord invasions and subsequent lactiferous duct systems per teat is species dependent (approximately: 1 medications xarelto 100 mg lamotrigine mastercard, sheep symptoms checker discount lamotrigine 200mg free shipping, goat medicine 5 rights buy 50mg lamotrigine, cow; 2 mare sow; 6 medicine jokes buy 200 mg lamotrigine with visa, queen; 12 symptoms wheat allergy discount lamotrigine 100mg online, bitch) medicine 968 buy lamotrigine 100mg on line. In some cases, multiple lactiferous ducts open into a pit (inverted nipple) that becomes a nipple following proliferation of underlaying mesoderm. It is common for extra buds develop and degenerate, failure to degenerate results in supernumerary teats. Because the face develops separately, and it can undergo wide variation in shape & size, as seen in dogs. Tissue separating external clefts and internal pharyngeal pouches degenerates, creating gill slits. Note: Somitomeres originate from paraxial mesoderm located rostral to the notochord and are less developed somites. Depending on species, the thyroid may remain single (pig) or split into bilateral lobes connected by an isthmus (horse) or become separate paired lobes (dog). The thyroid connection to the pharynx normally degenerates, but rarely a remnant persists as a cyst that can enlarge and interfere with breathing by compressing the pharynx. The condition may be inherited or be the result of exposure to a teratogen (an agent that causes birth defects). Cleft palate is often fatal in animals due to inability to suckle or because of aspiration of milk into the lungs (aspiration pneumonia). Although they are independent glands embryologically, they appear to form a single mass and in gross anatomy they are collectively identified as a single gland. Hypothalamic neurons must release hormones into the blood stream to control the adenohypophysis. Axons of hypothalamic neurons run through the infundibulum and terminate in the neurohypophysis. In the process of separating from overlaying ectoderm, some neural plate cells become detached from the tube and collect bilateral to it, forming neural crest. The cavity of the tube (neural cavity) becomes the ventricles of the brain and central canal of the spinal cord. Additionally, neural crest cells Neurulation become adrenal medulla cells, melanocytes of skin and a variety of structures in the face. Neural Tube neural cavity neuroepithelium wall lumen side Some cell divisions are differential, producing neuroblasts which give rise to neurons or glioblasts (spongioblasts) which give rise to glial cells (oligodendrogliocytes and astrocytes). Neuroblasts and glioblasts lose contact with surfaces of the neural tube and migrate toward the center of the neural tubewall. Note: Microglial are derived from mesoderm associated with invading blood vessels. Layers and plates of the neural tube: Accumulated neuroblasts and glioblasts form the mantle layer, a zone of high cell density in the wall of the nerual tube. Cells that remain lining the neural cavity are designated ependymal cells; they form an ependymal layer. Surrounding the mantle layer, a cellsparse zone where axons of neurons and some glial cells are present is designated the marginal layer. A bilateral indentation evident in the neural cavity (the sulcuslimitans) serves as a landmark to divide each lateral wall into an alar plate (dorsal) and a basalplate (ventral). Midline regions dorsal and ventral to the neural cavity constitute, respectively, the roofplate and the floorplate. Embryonic Cord Regions 57 floor plate outside wall Generally, neurons are incapable of cell division, so all neurons must be formed during nervous system development. However, in hippocampus and olfactory bulb, some stem cells or neuroblasts persist and can give rise to a small number of new neurons postnatally. One process, the axon, is generally long and often encased in a myelinsheath formed by glial cells. Graymatter has sparse myelinated axons and generally a high density of neuron cell bodies. Neurons that fail to contact an appropriate target will degenerate and disappear, because they do not receive sufficient neurotrophic molecules. For the same reason, processes of surviving neurons will undergo degeneration if they fail to contact an appropriate target (selective pruning). Neurotrophic molecules are released by target cells to nurture neurons (and by neurons to modify target cells). Selective degeneration of neurons and neuronal processes is the result of functional competition. More appropriate targets are associated with more excitation conduction and more neurotransmitter release. Thus developmental remodeling is a consequence of electrochemical activity related to experiences/behavior. Throughout life, experiences drive nervous system remodeling through selective growth and pruning of neuronal synapses. NeuromuscularInnervation Initially, individual neurons innervate an excessive number of muscle fibers and individual muscle fibers are innervated by a number motor neurons. Ultimately, motor neurons will innervate only about 10% of their initial muscle fibers and individual muscle fibers will retain only a single neuromuscular synapse. Flexures: During development, the brain undergoes three flexures which generally disappear (straighten out) in domestic animals. The cervicalflexure appears at the junction between the brain and spinal cord (it persists slightly in domestic animals). The pontineflexure is concave dorsally (the other flexures are concave ventrally). Hindbrain: Medulla oblongata and pons - alar plates move laterally and the cavity of the neural tube expands dorsally forming a fourth ventricle; the roof of the fourth ventricle (roof plate) choroid plexus ependymal cell layer pia mater - the basal plate (containing efferent neurons of cranial nerves) is positioned medial to the alar plate and ventral to the fourth ventricle; - white and gray matter (marginal & mantle layers) become intermixed (unlike spinal cord); cerebellar development adds extra structures. The cerebellum connects to the brain stem by means of three pair of cerebellarpeduncles, each composed of white matter fibers. Migration of neuron populations past one another allows connections to be established between neurons of the respective populations. Connections are made by axons that subsequently elongate as neurons migrate during growth. Midbrain - the neural cavity of the midbrain becomes mesencephalicaqueduct (which is not a ventricle because it is completely surrounded by brain tissue and thus it lacks a choroid plexus). Cell connections are established within the cerebral cortex as waves of newly arriving neurons migrate through populations of neurons that arrived earlier. Nerve fibers within peripheral nerves may be classified as afferent (sensory) or efferent (motor) and as somatic (innervating skin and skeletal muscle) or visceral (innervating vessels and viscera). Postganglionic visceral efferent neurons have their cell bodies in autonomic ganglia. Innervation continuity is retained even when the derivatives are considerably displaced or when other structures have obstructed the pathway. The early establishment of an innervation connection explains why some nerves travel extended distances and make detours to reach distant inaccessible targets. The foremost example is the recurrent laryngeal nerve which courses from the brainstem to the 63 larynx via the thorax, because the heart migrates from the neck to the thorax pulling the nerve with it. Three meningeal layers (dura mater, arachnoid, and pia mater) are formed as follows: - mesenchyme surrounding the neural tube aggregates into two layers; - the outer layer forms dura mater; - cavities develop and coalesce within the inner layer, dividing it into arachnoid and pia mater; the cavity becomes the subarachnoid space which contains cerebrospinal fluid. The single field separates into bilateral fields associated with the diencephalon. The outer wall of the cup forms the outer pigmented layer of the retina, and the inner wall forms neural layers of the retina. Optic Stalk Optic Nerve central vessels (in primates) hyaloid artery in optic fissure axons from the retina optic nerve fibers 65 - ectomesenchyme (from neural crest) surrounding the optic cup condenses to form inner and outer layers, the future choroid and sclera, respectively; - the ciliarybody is formed by thickening of choroid ectomesenchyme plus two layers of epithelium derived from the underlying optic cup; the ectomesenchyme forms ciliary muscle and the collage- the iris is formed by lacrimal dorsal choroid ectomesenchyme plus the conjunctival gland eyelid sac superficial edge of the optic cup; the optic cup cornea outer layer of the cup forms dilator and constrictor muscles and the inner vitreous compartment layer forms pigmented epithelium; the ectomesenchyme of the iris forms a pupillary membrane that conveys an anterior blood supply to the dehyaloid veloping lens; when the membrane lens artery degenerates following development of the lens, a pupil is formed; - the cornea develops from two sources: the layer of ectomesenciliary chyme that forms sclera is induced body by the lens to become inner epitheanterior lium and stroma of the cornea, while compartment surface ectoderm forms the outer pupillary iris epithelium of the cornea; the antemembrane riorchamberof the eye develops as a cleft in the ectomesenchyme situated between the cornea and the lens; - the eyelids are formed by upper and lower folds of ectoderm, each fold includes a mesenchyme core; the folds adhere to one another but they ultimately separate either prenatally (ungulates) or approximately two weeks postnatally (carnivores); ectoderm lining the inner surfaces of the folds becomes conjunctiva, and lacrimalglands develop by budding of conjunctival ectoderm; - skeletal muscles that move the eye (extraoculareyemm. The innerearcontains sense organs for hearing (cochlea) and detecting head acceleration (vestibular apparatus), the latter is important in balance. The middleear contains bones (ossicles) that convey vibrations from the tympanic membrane (ear drum) to the inner ear. Afferent innervation is necessary to induce taste bud formation and maintain taste buds. Olfaction Olfaction (smell) involves olfactory mucosa located caudally in the nasal cavity and the vomeronasal organ located rostrally on the floor of the nasal cavity. Mitosis = cell division where each of two daughter cells receives chromosomal Stages of mitosis: material identical to the parent cell. Prophase - chromosomes become visible and the nuclear membrane disappears under the light microscope (90 min. The number of possible assortments = 2N, where N = number of chromosomes/gamete. Crossover during Meiosis I riod) Metaphase - individual chromosomes align at equatorial region between centrioles. Anaphase - the two chromatids per chromosome separate at the centromere region - each chromatid moves toward its respective centriole and becomes a chromosome in a new nucleus synaptonemal Telophase complex - chromosomes become less visible; nuclear membrane reappears; cytoplasm division occurs (cytokinesis). Candidates are expected to have a detailed knowledge of the procedure itself, as well as pre- and postprocedure care. Note that lumbar puncture and myelography will be covered in the neuroradiology section. Test items will also cover pre- and postprocedure care in more detail because general radiologists are often the first to encounter patients whose clinical presentation and imaging findings warrant these complex interventions. Candidates are also expected to correctly distinguish between expected and unexpected clinical and imaging findings after these procedures. Normal and other i) Radiopharmaceutical: all of the above ii) Imaging techniques: all of the above iii) Typical indications: Pleuro-peritoneal fistula, peritoneovenous shunt evaluation and all of the above k) Artifacts and quality control i) Patient issues: preparation, motion, positioning, and contamination ii) Radiopharmaceutical issues: preparation, administration technique, and altered biodistribution iii) Technical issues Instrumentation, acquisition and processing, pharmaceutical injection (morphine sulfate), infusion (sincalide) protocols, and fatty-meal challenge; quantification. Specifics: 1) Radiation Physics a) Radioactive decay modes b) Mathematics of radioactive decay c) Radioactive equilibrium d) Units of radioactivity and conversions e) Gamma ray and charged particle interactions f) Radiation dose i. Effective dose 2) Radiation measurement instruments a) Survey meters (principles, operation, and use; quality assurance/quality control) i. Since the range of content relevant to these topics is broad, a separate Study Guide has been produced to serve as a syllabus of the "core" knowledge that residents eligible to take the Core Exam and Certifying Exam are expected to know. The Study Guide should be considered a major resource to identify topics and content for the examination, but it is not the "last word" on these topics, nor does it take the place of textbooks, other definitive source material, education you should have received during your residency or fellowship training, or continuing education. We highly recommend these "deeper" resources to provide perspective and depth of understanding of the concepts that are only superficially outlined here. Practical Quality and Safety Applications in Healthcare a) Practical Quality Applications in Healthcare b) Daily Management Systems c) Project-based Improvement Methods d) Practical Safety Applications in Healthcare e) Periprocedural Care f) Hand Hygiene g) Root Cause Analysis Core Examination Study Guide Page 100 Core Examination Study Guide 4. Knowledge should include diseases for which these signs are classic, potential alternative diagnoses, or pitfalls [Hansell et al. Vasculitis (Takayasu) 18) Postoperative and Post-treatment Thorax a) Lung resection, including post-lobectomy, post-wedge resection, pneumonectomy, and post-pneumonectomy syndrome b) Lobar torsion c) Radiation fibrosis and pneumonitis d) Post lung transplantation, including acute, subacute, and chronic complications, single and bilateral transplantation e) Post-esophagectomy f) Post-lung volume reduction surgery g) Airway and esophageal stents h) Eloesser flap 19) Percutaneous Thoracic Interventions a. Clinical indications and contraindications Core Examination Study Guide Page 108 Core Examination Study Guide c. Examples include: a) Aortic aneurysms before and after stent graft placement b) Arterial and venous stenosis/occlusions before and after endovascular procedures, such as angioplasty, stent placement, lysis, or thrombectomy c) Anatomy and pathology seen before and after open vascular procedures. Introduction and Overview the Wound, Ostomy Continence Nurses Society recognizes and supports best practices in ostomy care, involving both fecal and urinary stomas. In pediatric cases, factors such as the growth and development of the child and the need for training and support of parents and caregivers are also involved. This document ad- dresses clinical issues as well as the need for awareness and sensitivity when dealing with an infant or child as patient, and the understandable concerns of parents and caregivers. Introduction An ostomy, also called a stoma, is a surgically created opening in the abdomen. Fecal and urinary stomas are constructed from a part of the gastrointestinal tract or urinary tract and divert waste material to the outside of the body. Typically, a stoma is moist, bright pink or red in color, shiny, and feels like the inside lining of the mouth. The stoma may change to pale, gray or white when child is crying but this is temporary and will return to normal color after crying subsides.

Carcinoma of the esophagus Epidemiology > 60 years M > F 5% of all cancers Predisposing factors Ingestion of hot meal medications without a script discount lamotrigine 25 mg fast delivery, smoking treatment of tuberculosis cheap lamotrigine 50 mg with mastercard, alcohol intake counterfeit medications 60 minutes 200 mg lamotrigine with visa, etc Pathology Microscopic: squamous cell carcinoma medications known to cause seizures buy generic lamotrigine 50 mg line, Adeno carcinoma Macroscopically: Annular stenosing symptoms 3 dpo buy generic lamotrigine 25 mg, ulcer treatment arthritis buy 50 mg lamotrigine visa, fungating, cauli flower like 215 Spread Direct, lymphatic and blood stream to liver and bone Clinical feature Dysphagia, regurgitation, anorexia, weight loss Diagnosis - Barium swallow - Irregular, ragged pattern of mucosa with narrow lumen - Esophagoscopy and biopsy - Bronchoscopy - to see bronchial involvement - Endoluminal Ultrasonography(U/S) - U/S - liver secondaries - Hgb, plasma proteins, blood chemistry Treatment Curative - surgery - Radiotherapy Palliative - Intubation with specially designed tubes - Radiotherapy Foreign bodies Coins, pins, dentures, etc Diagnosis Treatment Removal by rigid esophagoscope Radiography (neck and chest x-ray) Esophagoscopy Oesophagitis Acute - burns or scalds - Infective (spreading from the pharynx). What are the investigations which are important in the differential diagnosis of dysphagia Compare and contrast a patient with achalasia with another patient having esophageal cancer (clinical presentation, diagnosis, treatment and prognosis). It also communicates with the external environment and exposed to microbes causing diseases. Hence the student must be very well versed about the practice of the common urological problems. Urinary symptoms and Investigations of Urinary Tract problems: Introduction Urinary pathologies are fairly common problems that health workers encounter in his/her daily activities. The symptoms are not always specific to urinary tract diseases; some of these symptoms are merely feature of generalized illness. Pain: Pain in the urinary tract can arise from the kidneys (renal colic), which is due to obstruction of one of the calyces by stone. If pain is sudden in onset and severe radiating to the groin from the flank, it is most likely due to passage of stone in the ureter. Pain arising from bladder pathologies is located in the suprapubic region, the cause of which maybe urinary retention or cystitis. It can be divided as initial hematuria, terminal hematuria and bloody urine throughout. It may be associated with pain, and described as painful or without pain (painless hematuria). Microscopic hematuria is only evident when we see red blood cells in the urine under the microscope. Frequency: it is an increased number of voiding urine; it is due to incomplete emptying and/or irritability of the bladder. Urgency: the feeling to void is very high urging the patient to void now and then G. Patient hesitates void, when he reaches to toilet though he had great feeling to void. Kidneys fail to produce adequate urine out put to wash out all harmful toxic products such as nitrogen products. Diuretic challenge In established cases: fluid restriction, and fluid administration based on replacement of the ongoing losses. Renal supportive methods, such as dialysis (peritoneal and hemodialysis) performed to remove toxic chemicals and decrease the potassium level (k+) level in the blood to normal. Congenital Congenital stricture of external urethral meatus, Acquired Benign prostatic enlargement Urethral stricture Post- circumcision phymosis Stone diseases phymosis Congenital valves of the posterior male urethra Idiopathic pelvi-ureteric junction obstruction 223 Pathophysiology When obstruction of urine flow is not relieved the following conditions happen: the pelvis will be dilated, and more and more urine is collected. Choice should be based on clinical and epidemiological evidences, and then tailored by the results of culture and sensitivity. Vesico-ureteric reflux Repeated courses of antibiotic treatment may be necessary Perinephric abscess Definition Perinephric abscess is an infection of the perinephric fat resulting in pus collection. Pathogenesis the infection, once established in the kidney, tuberculous granuloma is formed. The granulomas are changed to ulcers and several ulcers coalesce to from an abscess. Healing of the inflammatory processes lead to extensive fibrosis and then to Tb pyonephroses. Differential diagnoses of opacity in X-ray film are: - calcified mesenteric lymph node Gall stones or concretion in appendix Phlebolith or any calcified lesion Treatment: Most small ureteric stones and non-obstructive kidney stones can be managed conservatively by treating the pain and any underlying infection with analgesics and antibiotics and then expecting the stone to be washed out by the urine and following the patient taking a follow up x-ray. Big stones, obstructing the urine outflow, and failure of expectant treatment are the indication for the following. Benign tumors of the kidney vary greatly, and have little significance most of the time. Renal injuries Renal injuries are relatively uncommon injuries partly due to the inaccessible location of the kidneys in the retroperitoneum. Injuries to ureters are extremely rare in traumas; however ureteric injuries are fairly common in endoscopic ureteric procedures. Renal injuries can be divided as mild, moderate severe or first, second and third degree renal injuries respectively. First degree renal injury is an injury limited to the kidney parenchyma resulting in only subcapsular hematoma, hematuria may not be there. Bladder rupture can be either intra peritoneal where urine peritonitis occurs and needs laparotomy and closure, While extra peritoneal rupture can be managed conservatively by passing an indwelling catheter. Bladder outlet obstruction this is the commonest presentation of all urologic problems and quite diverse disorders produce bladder outlet obstruction. If the cause is urethral stricture, suprapubic cystostomy is done to relieve the acute retention. Bladder Stones Stones are also formed in the bladder, and if stone is formed without any predisposing factor it is called primary vesical calculus. Whereas, a stone formed in the presence of distal obstruction or foreign body acting as a nidus, is called secondary vesical calculus. Clinical Feature Males are more effected than females Pain characteristically occurs at the end of micturition the pain is referred at the end of the penis or labia majora In young boys, screaming and pulling of the penis with hand at the end of micturition Interruption of urinary stream and changing of body position to resume micturition. Diagnosis Radio opaque stone or filling defect in X-ray film 230 Treatment Cystolithotomy (Open surgical removal) Bladder Cancer Bladder tumor is common in people exposed to chemical carcinogens. Occupational exposure to chemicals such as dye factory workers and cigarette smoking are considered to be strongly associated with bladder cancer. More than 80% of bladder cancer is transitional cell origin and only 25% of the tumors are muscle invasive. Muscle invasive transitional cell Carcinoma is solid tumor, large based and possesses potential of distant metastasis to the lungs, bones and liver. Possible treatment is radical surgery, removing the bladder and lymph nodes around it, then urinary diversion. Periurethral zone: this part is on which most of benign enlargement of the prostate arises. Benign prostatic Hyperplasia starts in the periurethral zone and as it increases in size it compresses the outer peripheral zone. The gland is acted upon by testosterone, male hormone, incriminated to cause the enlargement. Clinical Feature acute urinary obstruction Symptoms of prostatism (frequency, dysuria, urgency, dribbling, hesitancy) Chronic retention, overflow incontinence, and renal insufficiency. In cases only with symptoms of prostatism, other conservative measures can be tried. Prostatic carcinoma Prostatic cancer is most common malignant tumor in men over the age of 65 years. Bilateral orchidectomy the urethra and penis the urethra Congenital abnormalities Meatal stenosis this is a condition which usually follows fibrosis after circumcision and if left untreated leads to chronic retention then chronic renal failure Clinical Feature Spraying and dribbling in lesser degree of stenosis Urinary retention Treatment Meatotomy/meatoplasty (Plastic reconstruction of the meatus) Congenital valves of the posterior urethra this is a condition with presence of symmetrical of valves. It can cause obstruction to the urethra of boys and is not visualized on urethroscope. Hypospadias this is the most common congenital malformation where meatus open onto the under side of the penis, perineum or prepuce. Rupture of the membranous urethra: most commonly due to pelvic fracture or can also be due to penetrating injuries. Road traffic accidents, severe crush injuries and falls all can cause this injury Pain, bruising and dullness to percussion above the umbilicus Treatment Initial suprapubic catheter can be put to relieve urinary obstruction followed by urethroplasty Complication Urethral stricture Urinary incontinence Urethral Stricture Causes - Traumatic - Inflammatory - Latrogenic Clinical Features Bladder outlet obstruction, younger age than the prostate Patients Diagnosis Urethroscopy Urethrography Treatment Dilation with elastic or metallic boogie Urethrotomy, internal visual incision of stricture Urethroplasty, Excision and end to end anastomosis, patch urethroplasty Road traffic accident, falls, penetrating injuries Gonococcus, Mycobacterium tuberculosis Catheterization, instrumentation 234 the Penis Phymosis: Is an adhesion of the foreskin. Treatment: is circumcision Paraphymosis: Is a condition in which tight foreskin is retracted and causes constriction to the penis. The Testis and Scrotum the Testis Incomplete Descent this is a condition in which the testis is arrested in some part of its path to the scrotum. Clinical Features Right side in 50% of the cases Left 30%, bilateral in 20% the position of the undescended testis is intra abdominal or inguinal canal or in the superficial inguinal pouch. Hazards the risks of incomplete descent of the testes include Sterility in bilateral cases Pain due to trauma Associated inguinal hernia Torsion Epididymo-orchitis Atrophy Increased liability to malignant diseases Treatment: Orchidopexy Testicular Torsion Torsion of the spermatic cord may cause ischemia and necrosis of the testis 235 Predisposing conditions Inversion of the testis (rotated testes, upside down, or transverse lie) High investment of the tunica vaginalis (clapper-bell deformity) Separation of epididymis from the body of testis Clinical Features Most common between 10-25 years of age. Vomiting is also common Treatment emergency exploration is mandatory orchidectomy if necrotic testis is found, orchidopexy if viable orchiopexy is advised on the unaffected side Hydrocele Hydrocele is an abnormal collection of serous fluid in the tunica. Types include:Primary Secondary Etiology: - excessive production and defective absorption Treatment: - Hydrocelectomy Malignant tumors of the Testis 1-2% of all malignant tumors are Testicular Carcinoma. Classification Tumors are classified based on Histologic predominant cells Seminoma (40%) Teratoma (32%) Combined seminoma and teratoma (14%) Lymphoma (7%) Other (7%) Seminoma Occurs in age range between 35-45 years Extremely rare in children before puberty Tumor compresses the neighboring structure as it grows In rapidly growing tumors there may be areas of necrosis Spread is via the lymphatics, blood born is rare. Secondary Hydrocele in 10% Treatment Orchidectomy: removes primary tumor Seminoma: Radiotherapy after orchidectomy Chemotherapy Teratomas: - Chemotherapy is the treatment of choice Follow up by serum tumor markers Prognosis Excellent Seminoma, Teratoma, 95% 5 years survival 85% 5 year survival 237 Review Questions 1. Outline the important steps of investigating a patient with right flank mass and hematuria. Discuss the management of a 13 year-old patient with intermittent urinary retention and initial hematuria. Outline common causes of acute urinary retention and indicate the recommended treatment. We w choose different ways to spend our spare time, and we have some very differing definitions of work-life balance. We live to learn and continue to improve our ability to practice, we value our patients and our clients and will do whatever we can to help them, and most of us like new shiny toys. The medicine we practice continues to advance at an exponential rate, often due to technologic innovation. The reality is that, at times, we can obtain the tools to do more than we have the competence to do. In the beginning of my career, any horse that needed stifle radiographs was sent in to the hospital because the radiography equipment available at the time was incapable of taking quality stifle radiographs. Today, it would be unheard of for those horses to be referred to a hospital for radiographs because the portable radiology equipment we have at our disposal is amazing. As with any other skill, advanced procedures require advanced training followed by practice to gain experience. Without the training, it is unlikely that techniques are being performed with competence, and also unlikely that the client will be able to make that determination. Hughes and board certification frequently results in competence in advanced procedures and all the things that can go wrong with them. There are multiple continuing education opportunities available in almost all advanced procedures. How much is it worth for someone to help teach you in two to three days what it took them years or a lifetime to learn Sometimes it is easier to think about the cost of these opportunities as part of the cost of purchasing and maximizing the use of our new shiny toys. It seemed with the Great Recession that there was an uptick in the pressure from clients to perform more procedures on the farm. At the same time, there were many veterinarians who had more time to spend with each client to do those procedures. It is the responsibility of the care provider to know when to refer due to lack of expertise. It is damaging to the reputation of our profession and to the health of our patients for that decision to be made too late or not at all. This is not to say that I wish we still did all stifle radiographs in the hospital. Our ability to diagnose and treat horses has advanced in all arenas, and none of us are exempt from the necessity of continued advanced training. As long as communication remains a priority between referring and referral veterinarians, the patient is being managed by a team, and the client is being best served. There are many situations in life where knowing your limits is important, and veterinary practice is no exception. That same equipment can take high-quality skull radiographs too, but not all veterinarians are trained to know how to take and interpret proper skull radiographs. They often still end up coming in to the hospital, but not because the equipment was inadequate. The same story could be told for ultrasound exams of the stifle, ultrasound-guided sacroiliac and vertebral facet injections, radiography of the cervical spine, and field colic surgery, to list a few. Sometimes it is as simple as being a reproductive veterinarian who is asked to perform a lameness/prepurchase exam on an upper-level dressage horse.

This finding is consistent with which of the following genetic polymorphisms in drug metabolism He has been taking a drug for the past 7 years to control severe behavioral and psychiatric symptoms associated with dementia xerostomia medications side effects best 50 mg lamotrigine, Alzheimer type medicine emoji lamotrigine 25 mg with visa. The pharmacotherapy was effective because of inhibition of which of the following A 62-year-old man comes to the physician because of burning pain and tenderness of his right great toe 1 day after heavy ethanol consumption medicine 319 order lamotrigine 50 mg on-line. Physical examination shows erythema medicine youth lyrics 100mg lamotrigine with amex, swelling symptoms for hiv buy generic lamotrigine 200mg online, warmth treatment zinc overdose purchase 200 mg lamotrigine with visa, and tenderness of the right great toe. After a 2-week course of nonsteroidal anti-inflammatory drug treatment, his symptoms decrease in severity but do not completely resolve. The serum concentration of which of the following is most likely increased in this patient A 62-year-old man is being treated with cisplatin for small cell carcinoma of the lungs. An 18-year-old woman comes to the physician because of nausea, vomiting, and abdominal pain 1 hour after ingesting a glass of wine with dinner. Three days ago, she began antibiotic treatment for vaginitis after a wet mount preparation of vaginal discharge showed a motile protozoan. A 20-year-old woman comes to the emergency department after ingesting at least 30 tablets of an unknown drug. A 42-year-old woman who is a chemist is brought to the emergency department because of a 1-hour history of severe abdominal cramps, nausea and vomiting, hypotension, bradycardia, sweating, and difficulty breathing due to bronchospasm and congestion. In a 40-year-old man with hypertension, which of the following agents has the greatest potential to activate presynaptic autoreceptors, inhibit norepinephrine release, and decrease sympathetic outflow A 35-year-old woman is brought to the emergency department because of an 18-hour history of severe pain, nausea, vomiting, diarrhea, and anxiety. She was discharged with a pain medication from the hospital 2 weeks ago after treatment of multiple injuries sustained in a motor vehicle collision. She asks the physician if she can take any vitamins to decrease her risk for conceiving a fetus with anencephaly. It is most appropriate for the physician to recommend which of the following vitamins A 38-year-old man comes to the physician because of a 6-month history of occasional episodes of chest tightness, wheezing, and cough. Which of the following agents is most appropriate to treat acute episodes in this patient A new drug, Drug X, relieves pain by interacting with a specific receptor in the body. Drug X binds irreversibly to this receptor, resulting in a long duration of action. Which of the following types of bonds is most likely formed between Drug X and its receptor A 49-year-old man with hypertension comes to the physician for a follow-up examination. At his last visit 2 months ago, his serum total cholesterol concentration was 320 mg/dL. The most appropriate pharmacotherapy for this patient is a drug that has which of the following mechanisms of action A 17-year-old girl is brought to the physician by her parents 30 minutes after having a generalized tonic-clonic seizure while playing in a soccer game. A slit-lamp examination shows the presence of brownish rings in the cornea, surrounding the iris. The most appropriate treatment at this time is a drug with which of the following mechanisms of action A 60-year-old woman comes to the physician because she recently was diagnosed with non-small cell lung carcinoma and she wants to discuss possible treatment options. She tells the physician that she is concerned about the possible adverse effects of chemotherapy. The physician says that serious toxicity caused by antineoplastic drugs is seen in the bone marrow. A 38-year-old woman with an 18-year history of type 1 diabetes mellitus and progressive renal failure is being considered for dialysis. Which of the following medications is most appropriate to treat the anemia in this patient A 47-year-old woman is admitted to the hospital for treatment of pneumococcal pneumonia. Within 10 minutes of the administration of antimicrobial therapy, her respirations increase to 30/min, and blood pressure decreases to 80/40 mm Hg. Her antimicrobial therapy is changed to gentamicin only, and her condition continues to improve. Administration of which of the following types of drugs is most likely to cause a similar adverse reaction in this patient A hormone is known to activate phospholipase C with subsequent release of calcium from internal stores. The release of calcium most likely occurs as a result of an increase in the concentration of which of the following intracellular second messengers A 28-year-old man with a history of intravenous drug use comes to the physician because of a 6-week history of fever, nonproductive cough, chills, and progressive shortness of breath. Physical examination shows a white, patchy, loosely adherent exudate on the buccal mucosa bilaterally. She is removed from the water within 1 minute, but dry clothing is not available, and she is still cold and wet 20 minutes later. A 39-year-old woman comes to the physician for a follow-up examination because she recently was diagnosed with hypertension. A 24-hour urine collection shows three times the normal excretion of epinephrine and metanephrine. The excessive epinephrine production in this patient is most likely caused by which of the following cell types The blood flow through an organ is measured while the perfusion pressure is varied experimentally. An abrupt, sustained increase in perfusion pressure increases flow initially, but over the course of 1 minute, the flow returns nearly to the baseline level despite continued elevation of the perfusion pressure. After an overnight fast, a 52-year-old man undergoes infusion of acid through a catheter into the upper duodenum. This most likely will increase pancreatic secretion mainly through the action of which of the following substances A 20-year-old woman is brought to the emergency department 20 minutes after being stung by a wasp. A demonstration is performed during a lecture on muscle physiology in which a student is asked to fully extend his right arm with the palm up. Which of the following facilitates the maximum amount of tension that allows the student to keep his arm extended in place under the increasing weight of the books During an experiment on the cough reflex in humans, a volunteer inhales air containing different amounts of particles that will impact and adhere to mucus primarily in the trachea. Examination of the lungs at autopsy shows lung alveoli with radii of less than 50 m (N=100). A 55-year-old woman who is obese has a greater risk for endometrial carcinoma than a 55-year-old woman with the same health history and status who is not obese. Alveolar macrophages Pneumocytes Pulmonary chondrocytes Pulmonary vascular endothelial cells Smooth muscle cells A 22-year-old man is brought to the emergency department because of a 6-hour history of severe, sharp, upper back pain. A 25-year-old woman comes to the physician because of a 2-day history of muscle cramps and profuse, watery stools. Stool culture shows numerous curved, gram-negative bacteria; there are no erythrocytes or leukocytes. The oral hydration formula most likely promotes sodium absorption via the gut by allowing cotransport with which of the following A 26-year-old woman is brought to the emergency department because of a 4-day history of flu-like symptoms accompanied by vomiting following each attempt to eat or drink. A 77-year-old man comes to the physician because of swelling of his legs and feet for 6 months. A decrease in which of the following most likely promotes edema formation in this patient During a study of gastric parietal cells, an investigator attempts to elicit maximum hydrochloric acid secretion from the stomach of an experimental animal. Which of the following combinations of substances is most likely to lead to this desired effect Acetylcholine Increased Increased Increased Decreased Decreased Decreased Decreased Gastrin increased increased decreased increased decreased decreased decreased Histamine increased increased decreased increased increased decreased decreased Secretin increased decreased increased increased increased decreased decreased (A) (B) (C) (D) (E) (F) (G) 66 19. A 30-year-old woman comes to the physician for a routine health maintenance examination. An increase in which of the following substances is the most likely cause of the serum finding in this patient A 28-year-old woman comes to the physician because of a 3-month history of shortness of breath with exertion. Cardiac examination shows a regular rate and rhythm; S 2 is slightly louder than S1. B F B C C B E B D E 69 Ambulatory Care Systems General Principles, Including Normal Age-Related Findings and Care of the Well Patient Immune System Blood & Lymphoreticular System Behavioral Health Nervous System & Special Senses Skin & Subcutaneous Tissue Musculoskeletal System Cardiovascular System Respiratory System Gastrointestinal System Renal & Urinary System Female Reproductive System & Breast Male Reproductive System Endocrine System Multisystem Processes & Disorders Biostatistics, Epidemiology/Population Health, & Interpretation of the Medical Lit. A 32-year-old woman comes to the office because of a 1-day history of easy bruising. On physical examination, the posterior oropharynx is erythematous without exudate. Laboratory studies show: Hematocrit Leukocyte count Platelet count 37% 12,000/mm3 180,000/mm3 Which of the following parameters is most likely to be abnormal in this patient On mental status examination, he is oriented to person and place but misses the date by 2 days. A 52-year-old woman comes to the office because of a 2-month history of pain, swelling, and stiffness of her knees. Laboratory studies show: Hemoglobin Leukocyte count Erythrocyte sedimentation rate 10 g/dL 10,000/mm3 50 mm/h X-rays of the knees disclose osteopenia and subcartilaginous cysts around the joints. A 67-year-old woman comes to the office because of a 2-week history of episodes of shoulder pain and nausea that are precipitated by climbing stairs or vacuuming and resolve in 5 to 10 minutes with rest. Physical examination shows Heberden nodes at several distal interphalangeal joints of the hands. The patient drinks one glass of wine five times weekly and two cups of coffee daily. A 57-year-old woman comes to the office because of a 6-month history of fatigue and headaches. Serum urea nitrogen concentration is 24 mg/dL and serum creatinine concentration is 1. Arteriography shows 95% stenosis of the right renal artery with no significant narrowing of the left renal artery. A 35-year-old man comes to the office because of a 6-month history of a chronic daily dry cough. The patient reports that the cough is accompanied by a tight feeling in the chest. During the past 2 years, he has had similar episodes that lasted for several weeks at a time. He has noted that the cough is exacerbated by cold weather and playing basketball. He has allergic rhinitis that is well controlled with loratadine; he does not have postnasal drip or heartburn. Physical examination shows nontender sinuses, no erythema of the tympanic membranes, and no injection of the pharynx. A 47-year-old man comes to the office because of a 3-week history of progressive shortness of breath and fever and a 5-day history of pleuritic chest pain. Auscultation of the chest discloses dullness to percussion over the left lower lung field. A 32-year-old woman comes to the office because of a 3-day history of temperatures to 39. On physical examination, the abdomen is soft and nontender; there are no masses or organomegaly. Test of the stool for occult blood is positive; microscopic examination shows leukocytes. Abnormal intestinal motility Inflammatory process Malabsorption Secretory process A 57-year-old man comes to the office because of a 2-week history of fatigue and light-headedness. A 27-year-old man comes to the office because of a 1-day history of yellow-colored eyes, a 3-day history of nasal congestion, and a 2-day history of a temperature of 38.

Global Change Research Program medicine 018 purchase lamotrigine 100 mg with amex, National Coordination Office; Lizna Makhani symptoms nausea headache fatigue purchase lamotrigine 200 mg otc, Formerly of the U symptoms gout generic lamotrigine 100 mg otc. Department of Health and Human Services medicine woman buy 25 mg lamotrigine with visa, Substance Abuse and Mental Health Services Administration Recommended Citation: Dodgen symptoms narcolepsy cheap 25 mg lamotrigine with mastercard, D symptoms sleep apnea discount 100 mg lamotrigine visa. Specific Groups of People Are at Higher Risk Key Finding 2: Specific groups of people are at higher risk for distress and other adverse mental health consequences from exposure to climate-related or weather-related disasters. These groups include children, the elderly, women (especially pregnant and post-partum women), people with preexisting mental illness, the economically disadvantaged, the homeless, and first responders [High Confidence]. Extreme Heat Increases Risks for People with Mental Illness Key Finding 4: People with mental illness are at higher risk for poor physical and mental health due to extreme heat [High Confidence]. Mental health consequences of climate change range from minimal stress and distress symptoms to clinical disorders, such as anxiety, depression, post-traumatic stress, and suicidal thoughts. These consequences of climate change related impacts rarely occur in isolation, but often interact with other social and environmental stressors. Climate Change and Mental Health and Wellness Figure 1: this conceptual diagram illustrates the key pathways by which humans are exposed to health threats from climate drivers, and potential resulting mental health and well-being outcomes (center boxes). Individuals and communities are affected both by direct experience of local events attributed to climate change and by exposure to information regarding climate change and its effects. The interactive and cumulative nature of climate change effects on health, mental health, and well-being are critical factors in understanding the overall consequences of climate change on human health. There is also an array of interventions and treatments that mental health practitioners use to address mental health conditions and stress reactions. These interventions occur within the context of health systems that have finite resources to deliver these services. These considerations are not discussed in detail, as this chapter focuses on the state of the science regarding the effects of climate change on mental health and well-being, rather than potential actions that could be taken in response to the impacts and risks associated with climate change. Residents and volunteers in Queens, New York City, filter through clothes and food supplies from donors following Superstorm Sandy on November 3, 2012. A majority of individuals psychologically affected by a traumatic event recover over time, and some experience a set of positive changes that known as post-traumatic growth as a result of coping with or experiencing a traumatic event. These impacts include expoand suicide in affected commusures to higher temperatures nities. Following exposure to Hurricane Katrina, veterans with preexisting mental Extreme Weather Events illness had a 6. The mental health impacts of these events, such a loss of life, resources, or social support and social networks as hurricanes, floods, and drought, can be expected to increase or events that involve extensive relocation and life disruption. Communities adversely affected by these events also have diminished interpersonal and social networks available to support mental health needs and recovery due to the destruction and disruption caused by the event. Drought-related worry and psychological distress Impact of Climate Change on Physical, Mental, and Community Health Figure 2: At the center of the diagram are human figures representing adults, children, older adults, and people with disabilities. The left circle depicts climate impacts including air quality, wildfire, sea level rise and storm surge, heat, storms, and drought. The right circle shows the three interconnected health domains that will be affected by climate impacts-Medical and Physical Health, Mental Health, and Community Health. The impact of extreme heat on mental health is associated with increased incidence of disease and death, aggressive behavior, violence, and suicide and increases in hospital and emergency room admissions for those with mental health or psychiatric conditions. For many, reductions in outdoor exercise and stress-reducing activities lead to diminished physical health, increased stress, and poor mental health. Forty percent of Americans report hearing about climate change in the media at least once a month. However, these people tended to see climate change as a relatively distant threat: 36% said global warming would harm them personally, while more expected harm to come to people in other countries and to future generations. In six case-control studies involving 1,065 heat wave-related deaths, preexisting mental illness was found to triple the risk of death due to heat wave exposure. A hybrid risk is an ongoing threat or event, which is perceived or understood as reflecting both natural and human causes and processes. These responses include heightened risk perceptions, preoccupation, general anxiety, pessimism, helplessness, eroded sense of self and collective control, stress, distress, sadness, loss, and guilt. They also are directly exposed to increasingly visible changes in local environments and seasonal patterns, and in the frequency, magnitude, and intensity of extreme weather events. However, effective risk communication promotes adaptive and preventive individual or collective action. While most people who are exposed to a traumatic event can be expected to recover over time, a significant proportion (up to 20%) of individuals directly exposed develop chronic levels of psychological dysfunction, which may not get better or be resolved. Disaster-related stress reactions and accompanying psychological impacts occur in many individuals directly exposed to the event and can continue over extended time periods (up to a year or more). At 10 months post-disaster, this proportion declined to about 18%,21, 44 representing a substantial decrease but still indicating a significant number of individuals with serious mental health issues resulting from the disaster event. Emerging evidence shows that individuals who are actively involved in climate change adaptation or mitigation actions experience appreciable health and well-being benefit from such engagement. However, when people do have distress related to relevant media exposure or to thinking about or discussing climate change, taking action to address the issue can buffer against distress. Children Children are at particular risk for distress, anxiety, and other adverse mental health effects in the aftermath of an extreme event. As children are constantly developing, their reactions will vary by age and developmental level. Children have been shown to possess an innate resilience to adverse events,146, 147, 148, 149 but despite this resilience, children can and do exhibit various stress symptoms when exposed to a traumatic event. However, children may be at a higher risk than adults of having symptoms persist in the long-term. Poor nutrition can lead to difficult pregnancies, delivery problems, low birth weight, and even death of a newborn, all of which can be immensely stressful to the mother. Physical health problems are associated with the development of mental health problems,163, 164 particularly among older adults. They are less able to evacuate should there be a natural disaster, and are more exposed to harmful conditions created by heat waves and poor air quality. Low-income people disproportionately experience the most negative impacts and weather-related mental distress due to more fragile overall health, reduced mobility, reduced access to health care, and economic limitations that reduce the ability to buy goods and services that could provide basic comfort and mitigate the effects of disasters. As observed internationally, such individuals also have higher levels of distress and are more vulnerable to experiencing poor mental health due to extreme weather events or other climate change impacts. For example, older farmers in Australia reported experiencing an overwhelming sense of loss as a result of chronic drought and its economic consequences. The level of stress and distress in responders increases when the injured are children or people they know. Some extreme weather events are projected to become more frequent and severe, and those who become homeless due to these disasters are at increased risk for post-traumatic stress symptoms. People experiencing homelessness are also vulnerable to acquiring a vector-borne illness. Extreme weather events carry threats of psychological trauma and disruption to behavioral health services systems. When infrastructure is damaged and communication lines are weakened, mental health services and personal support networks are also disruptU. Global Change Research Program Many medications used to treat a variety of mental health disorders interfere with temperature regulation and heat elimination and may directly induce hyperthermia. Many medications used to treat a variety of mental health disorders interfere with temperature regulation and heat elimination and may directly induce hyperthermia. Being dehydrated can also influence the way some medications such as lithium (used to stabilize mood)82, 189 or anti-epileptics work in the body. Persons with a combination of mental and physical disorders and who are taking more than one kind of medication are also at greater risk of heat-related death. A more specific emerging issue is the effect of extreme temperatures on mental health, in particular suicide. Some studies report a connection between higher temperature and suicide;199 with some indicating increased risk of suicide. In addition, more frequent and prolonged heat waves may increase the amount of time spent indoors, which could have an effect on mental health, particularly for children and those who use the outdoors for exercise and stress management. As more is learned about the relationship between climate change and vector-borne illnesses, it will be important to further understand the scope of mental health consequences for those who become infected. The severity of risks to mental health and well-being for Indigenous populations that have a close connection to the environment, and in some cases lower economic resources, is also a concern. Malnutrition (specifically, iron deficiencies) can cause fatigue and depression in children and adolescents. Parents of children with food allergies have been found to have higher rates of stress and anxiety than parents of children without food allergies. Studies of the broad range of health effects of climate change should incorporate mental health effects and consequences, since many mental health impacts are secondary to other health problems. S does not currently have sustained psychological and social impact assessments or monitoring programs and measures necessary to identify important changes in mental health and well-being associated with climate change. National psychosocial impact assessment and monitoring programs could enhance the development of standardized methodologies and measures of psychological and social pathways needed to better predict mental health and well-being outcomes. Areas of focus for the Mental Health and Well-Being chapter were determined based on the most relevant available scientific literature relating to mental health, wellness, and climate change, as well as the mental health impacts of events associated with climate change. Much of the evidence on these impacts has been compiled in countries outside the United States; however, the scenarios are similar and the evidence directly relevant to the situation in the United States, and thus this literature has been considered in the chapter. The evidence-base on mental health and wellness following extreme weather disasters is both well-established and relevant to climate change. The existence of highly relevant scientific literature on specific concerns directly influenced by climate change-such as the effects of extreme heat, stress associated with the threat and perception of climate change, and special population risks-resulted in the inclusion of these more targeted topics. Although significant scientific literature for resilience exists, in-depth discussions of adaptation, coping, and treatment approaches are outside the scope of this chapter, but are discussed in brief in the Resilience and Recovery section. However, a convincing body of recent research shows that a significant proportion (typically up to 20%) of individuals directly exposed to the event will develop chronic levels of psychological dysfunction, which may not get better or be resolved. An increase in the scope, frequency, or severity of these events will increase the number of people impacted and the degree to which they are affected. However, efforts that effectively increase preparation for both the physical and psychological consequences of extreme weather- and climate-related events could decrease the impact on mental health and wellbeing. Assessment of confidence and likelihood based on evidence Numerous and recent studies have examined the mental health and wellness impacts of climate- and weather-related events among a variety of populations. Taken as a whole, the strength of this scientific evidence provides very high confidence regarding the adverse impacts of environmental changes and events associated with global climate change on individual and societal mental health and well-being, and high confidence that these impacts will be long-lasting for a significant portion of the impacted population. Exposure to Weather-Related Disasters Results in Mental Health Consequences Key Finding 1: Many people exposed to climate-related or weather-related disasters experience stress and serious mental health consequences. The majority of affected people recover over time, although a significant proportion of exposed individuals develop chronic psychological dysfunction [High Confidence]. Description of evidence base Very strong evidence from multiple studies shows a consensus that many people exposed to climate- or weather-related natural disasters experience stress reactions and serious psychological harm, which often occur simultaneously. These groups include children, the elderly, women (especially pregnant and post-partum women), people with preexisting mental illness, the economically disadvantaged, the homeless, and first-responders [High Confidence]. Description of evidence base Multiple studies have identified specific populations within the United States that are particularly vulnerable to the mental health impacts of climate change events. Global Change Research Program exposure, sensitivity, and adaptive capacity change over time and location for specific populations of concern is challenging. Assessment of confidence and likelihood based on evidence the combined breadth and strength of the scientific literature supports high confidence that certain vulnerable populations will face psychological tolls in the aftermath of climate-related disasters. An increase in adverse climate-related events will result in increased exposure of such populations of concern and an increased likelihood of elevated risk for mental health consequences. There is also high confidence that naturalresource-dependent communities and populations living in areas most susceptible to specific climate change events are at increased risk for adverse mental health outcomes. Media and popular culture representations of climate change influence stress responses and mental health and well-being [Medium Confidence]. Description of evidence base A strong combination of mental health epidemiological research, social science-based national survey research, social and clinical psychology, environmental risk perception research, and disaster mental health research supports the finding that the threat of climate change and perceptions of its related physical environment changes and extreme events together constitute a significant environmental stressor. The multimedia information environment to which individuals are exposed and its coverage of climate change and related events can contribute to complicated public perceptions and strong emotional responses related to climate change as a social, environmental, and political issue. Emerging evidence suggests there is medium confidence that media representations of climate change influence stress responses and mental health and well-being. Assessment of confidence and likelihood based on evidence A large body of established scientific evidence shows there is high confidence that people with mental illness are at greater risk for poor physical and mental health outcomes from climate change. Similarly, there is high confidence that exposure to extreme heat will exacerbate such outcomes, particularly for the elderly and those who take certain prescription medications to treat their mental illnesses. Given predictions of growth in the subgroup of the population who have mental health conditions and who take pharmaceuticals that sensitize them to heat, increases in the number of people experiencing related negative health outcomes due to climate change is expected to occur. Description of evidence base Mental, behavioral, and cognitive disorders can be triggered or exacerbated by heat waves. An increased susceptibility to heat due to medication use for psychiatric and other mental health disorders, as well as for alcohol- and drug-dependent people, is supported by numerous studies,81, 189, 193, 194, 195, 196, 197 and the influence of dehydration on the effects of psychotropic medications is well-documented. Global Change Research Program Confidence Level Very High Strong evidence (established theory, multiple sources, consistent results, well documented and accepted methods, etc. Global Change Research Program 232 Impacts of Climate Change on Human Health in the United States References 1. Schafer, 2013: Media attention for climate change around the world: A comparative analysis of newspaper coverage in 27 countries. Joffe, 2013: How the public engages with global warming: A social representations approach. The relevance of place attachments and place identities in a climate changed world. Armitage, 2012: Place identity and climate change adaptation: A synthesis and framework for understanding.

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