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By M. Sven. Clarkson University. 2018.

Allow at least 5 min after instillation of the lidocaine jelly for the anesthetic ef- fect to take place buy zudena 100 mg with amex. These maneuvers ensure that the balloon inflates in the bladder and not in the urethra discount 100 mg zudena overnight delivery. After inflation order zudena 100 mg fast delivery, pull the catheter back so that the balloon comes to rest on the bladder neck buy 100mg zudena mastercard. If a large amount of lubricant jelly was placed into the urethra zudena 100mg overnight delivery, the catheter may need to be flushed with sterile saline to clear the excess lubricant. Any male who is uncircumcised should have the foreskin repositioned to prevent mas- 13 sive edema of the glans after the catheter is inserted. In males, the catheter should be taped to the abdominal wall to decrease stress on the posterior urethra and help prevent stricture formation. The catheter is usually attached to a gravity drainage bag or some device for measuring the amount of urine. These systems are considered “closed” and should not be opened if at all possible. If urine is needed for analysis or for culture and sensitivity, especially in a female pa- tient, a so-called in-and-out cath can be done. The main dif- ference is that a red rubber catheter (no balloon) is often used and is removed immedi- ately after the specimen is collected. A clean-catch urine is useful for routine urinalysis, is usually good for culturing urine from males, but is only fair for culturing urine from females because of the potential for contamination. Expose the glans, clean with a povidone–iodine solution and dry it with a sterile pad. Collect a midstream urine in a sterile container after the initial flow has escaped. Separate the labia widely to expose the urethral meatus; keep the labia spread throughout the procedure. Cleanse the urethral meatus with povidone–iodine solution from front to back, and rinse with sterile water. Percutaneous Suprapubic Bladder Aspiration Indications (Used most frequently in young children) • When urine cannot be obtained by a less invasive method • In the presence of urethral abnormalities • In the presence of a refractory UTI Contraindications • If the child has voided within the last hour, or if the bladder cannot be percussed Procedure 1. This procedure is almost exclusively limited to the very young pediatric patient (usu- ally <6 months). Palpate the bladder above the pubic symphysis (the bladder sticks high above the pubis in a young child when it is full). Some suggest occluding the urethra by holding the penis in a male and by inserting a finger in the rectum to exert pressure in the female. Insert the needle perpendicular to the skin in the midline; maintain negative pressure on the downstroke and on withdrawal until urine is obtained (Fig. Penrose drain or glove is acceptable) • Alcohol prep sponge • Proper specimen tubes for desired studies (red top, purple top, etc. Blood cultures, IV techniques, and arterial punctures are discussed in other sec- tions of the chapter. T A B L E 1 3 – 7 T u b e G u i d e f o r V e n i p u n c t u r e U s i n g t h e V a c u t a i n e r S y s t e m * N u m b e r o r V a c u t a i n e r I n v e r s i o n s a t V a c u t a i n e r H e m o g a r d B l o o d C o l l e c t i o n T u b e s C l o s u r e A d d i t i v e ( I n v e r t g e n t l y, d o n o t s h a k e ) L a b o r a t o r y U s e B l a c k / r e d m a r b l e d G o l d C l o t a c t i v a t o r a n d 5 S S T b r a n d t u b e f o r s e r u m d e m o n - ( “ T i g e r T o p ” ) g e l f o r s e r u m s t r a t i o n s i n c h e m i s t r y. T u b e i n v e r s i o n s s e p a r a t i o n e n s u r e m i x i n g o f c l o t a c t i v a t o r w i t h b l o o d a n d c l o t t i n g w i t h i n 3 0 m i n G r e e n / r e d m a r b l e d L i g h t g r e e n L i t h i u m h e p a r i n a n d 8 P S T b r a n d t u b e f o r p l a s m a g e l f o r p l a s m a d e t e r m i n a t i o n s i n c h e m i s t r y. T u b e s e p a r a t i o n i n v e r s i o n s p r e v e n t c l o t t i n g R e d R e d N o n e 0 F o r s e r u m d e t e r m i n a t i o n s i n c h e m i s t r y, s e r o l o g y, a n d b l o o d b a n k i n g. Y e l l o w / b l a c k O r a n g e T h r o m b i n 8 F o r s t a t s e r u m d e t e r m i n a t i o n s i n m a r b l e d c h e m i s t r y. T u b e i n v e r s i o n s p r e v e n t c l o t t i n g, u s u a l l y i n l e s s t h a n 5 m i n R o y a l b l u e R o y a l b l u e S o d i u m h e p a r i n 8 F o r t r a c e e l e m e n t, t o x i c o l o g y, a n d N a E D T A 8 n u t r i e n t d e t e r m i n a t i o n s. S p e c i a l N o n e 0 s t o p p e r f o r m u l a t i o n o f f e r s t h e l o w e s t v e r i f i e d l e v e l s o f t r a c e e l e m e n t s a v a i l a b l e. T u b e i n v e r s i o n s p r e v e n t A m m o n i u m h e p a r i n 8 c l o t t i n g ( c o n t i n u e d ) T A B L E 1 3 – 7 ( C o n t i n u e d ) N u m b e r o r V a c u t a i n e r I n v e r s i o n s a t V a c u t a i n e r H e m o g a r d B l o o d C o l l e c t i o n T u b e s C l o s u r e A d d i t i v e ( I n v e r t g e n t l y, d o n o t s h a k e ) L a b o r a t o r y U s e G r a y G r a y P o t a s s i u m o x a l a t e / 8 F o r g l u c o s e d e t e r m i n a t i o n s. T u b e S o d i u m f l u o r i d e i n v e r s i o n s e n s u r e p r o p e r m i x i n g o f S o d i u m f l u o r i d e 8 a d d i t i v e a n d b l o o d. O x a l a t e a n d L i t h i u m i o d o a c e t a t e 8 h e p a r i n, a n t i c o a g u l a n t s, w i l l g i v e 8 s a m p l e s t h a t a r e s e r u m B r o w n B r o w n S o d i u m h e p a r i n 8 F o r l e a d d e t e r m i n a t i o n s. T u b e i n v e r s i o n s p r e v e n t c l o t t i n g Y e l l o w Y e l l o w S o d i u m 8 F o r b l o o d c u l t u r e s p e c i m e n p o l y a n e t h o l e s u l f o n a t e c o l l e c t i o n s i n m i c r o b i o l o g y.

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Hor- to progestin buy zudena 100mg without prescription, can be treated with a variety of agents generic zudena 100 mg with mastercard, in- monal therapy of advanced breast cancer is not cura- cluding estrogen–progestin replacement purchase 100 mg zudena with amex, clomiphene tive discount 100 mg zudena free shipping, but extended control of disease is possible by the citrate zudena 100 mg with visa, bromocriptine, FSH, LH, human chorionic go- use of different hormonal therapies sequentially. Clomiphene citrate (Clomid, Estrogen receptor–positive breast cancer in pre- Serophene) and bromocriptine (Parlodel) are the two menopausal and postmenopausal women responds most widely used agents. In addi- tion, daily tamoxifen administration for 5 years is a suc- Induction of Ovulation cessful therapy for the prevention of breast cancer in Anovulation can be due to an insufficient release of LH the contralateral breast in women who have already and FSH during the mid phase of the menstrual cycle. Induction of ovulation by clomiphene citrate is the re- Progestins have been used with some success in the sult of stimulation of FSH and LH release. The mecha- treatment of breast cancer, and the response rate is ap- nism of this action is probably related to the estrogen proximately the same as with tamoxifen. Although experience has been obtained using oral megestrol ac- estrogens generally exert a negative-feedback inhibi- etate. Determination of hormone receptor levels in tumor normal pituitary and hypothalamic function respond samples is highly recommended before selecting a most frequently to treatment with clomiphene citrate. In this group, the ovulation rate following clomiphene Although estrone is a weak estrogen, breast tissue citrate may be 80%. Clomiphene citrate is administered metabolizes estrone and estrone sulfate to estradiol, on a cyclic schedule. Pregnancy rates approach 50 to inhibitor that dramatically reduces serum levels of 80% after six such treatment cycles, with most pregnan- estradiol, estrone, and estrone sulfate in postmeno- cies occurring during the first three treatment cycles. It does not change Certain tissues of the female reproductive tract, which serum corticosteroid, aldosterone, or thyroid hormone are subject to the trophic action of hormones, exhibit a levels. The toxicity of these hormonal treatments com- Progesterone administration induces remissions in ap- pared with standard cancer chemotherapy is low. Preliminary data show Early breast cancer is usually treated by surgery and lo- a correlation between progesterone receptor status and cal irradiation. Breast fect of progesterone on endometrial cancer is not cancer occurs in both premenopausal and postmeno- known. Other clinical uses of estrogens and progestins include Mild hypertension and fluid retention frequently oc- the treatment of dysfunctional uterine bleeding, dys- cur in oral contraceptive users. Systolic blood pressure menorrhea, endometriosis, and rarely, metastatic pros- is elevated 5 to 6 mm Hg; diastolic blood pressure in- tate cancer. Hypertension is not commonly a problem in postmenopausal women Breast Cancer receiving conjugated estrogens. Migraine headaches (conjugated equine estrogens plus medroxyproges- may be a warning signal for an oncoming stroke, and terone acetate) compared with women taking estrogen immediate discontinuation of oral contraceptive use is alone (conjugated equine estrogens). Thus, the ability of progestins to Teratogenesis protect the endometrium from cancer risk is not ob- served in breast tissue. Oral contraceptive use in Diethylstilbestrol (DES) was once given to prevent younger women does not seem to be associated with an spontaneous abortion, but it no longer has such a med- increased breast cancer risk. An increased Oral contraceptive use lessens the incidence of ovarian cancer incidence in male offspring of mothers who had cancer. Therefore, if pregnancy is sus- pected, oral contraceptive use should not be initiated or Hepatocellular carcinoma and benign hepatomas are use should be stopped promptly. Fertility Cardiovascular Complications There is some delay in the return of fertility after dis- continuation of oral contraceptive use. Gonadotropin Estrogen replacement therapy is associated with an in- profiles should be normal 3 months after combination creased risk of thromboembolic disease, and alternative oral contraceptive use is stopped. The incidence of pro- therapies for osteoporosis and cardiovascular protec- longed amenorrhea extending beyond 6 months is 2 to tion are recommended for individuals with prior throm- 3%. Breast Feeding These preparations alter liver function more signifi- cantly than do the natural estrogens, such as the sulfate The use of oral contraceptives may interfere with lacta- conjugates or esterified estrogens. If factors and fibrinogen, are implicated in the formation breast feeding is planned, the use of oral contraceptives of thromboembolisms. Gallbladder Disease Current estimates are that oral contraceptive use doubles to triples the overall risk of thromboembolic There is a 2. At very high doses, generally Estrogen usage is associated with a mild decrease in no longer used in cancer treatment, ocular toxicity has glucose tolerance. There is a slight risk of hepatocellular their concurrent use in the diabetic patient may neces- carcinoma in humans receiving long-term (5 years) ta- sitate adjustment in insulin dosage. Raloxifene and clomiphene use is associated with an ADVERSE EFFECTS increased frequency of vasomotor disturbances (hot Common side effects associated with estrogen use in- flashes) and thromboembolism formation. INTERACTIONS Low-dose estrogen combination oral contraceptives Some of the contraindications to the use of estrogens, result in irregular midcycle bleeding episodes in some progestins, and estrogen–progestin combinations are patients. This reaction is generally regarded to neomycin, penicillin V, chloramphenicol, sulfonamides, be a premalignant state, because individuals reported nitrofurantoin, phenytoin, barbiturates, primidone, to have endometrial hyperplasia later have a higher analgesics, and phenothiazines.

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Treatment • If asymptomatic (good urine output cheap zudena 100mg on line, adequate BP purchase zudena 100mg visa, and normal sensorium) cheap zudena 100mg without a prescription, no ther- apy needed generic 100mg zudena amex. Atrial Arrhythmias PAC: Ectopic atrial focus firing prematurely followed by a normal QRS (Figure 19–8) generic zudena 100 mg on-line. The compensatory pause following the PAC is partial; the RR interval between beats 4 and 6 is less than between beats 1 and 3 or 6 and 8. Usually not of clinical significance; can be caused by stress, caf- feine, and myocardial disease PAT: A run of three or more consecutive PACs. Can be seen in healthy individuals but also occurs with a variety of heart diseases. Can include adenosine, verapamil, digoxin, edrophonium, or beta-blockers (propranolol, metoprolol, and esmolol). Verapamil and beta-blockers should be used cautiously at the same time because asystole can occur. Particularly in the hemodynamically unstable patient (see Chapter 21, page 467) MAT: An atrial arrhythmia that originates from ectopic atrial foci. It is characterized by varying P-wave morphology and PR interval and is irregular (Figure 19–10). Most commonly associated with COPD, also seen in elderly pa- tients, CHF, diabetes, or use of theophylline. The ventricular response is slower with digoxin, verapamil, or beta-blocker therapy and with AV nodal disease. Seen in some healthy individuals but commonly associated with organic heart disease (CAD, hypertensive heart disease, or rheumatic mitral valve disease), thyrotoxicosis, alcohol abuse, pericarditis, PE, and postoperatively. Intravenous adenosine, verapamil, digoxin, and beta- blockers (propranolol, metoprolol, and esmolol) can be used to slow down the ventricular response, and quinidine, procainamide, propafenone, ibutilide, and 19 FIGURE 19–8 Premature atrial contraction (PAC). Indicated if associated with increased myocar- dial ischemia, hypotension, or pulmonary edema (see Chapter 21, page 467) Atrial Flutter: Characterized by sawtooth flutter waves with an atrial rate between 250 and 350 bpm; the rate may be regular or irregular depending on whether the atrial impulses are conducted through the AV node at a regular interval or at a variable interval (Fig- ure 19–12). Example: One ventricular contraction (QRS) for every two flutter waves = 2:1 flutter. Seen with valvular heart disease, pericarditis, ischemic heart dis- ease, pulmonary disease including PE, and alcohol abuse Treatment. Do NOT use quinidine or procainamide (atrial conduction may decrease to the point where 1:1 atrial:ventricular conduction can occur and the ventricular rate will in- crease and hemodynamic compromise can occur), otherwise, similar to treatment of atrial fibrillation. If the P wave is present, it is negative in lead II and positive in aVR (just the opposite of normal sinus rhythm) (Fig- 19 FIGURE 19–10 Multifocal atrial tachycardia. Three or more premature junctional beats in a row constitute a junctional tachy- cardia, which has the same clinical significance as PAT. Ventricular Arrhythmias PVC: As implied by the name, a premature beat arising in the ventricle. A compensatory pause follows a PVC that is usually longer than after a PAC (Figure 19–14). One normal sinus beat followed by one PVC in an alternating fashion (Figure 19–15) • Trigeminy. Arise from different sites; therefore, have different shapes (Figure 19–16) Clinical Correlations. PVCs occur in healthy persons and with excessive caffeine ingestion, anemia, anxiety, organic heart disease (ischemic, valvular, or hypertensive), secondary to medications (epinephrine and isoproterenol; from toxic level of digitalis and theophylline), 19 FIGURE 19–12 Atrial flutter with atrioventricular (AV) block (3:1 to 5:1 conduc- tion). In the setting of an AMI: • >5 PVCs in 1 min (many clinicians would treat any PVC associated with an MI or injury pattern on ECG) • PVCs in couplets (two in a row) • Numerous multifocal PVCs • PVC that falls on the preceding T wave (R on T) Treatment. Appears as a wide QRS usually with an LBBB pattern (as opposed to a narrow complex seen with supraventricular tachycardia). May occur as a short paroxysm or as a sustained run with a rate between 120 and 250 bpm. Can be life-threatening because of associated hy- potension and has a tendency to degenerate into ventricular fibrillation. Patients with ventricular aneurysm are more susceptible to developing ventricular arrhythmias. Ventricular Fibrillation: Erratic electrical activity from the ventricles, which fibrillate or twitch asynchronously. One of two patterns seen with cardiac arrest (the other would be asystole or flat line) Treatment. Drugs such as beta-blockers, digitalis, and calcium channel blockers (especially verapamil) can cause first-degree block. Progressive prolongation of the PR interval until the P wave is blocked and not followed by a QRS complex (Figure 19–20).

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Sengstaken–Blakemore tube:A triple-lumen tube used exclusively for the con- trol of bleeding esophageal varices by tamponade order zudena 100mg amex. One lumen is for gastric aspira- tion order 100mg zudena with amex, one is for the gastric balloon zudena 100 mg with mastercard, and the third is for the esophageal balloon purchase 100mg zudena mastercard. Other types of tubes used to control esophageal bleeding include the Linton and Minnesota tubes discount zudena 100 mg with visa. Ewald tube:An orogastric tube used almost exclusively for gastric evacuation of blood or drug overdose. Dennis, Baker, Leonard tubes: These are used for intraoperative decompression of the bowel and are manually passed into the bowel at the time of laparotomy. Inform the patient of the nature of the procedure and encourage cooperation if the pa- tient is able. Maintain 13 gentle pressure that will allow the tube to pass into the nasopharynx. When the patient can feel the tube in the back of the throat, ask patient to swallow small amounts of water through a straw as you advance the tube 2–3 in. To be sure that the tube is in the stomach, aspirate gastric contents or blow air into the tube with a catheter-tipped syringe and listen over the stomach with your stethoscope for a “pop” or “gurgle. NG tubes are usually attached either to low wall suction (Salem-sump type tubes with a vent) or to intermittent suction (Levin type tubes). The latter allows the tube to fall away from the gastric wall between suction cycles. Feeding and pediatric feeding tubes in adults are more difficult to insert because they are more flexible. Feed- ing tubes are best placed into the duodenum or jejunum in order to decrease the risk of aspiration. Administering 10 mg of metoclopramide (Reglan) IV 10 min before inser- tion of the tube assists in placing the tube into the duodenum. As the tube is advanced, air can be injected to confirm progression of the tube to the right, toward the duodenum. If the sound of the air becomes fainter, the tube is probably curling in the stomach. Pass the tube until a slight resistance is felt, heralding the presence of the tip of the tube at the pylorus. Holding constant pressure and slowly injecting water through the tube is often rewarded with a “give,” which signifies passage through the pylorus. The duodenum usually provides constant resistance which will give with slow injection of water. Placing the patient in the right lateral decubitus position may help the tube enter the duodenum. Tape the tube securely in place but do not allow it to apply pressure to the ala of the nose. Patients have been disfigured because of ischemic necrosis of the nose caused by a poorly positioned NG tube. Complications • Inadvertent passage into the trachea may provoke coughing or gagging in the patient. HEELSTICK Indication • Frequently used to collect blood samples from infants 13 Materials • Alcohol swabs • Lancet • Capillary or caraway collection tubes • Clay tube sealer Technique 1. Although called a “heelstick,” any highly vascularized capillary bed can be used (fin- ger, ear lobe, or great toe). Auto- mated safety lancets (eg, BD Genie lancet for fingersticks and the BD Quick Heel Lancer for heelsticks) are also available. Most labs can usually make laboratory determinations on small samples from the pedi- atric age group. For a capillary blood gas, the blood is usually transferred to a 1-mL heparinized syringe and placed on ice. Position the patient in the dorsal lithotomy position (knees flexed and abducted), and per- form an aseptic perineal prep with sterile vaginal lubricant or povidone–iodine spray. Remove the spiral electrode from the sterile package and place the guide tube firmly against the fetal presenting part. Advance the drive tube and electrode until the electrode contacts the presenting part.

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This inflammatory reaction is accompanied by four virus purchase zudena 100 mg on-line, and it was called interferon because it “interferes” classic symptoms: heat zudena 100mg amex, redness order 100 mg zudena with mastercard, swelling order zudena 100mg without a prescription, and pain buy discount zudena 100mg online, as de- with multiplication and spread of the virus. Each is abbrevi- When tissues are injured, histamine (HIS-tah-mene) ated IFN with a Greek letter, alpha ( ), beta ( ), or and other substances are released from the damaged cells, gamma ( ) to indicate the category of interferon and ad- causing the small blood vessels to dilate (widen). Pure interferons are now available in adequate quan- With the increased blood flow come a vast number of tities for treatment because they are produced by genetic leukocytes. They have been used with varying tered walls and into the tissue, where they can reach the success to boost the immune response in the treatment of irritant directly. Interestingly, in- When this response occurs in a local area, it helps terferon is used to treat the autoimmune disorder mul- prevent the spread of the foreign agent. In a broader sense, the im- 348 ✦ CHAPTER SEVENTEEN mune system will recognize any foreign material and at- Some members of a given group have a more highly tempt to rid the body of it, as occurs in tissue transplan- developed individual immunity to specific diseases. Immunity is a se- example, some people are prone to cold sores (fever blis- lective process; that is, immunity to one disease does not ters) caused by herpes virus, whereas others have never necessarily cause immunity to another. Although cer- If the following description of the immune system tain diseases found in animals may be transmitted to hu- seems complex, bear in mind that from infancy on, your mans, many infections, such as chicken cholera, hog immune system is able to protect you from millions of cholera, distemper, and other animal diseases, do not af- foreign substances, even synthetic substances not found fect human beings. All the while, the system is kept in check, so ences that make human beings immune to these disorders that it does not usually overreact to produce allergies or also make them susceptible to others that do not affect mistakenly attack and damage your own body tissues. Such infections as measles, scarlet fever and diphtheria do not appear to affect animals who come Checkpoint 17-4 What is the difference between inborn and acquired immunity? Antigens Natural Artificial may be found on the surface of patho- genic organisms, on the surface of red blood cells and tissue cells, on pollens, in toxins, and in foods. The critical feature of any substance described as Active Passive Active Passive an antigen is that it stimulates the ac- tivity of certain lymphocytes classified Contact with Placenta Vaccine: Immune as T or B cells. The different types of T cells and some of their leukocyte antigens), because white blood cells are used in functions are as follows: testing tissues for compatibility. The activated Th then produces inter- There are several subtypes of these helper T cells, one leukins (ILs), which stimulate other leukocytes, such as of which is infected and destroyed by the AIDS virus B cells. They are produced by white cells and also by fi- ◗ Regulatory T cells (Treg) suppress the immune re- broblasts (cells in connective tissue that produce fibers) sponse in order to prevent overactivity. B Cells and Antibodies An antibody (Ab), also known as an immunoglobulin (Ig), is a substance pro- The Role of Macrophages Macrophages are phago- duced in response to an antigen. They ingest foreign proteins, such as mature in the fetal liver or in lymphoid tissue before be- disease organisms, and break them down within phago- coming active in the blood. Foreign antigen T cell receptor Helper T cell MHC protein Antigen fragment Activated helper Lysosome Phagocytic vesicle T cell Interleukin 1 Macrophage ingests 2 Macrophage presents 3 Activated T cell foreign antigen antigen fragment with produces interleukin, MHC proteins to which stimulates helper T cell other leukocytes Figure 17-2 Activation of a helper T cell by a macrophage (antigen-presenting cell). The Antigen–Antibody B Reaction memory The antibody that is produced in re- cells sponse to a specific antigen, such as a Plasma bacterial cell or a toxin, has a shape cells that matches some part of that antigen, much in the same way that the shape of a key matches the shape of its lock. Some of the actions of complement are: ulates the cells to multiply rapidly and produce large ◗ It coats foreign cells to help phagocytes recognize and numbers (clones) of plasma cells. BODY DEFENSES, IMMUNITY, AND VACCINES ✦ 351 Box 17-1 A Closer Look Antibodies: A Protein Army That Fights DiseaseAntibodies: A Protein Army That Fights Disease ntibodies are proteins secreted by plasma cells (activated immunoglobulins that vary in molecular size and in function AB cells) in response to specific antigens. Because the plasma contains other globulins as well, bodies, because they are the first to be produced in an immune antibodies have become known as immunoglobulins (Ig). Each time a person is invaded by disease organisms, his or her cells manufacture antibodies that provide im- Artificially Acquired Immunity munity against the infection. Because the host is ac- A person who has not been exposed to repeated small tively involved in the production of antibodies, this type doses of a particular organism has no antibodies against of immunity is called active immunity. This 352 ✦ CHAPTER SEVENTEEN protective process is known as vacci- Table 17•1 Antigen-Antibody Interactions and Their nation (vak-sin-A-shun), or immu- Effects nization, and the solution used is Interaction Effects called a vaccine (vak-SENE). Ordinar- ily, the administration of a vaccine is Prevention of attachment A pathogen coated with antibody is a preventive measure designed to pro- Antibody prevented from attaching to a cell. Clumping of antigen Antibodies can link antigens together, (The term even comes from the Latin forming a cluster that phagocytes word for cow, referring to cowpox, Foreign cell can ingest. Mandatory vaccination has Antibody been discontinued because the chance of adverse side effects from the vaccine is thought to be greater than the prob- Help with phagocytosis Phagocytes can attach more easily to ability of contracting the disease. Also pregnant women should not Activation of complement When complement attaches to anti- receive live virus vaccine because the Complement body on a cell surface, a series of virus could cross the placenta and harm Antibody reactions begins that activates com- the fetus. Types of Vaccines Vaccines can Activation of NK cells NK cells respond to antibody adhering be made with live organisms or with NK cell to a cell surface and attack the cell. Antibody If live organisms are used, they must Foreign cell be nonvirulent for humans, such as the cowpox virus used for smallpox Box 17-2 Clinical Perspectives Too Much Stress Makes The Immune System SickToo Much Stress Makes The Immune System Sick he impact of stress on the immune system is the most ◗ inhibit histamine release from damaged tissues, thereby Twide-ranging and significant of its many effects on the blocking inflammation and the arrival of phagocytic leuko- body. However, the ab- Box 12-3, Stress: Mechanisms for Coping, suggests some normally high levels of cortisol that appear during periods of strategies for reducing stress. This acellular (aP) vaccine usually tered with heat or chemicals to reduce its harmfulness, is given in a mixture with diphtheria toxoid and tetanus but it can still function as an antigen to induce immunity.

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