By J. Ernesto. Williams Baptist College.

In addition to hyperglycemia buy 100mcg combivent amex medicine 3601, chronically elevated glucocorticoids compromise immunity buy 100 mcg combivent amex medicine vs nursing, resistance to infection, and memory, and can result in rapid weight gain and hair loss. In contrast, the hyposecretion of corticosteroids can result in Addison’s disease, a rare disorder that causes low blood glucose levels and low blood sodium levels. The signs and symptoms of Addison’s disease are vague and are typical of other disorders as well, making diagnosis difficult. They may include general weakness, abdominal pain, weight loss, nausea, vomiting, sweating, and cravings for salty food. Inferior but somewhat posterior to the thalamus is the pineal gland, a tiny endocrine gland whose functions are not entirely clear. The pinealocyte cells that make up the pineal gland are known to produce and secrete the amine hormone melatonin, which is derived from serotonin. In contrast, as light levels decline—such as during the evening—melatonin production increases, boosting blood levels and causing drowsiness. The secretion of melatonin may influence the body’s circadian rhythms, the dark-light fluctuations that affect not only sleepiness and wakefulness, but also appetite and body temperature. Interestingly, children have higher melatonin levels than adults, which may prevent the release of gonadotropins from the anterior pituitary, thereby inhibiting the onset of puberty. Jet lag occurs when a person travels across several time zones and feels sleepy during the day or wakeful at night. Traveling across multiple time zones significantly disturbs the light-dark cycle regulated by melatonin. It can take up to several days for melatonin synthesis to adjust to the light-dark patterns in the new environment, resulting in jet lag. The primary hormone produced by the male testes is testosterone, a steroid hormone important in the development of the male reproductive system, the maturation of sperm cells, and the development of male secondary sex characteristics such as a deepened voice, body hair, and increased muscle mass. The primary hormones produced by the ovaries are estrogens, which include estradiol, estriol, and estrone. Estrogens play an important role in a larger number of physiological processes, including the development of the female reproductive system, regulation of the menstrual cycle, the development of female secondary sex characteristics such as increased adipose tissue and the development of breast tissue, and the maintenance of pregnancy. Another significant ovarian hormone is progesterone, which contributes to regulation of the menstrual cycle and is important in preparing the body for pregnancy as well as maintaining pregnancy. The placenta supplies oxygen and nutrients to the fetus, excretes waste products, and produces and secretes estrogens and progesterone. Commonly used for performance enhancement, anabolic steroids are synthetic versions of the male sex hormone, testosterone. The use of performance-enhancing drugs is banned by all major collegiate and professional sports organizations in the United States because they impart an unfair advantage to athletes who take them. For example, anabolic steroid use can increase cholesterol levels, raise blood pressure, and damage the liver. Altered testosterone levels (both too low or too high) have been implicated in causing structural damage to the heart, and increasing the risk for cardiac arrhythmias, heart attacks, congestive heart failure, and sudden death. Paradoxically, steroids can have a feminizing effect in males, including shriveled testicles and enlarged breast tissue. In females, their use can cause masculinizing effects such as an enlarged clitoris and growth of facial hair. In both sexes, their use can promote increased aggression (commonly known as “roid-rage”), depression, sleep disturbances, severe acne, and infertility. Although it is primarily an exocrine gland, secreting a variety of digestive enzymes, the pancreas has an endocrine function. Its endocrine function involves the secretion of insulin (produced by beta cells) and glucagon (produced by alpha cells) within the pancreatic islets. Cells and Secretions of the Pancreatic Islets The pancreatic islets each contain four varieties of cells: • The alpha cell produces the hormone glucagon and makes up approximately 20 percent of each islet. Glucagon plays an important role in blood glucose regulation; low blood glucose levels stimulate its release. It is thought to play a role in appetite, as well as in the regulation of pancreatic exocrine and endocrine secretions.

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The clinical distinction between direct and indirect inguinal hernias • L4: the transtubercular plane purchase combivent 100mcg line treatment mononucleosis. Vertical lines: these are imaginary and most often used with the sub- costal and intertubercular planes discount combivent 100mcg fast delivery medicine 1800s, for purposes of description, to subdi- Surface markings of the abdominal viscera (Fig. They pass vertically, on • Liver: the lower border of the liver is usually just palpable on deep either side, through the point halfway between the anterior superior inspiration in slim individuals. More commonly used, for descrip- face of the diaphragm and reaches a level just below the nipple on each tion of pain location, are quadrants. The surface marking corresponds to a point where the lat- ally and the cartilages of the 11th and 12th ribs posteriorly. The pubic • Pancreas: the pancreatic neck lies on the level of the transpyloric tubercle is an important landmark and is identifiable on the superior plane (L1). The lower pole of the right kidney usually extends 3 cm below the defect in the external oblique aponeurosis. It extends as a de- • Bladder: in adults the bladder is a pelvic organ and can be palpated pression in the midline from the xiphoid process to the symphysis pubis. Surface anatomy of the abdomen 53 23 The pelvis Icthe bony and ligamentous pelvis Iliac crest Anterior gluteal line Iliac fossa Inferior gluteal line Posterior superior Anterior superior iliac spine iliac spine Anterior inferior Posterior gluteal line Auricular iliac spine surface Acetabulum Greater sciatic notch Obturator foramen Iliopectineal Pubic tubercle Spine of ischium line Pubic crest Lesser sciatic notch Pubic tubercle Body of pubis Ischial tuberosity Pubic Ramus of ischium Inferior ramus symphysis Fig. Prostate Obturator fascia The blue line represents the origin Obturator internus of levator ani from the obturator Anterior edge Levator prostatae fascia of levator ani 54 Abdomen and pelvis The pelvis is bounded posteriorly by the sacrum and coccyx and antero- The pelvic cavity laterally by the innominate bones. The pelvic brim (also termed the pelvic inlet) separates the pelvis into the false pelvis (above) and the true pelvis (below). By adulthood the constituent bones have fused together at the behind, the ischial tuberosities laterally and the pubic arch anteriorly. Posteriorly each hip bone articulates with the sacrum at the The true pelvis (pelvic cavity) lies between the inlet and outlet. It runs back- wards from the anterior superior iliac spine to the posterior superior The ligaments of the pelvis (Fig. The outer surface of the ilium is termed the gluteal sur- • Sacrotuberous ligament: extends from the lateral part of the sacrum face as it is where the gluteal muscles are attached. The The above ligaments, together with the sacro-iliac ligaments, bind auricular surface of the ilium articulates with the sacrum at the sacro- the sacrum and coccyx to the os and prevent excessive movement at the iliac joints (synovial joints). In addition, these ligaments create the greater and iliac ligaments strengthen the sacro-iliac joints. The pelvic floor muscles: support the viscera; produce a sphincter • Ischium: comprises a spine on its posterior part which demarcates action on the rectum and vagina and help to produce increases in intra- the greater (above) and lesser sciatic (below) notches. The rectum, urethra and vagina tuberosity is a thickening on the lower part of the body of the ischium (in the female) traverse the pelvic floor to gain access to the exterior. The ischial ramus projects The levator ani and coccygeus muscles form the pelvic floor, while piri- forwards from the tuberosity to meet and fuse with the inferior pubic formis covers the front of the sacrum. It overlying obturator internus on the side wall of the pelvis and the articulates with the pubic bone of the other side at the symphysis pubis ischial spine. The superior surface of the body the midline as follows: bears the pubic crest and the pubic tubercle (Fig. The anterior and lateral anorectal junction and also insert into the deep part of the anal aspects of the sacrum are termed the central and lateral masses, respect- sphincter. Posteriorly, the fused pedicles and laminae form aspect of the coccyx and a median fibrous raphe (the anococcygeal the sacral canal representing a continuation of the vertebral canal. Sacral cornua • Coccygeus: arises from the ischial spine and inserts into the lower bound the hiatus inferiorly on either side. It comprises The female pelvis differs from that of the male for the purpose of child- between three and five fused rudimentary vertebrae. In the male the sacral promon- The obturator membrane tory is prominent, producing a heart-shaped inlet. The obturator membrane is a sheet of fibrous tissue which covers the 2 The pelvic outlet is wider in females as the ischial tuberosities are obturator foramen with the exception of a small area for the passage of everted. The latter branch The pelvic fascia is the term given to the connective tissue that lines the gains access to the rectus sheath, which it supplies, and eventually pelvis covering levator ani and obturator internus. These ligaments include the: Branches of the anterior trunk • Cardinal (Mackenrodt’s) ligaments: pass laterally from the cervix • Obturator artery: passes with the obturator nerve through the obtur- and upper vagina to the pelvic side walls.

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To date purchase combivent 100mcg medicine to stop contractions, all outbreaks of the highly pathogenic form have been caused by influenza A viruses of the subtypes H5 and H7 cheap combivent 100mcg overnight delivery medications or drugs. In the past outbreaks, illegal trade or movements of infected live birds or their un- processed products, and unintended mechanical passing-on of virus through human movements (travellers, refugees, etc. The simultaneous occurrence in several countries of large epidemics of highly pathogenic H5N1 influenza in domestic poultry is unprecedented. Despite the culling and the pre-emptive destruction of some 150 million birds, H5N1 is now considered endemic in many parts of Indonesia and Vietnam and in some parts of Cambodia, China, Thailand, and possibly also the Lao People’s Democratic Republic. In April 2005, yet another level of the epizootic was reached, when, for the Þrst time, the H5N1 strain obtained access to wild bird populations on a larger scale Economic Consequences 67 (Chen 2005, Liu 2005). At Lake Qinghai in North Western China several thousands of bar-headed geese, a migratory species, succumbed to the infection. When, in the summer and early autumn of 2005, H5N1 outbreaks were reported for the Þrst time from geographically adjacent Mongolia, Kazakhstan, and Southern Siberia, migratory birds were suspected of spreading the virus. Further outbreaks along and between overlapping migratory flyways from inner Asia towards the Middle East and Africa hit Turkey, Romania, Croatia, and the Crimean peninsula in late 2005. In all instances (except those in Mongolia and Croatia) both poultry and wild aquatic birds were found to be affected. Often the index cases in poultry appeared to be in close proximity to lakes and marshes inhabited by wild aquatic birds. The true status of H5N1 in the populations of wild water birds and their role in the spread of the infection re- mains enigmatic. Presently, it can only be speculated as to whether wild aquatic birds can carry the virus over long distances during the incubation period, or whether some species indeed remain mobile despite an H5N1 infection. Meanwhile, however, studies in China have revealed the presence of more new genotypes of the Asian lineage H5N1 virus in tree sparrows (Kou 2005). Neither the sparrows from which the viruses were isolated, nor the ducks that were experi- mentally infected with these viruses, showed any symptoms. The human epidemic is currently limited to Cambodia, Indonesia, Thailand, and the epicentre Vietnam (65. Economic Consequences Outbreaks of highly pathogenic avian influenza can be catastrophic for single farm- ers and for the poultry industry of an affected region as a whole (see Table 1). It is pivotal that movements of live poultry and also, possibly, poultry prod- ucts, both within and between countries, are restricted during outbreaks. SpeciÞc problems of this eradication concept may arise in areas (i) with a high den- sity of poultry populations (Marangon 2004, Stegemann 2004, Mannelli 2005) and (ii) where small backyard holdings of free roaming poultry prevail (Witt and Malone 2005). Due to the close proximity of poultry holdings and intertwining structures of the industry, spread of the disease is faster than the eradication meas- ures. Therefore, during the Italian outbreak of 1999/2000 not only infected or con- tact holdings were destroyed, but also ßocks with a risk of infection within a radius of one kilometre from the infected farm were pre-emptively killed. Nevertheless, eradication required four months and demanded the death of 13 millions birds (Capua 2003). So, not only the disease itself, but also the pre-emptive culling of animals led to losses of 30 and 19 million birds, respectively. In 1997, the Hong Kong authorities culled the entire th th st poultry population within three days (on the 29 , 30 , and 31 December; 1. However, this will afflict the poultry Vaccination 69 industry significantly and also prompts ethical concern from the public against the culling of millions of healthy and uninfected animals in the buffer zones. Such measures are most difficult to implement in rural areas with traditional forms of poultry holdings where chickens and ducks roam freely and mingle with wild birds or share water sources with them. Vaccination has been widely used in these circumstances and may also be a sup- plementary tool in the eradication process of outbreaks in non-endemic areas. In the field of influenza vaccination, neither commercially available nor experi- mentally tested vaccines have been shown so far to fulfil all of these requirements (Lee and Suarez 2005). The risk of infection of vac- cinees with, and excretion of, virulent field virus is usually reduced but not fully prevented.

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