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Another important group of antibiotics was introduced by Benjamin Duggar: the tetracyclines 200 mg extra super viagra with amex erectile dysfunction mental, of which chlortetracycline buy cheap extra super viagra 200 mg erectile dysfunction devices diabetes, isolated from the soil bacteria Strepromyces aureofaciens proven extra super viagra 200 mg erectile dysfunction new zealand, was the first [17]. In the same year, David Gottlieb reported the isolation of a new broad spectrum antibiotic from the soil bacterium Streptomyces venezuelae called chloramphenicol [18] (figure 1. Although, as these examples show, many antibiotics were first isolated from a natural source, most of them are now produced synthetically and new antibiotics are usually semisynthetic modifications thereof [19]. Molecular structure of the carbapenems: meropenem, imipenem, ertapenem, doripenem and biapenem. Antibiotics are used to treat bacterially infected animals but are also administered as a preventive measure. Furthermore, administration of antibiotics at sub-therapeutic doses has a growth promoting effects, making its use economically advantageous [22]. This is especially of interest since the ban of antimicrobial growth promoting substances in animal feed since 2006 [23,24]. Antibiotic usage in veterinary practice in the Netherlands is monitored to obtain insight in the exposure of farm animals to antibiotics. One way of monitoring antibiotic usage is registering antibiotic sales for therapeutic use. The livestock population remained roughly constant over the years [25] and thus is concluded that sales by the pharmaceutical industry of antibiotics for veterinary therapeutic use increased from 1999 to 2007. In all years monitored, tetracyclines are sold the most followed by sulfonamides/trimethoprim and penicillins/cephalosporins. In 2009, for pigs a tendency to reintroduce traditional antibiotics like tetracyclines and sulfonamides/trimethoprim was observed, whereas for veal calves and dairy cows, besides the traditional rd th antibiotics, newer antibiotics like 3 and 4 generation cephalosporins and fluoroquinolones were more frequently used. For broilers a severe increase of the use of penicillin antibiotics was observed in 2009 compared to previous years, possibly because penicillin administration results in the enhancement of the feed conversion and growth rate [26]. Adverse effects of antibiotic usage Excessive antibiotic usage in veterinary practice in food producing animals can have adverse effects on human health [27-29]. Some antibiotics are banned for use in veterinary practice because of their negative effects on health, like bone marrow toxicity, aplastic anemia and carcinogenicity [28,30]. If these antibiotics are illegally administered, residues might occur in food products of animal origin. The adverse effects of the occurrence of these antibiotics in the food chain do not need any further elaboration. Less obvious is that also the irresponsible and excessive use of regulated antibiotics is a risk to human health [4,27,29,31]. About six to eight percent of the population show a hypersensitive reaction to covalent penicillin-protein conjugates that can be present in food products from animals that have been treated with penicillin antibiotics [32]. Furthermore, the use of antibiotics in veterinary practice can result in the occurrence of resistant bacteria that can be disseminated throughout the food chain and the environment and thus possibly be transferred from animals to humans [31]. Furthermore, low levels of these antibiotics can end up in the human food chain or the environment and do contribute to the evolvement of bacterial resistance as well [29,33]. Resistance development to ß-lactam antibiotics is caused by the expression of ß- lactamases, which are enzymes that hydrolyse the four-membered ß-lactam ring and thus inactivates the antibiotics [4,43]. Steadily increasing antibiotic resistance and the lack of the development of new still effective antibiotics appear to result in a period during which treatment of infections will become increasingly difficult [49,50]. Especially if one realises that many antibiotics applied in veterinary practice are the same antibiotics as used to treat bacterial infections in humans, it is clear that the occurrence of bacterial resistance is a serious healthcare issue [51-53]. It also takes into account other relevant public health risks as well as food technology aspects. Last, this document very specifically describes requirements for monitoring plans for the detection of residues of the 19 mentioned substances in live animals, their excrements, body fluids, tissues, animal products, animal feed and drinking water. In Dutch legislation the focus is on self- control in which producers are responsible for product quality. More recently, legislation has been established on registration and justification of antibiotic use in poultry breeding [68] aiming for a decrease in antibiotic usage. General legislation on the obligation of keeping an administration on antibiotic usage in veterinary practice is in preparation [69] as well as additional legislation to prevent the unnecessary use of third and fourth generation cephalosporins and fluoroquinolones in veterinary practice. In this it is stated that these antibiotics are only allowed after demonstration of resistance against other antibiotic substances [69]. In this document the minimum requirements of analytical methods used in the analysis of veterinary drug residues, be it screening or confirmatory methods, were described. These methods have the capability for a high sample throughput and are used to sift large numbers of samples for potential non-compliant results. It is intended to harmonise the analytical performance of methods for substances for which no permitted limited has been established. Due to the principle of equality this guideline is considered to apply not only for imported products but for all products tested [73,74]. Criteria for quantitative residue analysis For quantitative results, the measurement uncertainty expresses the dispersion of the quantitative value of a single analytical result. In the case of substances for which no permitted limit has been established, the detection capability is the lowest concentration at which a method is able to detect truly contaminated samples with a statistical certainty of 1 – β. In the case of substances 22 Chapter 1 with an established permitted limit, this means that the detection capability is the concentration at which the method is able to detect permitted limit concentrations with a statistical certainty of 1 – β. For confirmatory analysis a requirement is that “the observed response must without question be due to the compound being measured and only this compound” [79].

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One area of obvious restriction in the distribution of antibi- otics is their use for growth promotion in animal husbandry purchase extra super viagra 200mg mastercard erectile dysfunction pump implant video. It took almost 40 years buy extra super viagra 200 mg on-line icd-9 erectile dysfunction diabetes, however generic 200 mg extra super viagra with amex jack3d causes erectile dysfunction, for these ideas to be translated into legislation in Europe. Introduction of Truly New Antibacterial Agents A solution to the present clinical situation with increasing antibi- otic resistance would be to find new antibacterial agents with truly new properties of action. Literally thousands of antibiotics have been isolated since the 1940s, but only a small fraction of these have proved suitable for medical and veterinary use. Also, the pace of discovering new antibacterial agents has slowed through the years. Trimethoprim was introduced in 1970 and oxa- zolidinones in 2000, both representing new antibacterial agents in the true sense at their introduction, that is, no truly new antibacterials were introduced for 30 years. This could be taken to mean that the screening of natural products and of presumed antimetabolites will be able to contribute less and less to finding new antibiotics. New principles for antibacterial treatment that are conceptually different from the antibiotics used presently are needed urgently. Antibacterial Peptides Humans and animals have an inborn mechanism of protection against bacterial infections which acts instantly; that is, it works differently from the immune system, the response of which has to await the growth of antibody-producing cells. Host defense peptides or antibacterial peptides of this type seem to be produced by all multicellular organisms, including plants, and also by many unicellular organisms. Compared to antibiotics, which are target-specific molecules acting in a single well-defined manner, these peptides have more complex inhibitory patterns and multiple activities. They are amphi- phile, cationic molecules, which with their positive charge bind to the negatively charged membrane of microbes. The crucial physicochemical feature for the antibiotic activity of host defense peptides is their amphiphilic character, which enables them to adopt conformations in which polar and charged amino acid side chains orient to one side and apolar residues to the other (Fig. These peptides can then bind to negatively charged bacterial surfaces and integrate into and disrupt underlying cytoplasmic membranes. There is substantial evidence that the charge-mediated binding of host defense peptides is critical for their antibacterial activity. This knowledge regarding the lipid bilayer disturbing effect is, however, based on studies of model membranes, which leaves many questions regarding the precise mechanism of the bacteria-killing activity. Several hundred peptides of this kind have now been described and classified according to structural characteristics; they include alpha- and beta-defensins, cathelicidines, cecropins, magainins, bactenecins, and protegrins. Those that are called cathelicidines and defensins dominate within the group of ver- tebrates. Cathelicidines in an active form vary in size between 12 and about 80 amino acid residues and appear in various ter- tiary structures. Amino acid sequences are given for the two peptides and for the human betade- fensin, also the intramolecular cystine disulfide bridges mentioned in the text. Defensins and other antimicrobial peptides are possible candidates to be pharmaceutical preparations for use in the clinical treatment of bacterial infections. A rather recently published example of such a candidate peptide is plectasin, an antimicrobial defensin isolated from the mold Pseudoplectania nigrella. It was reported that the plectasin- producing gene could be transferred to another fungus, which could produce and excrete plectasin in large amounts. This could be a solution to a serious problem with antibacterial peptides, which is to produce them in sufficient amounts and in a way that is economically defendable. The mice test is a parallel to the historically famous experiment with penicillin by Howard Florey in May 1940. In a recent report it was found, astonishingly, that the plectasin peptide of 40 amino acid residues with its amphipathic nature does not compromise bacterial membrane integrity as do similar defensins with the characteristic intramolecular cystine disulfide bridges stabiliz- ing their tertiary structures. Instead, it was actually found to interfere with bacterial cell wall synthesis, which was originally observed as severe cell-shaped deformations occurring in its presence. In more detail, the action of plectasin was more like the glycopeptide antibiotics (such as vancomycin, Chapter 5) found to form a stoichiometric complex with an intermediate in the biosynthetic pathway of cell wall formation. This intermediate is the glycopeptide–lipid complex, which translocates across the cytoplasmic membrane to the outside, where the glycopeptide is incorporated into the peptidoglycan polymer through the activity of transglycosylases and transpeptidases (see Chapter 4). It can be concluded that plectasin is a promising substance for further drug development. The results obtained seem to show that in the future, antibacterial peptides could play an important role in the treatment of infectious disease. One obstacle is that they are peptides susceptible to degradation in the gastrointestinal tract. This could, for example, be to inhibit the adhesion of bacteria to the epithelial cells of the ureters in the urinary tract in severe infections in the upper parts of this tract. This complexity and the fact that trans- port through the syringe needle requires energy makes it likely that the proper secretion mechanism could be inhibited without interfering with the growth of the bacterium. Small molecular inhibitors with this effect have been identified and ought to be developed into anti-infectious remedies. The new and important aspect of this approach is that only the pathogenicity is inter- fered with; bacterial growth and survival are unaffected. This is different from other antibacterial agents and eliminates the immediate risk of resistance development. Bacterial growth is normal, which means that mutations affecting the pathogenic- ity inhibition are not selected. Inhibition of Bacterial Fatty Acid Synthesis Pharmaceutical companies have to a large extent retreated from the field of antibacterial drugs, concentrating instead on chronic diseases, which has market advantages. Earlier, there was a cooperation between the health care and pharmaceuti- cal industries, which has now ceased, particularly regarding antibacterial agents. It was therefore very encouraging that the Merck pharmaceutical company took on the work of character- izing and developing a new approach to antibacterial action.

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This was followed by trials of clonidine for hypertension and methadone for pain control 200mg extra super viagra visa impotence in xala, with bladder retention noted after clonidine administration generic 200mg extra super viagra otc erectile dysfunction age 60. Upon catheter removal cheap extra super viagra 200mg free shipping erectile dysfunction medicine in ayurveda, the patient noted the subacute onset of paresis, paresthesias, and pain in the legs approxi- 1 mately 2 ⁄2 to 3 hours later. Differential diagnoses include a subarachnoid hemorrhage, epidural abscess, and transverse myelitis. What was the original cause of the patient’s current problems and what treatments were provided? Eye • Recognize, pronounce, spell, and build words related Fibrous Tunic to the special senses. Vascular Tunic • Describe pathological conditions, diagnostic and Sensory Tunic therapeutic procedures, and other terms related to Other Structures Ear the special senses. Hearing • Explain pharmacology related to the treatment of Equilibrium eye and ear disorders. Medical Word Elements • Demonstrate your knowledge of this chapter Pathology by completing the learning and medical record Eye Disorders activities. Specific sensations include smell Eye (olfaction), taste (gustation), vision, hearing (audi- tion), and equilibrium. Each specific sensation is The eye is a globe-shaped organ composed of connected to a specific organ or structure in the three distinct tunics, or layers: the fibrous tunic, body. Pronunciation Help Long Sound a—rate ¯ e—rebirth¯ ¯ı—isle o—over ¯ u—unite¯ Short Sound a—alone˘ e—ever ˘ ˘ı—it o—not˘ u—cut˘ Anatomy and Physiology 467 (4) Choroid (10) Retina (1) Sclera (5) Iris (2) Cornea (11) Fovea (in macula) Retinal artery and vein (7) Pupil (12) Optic nerve (8) Lens (13) Optic disc (15) Anterior chamber (17) Vitreous chamber (14) Posterior chamber Inferior rectus muscle (16) Canal of Schlemm (9) Suspensory ligament (3) Conjunctiva (6) Ciliary body Figure 15-1. Fibrous Tunic choroid allows the optic nerve to enter the inside of The outermost layer of the eyeball, the fibrous the eyeball. The anterior portion of the choroid tunic, serves as a protective coat for the more sen- contains two modified structures, the (5) iris and sitive structures beneath. The sclera, or “white of the tile membrane whose perforated center is called the eye,” provides strength, shape, and structure to the (7) pupil. As the sclera passes in front of the eye, it passing through the pupil to the interior of the eye. Rather than As environmental light increases, the pupil con- being opaque, the cornea is transparent, allowing stricts; as light decreases, the pupil dilates. The cornea is iary body is a circular muscle that produces aqueous one of the few body structures that does not con- humor. The ciliary body is attached to a capsular tain capillaries and must rely on eye fluids for bag that holds the (8) lens between the (9) suspen- nourishment. As the ciliary muscle contracts and tiva, covers the outer surface of the eye and lines relaxes, it alters the shape of the lens making it the eyelids. These changes in shape allow the eye to focus on an image, a process called Vascular Tunic accommodation. The (4) choroid pro- The innermost sensory tunic is the delicate, vides the blood supply for the entire eye. It consists of a thin, pigmented cells that prevent extraneous light from outer pigmented layer lying over the choroid and a entering the inside of the eye. It has two types the refractive structures of the eye, focusing light of visual receptors: rods and cones. Cones function in bright light and produce color The adnexa of the eye include all supporting vision. In the cen- control the movement of the eye: the superior, ter of the macula is the (11) fovea. When the eye inferior, lateral, and medial rectus muscles and the focuses on an object, light rays from that object are superior and inferior oblique muscles. Because the fovea is com- cles coordinate the eyes so that they move in a syn- posed of only cones that lie very close to each other, chronized manner. Two movable folds of skin constitute the eyelids, each with eyelashes that protect the front of the Other Structures eye. As light strikes the Lying superior and to the outer edge of each eye are photopigment, a chemical change occurs that stimu- the (2) lacrimal glands, which produce tears that lates rods and cones. The tears collect at the impulses that are transmitted through the (12) optic inner edges of the eyes, the canthi (singular, can- nerve to the brain, where they are interpreted as thus), and pass through pinpoint openings, the vision. The optic nerve and blood vessels of the eye (3) lacrimal canals, to the mucous membranes that enter at the (13) optic disc. It is found in the (14) posterior The ear is the sense receptor organ for hearing and chamber and (15) anterior chamber of the anterior equilibrium. Hearing is a function of the cochlea; segment and provides nourishment for the lens and the semicircular canals and vestibule control equi- the cornea. If aqueous humor fails to drain from the The ear consists of three major sections: the outer eye at the rate at which it is produced, a condition ear, or external ear; the middle ear, or tympanic called glaucoma results. Anatomy and Physiology 469 Temporal bone (6) Stapes (10) Semicircular canals (1) Auricle (5) Incus (4) Malleus Vestibular branch Vestibulocochlear nerve Cochlear branch (7) Cochlea (11) Vestibule (8) Oval window (9) Eustachian tube (2) External auditory (3) Tympanic canal membrane External ear Middle ear Inner ear Figure 15-3. Its inner surfaces are lined with a sions ultimately generates impulses that are sent to highly sensitive hearing structure called the organ of the brain and interpreted as sound. Corti, which contains tiny nerve endings called the An (1) auricle (or pinna) collects waves traveling hair cells. A membrane-covered opening on the through air and channels them to the (2) external external surface of the cochlea called the (8) oval auditory canal, also called the ear canal. The ear window provides a place for attachment of the canal is a slender tube lined with glands that pro- stapes. Its stickiness ear causes the stapes to exert a gentle pumping traps tiny foreign particles and prevents them from action against the oval window. The forces the perilymph to disturb the hair cells, gener- (3) tympanic membrane (also called the tympanum ating impulses that are transmitted to the brain by or eardrum) is a flat, membranous structure drawn way of the auditory nerve, where they are interpret- over the end of the ear canal.

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This process usually tion or other serious medical conditions buy generic extra super viagra 200mg online new erectile dysfunction drugs 2014, or marks patientsí first substantial exposure to the former patients who have tapered off mainte- treatment system purchase extra super viagra 200 mg without a prescription impotence guilt, including its personnel buy extra super viagra 200mg low price impotence use it or lose it, other nance medication but subsequently require patients, available services, rules, and require- renewed treatment. Continuity of care should be considered, of treatment, pat- designed to engage and referral to more suitable programs should terns of success or be the rule. Each new patient also should receive a handbook (or other appropriate materials), written at an understandable level Inform ation Collection and in the patientís first language if possible, that Dissem ination includes all relevant program-specific infor- mation needed to comply with treatment Collection of patient information and dissemi- requirements. Patient orientation should be nation of program information occur by vari- documented carefully for medical and legal ous methods, such as by telephone; through a reasons. Documentation should show that receptionist; and through handbooks, informa- patients have been informed of all aspects tion packets, and questionnaires. Therefore, screening and concerns about patient rights, medical assessment also should identify and grievance proce- document nonopioid substance use and deter- and stressing the dures, and circum- mine whether an alternative intervention stances under which (e. Procedures should be in place to should require determine any instances of misuse, overdose, ment retention... The potential for drug menting their partic- interactions, particularly with opioid treatment ipation in the orien- medications, should be noted (see chapter 3). Substance Abuse and Mental Health Services ï Pattern of daily preoccupation with opioids. A patientís living use to offset withdrawal is a clear indicator of environment, including the social network, physiological dependence. In addition, people those living in the residence, and stability of who are opioid addicted spend increasing housing, can support or jeopardize treatment. A patientís substance sometimes have other impulse control disor- abuse history should be recorded, focusing ders. A treatment provider should assess first on opioid use, including severity and age behaviors such as compulsive gambling or at onset of physical addiction, as well as use sexual behavior to develop a comprehensive patterns over the past year, especially the perspective on each patient. A baseline determination of ï Patient motivation and reasons for seeking current addiction should meet, to the extent treatment. Many present for treatment because they are in people who are opioid addicted use other withdrawal and want relief. They often are 48 Chapter 4 preoccupied with whether and when they can M edical Assessm ent receive medication. However, concerns about motivation by a program physician and then submitted to should not delay admission unless applicants the medical director in preparation for phar- clearly seem ambivalent. The consensus because, in most cases, applicants will present panel believes that identifying and addressing in some degree of opioid withdrawal. A Adm ission Eligibility patientís comments also can identify his or her recovery resources. These include com- Federal regulations on ments on satisfaction with marital status and living arrangements; use of leisure time; eligibility problems with family members, friends, Federal regulations state that, in general, significant others, neighbors, and coworkers; opioid pharmacotherapy is appropriate for the patientís view of the severity of these persons who currently are addicted to an opi- problems; insurance status; and employment, oid drug and became addicted at least 1 year vocational, and educational status. W hen an applicantís status is basis for a focused, individualized, and uncertain, admission decisions should be based effective treatment plan (see chapter 6). Initial Screening, Adm ission Procedures, and Assessm ent Techniques 49 A person younger than 18 must have under- History and Extent of gone at least two documented attempts at Nonopioid Substance Use and detoxification or outpatient psychosocial treatment within 12 months to be eligible for Treatm ent maintenance treatment. M edical History Cases of uncertainty A complete medical history should include organ system diagnoses and treatments and W hen absence of a treatment history or with- family and psychosocial histories. W omenís medical histories dependence on opioids can be demonstrated by also should document previous pregnancies; less drastic measures. For example, a patient types of delivery; complications; current preg- can be observed for the effects of withdrawal nancy status and involvement with prenatal after he or she has not used a short-acting care; alcohol and drug use, including over-the- opioid for 6 to 8 hours. Administering a low counter medications, caffeine, and nicotine, dose of methadone and then observing the before and during any pregnancies; and patient also is appropriate. It also requires invasive injec- tion, and the effects can disrupt or jeopardize Exam ination prospects for a sound therapeutic relationship Each patient must undergo a complete, fully with the patient. The panel recommends that documented physical examination by the pro- naloxone be reserved to treat opioid overdose gram physician, a primary care physician, or emergencies. The full medical examination, including the results of the serology and other tests, must be docu- mented in the patientís record within 14 days following admission. The examination should immune system compromised might have a cover major organ systems and the patientís negative purified protein derivative test, even overall health status and should document indi- with active infection. A chest x ray or sputum cations of infectious diseases; pulmonary, liver, analysis should be done if there is doubt. The among individuals involved with drugs (Batki consensus panel strongly recommends that et al. Anergy panel tests should be adminis- signal current infections, only that antibodies tered to anergic patients (those with diminished have developed. In studies by the manufacturer, the blood distress and psychiatric symptoms (McKinnon antibody test correctly identified 99. The first test is include, but not be limited to, patient especially important because it is part of the recollections of and attitudes about previous initial evaluation and may serve as documenta- substance abuse treatment; expectations and tion of current opioid use. As noted in Federal motivation for treatment; level of support for regulations, the presence of opioids in test a substance-free lifestyle; history of physical results does not establish a diagnosis of opioid or sexual abuse; military or combat history; addiction, and the absence of opioids does not traumatic life events; and the cultural, reli- rule it out. Clinical examination and an appli- gious, and spiritual basis for any values and cantís medical history are keys to determine the assumptions that might affect treatment. Chapter 9 discusses information should be included in an integrated drug-testing procedures and Federal regulations summary in which data are interpreted, governing these procedures. Treatment plans should be reviewed and updated, initially every 90 days and, after 1 year, biannually or whenever Com prehensive changes affect a patientís treatment outcomes.

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This remarkable structure delivers ment called an electrocardiograph records these nutrients and oxygen from the mother to the fetus electrical impulses buy 200 mg extra super viagra visa erectile dysfunction 22, using a needle buy 200mg extra super viagra impotence vs sterile, or stylus 200mg extra super viagra sale erectile dysfunction drugs prices, that and removes waste products from the fetus and records the activity on graph paper. The pla- deflection of the electrocardiograph produces centa develops during pregnancy and is expelled waves or peaks designated by the letters P, Q, R, S, after the delivery of the infant. From the left atrium, blood heartbeat: the contraction phase (systole) when enters the (11) left ventricle and finally exits the the blood is forced out of the heart, and the heart through the aorta, where it travels to the relaxation phase (diastole) when the ventricles head and upper extremities. Systole produces the max- nonfunctional, most of the blood in the pulmonary imum force; diastole, the weakest. These meas- arteries is shunted through a connecting vessel urements are recorded as two figures separated called the (12) ductus arteriosus to the aorta. Systolic pressure is given first, Immediately after birth, the ductus arteriosus followed by diastolic pressure. As circulation increases in blood pressure of 120/80 mm Hg means a sys- the neonate, the increase of blood flow to the right tolic pressure of 120 with a diastolic pressure of atrium forces the foramen ovale to close. Connecting Body Systems-Cardiovascular System The main function of the cardiovascular system is to provide a network of vessels though which blood is pumped by the heart to all body cells. Specific functional relationships between the cardio- vascular system and other body systems are discussed below. Blood, lymph, and immune Endocrine • Cardiovascular system transports the • Cardiovascular system delivers oxygen and products of the immune system. Anatomy and Physiology 193 Connecting Body Systems-Cardiovascular System—cont’d • Cardiovascular system provides the ves- Musculoskeletal sels of the placenta during pregnancy for • Cardiovascular system removes heat and the exchange of nutrients and waste waste products generated by muscle con- products. Integumentary • Cardiovascular system provides blood Respiratory vessels in the skin to regulate body tem- • Cardiovascular system transports oxygen perature and carbon dioxide between lungs and • Cardiovascular system transports clotting tissues factors to the skin to control bleeding. It is time to review cardiovascular structures by completing Learning Activity 8–1. Medical Word Elements This section introduces combining forms, suffixes, and prefixes related to the cardiovascular system. Most emboli are blood clots (thrombi) that have been transported from a distant vessel by the blood. Other common causes include smoking, diabetes, high blood pressure, obesity, and familial tendency. Pathology Arteriosclerosis Many cardiac disorders, especially coronary artery Arteriosclerosis is a hardening of arterial walls disease, and valvular disorders are associated with that causes them to become thickened and brit- a genetic predisposition. This hardening results from a build-up of a ry as well as a physical examination is essential in plaquelike substance composed of cholesterol, the diagnosis of cardiovascular disease. Over time, some of the most serious cardiovascular diseases it builds up on the inside lining (tunica intima) have few signs and symptoms, when they occur of the arterial walls. Eventually, the plaque hard- they may include chest pain (angina), palpita- ens (atherosclerosis), causing the vessel to lose tions, breathing difficulties (dyspnea), cardiac elasticity. The location, duration, pattern of becomes difficult for blood to pass through the radiation, and severity of pain are important qual- blocked areas. Tissues distal to the occlusion ities indifferentiating the various forms of cardio- become ischemic. In many instances, blood hem- vascular disease and are sometimes characteristic orrhages into the plaque and forms a clot of specific disorders. When a throm- nature of the signs and symptoms of cardiovascu- bus travels though the vascular system it is called lar disorders, invasive and noninvasive tests an embolus (plural, emboli). Emboli in venous cir- are usually required to confirm or rule out a sus- culation may cause death. Sometimes cardiovascular disorders, the medical services of a plaque weakens the vessel wall to such an extent specialist may be warranted. Cardiology is the that it forms a bulge (aneurysm) that may medical specialty concerned with disorders of the rupture. The physician who treats Arteriosclerosis usually affects large- or medium- these disorders is called a cardiologist. One of the monly use endarterectomy to treat carotid artery major risk factors for developing arteriosclerosis is disease, peripheral arterial disease, and diseases of an elevated cholesterol level (hypercholesterolemia). Other major risk factors include age, family history, smoking, hypertension, and diabetes. Coronary Artery Disease Treatment for arthrosclerosis varies depending on the location and symptoms. In one method, In order for the heart to function effectively, it occluding material and plaque are removed from must receive an uninterrupted supply of blood. Plaque reduces Blood flow blood flow is blocked Area of Area of ischemia infarct Figure 8-8. Its major cause is the accumulation of it releases several highly specific cardiac enzymes, plaque which causes the walls of the artery to including troponin T, troponin I, and creatinine kin- harden (arteriosclerosis). Arrhythmia with an small incision in the skin and into the diseased abnormally rapid heart rate (tachycardia) or an blood vessel. Sometimes, the physician will place a hol- low, thin mesh tube (stent) on the balloon and position it against the artery wall. It remains in place after the balloon catheter is removed and keeps the artery opened. One end of the graft ves- sel is sutured to the aorta and the other end is sutured to the coronary artery below the blocked area.

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