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D O P A M I N E T R A N S P O R T E R D I S E A S E : A N E X A M P L E O F A C O M M U N I C A T I O N D I S O R D E R Since the first imaging of d o p amine receptors in 1983 cheap nimotop online american express muscle relaxant and tylenol 3, there has been a steady increase in the n u m b e r of studies of the dopaminergic system in living h u m a n beings and experimental animals order nimotop australia muscle relaxant 4211. Today buy discount nimotop 30 mg muscle relaxant herbs, it is possible to examine all aspects of dopamine neurotransmission — the synthesis of dopamine with l8F L-dopa, the secretion of dopamine from the pre-synaptic neurons measured by its effect on post-synaptic receptors, the metabolism of dopamine by the m o n o a m i n e oxidase e n z y m e system, the re-uptake of unb o u n d dopamine by the pre-synaptic dopam i n e transporter with re-incorporation of dopamine into the vesicles of the pre-synaptic neuron. For example, w e can n o w select out f rom the heterogeneous sea of patients with m o v e m e n t disorders — patients with senile Parkinson’s disease, striatonigral degeneration, traumatic Parkinson’s disease, progressive supranuclear palsy, an idiopathic Parkinson’s disease — those patients w h o have a deficiency of d o p a m i ­ nergic pre-synaptic neurons. This s a m e approach to molecular diagnosis can also be applied to patients with other diseases, including cognitive disorders, emotional disorders and m a n y others. P R E V E N T I O N B Y M O L E C U L A R D I A G N O S I S In patients with idiopathic Parkinson’s disease, D, and D 2 dopamine receptors are normal; in striatonigral degeneration, there is degeneration of post-synaptic dopaminergic neurons as well. Early studies with the neurotoxin M P T P , injected into the carotid artery of baboons, left the post-synaptic receptors intact, but destroyed the pre-synaptic neurons. O n e could chemically resolve abnormalities in structures that wer e only micrometres apart. Several reports at this S y m p o s i u m s h o w e d that in the earliest stage of Parkinson’s disease, that is, w h e n only half of the bod y w a s involved, there w ere major deficiencies in pre-synaptic neurons, examined by injection of radiotracers that are accumulated by the pre-synaptic dopa­ m in e transporter. T h e tracer studies w ere m o r e sensitive than clinical manifestations Using the tracer n C W I N 35428, even in patients with stage I Parkinson’s disease, that is, w h e n half of the bod y function remains normal, there are striking reductions in the binding of the tracer to the transporters in the anterior and particularly the posterior putamen, which are remarkably different from normal persons. T h e decline in dopaminergic pre-synaptic neurons with increasing age even in normal persons supports the hypothesis that Parkinson’s disease occurs w h e n an environmental factor is superimposed on the normal decline in pre-synaptic neurons in the process of ageing. T h e similar effects of the neurotoxin M P T P on pre-synaptic dopaminergic neurons increases the possibility that a neurotoxin m a y play a role in Parkinson’s disease. T h e clinical manifestations of Parkinson’s disease are correlated with the degree of impairment of dopaminergic pre-synaptic neurons. Because drugs such as m o n o a m i n e oxidase inhibitors are effective iftreatment is begun early in Parkinson’s disease, the finding of the great sensitivity of a molecular diagnosis prior to s y m p ­ toms of Parkinson’s disease represents one of the most important advances in neurology in the past t w o decades. T h e accumulation of radiotracers that bind to dopamine transporters — both positron and single photon emitting radiotracers — can be used as markers to examine the role of genetic and environmental factors in Parkinson’s disease. These tracers cannot be used to assess secre­ tion of endogenous dopamine by its competitive effect in binding to the dopamine receptors. O n the other hand, if one is interested in assessing dopamine release, one uses a tracer with a lower affinity so that the endogenous dopamine can compete with the tracer. Investigators at K y u s h u University, Japan, have provided an excellent example of the use of receptor imaging to differentiate deafferentation from neuronal damage. In a patient with a thalamic infarction, there w a s a decrease in cerebral blood flow and ,8F-deoxyglucose (18F D G ) accumulation in the ipsilateral cerebral hemisphere, but normal accumulation of 123I-iomazanil, a tracer that binds to benzodiazapine receptors, in both cerebral hemispheres, indicating that the neurons themselves were intact. In this process of communication, nuclear medicine involves molecules with messages. T h e molecule that is the initiator of the molecular process is D N A , which eventually results in the production of neurotransmitters or ho r mones that continue the process of information transfer within and between cells. T h e process of communication exists even in unicellular organisms, and ‘de-differentiation’of the biochemical process within specialized cells can result in cancer. It is becoming increasingly clear that m e m b r a n e receptors are often expressed in great numbers in cancer cells. T h e next landmark will be to m o v e to the study of intracellular c o m ­ munication systems. Investigators at K yoto University produced an oligonucleotide that would bind to m R N A expressing peripheral benzodiazepin receptors, and labelled with 35S. Using the technique of in situ hybridization, these investigators found that hypoxia induced brain d a m a g e resulted in increased m R N A for these receptors which are k n o w n to be increased in glial cells in response to neuronal damage. T h e next step will be to try to extend these in vitro results to ex vivo studies in which the experimental animals are injected with this oligonucleotide. Developing single photon or positron emitting tracers of m R N A will not be easy because the numbers of binding sites are small and non-specific binding m a y be high. Nevertheless, w e are m o v i n g along this pathway, with m o r e and m o r e studies of small peptide molecules [2, 3] and oligonucleotides. D I S E A S E A S D I S S O N A N C E O n e can easily m o v e from neurosciences to oncology because both can be viewed as communication disorders — disease as dissonance. T h e fact that so m a n y neuroreceptors have been found o n so m a n y different types of neoplasms leads one to view the h u m a n nervous system as having evolved from unicellular organisms to facilitate intercellular molecular communication. Cells b e c o m e cancerous because they do not get the right messages, either because of a deficiency in the D N A transcription process or because of a failure in execution of the instructions. This finding opens up a whole n e w approach to the care of patients with metastatic thyroid carcinoma, s o m e of w h o m m a y have an increase in serum thyroglobulin with no other indication of where the métastasés are located. Hippocrates wrote: “It is disgraceful in every art and m o r e especially in medicine, after m u c h trouble, m u c h display and m u c h talk, to do no goo d after all. C O S T E F F E C T I V E N E S S O n e m a y ask w h o is going to pay for all these expensive studies in this era of cost containment? O n e might also think that there could not have been a worse time to introduce a new, expensive, high-tech procedure into medical practice. Paradoxi­ cally, nothing could be m o r e helpful than studies of cost effectiveness in increasing the use of nuclear medicine procedures. While there is clearly an overcapacity in m u c h of the supply of medical care, there is undercapacity and underutilization of nuclear medicine capacity, which is w h y it has been called the ‘best kept secret in medicine’. For example, one can exchange the cost of the nuclear medicine studies for surgery costs, which are far greater. Operative complications can be reduced by increasing knowledge of the extent of the spread of cancer. O n e can n o w be certain that w h e n the patient is operated upon, he or she will not be found to have lesions that m a k e the surgery fruitless. O v e r 30 0 0 0 thoracotomies are performed where the patients are found to have inoperable lung cancer. Every year, 25 0 0 0 thoracotomies are performed in the U S A for solitary pulmonary nodules that prove to be benign. There w a s a change in stage in 2 6 % of the patients (19/71), s o m e patients going to a higher and s o m e to a lower stage. T h oracotomy w a s avoided in 1 5 % of patients (16/104) with non-small-cell lung cancer. T h e sensitivity w a s 9 4 % , w hich w a s sufficiently high to avoid surgery, w h e n c o m bined with other data such as the appearance of the lesion in the radiograph, and the clinical history and physical examination of the patient. In 15 of 52 patients, they found one or m o r e foci of abnormal 18F D G accumulation beyond the lungs and mediastinal structures. Lasagna wrote: “Often w e d o n ’t k n o w h o w to tailor specific drugs to specific patients very well; w e could do that better and m a k e a qua n t u m j u m p in efficacy without even c o m i n g u p with any n e w drugs. For example, at Johns Hopkins w h e n patients are to have a partial hepatectomy for cancer metastatic to the liver, 25 % are found at surgery to be inoperable for one of the following reasons: (1) Both lobes of the liver w ere involved; (2) l y m p h nodes were involved; or (3) there were peritoneal or other extrahepatic métastasés. Others reported on the cost effectiveness of l8F D G imaging in recurrent colorectal cancer.

La sensibilidad de los estudios ictales es mucho mayor que los interictales purchase nimotop 30 mg without a prescription spasms after gallbladder surgery, llegando en algunas series hasta un 97% para la detección del foco purchase nimotop from india muscle relaxant comparison. The persis­ tence of perfusion defects suggests the presence of an altered underlying physiology effective 30mg nimotop muscle relaxant histamine release. Though cysticercosis and tuberculoma are the most commonly encountered entities responsible for these lesions, in a large number of cases no specific aetiology can be found and the exact cause of ring lesions in these cases remains an enigma. In some cases, these lesions have been found to resolve spontaneously in 4-12 weeks without any specific therapy. Various explanations have been given by different workers to explain these findings. Details of the seizure pattern, the treatment received and any history suggestive of underlying aetiological factors were acquired. The raw data were normalized for uniformity, centre of rotation and gantry motion correction. Trans­ verse slice reconstruction was performed by convolution back projection, with Ramp and Hamming filters, using the conventional software available with the equipment. Three dimensional image reconstruction was performed for better visualization of perfusion defects. Both visual asymmetry and quantitative asymmetries in count density were used to identify perfusion defects. A count difference of more than 10% betweeen the homologous regions of interest, if seen in at least two of the three planes (transaxial, coronal and saggital) and in at least two adjacent slices, was considered significant. It showed an area of hypoperfusion corresponding to the anatomical location of ring lesions. Apart from anticonvulsants, antitubercular treatment was given to two patients suspected of having tuberculosis — in one case, tuberculo­ sis was suspected owing to a history of weight loss and prolonged irregular low grade fever; in the other case, the ring lesion morphology was thought to be suggestive of tuberculosis. In the two cases where repeat scans showed complete resolution of ring lesions, one had received antitubercular treatment, while the second patient did not receive any specific therapy. In many cases these lesions disappear after four to eight weeks, reappearing only in a very small percentage of cases. They could be due to an alteration in the permeability of the blood brain barrier. In a ring lesion, cysticercosis is the most common aetiology and often the lesions are multiple. This observation indicates that even after the ring lesion disappears, that area continues to remain physiologically abnormal. A corol­ lary to this observation is that if anti-epileptic drugs are withdrawn soon after disap­ pearance of the ring lesion, there may be a recurrence of seizures. Increased regional cerebral blood flow was demonstrated in eight cases and was in agreement with the side selected for surgery in all of them. Another two cases demonstrated hypoperfusion of the temporal lobe extending to the adjacent cortical area in the side corresponding to the eventual site of surgery. Accurate pre-operative localization of seizure origin is essential to obtain complete or nearly complete control of seizures. The patients had been seizure free for at least 24 h, except in seven cases where the seizures were too frequent (seizure free for 4-20 h, with a mean time of 10 h). The patients were all closely observed for 10 min after tracer administration with no evidence of seizure during this time. The mean delay from seizure end to injection of the tracer was 86 ± 19 s (range 0-400 s). Sixty-four images were acquired with an acquisition time of 30 s per frame and an average of 70 000 counts per frame on a 64 x 64 matrix. Transaxial images were primarily obtained parallel to the long axis of the temporal lobe. The analysis was qualitative and an area was reported as abnormal if the increase or decrease of the tracer uptake was observed in at least two adjacent slices in comparison with the opposite temporal lobe. In two of them, lateralization differed from that obtained by the other methods and eventually the side of surgery. In two patients the hypoperfusion extended to the adjacent cortical areas, and in one case there was a contralateral cerebellar hypoper­ fusion. Another two cases demonstrated hypoperfusion of the temporal lobe extending to the adjacent cortical area, which corresponded to the eventual side of surgery (delay from seizure to injection was 70 and 400 s). Interictal hypoperfusion and ictal hyperperfusion in the temporal lobe corresponding to the eventual site of surgery was observed in six patients. In one of them, the interictal temporal hypoperfusion was associated with decreased ipsilateral parietal perfusion. The positive predictive value of combined ictal hyperperfusion and interictal hypoperfusion was 6/6 (100%). Ictal study reveals a markedly increased perfusion of the entire left temporal lobe. Ten patients were seizure free, four had nearly complete control of the seizure frequency (greater than 90% reduction in seizure frequency) and four had occasional simple partial seizures. For the successful excision of the epileptogenic focus, it is essential to obtain accurate pre-operative localization. It is therefore important to develop accurate, non-invasive methods of seizure focus localization. The reasons for these wide discrepancies may include the different popula­ tions of patients studied, the radiopharmaceutical used and the spatial resolution of the acquisition system. The degree of hypoperfusion seems to correlate inversely with the age of seizure onset [9]. When the tracer is administered in the post-ictal period, the sensitivity is lower, but seems to be higher than for interictal scans [9]. Consequently, better localization is obtained with ictal than with post-ictal studies and its sensitivity decreases with the time lag between seizure end and tracer injection [15]. During the seizure, it shows hyper- perfusion of the whole temporal lobe, up to 2 min post-ictally mesial hyperperfusion associated with ipsilateral lateral temporal lobe hypoperfusion, and hypoperfusion of the whole temporal lobe for the first few minutes after seizure onset [15]. Interictal hypoperfusion represents an area of dysfunction which may or may not be epileptogenic. However, when there is ictal hyperperfusion in the same focal area, it is highly suggestive of a seizure focus [15, 16]. It consists of two stages: initially it performs rotational and centring corrections in the coronal and transverse planes by maximizing two indices of bilateral hemispheric sym­ metry, and later it performs rotational correction in the sagittal plane from the automatic determination of the inclination angle of images in the sagittal plane. This is computed performing a line fit of the set of points of a curve that was defined by the inferior border of the encephalous in the image of the total sum of the sagittal planes. Using this value, and determining the orbito-meatal (O-M) position by a previous calibration study, the rotational correction in the sagittal plane is performed. In order to evaluate the algorithm, 20 patients were studied and a set of simulated symmetrical brain images with single and multiple lesions (software phantom) were examined. The relationship between the inclination angle of the volume and the O-M plane, computed in the calibration study, had a value of -8.

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Its mortality rate may be as high as 40% due to metastatic infection discount nimotop 30 mg otc muscle relaxant for migraine, severe valvular damage cheap 30mg nimotop fast delivery muscle relaxant lodine, and congestive heart failure buy discount nimotop 30 mg online muscle relaxant side effects. The silaic acid component of its capsule is a major virulence factor that inhibits the activation of the alternative complement pathway (14–16, 16a). Its connection with chronic liver disease has been more recently appreciated (21) Most isolates are quite sensitive to penicillin (22). The teichoic acid component of the cell wall facilitates its attachment to the nasal mucosa from which it may set up a “beachhead” on the skin of the patient. Any break in the dermis promotes the entry for the staphylococcus into the microcirculation. Most notable among these are fibronectin-binding proteins and various clumping factors. Staphylococci may remain dormant within the endothelial Infective Endocarditis and Its Mimics in Critical Care 221 cells but are eventually released back into the circulation. Once this pathogen is in the bloodstream, it makes effective use of its unique abilities to invade the endothelium and propagate the platelet fibrin thrombus (27–30). It resides on the skin of both the healthy and the ill as well as being colonizer of the nares. Among these are protein A; catalase; alpha, beta, and gamma toxins; leukocidins and its capsule. Upon the death of the white cell, the viable staphylococci are deposited into the surrounding tissue or return to the intravascular space. It also possesses a superb ability to infect prosthetic devices of all kinds including intravascular devices/catheters by means of its production of the glycocalix biofilm. This environment protects the organisms from the host’s defenses as well as from most antimicrobial agents (32). It is quite difficult for the clinical laboratory to differentiate them from other coagulase-negative organisms. Pseudomonas aeruginosa adheres to the endothelium the most effectively of any of the gram-negative rods. It elaborates several virulence factors, extracellular proteases, elastase alkaline proteases. These produce necrosis in a range of tissues especially in the elastic layer of the lamina propria of all caliber is the blood vessels. These toxins also disrupt the function of polymorphonuclear leukocytes, K- and T-cells, as well as the structure of complement and immunoglobulins. Exotoxin A disrupts protein synthesis and is the factor that is best correlated with systemic toxicity and mortality. Its polysaccharide capsule interferes with phagocytosis and the antibacterial effect of the aminoglycosides (35,36). These are genetically unrelated gram-negative bacilli/cocobacilli that share the oropharynx as the primary site of residence. They usually produce subacute disease that is notable for its massive arterial emboli (40). Most often, these infections are ventilator or intravascular catheter associated (43). What makes their treatment so difficult is the multiplicity of their defensive mechanisms that make them resistant to many classes of antibiotics. Risk factors for its development include exposure to broad-spectrum antibiotics and to cytotoxic agents (46). They enter the bloodstream from the injection site directly or from contamination of the drug paraphernalia (38). This rate may be higher in some areas in the world in which hard to grow organisms, such as Coxiella burnetti, are fairly common. The reason for so doing is well expressed by Friedland, “nosocomial endocarditis occurs in a definable subpopulation of hospitalized patients and is potentially preventable. It is defined as a valvular infection that presents either 48 hours after an individual has been hospitalized or one that is associated with a health-care facility procedure that has been performed within four weeks of the development of symptoms. The typical patient is older with a higher rate of underlying valvular abnormalities. The ever-expanding field of cardiovascular surgery and the increasing employment of various intravascular devices accounting great deal for this phenomenon. In a study of patients in the 1990s, the mean age was 50 with 35% more than 60 years of age. Individuals with congenital heart disease are living longer and frequently require heart surgery (4). In addition, rheumatic heart disease has essentially disappeared from the developed world. Change in the underlying valvular pathology: rheumatic heart disease <20% of cases b. The incidence ratio of men to women ranges up to 9/1 at 50 to 60 years of age (68). Although there are many types of valvular infections, they all share a common developmental pathway. Leukocytes adhere more readily to it and platelets become more reactive when in contact with it. As the infection progressed, the adherent bacteria were covered by successive layers of deposit fibrin. Within the thrombus, there is a tremendous concentration of organisms 9 (10 colony forming units per gram of tissue) (75). The endocardium of this area may be damaged by the force of the jet of blood hitting it (Mac Callums patch) (77). Bacterial infection of intravascular catheters depends on the response of the host to the presence of the foreign body, the pathogenic properties of the organisms, and the site of Table 5 Risk of Bacteremia Associated with Various Procedures Low (0%–20%) Moderate (20%–40%) High (40%–100%) Organism Tonsillectomy Bronchoscopy (rigid) Bronchoscopy (flexible) Streptococcal sp. Within a few days of its placement, a sleeve of biofilmconsisting of fibrin and fibronectin, along with platelets, albumin, and fibrinogen is deposited on the extraluminal surface of the catheter. This composite biofilm protects the pathogens from the host antibodies and white cells as well as administered antibiotics (86). For catheters that are left in place for less than nine days, contamination of the intracutaneous tracts by the patient’s skin flora is the most common source of infection (87). The bacteria migrate all the way from the insertion point to the tip of the catheter. It is the bacterial flora of health care workers hands that contaminate the hubs of the intravascular catheters as they go about their tasks of connecting infusate solutions or various types of measuring devices. The bacteria then migrate down the luminal wall and adhere to the biofilm and/or enter the bloodstream. For long-term catheters (those in place for more than 100 days), the concentration of bacteria that live within the biofilm of the luminal wall of the catheter is twice that of the exterior surface (88). Gram-negative aerobes such as Enterobacter, Pseudomonas, and Serratia species are the most likely to be involved because they are able to grow rapidly at room temperature in a variety of solutions. Because of its hypertonic nature, the solutions of total parenteral nutrition are bactericidal to most microorganisms except Candida spp. A wide variety of infused products may be contaminated during their manufacture (intrinsic contamination).

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Using this machine during the day and at particular risk of becoming infected with C buy online nimotop muscle relaxant 24. It causes diarrhea buy nimotop 30mg online infantile spasms 8 months, abdominal pain order nimotop from india muscle relaxant pakistan, severe inflamma- can have many causes, including infections (yeast, tion of the colon (colitis), fever, an elevated white bacterial, or viral), friction irritation, chemical blood cell count, vomiting, and dehydration. In allergies (perfumes, soaps), sweat, decomposed severely affected patients, the inner lining of the urine, and plugged sweat glands. Most diaper rash colon becomes severely inflamed (pseudomembra- problems can be solved by cleansing the skin with nous colitis). Rarely, the walls of the colon wear nonperfumed, gentle products; changing diapers away and holes develop (colon perforation), which frequently; and exposing the affected skin area to can lead to a life-threatening infection of the air. Treatment diaphragm 1 The muscle that separates the chest includes frequent administration of fluids to prevent (thoracic) cavity from the abdomen. Contraction of dehydration, rest, good nutrition, and in some cases the diaphragm helps to expand the lungs when one medication. See also birth diarrhea, travelers’ Illness, including diarrhea, control; contraceptive. Causes include viruses and the bacterium diaphragm pacing A procedure to help patients Escherichia coli, which may be transmitted via food with spinal cord injuries to breathe. Prevention involves drinking bottled water; is helped by setting the respiratory rate by electrical filtering tap water or, if camping, water from natural stimulation (pacing) of the phrenic nerve using sources; washing fruits and vegetables purchased in electrodes surgically implanted into the diaphragm local markets with a solution of water and a few muscle that is innervated by the nerve. There are many infec- diastolic Referring to the time when the heart is tious and noninfectious causes of diarrhea. Diastolic pressure is the cervix, and uterus and of having tubal (ectopic) minimum arterial pressure during relaxation and pregnancies, infertility, miscarriages, or premature dilation of the ventricles of the heart when the ven- births. In a blood pressure reading, posed to abnormalities of the testicles, such as the diastolic pressure is typically the second num- abnormally small testes and failure of the testes to ber recorded. For example, in a blood pressure descend into the scrotum; these abnormalities reading of 120/80 (“120 over 80”), the diastolic increase the risk of testicular cancer. A diastolic murmur is a heart murmur birth should inform their physicians of their expo- heard during diastole. For example, hemorrhagic diathesis dietitian A person trained in the design and man- means a tendency to bleed. A specific diet can be pre- against the probability of other diseases that might scribed for medical reasons according to a certain account for a patient’s illness. For examples, specific ferential diagnosis of a runny nose includes allergic diets are commonly prescribed for persons affected rhinitis (hay fever), the abuse of nasal deconges- by hypoglycemia, gout, celiac disease, dermatitis tants, and the common cold. Cells early in devel- opment have the potential to develop into many dif- dietary supplement A substance that can be ferent types of tissues of the body. Differentiation added to the diet, usually in pill, liquid, or powder occurs so the specific body tissues can form. Dietary supple- developed into a specific cell type, the cell has lost ments range from natural weight-gain concoctions its ability to differentiate into a cell for a different tis- used by body-builders, to joint pain relievers, vita- sue. Many dietary supplements are harmless Differentiated tumor cells resemble normal cells when taken as directed, and the health benefits of and tend to grow and spread at a slower rate than some have been substantiated. Dietary supplements undifferentiated or poorly differentiated tumor can interact with prescription medications, and cells, which lack the structure and function of nor- some are not suitable for people with certain med- mal cells and grow uncontrollably. They are also at increased characterized by low blood calcium because of risk of having anatomic abnormalities of the vagina, underdevelopment of the parathyroid glands http://www. The the amount of widening can be described in terms key gene that is lost is Tbx-1. Tbx-1 is a master con- of the number of fingers that could fit in the cervi- trol gene that regulates other genes required for the cal opening, or it is described in centimeters. Also known as hypoplasia of the dilation, pupil 1 A type of eye examination that thymus and parathyroids and as third and fourth enables an eye-care professional to see more of the pharyngeal pouch syndrome. Dilating the pupil permits the retina to be digestive system The system of organs responsi- examined for signs of disease. To dilate the pupil, ble for getting food into and out of the body and for drops are placed into the eye. The digestive sys- tem’s organs are joined in a long, twisting tube from dilation and curettage A minor operation in the mouth to the anus. Inside this tube is a lining which the cervix is expanded (dilatated) enough to called the mucosa. In the mouth, stomach, and small permit the cervical canal and uterine lining to be intestine, the mucosa contains tiny glands that pro- scraped with a spoon-shaped instrument called a duce juices to help digest food. D & C is liver and the pancreas (both of which are embry- normally used to remove abnormal material from ologically derived from the digestive tract), produce the uterus, such as unexpelled placental material digestive juices that reach the intestine through small after birth. In addition, parts of other organ systems (for instance, nerves and blood) play dilator A device used to stretch or enlarge an a major role in the digestive system. Patients with scarring of the esophagus can require a dilator procedure to open the esoph- digit A finger or toe. It is caused by digital rectal exam A routine exam in which a the bacteria Corynebacterium diphtheriae. The diploid The number of chromosomes in most Scottish physician William Withering discovered this cells of the body. Digitalis, its com- which is twice the haploid number of 23 chromo- ponents, and their derivatives have long been used somes contained in human eggs (ova) and sperm. Recommended disaster supplies items include mess kits (or paper cups, include the following: plates, and plastic utensils), an emer- gency-preparedness manual, a battery- • Water. Store at least 3 gallons of water operated radio with extra batteries, a per person (2 quarts for drinking, 2 flashlight with extra batteries, cash or trav- quarts for food preparation/sanitation × eler’s checks, change, a nonelectric can three days). Store it in plastic containers, opener, a utility knife, a small canister fire such as soft drink bottles. Store at least a 3-day supply of pliers, tape, a compass, matches in a foods that require no refrigeration, prepa- waterproof container, aluminum foil, plas- ration, or cooking (and little or no tic storage containers, a signal flare, paper water). If you must heat food, go to a and pencil, needles and thread, a shut-off camping goods store for options that do wrench for turning off household gas and not require electricity or natural gas. A meats, fruits, and vegetables; canned map showing the precise location of local juices, milk, and soup (if powdered, store shelters may be available in advance from extra water); staples, particularly sugar, your local emergency-preparedness office. Have on hand an adequate as peanut butter, granola bars, and trail supply of toilet paper and/or towelettes, mix; vitamin pills; special foods for soap, liquid detergent, feminine supplies, infants, elderly persons, or persons on personal hygiene items, plastic garbage special diets; and “comfort foods” such bags with ties for personal sanitation as cookies, hard candy, sweetened cere- uses, a plastic bucket with a tight lid, dis- als, lollipops, instant coffee, and tea. A first least one complete change of clothing aid kit should include sterile adhesive and footwear per person, preferably bandages in assorted sizes, four to six 2- items that are easy to clean. Depending inch sterile gauze pads, four to six 4-inch on your location, you may also need to sterile gauze pads, hypoallergenic adhe- include sturdy shoes or work boots, hats sive tape, three triangular bandages, and gloves, coats and/or rain gear, ther- three rolls of 2-inch sterile roller band- mal underwear, blankets or sleeping ages, three rolls of 3-inch sterile roller bags, and sunglasses. Remember family members and/or liquid), thermometer, two tongue with special needs, such as infants and depressors, a tube of petroleum jelly or elderly or disabled persons. For babies, other lubricant, assorted sizes of safety store an adequate supply of formula, dia- pins, cleansing agent and/or soap, a pers, bottles, powdered milk, and med- medicine dropper, two pairs of latex ications.

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