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Tumor Cell Division They dont stop because the brakes on cell division are not being used 10 mg uroxatral with mastercard. The brakes are another chemi- cal made by each cell for itself buy 10mg uroxatral visa, called pyruvic aldehyde. So, not only is there an accelerated multiplication of cells going on, but the brakes slowing them down are gone. Pyruvic aldehyde is susceptible to amines, much as car brakes are susceptible to drops of oil. But when massive amounts of amines appear in the cell, there may be no brakes on cell divi- sion for fifteen minutes at a time, followed by just one minute of pyruvic aldehyde, typical of a fast growing tumor. Some amines are produced naturally by our cells, perhaps to do exactly this release the brakes by combining with pyruvic aldehyde on a tight schedule. But for some reason the tumor cells can neither kill them, nor free themselves of them. The cells primitive solution to this impasse is to divide itself (release the brakes on cell divi- sion), so at least one of the two newly formed cells will escape and be free of the attacker, assuring survival. Like a fingernail you accidentally hit with a hammer, the nail will fall off eventu- ally and reveal a new one growing underneath. Tumor Cell Bacteria It is understandable now, why tumor cells are not able to do any work. That parasite then contrib- utes ortho-phospho-tyrosine to accelerate them into malignancy. Ordinarily when bacteria attack, either your cells or the bacteria win the battle. But if your cells win, the bacteria die and are digested by special little fortresses inside your cells called lysosomes. The virus genes now hidden amongst your own can be triggered by common chemicals (as anyone with chronic Herpes infection knows) to reproduce. Such an event is quite possible, even probable, when hordes of Clostridium bacteria have invaded your cells without killing them or being killed. Cell Defense Mechanisms Cells that are struggling for their lives call out for help. Ultimately, they call for self-destruction in a self-sacrificing way to protect you. Perhaps the metals arriving on the site destroy your white blood cells ability to find and home-in on 19 the infected cells. Perhaps the absence of germanium (the good, organic kind) suppresses immunity and does not let in- 20 terferon be made. Perhaps our white blood cells are smothered with ferritin or immobilized due to lanthanides (discussed in detail later). So for many reasons your cells cannot depend on your immune system to assist them. Their body temperature is H C C H often more than one degree C colder than normal! Oxidation means burning up by adding an oxygen atom or by subtracting an electron. Here is an example of oxidizing benzene (which looks simple, but is very difficult to do in your body). Sharing creates a strong bond between them, like two people holding hands tightly. Your body has the necessary enzyme to pry apart one of these strong bonds, and pull out an electron or insert an oxygen atom. The advantage gained is that the oxidized benzene atom is more soluble in water (namely urine) and can be excreted through the kidneys. If you live in a home with copper water pipes, the excess copper in your water is competing with the iron in your food. Other oxi- H C C H dizers like diamine oxidase, D- 23 amino acid oxidase, rhodi- zonic acid, and cytochrome C H C C H are also missing. Reduction, like oxidation, is strong chemistry, but in a cancer patient this mechanism is very 25 weak. Cell Mutations Meanwhile, as the cells are multiplying faster and faster, a sinister development takes place. The very act of mitosis (cell division) exposes the chromosomes to chemicals that might cause mutations. The protective nuclear membrane is temporar- ily gone, leaving the genes naked in the cell sap, called cyto- plasm.

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On plain abdominal films buy uroxatral 10 mg mastercard, look for the outline of an enlarged kidney buy uroxatral 10 mg, diffuse calcification, and obliteration of the psoas shadow. If the patient is toxic and febrile, suggesting a pyonephrosis, or a perinephric abscess, these need urgent drainage (6. If you have drained a pyo- or hydro-nephrosis externally, you can inject contrast through the nephrostomy tube. For upper ureteric strictures, a pyeloplasty is needed; for lower ureteric strictures, a re-implantation of the ureter or bladder flap. In endemic areas, Schistosomiasis is a common cause of a lower ureteric stricture. If there is still extreme frequency and dysuria after 6 months of treatment, suspect that there is a small contracted bladder. Dry the slide but do not smear it because this small, rubbery and symmetrical in the early phases. You will probably see so many patients with lymphadenopathy that you cannot reasonably biopsy them In about 40% of cases, you will be able to see caseation in all! The femoral nodes are a tuberculous lymph node with the naked eye, and in 70% often enlarged, especially if no shoes are worn and the feet of cases by microscopy. You will often be able to get extremely important Excising cysts may not be easy, especially in the neck: information from examination of lymph nodes. Excision biopsy of a lymph node in the neck may not be You should not use a trucut biopsy needle (24-3) for a neck easy, and it will be worthwhile to develop a cytology node. Most useful biopsies come from the neck or axilla; the groin often has low-grade infection and fibrosis and Macroscopic examination of a lymph node is useful if no unless the node is obviously abnormal, it will not be worth histology is available removing. A node may feel quite superficial, but then on exploration be under important structures, so familiarize Do not forget that not every swelling in the neck is a lymph yourself with the anatomy of the region you are operating node! Therefore, make sure you have a good supine; if the hair is likely to be in the way, shave it but operating light, and preferably diathermy available. Make a 5cm incision in the If not, be certain to have sufficient haemostats, gauze and groin crease or over the node, away from anywhere where a suction that is working available. Deepen the wound through and take a representative sample: do not try to be heroic the fascia. Keep the wound edges apart with self-retaining and excise a huge node without seeing what is underneath! There are many superficial veins; tie these or Try to handle the node as gently as possible because you diathermy them to keep a dry field. There are superficial distort the architecture if you are rough, and this makes nodes just below the inguinal ligament and around the long histological interpretation difficult. Tuberculous lymphadenitis (if fine needle aspiration is damaged, clamp it and ligate it. Suspicion of metastatic disease with the primary you are prepared for a block dissection (17. Make an incision over the node in the A normal node has a pale colour and is uniform; direction of Langers skin lines, and extend it 1cm to either you may be able to distinguish the cortex and medulla with side of the node. Deepen the incision and make sure histology and so you should not assume it to be normal; of haemostasis. Keep the wound edges apart with a however direct examination of nodes can give valuable self-retaining retractor. Under a good light, look for caseation or tuberculomas which are present in 75% of tuberculous nodes. Dissect gently down to the node, dividing only what you Pus within the node or showing purulent necrosis suggests can see. You should examine the pus and a smear of the cut see this to tie it off, or diathermy it. Ensure there is no bleeding; if there is some oozing, close the wound with interrupted non-absorbable 3/0 If you see hypervascular nodes, especially with a sutures around a small Penrose drain (4. Make a transverse If you cannot control the bleeding, do not plunge incision at least 5cm long and deepen it through the haemostats blind deep into a cavity. This exposes the fat of the under a good light so you can see properly, and apply a axilla and the tail of the breast; here are the pectoral group haemostat to the bleeding vessel. There are more nodes adjacent and behind the from a major vein or artery, and you cannot control it, axillary vein which is at the upper border of the axillary pack the wound again and press on it. Once you have sampled the node, ensure there is no When everything is ready, extend the incision to get good bleeding and close the wound as above. If all this fails, tightly pack the A very noticeable facial feature is bilateral parotid gland wound, wait 24hrs and re-explore the next day.

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You feel no uterine part is fixed in the pelvis order uroxatral 10 mg amex, and the uterus has not ruptured uroxatral 10 mg with mastercard, contractions, but you can usually feel the foetus through the and is in no danger of doing so. In the bustle of treating her, do not forget to complications of the surgery, not the labour. If you do not, she may blame you for its death, and not come to hospital when she is pregnant next time. Suspect obstructed labour or neglected obstructed labour if If a woman with obstructed labour is admitted from you find: home, she may have been in labour for days, and tried many (1). Hypertonic uterine contractions, with poor relaxation in Vaginal delivery is often possible, but try to predict when it between. If you are prepared to perform vacuum extraction (9) Offensive discharge or fever. A vesico- or recto-vaginal fistula (usually found you will be able to avoid around 25 subsequent Caesarean 2-3days after delivery). Of course a symphysiotomy is nearly absolutely contra-indicated if the foetus has died. Foetal distress Otherwise, with ultrasound guidance, you can try aspiration is shown by a rate of <120 or >160/min or slowing which with a long needle lateral to the uterus to reveal meconium- persists after a contraction (slowing during it is normal). You may not know if the uterus has ruptured, so do distressed and dehydrated, and the vulva and cervix may be all vaginal procedures for the relief of obstructed labour in oedematous. Putting her into the lithotomy position may make Hypovolaemic and/or septic shock are very common. Beware of routine use: the cut may become Resuscitation must be rapid, because delivery is urgent. If, in spite of adequate resuscitation, shock perhaps combined with fundal pressure to make up for the persists, try a titrated infusion of dopamine. Do not however waste time with sophisticated 2 (1) A live baby with > /5 of the foetal head above the brim. Record the pulse, and blood pressure every (1) Delivery with a vacuum extractor or outlet forceps 5mins. Do not assess this suggesting a large baby, perform the vacuum extraction in by vaginal examination only. There will be much caput the operating theatre, and prepare for symphysiotomy or (21. Such situations are: (2) Calculate the foetal moulding score: foetal distress, or an exhausted mother where her straining is 0 Bones still separate. A multipara who has been in labour for a pelvis is big enough (you can get your finger between the long time will have a lower segment which will be very thin. When the lower segment is paper thin, any destructive operation will rupture the uterus, unless you are above the pelvic brim and the cervix is 7cm dilated, simply decompressing a hydrocephalic head with a needle. If this fails, and the (2);A dead foetus <2/ above the pelvic brim, whose head foetus is mobile enough in the uterus, see if you can insert a 5 cannot be pushed down into the pelvis to perform a balloon catheter into the foetal rectum and apply traction for destructive operation safely. If it does cause trouble, but is thin, you may be able to If the foetus is alive and the cervix is not fully dilated, divide it. If there is an ovarian cyst or tumour, you can remove it at the same time as Caesarean Section. If there is a fibroid, leave it unless it has a thin pedicle, and remove it subsequently if necessary. Never try to remove a non-pedunculated fibroid at Caesarean Section, as it will bleed copiously. Before she goes home, make sure that she understands what operation she has had, and why it was done. She may fail to complain about sensory or tumour, you can remove it at Caesarean Section. If she has a foot drop, use a a secret cache of this drug so that you never run out. During the day, typical high basketball shoes The main dangers are that: make walking much easier. She is almost certain to recover, (1) The uterus may rupture if you administer too much too but this may take 2yrs. Early in pregnancy it is If despite infusion of large amounts of fluids, comparatively insensitive; it becomes much more sensitive only <400ml urine is passed in 24hrs, she is in renal later, especially in a multipara. Early treatment will improve her do not get the effect you want, use more in incremental prognosis, so watch for it. After delivery, or during an abortion, this rule does If this fails try dopamine if obtainable. Increase in steps till an effect has been (2) The supply of oxygen and nutrients to the foetus via the attained, this is usually at <20g/kg/min. The foetus might not cope, If labour was obstructed with cephalic presentation for a even if there is a normal placenta.

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