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R. Daryl, M.B. B.CH. B.A.O., Ph.D.

Vice Chair, University of Missouri-Columbia School of Medicine

Leukocytes A Review of Classic Physiological Systems 35 are white blood cells that vary in function. Some are phagocytes that are capable of consuming and destroying antigens or other types of harmful microorganisms. Other leukocytes produce antibodies, secrete or neutralize histamine, or promote or inhibit inflammation. They play a significant role in inflammatory reactions, but only live a day or two. They quickly begin an immune response, but are essentially destroyed by their effort. Neutrophils also can be harmful, contributing to tissue damage through inflammation that, for example, can worsen myocardial injury. Basophils contain vasoactive amines (substances that can exert a dilating effect on blood vessels and increase the permeability of small vessels), such as serotonin. They secrete histamine (which dilates blood vessels, increasing blood flow to damaged tissue) and heparin (which inhibits blood clot formation). They are weakly phagocytic, kill parasites, and secrete leukotrienes, prostaglandins, and some cytokines. Monocytes Monocytes, which are the largest of the white blood cells, are phagocytes with the capability of engulfing fairly large particles. Antigens have receptors that the monocyte can recognize (this is the recognition phase). Macrophages Macrophages are monocytes that are found in tissue and are thought to stay with you for most of your life. They circulate for about 40 hours and then lodge in tissue and increase in phagocytic activity and, thus, in size. They are present in the liver and spleen, where they phagocytize invading organisms before tissue damage occurs, and in the lymph nodes, where they cleanse the lymph. They come into areas of damaged tissue and help clean up the mess by devouring bacteria and cellular debris. Macrophages can remember thousands of antigens and can respond very quickly if this type of bacteria dares to enter the system again. They mediate nonspecific antigen destruction, eliminating tumor and bacteria cells in the absence of an antibody, but they can also have receptors for antibodies. Sometimes 36 the Scientific Basis of Integrative Medicine the macrophage presents a portion of partially digested antigen to B or T lymphocytes and alerts them to the situation. Osteoclasts Osteoclasts evolve from macrophages that have gathered in the bone marrow. This slow, lumbering cell may hang out in the bone until the brain calls it into circulation. It actually may be another method of cellular communication, a Paul Revere if you will, albeit a somewhat slow one. Microglia Microglia are cells whose job it is to make sure that no foreign invader protein gets into the nervous system. They become mobile and literally start eating up invading cells (and, therefore, are phagocytes). Microglia are fundamental to the removal of dead neurons, proliferating and then removing the dead cells (Streit and Kincaid-Colton, 1995). Cytokines are intercellular mediators that influence and sometimes regulate immune responses and even the production of other cytokines. Monocytes, macrophages, neutrophils, T lymphocytes, and natural killer cells all produce cytokines (Table 1. It is caused by secretion of hormones, such as cortisol, which have the capability to suppress the active immune response. It incites slow-wave sleep, inhibits food intake, and mediates fever (Krueger et al. This was groundbreaking information-information that immunologists and endocrinologists found astounding, as it did not fit conventional knowledge. However, it had me dancing with glee because it was solid medical evidence of what I (as well as colleagues) had intuited about systems interaction.

A chemical reaction occurs between the expired carbon dioxide and the material within the carbon dioxide filter, often soda lime. However, this type of reaction characteristically produces a great quantity of heat that is released into the surrounding environment. To prevent this phenomena from becoming problematic, an oxygen analyzer is placed within the circle to measure the percentage of oxygen within the breathable air. When the percent oxygen within the circle system decreases below a preset level, the oxygen analyzer, which is electronically coupled to a tank of high-pressure 100% oxygen (not air) within the unit, releases a measured quantity of oxygen into the circle system through the second stage (low-pressure) reducing valve. The first stage high-pressure reducing regulator is directly attached to the outlet valve of the oxygen tank. Advantages of the closed-circuit (circle) system include a longer period of usage without refilling the oxygen tank, usually in the neighborhood of 4 hour, as opposed to a maximum usage of 1 hour with an open system employing compressed air. Disadvantages would include the heavy weight of the system, although the open circuit is also heavy, and the exothermic (heat producing) reaction that takes place between carbon dioxide and soda lime or other carbon dioxide-removing substances. Oxygen readily supports combustion which is an Personal Protective Equipment: Practical and Theoretical Considerations 555 obvious disadvantage, as well as the necessity of having to periodically change the carbon dioxidefiltering material. If changing the carbon dioxide-filtering material is ignored, carbon dioxide levels within the circle system will continue to increase. As levels of carbon dioxide increase initially a cerebral vasodilatory effect (dilatation of blood vessels within the brain, which increases pressure on the brain) will occur, the extent of which will be directly proportional to the level of carbon dioxide. This will be expressed clinically with the development of an increasingly severe headache. At levels of carbon dioxide of approximately 80 mmHg or above (36­40 mmHg is considered normal), carbon dioxide will exert an anesthetic effect on the responder, and he may initially become light headed, dizzy, and may fall into a deep sleep from which arousal is difficult or impossible, depending on the levels of carbon dioxide within the circle system. A chemical reaction occurs within the filtering material when it becomes saturated with carbon dioxide and needs to be changed. The color of this material will undergo a color change, usually from white to blue. This water would then have to be drained from the system through a one-way valve mechanism. The exact composition of an air-purifying filter will be discussed later in this chapter. What is important is that the filter employed be able to remove the contaminant and in the concentrations present. Air is usually introduced into it by two one-way valves (one on each side) located inside the nosecup. Some respirators, especially those of British origin, lack the one-way valves, but strategically place the interconnection between inside and outside of the nosecup in a location that will not interfere with proper functioning of the nosecup. If this latter were to occur the temperature and humidity content of the air on the inside of the eye lens would be significantly greater than that on the outside of the eye lens, with resulting condensation of water vapor to liquid water on the inside of the eye lens, with the resulting obscuring of vision. It totally covers the head, has an opening for the facepiece of the respirator that is surrounded by an elasticized band to tightly secure the hood to the respirator facepiece, and additionally covers the shoulders and the upper chest (both front and rear aspects), and is secured by two straps that extend from the outside of the bottom of the rear aspect of the hood, with one strap extending under each axilla (armpit), and subsequently both straps attaching to the outside of the lower margin of the front aspect of the garment. If the task is performed in a sunny area, then radiant energy from the sun in the form of infrared rays provides additional heat accumulation within the ensemble. The following medications decrease blood flow to the skin: diuretics by producing fluid loss and dehydration with accompanying constriction of blood vessels, beta blockers by decreasing cardiac output, and alpha agonists by constricting blood vessels. Weight-loss medications have multiple effects, including increasing the rate of metabolism and hence heat production; and anticholinergic drugs decrease or prevent sweating thus decreasing or eliminating evaporative cooling. Consequences of heat stress would include reduced psychological functions including reduction in speed of thought, alertness, and reaction time. Resting body metabolism will produce heat energy equivalent to that produced by a 100 W light bulb, moderate work increases this to about 250 watts, whereas extreme work, such as running, increases this to approximately 1000 watts. The body attempts to dissipate heat production by increasing blood flow to the skin and increasing sweating. Cardiac output initially increases, but will fall as circulating volume decreases by sweating, and syncopal (fainting) episodes may result. When heat production exceeds heat dissipation, body temperature will begin and continue to rise.

I fail to understand why some of the basic medical education courses are not allowed in an eLearning format. It is my contention that before long, medical education will have to combine residential and virtual education, as it is a well-known fact that a global physician shortage is looming. A combination of technology-based medical courses and affiliations set up at universities and hospitals local to students in both underdeveloped countries as well as right here in the United States would permit medical education to occur with minimal disruption to family and financial matters-both of which are important factors in the decision of whether or not one can feasibly apply to medical school. With innovative planning, such as eLearning coursework, doctors largely could be educated in their local communities. These individuals, ideally, then would provide needed medical care to their native communities, solving the problems elucidated in the Two Guideposts: (1) serving the underserved of the world, and (2) assisting physicians to practice in their country of origin, rather than migrating, which can leave medical care deficits in countries most in need of physicians. In summary, the Four Pillars and Two Guideposts affirm the need for a more globally equitable system of medical care and ask physicians to increase their self-awareness and clinical compassion. The Four Pillars and Two Guideposts, coupled with a solid scientific-based program, are my 338 the Scientific Basis of Integrative Medicine vision of what constitutes optimal medical education and is an ideal that every healthcare provider might strive to obtain. It is imperative that medical education provides far more than scientific information and also offers a comprehensive approach to treating patients. The life work of a physician involves constant study, cultivation of a reverence for humanity, a thirst to seek self-knowledge, and a dedication to the patients for whom he/she is responsible. Albert Einstein stated, "The aim [of education] must be the training of independently acting and thinking individuals who, however, see in the service to the community their highest life achievement" (Einstein, 1936). It is incumbent upon each physician to possess a sense of responsibility to his or her own community and preferably, also to the global community, as we move toward globalization in the political, sociological, and personal aspects. Healthcare educational institutions that recognize the importance of teaching the fundamentals of the Four Pillars and Two Guideposts for the Healing Professions will better prepare students for the challenges and rewards of our rapidly changing world. Reverence for human suffering and human life, for the smallest and most insignificant, must be the inviolable law to rule the world from now on. We must recognize that only a deep-seated change of heart, spreading from one man to another, can achieve such a thing in this world. Albert Schweitzer, 1918 RefeRences American Association of Medical Colleges, Cultural Competence in Health-Professions Training: Considerations for Implementation, 2005, available at. American Medical Student Association, Cultural Competency in Medicine 2008a, available at. American Medical Student Association, Principles Regarding Service in Underserved Areas and Service Obligations, 2008b, available at. American Public Health Association, Ethical Restrictions on International Recruitment of Health Professionals to the U. Association of American Medical Colleges, Educating Doctors to Provide High Quality Medical Care, 2004 available at: services. Institute of Medicine, Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System For the 21st Century. Institute of Medicine, Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula, Washington, D. Licensing Committee for Medical Education, Accreditation issues related to distance learning: the perspective of the liaison committee on medical education, 2006. Alternative Medicine, Expanding Medical Horizons, A Report to the National Institutes of Health on Alternative Medical Systems and Practices in the United States; 1991. Department of Health and Human Services, Healthy People 2010 Progress Review: Terminology, 2007. Department of Health and Human Services, Office of the Surgeon General, Disease Prevention, 2008a. Department of Health and Human Service, Office of Minority Health, What Is Cultural Competency? Department of Health and Human Service, Office of Minority Health, Heart Disease and African Americans? World Health Organization Report, World Health Statistics Report: Health service coverage, 2008.

Mitochondrial function and glycolysis play critical roles in a variety of cellular processes, including cellular activation, proliferation, differentiation, cell death, and disease progression. Specific signatures of mitochondrial dysfunction that are associated with disease pathogenesis and/or progression are becoming increasingly important. In particular, the centrality of mitochondria in the pathological processes and clinical phenotypes associated with a range of lung diseases including chronic obstructive pulmonary disease, pulmonary fibrosis, acute lung injury, asthma and lung cancer is emerging. Understanding the molecular mechanisms regulating the mitochondrial processes of lung cells will help to better define phenotypes and clinical manifestations associated with respiratory disease and to identify potential diagnostic and therapeutic targets. In this session, attendees will discover how real-time, live cell analysis can provide a complete picture of mitochondrial phenotype and function in model systems and in human disease, with a particular focus on diseases area. Assays to Assess Mitochondrial Integrity: How to Know If Your Mitochondria Are Sick? We will combine didactic lectures with case-based instruction, and we will offer participants the opportunity to bring their own complex cases for review by an expert team of clinicians and physiologists. We will use a team approach to facilitating the small group discussions including content experts and pulmonary function laboratory medical directors from around the world. This course will focus on updates in lung function testing from the new technical standards published this past year and will provide hands-on experience in small group settings with the interpretation and reporting of pulmonary function 1:15 1:45 2:30 2:45 the information contained in this program is up to date as of April 16, 2018. This is a two day postgraduate course that consists of didactic lectures and hands-on stations. The focus is primarily bedside transthoracic echocardiography, with some diagnostic ultrasound. The topics include basic and intermediate critical care echocardiography (including hemodynamic measures), assessment of fluid status, procedural guidance for vascular access and thoracentesis, venography. The hands-on stations will include both healthy models and simulators that can demonstrate abnormal pathology. This course is designed to provide a comprehensive introduction to diagnostic and therapeutic flexible bronchoscopy. Participants will acquire the knowledge and skills to improve their proficiency in basic bronchoscopic techniques and be introduced to more advanced diagnostic bronchoscopy, including linear and radial endobronchial ultrasound and navigational bronchoscopy. A series of didactic lectures will be followed by intensive, hands-on training, through the use of physical and virtual reality simulators which will help participants strengthen their procedural skills. This course will be of particular interest to providers seeking to refine their flexible bronchoscopy skills and review the data behind the various bronchoscopic techniques. Assemblies on Allergy, Immunology and Inflammation; Clinical Problems; Respiratory Cell and Molecular Biology; Genetics and Genomics Section 8:00 a. Pharmacogenomics analyzes how the genetic makeup of an individual affects his/her responses to drugs. It can provide new insights on pathophysiology, focus the use of specific therapies to those who will benefit, and divert use in those in whom risk of harm is too great. There are an increasing number of successful applications of pharmacogenomics in lung diseases. This course will provide an overview of the key aspects in design and analyses of pharmacogenomic studies, some examples of its successful use, and outline some ongoing efforts to implement pharmacogenomic knowledge in clinical medicine. Qualitative research is a broad approach utilized to gain in-depth understanding of phenomena, answering questions of how and why. This practical skills development course will combine didactics with workshops to provide a toolkit for clinicians, educators, and researchers to apply and evaluate rigorous qualitative methods. Attendees will be introduced to qualitative research and learn about each step from the research question to dissemination of results; in addition a variety of examples will be presented. Participants will be divided in small groups by topic area, research, medical education, and quality improvement with facilitators who have expertise in applying qualitative research in each area. Assemblies on Clinical Problems; Allergy, Immunology and Inflammation; Behavioral Science and Health Services Research; Environmental, Occupational and Population Health; Nursing; Pulmonary Rehabilitation 8:00 a. The importance of making an accurate diagnosis will be demonstrated by live interactions with a panel of experts from multiple disciplines confronted with 3-4 cases unknown to them. This course will review major aspects of thoracic imaging with presentations targeted toward the pulmonologist and critical care physician using a case-based approach and audience participation. Subspecialized thoracic radiologists will give case-based presentations focusing on the practical aspects of chest imaging. Presentations will be image rich and focus on key imaging findings, differential diagnoses, and potential pitfalls. Topics will cover a broad range of chest disease and will be relevant to trainees, generalists, and specialists, alike.