By N. Dawson. Methodist Theological School in Ohio.

The skin and its accessory structures make up the integumentary system safe protonix 40mg, which provides the body with overall protection discount 20 mg protonix visa. The skin is made of multiple layers of cells and tissues best 20 mg protonix, which are held to underlying structures by connective tissue (Figure 5. It also has numerous sensory, and autonomic and sympathetic nerve fibers ensuring communication to and from the brain. Beneath the dermis lies the hypodermis, which is composed mainly of loose connective and fatty tissues. It has a fifth layer, called the stratum lucidum, located between the stratum corneum and the stratum granulosum (Figure 5. Keratin is an intracellular fibrous protein that gives hair, nails, and skin their hardness and water-resistant properties. The keratinocytes in the stratum corneum are dead and regularly slough away, being replaced by cells from the deeper layers (Figure 5. The basal layer consists of cuboidal cells, whereas the outer layers are squamous, keratinized cells, so the whole epithelium is often described as being keratinized stratified squamous epithelium. If you zoom on the cells at the outermost layer of this section of skin, what do you notice about the cells? Stratum Basale The stratum basale (also called the stratum germinativum) is the deepest epidermal layer and attaches the epidermis to the basal lamina, below which lie the layers of the dermis. The cells in the stratum basale bond to the dermis via intertwining collagen fibers, referred to as the basement membrane. A finger-like projection, or fold, known as the dermal papilla (plural = dermal papillae) is found in the superficial portion of the dermis. Dermal papillae increase the strength of the connection between the epidermis and dermis; the greater the folding, the stronger the connections made (Figure 5. A basal cell is a cuboidal-shaped stem cell that is a precursor of the keratinocytes of the epidermis. All of the keratinocytes are produced from this single layer of cells, 184 Chapter 5 | The Integumentary System which are constantly going through mitosis to produce new cells. The first is a Merkel cell, which functions as a receptor and is responsible for stimulating sensory nerves that the brain perceives as touch. In a growing fetus, fingerprints form where the cells of the stratum basale meet the papillae of the underlying dermal layer (papillary layer), resulting in the formation of the ridges on your fingers that you recognize as fingerprints. Fingerprints are unique to each individual and are used for forensic analyses because the patterns do not change with the growth and aging processes. Stratum Spinosum As the name suggests, the stratum spinosum is spiny in appearance due to the protruding cell processes that join the cells via a structure called a desmosome. It is interesting to note that the “spiny” nature of this layer is an artifact of the staining process.

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A large-scale study in Hyderabad city and its surrounding municipalities order protonix 40 mg with amex, covering a population of more than 54 lakh and 28 hospitals/health posts generic protonix 20mg line, was done in 2001 to collect cause-specific morbidity data cheap 20 mg protonix amex. Avoidance of pollution is advisable Early consultation with physician should be strongly encouraged and patient should be educated about the warning signs of acute exacerbation. Patient may be orthopneic and have swelling of feet, On examination there is increase in respiratory rate, tachycardia, flapping tremor and drowsiness ( if retention of carbon dioxide). Some patients who have predominant chronic bronchitis show features of chronic corpulmonale (Blue Bloaters) like pedal edema, raised jugular venous pressure, puffy face, central cyanosis, loud pulmonary heart sound and parasternal heave due to right ventricular hypertrophy. On the other patient with predominant emphysema (Pink Puffers) are usually thin built, plethoric due to associated secondary polycythemia, disproportionately dyspneic, features of hyper-inflated lungs like obliteration of liver and cardiac dullness, silent chest. Look for features of past tuberculosis  Pulse Oximetry  Sputum for gram stain, Culture and sensitivity, Acid Fast Bacilli stain. Watch for tachycardia or arrhythmias 4 o Inhaled beta 2 adrenergic receptor agonists in patients who are able to take metered dose inhalers (180 mcg) every 2-4 hours o Nebulised anticholinergic agent (ipratropium bromide) 0. In patients with more severe and recurrent disease gram negative organisms like Klebsiella pneumonia and Pseudomonas aeruginosa should also be considered. Usually a macrolide antibiotic like azithromycin or clarithromycin or a quinolone like levofloxacin or moxifloxacin is given. Upper airway obstruction  Hemodynamic instability- uncontrolled arrhythmia, patient on very high doses of inotropes, recent myocardial infarction. If the patient has a nasogastric tube put a seal connector in the dome of the mask to minimize air leakage. Standard critical care ventilators using flow by system ( non invasive mode option ) allow the patient to breathe without expending effort to open valves. In selected patients like those suffering from neuromuscular diseases, volume assist or volume control mode may be used. N Engl J Med 346(13):988–994  SnowV (2001) Evidence base for management of acute exacerbations of chronic obstructive pulmonary disease. Asthma is associated with considerable patient morbidity, a diminution in productivity and increase in health care utilization. The episode may be rapid in onset (in a matter of hours) or more typically progress during several hours to days. Prognosis of asthma in general is good but 10-20% of patents continue to have severe attacks throughout their lives.

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Biosecurity measures purchase 40mg protonix fast delivery, aiming at the isolation of large poultry holdings order protonix 40 mg visa, effectively prevent transmission from farm to farm by mechanical means discount protonix 40mg line, such as by contami- nated equipment, vehicles, feed, cages, or clothing – especially shoes. However, during outbreaks in the Netherlands (2003) and Canada (2004), airborne spread has been considered (Landman and Schrier 2004, Lees 2004). The role of live vectors such as rodents or flies, which may act as ‘mechanical vectors’ and are not themselves infected, is largely indetermined but certainly does not constitute a major factor. In April 2005, however, Asian lineage H5N1-associated disease surfaced at Lake Qinghai in North Western China affecting thousands of bar-headed geese and other migratory species of ducks, cormorants and gulls (Chen 2005, Liu 2005). Therefore, transmission of Asian lineage H5N1 viruses by wild birds must be taken into account in future preventive concepts (discussed below). Since late 2003, some H5N1 viruses have been encountered in Asia which were highly pathogenic for chickens but not for ducks (Sturm-Ramirez 2005). Experi- mental infections using these isolates revealed a heterogeneous mixture with respect to genetic analysis and plaque formation capacities in cell culture (Hulse Post 2005). Ducks that survived infection with these isolates were shown to shed a virus population on day 17 that had lost its pathogenic potential for ducks. Transmission to Humans Transmission of avian influenza viruses to humans, leading to the development of clinically overt disease is a rare event (Table 3). These cases were epidemiologically linked to an outbreak of highly pathogenic H5N1 in live-bird markets (Yuen 1998, Claas 1998, Katz 1999). The risk of direct transmission of the H5N1 virus from birds to humans seems to be greatest in persons who have close contact with live infected poultry, or surfaces and objects heavily contaminated with their droppings. Exposure risk is considered substantial during slaughter, defeathering, butchering and preparation of poultry for cooking (http://www. In several such instances, it was reported that the person who slaughtered or prepared a sick bird for consumption developed fatal illness, while family members who participated in the meal did not (http://www. The H9N2 strain circulating in poultry at these times provoked significant symptoms and lethality rates in highly vulnerable species such as turkeys and chickens. To date, there is no evidence that properly cooked poultry meat or poultry products are a source of human infection by the Asian lineage H5N1. Transmission 65 Transmission to other Mammals Avian influenza viruses have been transmitted to different mammal species on sev- eral occasions. In European pig populations, avian-like H1N1 viruses are highly prevalent (Heinen 2002) and an H1N2 virus, a human-avian reassortant vi- rus, Þrst isolated in the U. A H9N2 virus of avian provenance is moderately prevalent in swine populations in the East of China (Xu 2004).

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