INTRODUCTIONWhen responding to an emergency scene, many questions enter the mind of

the EMS professional. What are the possible conditions the patient might be suf-fering from? Will there be key information available that will allow me to deter-mine the condition the patient is most probably suffering from? What treatmentwill be required? How quickly will I need to proceed with the treatment? Will crit-ical interventions be necessary, such as endotracheal intubation or drug therapy?Will I need to change the treatment based on additional information gained in thehistory or physical examination? Will I need to transport the patient rapidly?

Categorize the Patient: Medical vs. TraumaA decision the EMS professional must try to make very early in the assessment iswhether this is a medical or a trauma patient. You can usually do this on the basisof the dispatch information and as part of your scene size-up. However, somescenes are very confusing and lack a wealth of overt clues as to whether the patientwas injured or is ill. You may not be able to determine the real nature of thepatient’s problem until you do the focused history and physical exam. You mustalways be prepared to change your direction of thought and focus based on furtherassessment findings. Dispatch information can be erroneous, or the patient’s realcomplaint can turn out to be something other than what you suspected when youformed your first impression.

Further, you must categorize the patient not only by mechanism of injury ornature of illness, but also—based on some very objective clinical indicators in theinitial assessment—you must determine if the patient is physiologically stable orunstable. The unstable patient will require immediate intervention and a muchmore aggressive and rapid management plan. Categorizing the patient by degree ofstability will allow you to manage immediately life-threatening conditions beforeproceeding to form differential field impressions as the basis for advanced patientmanagement.

Based on this assessment model, any immediately life-threatening conditionswill be managed very early in the assessment process. Once these conditions are

CASE STUDYYou are dispatched to an elderly patient for “respiratory distress for the past several days.” You arrive on the scene andare greeted at the door by the patient’s daughter. As you walk in, you scan the scene for safety hazards. You find the 86-year-old patient, who does not appear to be alert, lying supine on the couch. His daughter tells you, “He started com-plaining last week that he was having some trouble breathing. He had a cold, and I thought that was all it was. But it’sgotten much worse over the last few days. He wouldn’t let me take him to the doctor or emergency department.” Younotice an oxygen tank in the corner of the room. He had a cold, and I thought that was all it was. But it’s gotten muchworse over the last few days. He wouldn’t let me take him to the doctor or emergency department.” You notice an oxy-gen tank in the corner of the room.

As you approach the patient, you note that he appears cyanotic. He does not move or respond when you call hisname.

How would you proceed with the assessment and management of this patient?

A Babinski reflex,dorsiflexion of thegreat toe with fanningand extension of theother toes, may anormal presentation inan epileptic postictalpatient.

Clinical Insight

A n accurate and reliable patient assessment is one of the most importantskills that is performed in the prehospital environment. The EMS

professional must rely primarily on information gathered in the patient historyand on physical assessment findings to develop an appropriate approach to thepatient, identify priorities, and establish an emergency care plan. Developing asystematic assessment routine that you follow for every patient will increase yourconfidence in your assessment skills and ensure that life-threatening conditionswill be managed prior to other, non-life threats that may present moredramatically.

Topics that will be covered in this chapter are:

Components of the Medical Assessment

Dispatch Information

Scene Size-up

Physiologically Stable or Unstable Criteria

Initial Assessment

Focused History and Physical Exam

Possibilities to Probabilities: Forming a Differential Field Diagnosis

Detailed Physical Exam

Ongoing Assessment

1ASSESSMENT OF THE MEDICAL PATIENT

1

INTRODUCTIONThe case studies that follow include two kinds of material: a running narra-

tive of the case and, in italics, a commentary on the case. Each segment ends with aquestion or two in red type to encourage you to stop and think about what youhave just read—to ponder, analyze, speculate, or discuss with fellow students oryour instructor—before you read the commentary or the next section.

CASE STUDY SCANARIOS

CASE 1: DIFFICULTY BREATHING

At 18:00 hours you are dispatched to a 56-year-old male with difficulty breathing.On arrival, you find him leaning over the kitchen table, struggling to breathe. He isawake and appears very pale. He is clutching an inhaler in his left hand. As youintroduce yourself and begin an assessment, you note that his skin is cool andclammy. He has a radial pulse of 100, respirations of 24 with intercostal retractions,and a blood pressure of 156/90. He talks in two-to-three-word sentences. He tellsyou he started having trouble breathing this afternoon and has been gettingsteadily worse. He has had no relief from his inhaler. He denies chest pain but doesadmit to feeling a “weight” on his chest. He is on Ventolin (albuterol) and Vasotec(enalapril). Pulse oximetry reads 86%. When asked to rank the “weight” on a 1–10scale, he states, “It’s a 6.” What is this patient’s problem? Have you noted any clues,so far, to the underlying cause? What is your immediate task?

This patient has several signs of acute dyspnea. An inability to talk in complete sentences thatindicates inadequate minute volume which, at rest, is abnormal. His respiratory rate is 24 withintercostal retractions, which indicates labored breathing, and the pulse oximetry is 86%, wellbelow normal. His tachycardia may be due to his hypoxia. This man is in acute respiratory dis-tress. The task here is first to support vital functions, then to figure out the most likely cause soappropriate treatment can be implemented. The feeling of "weight" on his chest implies car-diac involvement. How should you proceed with assessment? with care?

While you are placing a nonrebreather mask with reservoir on the patient at15 lpm, your partner is attaching the cardiac monitor.

The patient reports a history of asbestosis, hypertension, and insulin-depen-dent diabetes. Last year he had a triple bypass done. He has bilateral wheezes, mostpronounced in the bases.

While your partner starts an IV of normal saline, you have the patient rinseout his mouth with water and give him a nitroglycerin tablet sublingually. Why didyou have the patient rinse his mouth? Why did you give nitroglycerin? What addi-tional clues to the etiology of his problem have you gathered?

The concern here is the cardiac implication of the patient feeling a “weight"” on his chest. It isprudent to interpret this as a description of cardiac involvement, although patients with COPDor asthma will also report chest “tightness” with bronchospasm.

This patient’s choice of words and cardiac history are more typical of angina, which is a logicalresult of poor oxygenation of heart muscle (pulse oximetry value of 86%).

Additional contributing factors include his cardiac history (bypass last year)and being an insulin-dependent diabetic. Diabetics are very prone to peripheral

11Scene Size-up

Dalton Limmer Mistovich WermanDalton Limmer Mistovich Werman

ADVANCEDMEDICALLIFE SUPPORT

ADVANCEDMEDICALLIFE SUPPORTTHIRD EDITION

Advanced Medical Life Support, 3eDalton, Limmer, et. al.Prentice Hall, © 2007Interior and Cover Design

Photo research of opener/cover image and 1 head icon. Photoshop work on those images

Programs: Quark, Photoshop

Duis autem vel eum iriure dolor in hendrerit invulputate velit esse molestie consequat, vel illum doloreeu feugiat nulla facilisis at vero eros et accumsan et iustoodio dignissim qui blandit praesent luptatum zzril delenitaugue duis dolore te feugait nulla facilisi. Nam libertempor cum soluta nobis eleifend option congue nihilimperdiet doming id quod mazim placerat facer possimassum. Lorem ipsum dolor sit amet, consectetuer adip-iscing elit, sed diam nonummy nibh euismod tincidunt utlaoreet dolore magna aliquam erat volutpa nonummynibh euismod tincidunt ut laoreet dolore magna aliquamerat volutpat.

Lorem ipsum dolor sit amet, consectetuer adipiscingelit, sed diam nonummy nibh euismod tincidunt utlaoreet dolore magna aliquam erat volutpat. Ut wisienim ad minim veniam, quis nostrud exerci tation ullam-corper suscipit lobortis nisl ut aliquip ex ea commodoconsequat. Duis autem vel eum iriure dolor in hendreritin vulputate velit esse molestie consequat, vel illumdolore eu feugiat nulla facilisis at vero eros et accumsanet iusto odio dignissim qui blandit praesent luptatumzzril delenit augue duis dolore te feugait nulla facilisi.Lorem ipsum dolor sit amet, consectetuer adipiscing elit,sed diam nonummy nibh euismod tincidunt ut laoreetdolore magna aliquam erat volutpat. Ut wisi enim adminim veniam, quis nostrud exerci tation ullamcorpersuscipit lobortis nisl ut aliquip ex ea commodo conse-quat.Lorem ipsum dolor sit amet, consectetuer adipisc-ing elit, sed diam nonummy nibh euismod tincidunt utlaoreet dolore magna aliquam erat volutpat. Ut wisienim ad minim veniam, quis nostrud exerci tation ullam-corper suscipit lobortis nisl ut aliquip ex ea commodoconsequat. Duis autem vel eum iriure dolor in hendrerit

in vulputate velit esse molestie consequat, vel illumdolore eu feugiat nulla facilisis at vero eros et accumsanet iusto odio dignissim qui blandit praesent luptatumzzril delenit augue duis dolore te feugait nulla facilisi.Lorem ipsum dolor sit amet, consectetuer adipiscing elit,sed diam nonummy nibh euismod tincidunt ut laoreetdolore magna aliquam erat volutpat.

PRACTICE 1.2

Make sure you know the meaning and location of thefollowing:

sulcigyri

cerebral cortexfrontal lobeparietal lobetemporal lobeoccipital lobeSylvian fissure

thalamushypothalamusbrainstemmidbrain

Lorem ipsum dolor sit amet, consectetuer adipiscingelit, sed diam nonummy nibh euismod tincidunt utlaoreet dolore magna aliquam erat volutpat. Ut wisienim ad minim veniam, quis nostrud exerci tation ullam-corper suscipit lobortis nisl ut aliquip ex ea commodoconsequat. Duis autem vel eum iriure dolor in hendrerit

7CYCLE 1-1 DIRECTIONAL TERMS AND OTHER BASIC NEUROANATOMIC NOMENCLATURE

T A B L E 1-1 Structures and their Functions

Structure Function

Corpus callosum

Septum pellucidium

Thalamus

Hypothalamus

Cerebral penduncles

Pyramids

Cerubellum

Cerebellar penduncles

Superior colliculus

Inferior pendiculus

Interconnects cerebral hemispheres

Separates the lateral ventricles

Relay from brainstem to cortex & between cortical regions

Appetite, thirst, sexual drive, neuroendocrine autonomic

Carry motor information from cerebrum to brainstem to spinal cord.

Carry motor information from brainstem to spinal cord.

Coordination of movement

Carry information to and from cerebellum

Virtual system

Auditory system

gyricerebral cortexfrontal lobeparietal lobe

temporal lobeoccipital lobeSylvian fissure

thalamushypothalamusbrainstemmidbrain

D uis autem vel eum iriure dolor in hendrerit invulputate velit esse molestie consequat, vel illumdolore eu feugiat nulla facilisis at vero eros et

accumsan et iusto odio dignissim qui blandit praesentluptatum zzril delenit augue duis dolore te feugait nullafacilisi. Nam liber tempor cum soluta nobis eleifendoption congue nihil imperdiet doming id quod mazimplacerat facer possim assum. Lorem ipsum dolor sitamet, consectetuer adipiscing elit, sed diam nonummynibh euismod tincidunt.

Duis autem vel eum iriure dolor in hendrerit invulputate velit esse molestie consequat, vel illum doloreeu feugiat nulla facilisis at vero eros et accumsan et iustoodio dignissim qui blandit praesent luptatum zzril delenitaugue duis dolore te feugait nulla facilisi. Nam libertempor cum soluta nobis eleifend option congue nihilimperdiet doming id quod mazim placerat facer possimassum. Lorem ipsum dolor sit amet, consectetuer adip-iscing elit, sed diam nonummy nibh euismot.

Ut wisi enim ad minim veniam, quis nostrud exercitation ullamcorper suscipit lobortis nisl ut aliquip ex eacommodo consequat. Duis autem vel eum iriure dolor inhendrerit in vulputate velit esse molestie consequat, velillum dolore eu feugiat nulla facilisis at vero eros etaccumsan et iusto odio dignissim qui blandit praesentluptatum zzril delenit augue duis dolore te feugait nullafacilisi. Lorem ipsum dolor sit amet, consectetuer adip-iscing elit, sed diam nonummy nibh euismod tincidunt utlaoreet dolore magna aliquam erat volutpat. Duis autemvel eum iriure dolor in hendrerit in vulputate velit essemolestie consequat, vel illum dolore eu feugiat nullafacilisis at vero eros et accumsan et iusto odio dignissimqui blandit praesent luptatum zzril delenit augue duisdolore te feugait nulla facilisi. Lorem ipsum dolor sitamet, consectetuer adipiscing elit, sed diam nonummynibh euismod tincidunt ut laoreet dolore magna aliquamerat volutpat. Ut wisi enim ad minim veniam, quis nos-trud exerci tation ullamcorper suscipit lobortis nisl utaliquip ex ea commodo consequat.

1. DeArmond SJ, Fusco MM, Dewey MM. (1988)Structure of the Human Brain, 3rd Edition, Oxford,New York.

2, Nolte J, Angevine JB, The Human Brain. St Louis:Mosby, 1995.

The following websites can be useful:

http://www.neurophys.wisc.edu/brain/

Ut wisi enim ad minim veniam, quis nostrud exercitation ullamcorper suscipit lobortis nisl ut aliquip ex eacommodo consequat. Duis autem vel eum iriure dolor inhendrerit in vulputate velit esse molestie consequat, velillum dolore eu feugiat nulla facilisis at vero eros etaccumsan et iusto odio dignissim qui blandit praesentluptatum zzril delenit augue duis dolore te feugait nullafacilisi.

Lorem ipsum dolor sit amet, consectetuer adipiscingelit, sed diam nonummy nibh euismod tincidunt utlaoreet dolore magna aliquam erat volutpat.

http://www9.biostr.washington.edu/da.html

http://www.anatomy.wisc.edu

Ut wisi enim ad minim veniam, quis nostrud exercitation ullamcorper suscipit lobortis nisl ut aliquip ex eacommodo consequat. Duis autem vel eum iriure dolor inhendrerit in vulputate velit esse molestie consequat, velillum dolore eu feugiat nulla facilisis at vero eros etaccumsan et iusto odio dignissim qui blandit praesentluptatum zzril delenit augue duis dolore te feugait nullafacilisi.

http://www.med.Harvard.edu/AANLIB/cases/caseM/case.html

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Ut wisi enim ad minim veniam, quis nostrud exercitation ullamcorper suscipit lobortis nisl ut aliquip ex eacommodo consequat. Lorem ipsum dolor sit amet, con-sectetuer adipiscing elit, sed diam nonummy nibh euis-mod tincidunt ut laoreet dolore magna aliquam eratvolutpat. Duis autem vel eum iriure dolor in hendrerit invulputate velit esse molestie consequat, vel illum doloreeu feugiat nulla facilisis at vero eros et accumsan et iustoodio dignissim qui blandit praesent luptatum zzril delenitaugue duis dolore te feugait nulla facilisi. Lorem ipsum

IntroductionTHE ROLE OF THROMBOSIS INPATHENOGENESIS OF STROKE

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• the aorta

• the proximal extracranial portions of the internalcarotid arteries (just distal to the common arterybifurcations in the neck)

• the distal most, intercranial portions of the verte-bral-arteries.

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Duis autem vel eum iriure dolor in hendrerit invulputate velit esse molestie consequat, vel illum doloreeu feugiat nulla facilisis at vero eros et accumsan et iustoodio dignissim qui blandit praesent luptatum zzril delenitaugue duis dolore te feugait nulla facilisi.

Lorem ipsum dolor sit amet, consectetuer adipiscingelit, sed diam nonummy nibh euismod tincidunt utlaoreet dolore magna aliquam erat volutpat. Ut wisienim ad minim veniam, quis nostrud exerci tation ullam-corper suscipit lobortis nisl nibh euismod tincidunt utlaoreet dolore magna aliquam erat volutpat. Ut wisienim ad minim veniam, quis nostrud exerci tation ullam-corper suscipit loboad minim veniam, quis nostrud exer-ci tation ullamcorper suscipit lobortis nisl nibh euismodtincidunt ut laoreet dolore magna aliquam erat volutpat.Ut wisi enim ad minim veniam, quis nostrud exercitation ullamcorper suscipit lotis nisl ut aliquip ex eacommodo.

In human brain:rostal = anterior = forwardcaudal = posterior = - backdorsal = superior = toward the top of the skullventral = inferior = away from the top of the

skullmedial = toward the midline

In human brainstem and spinal cord:rostal = anterior = forwardcaudal = posterior =- back

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Lorem ipsum dolor sit amet, consectetuer adipiscingelit, sed diam nonummy nibh euismod tincidunt utlaoreet dolore magna aliquam erat volutpat. Ut wisienim ad minim veniam, quis nostrud exerci tation ullam-corper suscipit lobortis nisl ut aliquip ex ea commodoconsequat. Ut wisi enim ad minim veniam, quis nostrudexerci tation ullamcorper suscipit lobortis nisl ut aliquipex ea commodo consequat. Duis autem vel eum iriuredolor in hendrerit in vulputate velit esse molestie conse-quat, vel illum dolore eu feugiat nulla facilisis at veroeros et accumsan et iusto odio dignissim qui blanditpraesent luptatum zzril delenit augue duis dolore te feu-gait nulla facilisi. Lorem ipsum dolor sit amet, con-sectetuer adipiscing elit, sed diam nonummy nibh euis-mod tincidunt ut laoreet dolore magna aliquam eratvolutpat. Ut wisi enim ad minim veniam, quis nostrudexerci tation ullamcorper suscipit lobortis nisl ut aliquipex ea commodo consequat.Ut wisi enim ad minim veni-am, quis nostrud exerci tation ullamcorper suscipitlobortis nisl ut aliquip ex ea commodo consequat. Duisautem vel eum iriure dolor in hendrerit in vulputate velitesse molestie consequat, vel illum dolore eu feugiatnulla facilisis at vero eros et accumsan et iusto odio dig-nissim qui blandit praesent luptatum zzril delenit augueduis dolore te feugait nulla facilisi. Lorem ipsum dolorsit amet, consectetuer adipiscing elit, sed diam nonum-my nibh euismod tincidunt ut laoreet dolore magna alis-

9CYCLE 1-1 DIRECTIONAL TERMS AND OTHER BASIC NEUROANATOMIC NOMENCLATURE

Case 1-1

Head TraumaA 17 year-old high school student is involved in a highspeed collision on the way back from a graduation party.He is not wearing a seat belt and his head striked thewindsheild. He arrives at the nearest hospital comatose.He has a fractured femur but no skull fracture. However,over the next 24 hours, massive brain swelling occurs tothe degree that intercranial pressure exceeds arterialpressure and his brain dies for lack of a blood supply. Apost mortem examination reveals extensive evidence ofshearing of neural pathways within the brain brainstemand cerebellum.

Comment: The great disparity between the brain velocityand skull velocity at the moment of impact has literally tornthe brain, notwithstanding the stabilizing force of the falx

Medical NeuroscienceNadeau, Ferguson, et. al.Saunders, © 2004Book Design, including Photoshop

work on Unit and Cycle artPrograms: Quark, Photoshop

S’MORES NACHOS [SUPERFAST]READY IN 5 MINUTES

Yield: 4 servings8 rectangular graham crackers3/4 cup milk chocolate chips11/2 cups miniature marshmallows

MARINATEDMUSHROOM–TOPPED

BURGERS

FRESH TOMATO AND LETTUCESALAD

PICKLES AND OLIVES

S’MORES NACHOS

Yield: 4 servings

MARINATED MUSHROOM–TOPPED BURGERSREADY IN 20 MINUTES

Yield: 4 sandwiches1 lb. lean (at least 80%) ground beef11/2 teaspoons lemon-pepper seasoning2 cups sliced fresh mushrooms (about 5 oz.)

1 Heat the grill. Shape and cook the ground beef patties.

2 While the patties cook, slice two tomatoes and arrange on

bibb lettuce or mixed salad greens. Serve with favorite saladdressing.

3 Toast rolls and make the burgers; serve with pickles and

olives.

4 For dessert, heat the broiler. Make the s’mores nachos.

1/4 cup balsamic vinaigrette4 kaiser rolls, split4 (1-oz.) slices Swiss cheese

1 Heat gas or charcoal grill. In mediumbowl, combine ground beef and 1 tea-spoon of the lemon-pepper seasoning;mix well. Shape mixture into 4 1/2-inch-thick) patties.

2 In another medium bowl, combinemushrooms, remaining 1/ 2 teaspoonlemon-pepper seasoning and vinai-grette; toss to coat. Set aside.

3 When grill is heated, place patties ongas grill over medium heat or on char-coal grill 4 to 6 inches from mediumcoals. Cook 11 to 13 minutes or untilpatties are thoroughly cooked, turningonce.

1 SANDWICH Calories 555 (Calories from Fat 295); Total Fat 33g (Saturated Fat 13g); Cholesterol90mg; Sodium 1,060mg; Total Carbohydrates 29g (Dietary Fiber 1g); Sugars 1g; Protein35g, % Daily Value: Vitamin A 6%; Vitamin C 0%; Calcium 32%; Iron 22% Exchanges: 2 Starch, 4 Medium-Fat Meat, 21/2 FatCarbohydrate Choices: 2

BROILED MARINATED MUSHROOM–TOPPED BURGERSPlace patties on broiler pan; broil 4 to 6 inch-es from heat using times above as a guide,turning once. To toast rolls, during last 1 to 2

minutes of cooking time, place rolls, cut sidesup, on broiler pan. Place 1 slice of cheese oneach patty; cook an additional minute.

Mushroom slicing is a thing of the past! Just look for packages of preslicedmushrooms next to the whole mushrooms in the produce department. They're agreat recipe time-saver!

1 Break each graham cracker into 4pieces. Pile pieces in ungreased metalor disposable foil pie pan. DO NOT USEGLASS. Top with chocolate chips andmarshmallows.

2 Broil 6 inches from heat for 30 to 60seconds or until marshmallows arepuffed and golden, watching to preventburning.

1 SERVINGCalories 340 (Calories fromFat 110); Total Fat 12g(Saturated Fat 6g);Cholesterol 5mg; Sodium190mg; Total Carbohydrates55g (Dietary Fiber 1g); Sugars40g; Protein 4g, % DailyValue: Vitamin A 0%; VitaminC 0%; Calcium 6%; Iron 6%Exchanges: 1 Starch, 21/2,Fat, 21/2 Other Carbohydrates Carbohydrate Choices: 31/2

The popular campfire s'mores use chocolate but for a flavor twist use butterscotch or peanut butterchips rather than the milk chocolate chips. Kids of all ages will love them

4 To toast rolls, during last 1 to 2 minutes ofcooking time, place rolls, cut sides down,on grill. Place 1 slice of cheese on eachpatty; cook an additional minute or untilcheese is melted.

8 9

Pillsbury Fix It Fast!Interior Design Proposal (design

on following page was chosen)Programs: Quark, Photoshop,

Illustrator

QU

ICK

FIX

Skillet Beef y Chili MacReady in 25 minutes 4 servings (1 1/2 cups each)

1 1/2 cups uncooked elbow macaroni (6 oz.)1 lb. lean (at least 80%) ground beef1 can (15 oz.) spicy chili beans, undrained1 can (14.5 oz.) diced zesty chili-style tomatoes, undrained1/4 teaspoon salt1/4 teaspoon pepper1 cup shredded Cheddar cheese (4 oz.)

1 Cook macaroni as directed on package. Drain; return tosaucepan. Cover to keep warm.

2 Meanwhile, in 12–inch nonstick skillet, cook ground beef overmedium-high heat for 5 to 7 minutes or until brown, stirringfrequently. Drain.

3 Reduce heat to medium. Stir in cooked macaroni, beans,tomatoes, salt and pepper. Cook an additional 3 to 5 minutesor until bubbly, stirring frequently. Sprinkle with cheese.

Skillet Beefy Chili Mac

Fettuccine with Beef and PeppersIItalian Mixed Salad

Beef and Ramen Noodle Bowls

Skillet Meatballs with LinguineCorn with Chives

Beef and Pasta AlfredoEasy Ham and NoodlesCaesar Tortellini with HamBasil-Pork and Asian NoodlesTuna and Ham with FettuccineRavioli with Broccoli,Tomatoes and MushroomsPenne with Cheesy Tomato-Sausage SauceChicken Puttanesca SautéTwo-Cheese Chicken with CouscousSouthwest Chicken and Fettuccine

Tortellini with ChickenStrawberry-Rhubarb Sundaes

Creamy Chicken and AsparagusLemon-Chicken PrimaveraRavioli with Corn and Cilantro

Three-Pepper Pasta with PestoPeas with Dill

Pesto Shrimp and PastaSummer Vegetable Ravioli

69JUMP START WITH PASTA

J um

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ithPa

sta

Three

Men

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1 SERVING

Calories 595 (Calories from Fat 245); Total Fat 27g (Saturated Fat 13g);Cholesterol 95mg; Sodium 1,490mg; Total Carbohydrates 55g (Dietary Fiber7g); Sugars 6g; Protein 40g

% Daily Value: Vitamin A 22%; Vitamin C20%; Calcium 22%; Iron 34%

Exchanges: 3 Starch, 4 1/2 Medium-FatMeat, 1 Fat

Carbohydrate Choices: 0

Men

uM

enu

Men

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If you don't have a can of zesty chili-style tomatoes on hand, use a can of plain dicedtomatoes and add 1/2 teaspoon chili powder.

11

Chicken, Vegetable and CreamCheese SandwichesnnnnReady in 10 minutes 4 sandwiches

8 slices pumpernickel rye bread1 container (6.5 oz.) gourmet spreadable cheese with garlic and

herbs (1 cup)16 thin slices cucumber1 lb. sliced cooked chicken (from deli)1 medium tomato, sliced1 slice (1/4 inch thick) sweet onion (Walla Walla, Maui or Texas

Sweet), separated into rings 1 cup coleslaw mix (from 16-oz. bag)

1 Spread one side of all slices of bread with gourmet spreadablecheese.

2 Top 4 bread slices, cheese side up, evenly with cucumber,chicken, tomato, onion and coleslaw mix. Cover withremaining bread slices, cheese side down.

10 PILLSBURY FIX IT FAST!

1 SANDWICH

Calories 480 (Calories from Fat 250); TotalFat 28g (Saturated Fat 13g); Cholesterol95mg; Sodium 2,040mg; TotalCarbohydrates 34g (Dietary Fiber 4g);Sugars 7g; Protein 23g

% Daily Value: Vitamin A 20%; Vitamin C22%; Calcium 10%; Iron 16%

Exchanges: 2 Starch, 2 1/2 Lean Meat, 4 Fat

Carbohydrate Choices: 2

QU

ICK

FIX Everyone on a different schedule? You'll feel good when you have these tasty sandwiches

in the refrigerator, wrapped and ready to eat for family members who are on the go!

Pillsbury Fix It Fast!Wiley, © 2006Interior Design and full compositionProgram: Quark

Understanding Meats and Game

chapte

r10

176

chapter 10Understanding

Meats and Game

Meat is muscle tissue. It is the flesh of

domestic animals (cattle, hogs, and lambs) and of wild game

animals (such as deer). As a cook, chef, or food service opera-

tor, you will be spending more of your time and money on

meats than on any other food.

It is important, then, to understand meats thoroughly in

order to cook them well and profitably. Why are some meats

tender and some tough? How can you tell one cut from

another when there are so many? How do you determine the

best way to cook each cut?

In order to answer questions like these, it is helpful to start at

the most basic level of composition and structure. We then

proceed to discuss grading and inspection, basic cuts, and

appropriate cooking and storage methods. In addition, we

discuss the characteristics of variety meats and of popular

game meats. Only then can we best approach the individual

cooking methods and recipes presented in the following

chapters.

CodType: Lean.Varieties: Small, young cod is called scrod.Characteristics: Lean, white, delicately flavored flesh

with large flakes. Most important food fish in NorthAmerica. Most fish sticks and similar items are madefrom cod.

Weights: Scrod: 1 to 2½ lb (0.5 to 1 kg).Cod: 2½ to 25 lb and up (1 to 11 kg).

GrouperType: Lean.Characteristics: Many varieties with varying shape

and skin color. Firm white fish, similar in textureand flavor to red snapper. Tough skin.

Weight: Up to 700 lb (300 kg), but most grouperson the market weigh 5 to 15 lb (2.3 to 7 kg).

HaddockType: Lean.Varieties: Finnan haddie is smoked haddock, not a separate kind of fish.Characteristics: Similar to cod, but generally smaller.Weight: 1 to 5 lb (0.5 to 2.3 kg).

JackType: Fat.Varieties: Members of the jack family include kingfish, blue runner, yellowtail, amber-

jack, and golden thread. The best-known jack is the pompano, listed separately.Characteristics: Smooth, shiny skin; firm, oily flesh; strong flavor. Some varieties are

much stronger than others.Weight: Varies greatly depending on variety.

John DoryAlso known as St. Peter’s fish, St. Pierre.Type: Lean.Characteristics: Identified by the characteristic black spot ("St. Peter’s thumbprint") on

each side of the body behind the head. Firm, sweet, white flesh with fine flakes; broad,thin fillets.

Weight: About 2 lb (900 g) average.

MackerelType: Fat.Varieties: Spanish and Boston mackerel are the most com-

mon small varieties. King mackerel is larger, usu-ally cut into steaks.

Characteristics: Fat, firm flesh withrich flavor and slightly dark color.

Weight: ½ to 5 lb (0.2 to 2.3 kg).

Mahi-mahiAlso known as dorado, dolphinfish (not related to the mammal called dolphin).Type: Lean.Characteristics: Firm, fine-textured pinkish flesh with

rich, sweet taste. Becomes very dry when overcooked,so best cooked with moist heat or with fat orserved with a sauce.

Weight: 5 to 40 lb (2.3 to 18 kg).

F in F ish 279

Cod

Grouper

Spanish mackerel

Jack

Blue runner, a type of Jack

Mahi-mahi

Boston mackerel

We can conclude that herbs and spices should cook with the foods long enough to releasetheir flavors but not so long that their flavors are lost. If cooking times are short, you can generallyadd spices and herbs at the beginning or middle of cooking time. On the other hand, if cookingtimes are long, it is usually better to add them in the middle or toward the end of cooking time.

Note: Food safety experts recommend adding dried spices and herbs at least 30 minutesbefore the end of cooking so that any microorganisms they might carry will be destroyed.

Common Seasoning andFlavoring IngredientsAny food product can be used as a flavoring ingredient, even meat (as when crumbled bacon isadded to sautéed potatoes or diced ham is included in a mirepoix). Sauces, which are com-pound preparations containing many flavoring ingredients, are themselves used as flavoringsfor meat, fish, vegetables, and desserts.

We obviously cannot treat all possible flavoring ingredients here, but we discuss some ofthe most important as follows. A survey of herbs and spices is provided in Table 4.1 on pages67–69. Ingredients used primarily in the bakeshop are discussed in Chapter 23.

1. Salt is the most important seasoning ingredient. Don’t use too much. You can always addmore, but you can’t take it out.

2. Pepper comes in three forms: white, black, and green. They are actually the same berry butprocessed differently. (Black pepper is picked unripe; white is ripened and the hull isremoved; green peppercorns are picked unripe and preserved before their color darkens.)

• Whole and crushed black pepper is used primarily in seasoning and flavoring stocks andsauces and, sometimes, red meats. Ground black pepper is used in the dining room bythe customer.

• Ground white pepper is more important as a seasoning in the food service kitchen. Itsflavor is slightly different from that of black pepper, and it blends well (in small quanti-ties) with many foods. Its white color makes it visually undetectable in light-coloredfoods.

• Green peppercorns are fairly expensive and are used in special recipes, primarily in lux-ury restaurants. The types packed in water, brine, or vinegar (those in water and in brinehave better flavor) are soft. Wet-pack peppercorns are perishable. Water-packed pepper-

corns will keep only a few days in the refrigerator after they are opened, whilethe others will keep longer. Dried green peppercorns are also available.

3. Red pepper or cayenne is completely unrelated to black and white pepper. It belongs to thesame family as paprika and fresh sweet bell peppers. Used in tiny amounts, it gives a spicyhotness to sauces and soups without actually altering the flavor. In larger amounts, it givesboth heat and flavor to many spicy foods, such as those of Mexico and India.

4. Lemon juice is an important seasoning, particularly for enlivening the flavor of sauces andsoups.

5. Fresh herbs are almost always superior to dried herbs. They should be used whenever costand availability permit. Not long ago, the only fresh herbs generally available in many areaswere parsley, chives, and, sometimes, mint and dill. Now, however, most herbs are availablefresh. The accompanying photos illustrate the most commonly used fresh herbs as well assome unusual fresh flavoring ingredients.

6. Onion, garlic, shallots, and other members of the onion family, as well as carrots and celery,are used as flavorings in virtually all stations of the kitchen except the bakeshop. Try toavoid the use of dried onion and garlic products. They have less flavor, and the fresh prod-uct is always available.

7. Wine, brandy, and other alcoholic beverages are used to flavor sauces, soups, and manyentrées. Brandy should be boiled or flamed to eliminate the high percentage of alcohol,which would be unpleasant in the finished dish. Table wines usually need some cooking orreduction (either separately or with other ingredients) to produce the desired flavors.Fortified wines like sherry and Madeira, on the other hand, may be added as flavorings atthe end of cooking.

8. Prepared mustard is a blend of ground mustard seed, vinegar, and other spices. It is used toflavor meats, sauces, and salad dressings and as a table condiment. For most cooking pur-poses, European styles such as Dijon (French) or Dusseldorf (German) workbest, while the bright-yellow American ballpark style is more appropriate as atable condiment than as a cooking ingredient. A coarse, grainy style is sometimescalled for in specialty recipes.

9. Grated lemon and orange rind is used in sauces, meats, and poultry (as in duckling àl’orange) as well as in the bakeshop. Only the colored outer portion, called the zest,which contains the flavorful oils, is used. The white pith is bitter.

10. MSG, or monosodium glutamate, is a flavor enhancer widely used in Asian cooking. MSGdoesn’t actually change the flavor of foods but acts on the taste buds. It has a bad reputationfor causing chest pains and headaches in some individuals.

Using Herbs and SpicesDEFINITIONS

Herbs are the leaves of certain plants that usually grow in temperate climates.Spices are the buds, fruits, flowers, bark, seeds, and roots of plants and trees,

many of which grow in tropical climates.

The distinction is often confusing, but it is not as important to know whichflavorings are spices and which are herbs as it is to use them skillfully.

64 C HAP TE R 4 Bas ic Cook ing Pr inc ip les Us ing Herbs and Spices 65

Basil

ChervilChives

Garlic chives

Cilantro

Dill

Epazote

Regular ginger and

green ginger LemongrassMarjoram

Mint Oregano

Parsley, flat

Parsley, curly

Rosemary

Sage

Tarragon

Thyme

Professional Cooking, 5e andEssentials of Professional Cooking, 1e

Wiley, © 2004Interior Design, page layout

and full compositionProgram: Quark

ASIAN STUDIES2000

Highlights 1

Asia Society 5

Foremother Legacies 6

Curriculums in Asian Studies 7

Asia General 8

Japan111

Korea 19

Tibet 22

China 23

Asia and the Pacific 28

The Mao Projects 37

Taiwan 39

Hong Kong 40

Russia in Asia 41

South and Southeast Asia 43

Reference 46

Sale 49

Periodicals 52

Index 53

Order Form: Back cover

Ordering Information: Inside Front Cover

M. E. Sharpe

Asian Studies CatalogueM.E. Sharpe, © 2000Design, page layout, compositionPrograms: Quark, Photoshop

ENTRY – ENTRY

WORLD ALMANAC SECTION

251

AZERBAIJANPopulation: 8,370,000

Ethnic groups: Azeri 90%, Dagestani 3%, Russian 3%,Armenian 2%

Principal languages: Azeri (official), Russian, Armenian

Chief religions: Muslim 93%, Russian Orthodox 3%, ArmenianOrthodox 2%

Area: 33,440 sq mi (86,600 sq km)

Topography: The Great Caucasus Mountains the north and the Karabakh Upland in the west border the Kur-Abas Lowland; climate is arid exceptin the subtropical southeast.

Capital: Baku (pop., 1,964,000)

Independence date: August 30, 1991 Government type: republic

Head of state: Pres. Haydar A. Aliyev

Head of government: Prime Min. Artur Rasizade

Monetary unit: manat

GDP: $24.3 billion (2001 est.) Per capita GDP: $3,100

Industries: petroleum products, oilfield equipment, steel, iron ore,cement, chemicals, textiles

Chief crops: cotton, grain, rice, grapes, fruit, vegetables, tea, tobacco

Minerals: petroleum, natural gas, iron ore, nonferrous metals, alumina

Life expectancy at birth (years): male, 59.0; female, 67.6

Literacy rate: 97%

Website: www.president.az

BAHRAINPopulation: 724,000

Ethnic groups: Arab 73%, Asian 19%, Iranian 8%

Principal languages: Arabic (official), English, Farsi, Urdu

Chief religions: Muslim (official; Shi'a 70%, Sunni 30%)

Area: 240 sq mi (620 sq km)

Topography: Bahrain Island, and several adjacent, smaller islands, areflat, hot, and humid, with little rain.

Capital: Manama (pop., 150,000) Independence date: August 15, 1971

Government type: constitutional monarchy

Head of state: King Hamad bin Isa al-Khalifa

Head of government: Prime Min. Khalifa bin Sulman al-Khalifa

Monetary unit: dinar

GDP: $24.3 billion (2001 est.) Per capita GDP: $13,000

Industries: petroleum processing and refining, aluminum smelting, off-shore banking, ship repairing, tourism

Chief crops: fruit, vegetables

Minerals: oil, natural gas

Life expectancy at birth (years): male, 71.3; female, 76.2

Literacy rate: 88.5%

Website: www.bahrain.gov.bh/english/index.asp

BANGLADESHPopulation: 146,736,000

Ethnic groups: Bengali 98%

Principal languages: Bangla (official, also known asBengali), English

Chief religions: Muslim (official) 83%, Hindu 16%

Area: 56,000 sq mi (144,000 sq km)

Topography: The country is mostly a low plain cut by the Ganges andBrahmaputra rivers and their delta. The land is alluvial and marshyalong the coast, with hills only in the extreme southeast and northeast.

Capital: Dhaka (pop., 13,181,000)

Independence date: December 16, 1971

Government type: parliamentary democracy

Head of state: Pres. Iajuddin Ahmed

Head of government: Prime Min. Khaleda Zia

Monetary unit: taka

GDP: $230 billion (2001 est.) Per capita GDP: $1,750

Industries: cotton textiles, jute, garments, tea processing, papernewsprint, cement, chemical fertilizer, light engineering

Chief crops: rice, jute, tea, wheat, sugarcane, potatoes, tobacco, puls-es, oilseeds, spices, fruit

Minerals: natural gas, coal

Life expectancy at birth (years): male, 61.5; female, 61.2

Literacy rate: 56%

Website: www.bangladeshgov.com

BHUTANPopulation: 2,257,000

Ethnic groups: Bhote 50%, Nepalese 35%, indigenous tribes 15%

Principal languages: Dzongkha (official), Tibetan, Nepalese dialects

Chief religions: Lamaistic Buddhist (official) 75%, Hindu 25%

Area: 18,000 sq mi (47,000 sq km)

Topography: Bhutan is comprised of very high mountains in the north, fer-tile valleys in the center, and thick forests in the Duar Plain in the south.

Capital: Thimphu (pop., 32,000)

Independence date: August 8, 1949

Government type: monarchy

Head of state and government: King Jigme Singye Wangchuk

Head of government: Prime Min. Lyonpo Kinzang Dorji

Monetary unit: ngultrum

GDP: $2.5 billion (2001 est.) Per capita GDP: $1,200

Industries: cement, wood products, processed fruits, alcoholic beverages

Chief crops: rice, corn, root crops, citrus, foodgrains

Minerals: gypsum, calcium carbide

Life expectancy at birth (years): male, 53.9; female, 53.3

Literacy rate: 42.2%

Website: www.kingdomofbhutan.com

BRUNEIPopulation: 358,000

Ethnic groups: Malay 67%, Chinese 15%, indigenous 6%

Principal languages: Malay (official), English, Chinese

Chief religions: Muslim (official) 67%; Buddhist 13%; Christian 10%;indigenous beliefs, other 10%

Area: 2,230 sq mi (5,770 sq km)

Topography: Brunei has a narrow coastal plain, with mountains in the east,hilly lowlands in the west. There are swamps in the west and northeast.

AZERBAIJAN – BRUNEI

250

WORLD ALMANAC SECTION

AFGHANISTANPopulation: 23,897,000

Ethnic groups: Pashtun 44%, Tajik 25%, Hazara 10%,Uzbek 8%

Principal languages: Dari (Afghan Persian), Pashtu (both official); Turkic(including Uzbek, Turkmen); Balochi, Pashai, many others

Chief religions: Muslim (official; Sunni 85%, Shi'a 15%)

Area: 250,000 sq mi (647,500 sq km)Topography: The country is landlocked and mountainous, much of itover 4,000 ft (1,200 m) above sea level. The Hindu Kush Mountainstower 16,000 ft (4,800 m) above Kabul and reach a height of 25,000ft (7,600 m) to the east. Trade with Pakistan flows through the 35-mi(56-km) Khyber Pass. There are large desert regions, though mountainrivers produce intermittent fertile valleys.

Capital: Kabul (pop., 2,734,000)

Independence date: August 19, 1919

Government type: transitional administration

Head of state and government: Pres. Hamid Karzai

Monetary unit: afghani

GDP: $21 billion (2000 est.) Per capita GDP: $800

Industries: textiles, soap, furniture, shoes, fertilizer, cement, handwoven carpets

Chief crops: wheat, fruits, nuts

Minerals: natural gas, petroleum, coal, copper, chromite, talc, barites,sulfur, lead, zinc, iron ore, salt, precious and semiprecious stones

Life expectancy at birth (years): male, 47.7; female, 46.2

Literacy rate: 36%

Website: www.afghanistanembassy.org

ARMENIAPopulation: 3,061,000

Ethnic groups: Armenian 93%, Russian 2%

Principal languages: Armenian (official), Russian

Chief religions: Armenian Apostolic 94%, other Christian 4%, Yezidi 2%

Area: 11,500 sq mi (29,800 sq km)

Topography: Mountainous, with many peaks above 10,000 ft (3,000 m).

Capital: Yerevan (pop., 1,420,000)

Independence date: September 21, 1991

Government type: republic

Head of state: Pres. Robert Kocharian

Head of government: Prime Min. Andranik Markarian

Monetary unit: dram

GDP: $11.2 billion (2001 est.)

Per capita GDP: $3,350

Industries: machine tools, forging-pressing machines, electric motors,tires, knitted wear, footwear, silk fabric, chemicals, trucks, instruments, microelectronics, jewelry, software development, foodprocessing

Chief crops: grapes, vegetables

Minerals: gold, copper, molybdenum, zinc, alumina

Life expectancy at birth (years): male, 62.4; female, 71.2

Literacy rate: 99%

Website: www.gov.am/en

Asia has three of the five most populous countries in the

world. China and India, each with more than 1 billion people,

rank number 1 and number 2, respectively. Indonesia, with

well over 200 million, is number 4.

ASIA

FOR MAP, SEE PAGE 89 FOR MAP, SEE PAGE 63

FOR MAP, SEE PAGE 63

FOR MAP, SEE PAGE 88

FOR MAP, SEE PAGE 82

FOR MAP, SEE PAGE 85

FOR MAP, SEE PAGE 80

AFGHANISTAN – ARMENIA

Nation Facts and Figures

Nation Facts and Figures252

WORLD ALMANAC SECTION

Capital: Bandar Seri Begawan (pop., 46,000)

Independence date: January 1, 1984

Government type: independent sultanate

Head of state and government: Sultan Sir Muda Hassanal BolkiahMu’izzadin Waddaulah

Monetary unit: Brunei dollar

GDP: $6.2 billion (2001 est.) Per capita GDP: $18,000

Industries: petroleum, petroleum refining, liquefied natural gas, construction

Chief crops: rice, vegetables, fruits

Minerals: petroleum, natural gas

Life expectancy at birth (years): male, 71.9; female, 76.8

Literacy rate: 88.2% Website: www.gov.bn

CAMBODIAPopulation: 14,144,000

Ethnic groups: Khmer 90%, Vietnamese 5%, Chinese 1%

Principal languages: Khmer (official), French, English

Chief religion: Theravada Buddhist (official) 95%

Area: 69,900 sq mi (181,040 sq km)

Topography: The central area, formed by the Mekong River basin andTonle Sap lake, is level. Hills and mountains are in the southeast, along escarpment separates the country from Thailand on the northwest.76% of the area is forested.

Capital: Phnom Penh (pop., 1,109,000)

Independence date: November 9, 1953

Government type: constitutional monarchy

Head of state: King Norodom Sihanouk

Head of government: Prime Min. Hun Sen

Monetary unit: riel

GDP: $18.7 billion (2001 est.) Per capita GDP: $1,500

Industries: tourism, garments, rice milling, fishing, wood and woodproducts, rubber, cement, gem mining, textiles

Chief crops: rice, rubber, corn, vegetables

Minerals: gemstones, iron ore, manganese, phosphates

Life expectancy at birth (years): male, 55.5; female, 60.5

Literacy rate: 35%

Website: www.cambodia.gov.kh

CHINA(Statistical data do not include Hong Kong or Macau.)

Population: 1,286,975,000

Ethnic groups: 56 groups; Han 92%; also Zhuang,Manchu, Hui, Miao, Uygur, Yi, Tujia, Tong, Tibetan,

Mongol, et al.

Principal languages: Mandarin (official), Yue (Cantonese), Wu(Shanghaiese), Minbei (Fuzhou),Minnan (Hokkien-Taiwanese), Xiang,Gan, Hakka, minority languages

Chief religions: officially atheist; Buddhism,Taoism; some Muslims, Christians

Area: 3,705,410 sq mi (9,596,960 sq km)

Topography: Two-thirds of China’s vast terri-tory is mountainous or desert; only one-tenth is cultivated. Rolling topographyrises to high elevations in theDaxinganlingshanmai separatingManchuria and Mongolia in the north; theTien Shan in Xinjiang; and the Himalayanrange and Kunlunshanmai in the south-west and in Tibet. Length is 1,860 mi(3,000 km) from north to south, widtheast to west is more than 2,000 mi(3,200 km). The eastern half of China isone of the world’s best-watered lands.Three great river systems, the Chang(Yangtze), Huang (Yellow), and Xi, providewater for vast farmlands.

Capital: Beijing (pop., 10,836,000)

Independence date: 221 BC

Government type: Communist Party-led state

Head of state: Pres. Hu Jintao

Head of government: Premier Wen Jiabao Monetary unit: renminbi

GDP: $5.56 trillion (2001 est.) Per capita GDP: $4,300

Industries: iron and steel, coal, machine building, armaments, textilesand apparel, petroleum, cement, chemical fertilizers, footwear, toys,food processing, automobiles, consumer electronics,telecommunications

Chief crops: rice, wheat, potatoes, sorghum, peanuts, tea, millet,barley, cotton, oilseed

Minerals: coal, iron ore, petroleum, natural gas, mercury, tin, tungsten,antimony, manganese, molybdenum, vanadium, magnetite, aluminum,lead, zinc, uranium

CAMBODIA – CHINA

Angkor Wat ruins, Cambodia

Li River and "pinnacles," China

The Forbidden City (former impe-rial residence), Beijing, China

Brunei (continued)

FOR MAP, SEE PAGE 78FOR MAP, SEE PAGE 70

WORLD ALMANAC SECTION

265

AUSTRALIA

r,

4

e:

AUSTRALIAPopulation: 19,731,000

Ethnic groups: white 92%, Asian 7%, Aborigine and other 1%

Principal languages: English (official), aboriginal languages

Chief religions: Anglican 26%, Roman Catholic 26%, other Christian 24%

Area: 2,967,910 sq mi (7,686,850 sq km)

Topography: An island continent. The Great Dividing Range along theeastern coast has Mt. Kosciusko, 7,310 ft (2,230 m). The westernplateau rises to 2,000 ft (600 m), with arid areas in the Great Sandyand Great Victoria deserts. The northwestern part of Western Australiaand the Northern Territory are arid and hot. The northeast has heavyrainfall, and Cape York Peninsula has jungles.

Capital: Canberra (pop., 387,000)

Independence date: January 1, 1901

Government type: democratic, federal state system

Head of state: Queen Elizabeth II, represented by Gov.-Gen. Michael Jeffery

Head of government: Prime Min. John Howard

Monetary unit: Australian dollar

GDP: $465.9 billion (2001 est.) Per capita GDP: $24,000

Industries: mining, industrial and transport equipment, food processing,chemicals, steel

Chief crops: wheat, barley, sugarcane, fruits

Minerals: bauxite, coal, iron ore, copper, tin, silver, uranium, nickel,tungsten, mineral sands, lead, zinc, diamonds, natural gas, petroleum

Life expectancy at birth (years): male, 77.3; female, 83.1

Literacy rate: 100% Website: www.gov.au

The nation of Australia, which spans the entire

continent of Australia, has the sixth biggest land

area among the countries of the world. The

Pacific island nations of Nauru and Tuvalu fall

among the world’s five smallest countries in terms

of land area; as of 2003, Tuvalu and Nauru, along

with Palau, ranked among the five smallest

countries in terms of population.

AUSTRALIA, NEW ZEALAND,AND THE PACIFIC

Ayers Rock (Uluru), Northern Territory, Australia Perth, Australia

FOR MAP, SEE PAGE 109

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At high iron loading, ferritin aggregates in thelysosomes (46)(47) to form hemosiderin, an ill-defined mix of protein, lipid and iron, in which ironis less accessible for cellular use (48, 49). The H-fer-ritin chain was specifically implicated in ferritinaggregation to form hemosiderin (50). The mode ofnucleation of iron, the specifically implicated in fer-ritin aggregation to formexchange of change of pro-tons, and the aggregation of ferritin in lysosome,can all contribute to ferritin detection by MRI.

REFERENCES

1 Bothwell TH. Overview and mechanisms of iron regu-lation. Nutr Rev 1995, 53(9):237-45.

2. Andrews NC. Disorders of iron metabolism. N Engl JMed 1999;341(26):1986-95.

3. Provan D. Mechanisms and management of iron defi-ciency anaemia. Br J Haematol 1999, 105 Suppl 1:19-26.

4. El-Serag HB, Inadomi JM, Kowdley KV. Screening forhereditary hemochromatosis in siblings and childrenof affected patients. A cost-effectiveness analysis. AnnIntern Med 2000, 132(4):261-9.

5. Merryweather-Clarke AT, Pointon J, Shearman JD,Robson KJ. Global prevalence of putative haemochro-matosis mutations. J Med Genet 1997;34(4):275-8.

6. Steinberg KK, Cogswell ME, Chang JC, et al.Prevalence of C282Y and H63D mutations in the

hemochromatosis (HFE) gene in the United States.Jama 2001, 285(17):2216-22.

7. Schenck JF, Zimmerman EA. High-field magnetic reso-nance imaging of brain iron: birth of a biomarker?NMR in biomedicine 2004;17(7):433-45.

8. Christoforidis A, Haritandi A, Tsitouridis I, et al.Correlative study of iron accumulation in liver,myocardium, and pituitary assessed with MRI inyoung thalassemic patients. J Pediatr Hematol Oncol2006, 28(5):311-5.

9. Bartzokis G, Beckson M, Hance DB, Marx P, FosterJA, Marder SR. MR evaluation of age-related increaseof brain iron in young adult and older normal males.Magn Reson Imaging 1997, 15(1):29-35.

10. Bartzokis G, Tishler TA, Shin IS, Lu PH, CummingsJL. Brain ferritin iron as a risk factor for age at onset inAnn N Y Acad Sci 2004, 1012:224-36.

FURTHER READING

Click here to insert Further reading text

CROSS-REFERENCES

MR relaxation properties of superparamagnetic iron oxide particle.

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WIREs Nanomedicine and Nanobiotechnology Nanomedicine strategies for lysosomal storage disease

NOTESThis work was supported by the Minerva foundation and by the Israel Science Foundation (to MN).

TABLE 1 This is to Represent the Table Title

Table Column Head

A column A Column Head Head Head

30,562.24 45,403.70 35.456.60

10,404.56 89,780.39 478,923.67

10,984.56 89,980.34 1,677,267.09

This is to represent a footnote to a table, and here is more for turnover

pose. For example, both metal and semiconductornanocrystals have properties. However, thosenanocrystals made exclusively of semiconductormaterials are optimal for optical applications. Thecomposition of the nanomaterial also defines itsfunction. In nano-scale science and technology, eachnanomaterial has a specific and very unique appli-cation. Some properties are shared among nanoma-terials of different chemical composition; but thereis always an optimal structure for the purpose.

Number 3 SubheadCarbon-based nanomaterials are best for mechanicaland electrical devices. Ceramic nanomaterials(including metal oxide materials) are ideal for mag-netic applications.

Number 4 SubheadOrganic nano particles, those made primarily of car-bon, oxygen, and hydrogen, are one class of nanoma-terials that are promising for sorptive applications,such as groundwater filtration or environmentalcleaning.

1. Particle size and size distributions are normallyrepresented graphically as population versussize. Sizing data can be acquired using a varietyof techniques. Sizing in

2. The wet phase (discussed later in this review)involves different techniques than sizing in thedry state.

3. Other methods include differential mobilityanalysis (DMA), time of flight mass spec-troscopy (TOF-MS), and specific surface areameasurements (SSA). These measurementsrequire the sample to be in the dry state.

Therefore, effects created from solvent are notaccounted for in these types of measurements.

MORPHOLOGY

One technique that characterizes both size andcrystallinity is X-ray diffraction (XRD). Nanocrystalsdiffract X-rays in unique ways. Their unique structureinfluences the nanoparticle’s chemical properties. AnX-ray diffraction pattern does not exist in an amor-phous sample diffraction pattern does not exist in anamorphous sample. In a crystalline sample, bothphase and grain size can be deduced. XRD confirmsa crystalline product, but requires ~100 mg of pow-der sample, nanoscience Their unique structure influ-ences the nanoparticle’s chemical properties. An X-ray diffraction pattern does not exist in a sample.

Size and Size DistributionMeasuring the size and size distribution of ananoparticle sample in the wet phase is analogouswith measuring its state of dispersion. The dispersionof a nanoparticle system can be reported as the num-ber or mass of monodispersedstrength of the solvent.Lastly, the solutes present sample in the wet phaseis(including biomolecules) the measuring its state ofdispersion.

CONCENTRATION & PURITY

The end product of a nanoparticle sample can be in one oftwo forms: a solid powder or in solution/suspension. For adried powder solution, concentration is easily determinedby dispersing a known amount of sample (in grams) into aknown amount of solvent (in liters). The final concentra-tion is then reported in weight per volume (i.e. mg/L orppm). For the best measurement of particles in solution,cryo-transmission electron microscopy should be used. Aknown volume (~2 mL) is used when preparing a samplefor cryo-TEM analysis. After an appropriate amount ofimages are taken from the sample, the nanoparticles ineach micrograph are counted. The final concre poor whendetermining nanoparticle concentrations entration is thenreported in number per volume (#/mL). Using Avagodro’snutions however, most synthetic schemes yield mber, theseunits can be converted to ppm. Traditional methods basedon reactants and % reactions.

FIGURE 3 | Challenges in the reconstruction of homologous collinear regions. The left-hand panel shows a'standard' region that is expected to be collinear along its entirelength. However, the presence of retrotransposed pseudogenes,assembly gaps and inversions complicates the problem. The right-hand panel shows a duplicated region for which, even when thereis ideal data, challenges are presented by aspects such as gene con-version between duplicated copies that make the relationshipbetween different copies in different genomes complex. In theexample shown, there are three copies of the duplication in human,one in dog, and two in mouse, which ideally should all be aligned ina collinear manner. In addition to the challenge of gene conversion,these regions usually contain the most complex assembly artefacts,including artificial expansions of duplicated regions into partiallyoverlapping contigs with inappropriate neighbouring data inter-spersed with the genuinely homologous regions (shown in human),or collapses in assembly where there is an apparent single regionthat is actually a chimaera of two regions (shown in mouse). Thenormal assembly issues of gaps and inversions also occur (shown indog), usually at a higher rate than in standard regions.

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WIREs Nanomedicine and Nanobiotechnology Nanomedicine strategies for lysosomal storage disease

Christie M. Sayes1 and David B. Warheit2

Nanomedicine strategies for lysosomal storage disease using novel pathways for intracellulardelivery and prolonged drug effect

Although some material properties like chemicalcomposition and crystal structure are the same

on the nanoscale as in the bulk phase, other proper-ties differ. Because of the small size (high surfacearea) and size-dependent properties (classical versusquantum mechanics), a nanoparticle retains propertiesof botih materials in the bulk phase and molecularprecursors.

TO REPRESENT A FIRST 1 HEAD

The physico-chemical properties that are consideredto be important for assessing biological effects ofnanomaterials include the following: particle size &size distribution, morphology, chemical composition,crystal structure, solubility, aggregation status, con-

comitant with surface chemistry & surface reactivityassessments. In this chapter, we have organized thesecharacteristics around three phases - based largelyupon the state of the test substance to be evaluated,(i.e. dry, wet, or in-life analyses). For organizationalpurposes, as primary and secondary phases.

There are differences in the thermodynamicsproperties of bulk materials and nanoparticles.22 DG,the free energy of the system, is dependant of DGs(the materials surface energy) and DGv (the materialsvolume):

DG = 4 p r2 DGs – 4/3 p r3 DG

Because DGs is large and DGv is small, the freeenergy of the system is much higher for a nanoparti-cle than for the bulk material of identical chemicalcomposition. This corresponds to different physicalproperties as compared, such as reduced meltingpoints and altered crystallographic structure.

The model nanoparticle sample has three dis-tinct features: a defined structure, monodispersity,and large surface area. However, the feature that ismost often cited is the particles size. This size, usu-ally reported as diameter, is not always useful.However, the feature that is most often cited is theparticles size. This size, usually reported.

Advanced Review

A key element of any nanomaterial toxicity screening strategy is a detailed andcomprehensive physico-chemical characterization of the test material beingstudied. This is a critical factor for correlating the nanoparticle surfacecharacteristics with any measured biological/toxicological responses, as well asto provide an adequate reference point for comparing toxicity results with thehazard-based findings of other investigators. Moreover, when hazard or risk-based evaluations are made on a particular nanomaterial (based on a variety ofstudies), it is important to ensure that the nanoparticle-types are identical orvery similar in composition. This can only be accomplished if rigorouscharacterization is conducted. In the absence of an adequate assessment of thephysical characteristics, it is easy to draw general conclusions on nanoparticle-types which may have similar chemical compositions but, in fact, have differentsizes, shapes, crystal structures, surface coatings, and surface reactivitycharacteristics.© 2009 John Wiley & Sons, Inc. Wiley Interdiscipl. Rev. Nanomed. Nanobiotechnol. 2009 1 53-61

(2-1)

1North Carolina State University-CVM, Department of ClinicalSciences, Center for Chemical Toxicology Research andPharmacokinetics, 4700 Hillsborough St., Raleigh, N.C. 27606,USA Nancy_Monteiro@ncsu.edu2Institute for Environmental Medicine (IFEM), University ofPennsylvania School of Medicine, 1 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA 19104-6068, USAMuzykant@mail.med.upenn.edu

DOI: 10.1002/wnan.10255

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