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M. Cole, MD

Assistant Professor, Wake Forest School of Medicine

Elective termination of the pregnancy to receive appropriate therapy without the risk to the fetus is no longer routinely recommended because it has not been demonstrated to improve survival. Paget disease of the breast represents a small percentage (1%) of all breast cancers and is thought to originate in the retroareolar lactiferous ducts. It progresses toward the nipple-areola complex in most patients, where it causes the typical clinical finding of nipple eczema and erosion. Nipple-areolar disease alone usually represents in situ cancer; these patients have a 10-year survival rate of over 80%. In contrast, if Paget disease presents with a mass, the mass is likely to be an infiltrating ductal carcinoma. The generally recommended surgical procedure for Paget disease is currently a modified radical mastectomy. Watchful waiting, steroid creams, and antibiotics are not appropriate forms of management in a woman who presents with a rash involving the nipple. The diagnosis depends on elevated levels of gastrin along with increased secretion of gastric acid. Patients with Zollinger-Ellison tumors have very high basal levels of gastric acid (> 35 mEq/h) and serum gastrin (usually > 1000 pg/mL). In equivocal cases, when the gastrin level is not markedly elevated, a secretin stimulation test is usually obtained. In this test, a fasting gastrin level is obtained before and after the administration of secretin (at 2, 5, 10, and 20 minutes). A paradoxical rise in serum gastrin after intravenous secretin is diagnostic of Zollinger-Ellison syndrome. Propylthiouracil or methimazole can also be used preoperatively but are contraindicated in pregnant women. These specific bone findings would not be present in sarcoidosis, Paget disease, or metastatic carcinoma. Vitamin D deficiency can lead to osteitis fibrosa cystica, but it would also be associated with hypocalcemia, not hypercalcemia. Parathyroidectomy without preoperative localization studies have a high success rate and low complication rate. Two adenomas are found less often (approximately 5% of cases) and hyperplasia of all 4 glands occurs in about 10% to 15% of patients. The remnant of the fourth gland can be identified with a metal clip in case reexploration becomes necessary. Alternatively, all 4 glands can be removed with autotransplantation of a small piece of parathyroid tissue into the forearm or sternocleidomastoid muscle. Subsequent hyperfunction, should it develop, can then be treated by removal of this tissue. Vitamin D supplementation may also be necessary if hypocalcemia develops and persists despite treatment with oral calcium. Steroids and radiation therapy have no role in the treatment of primary hyperparathyroidism. Radiation therapy and hemodialysis have no role in the treatment of thyroid storm. Hyperaldosteronism must be suspected in any hypertensive patient who presents with hypokalemia. Other individuals who should be evaluated for hyperaldosteronism include those with severe hypertension, hypertension refractory to medication, and young age at onset of hypertension. Plasma cortisol level and overnight low-dose dexamethasone suppression test are laboratory studies used in diagnosing Cushing syndrome. Neither urine electrolytes nor 24-hour urinary aldosterone level is beneficial in diagnosing hyperaldosteronism. Axillary lymphadenectomy, however, is seldom indicated without biopsy-positive demonstration of tumor in the nodes. The low incidence of metastatic disease suggests that adjunctive therapy is indicated only for known metastatic disease, even when the tumors are quite large and ulcerated.

Syndromes

• How many tampons or pads are required?
• Irritability
• Auscultation (listening to heart, breath, and stomach sounds)
• Sclerosing cholangitis
• Results will take 1 - 2 days to come back.
• Adrenal cancer
• Joint pain

Traditional processing methods, such as boiling, roasting and frying, are often applied to improve the taste and palatability of edible insects and have the added advantage of ensuring a safe food product. Cultural preferences and organoleptic (sensory) aspects play important roles in chosen preservation methods. Although a wide variety of modern preservation methods is available, specific measures to ensure a high-quality and safe food item may be required for different insect species, depending on their biological makeup. Determining optimal preservation methods will be a critical factor in the commercialization of edible insects on a global scale, be it for food or feed. In this chapter the main focus is on food; however, the same also applies for feed. Its focus is preventative in nature, rather than relying mainly on end-product testing. The system can be applied across the food chain, from primary production to final consumption. Although it has been stated that no significant health problems have arisen from the consumption of edible insects (Banjo, Lawal and Songonuga, 2006b), consumer confidence is arguably strongly correlated with the perceived safety of a given product. In this vein, the application of pesticides on insects destined for the food sector raises important issues, both for nutritional security and participation in the global market. It is well documented that species caught in fields, for example, are more likely to contain pesticides or heavy metals than those collected in dense forests. Many countries in Africa do not have policies governing the use of chemicals in fields in areas where villagers collect edible insects. Most of the time, collection takes place with little knowledge of the consequences that eating chemically treated insects might have (Ayieko et al. However, food-safety issues are important not only for insects collected in the wild but also for farmed insects. Live insects, after washing, are typically transported in ice coolers shortly after collection. The dry environments typically found in places where sun-drying is common practice limits the growth of most micro-organisms. In humid areas, however, even sun-dried caterpillars are susceptible to moisture, which can stimulate the growth of microbes. Insects can also be re-contaminated during the drying process through air or soil; for this reason, hygienic practices during processing are of great importance and an additional heating/cooling step is recommended before consumption (Amadi et al. In many parts of the world, "ready-to-eat" insects are often sold in local markets after frying or roasting. In such cases, hygienic handling is equally important to prevent the potential risk of re-contamination and cross-contamination. At a household level, fresh insects should be prepared hygienically and sufficient heat treatment applied to ensure a microbiologically safe food product. Other simple preservation methods such as acidifying the insects with vinegar have been successful. Another example is the use of insects for protein enrichment in fermented food products. This is a viable processing option with mutual benefits, since the decreased pH in lactic acid-fermented products prevents the growth of potentially harmful micro-organisms (Klunder et al. There has been some success in processing and commercializing insects in the Netherlands. Three insect species (yellow mealworm larvae, lesser mealworm larvae and migratory locusts) can be found in specialized shops in the country that are produced and processed specifically for human consumption. One-day fasting is applied to ensure that the insect has an empty gut (degutting), and the insect is then freeze-dried whole. This produces a safe product with a relatively long shelf life (one year), if stored appropriately in a cool, dry place. Nevertheless, obstacles remain: freeze-drying is expensive and often results in undesirable oxidation of Box 10. They should then be covered with polythene material and placed on a raised platform to prevent cross-infestation from the surrounding environment and moisture from the ground from penetrating the bags.

One explanation could be A) endometriosis B) ovarian cancer C) candidasis D) toxic shock syndrome E) amenorrhea 8. Mary is getting married and is not ready to become a mother- she chooses this birth control because of its high effectiveness A) natural family planning B) a diaphragm C) contraceptive injections D) a spermicide foam 9. When the ovaries stop producing estrogen, this occurs A) ovulation B) implantation C) premenstrual syndrome D) menopause 11. In this disorder the Leiden variant of factor V, cannot be inactivated by activated protein C. It is named after the city Leiden (The Netherlands), where it was first identified in 1994 by Prof R. The chapter will cover fertilization, implantation of the zygote, to becoming a fetus, the three trimesters, and the progressive development of the fetus through the weeks of pregnancy. A sperm is a male gamete that is released into the vagina of a female during intercourse. Every month one of the ovaries releases an egg which will meet one of the A 4 million sperm the male ejaculates into the vagina. The sperm swim through the cervix and into the uterus which lead to the fallopian tubes. The high amount of sperm in the ejaculate is needed because only around 100 survive to enter reach the fertilization site. In order to penetrate the egg the sperm must first break through two barriers A sperm fertilizing an ovum surrounding the ovum. The acrosome of sperm comes in contact with the corona radiata and releases digestive enzymes that break down a gelatinous layer around the egg called, the zona pellucida. Once a sperm reaches the plasma membrane of the egg it sets off a reaction that spreads across the membrane of the egg preventing other sperm from breaking through the egg membrane. Once the sperm reaches the inside of the egg it sheds its tail and the two nuclei fuse and now the 23 chromosomes from the egg and the 23 chromosomes of the sperm join and they become a zygote. Chromosomes contain all the information needed to determine the genetic structure of the new baby. Normally all human beings have two chromosomes that determine sex: A combination of X and Y makes a male or a combination of X and X makes a female. Pre-embryonic Period After fertilization, the zygote begins a process of dividing by mitosis in a process called cleavage. As the morula floats freely within the uterus, it starts to bring nutrients into the cells. The morula fills with fluid and the cells inside start to form two separate groups. The outer layer is called a trophoblast which will develop into part of the placenta. The trophoblast contains specialized cells that become extensions, like fingers, that grow into the endometrium once in contact with the well thickened endometrium. Implantation the blastocyst preserves itself by secreting a hormone that indirectly stops menstruation. In turn, the corpus luteum continues to secrete progesterone, which maintains the endometrium of the uterus in the secretory phase. This helps the blastocyst to continue to grow and stay embedded within the endometrium. The fetal life support system and the placenta begin to form, and eventually the placenta will take over the job of producing progesterone. Gastrulation and Formation the embryoblast within the blastocyst forms 3 primary germs layers: ectoderm, mesoderm, and endoderm. Ectoderm this forms the nervous tissue and the epithelium covering the outer body surface. Epidermis of skin, including hair and nails, glands of skin, linings of oral cavity, nasal cavity, anal canal, vagina, brain, spinal cord, sensory organs, lens of eye and epithelium of conjunctiva (a membrane that covers the sclera and lines the inside of the eyelids), pituitary gland, adrenal medulla, and enamel of teeth. Mesoderm this forms all of the muscle tissue and the connective tissue of the body, as well as the kidneys and the epithelium of the serous membranes and blood vessels. All muscle tissue (skeletal, smooth, cardiac), all connective tissue (fibrous connective tissue, bone, blood, cartilage), dentin of teeth, adrenal cortex, kidneys and ureters, internal reproductive viscera, epithelium lining vessels, joint cavities, and the serous body cavities. Lining epithelium and glands of digestive, respiratory, and parts of urogenital systems, thyroid and parathyroid glands, and thymus.

Diseases

• Metatrophic dysplasia
• Gaucher disease type 1
• Hyperglycinemia, isolated nonketotic type 1
• Young Hugues syndrome
• Mental retardation nasal hypoplasia obesity genital hypoplasia
• Labrador lung
• Pyoderma gangrenosum
• Tuberculosis