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X-1 intraoperative complications in organ salvage operations on the small pelvis organs] acne cyst removal discount benzac 20 gr on line. Radiographic and ultrasonographic in atypical leiomyoma and leiomyosarcoma findings of uterine neoplasms in nine dogs skin care quiz generic benzac 20 gr with amex. Abdominal ultrasound the measurement of stiffness of uterine guided transvaginal myometrial core needle smooth muscle tumor by elastography skin care wiki buy benzac 20 gr cheap. Clinical prospective analysis of feasibility acne zits cysts and boils popped purchase 20 gr benzac free shipping, safety skin care regimen buy cheap benzac 20 gr, efficiency investigation of laparoscopic and technique skin care treatments order generic benzac line. Effectiveness of hysteroscopic analyses of 6 different types of uterine repair of uterine lesions in reproductive smooth muscle tumors: Emphasis in atypical outcome. Immunohistochemical detection of Limits and complications of laparoscopic promyelocytic leukemia zinc finger and myomectomy: which are the best predictors Is myomectomy technique for diffuse uterine myomectomy in women aged 45 years and leiomyomatosis. Fertility outcomes after approach for analysis of uterine fibroid uterine artery occlusion in the management pseudocapsule thickness. Ultrasound laparoendoscopic single-site vs conventional guided transvaginal radiofrequency laparoscopic myomectomy. Laparotomic myomectomy in the 16th by transvaginal natural orifice transluminal week of pregnancy: a case report. Interval between hysterectomy and start Evaluation of the outcomes of laparoscopic of radiation treatment is predictive of hysterectomy for normal and enlarged uterus recurrence in patients with endometrial (>280 g). Uterine following myomectomy: experience of a artery embolization for severe symptomatic French Caribbean University Hospital. Myomectomy during caesarean: a Gynaecological laparoscopic surgery: eight retrospective evaluation of 16 cases. A clinically feasible treatment protocol high-intensity focused ultrasound ablation in for magnetic resonance-guided high the liver dome. Effects of magnetic resonance Improving thermal dose accuracy in guided high-intensity focused ultrasound magnetic resonance-guided focused ablation on bone mechanical properties and ultrasound surgery: Long-term thermometry modeling. High focused ultrasound probe for ablation of intensity focused ultrasound ablation for renal neoplasms. Critical uterine malignancy in women who have analysis of cases of endometrial carcinoma undergone myomectomy. X-3, X-4 and uterine morcellation: A case report from Asokoro District Hospital, Abuja, Nigeria. Use of outcome affected by tumor morcellation in Electric Power Morcellation and Prevalence unexpected early uterine leiomyosarcoma. Incidence Surgical removal of multiple mesenteric of Tissue Morcellation During Surgery for fibroids (Kg 4,500) by abdominal spread of Uterine Sarcoma at a Canadian Academic previous laparoscopic uterine myomectomy. A new in-bag system to reduce the risk of Should we abandon all conservative tissue morcellation: development and treatments for uterine fibroids Technical update on tissue morcellation Complete remission achieved by during gynaecologic surgery: its uses, oophorectomy for recurrent endometrial complications, and risks of unsuspected stromal sarcoma after laparoscopic malignancy. Delayed presentation of a paracytic myoma Comparison of morcellator and culdotomy fragment after laparoscopic supracervical for extraction of uterine fibroids hysterectomy requiring small bowel laparoscopically. X-2, X-3, X-4 cytoreduction for disseminated benign disease after open power uterine 347. Mitigating risks of specimen Laparoscopic supracervical hysterectomy extraction: is in-bag power morcellation an with transcervical morcellation: our answer Effects of laparoscopic myomectomy with laparoscopic versus minilaparotomic intracorporeal suture-tying and myomectomy on uterine leiomyoma: a transumbilical morcellation. Reply to in-bag Contained power morcellation within an morcellation for presumed myoma retrieval insufflated isolation bag. Total laparoscopic hysterectomy of very Retrospective cohort study evaluating the enlarged uterus (3030 g): case report and impact of intraperitoneal morcellation on review of the literature. Unanticipated uterine pathologic finding Laparoscopic hysterectomy in case of uteri after morcellation during robotic-assisted weighing >/=1 kilogram: a series of 71 cases supracervical hysterectomy and and review of the literature. X-3 Comparison of the initial surgical experience with robotic and laparoscopic 391. Power Morcellation Hysterectomy Treated 6 Months With of Unsuspected High-grade Ulipristal Acetate and Contained Power Leiomyosarcoma Within an Inflated Morcellation. In the Aftermath of the Storm Uterine Size, and Operative Morbidity in Called Power Morcellation. Erratum to: the laparoscopic modified Sugarbaker technique is safe and has a low 406. Surgical treatment: Myomectomy and Laparoscopic Chromopertubation, hysterectomy; Endoscopy: A major Myomectomy with Opening of the Uterine advancement. Iatrogenic parasitic Hysterectomy for benign disease: clinical leiomyoma and leiomyomatosis peritonealis practice guidelines from the French College disseminata following uterine morcellation. Feasibility of Thermal Imaging as a Future Prevalence of Occult Malignancy Within Portal Imaging Device for Therapeutic Morcellated Specimens Removed During Ultrasound. A Safety and economical innovations multicenter study comparing surgical regarding surgical treatment of fibroids. Women with 2 or More Recurrent [Management of uterine myomas during Pregnancy Losses: A Systematic Review. Tragedy, Trade resonance-guided laser interstitial thermal offs, and the Demise of Morcellation. Hand-Assisted Hysterectomy for a Benign Condition: A Laparoscopic Hysterectomy for Large Uteri. X-4 morcellation and extraction for an endobag with sealable ports: in vitro pilot study. X-1 Augmented reality in gynecologic surgery: evaluation of potential benefits for 445. Interim myomectomy in an experimental uterine analysis of a randomized controlled trial model. Magnetic resonance Erratum to: Is self-weighing an effective enema versus rectal water contrast tool for weight loss: a systematic literature transvaginal ultrasonography in the review and meta-analysis. Comparison Medicine essay on morcellation prompts a of Survival Outcomes in Women with call for retraction. Kacperczyk J, Bartnik P, Romejko Myomas and Endometriotic Nodule Wolniewicz E, et al. Letter to the Food and Drug Administration Ileo-uterine fistula in a degenerated Regarding the Use of Morcellation posterior wall fibroid after Caesarean Procedures in Women Having Surgery for section. Risk Feasible Treatment Modality for Desmoid of Occult Uterine Sarcoma in Women Tumors Rivas-Lopez R, Duron-Padilla R, Romero Incidence of occult leiomyosarcoma in Hernandez S, et al. Peritoneal Leyomyomatosis after Impact of the Food and Drug Administration Laparoscopic Morcellation-a Case Report]. Removal by Transvaginal and Uterine Universal Cystoscopy After Benign Morcellation Approaches. Kalogiannidis I, Stavrakis T, Dagklis T, et laparoscopic morcellation: a systematic al. Contained Spontaneous Uterine Rupture in a Preterm Morcellation for Laparoscopic Pregnancy following Myomectomy. X-2 Acetate for the Management of Fibroid Related Acute Abnormal Uterine Bleeding. X-4 Following Ulipristal Acetate Treatment in a Woman with a Symptomatic Uterine 505. Laparoscopic Approach for Fibroid Focused Ultrasound Ablation of Uterine Removal at 18 Weeks of Pregnancy. Predicting postoperative day 1 hematocrit method to determine the suitability for levels after uncomplicated hysterectomy. High gynaecological diseases: A review of safety intensity focused ultrasound ablation for and efficacy. Pregnancy outcomes Hydrothermal ablation complicated by acute after myomectomy with peritonitis due to thermal injury to the polytetrafluoroethylene placement. Reasons for exclusion: Key Question 4 (n = 979*) Exclusion Code Exclusion Reason Count* L1: X-1; L2: X-1 Not original research 272 L1: X-2 Not women with fibroids 345 L1: X-3; L2: X-4 Does not include at least patients treated for uterine fibroids 491 L1: X-4; L2: X-2 Does not report method for tissue removal 200 Does not report outcome(s) related to leiomyosarcoma subsequent to treatment for L1: X-5; L2: X-5 584 uterine fibroids L2: X-3 Ineligible study design or article type 9 L2: X-10 Unavailable 1 L2: X-11 Non-English 1 *Total count exceeds number of records as records can be excluded for more than one reason 1. Surgical Methods for the Treatment single-site myomectomy: initial report and of Uterine Fibroids Risk of Uterine technique. Intracorporeal electromechanical tissue Options on fibroid morcellation: a literature morcellation: a critical review and review. Is open advance access platforms and 3M Steri surgery the solution to avoid morcellation of Drape endobag. L1: X-1 during gynaecologic surgery: its uses, complications, and risks of unsuspected 17. A critical assessment of morcellation in Laparoscopic Supracervical and its impact on gynecologic surgery and Hysterectomy and Laparoscopic the limitations of the existing literature. Modified Effects of Morcellation of Uterine Smooth laparoscopic hepatectomy for hepatic Muscle Tumor of Uncertain Malignant hemangioma. Safe vaginal uterine morcellation Syndrome: a case report highlighting following total laparoscopic hysterectomy. Twelve-month morcellation on survival outcomes of outcomes for patients undergoing patients with unexpected uterine hysteroscopic morcellation of uterine polyps leiomyosarcoma: A systematic review and and myomas in an office or ambulatory meta-analysis. Open power morcellation versus 2, X-3, X-5 contained power morcellation within an 52. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Hamidouche A, Vincienne M, Thubert T, et Intracorporeal electromechanical tissue al. Outcome of occult uterine leiomyosarcoma Laparoscopic supracervical hysterectomy after surgery for presumed uterine fibroids: a with transcervical morcellation: our systematic review. Contained power morcellation within an Incidental gynecologic neoplasms in insufflated isolation bag. In-bag Arthroscopic delivery of cancellous tibial morcellation for presumed myoma retrieval autograft for unstable osteochondral lesions at laparoscopy. Interventions morcellation for presumed myoma retrieval to reduce haemorrhage during myomectomy at laparoscopy. Laparoscopic myomectomy: clinical morcellators: a review of current practice outcomes and comparative evidence. Uterine pathology in women undergoing Supracervical hysterectomy by minimally invasive hysterectomy using laparoendoscopic single site surgery. The Monopolar versus bipolar device: safety, Sydney Contained In Bag Morcellation feasibility, limits and perioperative technique. New hysteroscopic techniques laser (RevoLix) vaporesection versus for submucosal uterine fibroids. Loop the effects of dexamethasone and electrosurgical excision procedure and risk metoclopramide on early and late of preterm birth: a systematic review and postoperative nausea and vomiting in meta-analysis. Use of a transvaginal extraction for myoma retrieval hysteroscopic morcellator to resect after laparoscopic myomectomy: a miscarriage in a woman with recurrent propensity-matched analysis. Rywlin electrosurgical excision procedure to International Pathology Slide Series: pregnancy and pregnancy outcomes. Does loop electrosurgical excision Unanticipated uterine pathologic finding procedure of the uterine cervix affect anti after morcellation during robotic-assisted Mullerian hormone levels L1: X-1 Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic 119. L1: X hysterectomy, pelvic cytology, and lymph 2 vascular space invasion: a single institution study of 458 patients. L1: X-1 Simulation study comparing the effectiveness of the Gynecare Morcellex(R), 129. Electromechanical morcellators in Transvaginal specimen extraction after minimally invasive gynecologic surgery: an combined laparoscopic splenectomy and update. L1: X-3, X-4, X-5 Laparoscopic approach to fibroid torsion presenting as an acute abdomen in 142. Total removal of placental remnants: laparoscopic hysterectomy with prior uterine hysteroscopic morcellation. Comparison of serum anti-Mullerian Impact of surgical approach on blood loss hormone levels following hysterectomy and during intracapsular myomectomy. Biological aspects of holmium laser enucleation of the prostate of periodontal tissue regeneration: for benign prostatic hyperplasia. First experience with single incision Perioperative morbidity associated with laparoscopic surgery in Slovakia: abdominal myomectomy compared with concomitant cholecystectomy and total abdominal hysterectomy for uterine splenectomy in an 11-year-old girl with fibroids. Difficulty in the Laparoscopic nephrectomy in dogs: an intravesical morcellation procedure for initial experience of 16 experimental leiomyoma of the prostate enucleated by procedures. Deep neuromuscular blockade leads to a Single-site laparoscopic management of a larger intraabdominal volume during large adnexal mass. Cost-effectiveness of endometrial fentanyl requirements after a gynecologic evaluation prior to morcellation in surgical laparotomy. Morphine-sparing effect of high-intensity focused ultrasound treatment intravenous paracetamol for post operative on immune function in patients with uterine pain management following gynaecological fibroids. Iatrogenic intestinal and mesenteric injuries Postoperative infectious complications in with small bowel volvulus following use of our early experience with holmium laser barbed suture during laparoscopic enucleation of the prostate for benign myomectomy. Bogusiewicz M, Rosinska-Bogusiewicz K, Outpatient procedure for the treatment and Walczyna B, et al. X-3, X-4, X-5 Comparison of robot-assisted laparoscopic myomectomy and traditional laparoscopic 198.

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Cross-over trials For the 2009 update of this review (and subsequent updates) we made an a priori decision to include data from all phases of cross Unit of analysis issues over trials acne y estres buy benzac 20 gr online, wherever possible acne 2016 cheap 20 gr benzac visa. The strength of a cross-over design is that variation in repeated responses between women is usually less than that between different women and hence the trials can Denominator give more precise results skin care advice discount 20 gr benzac with visa. Methods are now available for meta-analysing cross In view of the difficulty in detecting and correcting for publica over trials and for combining the summary effect measures of par tion bias and other reporting biases skin care doctors edina order genuine benzac line, we aimed to minimise their allel and cross-over trials acne 40 year old woman generic benzac 20 gr without a prescription. However acne-fw13c buy benzac 20gr low price, to date the reporting of cross potential impact by ensuring a comprehensive search for eligible over trials has been very variable and the data required to include studies and by being alert for duplication of data. We used a funnel a paired analysis in a meta-analysis are frequently unreported so plot to assess the possibility of small study effects (a tendency for that there is insufficient information to apply any one synthesis estimates of the intervention effect to be more benecial in smaller method consistently (Elbourne 2002). We cautiously consid In this review, where cross-over trials were analysed using methods ered visible asymmetry in the funnel plot as a possible indication suitable for paired data and reported an overall measure of effect of publication bias. Where cross-over trials reported dichotomous data or continuous Data synthesis data analysed using non-paired methods, we extracted these data We synthesised (combined) the data from primary studies if they as if they derived from parallel trials. Nevertheless, this in cross-over and parallel data using the inverse variance method. We explored the effect of this choice pooled odds ratios for dichotomous data, with 95% condence of analysis in sensitivity analyses. An increase in the odds of a particular outcome, which may be benecial (for example, pain relief) or detrimen Dealing with missing data tal (for example, an adverse effect), is displayed graphically in the We only included analyses reported in the primary studies that meta-analyses to the right of the centre-line and a decrease in the included at least 80% of women in the review. Where analysed the available data, based on the numerator and denom trial results were presented only as graphs, we described the nd inator reported in study results or calculable from reported per ings in the text. We explored the effect of excluding studies with more We translated the key results into assumed and comparative risks than 10% of data missing in sensitivity analyses. We estimated control group risks for the main comparison from median values in the placebo group in 31 studies of pain relief and 19 of adverse effects in a previous version of this review, and we estimated the corresponding inter Assessment of heterogeneity vention group risk using the formula suggested in the Cochrane We considered whether the clinical and methodological charac Handbook for Systematic Reviews of Interventions (Higgins 2011; teristics of the included studies were sufficiently similar for meta Section 11. Sensitivity analysis We planned sensitivity analyses for the primary review outcomes to determine whether the results were robust to decisions made Included studies during the review process. They randomised a total of 5820 women, 2372 cross-over data were analysed as if they derived from parallel in parallel studies and 3448 in cross-over studies. Sample size in the cross-over trials ranged from 11 occurred occasionally where a study contributed more than one to 198. The majority were pub lished inEnglish, although ve were inSpanish, four inPortuguese Overall quality of the body of evidence: Summary of and one each in French, Italian and Norwegian. Trials were trans ndings table lated as required by members of the Cochrane Collaboration. We prepared a Summary of ndings table using the Guideline Development Tool software. All but three of the trials stated clearly idence quality (high, moderate or low) into the reporting of results either that they included only women with primary dysmenor for each primary outcome. The other three studies had less specic inclusion cri teria that did not dene dysmenorrhoea (Akerlund 1989; Pauls 1978), or included both primary and secondary dysmenorrhoea R E S U L T S but reported results separately (Sahin 2003). The diagnosis of pri mary dysmenorrhoea was conrmed by a physical or gynaecolog ical examination in 40 of the included studies. We retrieved 18 ar gesics or other medications that could interfere with the proposed ticles for further assessment regarding their eligibility, 10 from comparisons. Several of the included studies reported data tionnaire, record card or diary in which the women noted any on comparison arms receiving interventions not relevant to this re symptoms daily during their menstrual period. For details of the drug regimes used See Characteristics of excluded studies for more information. Risk of bias in included studies Outcomes the quality of the included studies is summarised in Figure 4. Allocation Potential bias related to study funding Allstudiesstatedthattheywererandomised,butonly23%(18/80) Seven studies (7/80; 9%) reported a non-commercial source of described in detail their method of generating a random allocation funding and we rated them as at low risk of potential bias related sequence. We rated the other studies as at unclear risk rated all the other studies as at unclear risk. Glossary Please refer to the Cochrane glossary for explanation of unfamiliar Blinding terms: community. All studies were described as double-blinded, and 50 studies (50/ 80: 63%) provided details of who was blinded or stated explicitly Effects of interventions that the placebo was identical to the active treatment. We compared to placebo for dysmenorrhoea; Summary of ndings rated the other 30 studies as at unclear risk of bias. Thirty-one of the studies (39%) included over 95% of women randomised in analysis for one of our primary outcomes. Losses to follow-up are meloxicam (one study), naproxen (21 studies), niumic acid (one likely to be associated with treatment inefficacy or adverse effects, study) and nimesulide (two studies); some trials included more and so have a high potential to bias results. The studiesanalysed atotal of 2602women, 2006 women in cross-over trials and 596 women in parallel trials. Effect sizes varied, with few studies and ies as at high risk of selective reporting bias because adverse events wide condence intervals for most comparisons. They made the following comparisons: aspirin difference in total pain relief using a time-weighted scale versus fenoprofen (Analysis 2. The placebo groups in two studies contributed twice to the two studies, I2 = 51% (Analysis 7. One found that no serious side effects occurred in association with either indomethacin more effective than aspirin (Kajanoja 1978), and piroxicam or placebo (Osinusi 1986). Twelve trials reported results on this outcome in such a way that no numerical data could be ex Gastrointestinal adverse effects tracted. Somepresentedgraphs(Arnold1983;Benassi1993;Costa 1987a; Costa 1987b; Kintigh 1995; Pedron 1995), or continuous Fourteen studies were suitable for meta-analysis for this outcome, data without standard deviations (Pasquale 1988; Saltveit 1989), which included adverse effects such as nausea and indigestion. Seven studies were suitable for meta-analysis for this outcome, which included adverse effects such as headache, drowsiness, dizzi Adverse effects ness and dryness of the mouth. Nor did we nd any evidence of a difference be cross-over studies and 419 in parallel-group studies. Two studies not included in meta-analysis also re versus nimesulide, and naproxen versus ketoprofen, meclofena ported this outcome: one found no evidence of a difference be mate and piroxicam. The second, comparing diclofenac versus meloxicam, re of a difference between the groups (Analysis 7. Only three studies reported data suitable for meta-analysis for this outcome (Analysis 8. Eight studies reported data suitable for meta-analysis compar However, there was only one study for each comparison. These studies analysed data for 306 women, 90 in cross-over studies and 216 in parallel-group studies. The placebo groups in two cross-over studies contributed twice to the pooled analysis but exclusion of these studies did not materially affect the results (Daniels 2009a; Daniels 2009b). They made the following comparisons: aspirin versus fenoprofen, ibuprofen ver Four studies, all parallel-group, were suitable for meta-analysis for sus piroxicam, ibuprofen versus fenoprofen, ibuprofen verus etori this outcome. One coxib, naproxen versus celecoxib (two studies) and naproxen ver compared diclofenac versus placebo and the other three compared sus urbiprofen. The results favoured indomethacin, but the statistical signicance = 61%), ibuprofen (I2 = 60%) and naproxen (I2 = 52%). Exclusion of studies that did not clearly describe adequate procedures for allocation concealment and blinding 3. Exclusion of studies in which cross-over data were There were insufficient studies to conduct this planned sensitivity analysed as if they derived from parallel-group studies analysis, as only nine studies in the review clearly described ad We excluded from Analysis 1. Exclusion of studies with more than 10% of data missing 1997;Milsom 2002d;Morrison1980;Rondel1984;Wilhelmsson for primary outcomes 1985b). A T U R N l P l: S:O I n: C: O I ll 9 5 % l l (9 5 % A 3 P l P 6 3 0 10 0 0 76 3 10 0 0 1. We excluded nearly 50 for unclear design, need to take the medications with food, even though they are lack of double-blinding or very large numbers of withdrawals, administered only for short-term use. Recently cause neurological side effects than placebo, dexketoprofen was published studies appeared to be no more likely than older stud more likely to cause gastrointestinal side effects and naproxen was ies to adequately describe their methods. Moreover the funnel there was no evidence of any difference between them with respect plot suggested a mild trend towards publication bias, with smaller to adverse effects. This review went on to suggest that com 30% of the studies described the use of prospective self report bined oral contraceptives are a more suitable option for women forms or diaries. As noted above, the use of oral contra follow-up appointments, were vague about their methods or failed ceptives for dysmenorrhoea is the topic of another Cochrane re to systematically report adverse effects. In order to fa trials to be given adequate weight in meta-analysis, study authors cilitate this process, trial publications need to provide a detailed need to report an explicit statement that they used paired statis account of statistical methods used and present full results with tical analysis, plus a summary effect measure and an estimate of summary effect measures and measures of variance. This was probably partly due to confounding by alone would be a useful topic for a further systematic review. A C K N O W L E D G E M E N T S For the 2015 update, we would like to thank Jack Wilkinson, Agreements and disagreements with other who peer reviewed the update and provided invaluable statistical studies or reviews advice to facilitate interpretation of effect estimates. Thanks also to Marian Showell (Trials Search Co-ordinator) for designing and running multiple searches for the 2009 and 2015 updates. Comparison of ketoprofen and a novel cyclooxygenase-2 selective inhibitor, is an effective naproxen in the treatment of dysmenorrhoea, with special and well-tolerated treatment for nausea. Use of mefenamic acid in the treatment of Akinluyi 1987 dysmenorrhea. Feldene in the al-Waili 1990 symptomatic treatment of primary dysmenorrhoea. Effects of naproxen sodium Andersch 1989 on menstrual prostaglandins and primary dysmenorrhea. Chantler 2009 Balsamo 1986 Chantler I, Mitchell D, Fuller A. Double-blind clinical trial with potassium attenuates dysmenorrhea and restores exercise performance diclofenac versus placebo in primary dysmenorrhoea in women with primary dysmenorrhea. Costa S, Mioli M, Ravaioli R, Bufalino L, Gardini Benassi 1993 F. Prostaglandin synthetase inhibitor piroxicam beta Benassi L, Bertani D, Avanzini A. Costa S, Mioli M, Ravaioli R, Bufalino L, Gardini Bitner 2004 {published data only (unpublished sought but not used)} F. Prostaglandin synthetase inhibitor piroxicam beta Bitner M, Katternhorn J, Gao J, Kellstein D. Double-blind study to evaluate efficacy inhibitor, is effective in treating primary dysmenorrhea. Menstrual prostaglandins randomized, double-blind, active and placebo-controlled and dysmenorrhea: modulation by non-steroidal crossover studies.

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To Characteristics of the deployed environment that were manage this condition acne gender equality purchase genuine benzac on-line, I have almost permanently problematic for menstrual hygiene included sand acne epiduo cheap 20 gr benzac free shipping, dirt skin care 8 year old purchase benzac uk, worn sanitary protection acne hoodie cheap 20 gr benzac. Heat was a major problem causing panty liners when I do not have a cough or am not general discomfort during menstruation and problems working in a cold climate or dusty environment skin care yang bagus untuk jerawat cheap benzac 20 gr with visa, with the use of menstrual products acne 19 year old male benzac 20gr discount. One soldier said, and much thicker pads when I am working in an the pads, they dont stick well in your underwear environment that is likely to make me cough on a when its hot youre sweating so much. Most women had to use port As an aid worker, my work involves a significant a-potties during the day, which presented challenges amount of travelling. The stress incontinence has like those that this soldier identified, Because the caused many problems during my travels for work, port-a-potties are just not sanitary, and its hard when and in particular when I have worked in cold climates youre in a little space and youre trying to change where I regularly get bad coughs. This soldier explained her efforts, You After two cold climate contracts where I found it manage but youre always dirty. From Trego L L (2007) However, I found out that it was possible to have a relatively simple operation for this condition. I think about women from Africa, Asia or elsewhere who suffer from this condition and the difficulties they must face at home and in the workplace; most of them very unlikely to ever have the opportunity to resolve this problem as I was lucky enough to be able to do. Making sure: Integrating menstrual Male managers and the difficulty of 5 6 care practices into daily living raising menstrual hygiene issues In order to manage the menstrual flow and continue the higher proportion of male staff that work on water to participate in daily life, women have created a self and sanitation programmes may mean it is difficult care process, which is termed making sure. Practices for their female colleagues to share their difficult for making sure will vary according to culture and experiences of menstruation management in their own context but essentially relate to ensuring that sanitary workplaces and while in the field for more than seven protection is effective so that menstruating women to eight hours. From Fernandes M (2010) A lawyer expressed her concern about making sure: Now court, this is a very limiting thing. You can be sure I wouldnt wear a white Inappropriate behaviour from skirt then, because that would be the last thing I would employers in relation to womens want to worry about. If I am in the courtroom, and 7 need to use the toilet Im going in at nine, I may not start until ten-thirty, and I may be striking a jury until eleven, and Ive been A factory boss who ordered women workers to wear a talking to people all that time, and I have not had time red sign around their necks when they wanted to use to think about me. The lessons learned could be an invaluable (involving the water, sanitation and hygiene, advocacy tool to raise awareness and bring about action. Ensuring opportunities for women and girls to feed back and voice opinions As menstrual hygiene is often a taboo subject, it can be diffcult to obtain opinions from women and girls on proposed interventions and get their feedback once a programme is underway. The only way the evaluator Tanzania, as part of a participatory exercise to could speak to the women was to set up an interview investigate the impact of poor water, sanitation and online. It would have been useful to ask questions about whether the programme adequately considered menstrual hygiene and get the womens proposals for future programmes in relation to this issue. In addition to discussing issues that have an impact on their Schoolgirls in Kibera, Kenya lives, they blog and Tweet about the subjects, giving them experience of using information technology and Organisations enabling them to connect with other girls online. ZanaAfrica, the Girl Effect, Upande Monitoring and evaluation activities Background ZanaAfrica field staff have collected performance metrics from the students in the empowerment club ZanaAfrica runs programmes that support girls programme between 2009 and 2010 to track their education in Kibera, Kenya. Work is ongoing with the support sanitary pads to girls to encourage them to attend of Upande and the Girl Effect to develop an online school during menstruation. This will allow girls empowerment clubs to provide schoolgirls with responses to be entered online or by mobile phone for psycho-social support and role models. They discuss important issues such as also recently started completing weekly surveys. This peer pressure, drug use, self-confidence, self-esteem, is providing ZanaAfrica staff with information on the relationships, love, health and diseases. Ministry of Education, Ministry of Public Health, Ministry Teachers and mothers were met with individually and of Relief and Rural Development, Islamic Republic of as a group. This information will be invaluable to other supported by WaterAid, the Sanitation and Hygiene practitioners who are starting to consider menstrual Applied Research for Equity consortium, the Water hygiene or want to improve the programmes they are Supply and Sanitation Collaborative Council, and the working on. There is currently a particular lack of London School of Hygiene and Tropical Medicine, information on the management of menstrual hygiene in with a number of academics and other organisations emergencies, so implementers are encouraged to document represented, 2011. It is clearly written and presented in hygiene, such as that held by the Water Research an attractive manner. The link for downloading and feeding back to communities on the impact on this briefng note can be found in the endnote. In between, they tary restrictions or refrain from reading the hide their cloths so that their fathers and Koran. Amina meets regularly with Shopna, Monira and girls in local schools to speak to them about hygiene, especially menstrual hygiene. Monira recollects: I was too scared to speak Other taboos and superstitions surround with my mother. Some of these links are highlighted below: Article 14(2)(h) of the Convention on the Article 11 of the International covenant elimination of all forms of discrimination on economic, social and cultural rights against women, which obliges states to affirming that it is derived from the right eliminate discrimination against women in to an adequate standard of living and the rural areas and ensure they have adequate right to the highest attainable standard living conditions, especially housing, of physical and mental health, as well as a sanitation, electricity and water supply, right to life and human dignity. The Convention on the rights of the child obliges states parties to take appropriate the Convention on the right of persons measures to combat disease and with disabilities establishes that the malnutrition through the provision of clean right to social protection requires states drinking water (Article 24(2)(c)) and to parties to ensure access by persons with promote basic education and support the disabilities to clean water services. It is also clear that several of the Millennium Development Goals will not be met unless menstrual hygiene needs have been responded to (see Table 9. This should be a key message when advocating menstrual hygiene to decision-makers. In some cases, female teachers are also absent due to a lack of menstruation facilities at school, affecting pupils educational experiences. Poor menstrual hygiene situations in any of these contexts can prevent them engaging fully. If girls are missing school because of menstrual hygiene, this could potentially contribute to reduced child survival. A hygiene working group is developing a proposal for how hygiene (including hand washing, food hygiene and menstrual hygiene) could be included in the post-2015 sustainable development targets. This is because for menstrual hygiene has been included in Toolkit menstrual hygiene has often been overlooked; it is 9. It identifes target groups, key information and associated with a wide range of taboos and expected communication channels and methodologies. Advocacy is needed at national and international levels as well as at local level. Notes on good practice when working with National art exhibition on the media have been included in Toolkit 9. Further menstrual hygiene, Dropping in on information on the general principals of advocacy can be found in WaterAids Advocacy sourcebook16. Ten artists produced used in Nepal and Zimbabwe by engaging famous artists or work to make the viewer consider menstrual hygiene, celebrities. She said, Imagine if Advocating menstrual hygiene on 19 there were no tampons or sanitary towels available. Practical solutions being supported you because he thinks you have slept with someone by ZanaAfrica are also shared. Unfortunately, for the women of Zimbabwe, this is not a situation they are left to imagine. The following example is an event facilitated by the Water Research Commission in South Africa. Inter-agency dialogue on menstrual hygiene (Water Research Commission, South Africa) Over 2 billion women globally are menstruating and will do so for an average of 200 days in their life. Why then, is it such a Dialogue was established between 60 delegates cause of shame and of shattering dreams Our goal is nothing short of becoming the leading expert in all issues relating to sanitary pad organisations and the private sector. This can only be attained through a group effort, and in this interconnected world, we invite you to add to the knowledge base. The lessons learned from the research will need to be targeted to different groups and communicated through appropriately selected channels and media for the greatest advocacy beneft. Qualitative participatory methods: In Malawi, 31% of girls finish primary school, and only 11% graduate from What Outcomes secondary school. Reports such as this are useful for provides learning opportunities for other sector actors. The aim of the document mainstream menstrual hygiene into advocacy activities in was to highlight the issue of poor water, sanitation and other sectors. The following example from Tanzania shows hygiene facilities in schools and call for increased effort how menstrual hygiene challenges faced by girls at school and resources. The target groups for the leafet included the Government of the United Republic of Tanzania and large donors funding the water sector. Menstrual hygiene issues were included as part of the information provided in the leafet. A recent basic education report estimates that in SubSaharan Africa half of all More children than ever before are attending school in girls who drop out of school say that a lack of adequate Tanzania as a result of a number of successful policy water and sanitation facilities are a contributing factor. A initiatives, most notably the abolition of school fees in further 10 per cent of schoolage girls who have reached 2002. The number of primary schools increased from the age of puberty do not attend school during 11,873 in 2001 to 14,700 in 2006. National or regional conferences or forums also offer an opportunity to reach target audiences. The Ministry of Educations Gender Education Policy calls 3 To lobby for policies in the best interest of the girl for partnership to cascade policy into implementation. A hygiene; Supporting the sanitary dignity campaign for women comparative study of four schools in different settings in and girls. Similar books are available or being developed in a number of other countries (eg Pakistan, Uganda, Ethiopia, Cambodia and Ghana). One sees that girls often cease to perform their regular activities due to the embarrassment associated with managing the menstrual fow. Gnapkins regularly during the places even in their homes to dry What about exercising During your period, majority of girls use cloth pads usually practice is responsible for a signifcant you can do everything you normally do, including daily bath or shower, torn from old saris, instead of sanitary proportion of illness and infection exercising, dancing and playing sports are all fne. These cloth pads are associated with female reproductive better by continuing your normal routine, and fnd that warm bath is a washed and used several times. A Menstruation as a regular process Myth: Taking bath during periods pollutes the environment culture of shame and embarrassment needs hygienic management. These were public places and when they took a bath in them What products do girls usually use during menstruation However, now times have changed and Clean cloth: these are cut to ft in the panty area by sewing several layers we have the privacy of a bathroom or a seperate place to bathe.

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Past medical history includes a diagnosis of mus cular hypotonia at fve months of age. A 71-year-old man presents to his physician tal drug to a standard medication used in the because of a six-week history of progressive treatment of psoriasis. The pertension and a 60-pack-year history of smok study runs for 12 months, during which 30 par ing. The patient has diffculty speaking and is ticipants drop out of the treatment group and breathing using his accessory respiratory mus 10 participants drop out of the control group. Neck vein distention and tongue swelling At the conclusion of the study, researchers de are evident. Which of the following is most cide to only analyze data from those who re likely diagnosis The results show that the (A) Gastric adenocarcinoma experimental drug is better than the standard (B) Hodgkin lymphoma medication at treating psoriasis. The results of (C) Hypertrophic cardiomyopathy this study may be invalid because of what ma (D) Idiopathic pulmonary fbrosis jor issue A screening test for disease (D) Selection bias X was just developed, with a sensitivity of 80% (E) Small number of patients in the study and a specifcity of 70%. In his early 20s, however, he begins to (A) 20 smoke cigarettes, initially smoking one pack a (B) 80 day, escalating eventually to two-three packs (C) 100 per day. As he ages, his lung function gradu (D) 270 ally declines, and at age 60, he notices that he (E) 630 becomes tired easily and cannot climb a fight of stairs without having to catch his breath. A 54-year-old woman has had longstanding goes to see his primary care physician, who rheumatoid arthritis. However, rologic examination cranial nerves are intact, he is able to respond to both verbal and written muscle strength is normal, and sensorium is commands such as close your eyes, and is normal. The patient sways during Rombergs visibly frustrated by his unsuccessful attempts test with eyes open or closed. What is the most man has a lesion that includes which of the likely etiology of the dilated ventricles A 50-year-old Chinese immigrant presents to his primary care physician complaining of fe ver, night sweats, and blood-tinged sputum for the past three weeks. Which of the following adverse effects is commonly associated with a drug used in the treatment of this mans disease A 76-year-old woman presents to the emer gency department complaining of blurry vision 27. Parents bring their 8-year-old boy to the emer and a headache that started fve hours ago. She gency department because his face appears has a long history of hypertension and poorly swollen. On fur rate of 75/min and blood pressure of 210/140 ther testing, he has a creatinine level of 1. Which of the fol likely see based on this patients history and lowing medications should be administered symptoms A 35-year-old man presents to his primary because he feels short of breath and has to stop care physician complaining of episodes of and walk after brief runs. Approximately one diac surgery when he was an infant for a con month ago he began running two miles on a genital heart defect. For the past two shows an intact right hemidiaphragm that is weeks he has experienced a severe, throbbing much higher than the left one. This boys exer pain in his chest and felt dizzy after running tional dyspnea is probably caused by which of for about 20 minutes, but claims that the pain the following conditions He (A) Damaged left phrenic nerve is concerned because his younger brother, who (B) Damaged right phrenic nerve is 32 years old, recently had a mild heart at (C) Eisenmenger syndrome tack. In addition, both his father and his uncle (D) Left diaphragmatic hernia died from complications after having heart at (E) Right diaphragmatic hernia tacks when they were 45 years old. Some fats and proteins are both produced by examination reveals the lesions shown in the the body and consumed in the diet. Many image; lesions are also present on his arms and other nutritional components, however, can knees. His blood pressure is 130/80 mm Hg, not be synthesized by the body and must be pulse is 85/min, and respiratory rate is 12/min. Which of the following sub Laboratory tests show a serum cholesterol level stances can a healthy adult synthesize This patients lipid disorder is char (B) the glucogenic amino acid histidine acterized by a defciency in which of the fol (C) the ketogenic amino acid leucine lowing Which of the following is the most likely explanation of the increased total protein observed in this man Ini (B) Follicular carcinoma of the thyroid tially the patient complained of generalized (C) Medullary carcinoma of the thyroid weakness and vision diffculties. Later, the pa (D) Thyroid lymphoma tient lost his peripheral vision and became un (E) Papillary carcinoma able to talk or walk. Oogenesis results in the production of one brain reveals multiple, non-contrast-enhancing haploid ovum and three polar bodies in a pro lesions in the white matter, primarily in the cess of meiotic cell division. What stage of the cell cycle do oocytes (A) Cryptococcal meningitis remain in from birth to ovulation Work-up suggests the nodule sity student reveals an obsession with a fellow to be neoplastic. A 28-year-old woman presents to the clinic concerned that she has begun growing hair on her upper lip and around her nipples. When (B) Frameshift mutation questioned, she admits she never has been sex (C) Insertion mutation ually active, and she always has had irregular, (D) Missense mutation spotty menstrual periods, often missing them (E) Nonsense mutation completely. Which laboratory fnding is most (F) Silent mutation closely associated with this patients condition A 4-year-old girl is transferred to the pediatric (B) Hyperinsulinemia intensive care unit because of suspected bacte (C) Hypermagnesemia rial sepsis secondary to a bout of Clostridium (D) Hyperuricemia diffcile enterocolitis. To ascertain the specifc genetic defect in pa later, the child begins crying inconsolably and tients with cystic fbrosis, scientists obtained scratching her face. This ing gel where the normal gene differs from the patients reaction was most likely caused by ad mutated gene is shown in the image. A 25-year-old man is witnessed by his family to 13 have a seizure of sudden onset. The seizure in 12 11 volved movement of all four of his extremities 10 and was associated with loss of consciousness. Which of the fol 4 lowing agents is an effective medication to be 3 given at this point A 45-year-old man comes to the physician (C) Decreased prothrombin time because of a fever of 39. On time physical examination, the physician notes a (E) Increased International Normalized Ratio new-onset murmur along with white spots on (F) Increased prothrombin time the retina. A 43-year-old woman in a psychiatry ward is alone, is most likely to be used to treat this pa admitted from a medical foor after attempting tient prior to the results of blood culture She states that she recently broke up (for the ffth time) with her boyfriend, who disap proves of her cocaine and marijuana use. She also states that she and her ex-boyfriend fght constantly, and that she has made hundreds of suicide attempts and has been hospitalized many times. Physical examination reveals reddened conjunctivae, an eroded nasal sep tum, and numerous small, uniformly sized punched-out skin lesions on the upper and lower extremities. Which of the following de fense mechanisms is associated with this pa tients condition A 20-year-old man is brought to the emergency (E) Vancomycin department by the police after being picked up in the streets for acting violently towards 44. He was found in an agitated state, act because of an intraventricular hemorrhage ing belligerently. For accurate coagulation studies to be Which of the following treatments should this obtained, the frst 5 mL of blood drawn from patient receive Which of the following laboratory (B) Flumazenil results is most likely in this patient if the frst 5 (C) N-acetylcysteine mL of blood are not discarded A 70-year-old woman presents with fevers, (A) Aspergillosis chills, and a nonproductive cough. She has (B) Brucellosis also been experiencing chest pain, and diar (C) Legionnaires disease rhea. Gram stain and routine culture of in (D) Mycoplasma pneumonia duced sputum is unrevealing. A silver stain (E) Pneumocystis jiroveci pneumonia of an induced sputum specimen is shown in the image. Ultrasonography reveals a small mass in the left adnexa, along with a thickened endo metrial stripe. Sulfamethoxazole, the upper Mississippi and Ohio River basins as is the case with all sulfonamides, binds to as well as around the Great Lakes. Diagnosis and will displace unconjugated bilirubin from is made by use of potassium hydroxide prep to albumin. In a newborn this can lead to kernic reveal big, broad, budding organisms in spu terus, also known as bilirubin encephalopathy. Some patients will fail to re the condition results from bilirubin deposi cover from an acute infection and progress to tion and accumulation in the brain because of develop chronic pulmonary infection or wide an incompletely formed blood-brain barrier. Fluconazole or the basal ganglia are particularly susceptible ketoconazole is used for the treatment of local to injury. Early symptoms include lethargy, blastomycosis, and amphotericin B is used for poor feeding, and an absent Moro refex. Coccidioidomycosis is retardation, deafness, choreoathetoid move the second most common fungal infection en ments, and decreased upward eye movements. Nitrofurantoin, com of appetite, weight loss, a painful red rash on monly used to treat urinary tract infections, is the legs, and change in mental status. Symp schenckii is introduced via inoculation of soil toms of this infection include hypo-pigmented through the skin, usually by a thorn prick, a skin lesions that occur in hot and humid con papule develops days to weeks later at the site ditions. The primary lesion can ulcer ball appearance on slides because of the ate or stay nodular, and similar lesions can short curved hyphae and yeast clusters, and is be found along lymphatic channels (ascend treated with topical miconazole or selenium ing lymphangitis). Itraconazole or potassium iodide is used or inherited immune defciencies, P jiroveci for the treatment of sporotrichosis. The diffuse interstitial adverse effect associated with aminoglycosides pneumonia gives a ground-glass appearance on and vancomycin. Langerhans cells are a type of mal stature, to frequent childhood fractures, to dendritic cells present within the skin. T lymphocytes and in fetal death (Note that gravida 2 para 0 in natural killer cells are not professional antigen dicates a prior unsuccessful pregnancy). Epithelial cells are not the frst of which may occur during birth; blue professional antigen-presenting cells. This patient presents other connective tissue disease that may pre with stage 2 Lyme disease, which is marked by sent with hearing loss. A defective basement close the eye or seal the corner of the mouth membrane tends to cause problems in the kid on the affected side. Patients with Alport acquired Lyme disease from an Ixodes tick syndrome typically have a history of glomeru bite during his recent camping trip to upstate lar nephritis and sensorineural hearing loss. Acute cholestatic hepa and a predisposition to aortic dissection due to titis is an adverse effect of macrolides. Vitamin D is necessary teeth from doxycycline occurs among children for ossifcation of the cartilaginous framework. The appropriate lymphoid or hematopoietic lineage as well as response when a patient expresses concerns by the level of differentiation seen. They are about another physician is to have the patient not characterized by the presence of Reed address those concerns with that physician di Sternberg cells. Multiple myeloma is a offce staff, tell the patient you will speak to blood dyscrasia characterized by a hyperprolif that individual.

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Epithelia have a paucity of intercellular substance and are interconnected by junctional complexes skin care regimen buy benzac. Components of the junctional complex include the zonula occludens (tight junction) acne pictures benzac 20 gr mastercard, which prevents leakage between the adjoining cells and maintains apical/basolateral polarity; zonula adherens acne executioner purchase 20 gr benzac with mastercard, which links the actin networks within adjacent cells; and macula adherens (desmosome) skin care kemayoran generic 20gr benzac with amex, which links the intermediate filament networks of adjacent cells skin care vitamins and minerals buy discount benzac 20 gr line. Epithelial cells also form a firm attachment to the basal lamina acne 4 weeks pregnant cheap benzac 20gr fast delivery, which they secrete. Gap junctions or nexi permit passage of small molecules High-Yield Facts 19 directly between cells. Apical specializations are prominent in epithelia and include microvilli that increase surface area; stereocilia, which are non motile modified microvilli; and cilia and flagella, which are motile struc tures. Cilia and flagella have the classic 9 + 2 microtubular arrangement emanating from basal bodies. The basal surface may be modified with infoldings that house numerous mitochondria as found in proximal and distal tubule cells of the kidney and striated duct cells of the salivary glands. B cells are involved in humoral immunity and T cells in cell-mediated immunity as well as humoral immunity (helper T cells). Neutrophils phagocytose bacteria; the dead neutrophils are a major component of pus. Basophils, like mast cells, release histamine although they originate from a different bone marrow stem cell. Eosinophilic granules contain a crystalline core of major basic protein, which is toxic for parasites and histaminase, which breaks down histamine and limits the allergic response. Type I collagen and elastin make up the predominant fibers found in connective tissue. Ground substance includes proteoglycans and glycoproteins that organize and stabilize the fibrillar network. Osteoclastic activity uses protons (H+) derived from carbonic acid formed by the enzyme carbonic anyhydrase. Breakdown of bone occurs due to the acidification of this extra cellular compartment that is analogous to an intracellular secondary lyso some. This has been one of the problems in treating osteoporosis in which osteoclastic activity dominates osteoblastic activity. In con trast, the three types of cartilage are avascular and contain chondrocytes that 22 Anatomy, Histology, and Cell Biology synthesize fibers and ground substance. Hyaline cartilage covers articular surfaces and forms the cartilage model in long bone development. Elastic cartilage is found in the pinna of the ear and in the epiglotlis, while fibro cartilage is an intermediate form found in the intervertebral disc, pubic sym physis, and connecting tendon and bone. Myosin contains a motor that interacts with the actin filament and allows myosin to ratchet along the actin. The filaments are arranged in a banded pattern in individual sar comeres, which act in series. Specialized invaginations of the plasma mem brane (T tubules) spread the surface depolarization to the interior of the cell to release calcium from the sarcoplasmic reticulum, initiating contraction. Troponin and tropomyosin are specialized proteins that permit contraction of skeletal and cardiac muscle to be regulated by calcium. Skeletal muscle is a syncytium, while cardiac muscle consists of individual cells connected by intercalated disks. High-Yield Facts 23 Smooth muscle contraction closely resembles the cell motility exhib ited in other cell types. It also occurs through the action of actin and myosin, which are arranged in a lattice-like pattern. Astrocytes induce and maintain the blood-brain-barrier, but they do not constitute the barrier function of the blood-brain barrier which is estab lished by endothelial tight junctions (zonula occludens). Neurons con duct electrochemical impulses and move neurotransmitters to their synaptic termini by axoplasmic transport. Transneuronal transmission is accomplished by calcium-regulated release of synaptic vesicles. A typical contact between a myelinated neuron and skeletal muscle (neuromuscular junction) is shown below. Axonal terminals (telodendria) rest in shallow depressions (primary clefts) on the surface of the striated muscle fiber. Secondary clefts increase the surface area for interaction with a neurotransmitter (acetylcholine). The cerebral cortex consists of a homogenous layer I with multiple deeper lay ers of large pyramidal and other types of neurons. In large arteries close to the heart, the tunica media contains high amounts of elastin to buffer the hearts pulsatile output. Endothelial cells lining the vascular lumen secrete vasoactive sub stances that regulate relaxation and contraction of the underlying smooth muscle. Prostacyclin inhibits platelet adhesion and prevents intravascular clot formation. Endothelial cells produce molecules that regulate fibrinolysis and thrombogenesis. Endothe lial cell-derived factors are stored in intracellular granules and released into the blood stream upon stimulation. Endothelial cells also produce tissue factor, the only non plasma protein in the clotting cascade, which initiates the common blood clotting pathway. E-selectin expression on endothelial cells modulates extravasation of monocytes and neutrophils. Chemokines (chemoat tractant cytokines) induce expression of E-selectins on the endothelium under normal conditions and following inflammation. Blood cells include erythrocytes, which are specialized for oxygen transport; lymphocytes that function in cellular and humoral immune responses; neutrophils, which are early responders to acute inflammation; monocytes that are the precursors of tissue macrophages; eosinophils, which respond to parasitic infection and release histaminases to counteract basophils and mast cells; and basophils, which contain histamine and heparin and assist mast cell function. The ery throcyte lineage includes the following stages: proerythroblasts > basophilic erythroblasts > polychromatophilic erythroblasts > orthochromatophilic erythrocytes. The white cell series includes myeloblasts > promyelocytes > myelocytes > metamyelocytes > mature granular leukocytes. Innate immunity is not specific for particular pathogens or indi viduals of the species. On first exposure to an antigen it recognizes on its surface, a naive B cell proliferates to produce a memory B cell and a plasma cell that is the effector, synthesizing antibodies for release. Organs Lymphoid organs may be either primary (bone marrow and thymus) or secondary (lymph nodes and dispersed lymphatic nodules, spleen, and tonsils). The B lymphocytes are educated in the bone marrow [differ entiation of antigen-binding receptors (antibodies)] and are seeded to spe cific B cell regions of the secondary lymphoid organs, while T lymphocytes are educated in the thymus [differentiation of T cell receptors (TcR)] and are seeded to T cell-dependent regions of the secondary lymphoid organs. The thymus is recognized by lobulation, separate cortex and medulla in each lobule, the absence of germinal centers, and the presence of Hassalls corpuscles. The lymph nodes, which filter lymph and blood, are characterized by a central medulla consisting of cords with many plasma cells and a cortex containing primary and secondary follicles. That lin ing is stratified squamous epithelium in palatine tonsils and pseudostrati fied epithelium on pharyngeal tonsils. Ciliated cells appear in all portions of the respiratory system except the respiratory epithelium and move mucus and particulates toward the oropharynx (mucociliary escalator). Gas exchange in the lungs takes place across a minimal barrier consisting of the capillary endothelium, a joint basal lamina, and an exceedingly thin alveolar epithelium consisting primarily 28 Anatomy, Histology, and Cell Biology of type I pneumocytes. The result is thick, more viscous (less watery) mucus in the airways that promotes bacterial infections and reduces the effectiveness of the mucociliary escalator. Specialized structures of the skin include hair fol licles (found only in thin skin), nails, and sweat glands and ducts. Nonker atinocyte epidermal cells include melanocytes (derived from neural crest), Langerhans cells (antigen-presenting cells derived from mono cytes), and Merkel cells (sensory mechanoreceptors). Various sensory receptors and extensive capillary networks are found in the underlying der mis. Psoriasis is a dis ease characterized by dermal and epidermal infiltration of inflammatory cells. Proliferation occurs throughout the epidermis and is no longer restricted to the basal layer and there is a thickening of the stratum corneum with nucleated keratinocytes present. Pemphigus is an autoim mune disease in which autoantibodies are produced to the desmogleins, members of the cadherin family. The desmosomes break apart resulting in High-Yield Facts 29 blistering of the skin. The basal layer remains intact and attached to the basal lamina because the hemidesmosomes do not contain cadherins. Bullous pemphigoid is also a blistering disease, but the blistering occurs at the epidermal-dermal junction. The stomach is a grinding organ with glands in the fundus and body that produce mucus (surface and neck cells), pepsinogen (chief cells), and acid and intrinsic factor (parietal cells). Intrinsic factor binds to vitamin B12 and is required for uptake of that vita min from the intestine. The parietal cell functions in a similar fashion to the osteoclast in using carbonic anhydrase to produce protons that are pumped into the intracellular canaliculi, which are lined by microvilli in the active parietal cell. In the inactive parietal cell, the proton pumps are sequestered in tubulovesicles in the cytosol. The small intestine is an absorptive organ with folds at several levels (plicae, villi, and microvilli) that increase surface area for more efficient absorption. The microvilli also contain specific enzymes for the breakdown of sugars (disaccharidases), lipids (lipases), and peptides (peptidases). The major digestive processes in the small intestine occur through the action of the pancreatic juice, which contains trypsinogen, chy motrypsinogen, procarboxypeptidases, amylase, lipase, and other enzymes. Lipids are broken down to triglycerides in the small intestinal lumen which are subsequently degraded to glycerol, fatty acids, and monoglycerides that are transported into the enterocyte. The chylomicra are exocy tosed into the lacteals and travel to the cisterna chyli and through the tho racic duct to the venous system. Other digested materials travel through the hepatic portal vein to the liver where hepatocytes process the digested nutrients. Cell types in the small intestine include enterocytes (absorption), Paneth cells (production of lysozyme, defensins, and cryptidins), gob let cells (mucus), and enteroendocrine cells (secretion of peptide hor mones). New cells are born in the crypt, move up the villus, die by apoptosis, and are sloughed off at the tip. The primary function of the colon, which appears histologically as crypts with prominent goblet cells and no villi, is water resorption. The major salivary glands (parotid, submandibular, and sublingual) are exocrine glands that secrete amylase and mucus, primarily regulated by the autonomic nervous system. The liver is also a dual-function gland whose exocrine product is bile, synthesized by hepatocytes, and transported by a duct system to the gallblad der for storage and concentration. The endocrine products include glucose and major blood proteins (albumin, fibrinogen, coagulation proteins). Alcohol detoxification is one of the major processes carried out in the hepatocyte. The bile canaliculus is defined as apical, the junctional com plexes as lateral, and the blood surface with the space of Disse and hepatic sinusoids is considered basal. The sinusoids are lined by hepatic stellate cells, endothelial cells, and Kupffer cells. The hepatic stellate cells are affected following chronic alcohol toxicity and are converted into myofibrob lasts during the onset of cirrhosis. Those cells synthesize large quantities of High-Yield Facts 31 collagen and are responsible for the fibrotic changes observed in cirrhosis. The Kupffer cells are the antigen-presenting cells of the liver and are derived from monocytes. Hepatocytes are arranged in interlocking cords and plates so there are several ways of analyzing the histological organization of the liver. The classic lobule emphasizes the endocrine function of the liver; the portal lobule emphasizes the exocrine function of the liver, and the liver acinus focuses on actual blood supply and regeneration. The adenohypophysis is derived from the oral ectoderm of Rathkes pouch and is regulated through a hypophyseal portal system carrying factors that stimulate or inhibit secretion. The neurohy pophysis is derived from the floor of the diencephalon and consists of astrocyte-like glial cells (pituicytes) and expanded terminals of nerve fibers originating in the hypothalamus. The neurohypophysis contains the hor mones vasopressin and oxytocin, which are synthesized primarily in the supraoptic and paraventricular nuclei respectively. The adrenal medulla, derived from the neural crest, synthesizes epinephrine and nor epinephrine (see figure on the following page). Most of the blood that reaches the adrenal medulla has passed through the adrenal cortex and contains glucocorticoids that regulate the norepinephrine/epinephrine bal ance in the adrenal medulla through regulation of phenylethanolamine-N methyl-transferase. The fetal adrenal cortex functions to produce dehydroepiadrosterone, an androgen that is transported to the placenta where it serves as a precursor of estrogen. The gland is covered by a connective tissue capsule and divided into a cortex containing steroid-producing cells with prominent lipid droplets and a medulla containing chromaffin cells that secrete catecholamines and neuropeptides. Congenital viriliz ing adrenal hyperplasia results from the deficiency of an enzyme required for cortisol production. Hypercortisolism or Cushings syndrome is five times more common in women than men. Cushings syndrome may be caused by a tumor in the corticotrophs of the anterior pituitary (Cushings disease), an adrenal adenoma, or administration of exogenous glucocorticoids.

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