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After a period of stabilization, the sympathetic nervous system is able to compensate for the loss of adrenal medullary function and hormone replacement is no longer necessary. For example, stomach emptying is inhibited when the ileum is full and when the anus is mechanically distended. When the urinary sodium level exceeds the urinary potassium level, spironolactone is exerting its maximal effect. Symptoms are more dramatic if adrenal destruction is sudden (hemorrhage) or if a stressor, such as trauma, causes sudden decompensation in a patient with chronic adrenal insuficiency. There is greater vascular fragility, leading to the frequent appearance of hemorrhages (senile purpura); cherry angiomas; venous stasis; and venous lakes on the ears, face, lips, and neck. Induction the process of stimulating and determining morphogenetic differentiation in a developing embryo. Epigenetic changes can arise within a single generation and remain ixed there; alternatively, as in the case of maintenance methylation, the changes can also be preserved and inherited. A familiar example is the pain of myocardial infarction that is felt in the jaw or left arm. The fatigue can also make ordinary daily activities, once performed automatically, nearly impossible. The endocytic vesicle combines with a lysosome, and the thyroid hormones are cleaved from thyroglobulin. Shock A condition of severe hemodynamic and metabolic disturbance resulting in an imbalance between oxygen supply and oxygen demand at the cellular level. Lumbosacral transitional vertebrae may result in numbering errors, when the radiologist counts up from the last lumbar appearing vertebra to identify and enumerate the vertebra on a lumbar spine study. In the lower extremity, the patient may have problems with hip and knee extension. A proper skin examination also describes the objective signs of dermatologic disease, including all types of lesions and their distribution. Scarlet fever is a systemic reaction to the toxins produced by group A -hemolytic streptococci. Associated signs of injury include perisplenic fluid or hematoma, left rib fractures, and other solid organ injury. In the early stages, the pain, called intermittent claudication, is associated with physical activity, is alleviated with rest, and has a cramping quality. The acidity is also too low to digest protein in the stomach via the enzyme pepsin. Seborrhea and psoriasis in the scalp may be treated with aerosols, which are quick and easy to use and are associated with a high degree of patient compliance. It can develop rather acutely or more subacutely, as the patient recuperates from the acute illness. Minor trauma can cause small bruises or ecchymotic lesions, which largely occur on the extensor surface of the forearms. However, in young children, care must be taken to avoid topical preparations of Caladryl containing diphenhydramine to circumvent possible overdose of this agent through systemic absorption. The complete blood cell count and coagulation parameters must be closely monitored for trends in changes. As with other tissue of the musculoskeletal system, muscle atrophies in response to disuse and immobilization, and hypertrophies when subjected to increased stress. Neonatal hypoglycemia, kernicterus, prematurity, and low birth weight are also risk factors. Persons with opacity in the central portion of the lens can generally see better in dim light when the pupil is dilated. Proteins Amino acids are transported across the epithelial membrane by means of an active transport carrier system in much the same way as monosaccharides. There is often a diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). No matter what the age of the patient, adequate pain control is important to his or her care.

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In many cases, surgery provides patients with long-term results of weight loss and reduction or remission of chronic illness, including diabetes type 2, hypertension, and improvement with chronic pain issues. Alterations in uterine position and pelvic support, including uterine prolapse, retrodisplacement of the uterus, cystocele, and rectocele, may result in severe symptoms and require surgical correction. These types of treatment are known to focus on social skills acquisition and environmental modifications, such as the use of schedules, visual cueing, and structured settings. A second class of surface receptors important in endocrine signaling is the protein kinase receptor family. After the wound is clean, topical antibacterial agents are applied and covered with a light dressing (Table 54-4). Increased basal metabolic rate may result in weight loss, even though appetite and dietary intake increase. Individuals are prone to kidney stones and to bone demineralization (osteoporosis). It is also responsible for inactivation of cytochrome oxidase, an enzyme that aids in oxygen utilization. Most neurons have many contacts, some inhibitory and some excitatory, such that the response of the postsynaptic neuron is a summation of all the input. Scarlet fever frequently occurs in association 1142 Glossary Segmentation contractions A set of move- with streptococcal sore throat (strep throat), but it may also be associated with a wound, skin infection, or puerperal infection. However, when diverticula become inlamed, the condition is referred to as diverticulitis (see Box 36-1 for the terminology of diverticulosis). The effect of vaccination is considered long-lasting, and booster shots are not required. This condition improves gradually and usually resolves within 4 to 6 weeks after injury. In myelinated neurons, action potentials are generated only at the nodes of Ranvier, allowing the impulse to hop quickly from node to node down the axon. The inlammatory cascade that results in migraine can be initiated by many "migraine triggers. Impaired removal of glutamate from the synapse by energy-requiring reuptake mechanisms on the presynaptic membrane contributes to excessive glutamate in the synapse. As the cataract worsens or "matures," visualization of the retina becomes increasingly dificult until inally the pupil appears white and the retina cannot be visualized at all. Percutaneous catheter drainage or endoscopic drainage with stent placement may be performed to relieve obstruction, particularly if infection is involved. Importance Flexion and extension radiographs of the cervical spine have been used since the 1930s [2] and have been advocated in the acute setting after blunt trauma since the 1960s. Subacute subdural hematomas can present a diagnostic challenge because the symptoms may be so delayed that the patient does not associate them with a head injury event. Systemic therapeutic agents include tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants. Pain is a symptom of an underlying problem rather than a primary disorder; attempts to alleviate pain should be accompanied by efforts to locate and manage the underlying etiology. Alternatively, gamma knife or stereotactic radiosurgery can be used to deliver precisely aligned beams of gamma radiation to shrink the abnormal vascular tissue. Clues that suggest an etiology other than sinus hypoplasia or aplasia include: Secondary signs of thrombosis or injury. Mutation and underexpression of tumor suppressor genes are associated with the development of cancer. These organisms can be transmitted during sexual intercourse and are discussed in detail in Chapter 34. Differential diagnosis Differential considerations include a pancreatic pseudocyst, cystic neoplasm of the pancreas, duodenal ulcer, contained duodenal rupture, transmural duodenal injury, abscess, and duodenal diverticulitis. It is probable that during bed rest, age-related bone loss might be temporarily accelerated and may result in a greater decline in bone mass over time. The stimuli that trigger steroid secretion induce the enzymes in the pathway to synthesize the necessary hormones from cholesterol. In a rehabilitative situation, it is interesting to note that isometric contractions generate greater tension than concentric contractions.

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After 10 to 40 minutes of exercise, blood glucose use by muscle tissue increases 7 to 20 times. Endovascular treatment of the fistula with embolic agents provides permanent occlusion and up to 60% of patients experience symptom improvement [2]. The process by which these changes occur is not known but may represent an autoimmune mechanism or primary vasculopathy. It is essential that health care professionals continue to encourage this enhanced role and provide accurate information about breast health to their clients. Reliability the extent to which a test measurement produces the same results with different investigators or with repeated measures over time. Sensory seizures may result in tingling or numbness that spreads or "marches" to different parts of the limb or body (depending on the location of the seizure activity in the brain) or may involve the special senses, producing auditory (buzzing sounds), olfactory, or visual manifestations (lashing lights). Bone healing can be delayed by additional factors such as smoking, malnutrition, use of corticosteroids, and poor vascular circulation to the area. It is often profuse when the tear is near the cardia of the stomach and may proceed to fatal shock in this circumstance. This phenomenon, known as "capillary leak," occurs within a few minutes of injury and persists for 24 hours. Carbonic anhydrase the enzyme that catalyzes the reversible conversion of carbon dioxide and water to carbonic acid. Over the next 2 to 3 weeks, continuous columns of short Schwann cells mark the course of the lost axons. Metabolism refers to the dynamic state of simultaneously occurring anabolism and catabolism. A syndesmosis joint is a joint in which the two bony components are joined by a ligament or interosseous membrane. The second type, tractional retinal detachment, occurs when mechanical forces on the retina caused by ibrosis and scarring pull it away from the underlying epithelium (injury or surgery to the eye). Clinical manifestations often begin with Raynaud phenomenon (blanching of the digits in response to cold) and pufiness of the ingers, which can precede the development of other clinical features by many months. Within certain boundaries, it appears that greater exposure to a particular stimulus prompts the brain to dedicate more neurons to that stimulus (and a lack of stimulation allows the brain to reassign neurons to a different function)-and so the old adage "use it or lose it" appears to hold true for the brain. Individuals at risk for glucose intolerance include those with a history of glucose intolerance and those with a positive family history, obesity, or other risk factors. The Z lines at the ends of the sarcomere move closer together as interdigitating actin and myosin ilaments slide past one another. Diffuse systemic sclerosis involves the skin of proximal and distal extremities and can spread rapidly to the face and trunk. The most commonly used psychostimulant is methylphenidate, which is available in both short-acting and longacting agents. The etiology of renal failure in rhabdomyolysis is twofold: irst, the shift of luid in to damaged muscle from the intravascular space. Its role in men is not well understood, but in women it is proposed to affect sperm motility through uterine contractions. Renal hypoplasia An abnormally small kidney that is morphologically normal but has either a reduced number of nephrons or smaller nephrons. Hypodensity extends in to the cortex and there is mild right to left midline shift. Clinicians who work with patients experiencing dysfunctions of the musculoskeletal system must have a solid background in evaluation and management of such disorders. Progression of the disease results in muscle atrophy and contractures, skin telangiectasias (vascular lesions formed by blood vessel dilation) and atrophy, and generalized organ involvement. Anxiety disorders are characterized by irrational fears and have great potential to cause disability in affected persons. Invasion the process by which malignant cells move through the basement membrane and gain access to blood vessels and lymphatic channels. Knowledge of the normal ossification patterns will allow identification of many of these variants. Barrett esophagus A complication of chronic gastroesophageal relux disease that represents replacement of the normal squamous epithelium of the distal esophagus by columnar tissue.

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Garcia-Tsao G, et al: Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis, Hepatology 46:922, 2007. Primary glomerulopathy Disease states resulting from alterations in the structure and function of the glomerular capillary circulation, in which the kidney is the only or primary organ involved. Stratum lucidum Second layer of the epidermis, appearing as a translucent line of lat cells. This inding of low cardiac output in the presence of vigorous intravenous luid resuscitation and massive catecholamine release has led to the suggestion of a speciic myocardial depressant factor. From 2005 to 2009, residential ires resulted in nearly $7 billion per year in property damage. Viral serologies, serum acetaminophen levels, and tests for certain metabolic disorders. Currently, two classes of drugs are approved by the Food and Drug Administration for the treatment of Alzheimer disease. Rupture of a pelvic abscess is a potentially life-threatening condition, and a total abdominal hysterectomy (removal of the uterus) with bilateral salpingo-oophorectomy (removal of both oviducts and ovaries) may be indicated in this situation. Gastrointestinal sympathetic activity can also initiate vomiting through a complex sequence of events mediated by various neurotransmitters. Lack of cervical lymphadenopathy is also a helpful sign to differentiate calcific tendinitis from an infection [1]. Metal storage diseases are genetic disorders in which excessive minerals are absorbed and subsequently deposited in the liver. Antibiotics, especially tetracycline and erythromycin, have long been used in such treatments. A dislocation is displacement of a bone from its normal position to the extent that articulating surfaces completely lose contact. Cholesterol A lipid-soluble compound that facilitates the absorption and transport of fatty acids in bile and provides the building blocks for steroid hormone production. This blood drains in to the central veins, which inally coalesce in to the hepatic vein and empty in to the inferior vena cava. Immunosuppression the inability to produce an immune response to an antigen, resulting in reduced resistance to infection. Under the control of the vagus pathway, the parasympathetic nervous system not only stimulates the release of insulin but also can inluence the secretion activity and -cell mass. The cortex is characterized by its convoluted exterior having ridges (gyri), grooves (sulci), and deeper depressions (issures). Surgical treatment may include aspiration of lymph nodes as needed; rectal strictures and istulas may require surgical correction. Apocrine glands do not decrease in number or size, but they do decrease in function. Full-thickness excision often leaves an uneven contour, which presents dificulty with grafting, resulting in poor cosmesis. Ureterolithiasis the presence of calculi (stones) in the urinary system, particularly the ureters. The motor unit is the functional unit of skeletal muscle and consists of the -motor neuron and all of the muscle ibers that it innervates. Males are three to four times more likely to have suffered a spinal cord injury, and these injuries are most common on the weekends and during the summer months. Myosin A cytoskeletal protein that comprises the thick ilament of the muscle sarcomere in skeletal and cardiac muscle. Perilymph and endolymph transmit the mechanical vibrations from the footplate of the stapes to the organ of Corti. After a period of bleeding, clotting occurs at the fracture site and for a short distance on both sides of the fracture. Patients with chronic active hepatitis C infection should be vaccinated against hepatitis A and hepatitis B and counseled regarding blood-borne precautions. Lymphatics form in the matrix, prevent additional edema, and assist in preventing infection. Ileocecal valve Sphincter between the small and large intestines that is normally closed, so that the contents of the large intestine cannot move in a retrograde fashion back in to the small intestine.

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Symphysis joints and synchondrosis joints are the two types of cartilaginous joints in the body. Several congenital skin lesions, such as Mongolian spots, hemangiomas, and nevi (moles), are nevertheless associated with the early neonatal period. Severe hypercalcemia causes a wide variety of effects, including polyuria and dehydration. In summary, the cerebrum is the largest brain structure, garnering about 70% of the neurons and supporting cells of the brain to accomplish its diverse and complex functions. One common cause of increased bone resorption is calcium and vitamin D deiciency, which causes more rapid mobilization of calcium from bone. Slow waves, as described previously in this chapter, occur at the membranes of the longitudinal smooth muscle, with frequencies of 11 to 12 per minute in the duodenum decreasing to 7 to 9 per minute in the terminal ileum. Topical burn agents penetrate the eschar, thereby inhibiting bacterial invasion of the wound. Comprehensive management guidelines for clinicians for speciic chemical exposures are readily accessible online at The World Health Organization provides a listing of international poison centers online at Because of the ability of hydrofluoric acid to penetrate tissue, poisoning can occur readily through exposure of skin or eyes, or when inhaled or swallowed. All gastric ulcers should be visualized with endoscopy and biopsied to rule out malignancy and conirm the presence of H. Slow waves can be any degree of intensity and are not the "all-or-nothing" type of action potential seen in other smooth muscle ibers in the body. Corticosteroids (prednisone) and immunosuppressants (azathioprine) are common therapeutics for autoimmune hepatitis. Thyroid dysgenesis (lack of thyroid gland development) accounts for most of the cases of congenital hypothyroidism. American Diabetes Association: Nutrition recommendations and interventions for diabetes. Teaching point Pancreatic clefts are normal structures most commonly found near the junction of the head and body. Divergence is a strategy used to send sensory input to a large number of receiving neurons. Treatment is geared primarily toward relief of symptoms, and recovery is usually complete. Diurnal variation the regular (24-hour) recurrence of certain biological phenomena under conditions of illumination; recurring during the daytime, or period of light. Gastroenteritis Inlammation of the stomach and intestines; may occur on an acute or chronic basis and is commonly caused by viruses. Aging also produces a decrease in the vascularity of the dermal skin, as evidenced by decreasing numbers of epithelial cells and blood vessels. Chyme then passes through the pylorus in to the duodenum, where further digestion occurs. In one series by Marti de Gracia and colleagues, the most common etiology was trauma [2]. Unfortunately, treatment is often limited to withdrawal of the offending agent and administration of supportive care. Look for the following common patterns: symmetric (affecting mirror-image portions of the body), sun-exposed (affecting skin sites that routinely receive solar irradiation), intertriginous (affecting warm, moist, apposed skin sites), acral (affecting the distal extremities, ears, and nose), genital, and lexor or extensor predominance. Detects presence of virus Not well standardized Measures level of viremia splanchnic bed around the cirrhotic obstructed liver and back to the heart. In obstructions of the distal portion of the small bowel or ileum, constipation may be an early manifestation, with massive accumulation of luid in the lumen occurring later. Some astrocytes have foot processes that contact the brain capillaries and help maintain the integrity of the blood-brain barrier. Activation of the sympathetic nervous system results in a predictable cluster of physical signs and symptoms, including an elevated heart rate, blood pressure, and respiratory rate, as well as dilated pupils, perspiration, and pallor20 (see Table 47-4).

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It contains T and B lymphocytes, secretes immunoglobulin A (IgA), and contributes to gut-associated lymphoid function. Chronic Otitis Media Chronic otitis media is inlammation in the middle ear lasting longer than 12 weeks. Lung windows at the same level demonstrate dark regions adjacent to the arteries, due to motion artifact (arrow). Characteristics of sagittal vertebral alignment in flexion determined by dynamic radiographs of the cervical spine. The mechanical response of a muscle to electrical stimulation causes movement in the joint, control of joint motion, or joint stabilization. The use of a pessary to support the uterus in a normal position may relieve the symptoms, but surgical correction is sometimes indicated when symptoms are severe. A variety of medications are known to alter the sense of taste, including certain antidepressant, antithyroid, antirheumatic, and anticancer medications. However, the biopsychological marker for the disorder is likely to be the overinterpretation of physical anxiety 991 symptoms. A benign disease in which the inlammation is conined to the portal triads without destruction of normal liver functions despite elevated serum transaminase levels. The relexive and voluntary movements begin to coordinate to create normal eye 951 alignment. May be insuficient in clients with schizophrenia who display anhedonia (loss of pleasure). The entire inner wall of the small intestine is marked by circular folds of a mucous membrane called the plicae circulares, permanent ridges that do not lose their elasticity when the intestine is distended. Actin ilaments are prevented from slipping back to their original position because some myosinactin bonds are forming while others are breaking. After -amyloid is formed, it is not known how it moves through or around the nerve cells. Proper care and cleaning of contact lenses and eyeglasses directly inluences the effectiveness of the prosthesis. The surgical formation of a colostomy, or an artiicial opening of the colon on the abdominal wall, may be performed after removal of the affected bowel segment. Airway resistance Relationship between pressure and low of gas, as determined by the radius of the airway. Hyperplasia Abnormal multiplication or increase in the number of normal cells in normal arrangement in a tissue. Although this decrease in muscle is associated with factors such as physical inactivity and a decrease in the number of neurons to muscle cells, endocrine factors also inluence the loss of muscle mass. Other features of foot involvement include swelling of joints, a cocking-up of the toes attributable to subluxation of the metatarsal heads (claw toes), and lateral deviation of the irst through fourth toes. Before surgery, sympathetic blocking medications may be prescribed to manage blood pressure and relieve symptoms. Hence, subcutaneous emphysema in one body region may occur from injury to another body region that might not be initially imaged. The major digestible carbohydrate in food is the polysaccharide plant starch, a large molecule composed of straight and branched chains of glucose. It is characterized by periods of exacerbations and remission, with multiple organ systems being affected at different times. Systemic toxicity associated with these injuries occurs primarily as a result of absorption through the skin and inhalation. Neuropathic complications are divided in to autonomic dysfunction and sensory dysfunction. In the chronic phase, the core of the abscess is liqueied and the peripheral portion forms a collagenous capsule that in turn is surrounded by ibrous gliosis. Oxygen consumption the amount of oxygen used by the tissues in 1 minute, usually expressed as V o2. However, for reasons not understood at the present time, cardiac output decreases to a little above normal during the last 8 weeks of pregnancy, although the high uterine blood low continues. Some highly specialized referral centers monitor patients with advanced hepatic encephalopathy by extradural pressure monitors to permit early detection.

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Nerve injury may initiate excitotoxic and apoptotic cell death of neurons within the spinal cord dorsal horn. Acute therapy with thrombolytic agents may limit infarct size in patients with ischemic stroke. Simple sugars and the amino acids are absorbed in to the blood capillaries of the villi. Biofeedback is a conditioned response that can be learned as a paincontrol strategy. The diagnosis is based on clinical characteristics, imaging studies, and laboratory evidence. Distribution of the hair in family members and ethnic background are thus important considerations in ascertaining hair growth. As the child develops the skin receptors begin to become more dispersed, decreasing skin sensitivity. Early infections are generally due to issues involving surgical technique and pre-existing infection. The major pathway for pain signal transmission up the spinal cord is the anterolateral tract, so named because it travels in the anterolateral portion of the white matter of the spinal column. Any of the branches of the trigeminal nerve can refer pain signals along this pathway. Cardiac output A measure of the amount of blood pumped by the heart in 1 minute; usually expressed in liters per minute. Importance Duodenal diverticula are commonly encountered, and should not be mistaken for duodenal perforation in blunt or penetrating trauma, or for a duodenal ulcer in patients with upper abdominal pain. An enzyme (acetylcholinesterase) in the synapse quickly degrades acetylcholine to stop receptor activation. Beginning on the irst day of menses, the important events of the cycle are as follows: 1. Elastosis Skin wrinkling due to changes in collagen, with ibers becoming cross-linked and rearranged in thicker bundles. In some cases endocrine disease occurs when the target tissue fails to respond to a hormone. Laparoscopic cholecystectomy was irst performed in 1987 and has beneited from rapid improvements in video laparoscopy and instrumentation. Unfortunately the signs and symptoms of esophageal rupture may mimic other causes of acute chest pain, such as aortic dissection, myocardial infarction, pneumonia, lung abscess, or acute pancreatitis. Because skin tissues are in an active phase of new growth, healing of skin injuries is often rapid and eficient. One in every 400 to 600 children and adolescents has type 1 diabetes, and 18 new cases per population of 100,000 are diagnosed yearly. Failure to heal is due to poor blood supply and repetitive stress on the fracture site, and can be the result of interposition of muscle, tendon, or soft tissue between fracture pieces; prolonged or excessive traction; poor immobilization that allows motion at the fracture site; poor internal ixation; or wound infection after internal ixation. Monosomy Having only one member of a homologous chromosome pair, as in monosomy X, also called Turner syndrome. Epilepsy and psychiatric disorders may be associated with olfactory hallucinations. Nevi may vary in shape or size, and they may be present at birth or develop later in life. Gunn Typical clinical scenario For penetrating abdominal trauma, a "triple contrast" technique, which employs oral, rectal, and intravenous contrast, yields the greatest sensitivity for bowel injury [2, 3]. Irritable bowel syndrome the presence of alternating diarrhea and constipation accompanied by abdominal cramping in the absence of any identiiable pathologic process in the gastrointestinal tract.

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Vesicoureteral relux Retrograde movement of urine from the bladder to the kidney as a result of a disruption in the normal valvular mechanism at the ureter-bladder junction. The prolapsed flaps (black arrows) were causing outflow obstruction during ventricular systole. Clinically, oligoarthritis typically appears 2 to 6 weeks after the onset of the infectious episode. The interactions of hormones thus produce the mixture of glucose and free fatty acids used by muscle tissue during exercise. Homologous chromosomes A pair of chromosomes in a diploid cell that contain similar gene loci, each being derived from a different parent. These patients are at a higher risk of developing progressive bone erosions, nodules, and poor functional outcome. The weight gain of pregnancy is also responsible for an increase in insulin resistance. Blood pressure the pressure exerted by the circulating volume of blood on the walls of the arteries. Along these degradation pathways, intermediates for biosynthesis are formed and used. Health care expenditures related to obesity were estimated to cost $147 billion in 2008. Actinic keratosis A horny premalignancy of skin epithelium caused by excessive exposure to sunlight. Repeat radiologic examination is indicated to determine if a new surgical lesion has developed. Supericial partial-thickness burn Marked by destruction of the epidermis and dermis, a supericial partial-thickness burn is also a second-degree burn. Strabismus, also called squint or cross-eyedness, is a condition of ocular misalignment. Axial T2-weighted image from a 40-year-old man with headaches and visual changes shows enlargement of the lateral and third ventricles which is out of proportion to the size of the sulci. The luid and electrolyte losses associated with colonic obstruction may not be as severe as those seen in obstruction of the small bowel. An exercise regimen is essential and should include regular stretching; improvement in physical conditioning via low-impact aerobic exercise (biking, swimming, walking); and measures of pacing, muscle protection, and relaxation. The muscular characteristics of the esophagus are of particular importance in effecting the third, or esophageal, stage of swallowing. Dietary sources of methylating agents, such as bioavailable folic acid, methionine, choline, betaine, and homocysteine, may have a permanent effect on the epigenetic methylation patterns of CpG islands and the coherence of histones in locus- and temporal-dependent genes. Acute hepatitis may be caused by many viruses, among them cytomegalovirus and EpsteinBarr virus. Women at risk for pregnancy-induced hypertension include teenagers and women in their late 30s and early 40s (also known as toxemia of pregnancy and preeclampsia-eclampsia). Neurons in the hypothalamus regulate the secretion of anterior pituitary hormones by releasing and inhibiting hormones (see Chapter 39 for a discussion of the endocrine system). The majority of patients are adolescents and young adults 20 to 30 years of age, although cases can be seen in adults 60 to 70 years old. Complications such as perianal issures, istulas, and abscesses are common in Crohn disease and may be the symptoms that lead individuals to seek health care. Disease progression is unpredictable, and the patient may periodically experience spontaneous exacerbations or remission. The term denotes both physical (gravity, mechanical force, pathogen, injury) and psychological (fear, anxiety, crisis, joy) forces that an individual may experience. The absence of surrounding inflammatory change will usually assist to differentiate between abscess, diverticulitis, and pseudocyst. Treatment of an individual experiencing a seizure is concentrated on maintaining an airway and protecting the individual from injury.