By X. Iomar. Seattle Pacific University. 2018.

Gross anatomy of the major lymphatics specially thoracic duct and its tributaries cheap 100mg zenegra. Surface Anatomy (a) Surface features of the body and projection of the outline of heart zenegra 100mg with amex, its borders generic zenegra 100mg otc, surfaces and valves, lungs, their borders, fissures and hila, pleura, liver, kidneys and various abdominal and pelvic organs and important vessels and nerves 13. Cross Sectional Anatomy Cross sections of thorax, abdomen and pelvis to understand the interrelationship of organs and structures. Microanatomy Microscope and basic principles of microscopy, commonly used stains, basophilic and acidophilic staining reactions and their significance. Brief principle of electron microscopy and interpretation of ultrastructural features. Four primary tissues Epithelium : Microscopic characteristics, types, functions, distribution, basal lamina, cell junctions, specialization of the cell surface and their structural details and functions; metaplasia. Intercellular substances, amorphous ground substance, types of connective tissue (loose areolar tissue, dense connective tissue) and their distribution. Specialized connective tissue : different types of cartilages and their functions and distribution. Bone : Cells, bone matrix, structural features of compact and cancellous bone, their distribution and functions, ossification, blood supply of a long bone. Different types of neurons and their specific structural and functional features and distribution. Axonal transport, synapse, morphological and functional characteristics of different types of synapses. Sensory and autonomic ganglia, peripheral nerves, myelin and myelination, degeneration and regeneration in peripheral nerves. Histology of various organs/organ systems Anatomy 5 Exocrine glands : Characteristics, simple and compound glands; types of secretions, modes of secretion, detailed structural features of a serous secreting cell and mucous secreting cell, serous and mucous acini, duct system, features of salivary glands, exocrine pancreas, sweat and sebaceous glands, mammary gland, bulbourethral gland etc. Circulatory system : Structural features of heart; conducting and distributing arteries and arterioles; types of capillaries, their structural features and distribution and microcirculation, detailed structure of endothelium; structural characteristics of large and small veins and venules arterio-venous shunts, lymphatics. Respiratory system : Structural features of nose, nasopharynx, larynx, trachea, principal brochi, lung including intrapulmonary bronchi, bronchioles, alveolar ducts, atria, alveoli, blood-air-barrier. Skin and nerve-end-organs : Thick, thin and hairy skin, cell renewal and pigmentation of skin, skin appendages, healing of skin wounds, sensory receptors of skin. Thymus, lymph nodes, spleen, tonsils and other mucous associated lymphoid follicles. Layers of tubular digestive tract, esophagus, stomach, small intestine, gastroesophageal junction, gastroduodenal junction, large intestine, anal canal and rectoanal junction. Liver, internal organization of liver, liver lobule, liver acinus, significance of zonation in liver acinus, liver sinusoids, detailed structure of hapatocyet, bile canaliculi, bile ducts, gall bladder, bile duct and pancreas. Endocrine glands : Thyroid, parathyroid, Islets of Langerhan’s gland, adrenal cortex and medulla, their structural details, functional mechanisms, hypophysis cerebri, cell types secretion and their functions, hypophyseal portal circulation, common endocrine disorders Urinary system : Detailed microscopic structure of kidney, cortex, medulla, pyramids, medullary rays, cortical columns, glomerulus, nephron, glomerular filtration juxtaglomerular apparatus, its structural features and functions, renal interstitium, collecting ducts, renal sinus, minor and major calyces, microcirculation of kidney, histophysiology of the kidney, renal pelvis and ureters, urinary bladder and urethra. Female reproductive system : Ovary, ovarian stroma, primary and secondary graafian follicles, functions of various constitutents and structural details of graafian follicles, atretic follicles, corpuluteum and its functions, corpus albicans. Oviducts, uterus, arterial supply of uterus, cyclic changes in uterine endometrium, fertilization, vagina, female external ganitalia and mammary glands. Male reproductive system : Testes, spermatogenesis, spermatozoon, cycle of seminiferous epithelium, sertoli cells, interstitial tissue Leydig cells, histophysiology of testes, epididymus, vas deferns, prostrate, seminal vesicles, penis. A General Embryology (a) Definition of embryology; gestation period: definition of gamete sperm, Ovum; gametogenesis, migration of primordial germ cells into gonadal ridge; spermatogenesis; structure of sperm, oogenesis; structure of ovum; growth of ovarian follicles, ovarian and uterine cycles. Implantation; formation of decidua, types of implantation and abnormal sites of implantation (e) Third Week of Development Appearance of primitive streak and primitive node; formation of intraembroynic mesoderm resulting in trilaminar germ disc; gastrulation formation of notochord, buccopharyngeal and cloacal membranes, paraxial, intermediate and lateral plate mesoderm, secondary yolk sac, intraembryonic coelom and allantoic diverticulum; derivatives of ectoderm, mesoderm and endoderm. Development from third month to birth (Fetal period) (g) Maturation of tissues and organs and rapid growth of body. Placenta (i) Formation of placenta and chorionic villi, decidua basalis; features and functions of placenta; placental circulation; abnormalities; placental barrier; placentome, types of placenta. Amniotic Cavity (k) Amniotic cavity and membrane; amniotic fluid – functions, expansions of amniotic cavity and fusion with chorion; chorion laeve with decidua capsularis; decidua capsularis with parietalis; obliteration of chorionic and uterine cavities; function of fused foetal membranes to dilate cervical canal. Teratology (o) Genetical and environmental factors as causative factors for congenital malformations. B Systemic Embryology (a) Development of the individual organs of digestive system, genital system, urinary system,, respiratory system, cardiovascular system. Abdomen: Dissection: Anterior abdominal wall and inguinal region, external genitalia. Lower Limb: Dissection: Gluteal region, front and back of thigh popliteal fossa, front back and lateral side of leg and dorsum of foot. Prosected Parts: Sole of the foot and joints Head & Neck: Dissection: Superficial and deep dissection of face and neck, orbit and eye ball. Submandibular region temporal and infratemporal fossa, cranial cavity, naso and oropharyngeal regions.

Hanski I zenegra 100 mg, von Hertzen L cheap 100mg zenegra otc, Fyhrquist N order 100mg zenegra mastercard, Koskinen K, Torppa K, Laatikainen T et al (2012) Environmental biodiversity, human microbiota, and allergy are interrelated. Hviid A, Svanstrom H, Frisch M (2011) Antibiotic use and inflammatory bowel diseases in childhood. Hemarajata P, Versalovic J (2013) Effects of probiotics on gut microbiota: mechanisms of intestinal immunomodulation and neuromodulation. Sotgiu S, Angius A, Embry A, Rosati G, Musumeci S (2008) Hygiene hypothesis: innate immunity, malaria and multiple sclerosis. Proc Natl Acad Sci U S A 109:5995–5999 15 Microbiota, Immunoregulatory Old Friends and Psychiatric Disorders 353 150. Calcagni E, Elenkov I (2006) Stress system activity, innate and T helper cytokines, and susceptibility to immune-related diseases. Hayakawa M, Asahara T, Henzan N, Murakami H, Yamamoto H, Mukai N et al (2011) Dramatic changes of the gut flora immediately after severe and sudden insults. Hagberg H, Gressens P, Mallard C (2012) Inflammation during fetal and neonatal life: implications for neurologic and neuropsychiatric disease in children and adults. Engelhardt B, Sorokin L (2009) The blood-brain and the blood-cerebrospinal fluid barriers: function and dysfunction. Schwarcz R, Pellicciari R (2002) Manipulation of brain kynurenines: glial targets, neuronal effects, and clinical opportunities. Hertz-Picciotto I, Delwiche L (2009) The rise in autism and the role of age at diagnosis. Epidemiology 20(1):84–90 15 Microbiota, Immunoregulatory Old Friends and Psychiatric Disorders 355 188. Hallmayer J, Cleveland S, Torres A, Phillips J, Cohen B, Torigoe T et al (2011) Genetic heritability and shared environmental factors among twin pairs with autism. Meyer U, Feldon J, Dammann O (2011) Schizophrenia and autism: both shared and disorder- specific pathogenesis via perinatal inflammation? Onore C, Careaga M, Ashwood P (2012) The role of immune dysfunction in the pathophysio- logy of autism. Margutti P, Delunardo F, Ortona E (2006) Autoantibodies associated with psychiatric disorders. Emanuele E, Orsi P, Boso M, Broglia D, Brondino N, Barale F et al (2010) Low-grade endotoxemia in patients with severe autism. Crespi B, Badcock C (2008) Psychosis and autism as diametrical disorders of the social brain. Arch Pediatr Adolesc Med 163(6):542–546 Chapter 16 M icrobiota-Gut-Brain Axis and Cognitive Function Melanie G. Gareau´ Abstract Recent studies have demonstrated a clear association between changes in the microbiota and cognitive behavior. This chapter will highlight recent findings in both human and animal studies indicating how changes in the composition and diversity of the microbiota can impact behavior and brain physiology in both disease states and in health. Cognitive behavior can not only be affected in cases of intestinal disease, but also manifests changes in extra-intestinal disease conditions. In laboratory animals cognition, or learning and memory, is assessed by specific behavioral tests (Table 16. Communication between the gut and the brain can occur via neuronal, endocrine and immunological pathways, highlighting the complexity in deciphering the specific mechanisms involved in mediating normal physiology and homeostasis [1]. These mouse models involving the presence of an altered microbiota can be used independently or in combination to study the overall impact of pathology, and chronic disease in changing cognitive behavior. This review will focus on the role of the gut-brain-microbiota axis in mediating alterations in cognition in both human and animal studies and comparing normal and disease states. Microbiota and Cognition The microbiome has emerged in recent years as a leading factor in establishing normal physiology and function of the host as well as being a causative factor in numerous disease states when inappropriately altered [2]. Changes in the intestinal microbiota, either due to inflammation, infection, or drugs—including administra- tion of antibiotics—can lead to extraintestinal effects, including changes in the brain. Alterations in behavior, including anxiety, depression and cognitive defects, 16 Microbiota-Gut-Brain Axis and Cognitive Function 359 Table 16. This supports the notion that the microbiota can regulate the development of the central response to stress, at least in rodents. In these studies, conventionalization of mice could normalize behavior, but only in early stages of life [8]. These pilot studies revealed a change in brain neurotransmitter levels impacted by the microbiota, which could significantly 360 M. Serotonin is important in cognition, with manipulations in the serotonergic system capable of producing changes in cognitive function independent of changes in overall mood [13].

In later stages discount 100mg zenegra amex, the loss of coordination of oral and pharyngeal muscles will require slow generic 100mg zenegra visa, careful feeding of pureed foods zenegra 100 mg low cost, and beverages will need to be thickened with Thick-It® or related agents to reduce choking. Gastrostomy tubes placed by percutaneous endoscopy or interventional radiology can provide palliation of suffering and afford maintenance of hydration and nutrition in late-stage disease. A discussion around the issue of tube feeding should be held while the individual is still able to express his or her wishes either informally or in an Advance Directive. Urinary frequency and urgency are common, and mobility issues can contribute to incontinence. Cognitive impairment and loss of executive function may result in lack of recognition of bladder or rectal fullness, and apathy may prevent timely travel to the commode. Urinary retention may occur, and urodynamic testing may reveal a neurogenic bladder. If problems persist or are severe, referral to an urologist or urogynecologist is strongly recommended, as both pharmacologic and behavioral techniques can help signifcantly. Other movement disorders such as myoclonus, tics, tremor or dystonia can be mistaken for seizures. If unprovoked seizures are suspected, pharmacologic treatment should be instituted based on the seizure type and concomitant medications. Chorea and dystonia require considerable energy and increase the individual’s caloric needs. Cognitive decline, behavioral changes, and apathy may make it more diffcult to plan, purchase and prepare food. Distractions can interfere with the ability to concentrate on eating, and swallow dysfunction may result in mealtimes that stretch to nearly an hour. Referral to a speech-language pathologist is recommended for a formal swallowing evaluation, once feeding or swallowing diffculties arise. Re-consultation with the speech-language pathologist is recommended as diffculties progress. A dietitian or nutritionist may be helpful in developing high calorie dietary plans that promote maintenance of weight and nourishment. For a discussion of issues related to the placement of feeding tubes, please see Chapter 8, under Oral-Motor Dysfunction. Strategies that help with diffcult behaviors will also beneft movement-related symptoms. Recognition and diagnosis of specifc motor and neurological disorders will determine the best therapy. This phenomenon can be explained by “unawareness” due to impaired frontal-striatal connections (see Chapter 5). The individual’s failure to report pain can make the recognition of serious injury or illness more challenging for caregivers and health professionals. The physician should look for behavioral changes that may signal pain, including restlessness, screaming, agitation, irritability and anger, resistance to care, or sometimes apathy and withdrawal. Physicians and health professionals should be attentive to conditions that are known to cause pain so that they can offer adequate pain management treatment. As later stage immobility progresses, analgesics should be increased in combination with low-dose opiates such as hydrocodone with acetaminophen, and in time, more long-lasting oral or transdermal opiates may be indicated. Case Study: #1 Treating Chorea A 44 year old man with a fve year history of Huntington’s Disease is seen for management of chorea. His symptoms of chorea have gradually increased, and are now constant, affecting his face, trunk and limbs. He complains of clumsiness, often drops items or spills liquids, and has had a few falls. The movements interfere with falling asleep, and his wife complains that he’s extremely restless at nighttime. His examination shows mild facial movements, motor impersistence of tongue protrusion, and frequent, moderate-amplitude repetitive irregular movements of his hands. His gait is characterized by frequent lurching movements of the trunk, with brief jerks of his lower legs affecting balance. However, when he returns after three months, his family reports that he’s been more withdrawn for the last few weeks, and he admits to feelings of depression and hopelessness. His examination reveals slight loss of facial expressivity and psychomotor slowing. The doctor, knowing that a reduction in dosage is often effective for managing depression induced by tetrabenazine, reduces the man’s dose to 12. The man’s symptoms of depression improve within a week, and he maintains effective chorea reduction. She complains that her movements interfere with writing, eating and dressing, and she has tripped and fallen several times. She returns in 6 weeks, and both she and her spouse report marked improvement in her chorea and insomnia. Three months later the woman’s spouse calls with a report that the woman has developed marked anxiety.

Methods of Communicable Disease Control There are three main methods of controlling communicable diseases: 1 buy generic zenegra 100mg on-line. Man as reservoir: When man is the reservoir buy zenegra 100 mg with amex, eradication of an infected host is not a viable option 100mg zenegra visa. Instead, the following options are considered: 19 Communicable Disease Control Detection and adequate treatment of cases: arrests the communicability of the disease (e. Isolation is indicated for infectious disease with the following features: - High morbidity and mortality - High infectivity Quarantine: limitation of the movement of apparently well person or animal who has been exposed to the infectious disease for a duration of the maximum incubation period of the disease. Animals as reservoir: Action will be determined by the usefulness of the animals, how intimately they are associated to man and the feasibility of protecting susceptible animals. For example: Plague: The rat is regarded as a pest and the objective would be to destroy the rat and exclude it from human habitation. Reservoir in non-living things: Possible to limit man’s exposure to the affected area (e. Interruption of transmission This involves the control of the modes of transmission from the reservoir to the potential new host through: Improvement of environmental sanitation and personal hygiene Control of vectors Disinfections and sterilization 3. Protection of susceptible host: This can be achieved through: Immunization: Active or Passive Chemo-prophylaxis- (e. State the six important factors that involve the chain of communicable diseases transmission. Oral-oral transmission occurs mostly through unapparent fecal contamination of food, water and hands. As indicated in the schematic diagram below, food takes a central position; it can be directly or indirectly contaminated via polluted water, dirty hands, contaminated soil, or flies. Infectious agent Salmonella typhi Salmonella enteritidis (rare cause) Epidemiology Occurrence- It occurs worldwide, particularly in poor socio- economic areas. Annual incidence is estimated at about 17 million cases with approximately 600,000 deaths worldwide. In endemic areas the disease is most common in preschool and school aged children (5-19 years of age). Reservoir- Humans Mode of transmission- By water and food contaminated by feces and urine of patients and carriers. Flies may infect foods in which the organisms then multiply to achieve an infective dose. Incubation period –1-3 weeks 25 Communicable Disease Control Period of communicability- As long as the bacilli appear in excreta, usually from the first week throughout convalescence. About 10% of untreated patients will discharge bacilli for 3 months after onset of symptoms, and 2%-5% become chronic carriers. Relative specific immunity follows recovery from clinical disease, unapparent infection and active immunization but inadequate to protect against subsequent ingestion of large numbers of organisms. Clinical manifestation First week- Mild illness characterized by fever rising stepwise (ladder type), anorexia, lethargy, malaise and general aches. Severe illness with weakness, mental dullness or delirium, abdominal discomfort and distension. If no complications occur, patient begins to improve and temperature decreases gradually. Clinical manifestations suggestive of typhoid fever Fever- Sustained fever (ladder fashion) Rose spots- Small pallor, blanching, slightly raised macules usually seen on chest and abdomen in the first week in 25% of white people. Diagnosis Based on clinical grounds but this is confused with wide variety of diseases. Follow strictly enteric precautions: wash hands wear gloves teach all persons about personal hygiene 6. Observe the patient closely for sign and symptoms of bowel perforation erosion of intestinal ulcers sudden pain in the lower right side of the abdomen abdominal rigidity sudden fall of temperature and blood pressure 7. Education on handwashing, particularly food handlers, patients and childcare givers 3. Group A= Shigella dysentraie (most common cause) Group B= Shigella flexneri Group C= Shigella boydii Group D= Shigella sonnei Epidemiology Occurrence- It occurs worldwide, and is endemic in both tropical and temperate climates. Outbreaks commonly occur under conditions of crowding and where personal hygiene is poor, such as in jails, institutions for children, day care 29 Communicable Disease Control centers, mental hospitals and refugee camps. Two-thirds of the cases, and most of the deaths, are in children under 10 years of age. Reservoir- Humans Mode of transmission- Mainly by direct or indirect fecal-oral transmission from a patient or carrier. Transmission through water and milk may occur as a result of direct fecal contamination. Flies can transfer organisms from latrines to a non-refrigerated food item in which organisms can survive and multiply. Incubation period- 12 hours-4 days (usually 1-3 days) Period of communicability- During acute infection and until the infectious agent is no longer present in feces, usually within four weeks after illness.

Models & theories: Are there any models zenegra 100mg with mastercard, theories or frameworks identified in the review? Comment if they are specific to the topic area or health communication communicable disease buy 100 mg zenegra with amex. Tools: Does the review identify any tools that facilitate practical step-by-step application? Comment if they are specific to topic area or health communication/communicable diseases purchase 100mg zenegra mastercard. Where possible, this should section should also include: Europe – is the identified application within Europe? Focus – are the applications focused on specific health topics, including communicable diseases/health communication? Targeting (hard-to-reach groups) – do the applications target hard-to-reach groups? Evidence: What evidence is identified in the review and what is the quality of this evidence? For example, these could be indirect indicators of success such as awareness /knowledge and ‘behavioural and other changes’, e. Evidence reviews A rapid evidence review of interventions for improving health literacy 10. Health literacy as a public health goal: a challenge for contemporary health and education and communication strategies into the 21st century. Complex interventions to improve the health of people with limited literacy: a systematic review. Interventions to improve health outcomes for patients with low literacy: a systematic reviewGeneIntern Med 2005; 20:185-92 18. Orthop Nurs 2008 Sep-Oct;27(5):302-17 A rapid evidence review of health advocacy for communicable diseases 20. Stop The Global Epidemic of Chronic Disease: A practical guide to successful advocacy. Public health campaigns to change industry practices that damage health: an analysis of 12 case studies. Advocacy, communication and social mobilisation for tuberculosis control: collection of country-level good practices [internet]. Evidence review: social marketing for the prevention and control of communicable disease 37. Developing a common language for using social marketing: an analysis of public health literature. The effectiveness of social marketing in reduction of teenage pregnancies: a review of studies in developed countries. Effectiveness of a hospital- wide programme to improve compliance with hand hygiene. Literature reviews A literature review on health information-seeking behaviour on the web: a health consumer and health professional perspective 50. Internet use and seeking health information online in Ireland: demographic characteristics and mental health characteristics of users and non-users. Group disparities and health information: a study of online access for the underserved. Effects of interactivity on the comprehension of and attitudes toward online health content. Journal of the American Society for Information Science and Technology 2007; 58(6):766-776 62. Using the internet for health-related activities: findings from a national probability sample. Reasons, assessments and actions taken: sex and age differences in uses of internet health information. Going online for health advice: changes in usage and trust practices over the last five years. Googling for a diagnosis – use of Google as a diagnostic aid: internet based study. The information-seeking behaviour of paediatricians accessing web-based resources. Internet-based information-seeking behaviour amongst doctors and nurses: a selective review of the literature. Assessment of internet use and effects among healthcare professionals: a cross sectional survey. Identifying strategies to improve access to credible and relevant information for public health professionals: a qualitative study. Patients using the internet to obtain health information: how this affects the patient-health professional relationship. Untangling the web – the impact of internet use on health care and the physician-patient relationship.

Without treatment at this stage purchase zenegra 100 mg on-line, patients may develop tertiary syphilis in one to 30 years order zenegra 100 mg otc, characterized by neurologic (stroke buy zenegra 100 mg on-line, dementia) or cardiac (heart valve disease) abnormalities. H-3 Chancroid is characterized by one to four very painful ulcers which often appear quite ragged. In either case, treatment is not urgent and evaluation and therapy can be delayed. The infectious agent is a Bedsonia organism closely related to that of psittacosis. Subclinical or inapparent infections, and an asymptomatic carrier state, have been described in females. After an incubation period averaging one to four weeks, a small painless genital lesion occurs in about one fourth of patients. The lesion is an inconspicuous bump, blister, or shallow ulcer that heals within a few days and typically goes unnoticed by 0 0 the patient. Shortly after the onset of these symptoms, the patient becomes aware of a painful swelling in one or both groin areas. Early in the course of regional node involvement, one can feel one or more enlarged discrete movable tender nodes. Because there are nodes in different stages of evolution, the mass becomes large and lobulated with alternating areas of softening and hardness. The overlying skin becomes swollen, sometimes bluish-red in color, and fixed to the underlying mass. When pus forms and breakdown occurs, multiple fistulous tracts may open to the skin surface. Other symptoms less commonly found include lower abdominal pain and diarrhea due to involvement of nodes in the pelvis and around the rectum. The pain is exaggerated when walking due to the pressure by the inguinal ligament. H-4 Pruritus (Itching) Pruritus may be caused by pubic lice (crabs) and scabies; both are parasites and in both cases, pruritus is caused by sensitization to the organism. The pruritus caused by lice is limited to the genital area while that due to scabies often occurs elsewhere on the body where the mite, Sarcoptes scabiei, has burrowed. For lice, the period between infestation and itching is 1-2 weeks for initial infections (and shorter for subsequent ones) while for scabies it is several weeks after initial infection but only a day or two after subsequent infection. Adult lice and their eggs (nits) in egg casings may be seen with the naked eye clinging to pubic hairs, or adult lice may be in the crusts of skin scabs formed from scratching; a magnifying lens helps visualize adults and eggs. Sarcoptes mites burrow under the skin, forming linear tracks and nodules (which house the mite); common locations are the groin, finger webs and axilla. Diagnosis of lice depends upon seeing the lice or their eggs; diagnosis of scabies depends upon seeing typical nodules. Pubic lice are treated by: lindane shampoo (1%), (not recommended for pregnant or nursing women, or children <2 years of age);or, permethrin creme rinse (1%) or pyrethrins with piperonylbutoxide. Scabies is treated by: permethrin cream (5%); or, lindane (1%), applied to the body from the neck down and washed off after 8 hours. For both diseases, bedding and clothing should be machine washed and machine dried using a hot cycle. Vaginal Discharge Vaginal discharge is a common symptom that can be normal or a symptom of various infections. Normal secretions are painless, clear, and thin, but can be quite profuse at some times of the month. Monilia, or a yeast infection, is characterized by a white, cheesy discharge resembling cottage cheese. Nonspecific vaginitis is due to a range of bacteria, and can have differing presentations. Since many things can cause this, thorough abdominal and pelvic examinations by a qualified and credentialed provider are usually needed for accurate diagnosis. Reasonable exclusion can be difficult, however, and consultation should be sought before beginning therapy. However, once the diagnosis is made, the patient can usually be treated with antibiotics as an out-patient. All patients with symptoms in the genital area, whether successfully treated or not, should not have sex until signs and symptoms have disappeared and they have been evaluated by skilled personnel. Sexual Practices Gonorrhea and other venereal diseases can occur at several sites. Gonorrhea may occur in the pharynx, but is usually asymptomatic and examination will be normal. Gonorrhea in the anus may be asymptomatic or associated with an anal discharge and rectal urgency. H-6 symptoms do not appear, seek medical attention for an examination as soon as feasible.