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Y. Darmok, M.A., M.D.

Vice Chair, University of Minnesota Medical School

Plasma cells are (a) responsible for specific immunity, (b) derived from B cells, (c) involved in the production of antibodies, (d) described by all of the preceding. Transfusing a person with blood plasma proteins from a person or animal that has been actively immunized against a specific antigen provides (a) active immunity, (b) passive immunity, (c) autoimmunity, (d) antiimmunity. Substances against which the body launches an immune response are called (a) antibodies, (b) antigens, (c) anticlines, (d) agglutinins. The antibodies produced and secreted by B lymphocytes are soluble proteins called (a) immunoglobulins, (b) immunosuppressants, (c) lymphokines, (d) histones. A dilation of the lymphatic duct in the lumbar region that marks the beginning of the thoracic duct is (a) the cisterna chyli, (b) the right lymphatic duct, (c) the hilum, (d) the mesenteric lymph node. The spleen does not (a) house lymphocytes; (b) filter foreign particles, damaged red blood cells, and cellular debris from the blood; (c) contain phagocytes; (d) change undifferentiated lymphocytes into T lymphocytes. The polypeptide chains of antibodies have portions that are constant and portions that are variable. A person who encounters a pathogen and who has a primary immune response develops passive immunity. If a child has a splenectomy, lymph nodes in the abdominal cavity enlarge and become splenic in function. Passive immunity is the transfer of antibodies developed in one individual into the body of another. Specialized bands of connective tissue, called, divide the lymph nodes. The is located in the anterior thorax, near the manubrium of the sternum. The immunoglobulin that aids in immunity against parasitic worms and other parasites is. Interferon (a) cancer characterized by an uncontrolled production of lymphocytes (b) any of a group of proteins produced by virus-infected cells (c) activate other T lymphocytes or activate B lymphocytes to become plasma cells (d) combine with the antigen on the surface of the foreign cells, causing lysis and the release of cytokines (e) blood type referred to as the "universal recipient" (f) blood type referred to as the "universal donor" (g) injected into a mother with Rh blood giving birth to an Rh child (h) autoimmune disease that affects many body systems (i) blood type with anti-B antibodies in the plasma (j) cells that are active in the production of antibodies Answers and Explanations for Review Exercises Multiple Choice 1. Lacteals are specialized lymph capillaries that transport lipids from the intestines to the cisterna chyli. All cells require a continuous supply of oxygen (O) and must continuously eliminate a metabolic means ventilation, or "breathing. External respiration is the process by which gases are exchanged between the blood and the air. Internal respiration is the process by which gases are exchanged between the blood and the cells. The major passages of the respiratory system are the nasal cavity, pharynx, larynx, and trachea monary alveoli (see fig. Within the lungs, the trachea branches into bronchi, bronchioles, and, finally, pul- Figure 18. The conducting division includes all cavities and structures that transport gases to and from the microscopic air pockets (pulmonary alveoli) in the lungs. The membranes through which gases are exchanged with the circulatory system must be thin and differentially permeable so that diffusion can occur easily. The surfaces for gas exchange must be located deep in the body so that the incoming air can be sufficiently warmed, moistened, and filtered. Assistance in abdominal compression during micturition (urination), defecation (passing of the feces), and parturition (childbirth) 4. Breathing, or pulmonary ventilation, consists of an inspiration (inhalation) phase and an expiration (exhalation) phase. Objective D To describe the nose, nasal cavity, and paranasal sinuses as respiratory structures. Su rvey the nose includes an external portion that juts out from the face and an internal nasal cavity for the passage of air. The nasal cavity is divided into two lateral halves, each referred to as a nasal fossa, by the nasal septum. In the lateral walls of either fossa are three shell-like concavities-the superior, middle, and inferior conchae (fig. The nostrils (external nares) open anteriorly into the nasal cavity, and the choanae (posterior nares) communicate posteriorly with the nasopharynx. The vestibules are lined with nonkeratinized stratified squamous epithelium (see table 4. The conchae of the nasal fossae are lined with pseudostratified ciliated columnar epithelium (table 4.

Diseases

• Uveitis, posterior
• Bubonic plague
• Osteopathia condensans disseminata with osteopoikilosis
• Split hand urinary anomalies spina bifida
• Keratosis, seborrheic
• Orstavik Lindemann Solberg syndrome

For each pain, ask her to describe what it feels like, where it is, when it occurs, how many days she has it per cycle, and what aggravates or relieves it. Ask about bladder symptoms (nocturia, frequency, urine infections, urgency), ask about bowel function (constipation, diarrhea or bloating, pain opening her bowels during her period), ask about pain with movement and pain in other areas of the body. Management options at the primary care level include monophasic oral contraceptive pills, such as 20­35 g ethinyl estradiol with 500­1,000 g norethisterone or 150 mg levonorgestrel, as well as pain medication. Traditional Chinese Medicine (acupuncture and herbal therapies) are also popular, but they should only be recommended if affordable and if the patient has a positive attitude. By providing them with strong analgesics to control severe pain if it occurs, this anticipation of pain can be reduced and they can regain control of the pain. Investigation Exclude pregnancy, including ectopic pregnancy, screen for sexually transmitted diseases if appropriate, and take a cervical smear if available (unnecessary for virgins). Ultrasound may show an endometrioma, but it is often normal, even with severe endometriosis. Dysmenorrhea (painful cramps) for more than 1­2 days is often due to endometriosis, even in teenagers. Management options include on the primary care level all the treatments used for dysmenorrhea above, a levonorgestrel intrauterine device, continuous progestogen (norethisterone 5­10 mg daily, dydrogesterone (a synthetic hormone similar to progesterone) How can I plan treatment for pelvic pain? Remember to treat any coexisting health Dysmenorrhea, Pelvic Pain, and Endometriosis 10 mg daily, or depot medroxyprogesterone acetate to achieve amenorrhea). If referral to a well-equipped hospital is an option, surgery, preferably laparoscopy, to diagnose and remove endometriosis, if medical treatments have failed, would be indicated. Hysterectomy is only indicated if the patient is older and her family is complete. Ovarian endometriomas can usually be treated with cystectomy rather than oophorectomy. Many women with bladder symptoms develop secondary pelvic floor dysfunction with dyspareunia and severe muscular pelvic pain. Where high-level surgical skills are available, excision of endometriosis lesions, if present, can sometimes improve the pain, although frequently this type of pain continues after surgery. Normal ovulation pain should only last for 1 day, occurs 14 days before a period, and changes sides each month. If more than the primary care level is available, and pain is severe or always unilateral, a laparoscopy with division of adhesions and removal of endometriosis is indicated. Dyspareunia (painful intercourse) may be the most distressing symptom for many women, as it interferes with the relationship they have with their husband. She may feel that she is letting her husband down when she is unable to have intercourse due to pain, and he may feel that she is avoiding intercourse because she no longer loves him. It is important to identify the cause of the problem: Examine the vulva visually for abnormalities (infection, dermatitis, lichen sclerosis). Push the cervix to one side to check for contralateral adnexal pain (to check for endometriosis, ovarian cysts, pelvic infection, or adhesions). Many women with pelvic pain describe frequent urination, nocturia, pain when voiding is delayed, suprapubic pain, vaginal pain, dyspareunia, or the feeling of having a urinary tract infection. There may be a history of frequent "urinary tract infections" but with negative urine culture. First, exclude urine infection, chlamydia, and gonococcal or tuberculous urethritis. Common triggers include coffee, cola drinks, tea (including green tea), vitamins B and C, citrus fruit, cranberries, fizzy drinks, chocolate, alcohol, artificial sweeteners, spicy foods, or tomatoes. Provide instructions about how to manage symptom flares (drink 500 mL water mixed with 1 teaspoon of bicarbonate of soda. For symptom control, try amitriptyline 5­25 mg at night, oxybutynin (start with 2. It is important to examine the lower vagina gently with one finger before using the speculum, or pelvic floor/ bladder pain may be missed. Generalized dyspareunia, especially where sharp pains are present, may be neuropathic. Include in the consultation a discussion about the relationship she has with her husband and whether he is supportive of her. The patient should not use soap and should avoid vulval products such as talc or oils.

According to the opioid equivalence dose list, he calculated the daily morphine demand to be 10 mg q. But his family was shocked to learn that the oldest son was now "on drugs" and joined him on his next visit to the doctor to complain. It took the doctor a lot of courage to explain why opioids were now inevitable and would have to be used by the patient for a long time to come. He also revealed to the patient and the family for the first time that the diagnosis was pancreatic cancer without surgical options. A Cuban doctor currently present at the department suggested a celiac plexus block, but Mr. Kassete travel back to Nazret, and he moved in with his family, which allowed him to use a small room for himself. The hospital dispensary had no slow-release morphine available but handed him morphine syrup in a 0. He was in bed most of the time now, and washing and sitting up for a little snack increased his pain unbearably. But he found that a regular smoke of some "bhanghi" helped reduce the nausea, allowing him, at least, a little food intake. In the next few weeks, his general condition deteriorated, but with 15 mg morphine 4 times daily, and sometimes 6 times daily, Mr. Kassete was fine until he again developed a massive abdominal swelling, with nausea and abdominal pain. Since he was now too weak to go to the hospital, a neighbor working as a nurse was called to see him. When she noticed the foul smell of the vomit, it was clear to her that intestinal obstruction was present, and no further efforts could be indicated to restore his bowel function. Kassete found some rest, was relieved from the pain and from vomiting twice daily, and was almost free of nausea. After becoming sleepy on the fourth day, he died in the night of the sixth day after the beginning of his deterioration. For example, in pancreatic cancer, symptom management and surgery are the only realistic treatment options, even in developed countries, since radiochemotherapy hardly influences the course of the illness. Constipation, although appearing to be a simple health problem, often complicates therapy and further decreases the quality of life of patients. Anorexia, cachexia, malabsorption, and pain may additionally complicate the course of abdominal cancer. Although awareness about the need to control cancer-related symptoms has increased in the last few decades, pain management often remains suboptimal. The average incidence of pain in cancer is 33% in the early stage and around 70% in the late stage of disease. With regard to pain intensity, about half of patients report moderate or major pain, with the incidence of major pain tending to be highest in cancer of the pancreas, esophagus, and stomach. Typical causes of pain in gastrointestinal cancer include stenosis in the small intestines and colon, capsula distension in metastatic liver disease, and obstructions of the bile duct and ureter due to infiltration by cancer tissue. Such visceral pain is difficult to localize by the patient due to the specific innervation of the abdominal organs, and it may appear as referred pain. From the literature, we know that in more than 90% of patients, the pain may be controlled with simple pain management algorithms. Observational studies from palliative care institutions, such as the Nairobi Hospice, Kenya, report an almost 100% success rate with a simple pain algorithm. Coanalgesics and invasive therapy options are rarely indicated (see other chapters on general rules for cancer pain management and on opioids). If fluoroscopy is available, along with adequately trained clinicians, neurolysis of the celiac plexus may be used to reduce the amount of opioids and augment pain control in hepatic and pancreatic cancer. Why it is so difficult for the patient with visceral pain to identify exactly the spot that hurts? Visceral afferent fibers (pain-conducting C fibers) converge on the spinal level at the dorsal horn. Therefore, discrimination of pain and exact localization of the source of pain is impossible for the patient.

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