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By S. Arokkh. Pennsylvania State University at Altoona.

Blood Group AntiGens And AntiBodies 127 which predicted genotype will result in red blood cells that lack the c antigen order cheap torsemide. If a person is D positive cheap torsemide express, using Weiner nomenclature discount torsemide 10 mg mastercard, his predicted genotype is designated with a capital R. This phenotype does not have the c antigen and can therefore, be transfused to a patient with anti-c. Finally, rr (dce/dce) (Answer E) is homozygous for c and should not be transfused (Table 6. Which of the following is the most common predicted Rh genotype in African American patients? Blood Group AntiGens And AntiBodies Answer: D—The table above demonstrates the prevalence of the more common predicted Rh genotypes in those of African ancestry. Antigen typing and determining possible and most probable predicted genotypes can allow transfusion medicine specialists to make assumptions about a patient’s true genotype. However, molecular techniques should be used to accurately determine this information. The other choices (Answers A, B, C, and E) are incorrect based on the table above. Anti-G should be suspected whenever a pattern of anti-D and anti-C is detected in red cell antibody identifcation panel testing. Rh antibodies are clinically signifcant and anti-D and anti-C/suspected anti-G should be further investigated, especially in the prenatal setting. Anti-G can be verifed when tested with a rare D-C-G+ cell or by double adsorption/elution techniques. Verifcation of the presence of anti-D/anti-C or anti-D/anti-C and anti-G is not generally pursued outside of the obstetric population since the provision of D-C- antigen negative units would be appropriate for a safe transfusion. Anti-D (Answer D) alone would not explain the positive reaction with panel cells no. The negativity of panel cell six rules out a combination of E and D (Answer B) and the negativity of panel cells seven and eight rules out Anti-C alone (Answer A). This individual may produce the a a corresponding antibody to the high incidence En antigen, anti-En. The U-negative phenotype is predominantly found in individuals of African ancestry. These individuals may produce the corresponding antibody to a high incidence antigen; anti-U. The frequency of the common antigens in this system, M, N, S, s, U, is useful to know for provision of a safe transfusion. Alternately, anti-En has been documented in the literature to be a clinically signifcant antibody. Provision of En(a−) or U− red cells is challenging, a since 99%–100% of the population is En(a+) and U+. Answer: D—The s antigen is present in 89% of the population; therefore, only 11% of the population would be compatible with the patient who has anti-s. Matching for the s antigen may be relatively diffcult (10% seronegative in the general population). If rare antisera is unavailable to confrm red cell a units as Kp(a−), what is the best choice for provision of blood for the patient with anti-Kp? Call the rare donor program a a Concept: Anti-Kp is an antibody to a low prevalence antigen. There is no reason to suggest this patient should not be transfused based on these test results 130 6. A 20-year-old woman is 21 weeks pregnant and initial antibody detection (screen) results are below. Anti-Fy Concept: Anti-K is an IgG reactive antibody, which is known to be clinically signifcant. Anti-K does not bind complement, but the antibody is able to cause extravascular hemolysis. Therefore, anti-K is typically considered clinically signifcant at a titer of 8, in contrast to other antibody groups that are considered signifcant at a titer of ∼16. None of the other antibodies are consistent with the screen results (Answers A, B, C, and E). Antibodies in the Lutheran system are generally not considered clinically signifcant. If a Lutheran antibody is associated with a hemolytic transfusion reaction, the reaction is generally mild. Lutheran antigens demonstrate variable strength observed in serologic testing, which accounts for the characteristic mixed-feld agglutination patterns observed. Lutheran antigens are present on blood vessels and tissues including brain, heart, kidney, liver, lung, placenta, pancreas, atrial wall, tongue, trachea, skin, skeletal muscle, cervix, ileum, colon, stomach, and gall bladder, but are not present on lymphocytes, granulocytes, monocytes and platelets. The antigens are detected on fetal cells at 10–12 weeks gestation and are poorly developed at birth. Answer: B—Lutheran antibodies are adsorbed by the Lutheran antigens present on the placenta and Lutheran antigens are only weakly expressed on cord cells. Lutheran antigens are able to stimulate IgG clinically signifcant antibodies, evidenced in a mild to moderate transfusion reactions which have been documented in the literature. The most common phenotype in the Duffy blood group system in the Caucasian population is which of the following? The system is made up of two common antigens which result in the common phenotypes of Fy(a+b−)/ in 20% of the Caucasian population, Fy(a+b+) in 48% of the Caucasian population and Fy(a−b+) in 32% of the Caucasian population. A null expression Fy(a−b−) is associated with black phenotypes with up to 67%–70% of African Americans lacking the Duffy antigens. Answer: B—Although Fy(a−b−) is the most common phenotype in the African/Black population (Answer D), the Fy(a+b+) phenotype is most common in the European/white populations (83%). Fy(a+b−) (Answer C) is the second most common phenotype in the Caucasian population. Fy(a−b−) x phenotypes (Answer D) are most common in individuals of African descent. The Fy (Answer E) allele correlates with an unusual weak expression of Fy antigen in a Caucasian. Of the following phenotypes, the most common among individuals of African ancestry is which of the following? Jk(a+) phenotypes are found in 91% of African/Black populations while only 77% of the European/Caucasian population. Another example is Jk(b−) phenotype is found in 57% of African/Black population while only 28% of the European/ Caucasian Anti-Jk3 made to a high prevalence antigen is produced by individuals who are Jk(a−b−) phenotype. This expression is more prevalent in Philippino, Polynesian, Chinese, Japanese, and Indonesian populations. The rare Jk(a−b−) (Answer D) phenotype is associated with Pacifc islander, Japanese and Chinese populations. None of the other choices (Answers B, C, and E) are correct for this ethnic group.

These protocols have more gradual increases in workload and can be modified to suit the individual buy genuine torsemide online. The Naughton protocol is good for older or debilitated persons and allows a gradual increase in workload purchase torsemide cheap online. The Cornell protocol is good for a wider range of fitness levels depending on the starting grade 20mg torsemide for sale. It allows for a gradual increase in grade and speed and may be started at 0%, 5%, or 10% grade, depending on fitness level. Ramp protocols are computer-driven protocols that continuously increase workload until maximum exertion is reached. This is the ultimate in continuous advancement, but steady state may not be reached at any given workload. Although not the only data that should be examined, electrocardiographic changes garner the most attention in test interpretation. During exercise, there is depression of the J junction that is maximal at peak exercise and returns to baseline during recovery. This normal depression is upsloping and typically <1 mm below the isoelectric line 80 ms after the J point. This change was made to have a more stable end point, because the end of the T-wave is much more difficult to find than the peak of the T-wave. Changes in the lateral leads, particularly V , are more specific than in any of the other leads. These changes do not imply ischemia (although they may imply viability) and should be interpreted as normal. The T-wave normally decreases gradually in early exercise and begins to increase in amplitude at maximal exercise. If the U-wave is upright at baseline, U-wave inversion may be associated with ischemia, left ventricular hypertrophy, and valvular disease. Ectopic atrial and ventricular beats during exercise are not predictive of outcome, but ventricular ectopy during recovery may be associated with worse outcome. Sustained ventricular tachycardia and ventricular fibrillation are abnormal but occur rarely. The longer into recovery that it takes for electrocardiographic changes to resolve, the higher is the probability that they are important. Rapid recovery (<1 minute) indicates less likelihood of disease and that disease if present is less severe. Heart rate should not be used as an indicator of maximal exertion or in the decision to terminate testing. If there are substantial electrocardiographic changes, the test is read as abnormal, regardless of the heart rate achieved. This is a subjective scale used to rate how much effort the subject feels he or she is expending during an exercise test. The subject should be advised to rate how he or she feels overall and not according to an individual element such as leg fatigue. Although subjective, the scale has been shown to be reproducible, and maximum ratings correspond well with maximum exertion. The original scale ranges from 6 to 20, which is meant to correspond to a heart rate increase from 60 to 200 beats/min during exercise. The scale includes word anchors, which are important for an accurate assessment of work level. A maximal level of exertion is marked by a score >18 (Borg scale) or 9 (modified Borg scale), respiratory quotient >1. Diastolic blood pressure decreases with exercise and may be audible down to 0 during vigorous activity. The presence or absence of symptoms and their change over time are included in the final report. On the basis of age and workload achieved, functional capacity can be divided into five classifications (Table 45. The adjusted relative risk for fair or poor functional capacity in this population was almost 4. The decision when to terminate a test ultimately relies on the expertise and judgment of those performing the test. Relative indications for termination of testing are findings that should increase the level of concern and vigilance among those administering the test and possibly cause cessation of testing. Relative indications for termination rely heavily on the judgment of the personnel performing the test, and the decision to continue the test should not be made lightly (Table 45. The length of the cool-down period may vary from 30 seconds to several minutes, depending on the person. A general rule is to allow enough time for the heart rate to drop to <110 beats/min. Although the terms positive and negative are often used, these terms do not accurately describe the results of an exercise electrocardiographic test and should be avoided. The information to include in an exercise electrocardiographic report is listed in Table 45. Exercise electrocardiographic test results can be normal, abnormal, normal except for, or nondiagnostic (Table 45. This nomogram was derived by means of regression analysis and can be a useful tool in determining prognosis and the degree of aggressiveness needed in treating a patient. The heart rate recovery, defined as the difference in heart rate at peak exercise and at 1 minute after cessation of exercise, has important prognostic significance. A heart rate recovery of 12 beats/min or less is considered abnormal during an upright cool- down period. For patients assuming an immediate supine position, such as during exercise echocardiography, a value of <18 beats/min is considered abnormal. Ventricular ectopy in recovery from exercise, including frequent ventricular ectopics (>7/min), couplets, bigeminy, trigeminy, ventricular tachycardia, and ventricular fibrillation, has been shown to be predictive of all-cause mortality. These findings in recovery are a better predictor of death than ventricular ectopy during exercise. Complications of exercise electrocardiographic testing are rare, but they do occur (Table 45. Several researchers have looked at large numbers of unselected persons involved in various activities to determine risk. For the general population, there is approximately 1 cardiac arrest per 565,000 person-hours of exercise. In one study, no complications occurred in 380,000 exercise tests of young persons with presumably no heart disease. In this population, they occur in 9% of tests compared with an overall incidence of 0. Atrial fibrillation is the most common arrhythmia that occurs during testing, occurring in 9. Deaths during exercise testing are exceedingly rare among well-monitored patients, but may occur in 1 of 25,000 tests.

The left lower lobe has apical (superior) buy discount torsemide, and basilar The airways can be divided into the upper airways segments anterior cheap 20mg torsemide with visa, lateral and posterior segments order torsemide 10mg visa. The worsens asthma and is an important cause for upper airways above thorax, best known as the chronic cough. The nasopharynx has become very upper respiratory tract includes the nose, mouth, important to the pulmonary physician, as it is the pharynx and larynx. The diagnosis is often occurs secondary to pulmonary or mediastinal suspected when a patient with respiratory disease. Vocal associated with malignant mediastinal lympha- cord paralysis also predisposes to aspiration denopathy, this condition is often seen with benign syndromes. Small airways less than 2 mm diameter, which largely correspond to the bronchioles, have been studied more recently and disorders of small airways can also be called bronchiolar disease. The small airways have been called the silent zone of the lungs as they contribute little to the resistance offered by the airways to airflow. The Pulmonary Parenchyma The lung parenchyma chiefly consists of the functional units called the acinus. In addition to the bronchiole, there are additional or collateral channels of ventilation present in the acinus. These are inter- alveolar pores of Kohn, the inter-bronchiolar channels of Lambert and the channel between one bronchiole to another alveolus described by Martin. These collaterals Disorders of the trachea are usually as a result of also help in spread of inflammation from one acinus obstruction by neoplasms, strictures, e. Filling up of an acinus with different intubation stricture, and external compression, e. Disorders 8-10 mm in diameter on chest radiographs, several of the upper airways causes dyspnea with stridor, of which coalesce to form patchy irregular opacities which is an inspiratory sound, often mistaken for and finally segmental or lobar opacities called acinar wheeze, but is differentiated by its loudness when pattern. Infectious or noninfectious inflammatory auscultated over the neck than over the chest. Rarely material as in pneumonia or sarcoidosis, blood as 6 Textbook of Pulmonary Medicine in alveolar hemorrhagic diseases, water as in of the pulmonary arteries divide and follow the alveolar stage of pulmonary edema, neoplastic bronchial branches up to the terminal bronchioles. After gas exchange at the Dilatation and destruction of the acinus is called alveolo-capillary membrane, oxygenated blood is emphysema. When the respiratory bronchiole are carried by pulmonary veins, which drain into the mainly affected it is called centrilobular emphysema left atrium. Rarely the bronchial artery alpha-1 anti trypsin deficiency and when the might have a common origin with the spinal artery. This knowledge is important while performing alveolus is predominantly affected it is called bronchial artery embolization for hemoptysis. The paraseptal emphysema, seen with pulmonary procedure should be abandoned if aortography fibrosis. The interstitium is the tissue framework that Disorders involving the pulmonary vasculature supports the airways, the pulmonary vasculature are common. It contains reticulin threads, when a remote thrombus usually from the calf veins elastic fibers and interstitial cells. Increase in the basement membrane of the alveolarepithelium pulmonary artery pressure is the commonest and capillary endothelium are fused. Decompensation of the alveolo-capillary membrane with alveolitis and enlarged right heart results in systemic venous vasculitis along with interstitial inflammation. The lungs have a dual blood supply namely the The Pulmonary Lymphatics pulmonary and bronchial systems. The pulmonary arteries, right and left carry de-oxygenated blood, The respiratory system has an extensive lymphatic which is brought to the right heart from the systemic drainage. Branches cisterna chyli, which ascends into the posterior The Respiratory System: Applied Anatomy and Physiology 7 mediastinum through the aortic hiatus to the right lymph drainage occurs through inter connecting of the midline between the aorta and the azygous mediastinal, paratracheal and sub diaphragmatic vein. Beyond this point it arches The Control of Respiration into the superior part of the mediastinum and The function of respiration is automatic and is under descends into the junction between the left internal the control of the respiratory center situated in the jugular and subclavian veins. Activity of the respiratory center is related why injury to the thoracic duct below 5th and 6th to level of activity of the brain stem, so that thoracic vertebra produces a right-sided chylothorax depression of brain by sleep, hypnotics and and injury above this level a left-sided chylothorax. With situated in the brain and peripheral chemoreceptors distal obstruction these collaterals become functional situated in the carotid and aortic bodies. Beyond from the respiratory center stimulate the respiratory the mediastinum the thoracic duct and its tributaries muscles causing expansion of the thoracic cage and receive additional non-chylous lymph from the lungs lung inflation. Pulmonary interstitial fluid lungs reach the respiratory center, which inhibits the enters lymphatic vessels at the level of the alveolar inspiratory center so that lungs deflate. The ducts, which drains centrally towards the hila and diaphragms and the parasternal muscles are the peripherally over the surface of the lungs into the main muscles of respiration, whereas the intercostal, inter-lobular lymphatics. The parietal pleura breathing the diaphragms move downwards causing remove pleural fluid via the intercostal lymphatics. The normal the main lobar bronchi—the hilar glands and around pattern of respiration therefore is both abdominal the trachea—the tracheobronchial glands. On the left and thoracic and there is no difference between side upper tracheobronchial group is separated from males and females as commonly believed. Paralysis the para-aortic glands which lie between the aorta or extreme flattening of the diaphragm as in and the pulmonary artery. These and the emphysema results in paradoxical movement of the paratracheal glands lie close to the left recurrent abdominal wall, which is well appreciated in the laryngeal nerve and enlargement of these groups of supine position. Respiratory Function Sternal glands lie on the inner surface of the anterior chest wall along the distribution of the internal The main function of the respiratory system is gas mammary artery, intercostal glands and the anterior exchange and it occurs by ventilation, perfusion and and posterior mediastinal glands are other intra- diffusion. The lymphatic drainage of the lungs Ventilation is movement of air in and out of the is peculiar, the entire right and the left lower lobe lungs, inspiration and expiration. Ventilation occurs draining right side nodes and the left upper lobe by overcoming the elastic resistance of the lungs and draining to the left side nodes. Extra pulmonary the chest wall and the non-elastic resistance offered 8 Textbook of Pulmonary Medicine by the airway. These are called restrictive ventilation, which is associated with reduced O2 and disorders as they prevent or restrict lung expansion. V/Q abnormalities Increase in non-elastic resistance occurs due to can be studied by ventilation perfusion scans and obstruction of the airways, e. Spirometry is used to Oxygen: Oxygen (O2) in blood is measured in various study ventilatory abnormalities (restrictive and ways. Abnormalities of Arterial Blood Gases Dead space effect: Absent perfusion with normal Hypoxemia: The partial pressure of O2 in the arterial ventilation. Diffusion defect: (central control, neuromuscular and chest wall) • Improves by O2 administration disorders. V/Q imbalance: not be given for more than 24 hours as it results in • Improves by O2 administration O toxicity. Particles greater than 10 microns are trapped in the nose and pharynx, particles of 2-10 microns are deposited in the mucociliary blanket of the tracheobronchial tree and particles of. Cough reflex: The cough is an important protective mechanism for effective removal of aspirated matter, excess secretions and foreign body in the trachea and main bronchi.

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