Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
In disease states risperidone 4 mg with visa symptoms nausea fatigue, tests show abnormally high or low levels of these chemicals or cells discount risperidone 3mg online medicine mart. Note order generic risperidone on-line treatment hyponatremia, however, that due to variations in individuals, normal values are almost always given in ranges. Normal ranges may vary somewhat from one source to another and may be reported in a variety of units. Hematology usually refers to the study of gross features of blood such as cell counts, bleeding time, etc. Metabolism metabolic reactions take place Dynamic steady state maintained by constant expenditure of body B 2. Match the following actions and reactions to the body chemicals: A Energizers and sources of energy 1. Electrolytes F Gatekeepers that allow movement of substances through cell walls 6. Identify the chief characteristics of red blood cells, white blood cells, and platelets 4. It distributes oxygen, nutrients, electrolytes, hormones, and enzymes throughout the body. Plasma, which makes up about 55% of blood, is the straw colored clear liquid in which cellular elements and dissolved substances (solutes) are suspended. Albumin controls water movement across membranes; afects blood viscosity (thickness), pressure, and volume; transports substances such as drugs. Products of metabolism: urea, uric add, creatine, creatinine, ammonium salts; toxic if not removed; carried in blood to organs of excretion Products of digestion. Amino acids, glucose, fatty adds all needed by cells for energy, repair, and reproduction Regulatory substances. Enzymes for cellular chemical reactions; hormones to regulate growth and development Electrolytes. Cell Types Found on Blood Smears from Normal Individuals Most blood samples are measured in microliters (?L); to give you a reference, a drop of blood is roughly 30 ?L. Large lymphocyte with purplish-red (azurophil) granules and deeplyelements: erythrocytes (red blood cells), leukocytesblunt pseudopods ?L indented by adjacent erythrocytes 4G. Basophil leukocytes, G = platelets (thrombocytes), H-J = ?L the arrangement is arbitrary and the number of leukocytes in relation to erythrocytes and thrombocytes is greater than would occur in an actual microscopic field. Also called thrombocytes, platelets are cell fragments that travel in the bloodstream. Platelets help prevent blood and fuid loss by clumping together to begin the coagulation process. A blood clot is formed when sticky platelets become covered with fbrin a plasma protein that holds the blood clot together. Each of the formed elements of blood will be covered in more detail in the following sections. Generations of cells eventually diferentiate into cell lines that will mature to produce erythrocytes, leukocytes, and platelets. Stem cells in bone marrow continuously proliferate usually at a steady state to maintain a constant population of mature blood cells. As they age and mature, they become smaller and change in their reaction to the dyes used to stain them for identifcation. Located beneath the diaphragm and behind the stomach, the spleen is an intricate flter that receives 5% of the total blood volume each minute. In the embryo, the spleen is a blood-forming center; it loses this function as the fetus matures. Old or damaged cells are removed; salvageable cells may be ?pitted?, that is, unwanted particles are removed without destroying the cells. Because it is not essential to life, the spleen may be removed (splenectomy) without serious efects. Proliferation of mature cells 7 Fill in the following blanks to characterize red blood cells. Although highly specialized, it is little more than a small bag a membrane surrounding a solution of protein and electrolytes. In appearance, an erythrocyte is a bi-concave, disc-shaped cell, somewhat like a doughnut that has no hole. A cell with basophilic staining properties is a cell that stains specifcally with basic dyes; a cell with eosinophilic staining properties is a cell that stains with eosin, a red acidic dye. Tissue hypoxia (abnormally low oxygen level) triggers the kidneys to increase production of erythropoietin. Poor absorption of vitamin B12 is due to lack of secretion of intrinsic factor by the gastric mucosa. These absorption and defciency problems can arise in alcoholics, geriatric patients, and in pregnant or lactating women. The oxygen-carrying capacity of hemoglobin can be afected by the formation of gases that can prevent O2 from reaching cells and by abnormalities of hemoglobin production and destruction. To keep hemoglobin and other functional iron levels constant, the body draws iron from storage. Because it is readily mobilized when iron is lost (through hemorrhage) or inadequate (poor diet), ferritin is depleted early in iron defciency.
- Cutaneous T-cell lymphoma
- Paramyotonia congenita of von Eulenburg
- Aplasia cutis congenita
- Landouzy Dejerine muscular dystrophy
- Eiken syndrome
- Microphthalmia, Lentz type
- Fetal acitretin syndrome
- Osteolysis syndrome recessive
Construction has that they may face include standing for including work with machines buy risperidone with paypal medicine 8162, vehicles buy risperidone 4mg mastercard symptoms 38 weeks pregnant, one of the highest rates of occupational long periods; carrying heavy loads; use of tools and animals; excessive noise and accidents and diseases of all industries purchase cheap risperidone on line medicine 3601, dangerous machines and tools; the risk vibration; slips, trips and falls from height; mainly because of the very hazardous of burns, allergies and infections; poor the need to lift heavy weights and do re nature of many construction tasks. The number environments, such as exposure to the cidents and diseases is also due to certain of jobs in the health and social services sun, extreme temperatures and inclem characteristics of the construction sector, subsector has been increasing worldwide, ent weather. Even though employment in such as the high proportion of small frms and young workers are taking up many agriculture is declining for both young and and extended contracting chains; multi of these jobs. For these reasons, mining and tic workers continue to be overworked, manufacturing in Africa and 20. In many developed are prohibited from working until they are ers are exposed are long working hours countries, it is the sector with the highest 18 years old. Moreover, they are relatively proportion of occupational accidents in ?invisible? where the authorities are con volving young workers. Young girls and migrants metallurgical industry, the food industry, sector is frequent interaction with custom who are domestic workers are particularly and the consumer goods industry. This character vulnerable to violence and abuse, in part industries present numerous safety and istic increases the likelihood that workers due to the lack of reporting mechanisms, health hazards for workers, such as the use will be exposed to psychosocial hazards, limited legal protections and the isolated of chemicals, machinery, vehicles and elec including verbal abuse, threats, humiliat nature of the work. Young domestic work tric tools, and physical hazards, such as in ing behaviour, bullying, harassment, physi ers often have to give up educational op adequate ventilation, high levels of noise, cal violence, and unwanted sexual atten portunities, which places them at greater high temperatures and poor lighting. The Convention also defnes employers? responsibilities, the rights of workers and their representatives, and requirements regarding information, education and training. The Recommendation also promotes the use of a gender-sensitive approach when designing national systems, so as to provide for the protection of both women and men. These requirements are extended and health of young persons shall not be less than to the age of 21 for occupations that involve high 18 years (exception may be permissible as from health risks. There are further provisions designed to safeguard the life and health of young specifc to young workers in conventions for the pro persons employed or working in underground tection of young seafarers and conventions on fshing mines. This extension should apply to, in that paragraph as from 16 years of age on condition that but not be limited to, all mining occupations, all employment appropriate prior training is given and the safety and health in hospitals, and employment in public entertainment such as of the young workers are fully protected. However, 42 per confned spaces type of employment or Work with dangerous cewnt of employed adoles work that by its nature or machinery, equipment and the circumstances in which cents between the ages of 15 tools, or work that involves it is carried out is likely to the manual handling or and 17 were still engaged in jeopardize the health, safety transport of heavy loads or morals of young persons hazardous work in 2016, con Work in an unhealthy shall not be less than 18 environment, which may, for stituting about 25 per cent of years; the Article includes example, expose children some exceptions. The types of work referred to under Article 3(d) are to be determined by national laws or regulations or by the authorities after consultation with the organizations of employers and workers concerned, taking into consideration relevant international standards. Two of the initial projects within chains in Indonesia, Myanmar, the Philippines and Viet Nam. Consequently, effective data collec Governments are responsible for the development tion and analysis is critical for the identifcation of and implementation of a national system for the noti workplace hazards, hazardous sectors and vulnerable fcation and recording of occupational accidents and groups of workers. An effective system should provide timely, comprehensive and reliable data on the incidence Data are also important for the development of of occupational accidents and diseases. Conse are frequently engaged in informal employment and quently, they are vital for the development and imple temporary work, two categories often not covered mentation of policies, strategies and programmes by national notifcation and recording systems. Governments and employer organizations should ensure that employ Young workers, especially, should be encouraged to ers have access to clear guidelines on how to meet participate in the reporting of workplace accidents these important requirements, and to training. With guidelines should provide guidance relating to the out encouragement and reassurance, young workers enterprise, sectoral and national levels. They also tend to know more than anyone else diseases to the employer and be able to do so with about potential hazards associated with their jobs. Ev Philippines eryone is invited to report occupational accidents by using the webpage ec-ulat. The policy should provide for the be identifed and addressed when developing such assessment of occupational risks or hazards, the com policies. Close attention should be paid to workers at batting of occupational risks or hazards at source, and higher risk, such as young workers. The Con ers should not be limited to young people under the vention lists four ?worst forms of child labour. It fourth item in the list is ?work which, by its nature or should be expressed in national laws, regulations and the circumstances in which it is carried out, is likely to policies that address the risk factors that cause young harm the health, safety or morals of children. The identifcation of these types of work plan and conduct the process so that the tripartite consulta often results in a ?hazardous child labour list. It also provides practical and easy access to reference materials that will assist the tripartite members of the consultation in their deliberations. When young workers over the age of Health Instrument prohibits the hiring of children 18 but under the age of 21 perform work considered and adolescents for work involving unhealthy or unhealthy or dangerous, annual medical examina dangerous activities that may affect their physical and tions must be carried out until such workers reach the mental development. It is their duty to care ers are recognized and addressed by such manage for the safety and health of their employees. These include the Employ institutions, employers, workers and their respec ers? and Workers? Handbook on Hazardous Child tive organizations, on how to establish, implement, Labour (2011) and the Safe work for youth Kit (2009). These include A 5-Step guide for employers, workers and their representa tives on conducting workplace risk assessments, and the Training package on workplace risk assessment and manage ment for small and medium-sized enterprises. Employers? organizations have a critical role requires more than just better data and laws and to play in helping their members acquire adequate skills policies that address the needs of young workers. Collaboration with workers is necessary for the elimina tion of hazards, for the minimizing of risks and for the To fulfl their duty to protect workers? safety and improvement of working conditions. Trade Unions increasingly recognize the importance fective prevention and risk control measures. As there are large numbers of girls work which employ large numbers of young workers and ing in these sectors, a gendered approach should be child labourers, and in which hazardous working adopted so as to ensure that these girls are included conditions are often found.
Dieting results in loss of fat from the rest of the body purchase cheapest risperidone medicine logo, but with little or no change to discount 2mg risperidone overnight delivery medicine for runny nose the area afected by lipoedema discount risperidone online mastercard 2 medications that help control bleeding. Those afected by lipoedema often complain that even the slightest knock on their legs causes pain and that they bruise easily. And if lymph oedema also develops (lipoedema-lymphoedema syndrome), it can complicate the problem, adding large quantities of fuid to already swollen, heavy limbs. There is often a family history the mother or a grandmother is usually afected which suggests it is an inherited genetic cause. The fact that men appear unafected also suggests a hormonal infuence but no hormonal abnormalities have ever been found. Penelope shares her experience of the condition: I am a thirty-one-year-old female and I have had prob lems with my legs from puberty. I loved participating in sport at school but I was often ridiculed and bullied for being overweight even though I wasn?t fat, except in my legs. I competed in dressage to a high level (I was lucky, a great sport for me as the horse didn?t care what I looked like! Other members of my family have always been keen on exercise, so apart from my love of horses I was encouraged to join them in the gym, where there are all shapes and sizes, but it didn?t have any effect on my legs. The weight fell off the top half of my body to the point that I looked wasted, but my legs never changed size or shape. My feet looked nor mal but my lower legs above my ankles were huge and my grandmother called them ?cankles? (chunky ankles). While the rest of my body looked toned my legs and thighs were wobbly with terrible cellulite. I am tall, and meas ure a size 12/14 on the top and a size 18 on the bottom; I?m just not the right shape for the high street! I currently have one pair of unfashionable jeans that I will wear until they fall apart. One day I?d like to fnd a trendy pair of skinny jeans that actually go over my calves! I was constantly being told that it was just stubborn fat that would shift in the end so I exer cised even more, but there was no change. Sadly, my legs have never made me feel attractive and this has affected my relationship with men. My legs being an object of derision, my self-esteem and confdence are always left shattered. Extra fat builds up in the lower leg immediately above the ankle bones, while the rest of the foot remains normal. Unfortunately, I had to go back several times before I was referred to a specialist, as they had never even heard of the condition. But eventually I was referred on to a doctor who confrmed that yes I did have lipoedema. It has been diffcult and has required perseverance, but exercise has been my saviour. My philosophy is no matter how much my legs hurt, never give up, and believe me they are heavy, ache and I constantly suffer knee and hip pain, but it is the exercise which has controlled my fat legs. It took a tremendous amount of effort as my legs felt heavy and the pain in my calves was unbearable, but I did it! No matter how unrealistic exercise seems, it really does help and I refuse to let lipoedema dictate my life. One of the problems with lipoedema is that although the condition itself is not obesity, the larger limbs can make exercise hard, and people can gain weight more easily. The defnitive treatment for lipoedema is liposuction, but that should not be tried unless ftness levels are good and any additional obesity has been addressed. The medical term for a failure of the lymph system within the digestive tract is intestinal lymphangiectasia, which is usually associated with lymphoedema. Diet is therefore extremely important in managing and alleviating the symptoms, as dietician Rani Nagarajah explains in relation to one of her patients: Daniel was born with his left leg longer than his right. Fat containing lymph, which had not been absorbed properly from the gut, was diverted to other parts of the lymph system such as the leg and genitalia, where it would leak out of his skin. Daniel would fnd this embarrassing because it would look as if he had wet himself. He was also prone to getting cellulitis, which would make him feel very ill, very quickly, and he suffered from frequent tummy pain and explosive diarrhoea. The symptoms interfered with his social life and relationships during his teens and then with his job when he left school. Daniel now works as a roofer and the constant bending and crouching made him feel uncomfortable and made the leaking worse. What fat he absorbed found its way into these abnormal lymph ves sels and then fowed in reverse to the skin of his genitals and foot. The size and location of the vessels meant that it would be too diffcult for a surgeon to remove, so he had to visit a dietician to customise a low-fat diet to compensate for the failure of the gut lymph system to absorb fat. As Daniel has a very physical job, it was important to compensate for the loss of energy from fat by adding extra protein and carbohydrate. Furthermore his lymphoedema swelling improved as he was now absorbing protein properly. Around the time of his thirtieth birthday, Daniel relaxed his diet and ate fatty foods for several days in a row. He immediately noticed a recurrence of diarrhoea and leaking of lymph from his toes. He now follows his strict low-fat diet six days a week but treats himself to a roast dinner or a pizza on a Sunday. This helps to ensure that there is no leaking and gives him good control over his bowels on workdays.
For example purchase risperidone 4mg without prescription medicine cards, ?My goal over the next month is to cheap risperidone 2 mg without a prescription medicine 319 meet my protein target by eating 1 cheap risperidone 3 mg free shipping symptoms 8 days post 5 day transfer. This decreases the amount of food you can eat, and can lead to weight loss and malnutrition. Keep a granola bar and meal supplement in the nightstand Make your calories count! High protein smoothie see Recipes chapter Meal replacement drink see Meal Supplements chapter Homemade cream soup Pudding, yogurt, and custard If you are up during the night, grab a quick snack or meal. Eating is so important because it provides the essential nutrients that can help with tiredness. If ?heart-healthy? options are available, choose these as they are usually lower in salt than other options remember to check the label! Look into meal-prep businesses the meal is assembled at their kitchen but is cooked at home. Ask friends and family for support by : Cooking and eating together Sharing meals Have a support person or friend prepare meals or snacks when possible Avoid prepared foods and take out foods! Patients with cirrhosis may experience day/night reversal this means a person is awake during the night and naps during the day. If this occurs, have 1 or 2 snacks between naps during the daytime and eat meals during the night. Nevertheless, it is important to stick as closely as possible to a regular eating schedule to help the liver. Take a lunch bag packed with items that will not spoil to every appointment, procedure, or hospital admission: Include meal supplements, such as Boost? or Ensure? Snack bag of unsalted nuts or trail mix High-protein granola or cereal bars 26 4 ?I don?t have enough money to buy food. The higher costs of fresh meat and dairy products means that it is important to watch for sales, look for alternative protein sources, and be creative to make the most of the grocery budget. Purchasing healthier, lower-sodium foods will also reduce grocery costs Watch for sales Portion out bulk foods into serving sizes that can be stored and used as needed? Total servings: 3 Nutritional facts per serving: Low-sodium Beef Taco Meat Calories: 133 kcal Homemade taco seasoning: Protein: 4 g 1 tbsp chili powder Sodium: 138 mg 2 tsp onion powder 1 tsp ground cumin 1 tsp garlic powder Gourmet Hamburgers 1 tsp paprika? Form into four 4? Add homemade taco seasoning (to taste) and 1-2 tbsp of round patties that are? Total servings: 4 Total servings: 4 Nutritional facts per serving (2 tacos): Nutritional facts per serving ~1 patty: Calories: 200 kcal Calories: 380 kcal Protein: 27 g Protein: 38 g Sodium: 78 mg Sodium: 124 mg Baked Chicken Thighs Tuna Salad 1 lb boneless, skinless chicken thighs (about 6 medium 1 can (120 g) tuna (canned in water, no salt added) thighs, thawed) 2 tbsp mayonnaise 1 tbsp sodium-free seasoning. Total servings: 1 Total servings: 3 Nutritional facts per serving (1 cup): Nutritional facts per serving (2 thighs): Calories: 355 kcal Calories: 260 kcal Protein: 30 g Protein: 40 g Sodium: 267 mg Sodium: 120 mg 28 Tangy Coleslaw Hamburger Soup 6 cups pre-chopped coleslaw mix (or chopped cabbage 1? Add remaining ingredients and bring to a Total servings: 6 boil, stirring frequently. Once boiling, turn the heat to Nutritional facts per serving (1 cup): medium-low and simmer for 2 hours. Calories: 105 kcal Protein: 2 g Total servings: 6 Sodium: 19 mg Nutritional facts per serving (~1. Dash? lemon and pepper salt-free spice mix Pizza Mix ingredients together in a medium bowl. Add margarine, sugar, and eggs and mix with a Total servings: 2 spatula until smooth. Protein: 25 g Sodium: 320 mg Total servings: 13 Nutritional facts per serving (1 mu? Protein: 13 g Add leftover rice and chicken, stirring them into the mix Sodium: 201 mg until the rice is broken up. Southwest Egg Burrito 1 large tortilla (use lowest sodium content) Total servings: 2 2 eggs Nutritional facts per serving (1 cup): 1 tsp cooking oil Calories: 302 kcal 2 tbsp diced onions Protein: 19 g 2 tbsp red pepper, chopped into bitesize pieces Sodium:137 mg 2 tbsp frozen corn niblets 2 tbsp shredded cheese 1 tbsp salsa Cheese Omelet Optional protein booster:? Pour the mixture into a Add frozen corn kernels (and black beans) and cook until warmed and greased non-stick fry pan. Transfer the cooked egg mixture to the center fold of the Fold one half over to the other half. Total servings: 1 Total servings: 1 Nutritional facts per serving (1 burrito): Nutritional facts per serving (1 omelet): Calories: 443 kcal Calories: 231 kcal Protein: 24 g Protein: 17 g Sodium: 382 mg Sodium: 233 mg Hummus Fruit Smoothie 15 oz can chickpeas, rinsed Blend together the following ingredients until the desired 1 garlic clove consistency is reached. Blend until the **If too thick, add water or juice to dilute mixture has a smooth consistency. Total servings: 1 Nutritional facts per serving (2 cups) with Total servings: 5 1 scoop whey protein powder: Nutritional facts per serving (? Puree the cooked mixture with a hand blender or cool slightly and puree in 2 batches using a blender or food processor. Ladle the soup into wide-mouthed bowls and top with tortilla chips, cheddar cheese, and a dollop of yogurt. For example, use after or instead of a meal if troubled by a poor appetite or getting full quickly. Here are some suggestions: If you have lost a lot of weight and muscle, choose a drink with 400 to 500 calories Mix chocolate or vanilla meal supplement with co? Nutritional Serving Calorie Protein Sodium Calcium Highlights meal size (kcal) (g) (mg) (mg) supplement Ensure? 1 bottle 235 9. However, liver fat can accumulate in overweight or obese people or those who have diabetes or high blood pressure. When losing weight, make small changes that can be easily maintained over a long Losing just 5-10% of current measured weight time. Tip Ask your healthcare practitioner or dietitian what your weight loss target is and how many calories per day you should be eating. If your weight has been stable to start with, a useful target is to decrease your caloric 34 intake by ~ 500 calories per day. My Weight: Date: ** Remember, there are online applications to track calories you eat in a day.
Purchase risperidone 2mg mastercard. Hypertrophic pyloric stenosis - causes symptoms diagnosis treatment pathology.
The men had worked at the factory for at least 1 year and discount risperidone online master card medicine 3 sixes, for the rheumatoid arthritis analysis order risperidone once a day medicine 8 iron stylings, were compared with 32 presumed non-exposed workers (clerks discount risperidone 3mg line symptoms xanax abuse, managers, and watchmen) or with the standard ized general population of Region Trentino-Alto Adige (where the factory was located) because there were few non-exposed foundry workers and high attrition rates. Requests for exemption health care fees were used as a surrogate measure to identify the most common morbid conditions in the general population, which were then applied to the cohort to compute the relative risks for each of the conditions. The workers were followed from March 19, 1979 (or their frst day of employment), through December 31, 2009, or date of death. The analysis for asthma was limited to 235 workers, and effect estimates were calculated using M antel-Haenszel tests. This study is most limited by the fact that foundry dust is a complex mixture, which made it impos sible to discern the impact of the specifc contaminants of the foundry dust on the health outcomes of those exposed workers. Exposure to foundry dust by the general population that was used for comparison was not discussed, although the foundry appears to be in the local vicinity, and emissions from it were reported to be present within a 2-kilometer radius. A study of occupational exposure to pesti cides in Ethiopian farmers and farm workers and respiratory health effects was conducted by Negatu et al. The study of electric arc foundry workers in Italy (Cappelletti, 2016) reported no difference in the risk of asthma, but this was based on two cases. Therefore, the prior assessment cannot be altered since the new fndings are mixed, and the study designs have limitations. Details on peptic ulcer and liver disease, the two conditions most often discussed in the literature reviewed, are provided below. The symptoms and signs of gastrointestinal disease and liver toxicity are highly varied and often vague. The essential functions of the gastrointestinal tract are to absorb nutrients and to eliminate waste. Those complex tasks involve numerous chemical and molecu lar interactions on the mucosal surface and complex local and distant neural and endocrine activity. One common condition of the gastrointestinal tract is motil ity disorder, which is present in about 15% of adults. The most convenient way to categorize diseases that affect the gastrointestinal system is according to the affected anatomic segment. Esophageal disorders predominantly affect swallow ing, gastric disorders are related to acid secretion, and conditions that affect the small and large intestines are refected in alterations in nutrition, mucosal integ rity, and motility. Some systemic disorders (infammatory, vascular, infectious, and neoplastic conditions) also affect the gastrointestinal system. Peptic-Ulcer Disease Peptic-ulcer disease refers to ulcerative disorders of the gastrointestinal tract that are caused by the action of acid and pepsin on the stomach or duodenal mucosa. Peptic-ulcer disease is characterized as gastric or duodenal ulcer, depending on the site of origin. Peptic-ulcer disease occurs when the corrosive action of gastric acid and pepsin overcomes the normal mucosal defense mechanisms that protect against ulceration. About 10% of the population has clinical evidence of having had a duodenal ulcer at some time in their lives; a similar percentage is affected by gastric ulcer. The incidence of duodenal ulcer peaks in the ffth decade, and the incidence of gastric ulcer about 10 years later. Evidence increasingly indicates that the bacterium Helicobacter pylori is linked to peptic-ulcer disease (both duodenal and gastric). Healthy people in the United States under 30 years old have gastric colonization rates of about 10%. Colonization alone, however, is not suffcient for the development of ulcer disease; only 15?20% of subjects who have H. The relative sensitivity and specifcity of those enzymes for diagnosing liver disease vary, and a diagnosis can require several tests. The estimated serum activity of that enzyme is a sensitive indicator of a variety of conditions, including alcohol and drug hepatotoxicity, infltrative lesions of the liver, parenchymal liver disease, and biliary tract obstruction. Increases are noted after many chemical and drug exposures that are not followed by evidence of liver injury. Cirrhosis is an irreversible chronic injury of the liver with extensive scarring and a resulting loss of function. Clinical symptoms and signs include jaundice, edema, abnormalities in blood clotting, and metabolic disturbances. Cirrhosis can lead to portal hypertension with associated gastroesophageal varices, an enlarged spleen, abdominal swelling attributable to ascites, and, ultimately, hepatic encephalopathy that can progress to coma. It is generally impossible to distinguish the various causes of cirrhosis through the clinical signs and symptoms or pathologic characteristics. The most com mon cause of cirrhosis in North America and many parts of western Europe and South America is excessive alcohol consumption. Other causes are chronic viral infection (hepatitis B or hepatitis C), the poorly understood condition primary biliary cirrhosis, chronic right-sided heart failure, and a variety of less common metabolic and drug-related conditions. Some studies that have been reviewed focused on liver enzymes, while others reported on specifc liver diseases. Studies of Vietnam veterans have generally examined different laboratory endpoints and clinical conditions, making comparisons and overall conclusions diffcult. However, mortality studies of the Ranch Hand cohort have not found an increased mortality related to gastrointestinal or liver disease (Ketchum and M ichalek, 2005). Studies of digestive and liver disease among other Vietnam veterans cohorts have not found associations with presumed herbicide exposure.