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Associate Professor, University of Oklahoma College of Medicine

The last sound heard before the onset of Phase V is considered to represent diastolic arterial pressure cholesterol foods to avoid chart buy caduet 5 mg overnight delivery. Although the cuff method has become a standard means of evaluating blood pressure in clinical settings results of cholesterol test buy caduet now, it is not without artifact errors cholesterol free cheese discount caduet 5 mg amex. A cuff that is too narrow will give a falsely high pressure because the pressure in the cuff is not fully transmitted to the underlying artery. In older adults (or those who have “stiff” or hard-to-compress blood vessels from other causes, such as arteriosclerosis), additional external pressure may be required to compress the blood vessels and stop the flow. This includes reduced arterial compliance associated with the aging process, restenosis phenomena, hardening following transplantations of vascular segments, and even atherosclerosis. However, these conditions all differ significantly with respect to key immune, mitogenic, and lipid components to their pathology. Typically, the term arteriosclerosis is used to describe the general progressive decrease in arterial compliance that accompanies the aging process (see Chapter 11). Even in the absence of true systemic arterial hypertension and atherosclerosis, people in their 70s have considerably stiffer arterial walls than those in their 20s. The process that leads to this arterial stiffening is thought to be related to the continual, day-to-day exposure of arteries to oxygen radicals produced in the arterial wall as the by-product of natural metabolism. However, it likely also results from accumulated insults to the arteries from lifestyles, dietary factors, and pathological conditions known to stimulate excess radical production such as tobacco use, hypertension, and diabetes mellitus. Arteries in young people owe their suppleness to the orderly arrangement of elastin and collagen in the arterial wall. Oxygen radicals attack the collagen and elastin matrix within the arteries, causing both strand breaks and rearrangement of elastic fibers into a more random configuration. In the absence of any other pathologic factors, an older person with this type of arteriosclerosis exhibits an increased pulse pressure associated with an increased systolic pressure, lower diastolic pressure, and normal mean arterial pressure compared with a healthy younger person (healthy meaning with a blood pressure of 120/80 mm Hg). People with this condition have what is called systolic hypertension because only their systolic pressure is elevated. Until somewhat recently, older patients with systolic hypertension were not treated with typical antihypertensive drug therapies for their condition. These people did not have the underlying vascular abnormalities associated with the increased arterial resistance of essential hypertension because their mean arterial pressure was not changed. Furthermore, their age led some to believe that there may be no long-term benefit to drug treatments, especially when such treatments were associated with serious side effects. However, systolic hypertension is no longer neglected in older adults and is instead treated with therapies designed to reduce arterial pressure. The reason for this is that systolic pressure is a key component of the wall stress that must be overcome for the heart to effectively contract. High systolic pressure leads to high stress that in turn increases oxygen demand by the heart. This places the heart at risk for ischemia and arrhythmias, whose incidence can be reduced if the systolic pressure is decreased. In addition, clinical trials have shown that the morbidity and mortality of older patients with systolic hypertension are improved with treatment to lower the systolic pressure, thus providing evidence-based support for antihypertensive therapies in older adults with systolic hypertension. Although the range of blood pressures in the population as a whole is rather broad, changes in a given patient are of diagnostic importance.

This condition occurs in patients who are taking tamsulosin (Flomax) for benign prostatic hypertrophy cholesterol ratio us cheap 5 mg caduet otc. Tamsulosin is a systemic sympathetic a1-A receptor blocker cholesterol levels shrimp scallops caduet 5 mg generic, which improves lower urinary tract flow by relaxing the neck of the bladder neck and prostatic smooth muscle cholesterol abbreviation cheap caduet 5 mg fast delivery. Patients taking tamsulosin who undergo cataract surgery manifest pupillary abnormalities that include a flaccid iris, which undulates and billows in response to intraocular fluid currents. There is also a tendency for the iris to prolapse through both the phaco incision and paracentesis. Last, there is typically a progressive intraoperative pupillary constriction despite apparent adequate pharmacologic dilation at the initiation of surgery. These iris abnormalities are believed to occur because the smooth muscle in the iris also has a1-adrenoreceptors that are affected by tamsulosin. Because cataract surgery is more difficult in patients with poorly dilating pupils and abnormalities as noted above, cataract surgery on patients taking tamsulosin can be more difficult as well. Interestingly, even if patients discontinue their tamsulosin for up to 4 weeks prior to cataract surgery, the pupil abnormalities persist. Surgical strategies for dealing with this situation include utilizing a highly cohesive viscoelastic agent and iris retractors. What is the difference between an anterior chamber lens and a posterior chamber lens? During surgery a circular opening termed a capsulorrhexis is made in the capsule that surrounds the cataractous lens. The cataract is removed and then the new lens is placed into ‘‘the capsular bag,’’ which is the membrane that is left behind once the cataract is removed. At times it is not possible to place a posterior chamber lens either because of inherent weakness in the capsular bag or an intraoperative complication that disrupts its integrity. In these cases one of the options is to place a lens in the front (or anterior) portion of the eye; hence the term anterior chamber lens. Over time, the capsule can become so cloudy it may seem as if the cataract has ‘‘come back. The initials are an acronym for neodymium, yttrium, aluminum, and garnet, which are the materials utilized to allow the laser to function properly and open the membrane. Laser is actually an acronym for light amplification by stimulated emission of radiation. This is the ‘‘old’’ type of cataract surgery back in the days when patients had a very large incision made at the corneoscleral limbus and the entire lens surrounded by the lens capsule was removed (usually with the aid of a freezing probe termed a cryoprobe). In an extracap or extracapsular surgery, the capsule surrounding the lens is opened and the cataractous lens removed. Couching describes an ancient technique for cataract surgery where a needle was inserted into the eye and used to push the opaque cataract back into the vitreous cavity. Although the complication rate of this is extremely high and the visual result limited, in antiquity it would allow patients with mature light perception cataracts to be able to regain a limited degree of vision. It is based on a patient’s personal needs and the physician’s judgment as to the probability of visual improvement. Others may choose to delay surgery because their cataracts do not seriously interfere with their lives. The key question is whether the patient perceives the cataract as interfering with his or her quality of life. Of course, the physician must be aware of state visual acuity requirements for driving.

A person or animal that harbours a specific infectious In diseases such as diphtheria and streptococcal agent in the absence of discernible clinical disease and infection in which mucous membranes are involved serves as a potential source of infection cholesterol levels 35 year old male effective caduet 5mg. The carrier state from the initial entry of the infectious agent cholesterol test when not fasting order 5 mg caduet with amex, the period may exist in an individual with an infection that is in- of communicability is from the date of first exposure to apparent throughout its course (commonly known as a source of infection until the infecting microorganism healthy or asymptomatic carrier) why so much cholesterol in shrimp order discount caduet online, or during the incuba- is no longer disseminated from the involved mucous tion period, convalescence, and postconvalescence of membranes, i. Under either circumstance the carrier state may incubation period than during actual illness. This term is most frequently malaria and yellow fever, the periods of applied to a specific outbreak of acute disease in which communicability (or more properly infectivity) are those all patients have been followed for an adequate period during which the infectious agent occurs in the blood of time to include all attributable deaths. The case fatality rate must be clearly differentiated from mortality or other tissues of the infected person in sufficient rate (qv). A period of communicability (transmissibility) is also to be noted for the arthropod vector, namely, when the agent is present Chemoprophylaxis in the tissues of the arthropod in such form and locus The administration of a chemical, including antibiotics, (Binfective state) as to be transmissible. An illness due to a specific infectious agent or its toxic Contamination on a body surface does not imply a 155 products which arises through transmission of that agent carrier state. Disinfection from a population or the first invasion by a disease not previously recognized in that area requires immediate Killing of infectious agents outside the body by direct reporting and epidemiologic investigation; two cases of exposure to chemical or physical agents. Epidemic is said to exist if number of infectious material from the body of an infected person, cases exceeds 2 standard error compared to previous or after the soiling of articles with such infectious 3 or 5 years. Fumigation Terminal disinfection is the application of disinfective Any process by which the killing of animal forms, measures after the patient has been removed by death especially arthropods and rodents, is accomplished by the or to a hospital, or has ceased to be a source of use of gaseous agents (see Insecticide and Rodenticide). Disinfection is necessary only for groups of people learn to behave in a manner diseases spread by indirect contact; steam sterilization conducive to the promotion, maintenance or or incineration of bedding and other items is restoration of health. Education for health begins with recommended after a disease such as Lassa fever or people as they are, with whatever interests they may other highly infectious diseases. In communicable disease control, Any physical or chemical process serving to destroy or health education commonly includes an appraisal of remove undesired small animal forms, particularly what is known by a population about a disease, an arthropods or rodents, present upon the person, the assessment of habits and attitudes of the people as they clothing, or in the environment of an individual, or on relate to spread and frequency of the disease, and the domestic animals (see Insecticide and Rodenticide). The resistance Endemic of a group to invasion and spread of an infectious agent, based on the resistance to infection of a high proportion The constant presence of a disease or infectious agent of individual members of the group. It provides an within a given geographic area; may also refer to the immunological barrier. It is never constant; rather it varies due to herd transmission and holoendemic a high level of infection structure (new birth, death, in migration, out migration) beginning early in life and affecting most of the and presence of an alternative host. Epidemic Host The occurrence in a community or region of cases of an illness (or an outbreak) clearly in excess of A person or other living animal, including birds and expectancy. The number of cases indicating presence arthropods, that affords subsistence or lodgment to an of an epidemic will vary according to the infectious infectious agent under natural (as opposed to experi- agent, size and type of population exposed, previous mental) conditions. Some protozoa and helminths pass experience or lack of exposure to the disease, and time successive stages in alternate hosts of different species. A transport host is a carrier in which the organism remains alive but does Attack rate, or case rate, is an incidence rate often not undergo development. The secondary attack rate in communicable disease practice A person or animal that has specific protective antibodies expresses the number of cases among familial or or cellular immunity as a result to previous infection or institutional contacts occurring within the accepted immunization, or is so conditioned by such previous incubation period following exposure to a primary case, specific experience as to respond adequately to prevent in relation to the total of exposed contacts; it may be infection and/or clinical illness following exposure to a restricted to susceptible contacts when determinable. Immunity is relative: An Infection rate expresses the incidence of all infections, ordinarily effective protection may be overwhelmed by manifest and inapparent. Passive humoral immunity is attained who has either manifest disease (see Patient or sick either naturally by transplacental transfer from the person) or inapparent infection (see Carrier). An infec- mother, or artificially by inoculation of specific protective tious person or animal is one from whom the infectious antibodies (From immunized animals, or convalescent agent can be naturally acquired. Active Infection humoral immunity, which usually lasts for years, is attained either naturally by infection with or without The entry and development or multiplication of an clinical manifestations, or artificially by inoculation of the infectious agent in the body of man or animals.

Glycogen test cholesterol jeun order caduet 5mg with amex, the main carbohydrate stored in the liver cholesterol molecule order caduet on line, comprises as much as 7% to 10% of the weight of a normal lowering cholesterol by eating oatmeal generic caduet 5 mg mastercard, healthy liver. The enzyme glycogen phosphorylase catalyzes the cleavage of glycogen into glucose 1-phosphate that is then converted to G6P by the enzyme phosphoglucomutase. The enzyme glucose-6-phosphatase, present in the liver but not in muscle or the brain, converts G6P to glucose that can then be released into the circulation. G6P is an important intermediate in carbohydrate metabolism because it can be used to provide blood glucose or to form glycogen. Therefore, the liver, which is hormone sensitive, is the first organ to respond to changes in plasma insulin levels. Almost half the insulin in portal blood is removed as it passes through the liver. Insulin tends to lower blood glucose by stimulating glycogenesis and suppressing glycogenolysis and gluconeogenesis. A doubling of portal insulin concentration completely shuts down hepatic glucose production. In contrast to insulin, glucagon stimulates glycogenolysis and gluconeogenesis, raising blood sugar levels. Regardless, the ultimate balance between hepatic glycogenesis and glycogenolysis involves hormonal input as well as input from glucose sensors in the portal vein. The closely regulated balance between glycogen synthesis and glucose release by the liver is key to maintaining normal glucose concentrations within a narrow limit of 70 to 100 mg/dL. Although patients with liver disease might be expected to have difficulty regulating blood glucose, this is usually not the case due to the relatively large reserve of hepatic function. However, in the case of chronic liver disease, reduced glycogen synthesis and reduced gluconeogenesis may occur. Some patients with advanced liver disease develop portal hypertension, which induces the formation of portosystemic shunting, resulting in elevated arterial blood levels of insulin and glucagon as a result of suppressed liver removal of these hormones. In the liver (but not in the muscle), the isoform glucokinase phosphorylates glucose to form G6P. Depending on the energy requirement, G6P is channeled to glycogen synthesis or used for energy production by the glycolytic pathway. The liver takes up fructose, and fructokinase phosphorylates fructose to form fructose 1-phosphate, which is either isomerized to form G6P or metabolized by the glycolytic pathway. Galactose is used to provide energy and in the biosynthesis of glycoproteins and glycolipids. Gluconeogenesis is the production of glucose from noncarbohydrate sources such as fat, amino acids, and lactate. Pyruvate is the initial substrate, and it can be derived from lactate or the metabolism of glucogenic amino acids (amino acids that can contribute to the formation of glucose). Gluconeogenesis is important in maintaining blood glucose homeostasis, especially during fasting. The red blood cells and renal medulla totally depend on blood glucose for energy, and glucose is the preferred substrate for the brain. Most amino acids can contribute carbon atoms to glucose synthesis, with alanine from muscle being the most important. The rate-limiting factor in gluconeogenesis is the availability of substrate molecules and not the amount of enzyme. Epinephrine and glucagon stimulate gluconeogenesis, but insulin greatly suppresses it. Thus, in type I diabetic patients, gluconeogenesis is greatly stimulated, contributing to the hyperglycemia observed in these patients (see Chapter 15).

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