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By: Q. Kor-Shach, M.A., Ph.D.

Professor, Duke University School of Medicine

Definition: Surfactant is a mixture of phospholipids that reduces surface tension and counteracts the tendency for alveoli to collapse allergy medicine philippines purchase nasonex nasal spray 18gm without prescription. Hyperglycemia in the mother causes fetal hyperglycemia that in turn causes increased insulin release allergy symptoms plugged ears generic 18 gm nasonex nasal spray with amex. The interstitium contains a few fibroblasts and scattered lymphocytes and macrophages allergy shots heart palpitations buy nasonex nasal spray 18 gm lowest price. Some macrophages, called alveolar macrophages, are also normally found inside the alveoli. Some of the dilated respiratory bronchioles and alveolar ducts are lined with a fibrin-rich membrane (hyaline membrane) (arrow). Note the fine, uniform granularity distributed throughout both lungs ("ground glass" appearance). Lack of the normal stress-induced increase in cortisol that is normally present in a vaginal delivery. Membranes are derived from proteins leaking out of damaged pulmonary capillary vessels. This may result in blindness and permanent damage to the small airways (bronchopulmonary dysplasia; Link 17-21). Microscopic section of lung tissue showing prominent hyaline membranes (eosinophilic exudate composed of fibrin and cellular debris) lining alveolar spaces. Adjacent alveolar tissue shows interstitial fibroblast proliferation with beginning synthesis of collagen. Definition: Accumulation of fluid in the alveoli of the lungs; results in poor alveolar gas exchange and breathing difficulties, making it difficult to breath (dyspnea) and exchange oxygen in the alveoli 2. Edema fluid in the alveoli has a pink discoloration; no inflammatory cells are present (Link 17-22). Edema may also be due to microvascular or alveolar injury (exudate) caused by: (1) infections. Definition: Noncardiogenic pulmonary edema resulting from acute alveolar-capillary damage. Insulin in newborns from fetal hyperglycemia fetal hypoglycemia post delivery Give newborn glucose! This histologic section shows lung alveoli filled with pink-stained edema fluid (F). This type of edema is a transudate that is low in protein and without inflammatory cells. Progression of respiratory distress to respiratory failure is faster than in adults. Important signs to recognize in respiratory failure include increased respiratory rate (tachypnea) with distress (nasal flaring, grunting, intercostal muscle retraction, seesaw breathing) and cyanosis despite supplementary oxygen. Crystal violet iodine complex: stains both gram-positive and -negative cell walls 2. Removes lipid from gram-negative bacteria, thereby losing the dye in the decolorization process b. Definition: Inflammation of the pulmonary parenchyma that is usually caused by either a bacterial or viral infection.

Male-dominant disorder; the diagnosis is usually made in the fifth decade of life allergy testing minneapolis buy nasonex nasal spray 18 gm fast delivery. In women allergy symptoms versus sinus infection buy nasonex nasal spray us, the diagnosis is usually made 10 to 20 years after menopause because the loss of iron during menses helps rid the body of excess iron during the reproductive period of life allergy forecast rapid city sd buy nasonex nasal spray amex. Ifthereismoretransferrinboundironthatbindstothereceptor(indicatingincreasedironstores),thenthereisincreasedliversynthesisandreleaseof hepcidin, and less iron is reabsorbed by the duodenum. Hepcidin unrestricted iron reabsorption by duodenum Liver target organ; pancreas, heart, joints, pituitary, adrenals, testes (4) Iron deposits in multiple organs, including the liver (target organ), pancreas, heart, joints, skin, pituitary, adrenals and testes. Loss of libido (desire for sex) in men is caused by decreased testosterone (T) levels (50% of cases). Liver disease progresses from acute hepatitis to cirrhosis and portal hypertension. A defect in this protein leads to: (a) defective hepatocyte transport of copper into bile for excretion. Note the hooklike osteophytes (arrows; bone projections) of the second and third metacarpophalangeal joints. Hemosiderin, demonstrated in this slide of a liver biopsy specimen as bluish pigment resulting from the Prussian blue reaction, is seen in the form of granules in liver cells and Kupffer cells. The gene defect in Wilson disease affects a copper transport system that produces a dual defect: decreased incorporation of copper into ceruloplasmin in the liver (ceruloplasminisdecreased)anddecreasedexcretionofcopperintobile(intrahepaticcopperisincreased). In a few years, unbound copper is released from the liver into the circulation(increasedinbloodandurine),whereitdamagesthebrain,kidneys,cornea,andothertissues. If the ceruloplasmin is decreased or the 24-hour urine copper is increased, then a liver biopsy is performed for histology and quantitative copper determination in the tissue to secure the diagnosis. Usually the concentration is >250 mcg/g (dry weight) but may be as high as 3000 mcg/g. By 15 years of age, more than 50% of patients have clinical manifestations of the disease. If deficient in the lungs, emphysema may occur because of a progressive loss of elastic tissue within the airways. If deficient in the liver, aggregates of defective protein are found leading to cirrhosis. Presents as neonatal hepatitis with intrahepatic cholestasis (see previous discussion of neonatal hepatitis) d. Enzymes are not markedly increased because of the loss of liver parenchymal cells that normally synthesize the enzymes. Definition: Localized non-neoplastic hyperplastic overgrowth of hepatocytes around a vascular anomaly, usually an arterial malformation 2. Poorly encapsulated nodule with a central depressed stellate scar that contains large blood vessels (Link 19-66) b. Definition: Benign tumor of the liver composed of a proliferation of widely dilated blood vessels. Definition: Benign hormone-induced liver tumor that has a predilection to hemorrhage into the peritoneal cavity b. Primary cancers of colon or rectum are the most common cancers, followed by the lung and breast cancer. Present as multiple nodular masses in the liver by physical exam or imaging studies 2. Note the sharply circumscribed yellow nodular mass that is lighter than the liver. The central stellate scar is very characteristic (arrow) as well as the radiating fibrous septae to the periphery of the nodule.

Definition: Result of weakening of the wall of the abdominal aorta allergy dermatitis purchase nasonex nasal spray 18gm on-line, leading to localized dilation of the aorta from increased wall stress 2 allergy shots gerd discount nasonex nasal spray online. Usually located below the renal artery orifices (no vasa vasorum in abdominal aorta; see following) 3 allergy shots unitedhealthcare buy nasonex nasal spray cheap online. This renders the aorta susceptible to endothelial injury and atherosclerosis with eventual weakening of the vessel. Portions of the atherosclerotic plaques may break off the aneurysm and embolize to the distal extremities. This may produce the "blue toe syndrome" from decreased blood flow and cyanosis of the overlying tissue. Endovascular repair is the usual treatment rather than surgical removal of the aneurysm. In an aortic dissection, blood enters the media of the vessel and "splits" the aortic wall under pressure. It is likely that this patient had signs and symptoms of peripheral vascular disease. Most common peripheral artery aneurysm; presents as a pulsatile mass behind the knee D. Definition: Aneurysm that is secondary to weakening of the vessel wall due to an infection (fungal or bacterial) 2. Fungi that commonly invade vessels and weaken them include Aspergillus, Candida, and Mucor. Bacteria that invade vessels and weaken them include Bacteroides fragilis, Pseudomonas aeruginosa, and Salmonella species. Definition: Saccular dilatation of a cerebral artery that is typically located at the base of the brain around the circle of Willis 2. Most common site of a berry aneurysm is at the junction of the communicating branches with the anterior cerebral artery. At the junction of the communicating branches with the main cerebral vessels, the vessel normally lacks an internal elastic lamina and smooth muscle. Rupture of the aneurysm releases blood into the subarachnoid space and/or into the brain parenchyma. Severe nuchal (neck) rigidity from irritation of the meninges Vascular Disorders 10-9: Syphilitic aortitis. Note the dilated aortic valve root and the irregular intimal wrinkling ("tree barking") due to scarring in the wall of the aorta from inflammation and repair of the vasa vasorum. This may produce hydrocephalus from blockage of foramina in the ventricles by blood. Definition: Complication of tertiary syphilis due to the spirochete Treponema pallidum 2. Pathogenesis (1) Treponema pallidum infects the vasa vasorum of the ascending and transverse portions of aortic arch. Plasma cell infiltrates are characteristic in all three stages of syphilis (primary, secondary, and tertiary). Involved areas of the aorta show irregular intimal wrinkling ("tree barking") due to scarring in the wall of the aorta from inflammation and repair of the vasa vasorum. Theincreaseinleftventricularend-diastolicvolumeresultsin an increase in stroke volume (increased systolic pressure). Blood rapidly draining back into the left ventricle decreases the diastolic pressure and also produces an early diastolic heart murmur right after the second heart sound (discussed in Chapter 11). An increase in the systolic pressure along with a decrease in the diastolic blood pressure produces a wide pulse pressure (difference between the systolic and diastolic pressure). Linear calcifications (dystrophic calcification) are usually seen in the aortic wall on a plain radiograph.

It is closed slightly before the tricuspid valve by the ventricular contraction the closure contributes to the first (lubb) heart sound allergy treatment side effects nasonex nasal spray 18gm on line. First (lubb) heart sounds is caused by the closure of the mitral and tricuspid valves (M1T1) at the onset of ventricular systole allergy medicine irritability buy nasonex nasal spray cheap. Second (dup) heart sound is caused by the closure of the aortic and pulmonary valves (A2P2) at the onset of ventricular diastole allergy medicine makes me pee order nasonex nasal spray 18 gm without prescription. Conduction System Conduction system of the heart is constituted by the specialized cardiac muscle cells that lie immediately beneath the endocardium and carry impulses throughout the cardiac muscle, signaling the heart chambers to contract in the proper sequence. Embryologically it develops at the upper end of crista terminalis (junction between the sinus venosus and the atrium proper). It is crescent-shaped sub-epicardial tissue (having specialized myocardial fibers) with a head, body and tail. It initiates the cardiac impulse, simply because it generates impulses slightly faster than the other areas with pacemaker potential. Its pace maker function is determined by its low maximum diastolic membrane potential and steep phase 4 spontaneous depolarization. Cardiomyocytes, like all muscle cells, have refractory periods following contraction during which additional contractions cannot be triggered; their pacemaker potential is overridden by the sinoatrial or atrioventricular nodes. Atrioventricular node is an oblique, half-oval atrial structure, located within the right side (atrial component) of the muscular atrioventricular septum near the ostium of the coronary sinus. Triangle of Koch: A roughly triangular area on the septal wall of the right atrium, bounded by the septal leaflet of the tricuspid valve inferiorly, the anteromedial margin of the orifice of the coronary sinus as a base, and the tendon of Todaro superiorly. It splits into right and left branches, which descend into the muscular part of the interventricular septum. Both bundle branches terminate in a complex network of intramural Purkinje myocytes to spread out into the ventricular walls. The boundaries are: Septal cusp of tricuspid valve; tendon of Todaro (fibrous skeleton of heart) and coronary sinus opening. It contains specialized cardiac muscle having fastest rate of impulse generation and initiates the cardiac conduction. It also serves as the origin and insertion sites of cardiac myocytes, and forms an electrical "barrier" between the atria and ventricles so that they contract independently. The right and left fibrous rings of heart (annulus fibrosus cordis) surround the atrioventricular and arterial orifices. The right fibrous ring is known as the annulus fibrosus dexter cordis, and the left is known as the annulus fibrosus sinister cordis. Heart (Surface Marking) Heart: the projection of the cardiac borders on the the anterior thoracic wall forms a trapezoid. A overlies the left second costal cartilage; B overlies the right third costal cartilage; C, right sixth costal cartilage; D, zone of location of the cardiac apex (fifth intercostal space). Inferior (acute) border: Runs leftwards from the sixth right costal cartilage to the cardiac apex, located approximately 9 (8. Table 33: Cardiac valves and auscultatory areas Cardiac valves Surface marking (orifice) Pulmonary Horizontal line (2.

It is located nasal (or medial) to the fovea centralis and the posterior pole of the eye allergy to yellow 5 symptoms buy cheap nasonex nasal spray on-line, has no receptors allergy treatment otc purchase nasonex nasal spray us, and is insensitive to light allergy testing for mold cheap nasonex nasal spray online visa. The wall of the eyeball is organized in three separate cocentric layers: an outer supporting fibrous layer, the corneoscleral coat; a middle vascular coat of uvea; and an inner layer consisting of the retina. The photosensitive and nonphotosensitive parts of the neural retina occupy different regions of the eye. The photosensitive part of the retina is found in the posterior part of the eye and terminates anteriorly along the ora serrata. The nonphotosensitive region of the retina is located anterior to the ora serrata and lines the inner aspect of the ciliary body and the posterior surface of the iris. The vitreous body (partially removed) occupies considerable space within the eyeball. Macula lutea, also called as the yellow spot, is the area near the center of the retina on the temporal side of the optic disk for the most distinct vision. It contains the fovea centralis, which is a central depression (foveola) in the macula. The iris is attached at its periphery to the middle of the anterior surface of the ciliary body. Peripheral to this attachment the ciliary body and narrow rim of sclera form the iridocorneal angle. Sinus venosus sclerae (canal of Schlemm) is a circularly running canal within the sclera, lying just behind the junction. Refractive media of the eyeball is constituted by the cornea, aqueous humor, lens, and vitreous body. Cornea has five layers: Corneal epithelium is non-keratinized stratified squamous epithelium. Corneal stroma (substantia propria) makes 90% of the corneal thickness and has regularly arranged collagen (type I) fibers along with sparsely distributed interconnected keratocytes (for repair and maintenance). Corneal endothelium is a simple squamous or low cuboidal epithelium, responsible for regulating fluid and solute transport between the aqueous and corneal stromal compartments. The cells of the endothelium do not regenerate, instead, they stretch to compensate for dead cells which reduces the overall cell density of the endothelium, which may affect fluid regulation. Cornea is supplied by the ophthalmic division of the trigeminal nerve by long & short ciliary nerves. Aqueous humor is formed by the ciliary processes and provides nutrients for the avascular cornea and lens. It passes through the pupil from the posterior chamber (between the iris and the lens) into the anterior chamber (between the cornea and the iris) and is drained into the scleral venous plexus through the canal of Schlemm at the iridocorneal angle. Impaired drainage causes an increased intraocular pressure, leading to atrophy of the retina and blindness. Lens is the transparent avascular biconvex body, 1 cm in diameter and 4 mm thick, placed between the anterior and posterior compartments of the eyeball. It is enclosed in an elastic capsule, held in position by radially arranged zonular fibers (suspensory ligament of the lens), which are attached medially to the lens capsule and laterally to the ciliary processes. It flattens to focus on distant objects by pulling the zonular fibers and gains more convex shape to accommodate the eye for near objects by contracting the ciliary muscle and thus relaxing zonular fibers. These cells are in direct contact with the aqueous humor of the anterior chamber of the eye. Head and Neck Vitreous body is the transparent gel called vitreous humor, which fills the eyeball posterior to the lens (vitreous chamber between the lens and the retina).

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