Adjusting treatment on the basis of off-central axis dose calculations can reduce dose inhomogeneity from differences in patient separation within the large mantle field diabetic candy buy cheap glipizide 10mg online. Extended source-to-skin distances of 110 cm or greater diabetes in dogs not eating buy 10 mg glipizide amex, rather than a source-to-skin distance of 100 cm japan diabetes prevention program buy glipizide 10mg without prescription, also reduces tissue inhomogeneity diabete omeopatia purchase glipizide 10 mg amex. Proper use of megavoltage energies will ensure that superficial nodes are not underdosed in the buildup region diabetes symptoms warning signs 10mg glipizide with visa. The mantle field encompasses the submandibular diabetes hyper signs generic 10mg glipizide with visa, cervical, supraclavicular, infraclavicular, axillary, mediastinal, subcarinal, and hilar lymph nodes. Areas of initial involvement should receive a total dose of 3600 to 4000 cGy through the addition of a cone-down field. When at least four cycles of chemotherapy have been given, radiation to initial uninvolved prophylactic sites probably is not needed. Further reduction to 1500 to 2500 cGy may be desirable in prepubertal patients receiving combined modality treatment or, occasionally, in patients with extensive nodal involvement who are receiving treatments to large radiation fields after chemotherapy. Involved field irradiation should encompass the entire involved lymph node region, as defined initially by Stanford University Medical School. Mantle paraaortic-splenic irradiation after a negative laparotomy occasionally is used as a radiotherapy-alone approach for early-stage disease patients who have not had a staging laparotomy. The paraaortic field encompasses the paraaortic nodes down to the fourth to fifth lumbar vertebral interspace (L4-5). The dose to the paraaortic lymph nodes should be 3000 cGy when there is no known disease, and radiotherapy alone is used. Beam divergence from the mantle and paraaortic fields creates the potential for an overdose at the spinal cord. Iliac wing blocks to spare bone marrow and a pelvic block to shield the bladder and central pelvic organs should be part of the treatment technique (which includes irradiation of inguinal and femoral nodes). From this model, the authors predicted that response to chemotherapy would depend on tumor burden, drug dose, and kinetics of residual tumor cells. It was further postulated that the simultaneous use of several drugs with different modes of action might yield superior results. The combination of drugs might be tolerated if the toxicities were nonoverlapping. Initial attempts with two-drug combinations revealed the potential of this approach. Further information on chemotherapy is provided in Advanced-Stage Disease later in this chapter. Combined Modality Chemotherapy In addition to the many factors that affect either chemotherapy or radiotherapy when used alone, there are several issues that arise specifically because of potential interaction and summing of effects when they are combined. Failure-free survival was the same in all groups, strongly implying that after optimal chemotherapy, irradiation dose, at least to nonbulky sites, can be reduced without sacrificing efficiency. The risk of two important late complications of irradiation may be reduced by lowering the dose. Stanford University investigators found that a higher dose of irradiation to the mediastinum was associated with increased mortality from cardiac disease. The same theoretic considerations that apply to irradiation are relevant when one considers reduction of the dose of chemotherapy used in combined modality treatment. In theory, either the chemotherapy or the radiotherapy could come first in the sequence of combined modality treatment. In practice, it is almost always desirable for chemotherapy to precede radiotherapy. The reason for this includes early effective treatment of disseminated disease, delay in induction of irreversible loss of bone marrow function, and the opportunity to use smaller, potentially less toxic radiation treatment fields after chemotherapy has induced tumor regression. Implicit in the rationale for this approach is the assumption of a steep dose-response relation for lymphoma patients subjected to chemoradiotherapy. Although care must be exercised in interpreting clinical results, both animal models and clinical studies support the existence of such a relationship. Mucositis and enterocolitis represent the most significant nonhematologic toxicities associated with high-dose melphalan. This information will generally be phrased in terms of probabilities-for instance, the probability of cure for various values of a prognostic factor. It may be used for informing the patient or, in the context of clinical trials, for defining or describing the study population or adjusting the data analysis; however, for the clinician, the most important role of the prognostic factor is to help in selecting an appropriate treatment strategy. Among the remaining patients with early-stage disease who had previously continued to receive radiotherapy alone, an "unfavorable" subgroup often was defined to select patients for combined modality therapy. Each group has thus been associated with a typical standard treatment strategy: Early stages, favorable: radiation alone (extended field) Early stages, unfavorable: moderate amount of chemotherapy (typically four cycles) plus radiation Advanced stages: extensive chemotherapy (typically eight cycles) with or without consolidating (usually local) radiation these "typical" strategies are not uniformly applied, and the investigation of alternatives. In the scheme just listed, two divisions between the three prognostic groups must be noted, each division possibly being defined by a different set of factors. Furthermore, the attempt has been made to identify advanced-stage patients with a particularly high risk of failure for intensified therapy. Prognostic factors are rarely the subject of specific clinical studies but are discovered and evaluated using data from large cohorts of uniformly treated, well-documented, and reliably followed-up patients, usually from large clinical trials. In the following few sections, recognized prognostic factors are described for early stages treated with radiotherapy alone, for early stages treated with chemotherapy, and for advanced stages (treated with chemotherapy), respectively. Such factors are required to show independent prognostic value in multivariate analyses of large numbers of patients. This account refers in general to clinically staged patients, because laparotomy is now rarely performed. The use of these factors to define prognostic groups for treatment purposes, as practiced by various institutions and study groups, are described. These factors are relevant to the decision as to which early-stage patients should be classed as unfavorable and receive combined modality therapy because their prognosis with radiotherapy alone is relatively poor. Favorable patients were generally given radiation only, although the additional application of mild chemotherapy has increased. A 30% long-term failure rate was observed, however, and this policy was not continued. All the factors listed for radiation-treated patients have also been reliably confirmed in cohorts who also received chemotherapy,161,162 either in early or in advanced stages. This similarity of prognostic effects is supported by the observation from a metaanalysis of radiotherapy versus combined modality treatment in early stages that the size of the difference in failure-free survival between these two treatment strategies was essentially constant over different prognostic groups. This gradual shift to use of more intensive therapy was based on prognostic factor analyses. Prognostic Factors for Advanced-Stage Disease the more uniform treatment modality and the greater frequency of treatment failure events has permitted more conclusive and generally applicable results for prognostic factor analyses for the advanced stages, as compared with early stages. The results of the International Prognostic Factors Project, 161 though not 164 necessarily including all possible factors, can be taken as reliable (Table 45. Final Cox Regression Model All these factors were highly significant in the multivariate analysis of data from 5141 patients treated in 25 centers, and their prognostic power was confirmed in an independent sample. Therefore, Hasenclever and Diehl 161 recommended combining these factors into a single score by simply counting the number of adverse factors, thus giving an integer prognostic score between 0 and 7. However, even patients exhibiting five or more factors (7% of cases) had a 5-year failure-free rate of more than 40%. A number of other factors have been shown to correlate with prognosis in advanced stages, but their independent importance is not proven due to conflicting results or lack of confirmation in a large data set. Factors relevant to advanced-stage patients may be used to identify patients for either treatment intensification or treatment reduction. Reduction can be achieved by creating a modified protocol or by including these patients in the early-stage group. However, none of these methods could consistently select a subset with a failure rate of less than 40% with conventional therapy. This means that the early high-dose approach is unlikely to show a clinically relevant long-term survival benefit as compared with conventional treatment. No data are available on the results of treatment reduction in a favorable subset of the advanced-stage patients. In conclusion, the three-level scheme of division into early-stage favorable, early-stage unfavorable, and advanced-stage cases remains valid according to current knowledge (see Table 45. Separation of very favorable early-stage or poor-risk advanced-stage patients for especially mild or intensive therapy, respectively, does not appear justified. Several prognostic factors, other than clinical stage, are used in the divisions among favorable, unfavorable, and advanced cases, and no universally valid set of factors has been determined. Nevertheless, the list of reliably confirmed, independent prognostic factors just reviewed encompasses most of the factors used by the major institutions and study groups. For early-stage and advanced-stage disease patients receiving radiotherapy or chemotherapy or both, the set of relevant factors is fairly similar. A number of other factors have been shown to correlate with prognosis in advanced stages, but their independent importance is not proven due to conflicting results or lack of confirmation in a large data set. The search for biologically specific factors directly related to tumor activity is now an important research goal. These include studies that look at reduction of radiation dose or reduction of field size in pure radiotherapy; seek an optimal, short, or less toxic chemotherapeutic regimen; explore an optimal radiation volume in combined modality therapy; or evaluate chemotherapy alone. Patients were randomized to receive either 40-Gy extended-field radiotherapy or 30-Gy extended-field radiotherapy followed by an additional 10 Gy to involved lymph node regions. Fewer recurrences were seen in patients who received both mantle irradiation and vinblastine chemotherapy. The freedom from recurrence was only 38% in the mantle-alone group, and the 15-year survival rate was only 58%. However, 23% of patients experienced relapse, yielding a 6-year event-free survival rate of 66%, a relapse-free survival rate of 73%, and overall and cause-specific survival rates of 96%. No differences were seen in disease-free survival or overall survival between the two treatment groups with or without paraaortic irradiation. A 1997 update of this trial shows no statistical difference between the two treatment arms, either for treatment failure probability (P =. These excellent results with mantle irradiation alone also have been seen in other retrospective studies. These trials use chemotherapeutic regimens given for four or six cycles in combination with radiotherapy. The regimens are combined with involved-field or regional (mantle) radiotherapy with the premise that the drugs being tested will be able to control both adjacent prophylactic sites and occult abdominal disease in clinically staged patients without upper abdominal and splenic irradiation. If successful, these regimens should reduce treatment-related morbidity and mortality by reducing both the amount and toxicity of chemotherapy and by using smaller radiation volumes. With the objective of reducing acute toxicity and chronic morbidity (sterility, increased risk of leukemia), Horning et al. Based on the Stanford trial results reported above, 175 a follow-up Stanford University trial has been completed. No differences in 4-year freedom from disease progression or survival were noted between the two arms of the trial. At 6 years, the relapse survival rate was significantly higher for patients on the combined chemoradiotherapy arm than for those on the radiotherapy-alone arm (92% vs. The trials noted here use combination chemoradiotherapy with fewer than four cycles of chemotherapy. Although the primary goal of these trials is to evaluate the efficacy of short courses of chemotherapy, new regimens are also being tested [i. The optimal extent of radiotherapy needed is less certain in the short-course trials. This uncertainty is reflected in some of the trial designs that use subtotal nodal and splenic irradiation rather than involved-field or mantle irradiation in combination with chemotherapy. As of June 1998, 284 patients have been enrolled in the study (information provided courtesy of Dr. The chemotherapeutic regimen includes mechlorethamine (6 mg/m 2 in weeks 1 and 5), doxorubicin (25 mg/m 2 in weeks 1, 3, 5, and 7), vinblastine (6 mg/m 2 in weeks 1, 3, 5, and 7), prednisone (40 mg/m 2 on days 1 through 36, followed by tapering), vincristine (1. However, the survival rate was significantly higher in patients treated with radiotherapy alone (93%) than in those treated with chemotherapy alone (56%). Overall, the 7-year disease-free survival rate was 71% for chemoradiotherapy as compared to 62% for chemotherapy alone (P =. It is possible that treatment approaches with chemotherapy alone may be more successful in children than in adult patients. This trial has enrolled approximately 120 patients of a planned total of 200 patients. These include the use of mantle irradiation alone for selected patients with negative laparotomy staging, mantle plus paraaortic and splenic irradiation without laparotomy staging, and combination chemotherapy and radiotherapy, often with a reduced number of cycles of chemotherapy and reduction of radiation field sizes and doses. Current clinical trials are evaluating the use of alternative chemotherapy combinations, shortened courses of chemotherapy, chemotherapy with smaller radiation fields or lower radiation doses, and chemotherapy without radiotherapy. Current trials must be judged by freedom-from-first-recurrence rates, acute morbidity, and by new criteria such as quality of life and, perhaps, cost-effectiveness. New methods in decision analysis should also help in the design of trials and in the analysis of retrospective data. With different treatment options, some of which may result in a higher recurrence risk at the gain of less toxic initial treatment, patient preferences must be assessed. In addition, treatment should be individualized when a particular treatment approach might result in a higher risk of a serious late complication. Many of the ongoing trials ask questions that will allow us to optimize treatment for early-stage patients and minimize long-term toxicity. Patients with unfavorable disease require, in general, more aggressive treatment than do those with favorable disease. The high recurrence rates with radiotherapy alone led to the development of strategies in current trials that use various combinations of chemotherapy and radiotherapy. Although overall survival did not differ (69% in both arms at 15 years), treatment failure (35% vs. In both trials, the arms using modified chemotherapy were associated with significantly higher recurrence rates. Trials to Identify the Appropriate Radiotherapy Volume Several randomized trials have addressed the question of radiotherapy volumes in combined modality programs.
Diseases
Thyroid carcinoma, papillary (TPC)
Diabetes mellitus type 2
Glaucoma, congenital
Small non-cleaved cell lymphoma
Motor neuropathy
Phosphoglucomutase deficiency
Hereditary type 2 neuropathy
Spinocerebellar ataxia dysmorphism
The fuzz on the tops of the stalks forms dead air spaces and makes a good down-like insulation when placed between two pieces of material blood sugar 60 discount glipizide 10mg with amex. The husk fibers from coconuts are very good for weaving ropes and diabetes mellitus en ingles discount glipizide 10mg visa, when dried metabolic disease pcos discount 10 mg glipizide otc, make excellent tinder and insulation diabetes diet for keralites cheap 10mg glipizide visa. You can use many materials to make equipment for the cooking diabetic heart disease buy cheap glipizide 10mg on-line, eating diabetes diet in french glipizide 10mg with amex, and storing of food. Usually all materials can serve some type of purpose when in a survival situation. To make wooden bowls, use a hollowed out piece of wood that will hold your food and enough water to cook it in. However, these containers will burn above the waterline unless you keep them moist or keep the fire low. Carve forks, knives, and spoons from nonresinous woods so that you do not get a wood resin aftertaste or do not taint the food. As described with bowls, using hot rocks in a hollowed out piece of wood is very effective. You must determine your equipment needs, the tactics you will use, and how the environment will affect you and your tactics. Your survival will depend upon your knowledge of the terrain, basic climatic elements, your ability to cope with these elements, and your will to survive. Cover and concealment may be very limited; therefore, the threat of exposure to the enemy remains constant. Scattered ranges or areas of barren hills or mountains separated by dry, flat basins characterize mountain deserts. High ground may rise gradually or abruptly from flat areas to several thousand meters above sea level. Most of the infrequent rainfall occurs on high ground and runs off rapidly in the form of flash floods. These floodwaters erode deep gullies and ravines and deposit sand and gravel around the edges of the basins. If enough water enters the basin to compensate for the rate of evaporation, shallow lakes may develop, such as the Great Salt Lake in Utah or the Dead Sea. Rocky plateau deserts have relatively slight relief interspersed with extensive flat areas with quantities of solid or broken rock at or near the surface. There may be steep-walled, eroded valleys, known as wadis in the Middle East and arroyos or canyons in the United States and Mexico. Although their flat bottoms may be superficially attractive as assembly areas, the narrower valleys can be extremely dangerous to men and material due to flash flooding after rains. Trafficability in such terrain will depend on the windward or leeward slope of the dunes and the texture of the sand. Examples of this type of desert include the edges of the Sahara, the empty quarter of the Arabian Desert, areas of California and New Mexico, and the Kalahari in South Africa. Salt marshes are flat, desolate areas, sometimes studded with clumps of grass but devoid of other vegetation. They occur in arid areas where rainwater has collected, evaporated, and left large deposits of alkali salts and water with a high salt concentration. A wadi may range from 3 meters (10 feet) wide and 2 meters (7 feet) deep to several hundred meters wide and deep. A wadi will give you good cover and concealment, but do not try to move through it because it is very difficult terrain to negotiate. Surviving and evading the enemy in an arid area depends on what you know and how prepared you are for the environmental conditions you will face. Some desert areas receive less than 10 centimeters (4 inches) of rain annually, and this rain comes in brief torrents that quickly run off the ground surface. In a desert survival situation, you must first consider the amount of water you have and other water sources. The temperature of desert sand and rock typically range from 16 to 22 degrees C (30 to 40 degrees F) more than that of the air. For instance, when the air temperature is 43 degrees C (110 degrees F), the sand temperature may be 60 degrees C (140 degrees F). To conserve your body fluids and energy, you will need a shelter to reduce your exposure to the heat of the day. Radios and sensitive items of equipment exposed to direct intense sunlight will malfunction. Temperatures in arid areas may get as high as 55 degrees C (130 degrees F) during the day and as low as 10 degrees C (50 degrees F) during the night. The drop in temperature at night occurs rapidly and will chill a person who lacks warm clothing and is unable to move about. If your plan is to rest at night, you will find a wool sweater, long underwear, and a wool stocking cap extremely helpful. During daylight hours, large areas of terrain are visible and easily controlled by a small opposing force. The temperature in shaded areas will be 11 to 17 degrees C (52 to 63 degrees F) cooler than the air temperature. The emptiness of desert terrain causes most people to underestimate distance by a factor of three: What appears to be 1 kilometer (1/2 mile) away is really 3 kilometers (1 3/4 miles) away. All arid regions have areas where the surface soil has a high mineral content (borax, salt, alkali, and lime). Material in contact with this soil wears out quickly, and water in these areas is extremely hard and undrinkable. The Great Salt Lake area in Utah is an example of this type of mineral-laden water and soil. The Seistan desert wind in Iran and Afghanistan blows constantly for up to 120 days. If natural shelter is unavailable, mark your direction of travel, lie down, and sit out the storm. Therefore, be ready to use other means for signaling, such as pyrotechnics, signal mirrors, or marker panels, if available. Mirages are optical phenomena caused by the refraction of light through heated air rising from a sandy or stony surface. They occur in the interior of the desert about 10 kilometers (6 miles) from the coast. This mirage effect makes it difficult for you to identify an object from a distance. It also blurs distant range contours so much that you feel surrounded by a sheet of water from which elevations stand out as "islands. The mirage effect makes it hard for a person to identify targets, estimate range, and see objects clearly. However, if you can get to high ground (3 meters [10 feet] or more above the desert floor), you can get above the superheated air close to the ground and overcome the mirage effect. You can survey the area at dawn, dusk, or by moonlight when there is little likelihood of mirage. Moonlit nights are usually crystal clear, winds die down, haze and glare disappear, and visibility is excellent. You must avoid getting lost, falling into ravines, or stumbling into enemy positions. Movement during such a night is practical only if you have a compass and have spent the day resting, observing, and memorizing the terrain, and selecting your route. Army thought it could condition men to do with less water by progressively reducing their water supplies during training. A key factor in desert survival is understanding the relationship between physical activity, air temperature, and water consumption. The body requires a certain amount of water for a certain level of activity at a certain temperature. For example, a person performing hard work in the sun at 43 degrees C (109 degrees F) requires 19 liters (5 gallons) of water daily. The warmer your body becomes-whether caused by work, exercise, or air temperature-the more you sweat. If you stop sweating during periods of high air temperature and heavy work or exercise, you will quickly develop heat stroke. Figure 13-2, page 13-9, shows daily water requirements for various levels of work. Understanding how the air temperature and your physical activity affect your water requirements allows you to take measures to get the most from your water supply. Roll the sleeves down, cover your head, and protect your neck with a scarf or similar item. These steps will protect your body from hot-blowing winds and the direct rays of the sun. Your clothing will absorb your sweat, keeping it against your skin so that you gain its full cooling effect. By staying in the shade quietly, fully clothed, not talking, keeping your mouth closed, and breathing through your nose, your water requirement for survival drops dramatically. Food requires water for digestion; therefore, eating food will use water that you need for cooling. A person who uses thirst as a guide will drink only twothirds of his daily water requirement. Drinking water at regular intervals helps your body remain cool and decreases sweating. Even when your water supply is low, sipping water constantly will keep your body cooler and reduce water loss through sweating. Your chances of becoming a heat casualty as a survivor are great, due to injury, stress, and lack of critical items of equipment. Following are the major types of heat casualties and their treatment when little water and no medical help are available. If you fail to recognize the early symptoms and continue your physical activity, you will have severe muscle cramps and pain. Symptoms are headache, mental confusion, irritability, excessive sweating, weakness, dizziness, cramps, and pale, moist, cold (clammy) skin. Make him lie on a stretcher or similar item about 45 centimeters (18 inches) off the ground. Symptoms are the lack of sweat, hot and dry skin, headache, dizziness, fast pulse, nausea and vomiting, and mental confusion leading to unconsciousness. Lay him on a stretcher or similar item about 45 centimeters (18 inches) off the ground. Pour water on him (it does not matter if the water is polluted or brackish) and fan him. If he regains consciousness, let him drink small amounts of water every 3 minutes. In a desert survival and evasion situation, it is unlikely that you will have a medic or medical supplies with you to treat heat injuries. If someone complains of tiredness or wanders away from the group, he may be a heat casualty. A light color means you are drinking enough water, a dark color means you need to drink more. These include insects, snakes, thorned plants and cacti, contaminated water, sunburn, eye irritation, and climatic stress. Old buildings, ruins, and caves are favorite habitats of spiders, scorpions, centipedes, lice, and mites. They inhabit ruins, native villages, garbage dumps, caves, and natural rock outcroppings that offer shade. Never go barefoot or walk through these areas without carefully inspecting them for snakes. A knowledge of field skills, the ability to improvise, and the application of the principles of survival will increase the prospects of survival. Everything in the jungle thrives, including disease germs and parasites that breed at an alarming rate. However, it will take an outsider some time to get used to the conditions and the nonstop activity of tropical survival. High temperatures, heavy rainfall, and oppressive humidity characterize equatorial and subtropical regions, except at high altitudes. At low altitudes, temperature variation is seldom less than 10 degrees C (50 degrees F) and is often more than 35 degrees C (95 degrees F). Sudden rain beats on the tree canopy, turning trickles into raging torrents and causing rivers to rise. Hurricanes, cyclones, and typhoons develop over the sea and rush inland, causing tidal waves and devastation ashore. In Southeast Asia, winds from the Indian Ocean bring the monsoon, but the area is dry when the wind blows from the landmass of China. You find these forests across the equator in the Amazon and Congo basins, parts of Indonesia, and several Pacific islands. Temperatures range from about 32 degrees C (90 degrees F) in the day to 21 degrees C (70 degrees F) at night.
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Recognizing that a decedent has edema while making a chemical selection will help the embalmer create a higher-preservative solution diabete 60 discount glipizide 10mg overnight delivery. When embalming a decedent with edema diabetes diet for cats discount glipizide 10mg on-line, no matter if it is generalized or localized to a specific area diabetes type 2 japan discount glipizide 10 mg without prescription, the embalmer must consider the secondary dilution of the embalming fluid: the wateriness of the edema will cause the solution to become weaker diabete 01 cheap 10mg glipizide. A body is generally composed of about 60% water; with generalized edema metabolic disease vs infection 10mg glipizide with visa, a 10% increase of fluid in the body is considered typical diabetes mellitus out of control buy cheap glipizide 10 mg on-line. A waterless or nearwaterless solution is recommended to achieve the best preservation. Severe edema may require use of plastic garments to control leakage, and embalming powder can be added inside the plastic garments to further control leakage and odor. When a diabetes case is presented, the embalmer must keep in mind that there are several conditions that will most likely accompany the disease. These conditions include acidosis, arteriosclerosis, dehydration, gangrene, pruritus, and decubitus ulcers, and emaciation. Acidosis is the increase of acidity in the blood; the presence of this excess acid will require a higher preservative demand. Arteriosclerosis, or the narrowing of the arteries caused by calcification, causes poor circulation during life and will affect and limit the fluid distribution during the narrowing of the arteries caused by calcification, c arterial embalming. Diabetics tend to exhibit will affect to excessive urination and changed dehydration due and limit the fluid distribution during the a osmotic balance during life; since the embalming exhibit dehydration due to excessive urination and is actually dehydrating the bodyactually dehydrating the bo since the embalming is even more, special attention should be given to making sure the body has should be given to making sure the body has enou enough moisture. Gangrene, pruritus, decubitus ulcers, anddecubitusare also common, and will be discussedcommon emaciation ulcers, and emaciation are also sections below. Diabetes mellitus Diabetes mellitus is a disease in which there is a persistent state of hyperglycemia and loss of glucose 26 Hart & Loeffler, 2012, p. In living bodies, gangrene can lead embalmer must keep in mind that there tissue; if gangrene is present in the deceased, it m are several conditions that will most likely Discolored tissue in the lower extremity Discolored tissue in the lower extremity indicating poor indicating poor circulation, like that caused by diabetes. In living bodies, gangrene can lead to amputations of decomposed tissue; if gangrene is present in the deceased, it must be dealt with. If the gangrene turns out to be gas gangrene, this causes even more problems for the embalmer. Although this organism is natural flora in the intestinal tract of the human body, it is problematic anywhere outside the intestinal tract. This bacterium produces gas and necrotizing toxins, which can spread rapidly to normal tissue. In a living body, this causes more gangrene and decomposition, and in dead tissue, it can lead to the very scary tissue gas. The gangrenous limb should be hypodermically injected with a strong preservative chemical. Once the limb has been thoroughly injected, topical embalming should be performed with either a surface pack of cotton saturated with cavity fluid or a cauterizing chemical, or autopsy gel. After the area is treated, and before dressing the body, it is best to utilize a plastic garment to contain the limb. They are caused when a person is not bathed frequently and/or not moved from position to position often enough. Hypodermic injection should be done around the ulcer if it is considerably large, and then topical embalming procedures should be utilized, such as a cavity pack, autopsy gel, or a cauterizing agent. Plastic garments should also be used prior to dressing the body to prevent leakage. Embalming powder in the plastic garments provides extra odor control and preservation. Emaciation Emaciation, or abnormal thinness, can be caused by diseases like diabetes, but it can also result from such conditions as dementia, failure to thrive, and malnutrition, just to name a few. The extreme thinness of the deceased creates a skeletal look on the entire body, but the sunken facial features tend to be the most problematic for the embalmer: emaciation makes it harder to make the facial features appear natural, and sometimes causes difficulty in setting the features as well. Sites like the temples, lips, cheeks, and eyes often can be injected with tissue builder. Obesity Obesity, or the accumulation and storage of excessive fat in the body, is a growing problem: 34. Obesity can pose many problems in embalming just focusing on the disease conditions alone; add in the extra adipose tissue and the difficulty in preserving it, and obese cases make for a difficult day in the embalming room. Handling the body is the first hurdle in the process: moving the body onto the embalming table is a challenge in itself. Once the body is on the embalming table, the pre-embalming steps can begin; be certain to plan for additional time and effort as the process moves forward, due to the sheer size of the body. Determining what disease conditions the deceased Pruritus Pruritus, or an extreme itching of the skin caused by irritation or rashes during life, could lead to bruises, discolorations, leaks, and blisters. After embalming is complete, any bruising and discolorations in an area visible during viewing of the body can be treated. If they are very light but still need attention, light cosmetic can be used to cover them. If they are too dark to cover with light cosmetic, a bleaching agent can be injected under the skin with a needle and syringe, or a surface pack saturated with a bleaching agent can be applied directly to the surface of the skin overnight (be sure to cover the surface pack with plastic to avoid exposure to the fumes). If severe enough, plastic garments can be used along with embalming powder sprinkled inside after they are treated. Decubitus ulcers Decubitus ulcers, or bedsores, are deep ulcers resulting from pressure on the skin. Since the embalmer generally does not know the cause of death upon beginning the embalming process, it is best to view an obese body as a "difficult" case: the embalmer should consider a higher formaldehyde demand when figuring the primary dilution factor and mixing the chemicals, and may also consider using a low water or waterless embalming. Especially with morbidly obese individuals, the fatty tissue of the stomach area, legs, and arms should be hypodermically injected with embalming solution or undiluted cavity fluid. In addition, surface embalming with surface packs may need to be utilized for chafed areas and other open sores caused by the excess amount of skin and weight rubbing together. Plastic garments may also need to be used to prevent leakage coming from fluid seeping through the pores, as well as the oil from the fatty tissue seeping through. Prior to embalming, purge coming from the stomach can burn the skin and cause discolorations; if it is noticed, it should be cleaned up and treated immediately. If purge of any kind occurs during the arterial and cavity embalming, it is best to just let it be: it can easily be washed away with the running water of continuous disinfection, which will avoid any burning on the skin. However, the embalmer should pay special attention to where the purge is coming from, and be sure to keep an eye on those areas after the embalming is complete: additional treatment, such as nasal aspiration or reaspiration of the cavities, may need to be done. Discolorations Discolorations can be present on a dead body for a number of reasons. Some discolorations are antemortem, meaning they happen prior to death, but remain on the body after death; other discolorations are postmortem, meaning they occurred after death. There are localized discolorations where the discoloration is contained in a small area, like a black eye; there are also generalized discolorations where the discoloration is over a large portion of, or sometimes the entire, body (we have already discussed one generalized discoloration, jaundice, on pages 20-21 of this text). In particular, embalmers should be aware of blood discolorations, which can be intravascular or extravascular. Intravascular discolorations, which can generally be remedied during the arterial embalming process with massaging, include hypostasis, the discoloration caused by carbon monoxide poisoning, capillary congestion, and livor mortis. Hypostatis of the blood, or the settle of blood to dependent areas of the body, is an antemortem blood discoloration and is a blue-black in color. Capillary congestion can cause a dark red color in dependent areas such as the back and buttocks. Livor mortis, the result of hypostasis, is a postmortem discoloration and results from capillary congestion once the blood stops circulating. Extravascular discolorations, on the other hand, cannot be removed with arterial embalming, so other methods must be employed to try to rid the body of these discolorations: for example, they can possibly be lightened with surface embalming, or by hypodermically injecting bleach into the discolored tissue. Extravascular blood discolorations include ecchymosis, purpura, petechia, and hematoma, as well as postmortem stain and Tardieu spots. Purge Purge, defined as the postmortem evacuation of any substance from any external orifice of the body as a result of pressure,34 is caused by a number of things. Purge coming from the stomach is brown and coarse, and is often described as looking similar to coffee grounds. Lung purge also comes out of the mouth and nose and is a bit frothy with a red tint. Anal purge comes from the anus and is generally fecal matter, possibly with blood mixed in. Applying pressure to the lower abdomen area will help relieve the body of this purge; running water can then be used to release any solid from the skin and wash it away down the table. Purge coming from the brain, generally as a result of some sort of fracture or trauma to the skull, is a white semisolid that comes out of the ears and nose. Advanced Embalming: Shipping Human Remains Shipping human remains via common carrier is not usual; however, it can always pose problems with the body. When shipping via common carrier, the body must either be embalmed or packed in dry ice. It A purpura is a flat hemorrhage beneath the skin surface that human remains must be consulted. This generally occurs when If just the body is being shipped without a casket, a the body has been lying in place for a time after death: Postmortem stain is caused when blood exits combination casesystem after a transferThis the vascular must be used: death. For example, if the body is face down lying in place for a box with a cardboard cover that is used in place of the of the and remains that way for some time, the upon deathbody receiving pressure are where the stain appears. Postmortem stain is hard to No matter how the remains are being hard to appear on the front-side of the body, especially the face. Postmortem stain isshipped, there alleviate, but is treated in the same way as previously are several things that alleviate, but is treated in the same way as previously mentionedmust be done to ensure safe extravascular mentioned extravascular discolorations. The body should be thoroughly cleansed Tardieu spots are very small petechial hemorrhages and dried with all orifices appropriately packed. Tardieu spots are very small petechial hemorrhages thatthen be placed from the garments and body should are caused in plastic rupture of They tend to appear around the eyes after deaths due at the eyes after deaths if just tiny blood vessels. They tend to appear aroundleast partially dressed, evendue toin a hospital to asphyxiation or other slow deaths. Before placing the body in either the casket or the combination unit, place a plastic shroud underneath the body, again to help with leakage either into the casket lining or seeping from the combination unit. If the body is in a casket, it is best to line the entire inside of the casket with plastic: it can be removed or tucked under the body upon its arrival at its destination. Abdominal discolorations Abdominal discolorations If the body is casketed, place the bed of the casket in a very low, if not the lowest, position. If in a Advanced Embalming: Shipping Human Remains combination unit, secure the body to the container 10. Include a copy of the that are human remains via common Shipping caused from the rupture of tiny carrier is not usual; however, it can always pose embalming report, the burial-transit permit, and a copy blood vessels. Purpura your embalming report before, during, and after a embalmed or packed in dry ice. Hematoma home if you foresee any problems or if there are any remains must be consulted. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Prevalence of childhood and adult obesity in the United States, 2011-2012, Journal of American Medical Association, 311(8), 806-814. Words to know: Chapter 14 Alimentary Canal Bile Chyme Mucosa Submucosa Serosa Peristalsis Papillae Pancreatic Juice Secretin Cholecystokinin Essential Nutrients Carbohydrates Proteins Lipids Undernutrition Overnutrition Gallstones Hepatic duct Cystic duct Duodenum Jejunum Ileum Esophagus Liver Pancreas Villi Microvilli Colon Cecum Appendix Questions to answer: 1. Explain the role of the hormones cholecystokinin and secretin in regulating the release of bile and pancreatic juices. Identify and describe the six major processes involved in gastrointestinal activity 8. Name a specific enzyme or substance that is responsible for the chemical digestion of: > carbohydrates: > proteins: > fats/lipids: 12. State where each of the following begin and complete chemical digestion: Digestion begins in the. In the picture below, identify the following digestive organs and accessory organs. Pharynx Tongue Rectum Esophagus Stomach Parotid Gland Submandibular Gland Sublingual Gland Pancreas Ascending Colon Descending Colon Sigmoid Colon Transverse Colon Jejunum Cardioesophageal Sphincter Ileocecal valve (sphincter) Appendix Ileum Liver Gallbladder Mouth Larynx Duodenum. Dudek, PhD Professor Brody School of Medicine East Carolina University Department of Anatomy and Cell Biology Greenville, North Carolina Acquisitions Editor: Crystal Taylor Product Manager: Sirkka E. Howes Marketing Manager: Jennifer Kuklinski Vendor Manager: Bridgett Dougherty Manufacturing Manager: Margie Orzech Design Coordinator: Terry Mallon Compositor: Aptara, Inc. 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