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Tyr Ohling Wilbanks, MD, FACS

• Assistant Clinical Professor of Surgery
• Columbia University College of Physicians
• and Surgeons
• Associate Chief of Surgery
• Lincoln Medical and Mental Health Center
• Bronx, New York

Typical schematic cross-sectional view of a liquid battery and a solid-state battery Future technologyFuture technology ɾɾMetal-airMetal-air ɾɾAll-solid-stateAll-solid-state 200 ɾetc arrhythmia forum buy cheap adalat 30mg on line. Li-ion the solid electrolyte is a key material for all-solid-state 100 batteries blood pressure medication that starts with a order adalat with paypal, and there are two types: oxide and sulfide arrhythmia research technology stock buy 20 mg adalat free shipping. On the other hand pulse pressure greater than 80 cheap adalat 20 mg, the sulfide solid 0 200 400 600 electrolyte has high ionic conductivity, but must be han Energy density per volume (Wh /Ὑ) dled in a dry atmosphere because hydrogen sulfide is gen erated upon contact with moisture in the air. Energy density of secondary batteries has so far studied sulfide solid electrolyte thin film that has 88 · All-Solid-State Lithium Batteries with Wide Operating Temperature Range high lithium ion conductivity, and we have already success 4. In this paper, we report on the charge/discharge characteristics at high and low tempera 4 tures that are expected with solid-state thin film lithium 3. To reduce interfacial resistance, the oxide buffer layer is inserted at the cathode interface. A sil icon layer is also inserted at the anode interface in order to acteristics at room temperature (25˚C) were investigated prevent electrochemical reduction of the solid electrolyte. Specifically, the discharge capacity was 89% of the capacity at a low rate, cathode film was deposited by sputtering; the buffer layer, which indicates that this battery has excellent power char solid electrolyte, and Si layer were deposited by pulsed laser acteristics. Thus, 24C All steps after the solid electrolyte film is deposited must be is the current value that can completely charge/discharge carried out under a dry atmosphere. This indicates that the thin film battery is capable of completing 90% charge/discharge in less than 3 minutes. Nevertheless, the capacity itself is not very large because the battery is made of “thin” films. Anode film (Li), 1µm Interfacial layer (Si), 20 nm Solid electrolyte film (Li2S-P S), 102 5 µm Buffer layer (LiNbO), 10 nm3 Cathode film (LiCoO), 12 ʙ10µm 4．Battery Performance at High Temperature Substrate (stainless steel), 500µm As mentioned above, the lithium ion secondary battery has a concern of boiling and evaporation of the organic Fig. Schematic cross-sectional view of the thin film battery liquid electrolyte, which is present at temperatures below about 60˚C. Moreover, since electrolyte deterioration and the side reactions are accelerated at high temperature, bat tery life generally tends to become shorter than that at room temperature. The cell element, as noted above, was evaluated in a Figure 5 shows the results of charge/discharge tests of 2032-type coin cell. A coin cell is usually sealed by caulking the thin film battery at a high temperature of 170˚C. The test conditions were a constant range is considered to be a big advantage in expanding the current of 0. Moreover, capacity degrada power characteristics comparable to those of current liquid tion was not observed during 100 cycles, confirming that batteries. These results indicate the high potential of solid there is no remarkable increase in side reactions. With continued development of materials able to operate at high temperatures enables the battery to and processes, the realization of a secondary battery with be used in hot areas, and thus battery applications are ex both excellent safety and battery performance is increas pected to become wider. Kondo, Solid State Ionics 79 tion, the reaction barely proceeds at low temperatures. Evans, Solid That is, the output characteristics are reduced due to the State Ionics 135 (2000) 33-45. Shokoohi, Solid State Ionics 69 (1994) batteries, the characteristics may deteriorate rapidly due to 357-368. Although battery performance unavoidably de grades such as at low capacity, it was confirmed that battery operation is basically possible. Cycle characteristics also confirmed that there was no degradation up to 100 cycles. Conclusion Battery performance of the solid-state battery at high and low temperatures was investigated, and it was con firmed that the battery can operate stably at high and low 90 · All-Solid-State Lithium Batteries with Wide Operating Temperature Range. Jones Department of Materials Science and Engineering University of Florida Software and Analysis of Advanced Materials Processing Center (kjones@eng. Power Sources, 89, 176, 2000 Software and Analysis of Advanced Materials Processing Center (kjones@eng. The desk top study is a review of the scientific literature and live export industry practices to investigate the use and potential benefits of electrolyte supplements during shipping. It identifies sea transport stress factors and describes the physiological and clinical effects of these in cattle and sheep and considers the benefits of electrolyte supplementation in treating these clinical syndromes. Recommendations for research are made to enable the development of robust and effective guidelines on the best use of electrolytes. It is proposed that field trials and development of best practice guidelines be carried out in the second stage of this project along with the development of a communication strategy to maximise uptake of the guidelines by industry. The main functions of electrolytes are to satisfy dietary nutrient requirements and maintain the acid-base balance (neutral pH) of the body. Hence, electrolyte treatments or supplements aim to replenish lost electrolytes and/or correct an acid-base imbalance and there are a number of products currently available in Australia that can do this during the live export of cattle and sheep. To be effective, electrolytes need to alleviate heat and nutritional stress that occurs during live export. Correcting the physiological imbalances that occur as a result of these stresses is the key to the best use of electrolytes. There is insufficient data to draw any conclusions on the cost-benefits of electrolytes during shipping or to make any recommendations on their best use. What electrolyte formulation is required to alleviate heat and fasting stress during shipping? What are the benefits of providing the correct electrolyte supplement during shipping? The actual physiological state of cattle and sheep during shipping has not been confirmed. The literature suggests that for cattle, heat stress encountered during shipping will result in metabolic acidosis, while experience suggests that respiratory alkalosis is a significant problem. For sheep, research findings suggest that glucose supplementation may be required to treat inanition, the main cause of deaths during shipping. The current use of electrolytes by the industry is not consistent with these findings. Land-based studies on the benefits of electrolytes are inconclusive and do not allow any conclusions to be drawn. A general pattern of electrolyte use and industry views on the benefits of electrolytes cannot be determined due to the differences in opinion that exist in the industry. Hence, we recommend that specific research under commercial conditions be conducted into the benefits and costs of electrolyte supplements during shipping. Following are the key findings of this review and recommendations for research to provide the necessary information for guidelines on the best use of electrolytes during shipping to be developed. Sodium, potassium, chloride and bicarbonate have the greatest effect on acid-base balance. Electrolyte supplements replenish lost electrolytes and/or correct an acid-base imbalance. Sea transport stress factors and their effects the main causes of stress in cattle and sheep during sea transport are: Heat; Poor ventilation; and Fasting. Heat, poor ventilation and nutritional stress result in: Hyperthermia (heat stress); Pneumonia (respiratory distress); Starvation; and Dehydration. The actual physiological state of cattle and sheep during sea transport is not confirmed. To be effective, electrolyte supplements used during shipping may need to do one or more of the following: Correct electrolyte deficiencies; Correct acidosis; Correct alkalosis; and Provide a mechanism for glucose supplementation. All of the currently available electrolytes that are suitable for use on a livestock vessel could potentially alleviate stress in cattle and sheep during shipping. An electrolyte supplement for cattle and sheep during shipping should include at least: glucose; sodium chloride; sodium bicarbonate; and potassium chloride. Constituent concentrations of electrolyte supplements for use during shipping would depend on the species and the predominant clinical syndrome that occurs during shipping. Results of land-based studies on the effects of short term electrolyte supplementation on alleviating stress in beef cattle do not allow conclusions to be drawn on the benefits of electrolytes during short-haul shipping. Results of land-based studies on the effects of long term electrolyte supplements indicate that continual electrolyte supplementation of cattle and sheep during long-haul sea transport could be beneficial.

Diseases

• Pelizaeus Merzbacher disease
• Oculopharyngeal muscular dystrophy
• Midline defects autosomal type
• Goodpasture pneumorenal syndrome
• Blomstrand syndrome
• Miller Dieker syndrome

Night sweats Note: Pruritus alone does not qualify for B classification nor does a short arrhythmia uti order adalat 20 mg, febrile illness associated with a known infection blood pressure chart generator cheap 30 mg adalat otc. Pathological Stages (pS) the definitions of the four stages follow the same criteria as the clinical stages but with the additional information obtained following laparotomy pulse pressure variation values buy 30mg adalat overnight delivery. Splenec tomy blood pressure chart software discount adalat 20 mg mastercard, liver biopsy, lymph node biopsy, and marrow biopsy are mandatory for the establishment of patho logical stages. Primary Sclerosing Cholangitis, Part 1: Epidemiology, Etiopathogenesis, Clinical Features, and Treatment James H. Dr Ali is a consequent decrease in survival (median, approximately 20 years) research fellow in the Division of and quality of life. Here, in the first of a 2-part series, we provide a review and Address correspondence to: Dr Keith D. Numerous agents have been tested, although none have yielded convincingly promising results. Biliary epithelial cells (ie, cholangiocytes) exist in an environment with multiple potential etiologic mediators of hepatobiliary injury. Approximately 95% of bile acids are reabsorbed in the terminal ileum and, together with other intestinal molecules, are transported back to the liver via the enterohepatic circulation. Portal blood flows into hepatic sinusoids, wherein hepatocytes may take up and modify these molecules and secrete them into bile, which is synthesized by hepatocytes and delivered into canaliculi by means of specialized membrane transporters. Canalicular bile drains into the biliary tree and is modified by cholangiocytes as it percolates through the biliary tree. Cholangiocytes recognize (eg, through cell surface receptors) and react to various molecules and may release chemokines/ cytokines, growth factors, and morphogens, initiating both autocrine and paracrine signaling cascades. With respect to the source of hepatobiliary injury, it remains uncertain whether there is (1) increased exposure to microbial molecules (eg, through the enterohepatic circulation, potentially facilitated by compromised intestinal barrier function), (2) alteration to the repertoire of microbial and other intestinal molecules (eg, due to microbial dysbiosis, xenobiotics), and/or (3) an aberrant or exaggerated cholangiocyte (or another hepatic cell) response to these molecules (eg, increased induction of cholangiocyte senescence and the senescence-associated secretory phenotype). Several theories Surrogate Endpoints have been proposed, many of which involve crosstalk between the infamed colon and the liver in susceptible Serum, imaging, and other biomarkers that could poten individuals116,117 or a connection to the enteric micro tially be used in clinical trials as surrogate endpoints in biome, as discussed earlier. The cholangiopathies: disorders of of magnitude higher compared to that of the general biliary epithelia. Prevalence of primary sclerosing population and even higher (nearly 30-fold) in patients cholangitis in patients with ulcerative colitis. Duration of infammatory bowel disease is associated with increased risk of cholangitis in Spain. Epidemiology and outcomes of primary primary sclerosing cholangitis: a pilot study. Patient age, sex, and infammatory bowel disease phenotype associate with course 12. An open-label pilot trial of cladibrine (2-cholordeoxyadenosine) in patients with 37. Ursodeoxycholic acid and methotrexate for primary sclerosing cholangitis: a with primary sclerosing cholangitis difers in the distribution of colitis. Characterization of cultured cholangiocytes isolated from livers of patients patients with primary sclerosing cholangitis: results of a pilot study. Prospective clinical trial of microbiota: current knowledge and perspectives on etiopathogenesis and emerging rifaximin therapy for patients with primary sclerosing cholangitis. Myco biota exacerbates hepatobiliary disease in a murine model of primary sclerosing phenolate mofetil for the treatment of primary sclerosing cholangitis. Budesonide or prednisone in combination with ursodeoxycholic acid in utes to chronic cholangitis. Enterohepatic circulation of bacterial chemotactic peptide in rats with experimen 27. Epidemiology of primary scleros prevents hepatobiliary injury in genetically susceptible rats with experimental ing cholangitis and primary biliary cirrhosis: a systematic review. The role of dominant stenoses in bacte mice spontaneously develop severe biliary fbrosis via massive dysregulation of rial infections of bile ducts in primary sclerosing cholangitis. A new xenobiotic-induced mouse ative colitis without biliary disease and healthy controls. The features of mucosa-associated microbiota cholic acid therapy for primary sclerosing cholangitis: results of a 2-year random in primary sclerosing cholangitis. Recent advances in the development of farne sclerosing cholangitis and ulcerative colitis in frst-degree relatives of patients with soid X receptor agonists. Genome-wide association analysis in controlled trial of obeticholic acid in primary biliary cholangitis. Fecal microbiota transplantation immune-related disease regions identifes nine new risk loci for primary sclerosing improves microbiome diversity and liver enzyme profle in primary sclerosing chol cholangitis. Balloon dilation compared to stent Population-based epidemiology, malignancy risk, and outcome of primary scleros ing of dominant strictures in primary sclerosing cholangitis. Lack of complica this and ulcerative colitis: evidence for increased neoplastic potential. Endoscopic management of biliary tract Alkaline phosphatase normalization is associated with better prognosis in primary strictures in primary sclerosing cholangitis. Improvement of transplantation in adults: 2013 practice guideline by the American Association for serum alkaline phosphatase to <1. Hepatol­ and reduced risk of cholangiocarcinoma in primary sclerosing cholangitis. Risk factors for recurrence of primary fbrosis and outcomes of patients with primary sclerosing cholangitis. Enhanced liver fbrosis score pre rence of primary sclerosing cholangitis after liver transplantation. Design and endpoints for the recurrence of primary sclerosing cholangitis in liver allografts. Natural history and prognostic 305 Swedish patients with primary sclerosing cholangitis. Characteriza pathogenesis of extra-intestinal manifestations of infammatory bowel disease. Clin tion, outcome, and prognosis in 273 patients with primary sclerosing cholangitis: Med (Lond). Primary sclerosing chol cells are retinoic acid dependent and not maintained by liver dendritic or stellate angitis: natural history, prognostic factors and survival analysis. Spleen size for the predic mal hepatic biochemistries in patients with infammatory bowel disease. A double-blind controlled trial of oral-pulse metho presence of varices in patients with primary sclerosing cholangitis. A pilot study of etanercept in the treatment of mally invasive technique for management of peristomal varices. Portal hypertensive bleed controlled pilot study of ursodeoxycholic acid combined with mycophenolate ing in cirrhosis: risk stratifcation, diagnosis, and management: 2016 practice mofetil in the treatment of primary sclerosing cholangitis. The impact of fragility fractures on health-related quality of life in patients with cessful treatment of recurrent primary sclerosing cholangitis after orthotopic liver primary sclerosing cholangitis. Prospective study of bezafbrate necrosis before and after orthotopic liver transplantation: long-term follow-up and for the treatment of primary sclerosing cholangitis. The document relates the science of pain to the clinical setting and explains the role of psychological, physical, interventional and complementary therapies in cancer pain. It is directed at physicians and other healthcare professionals who treat pain from cancer at any stage of the disease with the hope of raising awareness of the types of therapies that may be appropriate and increasing awareness of the role of the pain specialist in cancer pain management, which can lead to greater dialogue and liaison between oncology, specialist pain and palliative care professionals. The document is accompanied by information for patients that can help them and their carers understand the available techniques and that will support treatment choices. Methods this document has been produced by a consensus group of relevant healthcare professionals and patients’ representatives, making reference to the current body of evidence relating to cancer pain. In order to address these weaknesses, it is suggested that a more comprehensive model of cancer pain management is needed that is mechanism-based and multimodal, using combination therapies including interventions where appropriate, which is tailored to the needs of an individual, with the aim of optimising pain relief while minimalising adverse efects. A knowledge of these mechanisms and the ability to decide whether a pain is nociceptive, neuropathic, visceral or a combination of all three will lead to best practice in pain management. Accurate and meaningful assessment and reassessment of pain is essential and optimises pain relief. History, examination, psychosocial assessment and accurate record keeping should be routine, with pain and quality of life measurement tools used where appropriate. Combining these treatments with pharmacological and non-pharmocological methods of pain control can optimise pain relief, but the limitations of these treatments must also be acknowledged. Cancer pain is often under-reported and under-treated for a variety of complex reasons, partly due to a number of beliefs held by patients, families and healthcare professionals. Group format pain management programmes could contribute to the care of cancer survivors with persistent pain.

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The shaft arteria pudenda externa purchase adalat 20 mg on line, as its name suggests blood pressure bottom number 100 buy discount adalat, is the pay close attention to the margin of resection hypertension teaching plan order adalat 30mg amex. It is cov the epithelial margin arrhythmia headaches buy generic adalat 30 mg, and carefully inspect the ered by a loosely attached layer of rugated skin, surfaces of the specimen. Record the number, and it houses the three erectile bodies of the size, location, and appearance of any lesions. It sits Even if no lesions are appreciated on gross like a bonnet on the end of the shaft. The edge inspection, liberally sample foreskins removed of the glans at its base is referred to as the corona, from adults to look for early neoplastic changes. When a neo is a retractable fold of skin that partially covers plasm is suspected, each quadrant of the epithe the glans. The foreskin will sampling may be necessary if a visible lesion is obviously not be present in penectomies from large or if the lesion approaches the margin at circumcised males. Carefully examine the surfaces of the specimen, keeping in mind that the vast majority of penile neoplasms arise from the surface epithelium Penectomies of the glans and from the undersurface of the foreskin. Neoplasms may be concealed by the the diverse findings encountered in penectomies foreskin, so be sure to retract this skin fold and range from the essentially normal penis removed look at the entire surface including the epithelium from a patient undergoing a sex change operation lining the deep recesses of the coronal sulcus. Penis 175 deeply invasive—may be so subtle as to elude thick layer of loose connective tissue beneath the casual inspection; therefore, be sure to look epithelium; (3) the corpus spongiosum (grossly carefully for discolored plaque-like irregularities reddish, spongy tissue located between the that characterize superficial spreading carcino lamina propria and the tunica albuginea) sur mas. Do not stop once one lesion has been found; rounding the distal urethra; and (4) the corpora keep looking for others. Squamous carcinomas cavernosa (spongy reddish brown tissue encased of the penis tend to be multifocal, and these in a band of firm white tissue, the tunica albugi tumors will be overlooked if the entire epithelial nea). Describe the surfaces of each following: (1) a shave section from the shaft component, and note the number, size, color, margin (including the skin, erectile bodies, and and distribution of any lesions found. Assess the urethra); (2) sections of foreskin; (3) transverse tumor’s macroscopic pattern of growth. If it is care tions that demonstrate its relationships to the ad fully taken, this section will include margins of jacent surface epithelium, to the urethra, and to the skin, erectile bodies, and penile urethra. For of these components cannot be included in a tumors that involve the urethra, determine the single section, submit each component individu maximum tumor extension by submitting sec ally. Remove the foreskin from the uncircumcised tions at regular intervals along the entire length penectomy. The foreskin should then be separately processed according to the guidelines given pre Important Issues to Address viously in the section on the foreskin. The deep structures of the penis are most easily visualized in Your Surgical Pathology when the penis is sectioned in two different Report on Penectomies planes. For larger specimens, it is not practical to submit all of the chips for histologic evaluation. Needle biopsies of the prostate consist of delicate Although six to eight tissue cassettes are gener and thin cores of tan soft tissue. Measure each ally sufficient to detect the vast majority of inci piece of tissue, and document the total number dental carcinomas, the sensitivity of sampling can of pieces before carefully transferring them into be increased by selectively submitting those chips a tissue cassette. As is true for any small biopsy, that appear yellow, indurated, or in any other do not use forceps to pick up these biopsies, way grossly suspicious for carcinoma. More because forceps can squeeze and distort the extensive sampling is warranted in specimens tissue. Have the histology laboratory section from younger patients, since even a small focus of these biopsies at multiple levels, then have them carcinoma in these men may require aggressive stain alternating levels for routine histology. For patients under the age of 65, consider sections are later needed for additional studies submitting the entire specimen for histologic. Similarly, if cancer is identified histo will be readily available, and diagnostic material logically in a specimen that was partially submit will not be lost during sectioning of the tissue ted, the entire specimen should be submitted block. Specimensobtainedbyopenenucleationare either partially or totally intact nodules, but the Transurethral Resections anatomic orientation of these nodules is usually and Open Enucleations not practical or possible. After weighing and mea suring the tissue, serially section the specimen at 2 to 3-mm intervals. Note the appearance of Frequently, the central region of the prostate is the cut surface. Again, extensively sample the removed—either by transurethral resection or by specimen to detect incidental carcinomas. Submit open enucleation—to relieve symptoms of uri up to six to eight cassettes of tissue. As was true nary obstruction caused by nodules compressing for the prostate chips, remember to selectively the prostatic urethra. Although the majority of sample areas that appear grossly suspicious for these nodules are entirely benign, a small, yet carcinoma. Tissue fragments obtained from transurethral Radical Prostatectomies resections of the prostate—referred to as prostate chips—are generally tan, rubbery, and cylindrical. The total number of chips resected varies greatly One of the challenges of the dissection of radical from case to case. Measure the combined weight prostatectomies is to find a balance which will 176 177 178 Surgical Pathology Dissection maximize prognostic information while mini recent fixation protocols that utilize microwave mizing the number of tissue cassettes submitted. Indeed, radical prostatectomy specimens gross appearance of cancer and non-neo-plastic can now be fixed and sectioned on the same day prostate tissue can be hard to recognize. A number of the gross features the distal (apical) margin can be submitted in one of prostate cancer are outlined in Table 31-1 and oftwoways. Onemethodistosubmitthismargin can be helpful in distinguishing carcinoma from as a thinly shaved section. Amputate the distal 1 cm of the apex, Orient the prostate by locating the seminal vesi then section this apical cone at right angles to the cles and vasa deferentia. Thelattertech into the posterior aspect of the base (proximal end) nique allows for a more accurate assessment of of the gland and provide a landmark that is quick exactly how close the cancer approaches the distal and easy to find. If the proximal (bladder neck) base, the apex (distal end) of the prostate narrows and distal (apical) margins are taken as shave and becomes cone shaped. The contour of the sections, these sections should be very thin (1 mm gland can be used to distinguish the anterior and in thickness). The anterior sur among pathologists is that these sections are taken face of the prostate is rounded and convex, while to assess the status of the prostatic urethral the posterior surface is broad and flat. Once transected intact prostate for asymmetry, and palpate it for during surgery, the urethra retracts into the areas of induration. Fixation of the prostate before sec on these margin sections, and you should avoid tioning permits thinner sectioning of the gland thetendencytosubmitthickdoughnut-shaped and better assessment of the margins. It is not necessary to submit Location: the cut surface of the normal prostate shows entire tips of the seminal vesicles. Most carcinomas arise peripherally in the posterior tion the prostate at 2 to 3-mm intervals from and posterolateral portion of the gland. Do not use the urethra as a point of hyperplastic nodules tend to be located centrally around reference for these sections, because this structure the urethra. In Texture: Carcinomas tend to be solid and homogeneous, stead, section the prostate perpendicular to the while non-neoplastic prostate tissue is often spongy and broad flat posterior surface of the gland. Each individual slice should Color: Carcinomas vary in color from gray to brown to be intact, uniformly thin, and surrounded by a yellow. Sometimes these colors contrast sharply with the uniform tan appearance of non-neoplastic prostate. Structural Alterations: Prostatic carcinomas often cause structural changes that are apparent on close inspection Lay the individual slices out sequentially from of the cut surface. Be careful to asymmetry between the two sides of the gland and maintain the orientation. One remember the location of each individual slice simple method is to fasten the slices together with within the prostate. The arms of the U point to the posterior surface of Radical prostatectomies are usually accompanied the gland, and its convexity points to the anterior by a dissection of the pelvic lymph nodes. Find the fibromuscular band of tissue dissections are generally submitted by the sur that separates the central/anterior portion of the geon as separate specimens. Try to find the cancer using able numbers of lymph nodes embedded in fibro the guidelines outlined in Table 31-1.

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