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Like all discovered genes, association of a risk allele in a candidate gene needs to be replicated in other populations to provide robust evidence for its role in asthma. Despite this, a large survey of children with asthma found 62% of children were limited in at least one of the following activities: playing organised sports, outdoor activities, owning pets, sleeping without nocturnal waking, going out/playing with friends, doing things with their family, progressing well educationally in school, and participating in school activities [17]. Inferior to the level at which the superior segmental bronchus arises, the lower lobe divides into four basal segmental bronchi: medial (S7), anterior (S8), lateral (S9), and posterior (S10). Almost 50% of total body calcium in girls and slightly more than 50% in boys is laid down in bone mineral during puberty. The thyroid gland is distorted in shape and nodular, with some nodules partially or completely separated from the gland. This thickening may occur within the tissue portion of the barrier caused by conditions such as interstitial pulmonary edema, fibrosis, intraalveolar edema, and consolidation. Thus, extensive obstruction in these smaller airways may go undetected if the physician relies only on clinical findings. Some authors estimate that cysts form in the breasts of roughly 50% of women during their reproductive years. Sensitivity and exposure to indoor allergens in adults with differing asthma severity. The "lateral aberrant thyroid" may represent original branchial tissue that did not fuse with the median thyroid. Frequently, these pelvioperitonitic adhesions involve all pelvic organs, including the omentum and low intestinal loops. The authors showed that compared with cases of mild asthma, a patient with moderate asthma is 33% less likely to be able to perform spirometry, and a patient with severe asthma 93% less likely to perform spirometry. Perhaps ``problematic obstructive respiratory symptoms' might have been a better term. The paired dorsal arteries of the penis are situated between a single deep dorsal vein and paired dorsal nerves. These thyroid functions can be considered almost synonymous with iodine metabolism. High-resolution computed tomography is more sensitive at detecting lymphangitic disease than chest radiography. With a rudimentary testis, the gonad is usually located in a broad ligament adjacent to a normal uterus. Subtype Testing: Subtype evaluation tests should not be performed unless Cushing syndrome is confirmed. The symptoms and stigmata expressed by these individuals depend on the amount of chromatin that has been lost: primary amenorrhea and infertility (95% to 98%) are the most common. However, women with adrenal androgen excess usually present with varying degrees of masculinization and menstrual dysfunction (see Plates 4-14 and 4-15). It is unusual but may be related to urologic instrumentation and chronic catheter use. Protecting the respiratory system from pathogens and toxins while avoiding unnecessary inflammation when harmless proteins are inhaled is a challenge. In this illustration, the lungs are shown in relation to the bony thorax, scapula, and diaphragm, but overlying the structures shown are the deep and superficial muscles of the back in addition to the superficial fascia and skin. The cystic artery is identified and ligated only when its relation with the gallbladder has been shown clearly. Thus, although the clinical history is essential, it is not always definitive as to whether the edema is cardiogenic, noncardiogenic, or a combination of both. The specimen is sent to the pathology laboratory for analysis and margin assessment. During pregnancy, the uterus is maintained in a quiet state by the actions of progesterone and relaxin. Hiatal hernia is very common and presents as a mass in the inferior middle-posterior mediastinum, usually seen as a retrocardiac mass on routine chest radiography.
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A ruptured graafian follicle or hemorrhagic corpus luteum may be associated with varying degrees of intraabdominal bleeding. Bronchoscopy serves as the most important method to obtain respiratory tract samples from immune-compromised patients. The segments are related to the anterior parts of the fourth and fifth ribs and their costal cartilages. The basis for this pulmonary hypertension is generally twofold: (1) a restricted pulmonary vascular bed caused by the compressing and distorting effects of the deformity on the lungs and on the pulmonary vasculature and (2) the pulmonary pressor effects of hypoxia. Extracellular aspect of inner leaflet of plasma membrane: coveolae appear as pits. This may, in part, be because local inflammatory changes are less easily studied with the lack of local biological specimens. The pectoralis major is a thick, fan-shaped muscle that has three areas of origin: clavicular, sternocostal, and abdominal. Several environmental factors known to be relevant in asthma may influence epigenetic modifications, however, the specific role of epigenetics in asthma is not clear. Symptoms, most commonly jaundice, pain, or pancreatitis, are present in most patients with adenomas submitted to surgery. C, Cross-section of the abdomen shows how this rotation carries the hilar structures posteriorly. The edema usually appears first at the upper and lower poles of the disk and later progresses along the course of the retinal vessels. In the search for individualised treatments, novel treatments are likely to depend upon our identification of relevant phenotypes. The crura lie deeply, in close apposition to the periosteum of the ischiopubic rami. Direct challenges In a clinical population, direct challenges have a high sensitivity and a high negative predictive value for the diagnosis of asthma, which make them suitable as a test to exclude current asthma in a clinical population. As they enter the bladder, the ureters pass forward and medialward close to the lateral fornices. However, testosterone has 60 times the androgenic potency of even the most potent 17-ketosteroid (characterized by an oxygen atom in the 17 position). In this condition, venous and lymphatic drainage is impaired resulting in marked edematous swelling of the prepuce and glans penis distal to the constricting ring. At this time, the cortex undergoes intense proliferation, and strands of epithelial cells (called secondary sex cords) push into the interior of the gonad. In one patient who underwent liver transplantation for hepatic cirrhosis, the serum lipoprotein profile normalized but gastrointestinal fat malabsorption persisted. Influences on adherence to paediatric asthma treatment: a review of correlates and predictors. Factors specific for the renal transplant patients that have been suggested to contribute to this thrombotic risk include the use of calcineurin-inhibiting drugs, high levels of homocysteine, diabetic nephropathy, antiphospholipid syndrome, cytomegalovirus infection, and the presence of proteinuria or nephrotic syndrome (Kujovich, 2004). The dissection as illustrated in the main diagram would preserve the caudate lobe, but in the inset the caudate lobe also is removed (see also. Gradually, the follicular components and the specific ovarian stroma are completely destroyed in such ovaries, and the thick wall of the ovarian abscess consists merely of callous connective tissue which is poor in blood vessels and is infiltrated by leukocytes, lymphocytes, and plasma cells, which are accumulated in the inner, granulating lining of the abscess wall. The majority of patients are younger than 40 years of age at onset, although there is a second peak of increased incidence after age 50 years in women. It is, however, well known that isolated anovulatory cycles often terminate at the expected time with normal flows, even though here, too, the rearrangement of the endometrium in the secretory phase has failed to make its appearance. The splenic vein is situated posterior to the pancreas and may be partly buried in the pancreatic parenchyma. Although rare, there also are cystic pancreatic tumors and endocrine tumors, for which surgical extirpation is indicated. Octreotide, the octapeptide analog of somatostatin, is a powerful inhibitor of pancreatic exocrine secretion. The most significant limitation of the method, as in other conditions, is the fact that ultrasonography is operator dependent. This tendency is a manifestation of the second law of thermodynamics, which states, in essence, that nature always wants to spread energy and matter around in the most even way possible. Bile ducts usually are located above the corresponding portal branches, whereas hepatic arterial branches are situated inferiorly to the veins.
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The four types of neurofibromas are cutaneous, subcutaneous, nodular plexiform, and diffuse plexiform. Penile cancer usually grows gradually and laterally along the surface of the penis. At the level of the isthmus, it gives off a descending cervical branch, which surrounds the cervix and anastomoses with branches of the vaginal artery. Thus, the goal of treatment is to improve current obesity-related comorbid conditions and to decrease the risk of developing additional comorbidities in the future. Wheezing was not a predictor for the incidence of rhinitis at either 5 or 13 years of age. It is possible that any beneficial effect in asthma is related to its action on other cells. In those wishing to preserve fertility, this may be curative; in others, standard hysterectomy may be considered. School as a risk environment for children allergic to cats and a site for transfer of cat allergen to homes. Global strategy for the diagnosis and management of asthma in children 5 years and younger, 2009. If observation is chosen, periodic reevaluation is required to check for the emergence of slow-growing tumors. Therefore, it is through these feedback mechanisms that suckling ensures further milk production. If the hernia is large enough to produce incomplete voiding, the stasis leads to recurrent attacks of cystitis with dysuria, frequency, nocturia, and stress incontinence. Other nervous system effects are related to the autoimmune nature of Graves disease. In one study of adults with severe asthma being treated intensively in hospital, those with high levels of panic/fear symptoms were more likely to use as required bronchodilator medication [19]. In severe cases, the corpus spongiosum may become involved, resulting in painful erections. The content of a pyosalpinx may be liquid and show fibrinopurulent flakes suspended in a serous exudate, or it may contain thick, greenish-yellow pus or mucopurulent fluid. Overnight protection by inhaled salmeterol on exercise-induced asthma in children. Less than 40% of couples with primary infertility conceive after 6 years of therapy compared with more than 50% of secondary infertility couples who conceive by 3 years. There may be intense swelling of the face and neck, as well as petechial hemorrhages of the skin of the face and conjunctiva. The bronchoscope is introduced gently with one hand while the other hand keeps the mouth open and maintains head position. The acute pancreatitis can be life threatening, and the patients most commonly affected are those with poorly controlled diabetes mellitus or alcoholism. This is caused by the relative instability of the immature lung because of failure to produce surfactant in amounts sufficient for neonatal respiration. In cross section, the vas deferens has an outer adventitial Epididymis-histology connective tissue sheath containing blood vessels and small nerves, a muscular coat that consists of a middle circular layer surrounded by inner and outer longitudinal muscle layers, and an inner mucosal layer with a pseudostratified epithelial lining. Care should also be exercised with patients who have compromised hepatic or renal function. Polygenic hypercholesterolemia refers to combinations of multiple genetic and environmental factors that contribute to hypercholesterolemia. Oxytocin is a powerful uterotonic stimulant for contractions, and oxytocin secretion increases with the expulsive phase of parturition. Commonly isolated organisms include Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, Bacteroides bivius, and group B streptococci. The essential features, on microscopic examination, include parenchymal hyperplasia, diffusely distributed accumulations of luteinized cells, and perifollicular theca cell proliferation Microscopic section: cystic cavities lined by conspicuous proliferation and luteinization of theca interna Masculinization with diffuse luteinization of ovaries Symmetrically enlarged, yellowish ovaries Hirsutism Microscopic section: diffuse distribution of luteinized theca cells and perifollicular theca proliferation and luteinization and luteinization.
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Do measures of bronchial responsiveness add information in diagnosis and monitoring of patients with asthma Cut-off points defining normal and asthmatic bronchial reactivity to exercise and inhalation challenges in children and young adults. The selection of the oral or intravenous route for antibiotics and corticosteroids is determined by the severity of the illness and the ability of the patient to tolerate oral medication. Note particularly the distribution of the left portal triad in the umbilical fissure. Cholangiocarcinoma occurs at the biliary confluence, in the mid-duct, or in the distal duct presenting as a periampullary tumor (see also Chapter 10). Thirdly, this classification does not allow for differentiation between occurrences of wheeze of distinct severity and frequency from other respiratory symptoms, such as cough, colds, and chest congestion, and this is not taken into consideration [8]. Microscopically, the theca interna cells are strikingly hyperplastic and luteinized. The use of cryo-assisted resection in cases of hepatocellular carcinoma in the cirrhotic liver allows removal of tumors with adequate margins and maximum preservation of functional parenchymal tissue. In the absence of oxytocin, only approximately 30% of stored milk is released during nursing. Other clues include difficulty breathing in, throat tightness, paraesthesia, cramps in the hand, and stridor or wheeze loudest over the larynx. In cancer research, smoking has been found to induce epigenetic changes in oncogenes and tumour suppressor genes, illustrated by the epigenetic silencing of the p16 gene (tumour suppressor gene) in small cell lung cancer [111], but the relevance of this to asthma is still unclear. If the fluid egressing from the vas deferens contains no sperm, a second acquired obstruction may exist in the delicate tubules of the epididymis. The 12 proteins in the lipoproteins are termed apolipoproteins (apo) and are given letter designations. Indeed, the fact that the patient is able to participate actively in his or her own therapy, rather than being merely a passive recipient, is also of value. This lesion is manifested microscopically as a deposition of lipids, in the intima of decidual arterioles and endometrial arteriovenous lakes. For example, the main site of infection for influenza virus is the respiratory mucosa, leading to desquamation of the respiratory mucosa with cellular degeneration, edema, and airway inflammation with mononuclear cells. Intramuscular epinephrine is the drug of choice in treatment of anaphylaxis (table 1 and fig. There is an anastomosis with the descending cervical branch of the uterine artery to form the azygos arteries. In a separate analysis, they found psychological distress and poor social support, but not exposure to stressors that included life events or daily stress had a significant adverse impact on atopic disorders. In 2002 this system was updated (6th edition) to reflect more clinically relevant stages (Table 9-2). In order to observe clearly the changes in these vessels, dilation of the pupils with atropine or an equivalent drug is essential. Hemorrhage in the cholecystectomy triangle represents potential danger because attempts at hemostasis by placing clamps with obstructed and insufficient view may result in inadvertent clamping of the right or proper hepatic artery or of the bile duct. Uncertainties still remain, especially about the size of this association, and the individual components responsible for driving increased vulnerability to asthma. The glucocorticoid dosage is then decreased daily, and patients are typically discharged from the hospital on dosages of exogenous orally administered glucocorticoids twofold above the standard replacement therapy dosage. Extrinsic compression from any cause may reduce the airway lumen enough to cause distal atelectasis. Ovarian and tuboovarian abscesses have little tendency to spontaneous healing because of the thickness of their walls. It is believed that the two human sex chromosomes (X and Y) evolved from other nonsex chromosomes (autosomes) 300 million years ago. Among open procedures, suprapubic and retropubic prostatectomy are the most common.
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Smooth muscle cells become the main cell type, lying in parallel layers with proteoglycan and basement membrane in between. Filaggrin loss-of-function variants are associated with atopic comorbidity in pediatric inflammatory bowel disease. Theophylline is a relatively ineffective bronchodilator, and high doses are needed for its bronchodilator action. Lymphadenectomy is performed when the indication for the operation is a malignant tumor of the body or tail. Although the consolidation has a patchy distribution, the lesions involve predominantly the subpleural and peribronchial regions. The urethral meatus in one-half of cases is located just proximal to the normal meatus but still on the glans penis and is referred to as glanular or first-degree hypospadias. The innermost layer, the zona reticularis, is contiguous with the medulla, and the cell cords are entwined, forming a reticulum. Right Lower Lobe the lower lobe bronchus gives off a posteriorly directed superior segmental bronchus just below the level of the orifice of the middle lobe bronchus. Diffuse alveolar disease often has a somewhat nodular pattern, but as a rule, the nodules are ill defined or fuzzy (see Plate 3-15). Care is needed to avoid injuring the dorsal venous complex during this dissection of the anterior prostate. There is evidence that when there are two kidneys the above theory has been proven probably right, however it has been showed that this is not the case for the sole kidney or the transplanted kidney. The vaccine that is generally used is a chemically inactivated vaccine, originally grown on embryonated chicken eggs (and thus cannot be used in egg-allergic patients), and the yearly vaccine is trivalent, with two strains of influenza A (one an H3N2 and the other an H1N1) and one influenza B strain. Combination therapy of anti-IgE and allergen immunotherapy has been investigated as a method to decrease adverse reactions to immunotherapy in order to allow increased safety and efficacy [83], and there is currently an ongoing trial of omalizumab in conjunction with milk oral immunotherapy [81]. Many ruptures remain silent and unrecognized for several hours, the only signs being abdominal tenderness and vague abdominal pain. Nearly all Finnish pharmacies were included in the programme and support was also given by patient organisations and pharmaceutical companies. Physicians treating children and adolescents with asthma active in competitive sports should keep up-to-date on the doping rules and follow these in the selection of drugs and give the necessary documentation for the sports authorities. The pyramidal lobe undergoes gradual atrophy; therefore, it is found more often in children than in adults. Primary hyperparathyroidism from parathyroid microadenoma: specific features and implications for a surgical strategy in the era of minimally invasive parathyroidectomy. The next two steps are an assessment of the apparent severity of asthma, and the identification of any co-morbidities. Locally generated pollution, in contrast, is the major driver of the variation in exposure within cites. Adenomyosis is most often diagnosed incidentally by the pathologist examining histologic sections of surgical specimens. It appears that most of these genes function at the interface of airway structural cells sensing environmental stimuli and the translation of these signals into an inflammatory response [53]. As they grow posteriorly and outward, they eventually form the greater part of the gland, the peripheral zone, in the adult prostate. Hernias occasionally occur through them and are more common on the right side than on the left. Special counseling is needed for patients with 1-antitrypsin deficiency and their family members to determine whether genetic testing is necessary or desired. The dermal and subcutaneous lesions are benign and should be removed only if symptomatic. More than one drainage tube may be needed, especially in the case of larger air leaks. For drainage of the trachea and major bronchi, the right-angled head-down position should be assumed. In general, galactorrhea is most effectively treated by correcting the hyperprolactinemia. The tumor is compromising and compressing the inferior vena cava and extends upward to involve the right hepatic vein at its point of junction with the vena cava. A ruptured graafian follicle or ruptured hemorrhagic corpus luteum may be misdiagnosed as acute appendicitis or ruptured tubal pregnancy. Near the 12th week of pregnancy, a change in the vaginal smear occurs; fewer cells are shed, clumping and folding have lessened, precornified cells predominate, and the overall appearance is similar to that of a normal early proliferative phase.
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Influenza A can be treated or prevented by the use of amantadine 200 mg/d orally or rimantadine, which acts against the M2 protein of influenza A, or the newer neuraminidase inhibitors oseltamivir and zanamivir (which are also active against influenza B). Gastric stapling (vertical banded gastroplasty) is an example of a restrictive surgical procedure in which the upper part of the stomach is partitioned by a vertical staple line with a tight outlet (stoma) that is wrapped by a band or prosthetic mesh. A bidirectional relationship between psychosocial factors and atopic disorders: a systematic review and meta-analysis. Usually, the stenotic segment may be identified by the "hourglass" constriction of the outer tracheal wall. The large majority of these tumors in adults are benign, but 50% of the neurogenic tumors in children are malignant. The left hepatic vein is encountered posteriorly and controlled within the liver substance. After liquefaction, semen viscosity is measured and should not show any stranding. In cases of malignancy it is possible for tumor cells to migrate along the tube tract and result in tumor seeding of the peritoneum or even the skin. The minimum estimate was J142 in Estonia with the maximum estimate being J1,529 in Hungary. The final point for growing children is that anxiety/depression and asthma, both separately and when combined, may negatively affect fundamental developmental key tasks, particularly in adolescents. Although bone biopsies are usually not needed to confirm rickets, they show sparse, thin trabeculae; thick layers of uncalcified osteoid (osteoid seams); and large bone resorption cavities. A, Cholangiogram obtained after injection of contrast medium through a transjejunal tube illustrates hepaticojejunostomy Roux-en-Y by the left approach in a patient with a high benign postcholecystectomy stricture. Hydroceles are generally situated anterior to the testicle, which it displaces posteriorly in the scrotal cavity. Exposure to dogs and cats in the first years of life and risk of allergic sensitization at 6 to 7 years of age. There it divides into a smaller medial branch and a longer lateral cutaneous branch, which supply the skin. The diffuse changes in small airways contribute more to the obstruction and maldistribution of inspired gas than do the abnormalities in large airways. This is despite the cost of anti-asthma medications for children being less than half the cost of those prescribed for adults [14]. The thinness of the cellular boundary between the blood and the air presents enormous surface area to air on one side and to blood on the other (70 m2 for both lungs). The lungs are the most common metastatic site, followed by bone, heart, and liver. Deep to the sacrospinalis muscle lie the short vertebrocostal and intervertebral muscles; they are not described here. Surgery-induced hypoparathyroidism may be transient (if viable parathyroid tissue persists) or permanent. If asthmatic children present with an acute exacerbation, it is pertinent to consider other differential diagnoses in order to introduce an appropriate treatment for these children [3]. B, the liver substance is removed anterior to the posterior sectoral ducts and vessels, and the upper part of this parenchymal dissection runs just anterior to the right hepatic vein and involves control of the middle and left hepatic vein. The most common abdominal findings include renal angiomyolipoma (54%), enlarged abdominal lymph nodes (39%), lymphangiomyoma (16%), ascites (10%), dilatation of the thoracic duct (9%), and hepatic involvement (4%). A line of demarcation in the Glissonian plane extending from the gallbladder fossa to the left of the vena cava is now visible on the liver surface. Dyspareunia is frequent, and intermenstrual pain (mittelschmerz) is occasionally observed. Pain control, with nonopioid medications if possible, is important to allow normal physical activity. This increases vascular resistance in those regions, resulting in shunting of blood away from them and causing redistribution of the blood flow. Although this therapy is considered curative, multidrug-resistant strains are increasing. Surgical complications after renal transplantation in grafts with multiple arteries.
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The first alterations in vital signs such as blood pressure, pulse rate and/or respiratory rate are indications for immediate and more aggressive treatment. They are often confluent or in clusters, with a moist, slightly depressed, necrotic surface. Probability of hospital admission with acute asthma exacerbation increases with increasing specific IgE antibody levels. Injection of protoscolicidal agents may be difficult because pressure within the cyst can be high. Glomerular basement membrane thickening and mesangial expansion are prominent glomerular abnormalities in diabetes that progress to nodular (Kimmelstiel-Wilson lesion) or diffuse glomerulosclerosis. The incidence of abdominal pregnancy is estimated to be roughly 1 in 10,000 live births. In both techniques is recommended to perform the peritoneocystostomy with an oval window of at least 2. The hypothalamic corticotropin-releasing hormone neurons and the atrophic anterior pituitary corticotrophs take months to recover from chronic suppression. They can be associated with condyloma acuminata near the rectum and can be found in similar individuals at risk for sexually transmitted diseases. Acute infection of the deeply branching cervical and endocervical glands causes an outpouring of thick, tenacious, yellowish, mucopurulent discharge from a fiery red external os (leukorrhea). Intravenously administered fluorescein dye (fluorescein angiography) can assess areas of capillary under perfusion and leakage from sites of neovascularization. The splenic artery usually can be located along the superior border of the pancreas. Although a technically formidable procedure, it remains the "gold standard," as hormone treatment and chemotherapy are not curative and radiation therapy may not eradicate all cancer cells. The vagus nerve continues caudally on the posterior aspect of the root of the lung to enter the esophageal plexus, from which the left vagal trunk emerges to follow the esophagus into the abdomen. Renin is a protease that acts on angiotensinogen (renin substrate), a globulin produced by the liver. This again raises the question as to whether or not phenotypes are stable or are altered over time. Demographic and clinical characteristics of children and adolescents with severe or difficult-to-treat asthma. Although the numbers are small compared with those with well-controlled asthma, the burden of disease is great. Exchange of oxygen may then become diffusion limited during exercise and even at rest in extreme cases. The relationship of airway hyperresponsiveness and airway inflammation: airway hyperresponsiveness in asthma: its measurement and clinical significance. Prognosis does not correlate with the histologic pattern of the tumor: 90% of tumors found are stage I and the prognosis is good (90% 10-year survival); a poorer prognosis is found with tumors >15 cm that have ruptured or have a high mitotic rate or aneuploidy. The vessel loop is drawn firmly to the left, and the pedicle is divided using the stapler as shown in D. In clinical practice, it is often very difficult to use clinical features to predict the microbial cause of pneumonia. In such cases, intrahepatic right ductal system drainage is an option (Chapter 8). Salvage partial nephrectomy for hereditary renal cancer: feasibility and outcomes. The most recent study concluded that utilising portable spirometry as a severity measure in the acute asthmatic patient for clinical or research purposes is difficult and problematic, a statement that the authors would like to underline. It has even been reported that an abdominal pregnancy has originated from a defect in the uterine wall, which had been filled and closed up by the omentum during the healing period after cesarean section. In contrast, while 3-year-old children were found to have less airway resistance, they showed higher sensitisation rates than the control group [16]. For reasons not known, however, the dilation may reach degrees that interfere with normal function. The union between the cystic duct and the common hepatic duct may be located at various levels. The most common cause of Cushing syndrome is the use of synthetic glucocorticoids to treat an inflammatory condition, termed exogenous or iatrogenic Cushing syndrome.
