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By J. Flint. Union Theological Seminary.
Identifying a species and determining its limits presents the most challenging aspects of biological classification for any type of organism discount topiramate 100 mg free shipping. Monera ( the prokaryotes) Kingdom of Monera Three categories: - Eubacteria Are our common order topiramate 100mg on-line, everyday bacteria, some of which are disease – causing; also the taxon from which mitochondria originated. Distinctively, however, the members of Kingdom Protista are all eukaryotic while the mebers of kingdom Monera are all prokaryotic. Some members of protista are multicellular, however Kingdom protista represents a grab bag, essentially the place where the species are classified when they are not classified as either fungi, animals or plants. Kingdom Fungi Unlike pprotists, the eukaryotic fungi are typically non – aquatic species. They traditionally are nutrients absorbers plus have additional distinctive features. The domain system contains three members 9 ¾ Eukaryotes ( domain Eukarya ) ¾ Eubacteria ( domain Bacteria) ¾ Archaebacteria ( domain Archaea) Viral classification Classification of viruses is not nearly as well developed as the classification of cellular organisms. Today viruses tend to be classified by their chemical, morphological and physiological attributes (e. Binomial nomenclature is not employed to name viruses; instead viruses are named by their common names (e. The distinguishing features between Eukaryotic cell and Prokaryotic cell Features Prokaryotic cell Eukaryotic cell. Cellular element enclosed with in the cell envelope: Mesosomes, ribosomes, nuclear apparatus, polyamies and cytoplasmic granules. Cell wall Multi layered structure and constitutes about 20% of the bacterial dry weight. Young and rapidly growing bacteria has thin cell wall but old and slowly dividing bacteria has thick cell wall. It is composed of N-acetyl Muramic acid and N-acetyl Glucosamine back bones cross linked with peptide chain and pentaglycine bridge. Contains toxic components to host Bacteria with defective cell walls Bacteria with out cell wall can be induced by growth in the presence of antibiotics and a hypertonic environment to prevent lysis. Protoplasts: Derived from Gram-positive bacteria and totally lacking cell walls; unstable and osmotically fragile; produced artificially by lysozyme and hypertonic medium: require hypertonic conditions for maintenance. Spheroplast: Derived from Gram-negative bacteria; retain some residual but non-functional cellwall material; osmotically fragile;produced by growth with penicillin and must be maintained in hypertonic medium. L- forms: Cell wall-deficient forms of bacteria usually produced in the laboratory but sometimes spontaneously formed in the body of patients treated with penicillin; more stable than protoplasts or spheroplasts, they can replicate in ordinary media. Cell membrane Also named as cell membrane or cytoplasmic membrane It is a delicate trilaminar unit membrane. Mesosomes Convoluted invagination of cytoplasmic membrane often at sites of septum formation. Nuclear apparatus Well defined nucleus and nuclear membrane, discrete chromosome and mitotic apparatus are not present in bacteria ; so nuclear region of bacteria is named as nuclear body, nuclear apparatus and nucleoid. Besides nuclear apparatus, bacteria may have extra chromosomal genetic material named as plasmids. Plasmids do not play any role in the normal function of the bacterial cell but may confer certain additional properties(Eg. Virulence, drug resistance) which may facilitate survival and propagation of the micro- organism. Glycocalyx (capsule and slime layer) Capsule is gel firmly adherent to cell envelope. Capsule is composed of polysaccharide and protein(D-Glutamate of Bacillus anthracis) Features of capsule 1. Flagellum It is the organ of locomotion in bacterial cell and consists of thee parts. The basal body The basal body and hook are embedded in the cell surface while the filament is free on the surface of bacterial cell. Pili (fimbriae) It is hair like structure composed of protein (pilin) Two types (Based on function). Sex pili: The structure for transfer of genetic material from the donor to the recipient during the process of conjugation. Spores Resting cells which are capable of surviving under adverse environmental conditions like heat, drying, freezing, action of toxic chemicals and radiation. Classification of bacteria Bacterial classification depends on the following characteristics. Morphology of bacteria When bacteria are visualized under light microscope, the following morphology are seen. Bacilli (singular bacillus): Stick-like bacteria with rounded, tepered, square or swollen ends; with a size measuring 1-10μm in length by 0.
Wise useful in ruling in a complication of pregnancy purchase topiramate 200mg on line, such as early sponta- neous abortion or ectopic pregnancy purchase topiramate 200 mg with amex. Gastrointestinal Obstruction Although gastrointestinal obstruction conventionally is not character- ized as an acute surgical abdomen, its symptoms mimic the prodrome of an acute abdomen, and its complications merit the same manage- ment urgency. Gastric outlet obstruction most commonly occurs as a result of peptic ulcerative disease or neoplasm in the parapyloric regions. The pain of gastric outlet obstruction results from visceral distention and usually is relatively mild, with a signiﬁcant sense of fullness and dis- tress in the epigastrium. The vomitus usually is free of bile, but it may contain recently ingested food or be stained by blood. Penetrating lesions, such as peptic duodenal ulcer, often induce a variable period of gnawing or burning pain prior to the obstructive symptomatology. Acute gastric dilatation, a functional response to major thoracic and upper abdominal surgery or trauma, produces a clinical picture much like mechanical obstruction. Both entities appear as a large, left upper quadrant air-ﬂuid level that outlines the distended stomach on a plain upright abdominal radiograph. In most cases of gastric dilatation or obstruction, relief can be obtained by decompression of the stomach with a nasogastric tube. Subsequent management depends on etiologic factors that can be assessed with esophagogastric endoscopy. Surgical resection or bypass of the obstructed area is required to relieve most cases of neoplastic or postinﬂammatory ﬁxed ﬁbrotic stenosis. The intraperitoneal small intestine distal to the duodenum is the most common site for obstruction of the alimentary tract. Most often, a loop of bowel is ensnared within a narrow aperture created by a strategically positioned ﬁbrotic adhesive or congenital band. Similarly, it may be trapped in the neck of an abdominal wall or intraperitoneal hernia. Gastritis Herpes zoster Pancreatitis Myocardial ischemia Splenic enlargement Pneumonia Splenic rupture Empyema Splenic infarct Diverticulitis Splenic aneurysm Intestinal obstruction Pyelonephritis Inﬂammatory bowel disease Nephrolithiasis 21. Unable to empty in either direction, the “closed loop” and its compressed mesentery expe- rience vascular compromise, ﬁrst venous with resultant congestion and edema, and ﬁnally, if unrelieved, arterial with ischemia and necrosis. Clinically, intestinal obstruction is characterized by the onset of colicky midabdominal pain and vomiting. The abdomen usually is ﬁrm if there is signiﬁcant bowel distention, but initially there is little or no direct tenderness or true abdominal wall guarding. Firm pressure on dis- tended loops of bowel, however, creates a sense of discomfort not to be confused with real tenderness. Bowel sounds are hyperactive, high pitched, and interlaced with gurgling, rumbling, and tinklings. In the presence of obstruction, an abdominal surgical scar suggests a possible obstructing adhesive band. A tender, irreducible abdominal wall hernia or palpable intraabdominal mass may represent an incar- 402 A. Wise ceration, possibly ischemic closed loop of bowel, while ascites or a non- tender ﬁrm umbilical or deep mass implies a malignant etiology. Case Discussion The woman in Case 4 has had a prior abdominal operation and now presents with evidence of bowel obstruction. Small-bowel obstruction as a result of adhesions caused by a previous operation is likely. She needs to have ﬂuid resuscitation, a nasogastric tube for decompression of the stomach, and further workup to help determine if she requires an operation. Air-ﬂuid levels are absent in a small percentage of cases when the bowel contains ﬂuid but little gas or when the obstruction is high in the small bowel and most of the intestine distal to the obstruc- tion is collapsed. If gas is seen in the colon, it suggests an incomplete mechanical obstruction, a functional ileus, or that air has been intro- duced into the rectum during rectal examination or enema. Associated free intraabdominal air is an ominous sign, usually indicative of bowel perforation. Is this mechanical intestinal obstruction a paralytic ileus or gas- troenteritis masquerading as obstruction? With ileus, there usually is an identiﬁable inciting event that has initiated the ileus, and bowel sounds are diminished markedly or absent from the onset. With gas- troenteritis, the irritative hyperperistalsis usually produces diarrhea as opposed to the obstipation seen with mechanical obstruction. Success rates for standard (short) versus long intestinal tubes in patients with small-bowel obstruction. A prospective ran- domized trial of short versus long tubes in adhesive small bowel obstruction.
Frequently rinsing the mouth with nondrying solutions buy 200mg topiramate fast delivery, lubricating the lips generic topiramate 200mg amex, and removing encrustations relieve dryness and promote comfort. Most health care facilities have written protocols for managing these systems and maintaining their sterility; strict adherence to the protocols is essential. The patient is monitored for signs and symptoms of meningitis: fever, chills, nuchal (neck) rigidity, and increasing or persistent headache. The pulse pressure (the difference between the systolic and the diastolic pressures) widens. Temperature, pulse, and respirations are closely monitored for systemic signs of infection. All connections and stopcocks are checked for leaks, because even small leaks can distort pressure readings and lead to infection. For subsequent pressure readings, the head should be in the same position relative to the transducer. Fiberoptic catheters are calibrated before insertion and do not require further referencing; they do not require the head of the bed to be at a specific position to obtain an accurate reading. Whenever technology is associated with patient management, the nurse must be certain that the technological equipment is functioning properly. The most important concern, however, must be the patient who is attached to the equipment. The patient and family must be informed about the technology and the goals of its use. Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Assessing respiratory function is essential, because even a small degree of hypoxia can increase cerebral ischemia. The respiratory rate and pattern are monitored, and arterial blood gas values are assessed frequently. The nurse must be alert to the development of complications; all assessments are carried out with these problems in mind. Chart 61-2 provides an overview of the nursing management of the patient who has undergone intracranial surgery. Seizures are a potential complication, and any seizure activity is carefully recorded and reported. Restlessness may occur as the patient becomes more responsive, or restlessness may be caused by pain, confusion, hypoxia, or other stimuli. The endotracheal tube is left in place until the patient shows signs of awakening and has adequate spontaneous ventilation, as evaluated clinically and by arterial blood gas analysis. Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. Intraventricular drainage is carefully monitored, using strict asepsis when any part of the system is handled. Overview of Nursing Management for the Patient after Intracranial Surgery Postoperative Interventions Nursing Diagnosis: Risk for ineffective breathing pattern related to postoperative cerebral edema Goal: Achievement of adequate respiratory function Establish proper respiratory exchange to eliminate systemic hypercapnia and hypoxia, which increase cerebral edema. Nursing Diagnosis: Risk for imbalanced fluid volume related to intracranial pressure or diuretics Goal: Attainment of fluid and electrolyte balance Monitor for polyuria, especially during first postoperative week; diabetes insipidus may develop in patients with lesions around the pituitary or hypothalamus. Nursing Diagnosis: Disturbed sensory perception (visual/auditory) related to periorbital edema and head dressings Goal: Compensate for sensory deprivation; prevent injury Perform supportive measures until the patient can care for self. Temperature control may be impaired in certain neurologic states, and fever increases the metabolic demands of the brain. Assess temperature of extremities, which may be cold and dry due to impaired heat-losing mechanisms (vasodilation and sweating). The patient is asked about the factors or events that may precipitate the seizures. The nurse determines whether the patient has an aura before an epileptic seizure, which may indicate the origin of the seizure (eg, seeing a flashing light may indicate that the seizure originated in the occipital lobe). Observation and assessment during and after a seizure assist in identifying the type of seizure and its management. Planning and Goals The major goals for the patient may include prevention of injury, control of seizures, achievement of a satisfactory psychosocial adjustment, acquisition of knowledge and understanding about the condition, and absence of complications. Nursing Interventions Preventing Injury Injury prevention for the patient with seizures is a priority. If the type of seizure the patient is having places him or her at risk for injury, the patient should be lowered gently to the floor (if not in bed), and any potentially harmful items nearby (eg, furniture) should be removed. Patients for whom seizure precautions are instituted should have pads applied to the side rails while in bed. Cooperation of the patient and family and their trust in the prescribed regimen are essential for control of seizures.
Five-year survival topiramate 100mg with mastercard, however cheap 200 mg topiramate with mastercard, remains low, in the range of 50% to 60%, and this speaks to the advanced age of these patients and to the comor- bidities, particularly coronary artery disease, that afﬂict these patients. We generally speak in terms of primary and secondary patency and limb salvage when describing the success of lower extremity recon- structions. Increasingly, functional outcome data also are being assessed, which helps to provide a more detailed understanding of the beneﬁts of revascularization. In general, anatomic reconstructions have better long-term patency than extraanatomic reconstruction (e. Autologous conduits have better patency than prosthetic bypasses, particularly when the distal anastomosis is to an artery below the knee joint. It is important to remember that veins have valves and that these must be accounted for when a vein is going to be used as an arterial conduit. Endovascular procedures have been around since the early 1960s, but they have been reﬁned over the past decade. Most of these proce- dures can be performed percutaneously and therefore obviate the need for an incision and the associated pain, healing, and recovery. Many endovascular procedures, therefore, readily can be done using only local anesthesia or in combination with mild sedation. Most of the techniques are preformed with a guidewire technique devised originally by Seldinger. These are all in a state of evolution, but there is growing evidence to support their use in properly selected patients (Table 28. Comparative evaluation of prosthetic, reversed, and in situ vein bypass grafts in distal popliteal and tibialperoneal revascularization. Durability of the in situ saphenous vein arterial bypass: a com- parison of primary and secondary patency. Randomization of autogenous vein and polytetraﬂuoroethylene grafts in femoral-distal reconstruction. Improved patency in reversed femoral-infrapopliteal autogenous vein grafts by early detection and treatment of the failing graft. Successful vein bypass in patients with an ischemic limb and a palpable popliteal pulse. Results of revascularization and amputation in severe lower extremity ischemia: a ﬁve-year clinical experience. Short-term and midterm results of an all-autogenous tissue policy for infrainguinal reconstruction. Infrapopliteal arterial bypass for limb salvage: increased patency and uti- lization of the saphenous vein used “in situ. Long-term results of infragenicular bypasses with autogenous vein originating from the distal superﬁcial femoral and popliteal arteries. Autogenous reversed vein bypass for lower extrem- ity ischemia in patients with absent or inadequate greater saphenous vein. Present status of reversed vein bypass grafting: ﬁve-year results of a modern series. Inﬂuence of Losartan, an angiotensin receptor antag- onist, on neointimal proliferation in cultured human saphenous vein. Six-year prospective multicenter randomized comparison of autologous saphe- nous vein and expanded polytetraﬂuoroethylene grafts in infrainguinal arterial reconstructions. Percutaneous transluminal angioplasty of the arteries of the lower limbs: a 5-year follow-up. Percu- taneous transluminal angioplasty of the femoropopliteal artery: initial and long-term results. Results of percutaneous transluminal angioplasty for peripheral vascular occlusive disease. Case Discussion The most appropriate ﬁrst step in dealing with the presented patient would be to anticoagulate her with systemic heparin. If she is a rea- sonable operative candidate, then one could go to the operating room and, under local anesthesia, perform a diagnostic angiogram. Depend- ing on the ﬁndings, a decision could be made as to whether the ischemia could be resolved with either endovascular techniques (e. Caution should be taken, however, to avoid lengthy emergent surgical procedures on these very elderly patients with signiﬁcant comorbidities. Summary Lower leg ischemia as a manifestation of peripheral arterial disease is common. Patients, like the patient in our case, may present with acute ischemia and warrant more aggressive management. The level of intervention, however, always must be tailored to the overall condition of the patient. Given the presences of signiﬁcant comorbidities in our patient, signiﬁcant caution is warranted before 510 R.