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Associate Professor, University of Missouri–Kansas City School of Medicine

State what is novel about each study and how each study has advanced knowledge and understanding medicine of the future buy spirulina with amex. This is not to deny the importance of genetic predisposition in modifying susceptibility symptoms 3dpo buy generic spirulina 500 mg on-line. In the last chapter we examined evidence which showed that people who are physically active or fit are less likely to die over a defined period than those who are inactive and/or unfit 5 medications discount spirulina on line. We will now evaluate this evidence in accordance with the principles set out in Chapter 2 medications via g tube buy cheap spirulina 500mg online. A heart attack happens when blood flow to the myocardium is impaired, either because a thrombus forms or because the artery goes into spasm. The extent of the damage depends on the site of the obstruction; if flow is interrupted to a large area of the myocardium, the attack is life-threatening because the heart can no longer function as an effective pump. A stroke causes neurological damage, either because a blood vessel in the brain becomes blocked or because of a bleed into the tissues of the brain. It increases the work of the heart, damages the arterial wall and increases the possibility that a small blood vessel in the brain will rupture, causing a stroke. For example, heart failure is the principal manifestation of coronary atherosclerosis, heart attack, damaged valves or hypertension. Cerebrovascular disease (stroke): this can be due to the formation of a thrombus (blood clot), that is, a thromboembolytic or ischemic stroke, or to a bleed into the brain, that is, a haemorrhagic stroke. Heart failure: the heart is unable to pump blood forward at a rate sufficient to meet the metabolic demands of the body, usually because of impaired left ventricular function. Rheumatic heart disease: the valves of the heart are damaged, impairing its capability to control the direction of blood flow. Cardiomyopathies: disorders that occur due to major structural abnormalities of the myocardium. Each year about 780,000 people experience a new or recurrent stroke which accounts for approximately one of every 17 deaths in the United States; on average, every 40 seconds someone in the United States has a stroke. The reason for this discrepancy is unclear, but some evidence of atherosclerosis was found in all of these reports, confirming that the disease process begins early in life. The pathological hallmarks of atherosclerosis are the fatty streak (the earliest visible lesions) and the fibrous plaque (plaques are more advanced lesions that are the source of clinical symptoms). This was proposed in the early 1970s and states that the disease begins with an injury to the lining of an artery, that is, the endothelium. Endothelial injury or dysfunction thus leads to the accumulation of molecules, especially lipids, and a proliferation of cells in the intimal layer of an artery. Progression of atherosclerosis involves adhesion of white blood cells called monocytes to the endothelium. Macrophages and smooth muscle cells proliferate in the intima, the latter producing collagen and other molecules that increase the bulk of the lesion. Molecular factors such as cytokines, growth factors and nitric oxide all play a role in the proliferation and migration of smooth muscle cells. The size of the fatty streak increases and a cap of connective tissue may cover the Figure 4. Fatty streak Monocyte Blood Endothelium Intima Lipid-containing particles Foam cells Macrophage (differentiated monocyte) Cytokine Dividing smooth-muscle cells Growth factors Cytokine T-cell Smooth-muscle cell migration Smooth-muscle cells note: the media (middle layer of the artery wall) can be seen at the bottom of the diagram. The consequent reduction in blood flow leads to ischemia of an area of the myocardium. Natural history of atherosclerosis 70 Infarct Stroke Gangrene Aneurysm 60 50 Clinical horizon 40 Calcification Complicated lesion: haemorrhage, ulceration, thrombosis 30 Fibrous plaque 20 Fatty streak 10 0 Source: McGill et al. Plaques grow gradually, and only when a lesion restricts blood flow by around 45% do symptoms develop as the tissues supplied by that artery become ischemic. For example, rupture of a vulnerable plaque is often associated with thrombus formation, leading to a heart attack or stroke. An artery wall weakened by atherosclerosis can rupture, leading to internal bleeding.

Syndromes

• Low blood sugar (hypoglycemia)
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Most physicians will agree thatitiseasiertopercussandauscultateatthebackas you have more surface area available treatment 4 hiv cheap spirulina 500mg line. When the patient is lying down symptoms xanax addiction spirulina 500 mg on-line, palpate symptoms 13dpo order spirulina with visa,percussandauscultatetheanterioraspectofthe chest medications zolpidem purchase spirulina 500mg fast delivery. Whenheorsheissittingforwards,palpate,percuss and auscultate the posterior aspect, and examine for lymphadenopathyatthesametime. Students are often surprised when theydonotheardecreasedbreathsoundsatthesiteof lobectomy scars, which they may have done during their ward attachments. This is because, after a few months or years, patients with lobectomies develop Examinations: 2 Respiratory 9 (a) (b) Figure 2. This will not be the case immediatelyafterlobectomysurgeryassufficienttime hasnotsurpassedforcompensatoryhyperinflationto occur. Oneisthat thedifferencebetweentheintrapleuralpressureofthe apex and the base is greater in taller people, making it easier for a pneumothorax to form spontaneously. Another is that any anatomical defects or blebs will become more stretched if the length if the lung is longer,asisthecaseintallerindividuals. It is also useful to differentiate between lung hyperinflation pushing the liver down, and true hepatomegaly. Thesuperioraspectoftheliverusually liesbetweenthe4thand6thribs,andcontinuesdown to the last rib at the inferior border of the rib cage; hence, there should be dullness in all of this area. Doing this in an exam willmakethepatientuncomfortableanduseupyour valuable time without achieving very much. Identifying splenomegalyandgivingareasonablelistofdifferential diagnoses and investigations will usually be enough to score a decent pass. Distinguishing between mild/ moderate and gigantic splenomegaly will help to get you into the merit/distinction range. Allthe conditions that cause hepatomegaly or splenomegaly haveseveralperipheralsignssolookoutfortheseand usethemtosupportyourdifferentialdiagnosis. Make sure that you have a genericsystemforcategorisingthecauses,sothatyou canreeloffalistofdifferentialdiagnosesquickly,confidentlyandsystematically. Pseudoclubbing occurs because of tertiary hyperparathyroidism and althoughitlookslikeclubbing,withprominenceofthe distalphalanges,whatactuallyhappensisthattheproximal phalanges become narrow, and this makes the distalphalangeslookprominentdespitebeingnormal. Onceapatient is undergoing renal replacement therapy and their calcium levels normalise, the parathyroid continues producing excess parathyroid hormone, which results in hypercalcaemia and resorption of bone from the proximalphalanges,causingthemtonarrow. Spleen Cannot get above the spleen Moves downwards and medially with inspiration Not ballotable Palpable notch (medial aspect) Kidney Should be able to get above the kidney No movement with breathing Ballotable No notch Abdominal masses Ifyoufindamass,trytoanswertwoquestionsinyour mind. First identify the quadrant where the mass is located, and then think of the organs in that quadrant from whichthemassmightoriginate(Figure3. What is the one investigation you would do in a patient with known portal hypertension in order to reducemortality Ask them to stretch their arms out with the palms up at the level of their shoulders.

The lesson here is that a balanced chemical equation is not sufficient reason to conclude that a reaction will occur treatment 4 water order 500mg spirulina. That has a potential downside because elemental hydrogen is highly explosive and flammable and could cause an explosion or fire hazard 97140 treatment code spirulina 500 mg cheap. But medications not to take during pregnancy 500mg spirulina with mastercard, in a contained reaction vessel that allowed for capture of H2 symptoms 5th week of pregnancy purchase spirulina discount, the elemental hydrogen could be put to use as a fuel or reacted directly in a fuel cell to produce electricity (Section 3. In principle, the FeO required could be made by reacting scrap iron metal with oxygen from the air, 2Fe + O2 2FeO (4. In Chapter 1 yield was defined as a percentage of the degree to which a chemical reaction or synthesis goes to completion and atom economy was defined as the fraction of reactants that go into final products. Chemical Reactions: Making Materials Safely 87 this result shows that even with 100% yield, the reaction is only 34. One way of ridding automobile exhaust gases of this pollutant is to pump air into the exhaust and convert the carbon monoxide to carbon dioxide as shown by the reaction above. However, even in the presence of oxygen, this reaction does not proceed to completion in an ordinary automobile exhaust system. It is enabled to occur, however, by passing the exhaust mixed with air over a solid honeycomb-like surface of ceramic coated with a metal that enables the reaction to occur, but is not itself consumed in the reaction. Most people who have an automobile are vaguely aware that they have an automotive exhaust catalyst. That is because all living organisms have biological catalysts that enable reactions to occur. There are enzymes that detoxify toxic substances, and in some cases they inadvertantly make toxic substances out of nontoxic ones. Some of the more common cancer-causing substances are actually 88Green Chemistry, 2nd ed synthesized from other molecules by enzyme action. The simplest kind of chemical reaction to visualize is a combination reaction in which two substances come together to form a new substance. By injecting pulverized coal into a bed of CaO and other minerals kept in a fluid-like state by the injection of air, the sulfur dioxide produced has the opportunity to react with CaO and is not emitted as a pollutant with the stack gas. Addition reactions are very desirable in the practice of green chemistry because they are 100% atom economical. For example, impurity chloride ion, Cl-, must be avoided in solution because it can produce some Cl2 gas, a toxic, undesirable byproduct. Another inefficiency occurs because not all of the electricity passed through the solution is utilized to decompose water. The elemental carbon from this reaction is generated as a fine powder called carbonblack. Carbon black is an ingredient of the paste in dry cells (such as those used in portable electronic devices); it is used as a filler in tires and to make electrodes for electrolysis processes such as the one by which aluminum metal is prepared. This reaction also falls under the classification of reactions involving evolution of a gas, in this case evolution of hydrogen gas. A doublereplacement reaction, also called a metathesis reaction, is one in which two compounds trade ions or other groups. This is also a precipitation reaction in which a solid material forms from two substances dissolved in water; the solid formed is a precipitate. The removal of calcium from water as shown by this reaction is a common water treatment process called watersoftening. It is done because excessive levels of calcium cause formation of scale that can clog water pipes and damage plumbing apparatus. Exercise: Classify each of the following reactions as combination, decomposition, substitution, metathesis, neutralization, precipitation, or evolution of a gas. This name derives from the long standing use of oxidation to describe the reaction of a substance with oxygen. It is seen from this reaction that the calcium atoms lose electrons when they are oxidized and the oxygen atoms gain electrons.

The use of exhaust pollution control devices on automobiles have lowered these levels significantly during the last 30 years symptoms migraine purchase spirulina no prescription. The numerous fatal cases of carbon monoxide poisoning that occur each year are almost always the result of improperly vented heating devices in indoor areas medications narcolepsy order spirulina 500mg on-line. Carbon monoxide is produced by partial combustion of fuels symptoms 9 dpo order spirulina canada, largely in the internal combustion engine treatment jammed finger generic spirulina 500mg otc. Carbon monoxide emissions can be reduced by careful control of combustion conditions. The fate of sulfur dioxide in the atmosphere is oxidation and reaction with water to produce sulfuric acid. It is very important because it is the main mechanism for forming acid rain, which can be directly harmful to vegetation, fish (especially fingerlings), and materials, such as building stone that can be attacked by acid. As a result, much of the Eastern United States is covered by a slight haze of sulfuric acid droplets during much of the year. In recent years, some volcanic eruptions have blasted enough sulfur dioxide into the atmosphere to produce a sufficient amount of sunlight-reflecting sulfuric acid aerosol to cause a noticeable cooling of the atmosphere. In addition to indirect effects from the formation of acid rain, sulfur dioxide affects some plants directly, causing leaf necrosis (death of leaf tissue). Another symptom of sulfur dioxide phytotoxicity (toxicity to plants) is chlorosis, a bleaching or yellowing of green leaves. The most straightforward means of reducing sulfur dioxide emissions is to avoid having sulfur in fuels. Coal often has high levels of sulfur, and during recent years there has been a major shift to low sulfur coal in power plants. Much of the pyritic sulfur, FeS2, can be washed from coal because it exists in a separate mineral phase that can be separated from the combustible organic matter in coal. However, about half of the sulfur in coal typically is bound to the coal as organic sulfur, and cannot be removed. A number of coal-fired power plants have installed systems for removing sulfur dioxide resulting from the combustion of coal. GreenChemistryandSulfurDioxide the problem of sulfur in fuel provides an excellent illustration of the potential for the application of green chemistry to the elimination of a pollution problem. Sulfur is a valuable raw material required in the manufacture of sulfuric acid, one of the largest volume chemicals made. Rather than presenting a pollution problem, it is converted to elemental sulfur, then used to make sulfuric acid. The huge coal-fired power plant in Kalundborg uses lime scrubbing to remove sulfur dioxide from stack gas. This mineral is then used to make wallboard, thus solving a pollution problem from the production of spent lime and a raw materials problem arising from the need for gypsum to make wallboard needed for building construction. Of these, nitrous oxide is generated by bacteria and its release is one of the ways in which chemically fixed nitrogen in the biosphere is returned to the atmosphere. It is not involved much with chemical processes in the troposphere, but undergoes photochemical dissociation in the stratosphere: N2O + h N2 + O (8. Pollutant concentrations of these gases can become too high locally and regionally, causing air pollution problems. Nitrogen dioxide is very reactive, undergoing photodissociation within a minute or two in direct sunlight. Plants exposed to nitrogen dioxide may suffer decreased photosynthesis, leaf spotting, and breakdown of plant tissue. This figure illustrates that acidic precipitation is a regional air pollution problem, not widespread enough to be a global problem, but spreading beyond local Chap. Lines showing precipitation with the same pH (isopleths) in the 48 contiguous United States. The actual distribution of acidic precipitation varies constantly with time and climatic conditions, but is generally similar to the plot shown with lower values concentrating in the northeastern states. Transport processes that move atmospheric acids and their precursor acid gases from their sources to downwind areas are very important in determining areas affected by acid rain. Southern Norway, Sweden, and Finland receive acid precipitation originating farther south in Europe. Numerous adverse effects have been reported as the result of acidic precipitation.

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