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Delegates attending this short-course will benefit from an introductory overview of the terminology and classification of breast cancer and principle issues in its treatment mircette 15mcg fast delivery. Commonly available physiotherapy treatment options will be reviewed generic mircette 15mcg overnight delivery, particularly in relation to exercise prescription, management of complications and palliative care. We trust that the following short-course and information booklet will add to your knowledge around the area of breast cancer care and enhance your skills as a developing clinician. John Allen, Clodagh Burrell, Clara Caplice, Deirdre Collins, Patrick McGreal & Joanne Purcell. To outline the breast cancer provision of services and care pathways in Ireland and abroad. To give a comprehensive description of the role of the physiotherapist and exercise provision in the care of breast cancer patients. To outline and describe the role of the physiotherapist in the management of complications commonly experienced by breast cancer patients. To discuss possible medical oncological emergencies and to educate the physiotherapist in how to deal with such emergencies. To give an overview of the psychosocial impact of breast cancer diagnosis and treatment on a breast cancer patient. To discuss the long-term management of breast cancer patients in terms of return to work and the prevention of cancer recurrence. To give a brief overview of outcome measures used by physiotherapists in the management of breast cancer patients. To summarise effective communication methods that may be helpful when treating breast cancer patients. It consists of four phases; 1) M phase - Mitosis is an ongoing process and consists of the following stages: - Prophase - Chromosomes are visible, spindle fibres form, nuclear envelope dissolves - Metaphase - Chromosomes line up in the middle of the cell - Anaphase - Chromosome pairs separate to different sides by the spindle fibres. Cell Cycle (Langthorne et al, 2007) 7 Pathogenesis of Cancer: Cancer cells differ from their normal cells in that they have abnormal regulation. Six hallmarks form a principle that provides a logical framework for comprehending the diversity of neoplastic diseases. As normal cells progress to a neoplastic state, they acquire these hallmark capabilities. The Hallmarks of Cancer 1) Sustaining Proliferation: Cancer cells have the ability to sustain chronic proliferation without external stimulation. Normal tissues carefully control the production and release of growth-promoting signals, through proto-oncogenes, thereby ensuring a homeostasis of cell number and maintenance of normal tissue structure and function. In cancer cells, the change of pro-oncogenes to oncogenes promotes self-sufficient cell growth. In cancer cells, telomere shortening is averted by the enzyme telomerase, enabling widespread self-replication. Through angiogenesis, a vascular system is generated for continued tumour growth and metastasis. Chemotherapy and follow up care will be delivered more locally, according to care plans set at the cancer centres. Cancer centres aim to reform and restructure services to improve patient outcomes. It offers breast screening services free of charge to women who are aged between 50-64, repeat breast screening within an interval of 21-27 months. BreastCheck further plans to roll out screening to 64-69 year olds and to lower screening age to 47 in the coming years. Incidence rate and mortality rate in comparison to our European th counterparts leave us ranked in 4 place for both. Non-invasive means it hasn’t spread beyond the ducts into surrounding breast tissue. This form of cancer tends to be more aggressive and harder to treat than others and has a higher prevalence in younger women and African-American women. The nipple and areola often appear crusted and red, with the possibility of bleeding and oozing. These include: Female Gender Hormonal Factors Age Benign Breast Disease Personal history of cancer Obesity and Dietary Fat Family history of cancer and Radiation exposure genetics Female Gender Breast cancer accounts for over 32% of all invasive cancers in women and only 1% in men. Age The risk of breast cancer increases with age, with breast cancer extremely rare in those under 20 years, however incidence rates increase sharply and become substantial before 50 years. Personal History of Cancer Previously diagnosed breast cancer increases the risk by 4 times of breast cancer in the opposite breast. Previous ovarian, endometrial or colon cancer have been associated with a 1- 2 times increased risk over the general population. Hormonal Factors Early menarche (before 12), late menopause (after 55) and greater total duration of regular menses are associated with an increased risk of breast cancer. Radiation Exposure Women exposed to ionizing radiation of the chest have been shown to be at an increased risk of developing breast cancer. Obesity and Dietary Fat 16 Obesity occurs in approximately 60% of patients at diagnosis of breast cancer and a further 60-75% gain weight during treatment. The majority of studies indicate that being obese is a poor prognostic factor and are associated with less favourable nodal status as well as increased risk of contralateral disease, recurrence, co-morbid disease and overall mortality (Doyle et al, 2006).
Structurally order mircette 15 mcg with mastercard, the endometrium consists of two layers: the stratum basalis and the stratum functionalis (the basal and functional layers) mircette 15 mcg on-line. The stratum basalis layer is part of the lamina propria and is adjacent to the myometrium; this layer does not shed during menses. In contrast, the thicker stratum functionalis layer contains the glandular portion of the lamina propria and the endothelial tissue that lines the uterine lumen. It is the stratum functionalis that grows and thickens in response to increased levels of estrogen and progesterone. In the luteal phase of the menstrual cycle, special branches off of the uterine artery called spiral arteries supply the thickened stratum functionalis. This inner functional layer provides the proper site of implantation for the fertilized egg, and—should fertilization not occur—it is only the stratum functionalis layer of the endometrium that sheds during menstruation. Recall that during the follicular phase of the ovarian cycle, the tertiary follicles are growing and secreting estrogen. At the same time, the stratum functionalis of the endometrium is thickening to prepare for a potential implantation. The post- ovulatory increase in progesterone, which characterizes the luteal phase, is key for maintaining a thick stratum functionalis. As long as a functional corpus luteum is present in the ovary, the endometrial lining is prepared for implantation. Indeed, if an embryo implants, signals are sent to the corpus luteum to continue secreting progesterone to maintain the endometrium, and thus maintain the pregnancy. If an embryo does not implant, no signal is sent to the corpus luteum and it degrades, ceasing progesterone production and ending the luteal phase. Without progesterone, the endometrium thins and, under the influence of prostaglandins, the spiral arteries of the endometrium constrict and rupture, preventing oxygenated blood from reaching the endometrial tissue. As a result, endometrial tissue dies and blood, pieces of the endometrial tissue, and white blood cells are shed through the vagina during menstruation, or the menses. The first menses after puberty, called menarche, can occur either before or after the first ovulation. The Menstrual Cycle Now that we have discussed the maturation of the cohort of tertiary follicles in the ovary, the build-up and then shedding of the endometrial lining in the uterus, and the function of the uterine tubes and vagina, we can put everything together to talk about the three phases of the menstrual cycle—the series of changes in which the uterine lining is shed, rebuilds, and prepares for implantation. The timing of the menstrual cycle starts with the first day of menses, referred to as day one of a woman’s period. Cycle length is determined by counting the days between the onset of bleeding in two subsequent cycles. Because the average length of a woman’s menstrual cycle is 28 days, this is the time period used to identify the timing of events in the cycle. However, the length of the menstrual cycle varies among women, and even in the same woman from one cycle to the next, typically from 21 to 32 days. Just as the hormones produced by the granulosa and theca cells of the ovary “drive” the follicular and luteal phases of the ovarian cycle, they also control the three distinct phases of the menstrual cycle. Menses Phase The menses phase of the menstrual cycle is the phase during which the lining is shed; that is, the days that the woman menstruates. Recall that progesterone concentrations decline as a result of the degradation of the corpus luteum, marking the end of the luteal phase. Proliferative Phase Once menstrual flow ceases, the endometrium begins to proliferate again, marking the beginning of the proliferative phase of the menstrual cycle (see Figure 27. It occurs when the granulosa and theca cells of the tertiary follicles begin to produce increased amounts of estrogen. High estrogen levels also slightly decrease the acidity of the vagina, making it more hospitable to sperm. In the ovary, the luteinization of the granulosa cells of the collapsed follicle forms the progesterone- producing corpus luteum, marking the beginning of the luteal phase of the ovarian cycle. In the uterus, progesterone from the corpus luteum begins the secretory phase of the menstrual cycle, in which the endometrial lining prepares for implantation (see Figure 27. If fertilization has occurred, this fluid will nourish the ball of cells now developing from the zygote. If no pregnancy occurs within approximately 10 to 12 days, the corpus luteum will degrade into the corpus albicans. Prostaglandins will be secreted that cause constriction of the spiral arteries, reducing oxygen supply. In all cases, the virus enters body cells and uses its own genetic material to take over the host cell’s metabolic machinery and produce more virus particles. These women ranged in age from 14 to 59 years and differed in race, ethnicity, and number of sexual partners.
The distensible stomach is involved in both the mechanical and chemical breakdown of food cheap mircette 15 mcg fast delivery, and also serves as a temporary reservoir 15 mcg mircette sale. The gastric mucosa contains gastric pits (foveolae), which are surface invaginations that also serve as the ducts of the underlying intrinsic gastric glands. Three basic cell types contribute to the secretion of gastric juice, and each has a characteristic appearance under the light and electron microscope. Mucus-secreting cells: These cells form the surface epithelium and extend inward to line the gastric pits. Nuclei are basal, and the supranuclear cytoplasm containing mucinogen granules appears clear or vacuolated with H & E stain. Mucous neck cells occur in the junctional region of the gastric pits and glands, and it is in this region that cell proliferation for the renewal of the epithelium occurs. Parietal cells: These pyramidal or spherical cells appear wedged in between other cells of the gastric glands. They are characterized by their finely granular acidophilic cytoplasm due to an abundance of mitochondria, and by their central, spherical nucleus. Chief (zymogen) cells: These cells are involved in the secretion of enzymes, particularly the proteolytic enzyme pepsinogen (pepsin in the active state). As is characteristic of cells involved in protein synthesis and secretion, these cells contain basophilic cytoplasm, particularly at their base due to the extensive development of rough endoplasmic reticulum. Locate the following elements of the mucosa: the luminal surface mucous secreting cells, the gastric pits and the cells lining them. Note the loose connective tissue surrounding the gastric pits, the muscularis mucosae, which forms a boundary between the mucosa and submucosa, and the blood vessels in the submucosa. Examine the muscularis externa and notice that the smooth muscle is oriented in several different planes. Look for differences in the epithelial surface and note the thickening of the muscularis externa of the stomach as it becomes the pyloric sphincter. Although the gastric mucosa is characterized by surface pits and the intestinal mucosa is characterized by finger-like villi, this distinction is not always readily apparent on sections. One of the best ways to distinguish between the two organs is to examine the surface Small intestine on right, stomach on left 80 epithelium that lines the pits or villi. In the intestinal villi however, most of the cells are absorptive cells, and interspersed between these are the characteristic mucous-secreting goblet cells. In addition, a brush border can sometimes be seen on the free surface of the absorptive cells in well-preserved intestinal villi. The duodenum is also characterized by the presence of mucous-secreting duodenal glands (of Brunner) in its submucosa. These are characterized by the accumulation of large acidophilic granules in their apical cytoplasm, and by their strongly basophilic basal cytoplasm. Note also the staining in the loose connective tissue of the lamina propria and the intense staining of goblet cells in the epithelium. There are also mast cells, which are smaller than macrophages and filled with intensely stained granules. This is a good slide in which to review the structure of arteries, veins, and the peripheral autonomic plexus. There is an abrupt transition between the rectal simple columnar epithelium and the stratified epithelium of the anal canal. The anal epithelium may appear stratified cuboidal at the junction with the rectum, but it assumes a typical stratified squamous appearance more distally. The inner circular layer of the muscularis externa is thickened considerably to form the internal anal sphincter. Abnormal dilation and varicosity of these vessels causes an inward bulging of the mucous membrane and a partial occlusion of the anal canal, resulting in internal hemorrhoids. These glands are classified according to: (1) the organization of the cells in the secretory portion of the gland e. The parotid, submandibular, and sublingual glands are all compound (branched), tubulo-alveolar (acinar) glands with a merocrine (exocytotic) type of secretion. The secretory product is either serous (a protein product secreted in vesicles) or mucous (a large sulfated glycoprotein). The cytoplasm of mucous cells appears unstained due to the loss of the mucus product during tissue preparation. There are myoepithelial cells between the basal lamina and the basal plasma membrane of the secretory cells. A fibrous connective tissue capsule surrounds the gland and sends septa inward that subdivide the gland into lobules. Scan the slide on low power and observe that within each lobule there are several prominent ducts with a more distinct lumen, which stand out sharply from the surrounding acini because of their acidophilia.
However generic mircette 15mcg without prescription, a recent report describes a resistant H5N1 strain carry- ing the H274Y mutation causing viremia in two patients who subsequently died from avian influenza (de Jong 2005) generic mircette 15mcg with amex. Zanamivir seems to retain in vitro activity against some oseltamivir-resistant strains (McKimm-Breschkin 2003, Mishin 2005). Following clinical use, the incidence of development of resistant strains is lower among adults and adolescents older than 13 years, than among children. These findings are reason for concern, since children are an important transmission vector for the spread of influenza virus in the community. In the case of an H5N1 pandemic, the frequency of resistance emergence during osel- tamivir treatment of H5N1 paediatric patients is uncertain, but it is likely to be no less than that observed in children infected with currently circulating human influ- enza viruses (Hayden 2005). Neuraminidase inhibitors are effective against the virus that caused the 1918 pan- demic (Tumpey 2002). Indications for the Use of Neuraminidase Inhibitors ® ® Oseltamivir (Tamiflu ) and zanamivir (Relenza ) are currently licensed for the treatment of influenza A and B. They should be used only when symptoms have occurred within the previous 48 hours and should ideally be initiated within 12 hours of the start of illness. In addition, oseltamivir – but not zanamivir (with the exception of two countries) – is also licensed for prophylaxis when used within 48 hours of exposure to influ- enza and when influenza is circulating in the community; it is also licensed for use in exceptional circumstances (e. Oseltamivir and zanamivir seem to have similar efficacy, but they differ in their modes of delivery and tolerability. Zanamivir is delivered by inhalation and is well tolerated; however, children, especially those under 8 years old, are usually unable to use the delivery system appropriately and elderly people may have difficulties, too (Diggory 2001). Antiviral Drugs 173 M2 Ion Channel Inhibitors Amantadine and rimantadine are tricyclic symmetric adamantanamines. They are active only against influenza A virus (influenza B does not possess an M2 protein), have more side effects than neuraminidase inhibitors, and may select for readily transmissible drug-resistant viruses. M2 inhibitors block an ion channel formed by the M2 protein that spans the viral membrane (Hay 1985, Sugrue 1991) and is required for viral uncoating (for more details see the Drugs chapter). Both drugs are effective as treatment if started within 24 hours of illness onset, reducing fever and symptoms by 1–2 days (Wing- field 1969, Smorodintsev 1970, van Voris 1981). Daily prophylaxis during an influenza season reduces infection rates by 50–90 % (Dawkins 1968, Dolin 1982, Clover 1986). In one study, rimantadine was ineffective in pro- tecting household members from influenza A infection (Hayden 1989). In addition, amantadine has a wide range of toxicity which may be in part attributable to the anticholinergic effects of the drug. The same frequency of side effects was found when the drug was tested in young healthy volunteers over a four-week period. Among 44 individuals, side effects (dizziness, nervousness, and insomnia) were well tolerated by most subjects, but 6 volunteers discontinued amantadine because of marked complaints. When studied in 450 volunteers during an outbreak of influenza A, the prophylactic effects of rimantadine and amantadine were comparable. Influ- enza-like illness occurred in 14 % of the rimantadine group and in 9 % of the amantadine group (Dolin 1982). Withdrawal from the study because of central nervous system side effects was more frequent in the amantadine (13 %) than in the rimantadine group (6 %). The potential for drug interactions is greater for amantadine, especially when co- administered with central nervous system stimulants. Agents with anticholinergic properties may potentiate the anticholinergic-like side effects of amantadine. Point mutations in the M gene lead to amino acid changes in the transmembrane region of the M2 protein and may confer high-level resistance to amantadine. The genetic basis for resistance appears to be single amino acid substitutions at positions 26, 27, 30, 31 or 34 in the transmembrane portion of the M2 ion channel (Hay 1985). In an avian model, they were also genetically stable, showing no reversion to the wild- type after six passages in birds over a period of greater than 20 days (Bean 1989). Such strains may develop in up to one third of patients treated with amantadine or rimantadine; in immunocompromised individuals the percentage may even be higher (Englund 1998). Drug-resistant influenza A virus (H3N2) can be obtained from rimantadine-treated children and adults as early as 2 days after starting treat- ment (Hayden 1991). Some H5N1 strains which have been associated with human 174 Treatment and Prophylaxis disease in Southeast Asia are resistant against amantadine and rimantadine (Peiris 2004, Le 2005), while isolates from strains circulating in Indonesia and, more re- cently, in China, Mongolia, Russia, Turkey and Romania are amantadine sensitive (Hayden 2005). Some authors have suggested that the use of amantadine and rimantadine should be gen- erally discouraged (Jefferson 2006). Indications for the Use of M2 Inhibitors Comparative studies indicate that rimantadine is tolerated better than amantadine at equivalent doses (Stephenson 2001). Treatment of “Classic” Human Influenza In uncomplicated cases, bed rest with adequate hydration is the treatment of choice for most adolescents and young adult patients. However, salicylates must be avoided in children of 18 years or younger because of the association of salicylate use and Reye’s syndrome. Ideally, the choice of the drug should be guided by Gram staining and culture of respiratory specimens. In daily practice, however, the aetiology cannot always be determined, and so treatment is empirical, using antibacterial drugs ef- fective against the most common pathogens in these circumstances (most impor- tantly S.