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Bone marrow melancholy might require withholding bendamustine till recovery happens. One dose every day, normally at bedtime, offers aid for many patients; nevertheless, divided doses (two or four instances daily) could additionally be beneficial in selected sufferers. Most efficient with extrapyramidal problems that develop soon after beginning treatment with neuroleptic brokers. Drug-induced extrapyramidal issues that develop slowly could not reply to benztropine. Has atropine-like unwanted effects but may be used with warning in pediatric patients over 3 years of age. In the elderly, contemplate potential for age-related impaired organ perform and concomitant disease or drug therapy. A artificial compound containing structural features found in atropine and diphenhydramine. Provides relief of drooling, dysphagia, gait disturbances, pain brought on by muscle spasm, rigidity, tremor, and other annoying signs of parkinsonism. Use with haloperidol may worsen schizophrenic signs and may precipitate tardive dyskinesia. Reduce dose or briefly discontinue for severe dry mouth that results in problem swallowing or speaking or for lack of urge for food and weight. Unless particularly acknowledged in any other case, using the name bevacizumab or bevacizumab products applies to all formulations. Pretreatment: Do not begin therapy until a minimal of 28 days following surgical procedure and the wound is absolutely healed. BevacizumaB products May be used in mixture with different antineoplastic brokers or as a single agent. Dose Modifications for Adverse Reactions Adverse Reaction Severity � Gastrointestinal perforation, any grade � Tracheoesophageal fistula, any grade � Fistula, Grade four � Fistula formation involving any internal organ � Wound healing problems requiring medical intervention � Necrotizing fasciitis � Grade 3 or 4 � Recent history of hemoptysis of 1 2 teaspoon (2. Available in single-use vials containing 100 mg in 4 mL or 400 mg in 16 mL (25 mg/mL). Storage: Store in original carton in refrigerator at 2� to 8� C (36� to 46� F) until time of use. Second infusion: If the preliminary infusion is nicely tolerated, the second infusion may be ad- ministered equally distributed over 60 minutes. Subsequent infusions: If the 60-minute infusion is well tolerated, subsequent infusions may be administered equally distributed over 30 minutes. Used together with fluoropyrimidineirinotecan�based or fluoropyrimidine-oxaliplatin�based chemotherapy. BevacizumaB (avastin) Treatment of sufferers with platinum-resistant recurrent epithelial ovarian, fallopian tube, or main peritoneal cancer who obtained no extra than 2 prior chemotherapy regimens. Given in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan. Given together with carboplatin and paclitaxel or with carboplatin and gemcitabine, followed by bevacizumab as a single agent. Given together with carboplatin and paclitaxel, followed by bevacizumab as a single agent. Withhold bevacizumab for at least 28 days after major surgery; surgical incision have to be totally healed. Withhold at least 28 days before elective surgery (half-life is approximately 20 days but has a wide range). The majority of cases occurred inside the first 50 days of initiation of bevacizumab. Serious fistula formations involving tracheoesophageal, bronchopleural, biliary, vaginal, renal, and bladder areas have been reported. Do not administer bevacizumab to sufferers with serious bleeding or a latest historical past of hemoptysis of 1/2 teaspoon or more of pink blood. May present with blindness and different visual and neurologic disturbances, confusion, headache, lethargy, and seizures. Symptoms usually resolve progressively with discontinuation of bevacizumab and treatment of hypertension. Findings according to thrombotic microangiopathy have been discovered on kidney biopsy in some sufferers. In some however not all sufferers, proteinuria decreased inside several months after remedy was discontinued.

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Each zygoma has three factors of attachment: anteriorly with the maxillary bone, superiorly with the frontal bone, and posteriorly with the temporal bone. Trauma may cause them to become free-floating, an injury called a "tripod" fracture. Maxillary Bones the 2 maxillary bones are the largest immovable bones of the face and are solidly united midline inferiorly. Palatine Bones Forming the posterior a half of the exhausting palate are the 2 palatine bones. The palatine bones have vertical portions that extend superiorly and are minimally concerned in forming the orbit. Vomer the vomer forms the inferior a part of the bony nasal septum, while the perpendicular plate of the ethmoid bone forms the superior segment. Palatine strategy of maxilla Hard palate Maxilla Horizontal plate of palatine bone Vomer Zygomatic arch Lateral pterygoid lamina of sphenoid Medial pterygoid lamina of sphenoid Temporal bone Parietal bone Copyright � Cengage Learning. These processes articulate with the temporomandibular fossae of the temporal bones to kind the temporomandibular joints. The inferior portion of the bony nasal septum is a separate facial bone, the vomer. There are three pairs of conchae or turbinates: the superior, middle, and inferior. The superior and middle conchae are medial extensions off the two lateral masses of the ethmoid bone. The flooring is fashioned by the maxillary bone along the medial facet and the zygomatic bone along the lateral facet. The lateral wall is fashioned by the zygomatic bone and posterolaterally by the sphenoid bone. If someone receives a direct hit within the region of the orbit, the orbit will give in the weakest area, the floor. From a coronal perspective, you see all 4; from an axial perspective, you see the medial and lateral muscles; and from a sagittal perspective, you see the superior and inferior. The retina is the innermost layer in the posterior eye which incorporates the rods and cones, the nerve cells answerable for vision. The optic nerve exits by way of the optic foramen within the posterior orbit, carrying the sensory data acquired by the retina to the mind. It is clear and convex, allowing mild to reach the retina but on the identical time causing refraction of light. There may be either one or two, with a septum, or wall, dividing them if two exist. The many ethmoid sinuses are situated throughout the two lateral plenty of the ethmoid bone, found alongside the medial wall of every orbit. They are lined with mucous membranes, and with pathology, can become full of fluid. The frontal and sphenoids form around the age of 6 or 7, and the final to develop, in the late teenagers, are the ethmoids. A septum separates the sphenoid sinus from the ethmoid sinuses, and an additional septum exists if there are multiple sphenoid sinus. The frontal sinuses are the most superior and the maxillary sinuses probably the most inferior. Ethmoidal and sphenoidal paranasal sinuses; perpendicular plate of ethmoid bone 4. Also necessary is an understanding of the integration of the specific cranial and facial bones with respect to the formation of the nasal septum and fossae and the orbits. Familiarity with the buildings of the attention and its muscles, as seen on sectional pictures, have to be included in examine material. Of explicit interest are the paranasal sinuses and their relationships with each other and with the nasal fossae. The nasal bones are seen, along with the portions of the maxillary bones involved in forming the medial walls of the orbits, the frontal processes.

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Arsenic compounds have been used for more than 2400 years as each therapeutic brokers and poisons. In the late 19th century, Robert Ehrlich coined the phrases magic bullet and chemotherapy to describe his work utilizing the organic arsenic compound arsphenamine for the therapy for syphilis. The use of arsenic in medicine has been mostly phased out, however arsenic trioxide continues to be used as an efficient chemotherapy agent for acute promyelocytic leukemia (see Chapter 68). Arsenic naturally leaches out of soil and rocks into well and spring water (Mead, 2005). Poorly water-soluble compounds such as arsenic sulfide, lead 1308 A Fairbanks, Alaska Aleutian Islands British Brtish Columbia Western U. Map of Bangladesh demonstrating arsenic concentrations in drinking water in samples from wells throughout the country. Water-soluble arsenic compounds are readily absorbed via inhalation and ingestion. At low doses, arsenic is pretty evenly distributed all through the tissues of the physique. Nails and hair, due to their high sulfhydryl content material, exhibit high concentrations of arsenic. Because the pentavalent methylated arsenic compounds have greatly decreased toxicity, the methylation pathway was long thought to be a cleansing pathway. Elimination of arsenicals by people primarily is in the urine, although some is also excreted in feces, sweat, hair, nails, pores and skin, and exhaled air. Compared to most other toxic metals, arsenic is excreted quickly, with a t1/2 of 1�3 days. In people, ingested inorganic arsenic that seems in urine is a mix of 10%�30% inorganic arsenicals, 10%�20% monomethylated forms, and 60%�80% dimethylated varieties. This effect is characterised by the lack of sensation in the arms and toes, often adopted by muscle weakness. Acute high-dose arsenic exposure causes encephalopathy in rare circumstances, with symptoms that can embrace headache, lethargy, psychological confusion, hallucination, seizures, and coma. Humans are also uncovered to giant organic arsenic compounds in fish, that are relatively nontoxic. In the liver, arsenic causes fatty infiltrations, central necrosis, and cirrhosis of varying severity. The motion of arsenic on renal capillaries, tubules, and glomeruli may cause extreme kidney damage. Inhaled arsenic is irritating to the lungs, and ingested arsenic could induce bronchitis progressing to bronchopneumonia in some people. Acute and chronic arsenic exposure cause myocardial depolarization, cardiac arrhythmias, and ischemic coronary heart illness; these are recognized unwanted aspect effects of arsenic trioxide for the treatment for leukemia. Chronic publicity to arsenic may cause peripheral vascular illness, probably the most dramatic instance of which is "blackfoot disease," a condition characterized by cyanosis of the extremities, significantly the ft, progressing to gangrene. Blackfoot illness is endemic in regions of Taiwan, the place properly water incorporates arsenic at ranges of a hundred and seventy to 800 g/L. Arsenic dilates capillaries and increases their permeability; this causes edema after acute exposures and is likely responsible for peripheral vascular illness following persistent publicity. Arsenic induces hyperkeratinization of the skin (including formation of multiple corns or warts), notably of the palms of the hands and the soles of the feet. It also causes areas of hyperpigmentation interspersed with spots of hypopigmentation. These signs may be observed in individuals exposed to ingesting water with arsenic concentrations of a minimum of 100 g/L and are typical in those chronically uncovered to a lot greater ranges. Hyperpigmentation could be observed after 6 months of publicity; hyperkeratinization takes years. At greater doses, fluid varieties vesicles that may burst, resulting in inflammation and necrosis of the submucosa after which rupture of the intestinal wall. Regions with very excessive arsenic levels in drinking water consistently have considerably higher rates of skin most cancers, bladder cancer, and lung cancer. There are also associations between arsenic publicity and different cancers, including liver, kidney, and prostate tumors.

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Effective inside 5 to 10 minutes; reaches peak impact in 15 to 30 minutes and may last for two hours. If a second dose is indicated, administer at an alternate site to keep away from thrombophlebitis. Maternal/Child: Category B: use throughout pregnancy with excessive caution and provided that clearly needed; advantages must outweigh dangers. Elderly: Dosing ought to be cautious; see Dose Adjustments n Response just like that seen in younger adults. May have an additive effect when used concurrently with different antihypertensive agents. Correct potassium ranges first, then modify insulin or antidiabetic agent dose as indicated. Circulatory collapse, deafness (permanent), embolism, hepatic coma, vascular thrombosis, and dying have occurred. Reduce ethacrynic acid dose or discontinue if side effects are average or extreme. Maintain an adequate airway and use oxygen or artificial ventilation for respiratory distress as indicated. Smaller, incremental doses may be administered to adult patients during short operative procedures to supplement subpotent anesthetic brokers, such as nitrous oxide. Has little or no impact on myocardial metabolism, cardiac output, peripheral circulation, or pulmonary circulation. Usefulness of hemodynamic properties must be weighed in opposition to the excessive frequency of transient skeletal muscle movements. Use of larger, extra proximal arm veins is beneficial to reduce incidence and severity of pain on injection. Maternal/Child: Safety for use in being pregnant not established; profit should justify potential dangers to fetus; see Contraindications. Balance the benefits of applicable anesthesia in pregnant ladies, neonates, and young kids who require procedures with the potential dangers described. The commonest adverse reactions are transient venous pain on injection and transient skeletal muscle actions, together with myoclonus, averting movements, and eye actions. Less incessantly reported unwanted effects embody apnea of quick length (5 to ninety seconds with spontaneous recovery), arrhythmia, bradycardia, hiccups and/or loud night time breathing (may indicate partial airway obstruction), hypertension, hyperventilation, hypotension, hypoventilation, laryngospasm, postoperative nausea and vomiting, and tachycardia. Establish and maintain an airway; administer oxygen with assisted ventilation if wanted. Testicular cancer: 50 to 100 mg/M2 daily for five days or 100 mg/M2/day on Days 1, 3, and 5. Use in severe hepatic impairment is contraindicated in the Canadian product labeling. Store reconstituted solutions underneath refrigeration at 2� to 8� C (36� to 46� F) for 7 days. Etopophos (phosphate) is a phosphate ester of etoposide that promptly converts to etoposide in plasma. The pharmacokinetics and pharmacodynamics of etoposide are comparable after administration of both the phosphate or non-phosphate products. Primarily excreted as unchanged drug or metabolites by way of urine and bile (feces). Treatment of refractory testicular tumors (used in combination with different chemotherapeutic drugs). Hypersensitivity to etoposide, etoposide phosphate, or another component of the formulations. If a solution of etoposide contacts the skin, wash the skin instantly and totally with cleaning soap and water. Higher-than-recommended concentration, the presence of polysorbate 80, and a speedy fee of infusion might contribute to the event of these reactions. Avoid extravasation; may result in cellulitis, pain, swelling, and necrosis, including skin necrosis. Patient Education: Female sufferers ought to use effective contraception during remedy and for no much less than 6 months after the final dose. Males with feminine sexual companions of reproductive potential should use condoms during treatment and for 4 months after the final dose.

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Invasive arterial blood strain monitoring and central venous strain monitoring are really helpful. Whenever possible, administer infusion into a large vein; central line administration is most well-liked. These S/S usually subside rapidly, especially with relaxation, quiet, and recumbent positioning. Maternal/Child: Category C: assess threat versus profit; could cause fetal anoxia, spontaneous abortion, or each. In doses adequate to cut back uterine contraction, epinephrine may cause a chronic interval of uterine atony with hemorrhage. Although epinephrine improves maternal hypotension related to anaphylaxis, it could result in uterine vasoconstriction, decreased uterine blood circulate, and fetal anoxia. Clinical use information assist weight-based dosing for therapy of anaphylaxis and suggest that the antagonistic reactions seen in children are related in nature and extent to those reported for adults. Both are direct cardiac stimulants, and concomitant use may increase the danger of arrhythmia. Arrhythmias (including fatal ventricular fibrillation), rapid rises in blood strain producing cerebral hemorrhage, and angina have occurred. Overdose (frequently brought on by too-rapid injection): Arrhythmia (atrial and ventricular), bradycardia (transient followed by tachycardia), cardiomyopathy, cerebrovascular hemorrhage, extreme pallor and coldness of the skin, hypertension, metabolic acidosis as a outcome of elevated lactic acid levels, myocardial ischemia or infarction, pulmonary edema, pupillary dilation, renal failure, tachycardia, demise. If side effects from the common dose become progressively worse, discontinue the drug and notify the doctor. Treatment of pulmonary edema consists of a quickly appearing alpha-adrenergic blocking agent (such as phentolamine) and respiratory support. If extended hypotension follows such measures, it might be essential to administer one other pressor drug. Preassessment and baseline research required; see Premedication: Consider use of antiemetics earlier than administration of epirubicin or when clinically indicated to scale back nausea and vomiting, notably when given in conjunction with different emetigenic drugs. Patients receiving the 120-mg/M2 dose must also receive prophylactic antibiotic therapy with sulfamethoxazole/trimethoprim or a fluoroquinolone. Total dose may be given on Day 1 of every cycle or equally divided and given on Days 1 and 8 of each cycle. One routine used is 60 mg/M2 of epirubicin intravenously on Days 1 and 8 given in a regimen with oral cyclophosphamide seventy five mg/M2 on Days 1 to 14 and fluorouracil 500 mg/M2 on Days 1 and eight. Another regimen used is one hundred mg/M2 of epirubicin intravenously together with fluorouracil 500 mg/M2 and cyclophosphamide 500 mg/M2. In both routine the total dose of epirubicin could additionally be given on Day 1 of every cycle or equally divided and given on Days 1 and eight of every cycle. Used in combination Non-Hodgkin lymphoma: Single agent: 75 to ninety mg/M2 as soon as every 3 weeks. Used together with cyclophosphamide, prednisone, and with cisplatin, etoposide, mitomycin, and vinblastine. Hodgkin disease: Combination therapy: 35 mg/M2 once each 2 weeks or 70 mg/M2 as quickly as each 3 to four weeks. Locally unresectable or metastatic gastric cancer: Single agent: seventy five to one hundred mg/M2 as soon as every 3 weeks. EllEncE: Consider reducing starting dose to 75 to 90 mg/M2 in closely pretreated patients, these with pre-existing bone marrow suppression, or within the presence of neoplastic bone marrow infiltration. Use of the 100-mL vial should be restricted to a pharmacy admixture program utilizing a sterile transfer or dispensing system. FiltErS: Manufacturer signifies that studies show some preliminary potency loss in the first jiffy with using cellulose ester membrane or nylon filters; however, the whole amount of drug loss is negligible. Storage: Ellence: Refrigerate vials at 2� to 8� C (34� to 46� F); shield from light. Use any stuffed syringe inside 24 hours if saved at room temperature and inside forty eight hours if refrigerated. Syringes prepared from the pharmacy bulk vial have to be used within 24 or 48 hours of the preliminary puncture of that vial primarily based on technique of storage. Once the switch set has been inserted in the bulk vial, any remaining undispensed drug have to be discarded in 8 hours.

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Calcitriol could additionally be drawn up right into a syringe as much as eight hours before administration however should be shielded from direct daylight. A vitamin D�resistant state could exist in uremic patients due to the failure of the kidney to adequately convert precursors to the lively compound, calcitriol. Because calcitriol is probably the most potent type of vitamin D obtainable, oral vitamin D dietary supplements must be discontinued throughout remedy. Therefore gradual titration downward to a model new upkeep dose is recommended; see Dose Adjustments. Chronic hypercalcemia can result in generalized vascular calcification, nephrocalcinosis, and different soft-tissue calcification. Radiographic evaluation of suspect anatomic areas may be helpful in early detection of this condition; see Side Effects and Antidote. A determination must be made whether to discontinue nursing or to discontinue the drug. Consider age-related organ impairment, concomitant illness, and/or drug remedy; see Dose Adjustments. High consumption of calcium and phosphate concomitant with calcitriol remedy may result in related abnormalities. Signs and symptoms of vitamin D intoxication related to hypercalcemia include Early: bone pain, constipation, dry mouth, headache, metallic style, muscle ache, nausea, somnolence, vomiting, and weakness. Rare instances of hypersensitivity reactions, including anaphylaxis, have been reported. Treatment of sufferers with clinically significant hypercalcemia (more than 1 mg/dL above the upper limit of normal range) consists of supportive measures, quick dose reduction or interruption of remedy, initiation of a low-calcium food plan, withdrawal of calcium dietary supplements, affected person mobilization, attention to fluid and electrolyte imbalances, evaluation of electrocardiographic abnormalities (critical in sufferers receiving digoxin), and hemodialysis or peritoneal dialysis against a calcium-free dialysate, as warranted. Hypocalcemic problems (prophylaxis, treatment, electrolyte alternative, maintenance): 5 to 10 mL (500 mg to 1 Gm) at intervals of 1 to 3 days. Repeat doses may be required and are based on affected person response or serum calcium levels. Consider need for calcium (usually gluconate or gluceptate) for every 500 mL of complete blood if arrest occurs in a state of affairs requiring copious blood replacement. Sources counsel repeat doses each 4 to 6 hours based mostly on patient response or serum calcium levels. May be additional diluted with most typical infusion solutions and given as an intermittent or continuous infusion. Calcium salts not generally mixed with carbonates, phosphates, sulfates, or tartrates. Extreme caution and a specific multistep course of are required when calcium and phosphates are combined in parenteral diet options. It impacts bones, nerves, muscular tissues, glands, cardiac and vascular tone, and regular coagulation of the blood. Calcium preparations apart from calcium chloride are often most well-liked besides in cardiac resuscitation or calcium channel blocker toxicity. Unlabeled uses: Treatment of arrhythmias and/or hypotension brought on by an overdose of calcium channel blockers. May cause bradycardia; cardiac arrest; warmth waves; metallic, calcium, or chalky taste; prolonged state of cardiac contraction; sense of oppression; or tingling sensation, particularly with a too-rapid rate of administration. Overdose: Coma, intractable nausea and vomiting, lethargy, markedly elevated plasma calcium degree, weakness, and sudden death. Sodium chloride competes with calcium for reabsorption within the renal tubules; furosemide enhances the exercise. Disodium edetate may be used with excessive warning as a calcium chelating agent if overdose is important. For extravasation inject affected space with 1% procaine hydrochloride and hyaluronidase to reduce venospasm and dilute calcium. Calcium channel blocker overdose (unlabeled): 60 mg/kg/dose over 5 to 10 minutes (not to exceed three,000 to 6,000 mg/dose); may repeat each 10 to 20 minutes for 3 to 4 extra doses. Beta-blocker overdose (unlabeled): 60 mg/kg over 5 to 10 minutes followed by an infusion at 60 to 150 mg/kg/hr. If a precipitate is current, dissolve by warming the vial to 60� to 80� C (140� to 176� F) with occasional agitation until the answer becomes clear. Concurrent use can lead to formation of Extreme caution and a specific multistep course of are required when calcium and phosphates are combined in parenteral nutrition solutions.

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As such, it prevents injury to the duodenal mucosa by acid and pepsin and brings the pH of the contents into the optimum range for activity of the pancreatic enzymes. The enzymatic or protein part is a low-volume secretion containing enzymes for the digestion of all regular constituents of a meal. Unlike the enzymes secreted by the stomach and salivary glands, the pancreatic enzymes are essential to normal digestion and absorption. Each acinus is shaped from several pyramidal acinar cells oriented with their apices towards the lumen. The lumen of the spherical acinus is drained by a ductule whose epithelium extends into the acinus within the form of centroacinar cells. Ductules join to kind intralobular ducts, which in flip drain into interlobular ducts. Distributed all through the pancreatic parenchyma are the islets of Langerhans or the endocrine pancreas. In addition, the pancreas produces the candidate hormone pancreatic polypeptide and incorporates massive amounts of somatostatin, which may act as a paracrine to inhibit the release of insulin and glucagon. The efferent nerve provide to the pancreas includes each sympathetic and parasympathetic nerves. Sympathetic postganglionic fibers emanate from the celiac and superior mesenteric plexuses and accompany the arteries to the organ. Parasympathetic preganglionic fibers are distributed by branches of the vagi coursing down the antral-duodenal region. Hence surgical vagotomy for peptic ulcer disease impacts not only the supposed goal organ, the hypersecreting abdomen, but also the pancreas. More lately, more selective operations have been designed to resect solely the vagal branches passing to the stomach. Vagal fibers terminate both at acini and islets or on the intrinsic cholinergic nerves of the pancreas. In basic, the sympathetic nerves inhibit, and the parasympathetic nerves stimulate, pancreatic exocrine secretion. At all rates of secretion, pancreatic juice is actually isotonic with extracellular fluid. Potassium ions (K+) are present at all rates of secretion at a concentration equal to their focus in plasma. The concentrations of Na+ in pancreatic juice and in plasma also are approximately equal. Na+ moves paracellularly down the established electrochemical gradient from the plasma to the lumen of the gland. Pancreatic Secretion 81 Most water strikes through aquaporin 1 channels in each the basolateral and apical membranes. Thus the venous blood from an actively secreting pancreas has a decrease pH than that from an inactive gland. Because these relationships are analogous, it could be surmised that analogous theories have been proposed to explain them: � the two-component hypothesis assumes that one cell kind, the acinar cell, secretes a small amount of fluid whose major ions are Na+ and Cl-. At low rates of secretion, the Cl- focus of the juice is due to this fact comparatively excessive. Possibly on account of pinching off the transitional elements containing them, the enzymes turn out to be related to the Golgi vesicles (step 3), which transport them to condensing vacuoles (step 4). Energy is required for transport by way of the endoplasmic reticulum and Golgi vesicles to the condensing vacuoles. Within the condensing vacuoles, the enzymes are concentrated to form zymogen granules (step 5). They are then stored in the zymogen granules that gather on the apex of the cell. After a secretory stimulus, the membrane of the zymogen granule fuses with the cell membrane, thus finally rupturing and expelling the enzymes into the lumen (step 6). Both processes in all probability are concerned in figuring out the final composition of the secreted juice.