睿学教育Wisdome Education

Anthony G. Sclar, DMD

• Director, Clinical Research and Postgraduate Dental
• Implant Surgery
• Department of Oral and Maxillofacial Surgery
• Nova Southeastern University College of Dental Medicine
• Fort Lauderdale, Florida
• Chairman, Department of Education
• Sclar Center for Empowered Dental Implant Learning
• Miami, Florida

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So the populations’ • Clinicians receive much of their information from bad habits cannot alone be responsible for the generally industry and thereby from a biased source arteria ethmoidalis anterior purchase carvedilol with a mastercard. One way of achieving this is to ensure that • Sometimes research results are introduced in clinical the professionals are involved in developing the quality practice although the results are not robust and may indicator and feel that they have a degree of ownership hypertension 1 stage cheap carvedilol 25 mg buy. Sometimes robust data are Germany blood pressure medication when pregnant buy carvedilol with amex, for example, quality indicators are increasingly not introduced in clinical practice due to a number of developed together with the production of guidelines by barriers. Reviews need to be written and updated but this is sometimes regarded as a challenge if this task Registries is not fnanced. Some specifc speciality felds are not Good disease registries are a rich and important source recognised, and for these areas the knowing-doing of information and their number should be increased in gap is especially wide. They provide a powerful way to assess the imple • the Internet has changed the relationship between mentation and effectiveness of guidelines and treatment patient and physician due to the information being outcomes. However there remain serious challenges widely available, with most information being of poor surrounding the establishment and use of data from reg quality. In general practice the time is very short istries, centring largely on ethical and legal issues. It is they have been produced by specialists and not by vital that this is further developed so that Europe can a multidisciplinary team including other healthcare become a leading player in the feld of developing the professionals such as nurses, allied health profes tools for the new concept of personalised medicine. In Patient safety and quality handbook many countries economic considerations and cost In some specialities and in some hospitals and countries effectiveness issues need to be taken into account there is an especially strong focus on patient safety and when guidelines are produced. The German • the same criteria for drawing up guidelines are programme for disease management guidelines: evaluation by use not used across Europe. New information internet sites with quality information are available for is arising all the time and a slowly produced guideline patients, i. The use of • Normative guidelines may be impossible to use in international quality criteria of guidelines, described clinical practice. Effort should be made to ensure respect to evidence-based healthcare, using effec that guidelines are comprehensible and unambiguous tive educational methods, such as problem-based to everyone who will use them. Therefore guidelines need should be introduced in the medical curriculum at the to get to clinicians and practitioners in a timely way pre-graduate medical education stage with the goal of – new information is arising all the time and a guide developing a structured career path for health workers line slowly produced can become outdated. Data tions should be made explicit, allowing adaptation bases for professionals should include guidelines and to daily practice in local hospital settings. The Wellcome Trust proposal for a European repository linked to guidelines might be the solution. A data collection and overview of all available guidelines in countries in Europe and 111. Knowledge Implementation in Clinical Practice Key stakeholders Group 1: • Learned societies • Healthcare providers/hospitals: Healthcare professionals, i. Countries that have a strong focus on primary care have better health at lower costs and also greater equality in health112. Rules and rates for referral from primary to secondary care differ among countries. Medical research is, however, only to a modest degree guided by and based on questions relevant for general practice. As a consequence, specialist-driven research results may be diffcult to implement in primary care (see Box: Clinical everyday scenario and Figure 8). Clinical everyday scenario in general practice For the sake of characterising the general practice popu lation quite roughly, a four-category model has been introduced113. Patients have a subjective experience Implementation of medical research of good health or of degrees of bad health, and based on the biomedical approach to humans, doctors are the category of the “truly healthy” is steadily diminish presumed to be objective when distinguishing diseased ing. Biomedical norms and current defnitions tend to from non-diseased persons ure 9). Two causes can be Category 1 (“the truly healthy”) constitutes patients identifed. First, even if people feel healthy, medical tests who both feel healthy and who are also told, by their can identify risk markers for future diseases. Examples are patients with addiction, For the category of the “imagined ill” – comprising chronic pain, or fatigue. But “dysfunctional” medical theory and research approach, of course this model is a construction for the purpose focusing on objectively observable, general, group of conceptualising the problems that occur in a medi based, and fragmented knowledge, ignoring the impact cal approach that mainly focuses on objectivity in the of subjectivity and of personal experience on disease understanding of diseases and illnesses. Patients with organ dysfunction are exposed to an increasing amount of technology. Bucharest: Zeta Books, 2010 Forward Look – Implementation of Medical Research in Clinical Practice | 33 5.

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Comprehensive assessment of patents requires the recogniton that psychiatric problems ofen co occur in patents with medical problems hypertension heart rate generic carvedilol 25 mg overnight delivery. The pur ment 10 buy discount carvedilol 25 mg line, or diagnosis of the skin; the Latin root pose of this chapter is to help you identify these ele cutane is used primarily to describe an anatomical ments in order to construct medical terms correctly sinus arrhythmia 1102 order carvedilol with mastercard. This information is provided here to help avoid confusion and illustrate that there may be two different word roots for a single term. Medical Word Elements 3 Combining Forms Suffixes A combining form is created when a word root is A suffix is a word element placed at the end of a combined with a vowel. The combining vowel has no meaning of its the suffixes are itis (inflammation) and ectomy own, but enables two word elements to be con (excision, removal). In medical terminolo is the basic foundation to which other word gy, a suffix usually describes a pathology (disease elements are added to build a complete medical or abnormality), symptom, surgical or diagnostic word. Many suffixes as word root/vowel (such as gastr/o), as illustrated are derived from Greek or Latin words. Learning combining forms rather than word roots makes pronunciation a little easier because of the terminal vowel. For example, in the table below, the word roots gastr and nephr are difficult to pronounce, whereas their combining forms gastr/o and nephr/o are easier to pronounce. Word Root Vowel Combining Form Meaning erythr/ o erythr/o red gastr/ o gastr/o stomach hepat/ o hepat/o liver immun/ o immun/o immune, immunity, safe nephr/ o nephr/o kidney oste/ o = oste/o bone Table 1-3 Examples of Suffixes This table lists examples of pathological suffixes as well as their phonetic pronunciations. In A prefix is a word element attached to the beginning this case, the suffix itis, which means inflam of a word or word root. When you analyze gastroenteritis Basic Guidelines following the three previous rules, the meaning is: Defining and building medical words are crucial skills in mastering medical terminology. Defining Medical Words Thus, the meaning of gastroenteritis is inflam Here are three basic steps for defining medical mation (of ) stomach (and) intestine. Table 1-4 Examples of Prefixes This table lists examples of prefixes as well as their phonetic pronunciations. Combining Form Middle Suffix gastr/o enter/ itis stomach intestine inflammation (step 2) (step 3) (step 1) Basic Guidelines 5 Building Medical Words Rule #3 There are three basic rules for building medical A combining form links a root to another root to words. This rule holds true even if the next root begins with a vowel, as in osteoarthritis. Rule #1 Keep in mind that the rules for linking multiple roots A word root links a suffix that begins with a to each other are slightly different from the rules for vowel. Also, pronunciation guide Although pronunciations of medical words usually lines can be found on the inside front cover of this follows the same rules that govern pronunciations book and at the end of selected tables. Use them of English words, some medical words may be whenever you need help with pronunciation of difficult to pronounce when first encountered. It is Time to review pronunciations, analysis of word elements, and defining medical terms by completing Learning Activities 1-3, 1-4, and 1-5. Complete each activity and review your answers to evaluate your understand ing of this chapter. Learning Activity 1-1 Understanding Medical Word Elements Fill in the following blanks to complete the sentences correctly. True False Underline the word root in each of following combining forms. When pn is at the beginning of a word, it is pronounced only with the sound of (p, n). When e and es form the final letter or letters of a word, they are commonly pronounced as (combined, separate) syllables. Then analyze each term and write the element that is a prefix in the right-hand column. Correct Answers 10 % Score Learning Activities 11 Learning Activity 1-5 Defining Medical Words the three basic steps for defining medical words are: 1. If you are not certain of a definition, refer to Appendix C, Part 1, of this textbook, which provides an alphabetical list of word elements and their meanings. Write the number for the rule that applies to each listed term as well as a short summary of the rule.

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Epidural haematoma is accumulation of blood between the dura and the skull following fracture of the skull arrhythmia recognition quiz purchase carvedilol from india, most commonly from rupture of middle meningeal artery blood pressure smoothie order carvedilol with a mastercard. The haematoma expands rapidly since accumulating blood is arterial in origin and causes compression of the dura and flattening of underlying gyri blood pressure medication safe for breastfeeding purchase 6.25 mg carvedilol with amex. The patient develops progressive loss of consciousness if haematoma is not drained early. Subdural Haematoma Subdural haematoma is accumulation of blood between the dura and subarachnoid and develops most often from rupture of veins which cross the surface convexities of the cerebral hemispheres. Acute subdural haematoma develops following trauma and consists of clotted blood, often in the frontoparietal region. The serial numbers indicate the frequency of is of venous origin, symptoms appear slowly and may involvement. Chronic subdural haematoma is composed torn and cause multiple intracerebral haemorrhages. Head injury may be accompanied by brain is a membrane composed of granulation tissue. Some degree of axonal damage may also occur but demyelination is the predominant feature. The No significant morphologic change is noticed but more exact cause for demyelination is not known but currently severe concussion may cause diffuse axonal injury viral infection and autoimmunity are implicated in its (discussed below). These common cause of persistent coma or vegetative state conditions have known etiologies such as: genetically following head injury. The underlying cause is sudden determined defects in the myelin metabolism (leucodys angular acceleration or deceleration resulting in widespread trophies), slow virus diseases of oligodendrocytes (pro axonal shearing in the deep white matter of both the gressive multifocal leucoencephalopathy), and exposure to hemispheres. All these entities are Grossly, the changes are minimal to small multiple currently not classified as demyelinating diseases. Contusions and lacerations injured and are associated with considerable inflammatory are the result of direct damage to the brain parenchyma, exudate are included under the term ‘demyelinating particularly cerebral hemispheres, as occurs in the soft diseases’. Multiple or disseminated sclerosis subarachnoid haemorrhage invariably accompanies cerebral 2. Multiple (Disseminated) Sclerosis Microscopically, brain parenchyma at the affected site is haemorrhagic, necrotic and fragmented. The disease presents as recurrent attacks of focal neurologic disorder with predilection for involvement 884 of the spinal cord, optic nerve and brain. The first attack these groups along with the list of diseases included in each usually begins with a single sign or symptom, most group are briefly outlined below without going into the commonly optic neuritis, followed by recovery. As the details of individual diseases for which the interested reader disease becomes more progressive, remissions become may consult pertinent text on neuropathology and neurology. The etiology of multiple sclerosis remains unknown but a role for genetic susceptibility, Degenerative Diseases infectious agent and immunologic mechanism has been Degenerative diseases are disorders of unknown etiology proposed. The identification of these is the presence of many scattered discrete areas of diseases depends upon exclusion of diseases with known demyelination termed plaques. A consider defined, usually bilaterally symmetric areas in the white able proportion of degenerative disorders are genetic in matter. In venules and at the plaque margin where demyelination virtually all cases, the lesions have characteristic bilaterally is occurring. Another striking characteristic of the and presence of reactive astrocytosis with numerous lipid degenerative disorders is that particular anatomic or laden macrophages (microglia) in the plaque. The axons physiologic system of neurons may be selectively affected, in the plaque are generally intact. In old inactive plaques, there is no perivascular inflam Classification of degenerative diseases into individual matory cell infiltrate and nearly total absence of syndromes is based on clinical aspects and anatomic oligodendrocytes. Two of the Gliosis is well-developed but astrocytes are less important examples—Alzheimer’s disease and parkin prominent. Alzheimer’s disease is the most Perivenous Encephalomyelitis common cause of dementia in the elderly. The condition Perivenous encephalomyelitis includes two uncommon occurs after 5th decade of life and its incidence progressively diseases: acute disseminated encephalomyelitis and acute increases with advancing age. Both are monophasic but a few factors are implicated in its etiology which include diseases characterised by perivenous mononuclear positive family history and deposition of Aβ amyloid derived inflammatory cell infiltration. Microscopically, the main features are as under: Acute disseminated encephalomyelitis occurs usually i) Senile neuritic plaque is the most conspicuous lesion and following viral infection (measles, mumps, rubella, consists of focal area which has a central core containing chickenpox), whooping cough or vaccination.

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For example hypertension bradycardia carvedilol 12.5 mg with mastercard, the difference in incidence rates of liver cirrhosis among (a) heavy drinkers and (b) non-drinkers would blood pressure kidney disease order carvedilol 25 mg overnight delivery, in a European country heart attack protocol 25 mg carvedilol buy visa, indicate the rate of cirrhosis due to heavy alcohol consumption as this is by far the most important cause. Risk factor Disease risk Rate/10 000 per year Relative risk Attributable risk Exposed Unexposed Factor A Cancer 1. A good example of the application of this in practice can be seen with the respiratory and cardiovascular consequences of urban air pollution. If the ambient air of a city is polluted, it is very difficult for anyone to avoid exposure (a very high proportion of the population is exposed). From various studies, estimates of the mortality rates among non-smokers is 150 per 100 000/year and among smokers is 317 per 100 000/year. If the adult male population of the country is 20 million, how many deaths could theoretically be prevented if the smoking prevalence among men was reduced to 15 per cent? Much of this discussion is based on paper A: although published in 1981, this paper is worth studying as it illustrates very clearly how conclusions about prevention strategies can be derived from epidemiological principles and research findings. Please now read the excerpt from Rose (1981) (paper A) headed ‘Absolute and Relative Risk’, review Figure 2, and complete Exercise 10. Absolute and Relative Risk Life insurance experts concerned with charging the right premiums taught us that “high risk” meant “high relative risk,” and in this until recently they have been abetted by the epidemiologists. Figure 2(a), taken from life insurance data,1 shows for each of four age groups the relation of blood pressure to the relative risk of death, taking the risk for the whole of each age group as 100. The relative risk is seen to increase with increasing pressure, but the gradient gets a little less steep as age advances. That is perhaps not surprising, because a systolic pressure of 160 mm Hg is common in older men, and we would not expect it to be so unpleasant as at younger ages, when it is rare. In figure 2(b) the same data are shown but with a scale of absolute instead of relative risk. A systolic pressure of 160 mm Hg may be common at these ages, but common does not mean good. From Figure 2(b), the lower chart, estimate (as the actual values of the mortality are not given) the attributable risk of group 5 (systolic blood pressure 160–164) versus group 1 (systolic blood pressure <130), for age 30–39 years (you will need to estimate the difference between mortality rates). Number above each bar represents estimate of attributable deaths per 1000 population per 10 years. Reproduced from Figure 3 of paper A Information in the diagram Figure 3 presents three distinct pieces of information, each of which is highlighted by a box and arrow in Figure 10. First (A), there is a histogram (shaded columns) illustrating the distribution of serum cholesterol levels in the Framingham study: the scale (preva lence per cent) is on the right-hand y-axis, and you will see that the distribution is slightly positively skewed. Second (B), the dashed line rising across the histogram is the incidence (mortality) rate, with the scale on the left-hand y-axis. The rate for the highest category of cholesterol is about twice that of the lowest. Attributable risk When we look at the cases attributable to raised cholesterol (the numbers on top of the histogram) there is an important, and perhaps surprising, finding. These numbers have been obtained by applying the excess (attributable) mortality rates (deaths per 1000 population per 10 years) at each level of cholesterol to the numbers of people with those levels. The implications of these observations for prevention strategies are now becoming apparent, and are discussed further in the next section. The diagram is a schematic summary based on Figure 3 in paper A, and it shows: Frequency Relative risk Mean cholesterol Level indicating high Cholesterol risk distribution Relative risk Cholesterol level Figure 10. In the high-risk approach, individuals with cholesterol levels above a value associated with high risk (‘level indicating high risk’ in Figure 10. These people are represented by the shaded area under the distribution to the right of the cut-off arrow. The population (or mass) approach the population approach is illustrated in Figure 10. Frequency Relative risk Mean Mean after before shift shift Level indicating high risk B A Relative risk Cholesterol Figure 10. From our earlier discus sion in which we found that most cases arise from the majority of the population towards the centre the distribution, this should have a substantial impact on the overall burden of disease. Although this proportion is likely to be reduced somewhat with the population approach, it will not be eliminated. Both strategies are required From this examination of the distribution of risk we can see that neither strategy is sufficient on its own.

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Paradigm the overall effect of the acceptance of a particular gen eral theoretical approach blood pressure monitor amazon carvedilol 25 mg buy cheap, and the influence it has on the scientists’ view of the world blood pressure zyrtec carvedilol 25 mg with mastercard. According to Kuhn prehypertension symptoms discount carvedilol online amex, normal scientific activity is carried out within the terms of the paradigm. Parameter A measurable characteristic or feature that is shared in different populations. Parsimony Economy of explanation of phenomena, especially in for mulating theories. This term implies that the person takes an active role in the research by performing actions or providing information. Pilot study A pre-test of a questionnaire or other type of survey on a small number of cases in order to test the procedures and quality of responses. This is sometimes done by students who copy out chunks of text from publications or the Internet and include it in their writing without any acknowledgement to its source. Population A collective term used to describe the total quantity of cases of the type which are the subject of the study. Positivism An epistemological stance that maintains that all phe nomena, including social, can be analysed using scientific method. Everything can be measured and, if only one knew enough, the causes and effects of all phenomena could be uncovered. Postmodernism A movement that reacts against the all embracing theories of the Modern Movement and insists on the inseparable links between knowledge and power. Primary data Sources from which researchers can gain data by direct, detached observation or measurement of phenomena in the real world, undisturbed by any intermediary interpreter. It is a matter of philosophical debate as to what extent the detachment and undisturbed state are possible or even desirable. Proportional stratified sampling Used when cases in a population fall into distinctly different categories (strata) of a known proportion of that population. Proposition A theoretical statement that indicates a clear direction and scope of a research project. Quantification (of concepts) Measurement techniques used in asso ciation with operational definitions. Quota sampling An attempt to balance the sample by selecting responses from equal numbers of different respondents. This is an unregulated form of sampling as there is no knowledge of whether the respondents are typical of their class. Ratio level of measurement A scale with equal units of meas urement and containing a true zero equal to nought – the total absence of the quantity being measured. Regression A type of statistical analysis that uses simple and multiple predictions to predict Y from X values. Relational statements these impart information about a relationship between two concepts. They form the bedrock of scientific knowledge and explain, predict and provide us with a sense of understanding of our surroundings. Relativism the stance that implies that judgement is principally dependent on the values of the individuals or society and the per spectives from which they make their judgement. No universal cri teria can be ‘rationally’ applied, and an understanding of decisions made by individuals or organizations can only be gained through knowledge of the historical, psychological and social backgrounds of the individuals. Reliability In relation to human perception and intellect, the power of memory and reasoning to organize data and ideas in order to promote understanding. It is usually used to help formulate a research project and is the basis on which specific research questions, hypotheses or statements are based. Sample the small part of a whole (population) selected to show what the whole is like. Sampling error the differences between the random sample and the population from which it has been selected. It is based on observation and testing of the soundness of conclu sions commonly by using the hypothetico-deductive method.

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The program is easy to learn and use arrhythmia beta blocker buy carvedilol 6.25 mg, and courses on Microsoft Excel are frequently arranged prehypertension natural remedies buy 6.25 mg carvedilol free shipping. The program is blood pressure medication side effects fatigue carvedilol 6.25 mg buy online, however, not suitable for advanced statistical analyses, and the graphics program is not ideal. The package is a single unit developed by integrating several computer programs that were originally developed for social science research. The software is user friendly, high in quality, and comes with the appropriate manuals. It is available free of charge and is well suited for most clinical studies. However, specific scientific graphic tools can be purchased separately, such as: Sigmaplot sigmaplot. The program has to be purchased, but a 30-day free trial version can be downloaded from. It is recommended that researchers contact such specialists as early as possible in the planning stage of a study and continue to seek advice from a statistician as the study progresses. It should be discussed and agreed upon in advance whether the statistician is to be a co-author (the Vancouver “rules” on co-authorship must be followed, see Chapter 9), receive payment or be acknowledged in the planned publication(s). This field is rapidly evolving, and specific expertise is offered at the major research institutions. Websites Several websites feature accessible literature and background information regarding statistical methods, as well as various program packages, which include simple rules for calculating the number of patients (experimental animals/ subjects) needed for a study (power calculation): randomization. This is clear from the Helsinki Declaration: "Negative as well as positive results should be published or otherwise made publicly available" (Helsinkideklarasjonen; §36). The Norwegian “Act on medical and health research” (the “Health research act”, “helseforskningsloven”) also requires that the Research Director (“forskningsansvarlig”) and Project Manager (“prosjektleder”) ensure transparency in research by making research results publicly available (§ 39). Publishing scientific results is a significant part of the research process, and in doing so researchers contribute to the common fund of knowledge. The publication of results and methodology is a prerequisite for scientific debate. Publishing enables replication of a study and comparison of results with those of other studies. During the process of writing and summarizing results it is important to bear in mind the context in which the results are to be presented. Some may wish to report the results in a local setting or at an internal meeting only, whereas many researchers will present a poster or oral presentation at international conferences and submit a scientific paper to a medical or health sciences journal. The content of a lecture and the type of presentation will also differ according to whether it is to be a relatively comprehensive lecture in a hospital department setting or a ten-minute presentation at a scientific conference. Follow the guidelines of the journal or the conference organizer at all times, as this will make the paper formatting easier. Reading other papers in the journal is of benefit with respect to becoming familiar with the required format. The Vancouver Convention (“rules”) describes authorship with respect to publication of articles (see section 9. Title the title should indicate the content of the manuscript, attract the attention of the reader and must be in the format of the journal in question. Introduction Describe the background for the study and the scientific question being investigated. This is perhaps the most important part of the paper and will govern how information is presented throughout the remaining part of the article. The aim of the study may be divided it into a primary objective (aim) and secondary aims. Materials and methods these need to be described in sufficient detail for other researchers to be able to replicate the reported findings. Laboratory methods should indicate the coefficient of variation of the applied method. Choice of statistical analysis method should also be indicated; this is often done in a separate paragraph. Many journals restrict the length of the methods section, making it difficult to describe the methods in sufficient detail. In such cases, including supplemental materials might be a way to cover details that do not fit in the manuscript itself; check the “Instructions to authors” to see if this is possible.

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Normalizing symptoms (education that current symptoms are expected and common after 2 pulse pressure compliance buy generic carvedilol 25 mg on line. Reassurance about expected full recovery in the majority of patients within a few days hypertension teaching 25 mg carvedilol order visa, C weeks or months (e) d blood pressure medication makes me pee carvedilol 6.25 mg purchase amex. Techniques to manage stressa Scheduled telephone and/or in-person follow-up should be arranged. The focus of these ses sions should be to provide education regarding symptom management as well as strategies to 2. These sessions should be provided over the initial 12 weeks post-injury as required. Systematic review of multivariable prognostic models for mild traumatic brain injury. Driving after concussion: the acute effect of mild traumatic brain injury on drivers’ hazard perception. Fitness-to-drive after mild traumatic brain injury: mapping the time trajectory of recovery in the acute stages post injury. In search of evidence-based treatment for concussion: characteristics of current clinical trials. Adjusting to persistent post-concussive symptoms following mild traumatic brain injury and subsequent psycho-educational intervention: a qualitative analysis in military personnel. Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans. Randomised, waiting list controlled trial of cognitive-behavioural therapy for persistent postconcussional symptoms after predominantly mild-moderate traumatic brain injury. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Cognitive behavioural therapy and persistent post-concussional symptoms: integrating conceptual issues and practical aspects in treatment. Managing Traumatic Brain Injury: Appropriate Assessment and a Rationale for Using Neurofeedback and Biofeedback to Enhance Recovery in Postconcussion Syndrome. A randomized trial of two treatments for mild traumatic brain injury: 1 year follow-up. Removing barriers to rehabilitation: Theory-based family intervention in community settings after brain injury. Module A: Initial Presentation (>7 Days Post-injury) 1 Sidebar 1: Indicators for Immediate Referral Person injured with head 1. Typical symptoms would be: looking and feeling dazed and uncertain of what is happening, confusion, diffculty thinking clearly or responding appropriately to mental status questions, and being unable to describe events immediately before or after the trauma event. See the memorendum for more information ***Symptoms that may develop withing 30 days post-injury. For a narrative description and guideline recommendations related to this algorithm, please refer to Section 2. While the injury may result in neuropathological changes, the acute clinical signs and reported symptoms largely refect a functional disturbance rather than a structural injury. Accurate diagnosis, management, and return-to-sport decisions are essential at all levels of participation (i. However, there is currently insuffcient evidence that that prescribing complete rest is benefcial for recovery. Therefore, after a brief period of rest during the acute phase (24-48 hours) after injury, patients should be encouraged to become gradually and progressively more active while not increasing symptoms. In fact the term relative rest is more appropriate as patients may partake in activity in the initial stages as long as symptoms do not worsen. A reasonable approach involves the gradual return to daily tasks, school, and light physical activity in a way that does not result in a signifcant exacerbation of symptoms. Vigorous exertion or return to contact sport should be avoided while athletes are recovering. Individualized medical and rehabilitative care will be provided for the athlete and medical clearance is required before the athlete can return-to-sport. Given that the current guideline is not specifc to sport-related injuries, the information and guidance included herein for acute and subacute management is limited. Further, as discussed above, differences exist between the nature of injuries sustained during sport compared with other types of injuries.

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Pi Glc Glc Glc Glc Glc Glc Glc Glc Glc-1 P Pi phosphorylase Glc Glc Glc Glc Glc Glc Glc Glc Glc O Gg Glc-1 P Glc Glc Glc Glc Glc Glc Glc Glc Glc Glc Glc O Gg debranching enzyme H2O Glc Glc Glc Glc Glc Glc Glc Glc Glc Glc Glc Glc O Gg In the liver heart attack 8 trailer order carvedilol 6.25 mg line, which stores glycogen for the benefit of the entire body blood pressure medication urination buy carvedilol 12.5 mg free shipping, the lion’s share of glucose-6-phosphate will be dephosphorylated by glucose-6-phosphatase and then released into the circulation; overall prehypertension remedies order carvedilol without a prescription, this is equivalent to outright hydrolysis. However, muscle uses glycogen largely toward its own energy needs, and therefore glucose-6-phosphate will usually be funneled straight into glycolysis. Then, debranching enzyme takes over and transplants the stub to another free end, where it becomes again a substrate for phosphorylase. However, this reaction leaves behind a single residue attached by a α(1 6)-glycosidic bond. This residue is subsequently released by the same enzyme as free glucose through hydrolysis. Therefore, the energy efficiency of phosphorolysis was advantageous to those early organisms, too. This enzyme catalyzes the same reactions as intestinal amylase and maltase (see slide 1. The lysosomal degradation pathway is important for the disposal of structurally aberrant glycogen particles; additional metabolic roles may exist but are currently not well understood. On the other hand, glucose-6-phosphate will be plentiful when glucose itself is abundant, and therefore signals an opportunity for replenishing the glycogen stores. The activated kinase directly phosphorylates glycogen synthase, which inactivates that enzyme. Protein kinase A 118 8 Glycogen metabolism indirectly stimulates glycogen breakdown by phosphorylation of a dedicated regu latory enzyme, phosphorylase kinase, which in turn phosphorylates glycogen phos phorylase. Note that glycogen synthase and phosphorylase respond in opposite ways to phosphorylation: the synthase is inactivated, whereas the phosphorylase is acti vated. Glucose inhibits the liver enzyme but not the muscle enzyme, and Ca stimu 2+ lates the muscle enzyme but not the liver enzyme. As one would expect from their regulatory differences, the phosphorylases in liver and muscle are different molecules. Enzymes that catalyze the same reaction yet are separate molecules are referred to as isozymes. Although we usually don’t mention it, many other enzymes covered in this text occur as multiple isozymes, too. Liver glycogen is turned over rapidly; it serves as the major reserve of blood glucose during short-term fasts. Once liver glycogen is depleted, muscle glycogen can be drawn down; this, however, requires some roundabout metabolic trickery. The latter is transported to the endoplasmic reticulum, where it is dephosphorylated. However, the dominant glucose phosphorylating enzyme in the liver is glucokinase, which has fairly low affinity for glucose (see slide 3. As discussed above, this usage is facilitated by calcium-mediated activation of glycogen phosphorylase. Under suitable conditions, namely, prolonged fast without physical exercise, muscle glycogen can also contribute to the replenishment of blood glucose. However, even though muscle cells have been shown to express glucose-6-phosphatase [36] 120 8 Glycogen metabolism and thus are, in principle, able to produce free glucose, they should find it difficult to release it. This is because muscle contains hexokinase, which has a much greater substrate affinity than glucokinase and therefore will keep the intracellular level of free glucose well below the extracellular concentration. The net transport of glucose should therefore be directed inward at all times; this agrees with all the physiological evidence that I could find. The way around this obstacle is to convert glucose-6-phosphate to pyruvate and then lactate. At a low rate, lactate formation occurs even in resting muscle and under aerobic conditions. This lactate is derived in various proportions from blood glucose and glycogen, respectively. In animal experiments, epinephrine promotes glycogen utilization and lactate release [37–39], but overall the hormonal control of this process and the magnitude of its contribution to systemic glucose control are not well characterized. The lactate released in peripheral tissues is scooped up by the liver, which converts it back to glucose through gluconeogenesis. This process is known as the Cori cycle, named after its discoverers Carl and Gerti Cori, who worked it out as early as 1929 [40]. Some textbooks state that the Cori cycle resupplies the muscle with glucose in this situation also.

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Following endothelial cell injury prehypertension vitamins purchase generic carvedilol on-line, both haemostatic process and thrombus formation pulse pressure of 80 purchase 25 mg carvedilol with visa. The sequence of events is as under (blood) pathway arrhythmia high blood pressure generic 25 mg carvedilol overnight delivery, the extrinsic (tissue) pathway, and the. The blood is kept in fluid down, the blood cells including platelets marginate to the state normally and coagulation system kept in check by periphery and form a kind of pavement close to endothelium controlling mechanisms. These act on coagulation factors so as allows a higher release of oxygen from the blood, turbulence to oppose the formation of thrombin e. Plasmin, a potent fibrinolytic enzyme, is formed by the action of plasminogen activator on plasminogen present in the normal plasma. The platelets are present in the slow-moving laminar stream adjacent to the central stream while the peripheral stream consists of most slow-moving cell-free plasma close to endothelial layer. The effect of hypercoagulability on Thrombosis may occur in the heart, arteries, veins and the thrombosis is favoured by advancing age, smoking, use of capillaries. Hypercoagulability may formation at these sites, the clinical effects of these are even occur by the following changes in the composition of blood: more different. Arterial A number of primary (genetic) and secondary (acquired) factors favour thrombosis. Mixed or laminated Primary (Genetic) factors: thrombi are also common and consist of alternate white i) Deficiency of antithrombin and red layers called lines of Zahn. Red thrombi are soft, ii) Deficiency of protein C or S red and gelatinous whereas white thrombi are firm and iii) Defects in fibrinolysis iv) Mutation in factor V pale. Microscopically, the composition of thrombus is deter Secondary (acquired) factors: mined by the rate of flow of blood i. The lines of Zahn are formed by ii) Prolonged bed-rest iii) Immobilisation alternate layers of light-staining aggregated platelets iv) Cigarette smoking admixed with fibrin meshwork and dark-staining layer of red cells. Red (venous) thrombi have more abundant b) Clinical conditions predisposing to thrombosis: red cells, leucocytes and platelets entrapped in fibrin i) Heart diseases (e. Thus, red thrombi closely resemble blood clots rheumatic mitral stenosis, cardiomyopathy) ii) Vascular diseases (e. The thrombus is adherent to the arterial wall and is seen occluding most of the lumen. It shows lines of Zahn composed of granular-looking platelets and fibrin meshwork with entangled red cells and leucocytes. Relation to vessel wall Adherent to the vessel wall Weakly attached to the vessel wall 3. Shape May or may not fit their vascular contours Take the shape of vessel or its bifurcation 4. Microscopy the surface contains apparent lines of Zahn the surface is ‘chicken fat’ yellow covering the underlying red ‘currant jelly’ Origin of Thrombi v) Superior vena cava: infections in head and neck. Thrombi may arise from the heart, arteries, veins or in vi) Inferior vena cava: extension of thrombus from hepatic vein. They are more Distinguishing features between thrombi formed in common in the atrial appendages, especially of the right rapidly-flowing arterial circulation and slow-moving venous atrium, and on mitral and aortic valves called vegetations blood are given in Table 5. Cardiac thrombi are of packed red cells are formed in the capillaries in acute mural (non-occlusive) as are the mural thrombi encountered inflammatory lesions, vasculitis and in disseminated in the aorta in atherosclerosis and in aneurysmal dilatations. Rarely, large round thrombus may form and obstruct the mitral valve and is called ball-valve thrombus. Agonal thrombi Fate of Thrombus are formed shortly before death and may occur in either or the possible fate of thrombi can be as under. The examples of system with consequent release of plasmin which may major forms of vascular thrombi are as under: dissolve the thrombus completely resulting in resolution. Arterial thrombi: Usually, lysis is complete in small venous thrombi while large i) Aorta: aneurysms, arteritis. Phagocytic cells (neutrophils and vi) Cerebral artery: atherosclerosis, vasculitis. The proteolytic enzymes liberated by leucocytes i) Veins of lower limbs: deep veins of legs, varicose veins.

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Paracortical lymphoid hyperplasia is due to hyper plasia of T-cell-dependent area of the lymph node blood pressure medication pril carvedilol 25 mg purchase free shipping. Sinus histiocytosis with massive lymphadenopathy is characterised by marked enlargement of lymph nodes blood pressure medication without food purchase 12.5 mg carvedilol otc, Amongst the important causes are immunologic reactions especially of the neck arrhythmia that makes you cough order 25 mg carvedilol free shipping, in young adolescents. Its lymphadenopathy with fever and leucocytosis and histologic features are: usually runs a benign and self-limiting course. In the early stage marked follicular hyperplasia is the paracortical hyperplasia only, and there is proliferation dominant finding and reflects the polyclonal of blood vessels. However, Dermatopathic lymphadenopathy occurs in lymph node adenopathic form of Kaposi’s sarcoma too may develop draining an area of skin lesion. In the last stage, there is decrease in the lymph node within the macrophages in the lymph node. Microscopic findings of node at this stage enter extravascular tissues where they perform their main 345 reveal follicular involution and lymphocyte depletion. The myeloblast is the earliest the leucocytes of the peripheral blood are of 2 main varieties, recognisable precursor of the granulocytes, normally distinguished by the presence or absence of granules: comprising about 2% of the total marrow cells. The granulocytes, blast varies considerably in size (10-18 μm in diameter), according to the appearance of nuclei, are subdivided into having a large round to oval nucleus nearly filling the cell, polymorphonuclear leucocytes and monocytes. Further, has fine nuclear chromatin and contains 2-5 well-defined pale depending upon the colour of granules, polymorphonuclear nucleoli. The thin rim of cytoplasm is deeply basophilic and leucocytes are of 3 types: neutrophils, eosinophils and devoid of granules. As the cells All forms of granulocytes are produced in the bone marrow become mature lysosomal granules appear; firstly non and are termed,‘myeloid series’. Myeloid series include specific primary or azurophilic granules appear which are maturing stages: myeloblast (most primitive precursor), followed by specific or secondary granules that differentiate promyelocyte, myelocyte, metamyelocyte, band forms and the neutrophils, eosinophils and basophils. It possesses a round and segmented granulocytes) make up a ‘mature or post to oval nucleus, having fine nuclear chromatin which is mitotic pool’. It takes about 12 days for formation of mature slightly condensed around the nuclear membrane. Normally the bone nucleoli are present but are less prominent and fewer than marrow contains more myeloid cells than the erythroid cells those in the myeloblast. The main distinction of promyelocyte in the ratio of 2:1 to 15:1 (average 3:1), the largest proportion from myeloblast is in the cytoplasm which contains being that of metamyelocytes, band forms and segmented azurophilic (primary or non-specific) granules. The myelocyte is the stage in which Normally, the bone marrow storage compartment specific or secondary granules appear in the cytoplasm, and contains about 10-15 times the number of granulocytes found accordingly, the cell can be identified at this stage as in the peripheral blood. Following their release from the bone belonging to the neutrophilic, eosinophilic or basophilic marrow, granulocytes spend about 10 hours in the circulation myelocyte. Primary granules also persist at this stage but before they move into the tissues, where they perform their formation of new primary granules stops. The blood pool of granulocytes consists myelocyte is eccentric, round to oval, having somewhat of 2 components of about equal size—the circulating pool that coarse nuclear chromatin and no visible nucleoli. The is included in the blood count, and the marginating pool that myeloid cells up to the myelocyte stage continue to divide is not included in the blood count. The metamyelocyte stage is 10-18 compartments of granulocytes, a ‘feed-back system’ exists μm in diameter and is characterised by a clearly indented or between the circulating and tissue granulocytes on one side, horseshoe-shaped nucleus without nucleoli. The cytoplasm contains a humoral regulatory substance, ‘granulopoietin’ analogous both primary and secondary granules. Band form is juvenile granulocyte, 10 the kinetics of monocytes is less well understood than 16 μm in diameter, characterised by further condensation of that of other myeloid cells. Monocytes spend about 20-40 nuclear chromatin and transformation of nuclear shape into hours in the circulation after which they leave the blood to band configuration of uniform thickness. The mature poly and contains no azurophilic granules but may have fine morphonuclear leucocytes, namely: the neutrophils, eosino granules which are larger than those in the mature monocyte. It is very similar in appearance to myeloblasts except that it has Sites of Formation and Kinetics ground-glass cytoplasm with irregular border and may show the lymphocytes and the plasma cells are immunocompetent phagocytosis as indicated by the presence of engulfed red cells of the body. However, differentiation from are the primary lymphopoietic organs where lymphoid stem myeloblast at times may be difficult even by electron cells undergo spontaneous division independent of antigenic microscopy and, therefore, it is preferable to call the earliest stimulation.

Dudley, 56 years: In fact, it is not a matter of tion (do funduscopy, and/or refer to an eye emer investigate more or investigate less, it is: investigate gency department). Majority of leucocytes in the due to bone infarcts or subperiosteal infiltrates by leukaemic peripheral blood are blasts and there is often neutropenia cells. Patient D (Ron K) – Most likely got the virus by having a one night stand with a girl he met at a party. We can as well use the mechanical devices or the computer facility for tabulation purpose in case we want quick results, our budget permits their use and we have a large volume of straight forward tabulation involving a number of cross-breaks.

Fasim, 37 years: We would like to display and summarise the data, just as we did with a set of values of one variable. They are invariably quantitative models and are divided into two major categories, deterministic and stochastic models. In the course of the reaction, the enzyme becomes transiently bound to glutathione (in the following form: R – Se – S – G). The method has been extensively used by the life insurance industry to assess the risk of death of a prospective client, given age, sex, and various demographic and lifestyle factors for which age-specific death rates are available.

Brant, 39 years: Interestingly, the study did show that Fe++, but not Fe+++ could substitute for copper. It may occur at any age and in either sex but is Possibly, a hyperplastic nodule in the parathyroid gland found more frequently in adult life. The hypoder may be identified visually by their char mis contains subcutaneous adipose tissue acteristic tennis racket–shaped organelles with associated vascular and neural ele known as Birbeck granules that are a sub ments and contributes the largest bulk of domain of the endosomal recycling com the cutaneous organ. Part I consists of Chapters 1–5 and provides an introduction to research theory and general practice.

Umbrak, 21 years: Nephrotic syndrome It avoids the need for ionizing radiation and the gado Nephrotic syndrome is the term given to the constel linium-based contrast medium is non-nephrotoxic. We will now look at what is generally the next stage in investigating such relationships: that is, to describe how one variable (the outcome or dependent variable) depends on the other variable (the explanatory or independent variable). In sickle cell anemia, a mutation alters the hemoglobin molecule so that it precipitates when it gives up oxy gen and distorts the red blood cells into a crescent shape. Through rephrasing, the researcher puts the research problem in as specific terms as possible so that it may become operationally viable and may help in the development of working hypotheses.

Makas, 34 years: Persons who were unable to comment due to the recommendation being outside their area of expertise were able to skip recommendations. The public are most likely to say consent is not important when the information is ‘not generally regarded as being sensitive’ (35%). Abstract Context: Preclinical research has demonstrated a window of vulnerability in the immediate aftermath of concussion wherein continued activity and stimulation can impair or prolong neurobehavioral recovery. Management • Adequate dose of appropriate antibiotics • Drainage (multiple Burr holes, craniotomy, etc) • Excision of infected bone • Drainage of infected sinuses or mastoid air cells • Anticonvulsant therapy.

Owen, 48 years: This panel shows quite a range of statistical information, presented as line graphs over time (by year). The diagnosis of abdominal 15–30 minutes for 3 hours after ingestion of 50 g glu pain usually combines history, physical examina cose/lactulose. There may be suppurative these bodies ultrastructurally represent lysosomes filled exudate or ulcers on the bladder mucosa. Vesicoureteric reflux is important complications of acute pyelonephritis: particularly common in children, especially in girls, due to 1.

Armon, 28 years: Complete each activity and review your answers to evaluate your understanding of the chapter. The strategy would be in terms of collection of data in a manner that inspires confidence. The members of the team and to patients when information contained within the medical records requested can also be used to monitor service activity, and for G consider the importance of: audit and research purposes. For those readers with an advanced knowledge of research design and methodology, this book can be used as a concise summary of basic research techniques and principles, or as an adjunct to a more ad vanced research methodology and design textbook.

Kan, 22 years: Also important are frequent harmful cultural practices that impose fasting upon a child with measles. See Immunoglobulins IgA, IgG, IgM Hypoglycaemia the glucose threshold at which symptoms of hypoglycaemia develop varies widely between individuals but in general a glucose level < 3. The main reason for this is that the Greeks were the founders of rational medicine in the golden age of Greek civilization in th the 5 Century B. However, medial calcification also occurs in some pathological states like Figure 15.

Hanson, 46 years: Leptomeningitis, commonly called meningitis, is usually 875 the result of infection but infrequently chemical meningitis and carcinomatous meningitis by infiltration of the subarachnoid space by cancer cells may occur. It mostly occurs in middle-aged men and almost always involves pain at the base of the great toe. A researcher can not study unobservable processes like attitudes or thoughts using a natu ralistic observation study. The skeletal manifestations of cortex, while the cortex is relatively unaffected due to osteogenesis imperfecta are due to defective osteoblasts collateral circulation.

Navaras, 24 years: Confrmed by: histology (Reed–Sternberg cells in hodgkin’s or without in non-hodgkin’s). In a susceptible sero-negative host who lacks antibodies, B cells or due to viral replication within the salivary epithelial the virus in the contaminated saliva invades and replicates cells in early stage. Telephone interviews avoid the neces sity of travelling to the respondents and can therefore be carried out more quickly than face-to-face. Hematopoietic stem cells will start differentiating by first becoming one of two progenitor cells.

Ben, 41 years: The need, therefore, is for those concerned with research to pay due attention to designing and adhering to the appropriate methodology throughout for improving the quality of research. All philosophical positions and their attendant methodologies, explicitly or implicitly, hold a view about reality. Simultaneous to emigration of leucocytes, escape of red Neutrophils and macrophages on reaching the tissue cells through gaps between the endothelial cells, diapedesis, spaces produce several proteolyitc enzymes—lysozyme, takes place. Hyaluronate capsule of group A streptococcus is identical produced in experimental animals by induction of repeated to human hyaluronate present in joint tissues and thus these infection with β-haemolytic streptococci of group A.

Ugrasal, 44 years: Non-radiation physical agents are the various forms of hormone during their pregnancy. Finally, listen for wheezes, thus assessing airways, from small (high-pitched) to large (low-pitched). Trials, by their very nature, involve an experimental situation with something being done to the study subjects. Characteristics of a malignant, as compared with a benign, paraprotein are: • Anaemia, thrombocytopenia, neutropenia • Immune paresis, i.

Hauke, 50 years: The flap Errors of Refraction is lifted to the side while a laser reshapes the An error of refraction (ametropia) exists when underlying corneal tissue. In terms of variation within the given population, it is assumed that the values of (Xij) differ from the mean of this population only because of random effects i. In particular, I thank Katharina Glatz of Basel University for permission to use multiple histological pictures from her excellent website pathorama. For those of you who are still confused about the concept of generaliz ability, do not fret, because we revisit this issue in later chapters.

Jerek, 64 years: If there is a long list of factors that have to be matched, it would be very difficult and time-consuming to find a control that meets all of the criteria for each case. The specialised nerve endings present at some sites the stratum corneum that develop at specially modified perform specific functions. A type I error occurs if we reject the null hypothesis when it is in fact true (that is, there is no increased risk, as in this example). The main findings can often be presented in a figure (demonstrating the most interesting points), but bear in mind that figures, tables and text are meant to complement each other, not overlap.

Masil, 45 years: However, synovial sarcoma frequent variety of rhabdomyosarcoma occurs is also found in regions where synovial tissue is not present predominantly in older adults above the age of 40 years. This comprises deliberate acts of omission and commission to engineer the findings, and includes plagiarism, which means stealing the results of the others. The coronary arteries carry oxygenated­and­nutrient-flled­blood­to­the­myocardium (heart muscle). Simple mastectomy specimen shows classification of breast tumours has proposed the term replacement of almost whole breast with a large circumscribed, grey ‘phyllodes tumour’ in place of misleading term of ‘cysto white, firm, nodular mass having slit-like, compressed cystic areas (arrow) sarcoma phyllodes’.

Ugolf, 31 years: Tannenbaum (1957), is an attempt to measure the psychological meanings of an object to an individual. Acknowledgements the Pathology Units and Terminology Standardisation Steering Committee wishes to thank all the pathologists, other clinicians, scientists and informaticians who contributed to the discussion around this document. Phe nylalanine builds up and dislodges tryptophan from the shared transporter that mediates uptake of both amino acids into the brain, which causes a lack of tryptophan and hence serotonin in the brain. Haemoprotein-derived pigments i) Haemosiderin Melanin-like Pigments ii) Acid haematin (Haemozoin) c.

Thorus, 59 years: Allergic eye disease consists of four over Vernal conjunctivitis is a chronic, bilat lapping conditions, including (1) seasonal eral conjunctival inflammatory disease and perennial allergic conjunctivitis, (2) found primarily in young males with vernal conjunctivitis, (3) giant papillary history of atopy during spring months. Patch: A large (>2 cm) flat lesion with a color different from the surrounding skin. Hitching a ride inside a vagrant lysosome, an enzyme molecule may eventually alight upon the undegraded substrate within another endosome. Dilated pupil (except in diabetes intra-cavernous mellitus, syphilis, and brainstem ischaemia or posterior when pupil not dilated); other cranial nerve lesions communicating that form pattern (see E Multiple cranial nerve artery aneurysm, lesions, p.

Rathgar, 61 years: She appears to be responding to therapy at this time in that her temperature is coming down and also there has been a slight reduction in the leukocytosis from yesterday. Strategies related to discontinuation of pharmacoptherapy should be based on guidelines appropriate to the diagnosed mental health condition. Cut surface shows characteristic nutmeg* red pulp of the spleen (splenic macrophages). We would expect reliability to be high when measuring a stable construct, but not when measuring a transient one.

Kaffu, 36 years: The diffuse lesions are predominantly seen in cardiovascular and nervous systems which are described in detail later in the relevant chapters. Collin 1987, 1993, 2000 © Bloomsbury Publishing Plc 2004 © A & C Black Publishers Ltd 2005 All rights reserved. These were either taken from studies marked as include in the literature review, or from current guidelines. Lying over the bulbourethral glands provide the alkaline fluid superior surface of each testis is a single, tightly necessary for sperm viability.

Daro, 43 years: Management Most children can be treated at home • Treatment with antibiotics is not recommended • Give an antibiotic only if pneumonia [see 21. They may be the result of a developmental problem, injury, disease, or dietary deficiency. These antibodies are typically Monoclonal antibodies are now approved “humanized” mouse monoclonals, created for the treatment of non-Hodgkin’s lym by transposing the mouse antigen-binding phoma, myeloid and lymphocytic leuke sites onto a human antibody framework mia, breast cancer, and colorectal cancer (see Figure 3. Nitrogen that results from amino acid degradation inside the muscle cells is exported from the cell as glutamine or as alanine.

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