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Liver Stomach Gallbladder Large intestine Small intestine (b) (b) Lumen of small intestine Nucleus Creek Basement (a) membrane Goblet cell Cilia (c) FIGURE 4 40mg aristocort for sale. Histology © The McGraw−Hill Anatomy discount aristocort 10mg line, Sixth Edition of the Body Companies aristocort 15mg mastercard, 2001 Chapter 4 Histology 83 Body of uterus Uterine tube Uterine cavity Paras (b) Ovary Lumen of uterine tube Cilia (a) Vagina Cell membrane Nucleus Basement membrane (c) FIGURE 4 generic aristocort 4 mg free shipping. Specialized unicellular glands called goblet cells are scattered The tissue appears to be stratified because the nuclei of the cells through this tissue at most locations. Numerous goblet cells and a cili- bricative and protective mucus along the free surfaces of the ated exposed surface are characteristic of this epithelium. Simple columnar epithelium is found lining the inside walls found lining the inside walls of the trachea and the bronchial of the stomach and intestine. In the digestive system, it forms a tubes; hence, it is frequently called respiratory epithelium. Its func- highly absorptive surface and also secretes certain digestive tion is to remove foreign dust and bacteria entrapped in mucus chemicals. Within the stomach, simple columnar epithelium has from the lower respiratory system. Coughing and sneezing, or simply “clearing the throat,” are protective reflex mechanisms for clearing the respiratory pas- Simple Ciliated Columnar Epithelium sages of obstruction or of inhaled particles that have been trapped in the mucus along the ciliated lining. The material that is coughed up Simple ciliated columnar epithelium is characterized by the pres- consists of the mucus-entrapped particles. Cilia produce wavelike movements that transport materials through tubes or passage- Stratified Epithelia ways. This type of epithelium occurs in the female uterine tubes Stratified epithelia have two or more layers of cells. Stratified epithelia have a primarily evidence indicates that sperm introduced into the female protective function that is enhanced by rapid cell divisions. They vagina during sexual intercourse may be moved along the return cur- rents, or eddies, generated by ciliary movement. This greatly en- are classified according to the shape of the surface layer of cells, hances the likelihood of fertilization. Pseudostratified Ciliated Columnar Epithelium Stratified Squamous Epithelium As the name implies, this type of epithelium has a layered ap- pearance (strata = layers). Actually, it is not multilayered (pseudo Stratified squamous epithelium is composed of a variable number = false), because each cell is in contact with the basement mem- of cell layers that are flattest at the surface (fig. Histology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 84 Unit 3 Microscopic Structure of the Body Larynx Trachea Bronchiole Lung Secondary bronchi (b) (b) Cilia Goblet cell Bronchus Nucleus (a) Basement membrane Connective tissue (c) FIGURE 4. Uterine tube Ovary Uterus Urinary bladder Cervix Urethra Rectum Vagina Anus (b) (a) Stratified squamous epithelium (c) FIGURE 4. In the moistened areas, such as in the vagina (a), it is nonkeratinized, whereas in the epidermis of the skin it is keratinized. Histology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 Chapter 4 Histology 85 Parotid gland Nuclei Lumen of parotid duct Basement (b) membrane (c) Parotid duct (a) FIGURE 4. Stratified Cuboidal Epithelium As the newly produced cells grow in size, they are pushed toward Stratified cuboidal epithelium usually consists of only two or the surface, where they replace the cells that are sloughed off. This type of epithelium is Movement of the epithelial cells away from the supportive base- confined to the linings of the large ducts of sweat glands, salivary ment membrane is accompanied by the production of keratin (ker′a˘- glands, and the pancreas, where its stratification probably pro- tin) (described below), progressive dehydration, and flattening. There are two types of stratified squamous epithelial tis- sues: keratinized and nonkeratinized. Keratinized stratified squamous epithelium contains ker- atin, a protein that strengthens the tissue. Keratin makes Transitional epithelium is similar to nonkeratinized stratified the epidermis (outer layer) of the skin somewhat waterproof squamous epithelium except that the surface cells of the former and protects it from bacterial invasion. The outer layers of are large and round rather than flat, and some may have two nu- the skin are dead, but glandular secretions keep them soft clei (fig.

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That is purchase aristocort 10 mg with visa, the designers of the system encode in a formalism the medical knowledge that is required to make decisions generic 15 mg aristocort with mastercard. Such formalisms or models 171 THE EVIDENCE BASE OF CLINICAL DIAGNOSIS have traditionally been divided into two main groups: quantitative and qualitative aristocort 15mg free shipping. The quantitative models are based on well defined statistical methods and may rely on training sets of patient data to “train” the model generic 4mg aristocort mastercard. Examples of such models are neural networks, fuzzy sets, bayesian models, or belief nets. Qualitative models are typically less formal and are often based on perceptions of human reasoning. Increasingly, however, builders of decision support systems will combine different models in a given system: a bayesian network may be used to model the diagnostic knowledge and a decision tree may be used to model treatment decisions, and a pharmacokinetic model may be used to calculate dosage regimens. Some systems may require interaction between the system and the clinician. The clinician initiates a dialogue with the system and provides it with data by entering symptoms or answering questions. Experience has shown that the acceptance of this type of system by clinicians is relatively low. Other systems are integrated with electronic medical records, and use the data in them as input. In such settings, receiving decision support requires little or no additional data input on the part of the clinician. Finally, some systems are directly connected to the devices that generate the data, for example systems that interpret ECGs or laboratory data. By applying the medical knowledge to the patient data, the system generates patient-specific advice. Some systems, especially those integrated with electronic medical records, provide advice independent of a clinician’s request for it – unsolicited advice. Examples are reminding systems that continuously screen patient data for conditions that should be brought to the clinician’s attention (for example the patient’s kidney function is decreasing, or the patient is eligible for preventive screening). Other systems, such as critiquing systems, may monitor the decisions of the clinician and report deviations from guidelines. Although hundreds of clinical decision support systems have been reported in the literature, only a few have been the subject of a rigorous clinical evaluation. Of those that have been evaluated, however, the majority of the studies showed an impact on clinician performance. In light of the currently available evidence, clinical decision support systems constitute a possible method to support the implementation of clinical guidelines in practice. Observational databases As a result of the increased use of electronic medical records, large observational databases containing data on millions of patients have 172 DIAGNOSTIC DECISION SUPPORT become available for researchers. The data contained in these databases is not of the same quality as the data collected in, for example, a clinical trial. They are collected in routine practice, and, although most observational databases attempt to standardise the recording of data and to monitor their quality, only a few observational databases require the clinician to record additional information. The advantage of observational databases, however, is that they reflect current clinical practice. Moreover, the data are readily available and the costs are not prohibitive. In settings where all the medical data are recorded electronically, the opportunities for research are similar to studies carried out using paper charts. Compared to paper charts, these observational databases provide an environment where the analysis can be performed faster, the data are legible, “normal” practice can be studied, rare events can be studied, longitudinal follow up of patients is possible, and subgroups for further study (such as additional data collection, or patients eligible for prospective trails) can be identified. In cases where a rapid analysis is required (for example a suspected side effect of a drug), observational databases provide a setting for a quick assessment of the question.

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Changes in blood cal factors frequently determine the course vessels in the retina (retinopathy) can of diabetes mellitus generic aristocort 40 mg. Other may affect the management of diabetes complications associated with diabetes directly by inducing metabolic changes mellitus may involve changes in the nerv- that can affect individuals’ ability to con- ous system generic aristocort 40 mg on line. Changes in the peripheral trol blood glucose levels or indirectly by nerves buy aristocort 4 mg with mastercard, or peripheral neuropathy buy 4mg aristocort, may altering the degree to which individuals result in the loss of sensation in the follow instructions related to medication, extremities, so that the protective sensa- diet, and exercise. Motivation to follow tion of pain is absent, further making the prescribed treatment is paramount in them prone to injury. Others betes, resulting in foot ulcers that can lead may see no indication of chronic illness to need for amputation (Boulton, Kirsner, or disability that imposes restrictions, and & Vileikyte, 2004). Consequently, appro- therefore they may have no expectations priate foot care is a necessity to prevent that individuals may be restricted regard- serious complications. If Other effects of neuropathy may be sex- the individuals with diabetes have not ual impotence in men and decreased gen- adapted to their condition or if they fear ital sensation in women. Individuals with social rejection because of their condition, diabetes mellitus have a higher incidence they may attempt to hide their diagnosis 270 CHAPTER 9 ENDOCRINE CONDITIONS from others, ignoring dietary restrictions eling by plane, they should request special or engaging in activities outside their meals ahead of time, and they should be treatment plan. Some individuals may served at the time required for the regi- believe that following a diabetic diet draws men. They should carry insulin with them attention to the condition and, therefore, and should protect it against extremes of may neglect their diet. With guidance from physi- In some instances, the benefit of care- cians or dietitians, individuals can learn to ful adherence to the recommended regi- accommodate meals served at restaurants men is not always apparent to individuals or in other people’s homes. Even though in- and types of foods must be taken into structions have been followed carefully, account, however. Individuals with dia- the blood glucose level may remain elevat- betes must learn to judge calories and por- ed, or complications may still develop. If emphasis is placed centrated sweets and alcohol should usu- on the restrictions associated with treat- ally be avoided, planning may permit the ment of diabetes, individuals may feel incorporation of small quantities into the depressed and hopeless. Fear of complications that may lead to Diabetes mellitus does not usually affect blindness or possible amputation may cre- sexual activity unless there are complica- ate additional anxiety. Frequent vaginal infec- ping insulin injections and/or abandoning tions in women with diabetes may also the diet, both of which can imperil their alter sexual activity because of the physi- life, may result. Reproductive Many lifestyle changes are necessary for function is not affected in men who are individuals with diabetes mellitus, espe- not impotent. Although diet litus who become pregnant generally and insulin dosage can be adjusted to have more complicated pregnancies and account for different types of activities, need special medical attention to monitor advance planning is essential. Activities, the progress of the pregnancy and to alter including exercise and meal times, should insulin and caloric requirements. The effects of any chronic disease are Eating on the run or skipping meals is not limited to the individuals with the not feasible. This is especially true of dia- intake and insulin dosage must be betes mellitus, because so many lifestyle changed accordingly. If activities involve factors are involved in the adequate man- additional walking, comfortable and well- agement of the condition. Often, the fitting shoes should be worn to avoid for- degree to which individuals follow the mation of blisters that could become prescribed treatment protocol depends on infected. Individuals with diabetes mellitus The eating habits of family members, as should check with their physician about well as their understanding of the impor- insulin and food schedules before travel- tance of the diet prescribed for the indi- ing, especially across time zones. If trav- vidual with diabetes, can contribute Conditions of the Endocrine System 271 significantly to the individual’s willingness marital relationship or on plans for chil- to adapt to and follow the diabetic diet. Depending on the maturity, under- Acceptance and understanding of diabetes standing, and expectations of both indi- and its restrictions by friends and col- viduals in the marital relationship, prob- leagues also contribute to individuals’ self- lems related to the presence of diabetes concept and subsequent acceptance of may emerge, especially in the decision to their condition. If ity to carry out treatment recommenda- individuals with diabetes do not control tions, and the degree to which the pre- their diet or prepare their own meals, the scribed protocol controls their diabetes family member assuming this responsibil- determine the special needs of individu- ity has new status and influence.

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