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• Clinical Pharmacist Specialist, Hematology/BMT/Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Cancer Institute, The Ohio State University, Columbus, Ohio

Igs are produced in many different forms causes of erectile dysfunction young males cheap fildena online, each with different amino acid sequences and antigen binding sites erectile dysfunction causes natural cures buy fildena online pills. Through recruiting the complement system and various white blood cells erectile dysfunction doctors staten island order fildena with a mastercard, they protect the body by inactivating viruses and bacterial toxins and by killing invading microorganisms and larger parasites erectile dysfunction diabetes medication buy 25 mg fildena otc. Antigen Any molecule specifically recognized by B and/or T cells that can induce the formation of a specific antibody erectile dysfunction underlying causes purchase fildena without prescription. For vaccines erectile dysfunction doctor manila cheap fildena 25 mg without a prescription, the term antigen refers to a vaccine component that induces protection against a single disease. Antigenic Drift Minor changes in viral proteins (antigens) due to gene mutations within an influenza hemagglutinin or neuraminidase subtype. Antigenic Shift the sudden emergence of a new strain of influenza due to an abrupt change in the influenza hemagglutinin or neuraminidase protein type on the viral surface. These nucleotide sequences are not templates for synthesis but interact with complementary sequences in other molecules thereby affecting their function. Antisense oligonucleotides have been used to inhibit viral infections and to treat cancer and other diseases. Apoptosis An active form of cell death in which intrinsic cellular genetic programs are activated, leading to cellular suicide. Usually the enzymic activity is not just simple hydrolysis but rather a coupled system which is responsible for an energy-requiring process such as ion pumping. Autosomal Recessive A genetic trait that is only expressed when it is present on both alleles of a gene. Thus, two chromosomes bearing the gene anomaly are required, one from each parent. The risk of transmitting an autosomal recessive disease is 1/4 (25%) at each pregnancy. In general, axons transmit impulses to other nerve or effector cells via synaptic terminals. B B Cell One of two major classes of lymphocytes that develop in adult bone marrow and in the fetal liver of mammals. B cells express surface immunoglobulins (Igs), which act as specific antigen receptors. With a few exceptions, B cell activation is dependent on both 33 recognition of a specific antigen and T cell help. Activated B cells divide and differentiate into either memory cells or plasma cells. Memory B cells are long-lived and express antigen receptors other than IgM or IgD; they have undergone rearrangements in their Ig genes that result in increased affinity for that particular antigen. Bioavailability the proportion of an administered drug absorbed into the bloodstream, indicating the physiological concentration of that drug. Biomarker Characteristic that is objectively measured and evaluated as an indicator of normal biological processess, pathogenic processess or pharmacologic responses to a therapeutic intervention. Blind Trial, Single or Double See Single-Blind and Double-Blind Bronchitis Inflammation of the airways (bronchi) which connect the trachea to the lungs. Acute bronchitis occurs suddenly and is resolved within a few days, while chronic bronchitis persists over a long period of time and may recur over several years. Bronchus One of two subdivisions of the trachea that conveys air to and from the lungs. Bronchi are lined with stratified ciliated columnar epithelium, possess a lamina propria and are composed of longitudinal networks of elastic fibers. Spirally arranged bundles of smooth muscle are also present in addition to irregular plates of hyalin cartilage in the outer wall. There are three types of A subunits and two types of B subunits encoded by different genes. Calcineurin has been implicated in a wide variety of biological responses including lymphocyte activation, neuronal and muscle development, neurite outgrowth and morphogenesis of vertebrate heart valves. It has also been shown to have important roles in axonal guidance as well as memory and learning and plays a critical role in Ca(2+) signaling and stress responses. Blocking the calcineurin action would inhibit T-cell activation thus blocking transcription of these genes. This cell does not mature noramlly and eventually die but it divides prolifically. Cancers arising from epithelial cells are called carcinomas and those arising from mesenchymal tissues are called sarcomas. These chains are highly homologous cell surface proteins that are members of the immunoglobulin superfamily and contain a single extracellular immunoglobulin domain. These molecules display a certain degree of selectivity for various immune cell types and are involved in activation of leukocytes during transendothelial migration and chemotaxis in tissues. It is created by fusing two early blastula stage embryos, by reconstituting bone marrow in an irradiated recipient or by somatic segregation. Chlamydia A genus of prokaryotes that replicate in cytoplasmic vacuoles within susceptible eukaryotic cells. Other species of <I>Chlamydia</I> can cause a variety of infections including urethritis, epididymitis and proctitis in men, cervicitis, salpingitis and acute urethral syndrome in women and conjunctivitis and pneumonia in newborn infants. Chlamydia pneumoniae A bacteria belonging to the Chlamydiaceae family that causes pneumonia and diseases of the upper and lower respiratory tract. Persistent Chlamydia pneumoniae infections are thought to instigate or complicate the inflammatory response leading to atherosclerosis and/or angina pectoris. Consolidation the solidification into a firm dense mass as in inflammatory induration of a normally aerated lung due to the presence of cellular exudate in the pulmonary alveoli. The outer envelope of the virus has club shaped projections that radiate outwards and give a characteristic corona appearance to negatively stained virions. Corticosteroids A class of steroid hormones that are produced in the adrenal cortex and are involved in many physiologic processes including among others stress responses, immune responses, inflammation, carbohydrate metabolism, protein catabolism, electrolyte homeostasis and behavior. The class includes both glucocorticoids and mineralocorticoids although corticosteroid is often used synonymously for glucocorticoid. The word is thought to originate from the Greek "koryza" which means boiling over from the head. See also Rhinorrhea Creatine An amino acid that is found in muscle but does not occur in proteins. Phosphorylated creatine (creatine phosphate or phosphocreatine) is the energy source for muscle contraction. Crossover Trial A clinical study in which subjects receive two or more drugs separated by drug-free periods. Diabetes Mellitus A group of metabolic diseases characterized by chronic hyperglycemia with disturbances in carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both. This can result in structural and functional abnormalities including changes in vascular permeability and gene expression in the retina. Diarrhea A symptom characterized by loose or unformed stools, frequently accompanied by other gastrointestinal symptoms. It is nearly always a symptom of another disease or condition, rather than a disease in its own right. It is considered acute when it lasts for less than 4 weeks (typically associated with a bacterial or viral infection) and chronic when it persists for more than four weeks. Secretory diarrhea is caused by an increase in active secretion or an inhibition of absorption. Exudative diarrhea is characterized by the presence of blood and/or pus in the stool. Usually the comparison is between an experimental drug and a placebo or a standard comparison agent. Double-Dummy A research testing method in which patients in all treatment groups receive medication of the same appearance, one of which is inactive (placebo) and the other active. See also Upstream Dysplasia Pathological abnormality of development such as an alteration in size, shape and organization of adult cells. E Effectiveness the therapeutic effect of an intervention as demonstrated or observed in the real-world setting. See also Efficacy Efficacy the therapeutic effect of an intervention as demonstrated or observed in a controlled setting, such as a clinical trial. See also Effectiveness Emesis Emesis is the complex reflex consisting of ejecting the contents of the stomach through the mouth. Also known as vomiting, this reflex can be triggered by various endogenous or exogenous factors. Epithelium the cellular avascular tissue layer that covers all free cutaneous, mucous and serous surfaces. G G-Protein One of several mediators of activated cell surface receptors and their enzymes and ion channels. They are responsible for the signal transduction pathways which alter the concentration of intracellular second messengers. These second messengers in turn regulate the behavior of other intracellular target proteins, leading to the desired cellular response. G-Protein-Coupled Receptor Cell surface receptors that are coupled to G proteins. They have seven membrane spanning domains and have been divided into two subclasses: those in which the binding site is in the extracellular domain. Activation can result in potent anti-inflammatory activity as well as regulation of several cardiovascular, metabolic, immunologic and homeostatic responses. Glucocorticoids A family of steroid hormones generally synthesized and secreted by the adrenal medulla which affect intermediary metabolism such as hepatic glycogen deposition. Cortisol (also known as hydrocortisone) is the most potent naturally occurring hormone in this class. It regulates several cardiovascular, metabolic, immunologic and homeostatic responses. Headache Diffuse pain experienced in various regions of the head, not limited to the area of distribution of any single nerve. Hemagglutinin A membrane glycoprotein (550 amino acids) of the influenza virus type A involved in receptor binding and fusion. The name is derived from its capacity to agglutinate red blood cells at neutral pH. There are 15 hemagglutinin (H) subtypes of which only 3 (H1, H2 and H3) are associated with human illness. Hepatitis A A form of viral hepatitis that is known as infectious hepatitis because it can spread through contact with oral secretions or stool or through sexual contact. Liver disease caused by chronic hepatitis B can be fatal due to the development of cirrhosis leading to liver failure and an increased risk of hepatocellular liver cancer. These patients usually develop chronic hepatitis or become asymptomatic carriers of the virus. The surface coat is added on in the cytoplasm and, for unknown reasons, is produced in large quantities. Symptoms of hepatitis C may not manifest until the chronic stage and include jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea and vomiting. Cirrhosis from hepatitis C is the major condition responsible for the majority of orthotopic liver transplants in the U. Infection with hepatitis C has also been associated with increased risk of primary hepatocellular carcinoma. The virion consists of a nucleocapsid core and two envelope proteins within the lipid bilayer. Hepatitis, Fulminant A rare syndrome usually associated with hepatitis B and, in rare cases, with hepatitis A or E. It is characterized by rapid clinical deterioration and the onset of hepatic encephalopathy. The liver parenchyma undergoes massive necrosis and the organ size decreases significantly. Functional renal failure sometimes occurs; in some cases, coma may develop within hours of onset. Herd Immunity the indirect protection of unvaccinated individuals against a given disease achieved via immunity of a sufficiently large proportion of the surrounding population against the respective pathogen. The virus is spread via sexual contact with an infected individual, exposure to contaminated blood. Examples are hyaline cartilage and hyaline hyphae present in fungus such as Aspergillosis spp. I Immune System An integrated group of various cell types and the soluble molecules they secrete. Immunization the means to produce a protective immune response in susceptible individuals by administration of a living modified agent. Immunization, Active the means by which antibody production or cell-mediated immunity is stimulated by giving the antigen in the form of a vaccine or through exposure to naturally occurring antigens such as bacteria, viruses or fungi. Immunization, Passive A means to produce a temporary immune response against an infectious agent or toxin by giving preformed antibodies actively produced in another person or animal in the form of serum or gamma globulin. Immunocompromised Used to describe persons with an underdeveloped (as in the very young) or impaired immune system. The impairment may be a natural deterioration from age, or may be caused by disease or by the administration of immunosuppressive drugs. Immunogenic See Antigenic Immunoglobulin (Ig) A subgroup of globulins that are classified as alpha, beta and gamma according to lipid or carbohydrate content and physiological function. Serum Igs belong to the gamma group and constitute a family of glycoproteins that bind antigens. Immunoglobulin A (IgA) Major class of immunoglobulins found in mammalian serum, body fluids. Of the five types of Igs (IgM, IgG, IgA, IgE and IgD) in the body, only IgE has been shown to be involved in allergic reactions.

Very permeable fill materials should be avoided to prevent surface exposure of inadequately treated wastewater from too rapid movement through the fill erectile dysfunction drugs class quality fildena 100mg. Slowly permeable fill material should also be avoided to prevent impeded wastewater movement through the fill erectile dysfunction psychological causes treatment buy fildena with visa. If the in-situ unsaturated soil has a percolation rate faster than one (1) minute per inch erectile dysfunction in young 50 mg fildena with amex, sufficient stabilized soil with a percolation rate between five (5) and thirty (30) minutes per inch is required to maintain at least two (2) feet separation between the proposed bottom of the absorption trenches and in-situ soil leading causes erectile dysfunction cheap 100 mg fildena mastercard. The edge of the fill material beyond the basal area shall be tapered at a slope no greater than one (1) vertical to three (3) horizontal with a minimum taper length of twenty (20) feet erectile dysfunction doctors in sri lanka fildena 150 mg discount. All minimum horizontal separation distances as described in Table 2 shall be measured from the outer edge of the taper since the fill is considered a system component cialis causes erectile dysfunction buy fildena 50mg on-line. The fill must be stabilized prior to conducting final percolation tests and construction of the absorption trench system. Soils whose permeability characteristics could change significantly upon stabilization (soils containing clay and/or silt) shall be allowed to settle naturally for a period of at least six (6) months and include one freeze-thaw weather cycle. Soils whose permeability characteristics will not change significantly upon stabilization (sand and sandy loam) may be mechanically compacted or 78 Chapter 10: Alternative Subsurface Onsite Wastewater Treatment Systems allowed to settle naturally as indicated above. Mechanical compaction shall be achieved via track type machines (bulldozer or front-end loader with downward blade/bucket pressure) or steel wheeled roller. Mechanical compaction shall be accomplished in shallow lifts [approximately six (6) inches] to the approximate density of the undisturbed borrow pit soil. Compaction must be carried out carefully to avoid creating layers of different density. Distribution to the absorption trench system shall incorporate dosing, unless: (a) the system is to be installed under the jurisdiction of a local health department which has a program incorporating site evaluation, system design approval and construction inspection/certification, and (b) a minimum of two (2) feet of fill material with a percolation rate of five (5) to thirty (30) minutes/inch shall be placed between the bottom of the trenches and the existing ground. Curtain drains may be used on the uphill side of proposed fill areas on sloped sites to intercept and control ground water where high ground water levels exist. Non-perforated pipe constructed to convey ground water from the perforated drain pipes to the ground surface should be installed on in-situ soil bedding at least five (5) feet from the toe of the slope of the fill material. Excavated soil shall be used as backfill around and above the non-perforated pipe. The drainpipe surface outlet shall be protected from water infiltration, soil erosion and animal entry. This method of controlling groundwater level should be monitored to confirm effectiveness to ensure the absorption area maintains the two (2) foot separation to groundwater year-round. On sloped sites, a diversion ditch or curtain drain shall be constructed uphill from the fill to prevent surface runoff from entering the fill area. The topsoil surface of the fill shall be graded to enhance runoff of precipitation. The receiving soil will act as a final polishing media and distribute the treated wastewater into the soil. A conventional absorption trench shall be designed to distribute effluent evenly over the fill material basal area. Extreme care must be taken to assure that construction techniques do not compromise the integrity of the receiving soils or fill material. Heavy construction equipment must not be allowed within the area where the raised system is to be installed. Generally, sites with large trees, numerous small trees, or large boulders are unsuitable for a raised system because of the difficulty in preparing the surface and the reduced infiltration area beneath the system. Consideration should be given to increasing the size of the system to provide sufficient soil 79 Chapter 10: Alternative Subsurface Onsite Wastewater Treatment Systems to accept the effluent when tree stumps and/or boulders occupy a significant amount of the soil surface area. In areas that are suitable, all trees and stumps shall be cut at grade and removed. Plowing the area where the fill is to be placed turns over the soil without destroying the soil structure or infiltrative capability of the receiving soils. When the surface is plowed, a plow with at least a double bottomed blade/furrow plow with the furrow turned upslope is recommended. If other equipment (such as teeth from the bucket of a backhoe) or another method is used it must not destroy soil structure and cause smearing or compaction of receiving soils. Rototilling or soil scarification with construction equipment should always be avoided. After the site has been cleared and plowed all traffic shall be excluded from the area. Fill material can be deposited on the site with a front-end loader or pushed on from the side, preferably the upslope side, using a track type machine with at least six (6) inches of fill beneath the tracks. Fill should be placed on the site immediately after it is prepared to avoid undesirable changes to the native soil (traffic, compaction, erosion, etc. The fill shall be properly stabilized and the absorption trench system shall be constructed in the fill material. After the absorption trenches have been constructed in the stabilized fill (including backfilling the trenches), the entire surface of the raised system including the tapers shall be covered with a minimum of six (6) inches of topsoil, slightly mounded to enhance runoff of precipitation from the system (1% slope) and seeded to grass. Appropriate curtain drains and diversion ditches shall be constructed uphill from the absorption system on sloped sites to prevent ground water from interfering with absorption system operation or surface runoff from entering the fill. Mounds are a variation of the raised system except a specified and analyzed (sieve analysis) sandy fill material is utilized. The type of soil used does not require a stabilization period (freeze-thaw) prior to construction of the absorption trenches or bed in the fill. For sites with permeable soils of insufficient depth to groundwater, creviced rock or porous bedrock for a conventional absorption system, the specified fill material in the mound provides the necessary treatment of wastewater. The overall size of a mound system will usually be substantially smaller than a raised system because of the combination of using a specified fill material, the improved solids retention of the required multi-compartment septic tank or tanks in series and the required pressure distribution. Installation of water saving devices such as; faucets, showerheads, toilets and clothes washers are recommended for any residence using a mound system to minimize wastewater flow. When mound systems are proposed as replacement systems for existing homes, water saving fixtures should replace older household plumbing fixtures. Siting and design experience indicates that a mound should be long and narrow and should follow the site contour. At least one deep hole test at least four (4) feet deep or to bedrock shall be dug at the proposed location of the mound system to verify boundary conditions. On 1% to 12% sloping sites the basal area includes only the area under the absorption trenches or bed and the lower or downhill taper only. All minimum vertical separation distances depicted in Figure 30, 31 shall be met, and dimension D in Figures 32A and 32B must be at least one (1) foot. The required basal area is dependent upon the daily design flow rate and soil percolation test results of naturally occurring soil. Trench lengths listed in Table 6A or calculated from Table 6B for trenches, and basal areas listed in Tables 7A or calculated from Table 7B for absorption beds, shall be used when the percolation rate is between one (1) and sixty (60) minutes per 81 Chapter 10: Alternative Subsurface Onsite Wastewater Treatment Systems inch. Percolation test holes shall be approximately twelve (12) inches deep to determine the percolation rate of the upper foot of naturally occurring soil. Percolation tests should be conducted near each end of the proposed mound and the expansion area. The slowest percolation test results (worst case observed within the selected basal area) shall be used to design the basal area required. At least one (1) deep hole test should be performed at the proposed location of the reserve area to verify boundary condition separation, if available. The recommended separation distance between two (2) or more mound systems (toe of slope of fill to toe of slope of fill), perpendicular to ground contours is at least thirty (30) feet. Heavy construction equipment shall not be allowed within the basal area and a recommended minimum 20 feet wide area downslope of the basal area, which acts as a dispersal area for the mound. Percolation tests for the fill material shall be conducted at the borrow pit in areas representative of the soil to be obtained. Only uniform medium to course sand with a percolation rate between five (5) and thirty (30) minutes per inch shall be used for the fill material. A sieve analysis is recommended and may be necessary to verify compliance with the soil specifications. The percolation rate should be verified and take precedence to the fill gradation requirements when a mound is placed over very slow percolating soil to avoid rapid weeping of fluids at the ground surface. A pressure distribution network shall be utilized and timed dosing is recommended to control discharge to the mound. The width of the system shall be kept to a minimum and, in no case, shall the absorption area be wider than 20 feet. A mound shall not be expanded greater than 20 feet wide to satisfy absorption system expansion. In a distribution network using a central-manifold, distribution lines shall have a maximum total length of 200 feet (end cap to end cap) as depicted in Figure 16. In a distribution network using an end-manifold, distribution lines shall have a maximum length of 100 feet (manifold pipe to end cap) as depicted in Figure 15. The overall size of absorption facilities in a mound (bed or trenches) shall not exceed 20 feet by 205 feet for a central manifold distribution network or 20 feet by 105 feet for an end manifold distribution network. B = absorption trench or bed total length and shall not exceed 205 feet for a central manifold or 105 feet for an end manifold. C = downslope setback and shall be the larger of: (1) approximately three (3) times the height of the mound at the downslope edge of the absorption facility ([3] [E + F+ G]); or, (2) the dimension calculated from percolation tests on the naturally occurring soil plus flow rates to meet the required basal area. D = depth of fill at the upslope edge of the absorption facility between the top of the plowed surface and the bottom of the absorption facility and shall be at least one (1) foot. E = depth of fill at the downslope edge of the absorption facility between the top of the plowed surface and the bottom of the absorption facility and shall be equal to [D + (slope of site) (A)]. Gravelless absorption products may be used in place of aggregate in accordance with the manufacturers recommendations on a 1:1 basis only (mound and absorption area dimensions shall remain the same). G = depth of permeable soil cover plus topsoil at the upslope and downslope edges of the absorption facility and shall be at least one (1) foot [i. H = depth of permeable soil cover plus topsoil at the width center of the absorption facility and shall be at least 1. J = upslope setback and shall be at least: [3(D + F + G)] [Slope of Site] [(3) (D + F+ G)] = [1 Slope of Site] [(3) (D + F + G)]. K = side slope setback and shall be at least three (3) times the total height of the mound: D E [3][() + F+H]. Mound dimensions shall be consistent with Figures 30, 30A, 31, 31A, 32, 32A and 32B and meet or exceed those required by the local health department having jurisdiction. The required absorption area of the trenches or bed shall be based upon the daily design flow rate and the percolation rate of the in-situ fill material (at the borrow pit). Trench lengths are listed in Table 6A or calculated from Table 6B for trench systems, and basal areas are listed in Table 7A or calculated from Table 7B for absorption beds. A dual chamber septic tank or two tanks in series in addition to the dosing tank (with pump storage) shall be provided. An effluent filter or other outlet modification that enhances solids retention in the tank(s) is recommended. The in-situ soil beneath the mound basal area must be capable of absorbing the filtered effluent of the mound. Extreme care must be taken to assure that construction techniques do not compromise the integrity of the mound system or receiving soils. Heavy construction equipment must not be allowed within the fill area of the system or immediately downslope of the system. Placement of fill material or construction of absorption facilities in fill shall not occur when the soil moisture content is high. Generally, sites with large trees, numerous small trees or large boulders are unsuitable for a mound system because of the difficulty in properly preparing the surface and the reduced infiltration area available beneath the system. Other vegetation (brush, vines, weeds and grass) shall be cut as close to grade as possible and removed. The proposed mound area shall be plowed to a depth of about seven (7) to eight (8) inches preferably with a double-bottomed blade/furrow plow with the furrow turned upslope or a backhoe equipped with plowing blades. Other methods that will promote infiltration and not destroy soil structure may also be used. Fill should be placed on the site immediately after it is prepared to avoid undesirable changes to the plowed native soil, (traffic, compaction, erosion). Fill material can be deposited on the site with a front-end loader or pushed on from the side (preferably the upslope side) using a track type machine with at least six (6) inches of fill beneath the tracks. Construction of the absorption system in the fill material shall be in accord with Figures 30, 30A, 31, 31A, 32, 32A and 32B, including distribution laterals being installed parallel to the contour lines of the native soil prior to installing fill. The bottom and sidewalls of the absorption trenches or bed shall be raked prior to installing. The 84 Chapter 10: Alternative Subsurface Onsite Wastewater Treatment Systems aggregate in the trenches or bed shall be completely covered with a permeable non-woven geotextile to prevent infiltration of soil into the aggregate. The tapered slopes of the fill shall not exceed one (1) vertical to three (3) horizontal. The entire mound including the tapers shall be covered with six (6) inches of topsoil and seeded to grass. Appropriate curtain drains and diversion ditches shall be constructed uphill from the mound on sloped sites to prevent ground water from interfering with absorption system operation or surface water from entering the mound. Effluent is intermittently spread across the surface of a bed of specified sand (at least 24 inches thick) via perforated distribution lines installed in an upper layer of aggregate. A three (3) inch layer of 1/8 to 1/4 inch diameter washed crushed stone or washed gravel is placed beneath the sand layer and above a layer of 3/4 to 1-1/2 washed aggregate (at least ten (10) inches thick). Perforated collector pipes are installed in the bottom layer of aggregate to collect filtered wastewater for distribution to a subsurface soil absorption area for final treatment. Sand filter effluent shall be discharged to a subsurface absorption facility (to a downstream absorption mound or modified shallow trench system). Intermittent sand filters and downstream absorption systems should only be used on large lots. These systems are not intended for use where the surface soil is impermeable since the absorption system would exhibit continuous weeping. The downstream absorption system may exhibit some weeping of double-filtered wastewater during the wet season.

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