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Elias I. Traboulsi, M.D.

Cleveland Clinic Foundation
Division of Ophthalmology
Cleveland, Ohio

Drug resistance updates: reviews and commentaries in antimicrobial and anticancer chemotherapy 2004 medicine park lodging discount kemadrin 5 mg with visa, 7 (1) treatment 2 go cheap 5 mg kemadrin amex, 41-51 medications not covered by medicaid cheap 5 mg kemadrin with mastercard. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America 1995 medicine 4211 v cheap kemadrin 5 mg online, 20 (5) medications 10325 purchase kemadrin 5mg without prescription, 1207-16 medications used for fibromyalgia generic kemadrin 5 mg with visa. European journal of clinical microbiology & infectious diseases: official publication of the European Society of Clinical Microbiology 2004, 23 (5), 399-402. Three years earlier, William Boog Leishman had made similar observations from a British soldier in Dum Dum, West Bengal, India, and wrote a description nearly identical to the one generated by Donovan. Leishman also submitted his findings to the British Medical Journal back in England. Ronald Ross, then editor of that publication, deduced that each physician had discovered the exact same entity. Slides sent to him by Donovan confirmed the diagnosis as a new parasitic infection. Non-Pathogenic Protozoa Introduction We are constantly confronted with a plethora of microbes whose sole purpose is to colonize us and take advantage of our biochemical systems. The human body can be viewed as a series of ecological niches that select for numerous entities, including viruses, bacteria, fungi, protozoa, helminths, and arthropods. They enter through the gastrointestinal, urogenital, and respiratory tracts, through abrasions, and other portalsw of entry. This is mainly due to the inadequacy of their fundamental biological makeup, preventing them from thriving on or in us, and the resiliency of our microbiome. For example, the oral cavity harbors some 700 different species of bacteria (see. Our intestinal tract is another good example of "peaceful" coexistence between our symbiotic microbes and us, harboring some 500 species of "friendly" bacteria. This chapter is devoted to a brief mention of a few of those eukaryotic organisms that we routinely harbor, and which do us no harm. The clinician will undoubtedly receive a laboratory result with the name of one or more of them on it. How these "hitchhiker" species should be approached in the context of the clinical setting is the subject of this brief chapter. Under unusual conditions, a few have been shown to be associated with disease, but have never been implicated as the primary cause of illness. At those times, the clinician has a difficult time determining who did what to whom. The diagnostic microbiology laboratory now assumes a role of major importance, helping to catalogue microbes into the good, the bad, and the ugly. Resolving the primary cause of the disease often reverses the growth pattern of the opportunist. None of the organisms listed in the tables, except for rare cases of Entamoeba dispar and E. A representative of each organism mentioned in the following summaries can be found in Appendix C. A single case of Enteromonas hominis has been reported in which the patient experienced diarrhea and was treated successfully with metronidazole. Some bear a resemblance to Entamoeba histolytica, especially to the inexperienced laboratory technician, and they sometimes err on the side of this pathogen, rather than the commensal. Hence, the patient receives treatment for an entity that is not causing the problem. Commensal amoebae do not respond to the standard drugs used to eradicate Entamoeba histolytica, the pathogen most often confused with E. Bilharz, working in Egypt, made the connection between heavy hookworm infection and severe anemia. Some years later, Dubini was called in to help identify the cause of an epidemic of severe anemia and death among workers engaged in digging the 15 kilometer St. This seminal paper was to inspire studies into the cause of "southern laziness", a disease that gripped the southland following the American Civil War. The Nematodes Nematodes are non-segmented roundworms belonging to the phylum Nematoda, and are among the most abundant life forms on earth. The great majority of nematodes are free-living, inhabiting most essential niches in soil and freshwater and saltwater, as well as other, more specialized ones. Only a small fraction of the total number of species is parasitic, and only some of these infect the human host. Most parasitic nematodes have developed a highly specific biologic dependence on a particular species of host, and are incapable of survival in any other. Best known by far among the freeliving nematodes is Caenorhabditis elegans, whose entire genome has been sequenced (20,512 genes). There have only been 15,808 coding regions identified, implying that this parasite needs fewer, not more genes than its free-living relatives. Virulence factors, and other specialized compounds needed to resist digestion or immune attack are likely to be encoded by genes that permit the invader to live comfortably in the face of an exquisitely developed immune system. Infections caused by nematodes are among the most prevalent, affecting nearly all of us at one time in our lives. Children are particularly susceptible to acquiring large numbers of these parasites, and consequently suffer greater morbidity. The typical nematode, both larva and adult, is surrounded by a flexible, durable outer coating, the acellular cuticle, that is resistant to chemicals. It is a complex structure composed of a variety of layers, each of which has many components, including structural proteins, enzymes, and lipids. The cuticle of each species has a unique structure and composition; it not only protects the worm but may also be involved in active transport of small molecules, including water, electrolytes, and organic compounds. A further layer, the epicuticle, surrounds the cuticle of a few parasitic species, making them even more resistant to attack from enzymes, antibodies, and other host resistance factors. The muscle cells form an outer ring of tissue lying just underneath the cuticle, and their origins and insertions are in cuticular processes. In addition, there is some muscle tissue surrounding the buccal cavity and esophageal and sub-esophageal regions of the gut tract. These muscles are particularly important elements of the feeding apparatus in both parasitic and free-living nematodes. Each muscle cell consists of filaments, mitochondria, and cytoplasmic processes that connect it with a single nerve fiber. The nervous system consists of a dorsal nerve ring or a series of ganglia that give rise to the peripheral nerves - two lateral, one dorsal, and one ventral branch. Commissures connect the branches and allow for integration of signaling, which results in fluid, serpiginous movements. Several classes of drugs interfere only with nematode nerve signaling, and are thus effective treatments for nematode infections in humans. The oral cavity and hindgut are usually lined by cuticle; the midgut consists of columnar cells, complete with microvilli. The function of the midgut is to absorb ingested nutrients, whereas the usually muscular esophagus serves to deliver food to the midgut. In addition, a number of specialized exocrine glands open into the lumen of the digestive tract, usually in the region of the esophagus. These glands are thought to be largely concerned with digestion, but may be related to other functions as well. In other instances, there is a single row of cells called stichocytes that empty their products directly into the esophagus via a cuticular-lined duct. These cells occupy a large portion of the body mass of trichinella, trichuris, and capillaria, for example. The function of these cells is not fully understood, and may vary from species to species. Fluids are eliminated by means of the excretory system, consisting of two or more collecting tubes connected at one end to the ventral gland (a primitive kidney-like organ) and at the other end to the excretory pore. The adult female nematode has a large portion of her body devoted to reproduction. The male has a single testis connected to the vas deferens, seminal vesicle, ejaculatory duct, and cloaca. In addition, males of many species have specialized structures to aid in transfer of sperm to the female during mating. More about the biology of nematodes will be given within the text for each infectious agent as they are discussed, whenever it relates to the pathogenesis of the disease. Enterobius vermicularis (Linnaeus 1758) Introduction Enterobius vermicularis (pinworm) is the most prevalent nematode infection of humans, its only host. In the United States, pinworm still occurs with one estimate indicating that it may affect up to 40 million individuals or more. In some communities in Europe, the prevalence rates may be as high as 50% in children, especially in the poorer countries of Eastern Europe and the Balkans. Life Cycle the lifecycle of pinworm is one of the simplest among parasites, and has a typical nematode pattern of development; four larval stages (L1-L4), and the adult stage. Adult worms live freely in the lumen of the transverse and descending colon, and in the rectum. The adult worms mate, and within 6 weeks, each female contains approximately 10,000 fertilized, non-embryonated eggs. The gravid female migrates out the anus onto the perianal skin at night, most likely stimulated to do so by the drop in body temperature of the host. There, she experiences a prolapse of the uterus, expels all her eggs, and then dies. The eggs rapidly embryonate and become infective within 6 hours of being laid, exhibiting one of most rapid embryological developmental cycles among all nematode species. An uncomfortable perianal pruritis develops, called pruritis ani, that may be severe enough to cause sleeping disturbance. Ingestion of these eggs can occur when a child places infective hands into their mouth. Once they reach the small intestine, they shed their cuticle (molt) becoming L2 larvae. L4 larvae feed and then molt, transforming into adults that travel to the large intestine, where they take up residence. Alternatively, eggs can hatch on the skin at the site of deposition, and the L2 larvae can crawl back through the anus into the rectum, and eventually the colon, where they develop into reproducing adults. In female patients, the larvae that hatch on the skin near the anus occasionally crawl into the vagina instead of the rectum, establishing an aberrant infection. Aberrant infections also include pelvic peritonitis, ovarian infection, granuloma of the liver, and the appendix. The parasite elicits a mild, local inflammatory 204 the Nematodes humans, but the reasons for this are not clear. It remains to be determined whether this difference in susceptibility has an immunological or physiological basis. Those few who are symptomatic experience intense itching of the perianal area, which in rare instances leads to cellulitis. Enuresis has been attributed to infection with pinworm, but no causal relation has been established. Patients who experience abdominal pain during infection may do so because of co-infection with Dientamoeba fragilis. Since eggs are deposited on the perianal skin and not released into feces, stool examination for ova and parasites is of little utility in diagnosing this infection. Eggs are best obtained by harvesting of these from the perianal area using clear (not frosted) adhesive tape or the commercially available adhesive pinworm paddle. The adhesive tape or paddle should be applied to the perianal region in the early hours of the morning as the patient sleeps or as soon as the patient awakens. A few patients develop pruritus resulting from allergic responses to worm proteins. Whether pinworm infection causes secondary problems, such as appendicitis or pelvic inflammatory disease, is unclear. In other circumstances, pinworms have been implicated as an appendicolith that might have led to the chain of events leading to clinical appendicitis. Syphacia oblevata is a pinworm species that infects mice only, and reaches much larger numbers in nude (athymic) mice than it does in the same mice into which a subcutaneous implant of thymic tissue from syngeneic donors was introduced. These female worms are 8-13mm long and very thin having the appearance of small white pieces of thread. Adult pinworms can be readily identified when they are seen on histologic sections because of bilateral cuticular projections known as alae. In patients with abdominal pain or other gastrointestinal symptoms, a fecal examination may be necessary to rule out co-infection with other infectious agents. None of these drugs kills the eggs or developing larvae, therefore, "blind" re-treatment is the reason for a second treatment 2 weeks after the original therapy. This second round of therapy destroys worms that have hatched from eggs ingested after the first treatment. Since eggs can survive 2 to 3 weeks before being ingested, the timing of exposure for an infected patient is 1 to 2 months prior to appearance of adult female worms capable of producing infective eggs. Treatment of exposed contacts, all household members, and source patients, if not household members, is recommended and has been successful in both households and institutions. The groups showing highest prevalence of infection are school children and institutionalized individuals. Compounding the problem is the fact that the eggs can survive for several days under conditions of high humidity and intermediate to low temperatures. Thorough washing of hands with soap and water after using the toilet, changing diapers, or caring for school age children should help to reduce transmission.

The superior phrenic artery provides blood to the superior surface of the diaphragm medications you can give dogs buy 5mg kemadrin otc. Arteries of the Thoracic Region Vessel Visceral branches Bronchial artery Pericardial artery Table 20 symptoms of appendicitis generic kemadrin 5 mg with visa. This vessel remains to the left of the vertebral column and is embedded in adipose tissue behind the peritoneal cavity treatment 5th finger fracture buy kemadrin 5mg. It formally ends at approximately the level of vertebra L4 medicine 4839 generic kemadrin 5 mg mastercard, where it bifurcates to form the common iliac arteries medications quinapril buy kemadrin 5 mg. Before this division medicine online purchase kemadrin 5 mg otc, the abdominal aorta gives rise to several important branches. A single celiac trunk (artery) emerges and divides into the left gastric artery to supply blood to the stomach and esophagus, the splenic artery to supply blood to the spleen, and the common hepatic artery, which in turn gives rise to the hepatic artery proper to supply blood to the liver, the right gastric artery to supply blood to the stomach, the cystic artery to supply blood to the gall bladder, and several branches, one to supply blood to the duodenum and another to supply blood to the pancreas. The inferior mesenteric artery supplies blood to the distal segment of the large intestine, including the rectum. In addition to these single branches, the abdominal aorta gives rise to several significant paired arteries along the way. These include the inferior phrenic arteries, the adrenal arteries, the renal arteries, the gonadal arteries, and the lumbar arteries. Each inferior phrenic artery is a counterpart of a superior phrenic artery and supplies blood to the inferior surface of the diaphragm. The adrenal artery supplies blood to the adrenal (suprarenal) glands and arises near the superior mesenteric artery. The right renal artery is longer than the left since the aorta lies to the left of the vertebral column and the vessel must travel a greater distance to reach its target. Each gonadal artery supplies blood to the gonads, or reproductive organs, and is also described as either an ovarian artery or a testicular artery (internal spermatic), depending upon the sex of the individual. An ovarian artery supplies blood to an ovary, uterine (Fallopian) tube, and the uterus, and is located within the suspensory ligament of the uterus. It is considerably shorter than a testicular artery, which ultimately travels outside the body cavity to the testes, forming one component of the spermatic cord. The gonadal arteries arise inferior to the renal arteries and are generally retroperitoneal. The ovarian artery continues to the uterus where it forms an anastomosis with the uterine artery that supplies blood to the uterus. Both the uterine arteries and vaginal arteries, which distribute blood to the vagina, are branches of the internal iliac artery. The four paired lumbar arteries are the counterparts of the intercostal arteries and supply blood to the lumbar region, the abdominal wall, and the spinal cord. In some instances, a fifth pair of lumbar arteries emerges from the median sacral artery. The aorta divides at approximately the level of vertebra L4 into a left and a right common iliac artery but continues as a small vessel, the median sacral artery, into the sacrum. The common iliac arteries provide blood to the pelvic region and ultimately to the lower limbs. They split into external and internal iliac arteries approximately at the level of the lumbarsacral articulation. Each internal iliac artery sends branches to the urinary bladder, the walls of the pelvis, the external genitalia, and the medial portion of the femoral region. Vessels of the Abdominal Aorta Vessel Celiac trunk Left gastric artery Splenic artery Common hepatic artery Hepatic artery proper Right gastric artery Cystic artery Superior mesenteric artery Inferior mesenteric artery Table 20. Although it does branch and supply blood to the region near the head of the humerus (via the humeral circumflex arteries), the majority of the vessel continues into the upper arm, or brachium, and becomes the brachial artery (Figure 20. The brachial artery supplies blood to much of the brachial region and divides at the elbow into several smaller branches, including the deep brachial arteries, which provide blood to the posterior surface of the arm, and the ulnar collateral arteries, which supply blood to the region of the elbow. As the brachial artery approaches the coronoid fossa, it bifurcates into the radial and ulnar arteries, which continue into the forearm, or antebrachium. The radial artery and ulnar artery parallel their namesake bones, giving off smaller branches until they reach the wrist, or carpal region. At this level, they fuse to form the superficial and deep palmar arches that supply blood to the hand, as well as the digital arteries that supply blood to the digits. Arteries Serving the Upper Limbs Vessel Axillary artery Description Continuation of the subclavian artery as it penetrates the body wall and enters the axillary region; supplies blood to the region near the head of the humerus (humeral circumflex arteries); the majority of the vessel continues into the brachium and becomes the brachial artery Continuation of the axillary artery in the brachium; supplies blood to much of the brachial region; gives off several smaller branches that provide blood to the posterior surface of the arm in the region of the elbow; bifurcates into the radial and ulnar arteries at the coronoid fossa Formed at the bifurcation of the brachial artery; parallels the radius; gives off smaller branches until it reaches the carpal region where it fuses with the ulnar artery to form the superficial and deep palmar arches; supplies blood to the lower arm and carpal region Formed at the bifurcation of the brachial artery; parallels the ulna; gives off smaller branches until it reaches the carpal region where it fuses with the radial artery to form the superficial and deep palmar arches; supplies blood to the lower arm and carpal region Formed from anastomosis of the radial and ulnar arteries; supply blood to the hand and digital arteries Formed from the superficial and deep palmar arches; supply blood to the digits Brachial artery Radial artery Ulnar artery Palmar arches (superficial and deep) Digital arteries Table 20. It gives off several smaller branches as well as the lateral deep femoral artery that in turn gives rise to a lateral circumflex artery. These arteries supply blood to the deep muscles of the thigh as well as ventral and lateral regions of the integument. The femoral artery also gives rise to the genicular artery, which provides blood to the region of the knee. As the femoral artery passes posterior to the knee near the popliteal fossa, it is called the popliteal artery. The anterior tibial artery is located between the tibia and fibula, and supplies blood to the muscles and integument of the anterior tibial region. Upon reaching the tarsal region, it becomes the dorsalis pedis artery, which branches repeatedly and provides blood to the tarsal and dorsal regions of the foot. The posterior tibial artery provides blood to the muscles and integument on the posterior surface of the tibial region. It bifurcates and becomes the medial plantar artery and lateral plantar artery, providing blood to the plantar surfaces. There is an anastomosis with the dorsalis pedis artery, and the medial and lateral plantar arteries form two arches called the dorsal arch (also called the arcuate arch) and the plantar arch, which provide blood to the remainder of the foot and toes. Arteries Serving the Lower Limbs Vessel Femoral artery Deep femoral artery Lateral circumflex artery Description Continuation of the external iliac artery after it passes through the body cavity; divides into several smaller branches, the lateral deep femoral artery, and the genicular artery; becomes the popliteal artery as it passes posterior to the knee Branch of the femoral artery; gives rise to the lateral circumflex arteries Branch of the deep femoral artery; supplies blood to the deep muscles of the thigh and the ventral and lateral regions of the integument Genicular artery Branch of the femoral artery; supplies blood to the region of the knee Popliteal artery Anterior tibial artery Table 20. Since the blood has already passed through the systemic capillaries, it will be relatively low in oxygen concentration. In many cases, there will be veins draining organs and regions of the body with the same name as the arteries that supplied these regions and the two often parallel one another. However, there is a great deal more variability in the venous circulation than normally occurs in the arteries. For the sake of brevity and clarity, this text will discuss only the most commonly encountered patterns. However, keep this variation in mind when you move from the classroom to clinical practice. In both the neck and limb regions, there are often both superficial and deeper levels of veins. The superficial veins do not normally have direct arterial counterparts, but in addition to returning blood, they also make contributions to the maintenance of body temperature. When the ambient temperature is warm, more blood is diverted to the superficial veins where heat can be more easily dissipated to the environment. In colder weather, there is more constriction of the superficial veins and blood is diverted deeper where the body can retain more of the heat. The "Voyage of Discovery" analogy and stick drawings mentioned earlier remain valid techniques for the study of systemic veins, but veins present a more difficult challenge because there are numerous anastomoses and multiple branches. It is like following a river with many tributaries and channels, several of which interconnect. Tracing blood flow through arteries follows the current in the direction of blood flow, so that we move from the heart through the large arteries and into the smaller arteries to the capillaries. From the capillaries, we move into the smallest veins and follow the direction of blood flow into larger veins and back to the heart. If you draw an imaginary line at the level of the diaphragm, systemic venous circulation from above that line will generally flow into the superior vena cava; this includes blood from the head, neck, chest, shoulders, and upper limbs. The exception to this is that most venous blood flow from the coronary veins flows directly into the coronary sinus and from there directly into the right atrium. Beneath the diaphragm, systemic venous flow enters the inferior vena cava, that is, blood from the abdominal and pelvic regions and the lower limbs. The Superior Vena Cava the superior vena cava drains most of the body superior to the diaphragm (Figure 20. On both the left and right sides, the subclavian vein forms when the axillary vein passes through the body wall from the axillary region. It fuses with the external and internal jugular veins from the head and neck to form the brachiocephalic vein. Each vertebral vein also flows into the brachiocephalic vein close to this fusion. These veins arise from the base of the brain and the cervical region this content is available for free at textbookequity. Each internal thoracic vein, also known as an internal mammary vein, drains the anterior surface of the chest wall and flows into the brachiocephalic vein. Each intercostal vein drains muscles of the thoracic wall, each esophageal vein delivers blood from the inferior portions of the esophagus, each bronchial vein drains the systemic circulation from the lungs, and several smaller veins drain the mediastinal region. Bronchial veins carry approximately 13 percent of the blood that flows into the bronchial arteries; the remainder intermingles with the pulmonary circulation and returns to the heart via the pulmonary veins. These veins flow into the azygos vein, and with the smaller hemiazygos vein (hemi- = "half") on the left of the vertebral column, drain blood from the thoracic region. The hemiazygos vein does not drain directly into the superior vena cava but enters the brachiocephalic vein via the superior intercostal vein. The azygos vein passes through the diaphragm from the thoracic cavity on the right side of the vertebral column and begins in the lumbar region of the thoracic cavity. It flows into the superior vena cava at approximately the level of T2, making a significant contribution to the flow of blood. It combines with the two large left and right brachiocephalic veins to form the superior vena cava. Veins of the Thoracic Region Vessel Superior vena cava Description Large systemic vein; drains blood from most areas superior to the diaphragm; empties into the right atrium Located deep in the thoracic cavity; formed by the axillary vein as it enters the thoracic Subclavian vein cavity from the axillary region; drains the axillary and smaller local veins near the scapular region and leads to the brachiocephalic vein Table 20. Blood from the more superficial portions of the head, scalp, and cranial regions, including the temporal vein and maxillary vein, flow into each external jugular vein. Although the external and internal jugular veins are separate vessels, there are anastomoses between them close to the thoracic region. Major Veins of the Head and Neck Vessel Internal jugular vein Temporal vein Maxillary vein Description Parallel to the common carotid artery, which is more or less its counterpart, and passes through the jugular foramen and canal; primarily drains blood from the brain, receives the superficial facial vein, and empties into the subclavian vein Drains blood from the temporal region and flows into the external jugular vein Drains blood from the maxillary region and flows into the external jugular vein External jugular Drains blood from the more superficial portions of the head, scalp, and cranial regions, and vein leads to the subclavian vein Table 20. Many smaller veins of the brain stem and the superficial veins of the cerebrum lead to larger vessels referred to as intracranial sinuses. These include the superior and inferior sagittal sinuses, straight sinus, cavernous sinuses, left and right sinuses, the petrosal sinuses, and the occipital sinuses. Ultimately, sinuses will lead back to either the inferior jugular vein or vertebral vein. Most of the veins on the superior surface of the cerebrum flow into the largest of the sinuses, the superior sagittal sinus. It is located midsagittally between the meningeal and periosteal layers of the dura mater within the falx cerebri and, at first glance in images or models, can be mistaken for the subarachnoid space. Most reabsorption of cerebrospinal fluid this content is available for free at textbookequity. Blood from most of the smaller vessels originating from the inferior cerebral veins flows into the great cerebral vein and into the straight sinus. Other cerebral veins and those from the eye socket flow into the cavernous sinus, which flows into the petrosal sinus and then into the internal jugular vein. The occipital sinus, sagittal sinus, and straight sinuses all flow into the left and right transverse sinuses near the lambdoid suture. The transverse sinuses in turn flow into the sigmoid sinuses that pass through the jugular foramen and into the internal jugular vein. The internal jugular vein flows parallel to the common carotid artery and is more or less its counterpart. The veins draining the cervical vertebrae and the posterior surface of the skull, including some blood from the occipital sinus, flow into the vertebral veins. These parallel the vertebral arteries and travel through the transverse foramina of the cervical vertebrae. Major Veins of the Brain Vessel Description Enlarged vein located midsagittally between the meningeal and periosteal layers of the dura Superior sagittal mater within the falx cerebri; receives most of the blood drained from the superior surface of sinus the cerebrum and leads to the inferior jugular vein and the vertebral vein Great cerebral vein Straight sinus Cavernous sinus Table 20. From here, the veins come together to form the radial vein, the ulnar vein, and the median antebrachial vein. The radial vein and the ulnar vein parallel the bones of the forearm and join together at the antebrachium to form the brachial vein, a deep vein that flows into the axillary vein in the brachium. The median antebrachial vein parallels the ulnar vein, is more medial in location, and joins the basilic vein in the forearm. As the basilic vein reaches the antecubital region, it gives off a branch called the median cubital vein that crosses at an angle to join the cephalic vein. The median cubital vein is the most common site for drawing venous blood in humans. The basilic vein continues through the arm medially and superficially to the axillary vein. The cephalic vein begins in the antebrachium and drains blood from the superficial surface of the arm into the axillary vein. It is extremely superficial and easily seen along the surface of the biceps brachii muscle in individuals with good muscle tone and in those without excessive subcutaneous adipose tissue in the arms. The subscapular vein drains blood from the subscapular region and joins the cephalic vein to form the axillary vein. As it passes through the body wall and enters the thorax, the axillary vein becomes the subclavian vein.

Hollow visceral myopathy

The blood in the superior and inferior venae cavae flows into the right atrium medications prescribed for adhd order kemadrin 5mg amex, which pumps blood into the right ventricle medicine hollywood undead kemadrin 5mg low cost. This process of blood circulation continues as long as the individual remains alive medications you can give your cat 5mg kemadrin with visa. Understanding the flow of blood through the pulmonary and systemic circuits is critical to all health professions (Figure 19 symptoms 5 weeks pregnant cheap kemadrin 5 mg. The blood in the pulmonary artery branches is low in oxygen but relatively high in carbon dioxide treatment of chlamydia purchase kemadrin 5 mg with visa. Gas exchange occurs in the pulmonary capillaries (oxygen into the blood medicine valley high school generic kemadrin 5 mg fast delivery, carbon dioxide out), and blood high in oxygen and low in carbon dioxide is returned to the left atrium. From here, blood enters the left ventricle, which pumps it into the systemic circuit. Following exchange in the systemic capillaries (oxygen and nutrients out of the capillaries and carbon dioxide and wastes in), blood returns to the right atrium and the cycle is repeated. Membranes, Surface Features, and Layers Our exploration of more in-depth heart structures begins by examining the membrane that surrounds the heart, the prominent surface features of the heart, and the layers that form the wall of the heart. Membranes the membrane that directly surrounds the heart and defines the pericardial cavity is called the pericardium or pericardial sac. It also surrounds the "roots" of the major vessels, or the areas of closest proximity to the heart. The pericardium, which literally translates as "around the heart," consists of two distinct sublayers: the sturdy outer fibrous pericardium and the inner serous pericardium. The fibrous pericardium is made of tough, dense connective tissue that protects the heart and maintains its position in the thorax. The more delicate serous pericardium consists of two layers: the parietal pericardium, which is fused to the fibrous pericardium, and an inner visceral pericardium, or epicardium, which is fused to the heart and is part of the heart wall. The pericardial cavity, filled with lubricating serous fluid, lies between the epicardium and the pericardium. However, in the case of the heart, it is not a microscopic layer but rather a macroscopic layer, consisting of a simple squamous epithelium called a mesothelium, reinforced with loose, irregular, or areolar connective tissue that attaches to the pericardium. This mesothelium secretes the lubricating serous fluid that fills the pericardial cavity and reduces friction as the heart contracts. Heart: Cardiac Tamponade If excess fluid builds within the pericardial space, it can lead to a condition called cardiac tamponade, or pericardial tamponade. With each contraction of the heart, more fluid-in most instances, blood-accumulates within the pericardial cavity. However, the excess fluid in the pericardial cavity puts pressure on the heart and prevents full relaxation, so the chambers within the heart contain slightly less blood as they begin each heart cycle. If the fluid builds up slowly, as in hypothyroidism, the pericardial cavity may be able to expand gradually to accommodate this extra volume. Some cases of fluid in excess of one liter within the pericardial cavity have been reported. Rapid accumulation of as little as 100 mL of fluid following trauma may trigger cardiac tamponade. Other common causes include myocardial rupture, pericarditis, cancer, or even cardiac surgery. Removal of this excess fluid requires insertion of drainage tubes into the pericardial cavity. Premature removal of these drainage tubes, for example, following cardiac surgery, or clot formation within these tubes are causes of this condition. Surface Features of the Heart Inside the pericardium, the surface features of the heart are visible, including the four chambers. There is a superficial leaflike extension of the atria near the superior surface of the heart, one on each side, called an auricle-a name that means "ear like"-because its shape resembles the external ear of a human (Figure 19. Auricles are relatively thin-walled structures that can fill with blood and empty into the atria or upper chambers of the heart. Also prominent is a series of fat-filled grooves, each of which is known as a sulcus (plural = sulci), along the superior surfaces of the heart. Located between the left and right ventricles are two additional sulci that are not as deep as the coronary sulcus. From superficial to deep, these are the epicardium, the myocardium, and the endocardium (see Figure 19. The outermost layer of the wall of the heart is also the innermost layer of the pericardium, the epicardium, or the visceral pericardium discussed earlier. The middle and thickest layer is the myocardium, made largely of cardiac muscle cells. It is built upon a framework of collagenous fibers, plus the blood vessels that supply the myocardium and the nerve fibers that help regulate the heart. It is the contraction of the myocardium that pumps blood through the heart and into the major arteries. The muscle pattern is elegant and complex, as the muscle cells swirl and spiral around the chambers of the heart. They form a figure 8 pattern around the atria and around the bases of the great vessels. Deeper ventricular muscles also form a figure 8 around the two ventricles and proceed toward the apex. This complex swirling pattern allows the heart to pump blood more effectively than a simple linear pattern would. Although the ventricles on the right and left sides pump the same amount of blood per contraction, the muscle of the left ventricle is much thicker and better developed than that of the right ventricle. In order to overcome the high resistance required to pump blood into the long systemic circuit, the left ventricle must generate a great amount of pressure. The right ventricle does not need to generate as much pressure, since the pulmonary circuit is shorter and provides less resistance. Both ventricles pump the same amount of blood, but the left ventricle must generate a much greater pressure to overcome greater resistance in the systemic circuit. Note the differences in the relative size of the lumens, the region inside each ventricle where the blood is contained. The innermost layer of the heart wall, the endocardium, is joined to the myocardium with a thin layer of connective tissue. The endocardium lines the chambers where the blood circulates and covers the heart valves. It is made of simple squamous epithelium called endothelium, which is continuous with the endothelial lining of the blood vessels (see Figure 19. Once regarded as a simple lining layer, recent evidence indicates that the endothelium of the endocardium and the coronary capillaries may play active roles in regulating the contraction of the muscle within the myocardium. The endothelium may also regulate the growth patterns of the cardiac muscle cells throughout life, and the endothelins it secretes create an environment in the surrounding tissue fluids that regulates ionic concentrations and states of contractility. In order to develop a more precise understanding of cardiac function, it is first necessary to explore the internal anatomical structures in more detail. Septa of the Heart the word septum is derived from the Latin for "something that encloses;" in this case, a septum (plural = septa) refers to a wall or partition that divides the heart into chambers. Normally in an adult heart, the interatrial septum bears an oval-shaped depression known as the fossa ovalis, a remnant of an opening in the fetal heart known as the foramen ovale. The foramen ovale allowed blood in the fetal heart to pass directly from the right atrium to the left atrium, allowing some blood to bypass the pulmonary circuit. Within seconds after birth, a flap of tissue known as the septum primum that previously acted as a valve closes the foramen ovale and establishes the typical cardiac circulation pattern. Between the two ventricles is a second septum known as the interventricular septum. Unlike the interatrial septum, the interventricular septum is normally intact after its formation during fetal development. It is substantially thicker than the interatrial septum, since the ventricles generate far greater pressure when they contract. The septum between the atria and ventricles is known as the atrioventricular septum. It is marked by the presence of four openings that allow blood to move from the atria into the ventricles and from the ventricles into the pulmonary trunk and aorta. Located in each of these openings between the atria and ventricles is a valve, a specialized structure that ensures one-way flow of blood. The valves between the atria and ventricles are known generically as atrioventricular valves. The valves at the openings that lead to the pulmonary trunk and aorta are known generically as semilunar valves. In this figure, the atrioventricular septum has been removed to better show the bicupid and tricuspid valves; the interatrial septum is not visible, since its location is covered by the aorta and pulmonary trunk. Since these openings and valves structurally weaken the atrioventricular septum, the remaining tissue is heavily reinforced with dense connective tissue called the cardiac skeleton, or skeleton of the heart. It includes four rings that surround the openings between the atria and ventricles, and the openings to the pulmonary trunk and aorta, and serve as the point of attachment for the heart valves. The cardiac skeleton also provides an important boundary in the heart electrical conduction system. The presence of the pulmonary trunk and aorta covers the interatrial septum, and the atrioventricular septum is cut away to show the atrioventricular valves. Patent foramen ovale is normally detected by auscultation of a heart murmur (an abnormal heart sound) and confirmed by imaging with an echocardiogram. Despite its prevalence in the general population, the causes of patent ovale are unknown, and there are no known risk factors. In nonlife-threatening cases, it is better to monitor the condition than to risk heart surgery to repair and seal the opening. Coarctation of the aorta is a congenital abnormal narrowing of the aorta that is normally located at the insertion of the ligamentum arteriosum, the remnant of the fetal shunt called the ductus arteriosus. If severe, this condition drastically restricts blood flow through the primary systemic artery, which is life threatening. In some individuals, the condition may be fairly benign and not detected until later in life. Detectable symptoms in an infant include difficulty breathing, poor appetite, trouble feeding, or failure to thrive. In older individuals, symptoms include dizziness, fainting, shortness of breath, chest pain, fatigue, headache, and nosebleeds. Treatment involves surgery to resect (remove) the affected region or angioplasty to open the abnormally narrow passageway. Studies have shown that the earlier the surgery is performed, the better the chance of survival. A patent ductus arteriosus is a congenital condition in which the ductus arteriosus fails to close. Failure of the ductus arteriosus to close results in blood flowing from the higher pressure aorta into the lower pressure pulmonary trunk. This additional fluid moving toward the lungs increases pulmonary pressure and makes respiration difficult. Symptoms include shortness of breath (dyspnea), tachycardia, enlarged heart, a widened pulse pressure, and poor weight gain in infants. Treatments include surgical closure (ligation), manual closure using platinum coils or specialized mesh inserted via the femoral artery or vein, or nonsteroidal anti-inflammatory drugs to block the synthesis of prostaglandin E2, which maintains the vessel in an open position. Septal defects are not uncommon in individuals and may be congenital or caused by various disease processes. Tetralogy of Fallot is a congenital condition that may also occur from exposure to unknown environmental factors; it occurs when there is an opening in the interventricular septum caused by blockage of the pulmonary trunk, normally at the pulmonary semilunar valve. This allows blood that is relatively low in oxygen from the right ventricle to flow into the left ventricle and mix with the blood that is relatively high in oxygen. Symptoms include a distinct heart murmur, low blood oxygen percent saturation, dyspnea or difficulty in breathing, polycythemia, broadening (clubbing) of the fingers and toes, and in children, difficulty in feeding or failure to grow and develop. The term "tetralogy" is derived from the four components of the condition, although only three may be present in an individual patient: pulmonary infundibular stenosis (rigidity of the pulmonary valve), overriding aorta (the aorta is shifted above both ventricles), ventricular septal defect (opening), and right ventricular hypertrophy (enlargement of the right ventricle). Other heart defects may also accompany this condition, which is typically confirmed by echocardiography imaging. Normal treatment involves extensive surgical repair, including the use of stents to redirect blood flow and replacement of valves and patches to repair the septal defect, but the condition has a relatively high mortality. Survival rates are currently 75 percent during the first year of life; 60 percent by 4 years of age; 30 percent by 10 years; and 5 percent by 40 years. In the case of severe septal defects, including both tetralogy of Fallot and patent foramen ovale, failure of the heart to develop properly can lead to a condition commonly known as a "blue baby. Septal defects are commonly first detected through auscultation, listening to the chest using a stethoscope. In this case, instead of hearing normal heart sounds attributed to the flow of blood and closing of heart valves, unusual heart sounds may be detected. Right Atrium the right atrium serves as the receiving chamber for blood returning to the heart from the systemic circulation. The two major systemic veins, the superior and inferior venae cavae, and the large coronary vein called the coronary sinus that drains the heart myocardium empty into the right atrium. The superior vena cava drains blood from regions superior to the diaphragm: the head, neck, upper limbs, and the thoracic region. The inferior vena cava drains blood from areas inferior to the diaphragm: the lower limbs and abdominopelvic region of the body. It, too, empties into the posterior portion of the atria, but inferior to the opening of the superior vena cava. Immediately superior and slightly medial to the opening of the inferior vena cava on the posterior surface of the atrium is the opening of the coronary sinus. This thin-walled vessel drains most of the coronary veins that return systemic blood from the heart. The majority of the internal heart structures discussed in this and subsequent sections are illustrated in Figure 19.

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Members of the family Scarabaeidae are intermediate hosts of the spiny-headed worm Macracanthorhynchus hirudinaceus medications that cause hair loss order kemadrin 5 mg without prescription, a parasite of pigs symptoms gluten intolerance 5 mg kemadrin for sale, which rarely infects humans medications used to treat depression order kemadrin 5mg with visa. Cockroaches: Order Blattodea Blattodea is a large medicine that makes you throw up effective 5mg kemadrin, diverse order of primitive schedule 8 medications victoria discount kemadrin 5 mg visa, successful insects (over 4 medications used for fibromyalgia generic kemadrin 5mg overnight delivery,000 species, worldwide) that includes the grasshoppers and crickets, as well as cockroaches. The cockroaches are included in a single family, the Blattidae, with several members closely associated with human habitations. Some species retain the ootheca internally until the eggs hatch, others carry it externally for several weeks, and still others drop the ootheca soon after it is formed. After hatching, the young, wingless, feeding nymphs begin to undergo staged development. Some species progress through as many as 13 nymph stages, each being wingless and somewhat Beetles: Order Coleoptera larger than its predecessor, until the final molt Within the order Coleoptera, which com- produces the winged adult. With its series of prises a large group of insects, only a few wingless nymph stages, the cockroach is a 510 the Arthropods classic example of an insect developing by incomplete metamorphosis. Most cockroach species do not invade homes, confining themselves to outdoor habitats, although in the United States eleven species of cockroaches do invade human habitats. The most common is the German cockroach or croton bug, Blatella germanica, a small (<16 mm), light brown species. The American cockroach or palmetto bug, Periplaneta americana, is in fact an African species now found worldwide. Other species that may infest homes are the Oriental cockroach Blatta orientalis, the Australian cockroach P. Most of these species are cosmopolitan, having been distributed by ship traffic starting with the earliest voyages. They feed on a wide variety of nutrients, paper, book bindings, and human and animal feces. They serve as mechanical vectors of pathogens, carrying infectious agents from feces to food. Exposed foods or poor packaging and storage, open garbage, darkness and moisture are all conducive to the development of large cockroach populations. Initial infestations may be introduced with foodstuffs or migration from adjoining dwellings. In apartment buildings, the insecticide treatment of one apartment may cause the migration of cockroaches to adjoining, untreated apartments. Cockroach infestations are best controlled by cockroach baits pared with sanitation. Although cockroaches are resistant to a number of insecticides in some areas, compounds for control are commercially available. Coupled with improved housekeeping, treatment with these agents can be sufficient, although heavy infestations require repeated treatments by professional exterminators. Cockroaches, because of their close association with sewage and garbage, may serve as paratenic hosts for various pathogens. They have a pair of poisonous claws, or maxillipeds, on the first segment after the head, which are used for capturing prey. Most centipedes are predaceous insectivores, and humans are sometimes bitten accidentally. Centipede bites may be locally painful, causing transient swelling at the site of the bite. Tongue Worms: Class Pentastomida the pentastomids, or tongue worms, of the class Pentastomida are a small group of parasites of uncertain origin and affinity. Because their larvae superficially resemble the larvae of mites, they have been included among the Arthropoda, but they probably evolved early from annelid or arthropod ancestral stocks. They were first noted in the nasal cavities of dogs and horses during the eighteenth century and were later described in human autopsy material as insect larvae. The adult tongue worms are blood sucking, endoparasitic, legless vermiform inhabitants of the respiratory system of reptiles, 40. After being eaten by an intermediate host, they hatch in the gut, yielding a migratory larva that pierces the stomach wall and encysts in host tissue. In humans, encysted larvae have been found in the lungs, liver, intestine, spleen, and other internal organs. To his long list of credits, he single-handedly established the field of anatomic pathology and was a passionate advocate of the use of microscopy for describing pathological conditions. His insatiable curiosity led him to investigate the life cycle of Trichinella spiralis. Virchow proved that the infection was transmitted from animal to animal by the ingestion of raw meat that harbored the infective larvae. He further determined that if the meat was heated to 1370 F for ten minutes, the infective larvae were killed, and the meat could then be eaten without medical consequences. He proved that humans became sick when they ingested infected raw or undercooked meat, and helped to establish a meat inspection program aimed at eliminating the infection. He described numerous pathological conditions in humans, many of which still bear his name. He was also an opponent of the germ theory of disease, despite his work on Trichinella spiralis. Appendix A: Procedures for Collecting Clinical Specimens for 513 Diagnosing Protozoan and Helminthic Parasites Appendix A: Procedures for Collecting Clinical Specimens for Diagnosing Protozoan and Helminthic Parasites be completed on the day on which the specimen is received in the laboratory. If prompt examination or proper fixation cannot be carried out, formed specimens There is no substitute for a well-trained may be refrigerated for 1-2 days. But even received at night, on weekends, or when the best-trained personnel cannot make up no parasitologist is available), portions for an improper sample delivered to the should be preserved in fixatives such laboratory in the expectation of securing as 8% aqueous formalin or formolthe diagnosis. A ratio of one tory receives the right amount and type of part feces to three parts of fixative is patient specimen. The specimen may be placed in fixatives in the laboratory, Stool Specimens or the patient may be provided with fixatives and instructions for collection Proper collection and delivery of stool and preservation of their own specimens. The clinician can control the quality of this aspect, and in doing so, will insure both Stool specimens may be successfully the reliability and accuracy of any test they examined by any one of the three methods recommend, regardless of whether that test listed below. The advantages and limitations is carried out in-house or at a regional diag- of each technique must be recognized. Fresh, unpreserved feces should demonstrating the characteristic motility be obtained and transported to the of amoebae and flagellates. Fresh specimens seeing red cells inside a trophozoite of are preferred for examinations for an amoeba is indicative of infection with trophozoites, and are required when Entamoeba histolytica. These organisms tests for Strongyloides stercoralis larvae may be found in fresh stools, or are to be performed. Material within one hour after passage, especially should be obtained from several parts if the stool is loose or watery, and might of the specimen. An iodine stain (a drop contain trophozoites of pathogenic of 1% iodine in 2% potassium iodide) amoebae. Examination of formed stool mixed with a stool suspension in saline may be delayed for a short time, but must solution facilitates identification of 514 Appendix A: Procedures for Collecting Clinical Specimens for Diagnosing Protozoan and Helminthic Parasites protozoan cysts, but it kills and distorts or urine. Concentration techniques, useful for diagnosis, but this method is not for detecting small numbers of cysts always reliable; various fecal culture and helminth eggs, may be used on methods may also be used. Stained, thin smears of feces should therapy (three months after treatment be made if possible on all specimens for schistosomiasis or tapeworms). If properly prepared, they comprise the single Examination of Blood most productive stool examination for protozoa. It is important or with iron-hematoxylin (see Appendix that all involved laboratory personnel be B for colors of each). Any outstanding aware of the technique for making thick examples of positive specimens should films as they are useless if improperly be retained in a permanent file and used made. Giemsa solution and a minimum of 100 contiguous microscopic fields Number of Specimens Examined and examined before a specimen is reported Appropriate Intervals as "negative. To detect amoebae, a minimum of should be taken every six hours for the three specimens should be examined; first 24 hours after admission. When examining for filarial infection, intervals of 2-3 days) are negative and the possibility of diurnal or nocturnal amoebic infection remains a diagnostic periodicity of microfilariae in the consideration, additional specimens peripheral blood must be taken into should be examined. With suspected giardiasis, nucleic every six hours for the first 24 hours amplification testing and antigen after admission, as with malaria. With very light cases, serologic methods may be the only infections due to Schistosoma spp. Positive tests revealing the presence of specific antibodies are indirect evidence of infection, no matter how good the method. Tests employing antibody capture techniques, in which monoclonal antibodies are used to select for a single class of immunoglobulin increases the likelihood of a true positive result. Most serum specimens may be shipped frozen or preserved with thimerosal to a final concentration of 1:10,000 to a state public health laboratory for forwarding to the Centers for Disease Control and Prevention in Atlanta, Georgia. The vial, containing at least 2 ml of serum, should indicate the preservative used. These tests have already become the primary diagnostic tests in many clinical centers. Appendix B: Laboratory Diagnostic Methods 517 Appendix Methods B: Laboratory Diagnostic In recent years, a battery of cuttingedge diagnostic modalities have emerged, making the identification of many infectious diseases straightforward, without requiring any more skill than being able to read the instructions and to execute them. Each of the preceding chapters attests to this fact, with a robust sampling of modern serological and molecular diagnostic strategies. The vast majority of parasitology laboratories in hospitals and outpatient health clinics throughout the world continue to rely on more traditional approaches for the diagnosis of eukaryotic parasites. In these instances, microscopy remains the gold standard for pathogen identification. This chapter serves as a standard reference for these time-honored laboratory procedures. There is no single method that efficiently renders all stages of all parasites available for microscopic identification; several tests must often be performed to obtain optimal results. Unpreserved Stool Specimens Ideally, stool specimens should be less than one hour old when first examined, although this may not always be possible. Stools that are up to 24 hours old may still be useful for recovering protozoan cysts, larvae and eggs of helminthes, but trophozoites rarely survive that long. A confounding factor when examining specimens left at room temperature for more than 24 hours is that some parasites can grow and develop. Stools should not be frozen, as that would alter the morphology of the organisms examined. Because of day-to-day variability in the quantity of various stages of parasite shed by an infected individual, parasites may not be present in a single specimen, particularly when the infection is light. A total of three specimens collected on consecutive days are suggested when attempting to detect most enteric infections by visual microscopy. Patients should not be subjected to radiographic studies involving barium or given laxatives containing mineral oil until the stool specimens have been obtained. Observe and record the appearance of the entire specimen, noting the color, consistency, and odor. When motile amoebae are found on a direct smear, a stained preparation should also be examined for the definitive diagnosis. If the amoeba contains erythrocytes within the cytoplasm, it is indicative of infection caused by E. If the specimen appears negative, as may occur with light infections, the sample should be concentrated. Dip a wooden applicator stick into the Solution Time specimen to coat the tip of it with stool. Smear the stool onto a clear glass Ethanol 100% 1 minute microscope slide on which a drop of Xylol 1 minute normal saline solution has been placed and overlay with a coverslip. Smears Mount the coverslip in an appropriate must be thin enough to facilitate mounting medium and examine under a microscopic examination. Sedimentation by concentration and Trophozoites and cysts tend to shrink away from the background material and are exposure to formaldehyde-ethyl acetate concentrates cysts and eggs of parasites, but therefore relatively easy to locate. Centrifuge the strained stool (1 minute at Solution Time 2000 rpm) and discard the supernatant. Add approximately 3 ml of ethyl acetate, plug the tubes with stoppers, and agitate To remove excess stain, briefly dip the the mixture vigorously. Gently loosen the debris from the tube wall with an applicator stick, being dips to obtain optimal differentiation. Sedimentation by Gravity: the water sedimentation test is used primarily for the concentration and recovery 1. Strain the specimen through a single japonicum eggs, and it is effective for layer of gauze into conical sedimentation determining their viability. Allow the sediment to settle single test because schistosome eggs are (approximately 20 minutes) and discard shed sporadically. Discard final supernatant and save the single layer of gauze into conical sediment. Repeat steps 3 and 4 until the stages of parasites by taking advantage of supernatant is clear. Discard final supernatant and save the sediments to the bottom of the tube during sediment. Larvae concentrate in the sediment that accumulates in the base of the rubber tube connected to the funnel, and the fluid containing them is expressed into a test tube for microscopic identification 520 Appendix B: Laboratory Diagnostic Methods to the centrifuge or jar the tube, as either maneuver causes any eggs or cysts accumulated at the liquid-surface interface to sink. Using a bacteriologic loop, remove two aliquots from the surface and place them on a clean glass slide. The focal plane is important, because the oocysts are located on the inner surface of the coverslip, rather than on the slide itself. They are ovoid to spherical in shape, range in size from 5 to 6 um in diameter and are usually not sporulated.

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