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Subcuta- injections are administered through a hollow needle i n t o the s u b c u t a n e o u s layer b e n e a t h the s k i n blood pressure guidelines chart generic isoptin 40mg mastercard. S u b c u t a n e o u s i n j e c t i o n s a n d intramuscular injections blood pressure medication used for opiate withdrawal discount isoptin 120mg on line, administered into muscles blood pressure equipment generic isoptin 120mg free shipping, are s o m e t i m e s called h y p o d e r m i c injections arteria bologna 8 marzo 2014 purchase isoptin online from canada. S o m e s u b s t a n c e s are a d m i n i s t e r e d t h r o u g h the s k i n b y m e a n s o f an a d h e s i v e t r a n s d e r m a l p a t c h t h a t i n c l u d e s a s m a l l reservoir c o n t a i n i n g a d r u g. T h e d r u g p a s s e s f r o m the reservoir t h r o u g h a p e r m e a b l e m e m b r a n e a t a k n o w n rate. It the n diffuses epithelium into the e p i d e r m i s a n d enters the b l o o d vessels o f the dermis. Transdermal patches are used to deliver d r u g s that protect against m o t i o n sickness, alleviate chest pain associated with heart disease, and lower b l o o d pressure. A transdermal patch that delivers n i c o t i n e is u s e d t o help p e o p l e s t o p s m o k i n g. Adipose tissue Epidermis the e p i d e r m i s is c o m p o s e d entirely of stratified squam o u s e p i the l i u m, a n d the r e f o r e it l a c k s b l o o d stratum basale, vessels. The H o w e v e r, the deepest layer of epidermal cells, called the is c l o s e t o the d e r m i s a n d i s n o u r i s h e d b y d e r m a l b l o o d v e s s e l s, w h i c h e n a b l e s the m to d i v i d e a n d grow. A s n e w cells enlarge, they push the older epidermal c e l l s a w a y f r o m the d e r m i s t o w a r d the surface o f the skin. T h e farther the c e l l s are m o v e d, the p o o r e r the i r nutrient s u p p l y b e c o m e s, a n d. A basement m i s by short fibrils membrane and elastic fibers, s m o o t h m u s c l e tissue, n e r v o u s tissue, a n d that is a n c h o r e d t o I h e d e r separates the t w o skin layers. B e c a u s e b l o o d v e s s e l s in the d e r m i s s u p p l y n u t r i e n t s t o the e p i d e r m i s, i n t e r f e r e n c e w i t h b l o o d f l o w m a y kill e p i d e r m a l c e l l s. P r e s s u r e ulcers usually o c c u r in the skin o v e r l y i n g b o n y p r o j e c t i o n s, s u c h a s o n the h i p, heel, e l b o w, o r shoulder. Frequently changing body position or massaging the skin to s t i m u l a t e b l o o d f l o w in r e g i o n s a s s o c i a t e d w i t h b o n y p r o m i n e n c e s c a n p r e v e n t p r e s s u r e u l c e r s. In the c a s e o f a p a r a l y z e d p e r s o n w h o c a n n o t feel p r e s s u r e or r e s p o n d t o it b y shifting position, caregivers m u s t turn the b o d y often to prevent pressure ulcers. Beds, wheelchairs, a n d other specialized equipment can periodically shift the patient, lowering the Beneath the d e r m i s, masses of loose c o n n e c t i v e and a d i p o s e tissues b i n d the skin to u n d e r l y i n g organs. T h e c o l l a g e n o u s a n d e l a s t i c fibers o f t h i s l a y e r a r e c o n tinuous w i t h those of the dermis. Most of these fibers run p a r a l l e l to the s u r f a c e o f the s k i n, e x t e n d i n g i n a l l d i r e c tions. A s a result, n o sharp b o u n d a r y separates the d e r m i s a n d the s u b c u t a n e o u s layer. T h e a d i p o s e tissue of the subc u t a n e o u s l a y e r insulates, h e l p i n g to c o n s e r v e b o d y heat a n d i m p e d i n g the e n t r a n c e o f heat f r o m the o u t s i d. T h e subcutaneous layer also contains the m a j o r b l o o d vessels lhat s u p p l y I h e skin. B r a n c h e s o f the s e v e s s e l s f o r m a netw o r k (rete c u t a n e u m) b e t w e e n the d e r m i s and Ihe subcutan e o u s layer. T h e y, in turn, g i v e o f f smaller vessels that s u p p l y the d e r m i s a b o v e a n d the u n d e r l y i n g a d i p o s e tissue. T h e cell m e m b r a n e s o f o l d e r skin celts (keratinocytes) thicken a n d d e v e l o p m a n y d e s m o s o m e s that fasten the m to e a c h o the r (s e e c h a p t e r 3, p. T h i s happens, f o r e x a m p l e, w h e n the s k i n is r u b b e d b r i s k l y w i t h a t o w e l. T h e structural organization of the e p i d e r m i s varies f r o m r e g i o n t o r e g i o n. It is t h i c k e s t o n the p a l m s o f the h a n d s a n d the s o l e s o f the f e e t, w h e r e it m a y b e 0. In m o s t areas, o n l y f o u r l a y e r s c a n b e d i s t i n g u i s h e d. T h e y a r e the stratum spinosum; the stratum basale (stratum g e r m i n a t i v u m, and the or basal c e l l layer), w h i c h is the d e e p e s t layer; the granulosumstratum stratum keratin p r o t e i n s are s y n the s i z e d a n d s t o r e d w i t h i n the c e l l. A s a result, m a n y layers o f tough, tightly p a c k e d d e a d cells a c c u m u l a t e i n the e p i d e r m i s, f o r m i n g an o u t e r m o s t l a y e r c a l l e d the stratum corneum.
A 55-year-old woman developed toxic epidermal necrolysis while taking valdecoxib (dosage not stated) for knee pain hypertension bench buy 40 mg isoptin with amex. Eight days after starting to take valdecoxib arrhythmia icd 9 codes isoptin 40mg visa, she developed a diffuse erythematous rash and fever blood pressure blurry vision best order isoptin. Valdecoxib was withdrawn blood pressure medication benicar discount 240 mg isoptin otc, but her reaction worsened and she was transferred to a burns unit with lesions consistent with toxic epidermal necrolysis, with complete skin and hair loss, and received wound care for 12 days. Valdecoxib has been associated with rare cases of serious skin reactions and of hypersensitivity reactions in patients with or without a history of allergic reactions to sulfonamides and should not be given to patients with such a history (8). Valdecoxib-associated edema may have aggravated pre-existing carpal tunnel syndrome. However, epigastric pain, burning, and nausea have been experienced by patients taking zidometacin (1). Zomepirac General Information Although zomepirac is a pyrrole-acetic acid compound closely related to tolmetin, it was originally claimed to be a new type of analgesic drug. In 1982, because of the severity and frequency of hypersensitivity reactions, it was withdrawn voluntarily by the manufacturers worldwide on a temporary basis (1). The percentage was even higher (43%; 458 of 1079 patients) during short-term therapy (2 weeks). Metaanalysis: upper gastrointestinal tolerability of valdecoxib, a cyclooxygenase-2-specific inhibitor, compared with nonspecific nonsteroidal anti-inflammatory drugs among patients with osteoarthritis and rheumatoid arthritis. Cox-2 inhibitors induced anuric renal failure in a previously healthy young woman. Valdecoxib-induced toxic epidermal necrolysis in a patient allergic to sulfa drugs. A ``Dear Healthcare Professional' letter regarding important safety information for valdecoxib. Organs and Systems Gastrointestinal Adverse effects of zomepirac on the gastrointestinal tract were the most frequent reason for interruption of treatment. Nausea, vomiting, dyspepsia, discomfort, abdominal pain, and diarrhea or constipation have been recorded, as have stomatitis and tongue pain (4). Immunologic the manufacturers received 1100 reports of allergic reactions in the first 2 years after launch. Hypersensitivity reactions are characterized by hypotension, bronchospasm, and serious respiratory distress, with or without oropharyngeal edema. Suspicions based on cluster reports that zomepirac may be addictive have not been confirmed (7). Long-term safety of zomepirac: a double-blind comparison with aspirin in patients with osteoarthritis. Double-blind, placebo-controlled comparisons of adalimumab alone or combined with disease-modifying antirheumatic drugs showed no significant differences in the incidence of serious adverse effects and infections, but more frequent injection-site reactions with adalimumab (1,2,3). Adverse effects that have been reported in trials include worsening or initiation of congestive heart failure, raised transaminases, medically significant cytopenias, including pancytopenia, and a lupus-like syndrome. Other adverse effects include asthma (5), paresthesia in the leg and foot drop (6), and severe oral epithelial dysplasia (7). Adalimumab increases the risk of rare serious infections two-fold, and it should not be used during periods of active infection. Its most notable infectious complication is reactivation of tuberculosis and screening is recommended. Placebo-controlled studies In a multicenter, randomized, double-blind, placebo-controlled study of subcutaneous adalimumab 40 mg every other week for 24 weeks, those who received adalimumab reported more adverse events (75% versus 60%), but there was no statistically significant difference in the incidence of infections; most adverse events were mild or moderate in intensity (8). The dose of prednisone was increased to 90 mg/day, antibiotics were withdrawn, and 2 months later he was discharged in satisfactory condition (10). A 76-year-old woman with severe rheumatoid arthritis and no respiratory symptoms was given adalimumab instead of sulfasalazine and hydroxycholoroquine. Methotrexate and adalimumab were both withdrawn and she was given oral prednisolone. A patient receiving adalimumab developed fatal exacerbation of fibrosing alveolitis associated with systemic sclerosis (12). She was treated with oxygen, diuretics, azithromycin, and methylprednisolone 1 g/day for 3 days, followed by prednisone 1 mg/kg/day and azathioprine.
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The first case suggested that a sulfonamide-like allergic reaction was the pathogenic mechanism hypertension 9 code order isoptin 40 mg without prescription, and the same mechanism cannot be excluded in the other two patients blood pressure examples cheap 40 mg isoptin mastercard, as sulfonamide allergy is often ignored and is discovered only when an adverse reaction occurs hypertension the silent killer purchase isoptin 120mg without prescription. Sixteen cases of tubulointerstitial nephritis were reported to the manufacturers of celecoxib between the time when it was launched in 1999 and July 2001 blood pressure chart low purchase genuine isoptin on line, but the diagnosis was not confirmed in 12 of these cases (12). A 61-year-old woman with rheumatoid arthritis developed renal papillary necrosis after taken celecoxib (200 mg bd) for about 6 months. The drug history and clinical findings suggested celecoxib as the most likely cause (16). A 59-year-old man with type 2 diabetes mellitus developed acute allergic interstitial nephritis associated with minimal change disease after taking celecoxib (100200 mg/day) for 1 year. The laboratory abnormalities lasted for several months after withdrawal of celecoxib and normalized only after treatment with prednisone (17). A 78-year-old woman developed membranous glomerulopathy after taking celecoxib (200 mg bd) for 7 months. A 71-year-old man developed nausea and weakness 9 months after starting to take celecoxib (100 mg bd). Celecoxib was withdrawn and he was given prednisone for 4 weeks; the serum creatinine returned to normal 1 month later (31). A 57-year-old woman developed a fixed drug eruption while taking celecoxib (200 mg/day for 10 days) for osteoarthritis (28). Immunologic Drug-induced lupus-like syndrome has been associated with celecoxib (29). Minimal-change disease with interstitial nephritis and nephritic syndrome have been described in two elderly patients taking celecoxib (19,20). There was a significant reduction in glomerular filtration rate and renal plasma flow in the patients who took naproxen but not in the other two groups. A 68-year-old woman started to take celecoxib (200 mg/ day) and 2 weeks later developed generalized joint pains and a micropapular skin rash associated with a malar rash. Celecoxib was withdrawn and she was given oral antihistamines and glucocorticoids, with complete resolution of the reaction within 5 days. She underwent an oral rechallenge test with increasing doses of celecoxib up to 200 mg/day over 3 days. She had a weakly positive titer of antinuclear antibodies and a skin biopsy that was characteristic of lupus erythematosus. However, further investigations are required to confirm this, in view of a case report that suggested cross-reactivity of celecoxib with sulfamethoxazole (31). Thrombosis in patients with connective tissue diseases treated with specific cyclooxygenase 2 inhibitors. Membranous glomerulopathy and acute interstitial nephritis following treatment with celecoxib. Nephrotic syndrome associated with celecoxib . Effects of L, Gine P, Jime celecoxib and naproxen on renal function in nonazotemic patients with cirrhosis and ascites. The final medical outcome was classified as no effect in 82% of the cases, and minor effects in 12% of the cases. Adverse effects were listed in 5% of the patients, the most common being rash (3%), drowsiness (3%), pruritus (2%), and vomiting (2%). The most frequently listed treatment was decontamination by dilution (43%) or food (32%). However, this possibility requires confirmation, as serious, sometimes fatal, hemorrhage has been reported during the postmarketing use of clopidogrel alone (35). The proposed mechanism was a celecoxib-induced reduction in renal function, causing increased serum lithium concentrations.
T h e muscle functions with other abdominal a n d it a l s o h e l p s t o f l e x the v e r t e b r a l c o l u m n blood pressure and exercise isoptin 120 mg low cost. T h e p e l v i c d i a p h r a g m f o r m s the f l o o r o f Ihe p e l v i c cavity blood pressure unstable isoptin 120 mg amex, and the urogenital d i a p h r a g m f i l l s the s p a c e w i t h i n the p u b i c arch arterial blood gases purchase genuine isoptin online. T h e y i n c l u d e the f o l l o w i n g: Pelvic Diaphragm Levator ani Coccygeus Urogenital Diaphragm Superficial transversus perinei Bulbospongiosus Ischioca v e rnosus S p h i n c t e r urethrae broad heart attack get me going extended version cheap isoptin 40mg with amex, thin sheet of m u s c l e located beneath Ihe external o b l i q u. Its fibers r u n u p a n d f o r w a r d f r o m the p e l v i c g i r d l e t o the l o w e r r i b s. Its fibers r u n h o r i z o n t a l l y f r o m the l o w e r ribs, l u m b a r v e r t e b r a e, a n d i l i u m to the l i n e a a l b a a n d p u b i c b o n e s. It f u n c t i o n s i n the s a m e m a n n e r a s the external and internal obliques. Levator ani Coccygeus Superficial transversus perinei Bulbospongiosus Sacrum and coccyx Central tendon Males: Urogenital diaphragm and fascia of penis Females: Pubic arch and root of clitoris Pubic arch Fibers of each unite with those from other side S4 and S5 nerves Pudendal n. Ischiocavernosus Sphincter urethrae Ischial tuberosity Margins of pubis and ischium Pudendal n. T h e y are c o n n e c t e d at the m i d l i n e posteriorly b y a ligament that e x t e n d s f r o m the tip o f the c o c c y x to the anal c a n a l. A n t e r i o r l y, the y are separated in Ihe male by the urethra and the anal canal, a n d in the f e m a l e b y the urethra, v a g i n a, a n d anal canal. T h e s e m u s c l e s h e l p s u p p o r t the p e l v i c v i s c e r a and p r o v i d e s p h i n c t e r l i k e action in the anal canal and vagina. A n external anal sphincter lhat is u n d e r v o l u n t a r y c o n t r o l a n d an internal anal sphincter that is f o r m e d o f i n v o l u n t a r y m u s c l e fibers o f the i n t e s t i n e e n c i r c l e the anal canal and k e e p it c l o s e d. Together they act as a sphincter that c l o s e s the urethra by c o m p r e s s i o n a n d o p e n s it b y relaxation. Muscles That M o v e the Thigh the muscles thai m o v e the thigh are attached to the f e m u r a n d to s o m e part o f the p e l v i c g i r d l. T h e muscles o f the anterior g r o u p p r i m a r i l y Ilex the thigh; those o f I h e p o s t e r i o r g r o u p e x t e n d, abduct, o r rotate it. M u s c l e s that m o v e the thigh i n c l u d e the f o l l o w i n g: Anterior Group Psoas major Iliacus Posterior G r o u p Gluteus m a x i m u s Gluteus m e d i u s Gluteus m i n i m u s Tensor fasciae latae S t i l l another g r o u p o f muscles, attached to the f e m u r a n d p e l v i c g i r d l e, a d d u c t s the thigh. In f e m a l e s, these m u s c l e s are s e p a r a t e d m e d i a l l y b y the v a g i n a a n d constrict I h e v a g i n a l o p e n i n g. T h e y c a n a l s o retard the f l o w o f b l o o d in v e i n s, w h i c h h e l p s m a i n t a i n an e r e c t i o n in the p e n i s o f the m a l e and in the clitoris o f the f e m a l. T h e i l i a c u s the psoas m a j o r are the p r i m a r y f l e x o r s o f the thigh, they a d v a n c e the l o w e r l i m b in w a l k i n g m o v e m e n t s 9. Its f i b e r s e x t e n d f r o m I h e i l i u m to the f e m u r, a n d the y a b d u c t the t h i g h a n d rotate it. It c o n n e c t s the i l i u m, s a c r u m, a n d c o c c y x to the f e m u r b y fascia o f the thigh a n d e x t e n d s Ihe thigh. T h e g l u t e u s m a x i m u s h e l p s to s t r a i g h t e n the l o w e r l i m b at the h i p w h e n a p e r s o n w a l k s, runs, o r c l i m b s. It is a l s o u s e d t o r a i s e the b o d y f r o m a sitting p o s i t i o n (fig. It a d d u c t s the t h i g h a n d a s s i s t s i n f l e x i n g a n d r o t a t i n g it l a t e r a l l y (f i g. It a d d u c t s the t h i g h a n d a s s i s t s in f l e x i n g a n d r o t a t i n g it l a t e r a l l y (f i g. It i s a t r i a n g u l a r muscle the t h a t c o n n e c t s the i s c h i u m t o the f e m u r. It a d d u c t s m u s c l e a b d u c t s a n d f l e x e s the t h i g h a n d rotates it m e d i - the gluteus m e d i u s and gluteus minimus help support and maintain the normal position of the pelvis. If the s e m u s c l e s are paralyzed a s a result of injury or disease, the pelvis tends to drop to o n e s i d e w h e n e v e r the f o o t on that side is raised. Muscles That M o v e the Leg i s c h i u m to I h e p r o x i m a l e n d o f the tibia, the s e m i t e n d i nosus is so n a m e d b e c a u s e it b e c o m e s t e n d i n o u s in the m i d d l e o f the thigh, c o n t i n u i n g to its insertion as a l o n g, c o r d l i k e t e n d o n. It c o n n e c t s the i s c h i u m to the tibia and f l e x e s a n d rotates the l e g m e d i ally and extends the thigh (fig. It c o n n e c t s the i l i u m to the libia a n d f l e x e s the leg a n d the thigh. T h e muscles that m o v e the l e g c o n n e c t the tibia or fibula to the f e m u r o r to the p e l v i c g i r d l.
T h e w a l l s o f the l y m p h a t i c Lymphatic Trunks and Collecting Ducts the l y m p h a t i c trunks blood pressure chart by age nhs cost of isoptin, w h i c h drain l y m p h f r o m the l y m p h a t i c v e s s e l s blood pressure higher at night buy isoptin american express, are n a m e d f o r the r e g i o n s they s e r v heart attack vol 1 pt 3 purchase 40 mg isoptin fast delivery. I h e lumbar trunk drains l y m p h f r o m the l o w e r l i m b s arrhythmia bat pony discount isoptin 40 mg visa, l o w e r a b d o m i n a l w a l l, a n d p e l v i c organs; the intestinal trunk d r a i n s the a b d o m i n a l v i s c e r a; the intercostal and bronchomediastinal trunks drain l y m p h f r o m p o r t i o n s of the t h o r a x: the subclavian trunk d r a i n s the u p p e r l i m b; and the jugular trunk drains p o r t i o n s o f the neck and h e a d. T h e s e l y m p h a t i c trunks the n join o n e o f t w o c o l l e c t i n g d u c t s - the t h o r a c i c duct or the right l y m p h a t i c duct. T h e t h o r a c i c duct is the larger and longer o f the t w o c o l l e c t i n g ducts. It begins in the a b d o m e n, passes u p w a r d through the diaphragm b e s i d e the aorta, ascends anterior to Ihe vertebral c o l u m n through Ihe m e d i a s t i n u m, and e m p ties into the left subclavian v e i n near the junction o f the left jugular v e i n. T h i s d u c t drains l y m p h f r o m Ihe intestinal, lumbar, and intercostal trunks, as w e l l as from the left subclavian, left jugular, and left bronchomediastinal trunks. T h e right l y m p h a t i c duct originates in the right thorax at the u n i o n o f the right jugular, right subclavian, a n d right b r o n c h o m e d i a s t i n a l trunks. T h u s, l y m p h f r o m I h e l o w e r b o d y r e g i o n s, the l e f t u p p e r l i m b, a n d the lefl s i d e o f the h e a d and neck enters the thoracic duct; l y m p h f r o m the right s i d e o f the h e a d a n d n e c k, the right u p p e r l i m b, and the right thorax enters the right l y m p h a t i c duct (fig. Surgery t o remove a cancerous breast c a n disrupt this drainage, causing painful swelling. T h i s increases the tissue f l u i d hydrostatic pressure s o m e w h a t, f a v o r i n g m o v e m e n t of tissue Quid into l y m p h a t i c capillaries, f o r m i n g l y m p h. L y m p h also returns to the b l o o d s t r e a m m o s t o f the s m a l l p r o t e i n s that the b l o o d c a p i l l a r i e s f i l t e r e d. A t the s a m e t i m e, l y m p h transports f o r e i g n particles, such as bacteria or viruses, to l y m p h n o d e s. A l t h o u g h p r o t e i n s a n d f o r e i g n particles c a n n o t easi l y e n t e r b l o o d c a p i l l a r i e s, the l y m p h a t i c c a p i l l a r i e s are adapted t o r e c e i v e the m. S p e c i f i c a l l y, the e p i the l i a l c e l l s that f o r m the w a l l s o f l y m p h a t i c v e s s e l s o v e r l a p but are not attached to e a c h other. T h e e p i the l i a l c e l l s o f the l y m p h a t i c c a p i l l a r y w a l l are a l s o attached to s u r r o u n d i n g c o n n e c t i v e tissue c e l l s by thin p r o t e i n filaments. A s a result, the l u m e n o f a l y m p h a t i c c a p i l l a r y r e m a i n s o p e n e v e n w h e n the o u t s i d e Collecting duct Subclavian vein F I G U R E 16. Consequently, if the skin is broken, or if something is injected into it (such as venom from a stinging insect), foreign substances rapidly enter the lymphatic system. Through which lymphatic structures would lymph pass in traveling from a lower limb back to the bloodstream? Flow of lymph Tissue Fluid and Lymph L y m p h is e s s e n t i a l l y tissue f l u i d that has e n t e r e d a l y m phatic capillary. Tissue F l u i d F o r m a t i o n Capillary b l o o d pressure filters water and small molec u l e s f r o m the plasma. T h e r e s u l t i n g f l u i d has m u c h the s a m e c o m p o s i t i o n as the plasma (i n c l u d i n g nutrients, gases, and h o r m o n e s), w i t h the important e x c e p t i o n o f the p l a s m a p r o t e i n s, w h i c h are g e n e r a l l y t o o large to pass t h r o u g h the c a p i l l a r y w a l l s. T h e o s m o t i c e f f e c t o f these (c a l l e d the plasma colloid osmotic pressure) h e l p s to d r a w fluid back into the capillaries by osmosis. Lymph N o d e s L y m p h n o d e s (l y m p h g l a n d s) are l o c a t e d a l o n g the l y m p h a t i c p a t h w a y s. H o w e v e r, muscular activity l a r g e l y i n f l u e n c e s the m o v e m e n t o f l y m p h through the l y m p h a t i c vessels. L y m p h n o d e s v a r y in s i z e a n d s h a p e but are usually less than 2. B l o o d v e s s e l s a n d nerves join a l y m p h n o d e through the i n d e n t e d r e g i o n o f the n o d e, c a l l e d the h i l u m. T h e l y m p h a t i c v e s s e l s l e a d i n g to a n o d e (a f f e r e n t v e s s e l s) e n t e r s e p a r a t e l y at v a r i o u s p o i n t s on its c o n v e x s u r f a c e, but the l y m p h a t i c v e s s e l s l e a v i n g the n o d e (e f f e r e n t vessels) exit f r o m the h i l u m. A capsule o f c o n n e c t i v e tissue w i t h n u m e r o u s fibers e n c l o s e s each l y m p h n o d. T h e c a p s u l e e x t e n d s i n t o the n o d e a n d partially s u b d i v i d e s it i n t o c o m p a r t m e n t s c a l l e d l y m p h nodules, w i t h lighter-staining germinal centers that c o n t a i n d e n s e m a s s e s o f a c t i v e l y d i v i d i n g l y m p h o c y t e s a n d m a c r o p h a g e s.
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