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By: Andrew D Bersten, MB, BS, MD, FANZCA, FJFICM

  • Department of Critical Care Medicine, Flinders Medical Centre and School of Medicine, Flinders University, Adelaide, Australia

Consideration of the spatial organization of amino acids can be used in the design of surfaces to asthmatic bronchitis buy advair diskus 500mcg otc enhance protein interactions (36) asthma treatment breathing exercises purchase advair diskus 500 mcg with mastercard. As previously mentioned asthma upper back pain purchase 100mcg advair diskus mastercard, for some proteins asthma clinical definition advair diskus 250mcg, hydrophilic and hydrophobic amino acids are present primarily on the exterior and interior, respectively. This spatial arrangement has a direct consequence on the initial interactions of these proteins with surfaces. For example, a surface that initiates interactions with the exterior hydrophilic amino acid residues in that type of a protein may promote its adsorption. In contrast, for the interior hydrophobic amino acid residues to interact with material surfaces, which may contain desirable cell adhesive epitopes. For this reason, one approach to increase the adsorption of a protein whose external amino acids are largely hydrophilic, would be to design a material surface which exhibits polar properties. The same can be said for any type of protein; that is, through an understanding of the amino acids that reside on the protein exterior when in the appropriate biological milieu, a complimentary surface can be designed. It is important to note, though, that this is a generalization as many proteins have a diverse collection of hydrophilic­hydrophobic amino acids externally that must be considered. In addition, as previously mentioned, proteins adsorb to surfaces in a competitive manner in which the adsorption of one protein will influence that of another. Several studies have confirmed these speculations that properties (chemistry, charge, topography, etc. It has been reported in the literature that changes in the type and concentration (up to 2100, 84, and 53% for albumin (40), fibronectin (41), and vitronectin (34), respectively) of protein adsorption on material surfaces depends on material surface properties, such as chemistry. Consequently, since protein interactions can be controlled on porous biomaterial surfaces, so can cell adhesion. Only when porous biomaterials are considered from the context of protein interactions necessary for desirable cell interactions, will better tissue engineering materials be formulated. Mechanical Properties and Degradation Byproducts Although porous biomaterial surface properties determine cell attachment, mechanical strength of the scaffold and the mechanical environment it provides plays an equally important role in enhancing subsequent cell functions leading to tissue growth (45). It is for these reasons that mechanical properties must also be carefully controlled in porous biomaterials. This result implies that the mechanical stimuli applied to cells within a porous biomaterial may influence the biomechanical functionality of the regenerated tissue. Although most agree that the mechanical properties of a porous biomaterial should match those of the physiological tissue they are intending to replace, the specific parameters and values desirable in these studies vary. Clearly, this wide range in mechanical values can provide for much different porous biomaterial efficacies and a consensus needs to be established. Once deciding on the optimal mechanical properties needed in scaffold structures, there are numerous design parameters that can be exploited to match such values. For example, for a fibrous mesh, a decrease in fiber diameter increases mechanical strength due to an increase in fiber density (50). Obviously, increasing percent porosity and the diameters of individual pores can also be used to decrease the strength of scaffolds to match desired values. These properties not only influence inherent mechanical properties of scaffolds, but they can also be used to manipulate cell functions. Specifically, Maroudas postulated that the scaffold surface rigidity or stiffness enhances cell adhesiveness and cell spreading (51). Pelham and Wang (52) have shown that focal adhesion contacts in cells and their migration on acrylamide gels are controlled by scaffold flexibility. They also suggested that tyrosine phosphorylation might be involved, activated by local tension at cell adhesion sites (53). These authors also noticed that cells preferred to adhere to stiffer regions within the hydrogel. Common pore shapes in porous biomaterials include tube-like, spherical, and randomly spaced shapes. Differences in cell attachment, growth, migration, and matrix deposition by cells have all been observed depending on pore structure. Specifically, certain cell types prefer a select pore structure in accordance to their physiological matrix environment. For example, orthopedic tissue engineering scaffolds should have spherical pores with a high porosity to allow for immediate bone ingrowth, while maintaining the mechanical strength and integrity necessary due to their harsh mechanical environments In vivo (36). Not only does pore interconnectivity in a porous biomaterial affect nutrient­waste diffusion, but it also influences cell growth.

It is used in practice to hfa asthma definition purchase advair diskus 250 mcg free shipping characterize eye disorders with abnormalities in visual pigments asthmatic bronchitis elderly discount advair diskus 500 mcg free shipping, to asthmatic bronchitis pain back buy advair diskus 500mcg visa detect autofluorescence of retinal lesions asthmatic bronchitis 2 month order 100 mcg advair diskus amex, and for various research studies in animals and humans (1). In 1952, the absorption spectrum of macular pigment was measured by Brindley and Willmer (4,5). In 1954­1971, the density and spectral properties of human rhodopsin was established by Rushton (6,7). A spectrophotographic technique that projects the entire spectrum of light was developed by Weale in 1953. The rods are concerned 135 with scotopic vision (dim lighting conditions) and the cones are responsible for photopic (daytime vision) and color vision. Ultrastructure of both the types of photoreceptors as studied by electronmicroscopy consists of an outer and inner segment. The inner segment is responsible for pigment production and regeneration of outer segments. The pigment in rods is an aldehyde of vitamin A and in combination with protein (opsin) forms a compound known as rhodopsin. Of the various isomeric forms, the 11-cis form is a vital component of visual cycle and is converted to all-trans state on absorption of a photon (8). This sequence of events is responsible for vision and a similar process occurs in the cones (9). The ability of visual pigments to absorb certain wavelength of the projected light can be determined by spectrophotographic techniques. In in vitro conditions, a monochromatic light can be projected on a sample of pigment and the intensity of the emergent beam is measured. It is possible to deduce the absorbing effect of the pigment by again projecting the light without the pigment. However, this is not possible in vivo, and hence an alternative technique has been devised. It consists of measuring the intensity of the emergent beam before and after bleaching of the pigment in vivo. The various types of spectral reflectometers are Utrecht, Boston 1, Jena, Boston 2, and Utrecht 21. The Utrecht reflectometer measures the foveal reflectance and determines the absorption characteristics of the cone visual pigments. The Utrecht 2 is a newer device and measures cone-photoreceptor directionality along with foveal reflectometry. The Boston 1 reflectometer was devised for oximetry and could simultaneously measure the reflectance at six wavelengths between 400 and 800 nm. The Boston 2 consisted of a modified Zeiss fundus camera, which could assess the orientation of foveal photoreceptors, their directionality, and the ratio of directional to diffuse flux (10­13). The Jena was a combination of a xenon lamp with a monochromator, and measured reflectance by photon-counting techniques. This is called as imaging densitometry and has inferior resolution as compared to spectral densitometry. The above-mentioned techniques of reflectometry have been used to develop models to quantify the spectral distribution of light pathways in human fundus. The various structures in the eye with reflectance properties include the cornea, lens, internal limiting membrane, nerve fiber layer, photoreceptors, retinal pigment epithelium, and sclera (15). On the contrary, the various structures that absorb light include lens, macular pigments, visual pigment, lipofuscin, melanin, and hemoglobin. Taking into consideration these various structures and their reflectance properties, numerous attempts have been made to study the visual cycle. These can be as simple as measuring light transmission by the retina to determining foveal fundus reflectance using spectral, directional (16­19) and bleaching effects. In the lens and macular pigments, optical density measurement helps in determining the effects of aging. Visual pigments are vital component of the light cycle and densitometry can be used to classify photoreceptors on the basis of wavelength sensitive pigments.

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Biochemical outcome after radical prostatectomy asthma treatment doctor cheap advair diskus 100 mcg fast delivery, external beam radiation therapy asthma treatment vancouver cheap 100 mcg advair diskus mastercard, or interstitial radiation therapy for clinically localized prostate cancer asthma treatment list buy 250mcg advair diskus mastercard. Prostate cancer-specific mortality after radical prostatectomy for patients treated in the prostate-specific antigen era asthma symptoms and joint pain buy generic advair diskus 250 mcg line. Prognostic value of a cell cycle progression signature for prostate cancer death in a conservatively managed needle biopsy cohort. Prognostic utility of the cell cycle progression score generated from biopsy in men treated with prostatectomy. A 17-gene assay to predict prostate cancer aggressiveness in the context of Gleason grade heterogeneity, tumor multifocality, and biopsy undersampling. Postoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy. Morbidity and functional outcomes of salvage radical prostatectomy for locally recurrent prostate cancer after radiation therapy. Preoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy. Predicting 15-year prostate cancer specific mortality after radical prostatectomy. Guidance for Industry: Clinical Trial Endpoints for the Approval of Cancer Drugs and Biologics. Bisphosphonates to prevent skeletal complications in men with metastatic prostate cancer. Magnetic resonance imaging for predicting prostate biopsy findings in patients considered for active surveillance of clinically low risk prostate cancer. Active surveillance versus surgery for low risk prostate cancer: a clinical decision analysis. Multiparametric magnetic resonance imaging findings in men with low-risk prostate cancer followed using active surveillance. Pelvic lymph node dissection for prostate cancer: frequency and distribution of nodal metastases in a contemporary radical prostatectomy series. Temporal trends and predictors of pelvic lymph node dissection in open or minimally invasive radical prostatectomy. Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis. Indications for and anatomical extent of pelvic lymph node dissection for prostate cancer: practice patterns of uro-oncologists in North America. Long-term outcomes of patients with lymph node metastasis treated with radical prostatectomy without adjuvant androgen-deprivation therapy. Pathological features of lymph node metastasis for predicting biochemical recurrence after radical prostatectomy for prostate cancer. Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function ("trifecta"). Cancer control and functional outcomes after radical prostatectomy as markers of surgical quality: analysis of heterogeneity between surgeons at a single cancer center. Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era. Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications. Individualized estimation of the benefit of radical prostatectomy from the Scandinavian Prostate Cancer Group randomized trial. Biochemical (prostate specific antigen) recurrence probability following radical prostatectomy for clinically localized prostate cancer. Long-term (15 years) results after radical prostatectomy for clinically localized (stage T2c or lower) prostate cancer. Secondary therapy, metastatic progression, and cancer-specific mortality in men with clinically highrisk prostate cancer treated with radical prostatectomy. Update of Dutch multicenter dose-escalation trial of radiotherapy for localized prostate cancer. Randomized trial comparing conventional-dose with high-dose conformal radiation therapy in early-stage adenocarcinoma of the prostate: long-term results from Proton Radiation Oncology Group/American College of Radiology 95-09. Long-term failure patterns and survival in a randomized dose-escalation trial for prostate cancer. Long-term survival and toxicity in patients treated with high-dose intensity modulated radiation therapy for localized prostate cancer.

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Patients with ostomies should receive information on deodorants to asthma definition history order 500 mcg advair diskus visa minimize odor asthma zone chart advair diskus 100mcg on line, as well as on foods that are likely to asthma definition and implications for treatment buy advair diskus 250 mcg with visa cause stronger odors asthma symptoms toddler order 500 mcg advair diskus with amex, gas, or diarrhea. Patients should also receive information on pouch covers, and suggestions such as changing positions to avoid pain during intercourse and emptying the stoma before sexual activity. However, aside from body image and maintaining body integrity, breast surgery can still have a significantly negative impact on sexuality. In particular, women who undergo breast reconstruction are typically left with a complete lack of sensation, including nipple sensation. The nipple has been shown to be the most sensitive area of the breast and loss of nipple sensation is akin to losing a key erogenous zone for many women. These surgeries, although more intensive than implant surgery, offer the advantage of reconstruction that often feels and looks more natural without the concern about implant rupture or the need to replace implants over time. There is growing attention now being paid to the use of nipple-sparing mastectomy; however, although the nipple and areola may be left in place and breast tissue is removed, sensation is no longer intact. Radiation can result in skin fibrosis, additional loss of sensitivity in the skin, and fatigue, all which can contribute to low desire. However, there has hardly been any research conducted that specifically examines the effects of breast cancer­related radiotherapy on sexuality. Intervention Several approaches for addressing sexual problems after breast cancer have been identified. Most approaches focus on individually based information and education about the management of sexual side effects, such as vaginal dryness. The minority of interventions have been developed aimed at working with couples to establish new norms for intimacy after cancer. Ganz and colleagues218 demonstrated that nurse-delivered individually based counseling was more successful in managing menopausal and sexual side effects from treatment over a 4-month period than usual care. It is imperative that women receive information and education about how to maintain and restore good sexual health in the context of maintaining good vaginal health as well as overall well-being after breast cancer. In anticipation of the common side effects of both chemotherapy-induced menopause as well as adjuvant hormonal therapies, we believe that all women should receive information as part of their overall treatment planning about (1) nonhormonal vaginal moisturizers, (2) water-based vaginal lubricants, (3) pelvic floor strengthening (Kegel) exercises, and (4) the value of maintaining blood flow to vaginal tissue to prevent vaginal atrophy. This kind of information is readily available to patients through a number of resources, including a free, recently updated booklet by the American Cancer Society called "Sexuality and Cancer: For the Woman Who Has Cancer and Her Partner. In addition, the National Cancer Institute as well as the Lance Armstrong Foundation have information about sexuality on their Web sites. For the majority of breast cancer patients who are in a partnered relationship, it may also be important to acknowledge that sexuality is experienced in a context. Often, patients do not realize that partners may benefit from looking at some of the same educational resources, and many popular books and Web sites about sexuality after breast cancer actually have sections that are specifically written for partners. Chemotherapy Disruption of sexual function after breast cancer seems to be significantly related to whether a woman undergoes chemotherapy as part of her treatment. Schover207 has noted that younger women who undergo abrupt chemotherapy-related menopause are at the highest risk for sexual problems, and that the rates of sexual dysfunction in these women are clearly higher than would be expected in a healthy, community-based sample. In particular, the intensive estrogen deficiency that comes with chemotherapy-induced menopause often leads to severe vaginal dryness and vaginal atrophy, which makes penetration painful. Tamoxifen has been used as systemic adjuvant treatment for over 20 years and primary side effects are hot flashes, fatigue, and nausea. Regarding sexual function, tamoxifen use has been associated with vaginal dryness and low desire,211 although in the large-scale Breast Cancer Prevention Trial, there were no differences found in the frequency of sexual activity between those using tamoxifen versus placebo. For patients that are not currently in a relationship, sexuality is, in part, still a relational experience whether based on past relationships or in the context of hopes for future relationships. Patients who are not partnered are frequently unsure of how to proceed in terms of dating and lack of confidence in initiating new sexual relationships after their treatment. Often, these patients gain enormous benefit from being able to talk about these challenges and strategize about communication with a new potential partner. Gynecologic Cancers Treatments for gynecologic cancer often result in sexual dysfunction that may affect a substantial number of patients and can persist for many years after diagnosis. In addition, women who receive radiation therapy are at risk for developing vaginal fibrosis and stenosis, and hormonal interventions are likely to result in an abrupt development of menopausal symptoms, all of which can considerably disrupt sexual functioning. Moreover, research has found that ovarian cancer survivors report significantly less sexual pleasure than disease-free controls. Moreover, the authors223 found that the changes in sexual function reported by the survivors were associated with the effects of surgery, whether or not the treatment included radiotherapy.

References:

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