Valerie L. Katz, MD, FACS
- Assistant Professor of Clinical Surgery
- Weill Medical College of Cornell University
- Section Chief, Department of General Surgery
- Lincoln Medical and Mental Health Center
- Bronx, New York
Therapeutic Uses: Fever allergy testing colorado springs beconase aq 200mdi amex, Cachexia allergy medicine nightmares purchase beconase aq now, Seasickness allergy symptoms medications 200mdi beconase aq fast delivery, Sore throat allergy treatment products generic 200mdi beconase aq visa, Hoarseness allergy medication for dogs order beconase aq, Warts allergy forecast spring tx 200mdi beconase aq mastercard, Boils, Toothache, Cardiac debility, Haemoptysis, Haemorrhages, Anaemia, Strangury, Dyspepsia, Jaundice, Flatulence, Colic, Dysentery, Diarrhoea, Cough, Bronchitis, Asthma, 125-127,130 Opthalmopathy, Epilepsy, Leprosy, Cancer. Chemical constituents: A) Organic Steroid/ Triterpenes, Flavonoids,Carbohydrates, Reducing sugars,Protein/ Amino acids, Fatty acids and oils, Malic, Tartaric and Oxalic acids, Tannins, gum. B) Inorganic 48,142,151 Sodium, Potassium, Calcium, Iron, Copper, Chloride, Phosphate. The antioxidant activities were thus comparable to those previously found for wines. The acute and subacute antidiabetic activities of the ethanolic extract of Vitis vinifera leaves were investigated. The acute effect was studied on the normoglycaemic, glucose hyperglycaemic and streptozotocin-induced diabetic rats; and the subacute effect was studied on same diabetic rats for 15 days. The blood glucose levels were measured by using blood glucose measuring strips based on glucose-oxidase method. Mainly condensed tannins and flavonoids were suggested to contribute in the 194 activities. These findings suggest that grape seed extract supplements in high fat diet might normalize body weight, epididymal and back fat weights, lipid concentrations, and carnitine levels through controlling lipid 195 metabolism. The methanol extract of Vitis vinifera seed was studied against the Indian Dodoia/ vipera russelli venom induced local effects. The extract abolished the proteolytic and hyalunidase activities and also efficiently neutralized the hemorrhage, edema inducing and myonecrotic properties of the venom. Reports have shown the antioxidant, hypotensive, hypolipidemic and vasodilatory effects of Vitis vinifera seed extract. A study has recently shown the relaxatory effect of grape leaf extract on rat uterus and reduction of frog heart rate and 197 contractility. Before starting clinical trial, the research protocol was submitted to Ethical committee of National Institute of Unani Medicine and ethical clearance was obtained from the committee. After ethical clearance, the study was started by enrolling eligible patients into Test and Standard control groups by random allocation. The patients were selected on the basis of history, physical examination, and investigations. Criteria for Selection of Cases a) Inclusion Criteria Clinically diagnosed patients of Hypothyroidism. During the selection procedure, complete history including general physical and systemic examination was carried out and recorded on a prescribed case report form which was designed with the consultation of the guide. The patients were enquired about their name, age, sex, marital status, address and occupation. All the patients were interrogated about their chief complaints and duration of illness in detail which were noted down in chronological order in the prescribed proforma. Patients were also asked about their habitat, whether belonging to endemic area of goiter or iodine deficient region. Regarding family history, patients were asked about the presence of any significant history of thyroid disease in the family. After history, general physical examination was done with special emphasis on pulse (rate, rhythm, character and volume), blood pressure, temperature, respiratory rate, respiratory distress with simple activities, build, skin, hair, tongue, eyes, clubbing of fingers, cyanosis, pallor, anaemia, oedema and lymphadenopathy etc. Likewise, a careful systemic and local examination was also done to look for any findings and involvement of any other serious illness. Examination of the Breasts and Genitalia the breasts was examined for mass lesions and, if suggested by the history, for galactorrhoea. This may range from minor degrees of subareolar glandular enlargement to substantial breast prominence to exclude true gynaecomastia. Examination of Nervous System Patients were examined for fine tremors, proximal weakness with or without wasting of the shoulder and hip girdle musculature (proximal myopathy) to exclude thyrotoxicosis, glucocorticoid excess and vitamin D deficiency. These diagnosed patients if fulfilled all the terms of inclusion criteria, were selected for the study and allocated into Control and Test groups by randomization. Written informed consent was sought from every patient before inclusion in the study. Investigations Following investigations were carried out to exclude the patients other than Qillate Ifraze Darqia, to assess the efficacy of various treatment groups and to establish the safety of the test drug. Informed consent Patients, fulfilling the inclusion criteria as mentioned above, were given the information sheet having details regarding the nature of the study, the drug to be used, method of treatment etc. Patients were given enough time to go through the contents of informed consent sheet. They were given the opportunity to ask any question, and if agreed, they were asked to sign the informed consent form. Study design the study was designed as a randomized, single blind with standard controlled clinical study. Allocation of subjects into groups the 30 patients were randomly allocated by using lottery method into two groups comprising 20 patients in test (Group A) and 10 patients in control (Group B) groups. Assessment of Mizaj Determination of Mizaj was done on the basis of assessment of different parameters mentioned in literature. Duration of protocol therapy the treatment period in both Test and Control groups was 60 days. Follow up during treatment Sixty days study was divided into two visits of follow up which were made at an interval of 30 days. At every visit, the patients were asked about the improvement or worsening in their symptoms and subjected to examination to assess clinical findings. The patients, who were taking any other medicine as a treatment of hypothyroidism, were advised to observe abstinence for two week from consuming any other drug before commencing treatment with the test or control drug. Method of preparation, dosage and mode of administration of test drug All the drugs were provided by the pharmacy of National Institute of Unani Medicine, Bangalore. Before preparing the formulation, all the ingredients were properly identified by an expert to ascertain their originality. Equal quantity of above mentioned drugs were grinded to form powder and mixed with half weight of sugar than Maviz munaqqa (Vitis vinifera) is taken grinded and mixed with Sufoof to form a tablet. Each patient in test group was given test drug in the dose of 3gm twice a day in the form of tablet (4 tablets twice a day each tablet weighing 750 mg of test drug) 14. Efficacy assessment the assessment of the efficacy in the test and control groups was based on Subjective and Objective parameters. Subjective parameters included Lethargy, Weight gain, Cold intolerance, Hoarseness of voice, Dry and coarse skin, Puffiness of the face, Goitre. As these subjective parameters differ in 102 Methodology severity from patient to patient, therefore an arbitrary grading of subjective parameters was improvised for appropriate assessment and statistical evaluation of various signs and symptoms to evaluate the efficacy of the Test drugs. Before starting treatment, each sign and symptom was recorded in the case report form according to their grades (all the subjective parameters were graded on the basis of severity of symptoms by using 4-point scale, where 0 corresponded to no symptoms, 1 to mild symptoms, 2 to moderate symptoms and 3 to severe symptoms) at the maiden visit and any worsening or improvement in any of the parameters was noted down at every visit of follow up till the end of the treatment. After 60 days of the treatment, the pre and post treatment values of different parameters (subjective and objective) were analyzed and subjected to comparison and statistical analysis to evaluate the efficacy of the treatment. Subjective parameters For subjective parameters each grade was given according to following scoring pattern. Withdrawal criteria a) Failure to follow the protocol b) Any adverse reaction or adverse event c) Drug defaulters 17. Family history of thyroid diseases was present in 30% patients and absent in 70 % patients. In total 30 patients, Upper; Upper Middle, Lower Middle, Upper Lower and Lower were 0%, 17%, 40%, 43% and 0%. Out of 30 patients 20% were Vegetarian and 80% were found to be of mixed dietary habit. In total 30 patients, 83% patients were observed in Balghami Mizaj, 17% patients in Damavi Mizaj and 0% in Safrai Mizaj and Saudavi Mizaj. It most frequently reflects a disease of the gland itself (primary hypothyroidism) but can also be caused by pituitary disease (secondary hypothyroidism) or hypothalamic disease (tertiary 7-9 hypothyroidism). Hypothyroidism is a common disorder arising more often in women than men and increasing in incidence with age, especially after the onset of middle life. Signs and symptoms includes confusion, memory loss, lethargy, slow speech, cerebellar ataxia, decreased libido and sexual function, anaemia, decreased heart rate, cold skin, cold intolerance, dyspnoea, and reduced renal blood flow. Patients may also exhibit weight gain, constipation, fluid retention, elevated blood lipids, slow movements, dry and flaky skin, brittle hair, 7-10,62,65 myxedema, aching and stiffness in muscles and joints. The present clinical study was conducted to evaluate the efficacy of a test formulation in the management of Qillate Ifraze Darqia Ibtidai. During screening 14 patients did not fulfill inclusion criteria and excluded from the study, remaining 46 patients were randomly allocated to test (Group A) and control (Group B) groups respectively. But 9 patients from test group and 7 patients from control group did not complete the full course of treatment leaving behind 20 patients in test and 10 patients in control group who completed the 130 Discussion course of treatment completely. Group A was given test drug in the dose of 3gm twice a day in the form of tablet (4 tablets twice a day each tablet weighing 750 mg of test drug) containing Filfil siyah (Piper nigrum), Filfil safaid (Piper nigrum), Peepal (Ficus religiosa), Darchini (Cinnamomum zeylanicum), Salikha (Cinnamomum cassia), Khulanjan (Alpinia galanga), Naushadar (Ammonium chloride),Tukhme khayar (Cucumis sativus), Podina dashti (Mentha longofolia) and Maviz munaqqa (Vitis vinifera). The demographic data and findings are being discussed in the following paragraphs. As far as relation of the age with the disease is concerned, it is evident from the table No. The disease has a definite relation with sex because in this clinical trial, the highest incidence of 27 (90%) was observed in female patients while 3 (10%) in male patients in both test and control groups (Table No. These data are in agreement with the findings reported by 1,12,16,72 Ashraf Aminorroaya, et al and Madhuri Devdhar, et al. No convincing data is available to demonstrate the existence of this disease among different religious communities in the society. As far as the Marital Status of hypothyroidism patients is concerned, out of 30 patients, 29 (97%) patients were married and 1 (3%) patient was unmarried (Table th th No. As this disease usually occurs in the 4 and 5 decade, Therefore, the majority 12,16,71 of the patients was married. As far as the family history of hypothyroidism is concerned, in the study, family history of hypothyroidism was positive in 9 (30%) patients where as it was negative in 21 (70%) patients. No convincing data is available to demonstrate the existence of this disease among different Socioeconomic Status in the society. A maximum of 25 (83%) patients were found having Balghami Mizaj followed by 5 (17%) patients having the Damvi, 0 (0%) patients having Safravi and Saudavi Mizaj (Table No. It indicates that Qillate Ifraze Darqia (hypothyroidism) is more prevalent in Balghami Mizaj patients. Since the clinical manifestations and complications of this disease closely resemble with the Alamaat wa Awarizat of Sue Mizaj Barid Balghami. The result of present study is inconsonance with the 132 Discussion 2,24,25,27description of Ibn Sina, Abu Bakr Zakaria Razi, Rabban Tabri, Akber Arzani. This indicates that the disease is chronic and resilient in nature and 7-10,62,65 progresses slowly. To assess the effects of Test and Control drugs on subjective and objective parameters the patients were assessed for various signs and symptoms (Lethargy, Weight gain, Cold intolerance, Hoarseness of voice, Dry and coarse skin, Puffiness of the face, Goitre). The severity was rated as severe, moderate, mild and absent and graded as 3, 2, I and 0, respectively, based on arbitrary grading system. The median score of lethargy in group A (Test group) was 3 (2,3) on 0 day, 2 (0,3) on th th 30 and 1 (0,3) on 60 day; whereas in group B (Cotrol group) the median score was th th 3 (2,3) on 0 day, 2 (1,3) on 30 day and 1(0,2) on 60 day. The improvement in lethargy may be due to the Muqawwie aam, Muharrik and Muqawwie asab effect of Filfil siyah (Piper nigrum), Darchini (Cinnamomum zeylanicum), Salikha (Cinnamomum cassia), Khulanjan (Alpinia galanga), ingredients of the test 43-49,121,122,158 formulation. This improvement might be due to Mudir, Muhallil, Mushile balgham, Dafae fasade balgham, and Muarriq properties of most of the ingredients of test drug i. Filfil siyah (Piper nigrum), Peepal (Ficus religiosa), Darchini (Cinnamomum zeylanicum), Salikha (Cinnamomum cassia), Khulanjan (Alpinia galanga), Naushadar (Ammonium chloride), these results are in accordance with the properties of the drugs suggested by Ibn Baitar, Ibn Hubal Baghdadi, Ibn Rushd, Najmul Ghani, 43-49,55,121,122,158 Kabeeruddin, etc. In the assessment of cold intolerance, the median score in test group was 2 (1,3) on th th baseline, 2(1,3) on 30 day and 1 (0,1) on 60 day; whereas in control group, the th th median score was 3 (2,3) on 0 day, 2 (1,3) on 30 day and 1 (0,1) on 60 day. The effect may be because of most ingredients of test formulation have Haar Mizaj and possess Musakhkhin properties like Filfil siyah (Piper nigrum), Filfil safaid (Piper nigrum), Peepal (Ficus religiosa), Darchini (Cinnamomum zeylanicum), Salikha (Cinnamomum cassia), Khulanjan (Alpinia galanga), Naushadar (Ammonium chloride), etc. These results are in accordance with the properties of the drugs suggested by Ibn Baitar, Ibn Hubal Baghdadi, Ibn Rushd, 43-49,121,122,158 Najmul Ghani, Kabeeruddin, etc. The median score of Hoarseness of voice in group A (Test group) was 0 (0,3) on 0 th th day, 0 (0,2) on 30 day and 0 (0,2) on 60 day; whereas in group B (Cotrol group) the th th median score was 0(0,3) on 0 day,0 (0,3) on 30 day and 0 (0,2) on 60 day. The puffiness of face was noted mainly in chronic patients of hypothyroidism in almost all groups of patients.
The great majority of cases of hypertension are classified as essential hypertension allergy forecast topeka ks order 200mdi beconase aq fast delivery. Essential hypertension results from the interactions of predisposing determinants and exogenous factors allergy testing kildare buy beconase aq 200mdi lowest price, including family history allergy testing tulsa 200mdi beconase aq for sale, ethnicity allergy testing on a two year old purchase cheap beconase aq line, stress allergy gainesville band purchase line beconase aq, obesity allergy to zpack symptoms beconase aq 200mdi, sodium intake, smoking, and physical activity. Unilateral renal artery stenosis is a secondary cause that is typically correctable by surgery. Causes include partial or complete interruption of arterial blood flow to the myocardium. Frequency is increased in patients who manifest the metabolic syndrome, a group of risk factors including central obesity, atherogenic lipid patterns, hypertension, insulin resistance (sometimes overt diabetes), and evidence of a proinflammatory state, such as elevated C-reactive protein. Obesity and physical inactivity, and probably genetic factors, predispose to the metabolic syndrome. It is pain that is precipitated by exertion and is relieved by rest or by vasodilators, such as nitroglycerin. It results from severe narrowing of atherosclerotic coronary vessels, which are thus unable to supply sufficient oxygenated blood to support the increased myocardial demands of exertion. It is generally caused by disruption of an atherosclerotic plaque with superimposed thrombosis. Myocardial coagulative necrosis caused by coronary artery occlusion is characteristic. Myocardial infarction is marked by a series of progressive changes involving the gross and microscopic appearances of the heart (Table 10-1). The cells involved in the evolution of a myocardial infarct include neutrophils, macrophages, and fibroblasts. Myoglobin is the most sensitive of the cardiac markers and is the earliest to appear after myocardial infarction; however, it is not very cardiospecific. The likelihood and severity are determined by the size and location of the lesion. Rheumatic fever is a multisystem inflammatory disorder with major cardiac manifestations and sequelae, most often affecting children between 5 and 15 years of age. It usually occurs 1 to 4 weeks after an episode of pharyngitis caused by group a hemolytic streptococci. Group A streptococcal infections of other parts of the body rarely lead to rheumatic fever. Rheumatic fever is apparently of immunologic origin rather than a result of direct bacterial involvement; however, the precise nature of the immune mechanisms of injury remains unclear. This is an area of focal interstitial myocardial inflammation that is characterized by fragmented collagen and fibrinoid material, by large cells (Anitschkow myocytes), and by occasional multinucleated giant cells (Aschoff cells) (Figure 10-1). Other anatomic changes Characteristics include pancarditis, inflammation of the pericardium, myocardium, and endocardium. The mitral and aortic valves, which are subjected to much greater pressure and turbulence, are more likely to be affected than are the tricuspid and pulmonary valves. In the early stage, the valve leaflets are red and swollen, and tiny, warty, bead-like, rubbery vegetations (verrucae) form along the lines of closure of the valve leaflet. As a consequence of fibrotic healing, the valves become thickened, fibrotic, and deformed, often with fusion of valve cusps, as well as thickening of the chordae tendineae. The myocardial interstitium shows collagen degeneration, lymphocytic infiltration, and a multinucleated Aschoff giant cell. Complications may include ulceration, often with perforation, of the valve cusps or rupture of one of the chordae tendineae. This type of endocarditis tends to occur in patients with congenital heart disease or preexisting valvular heart disease, often of rheumatic origin. Characteristics include small, sterile fibrin deposits randomly arranged along the line of closure of the valve leaflets. The small vegetations in this condition can embolize in a manner similar to that in bacterial endocarditis, but these emboli are sterile. The cause is secretory products of carcinoid tumors (vasoactive peptides and amines, especially serotonin [5-hydroxytryptamine]). The valves on the left side of the heart are rarely involved, because serotonin and other carcinoid secretory products are detoxified in the lung. This form of endocarditis results in thickened endocardial plaques characteristically involving the mural endocardium or the valvular cusps of the right side of the heart. In addition, valvular heart disease can occur even with prosthetic cardiac valves, which are subject to physical deterioration or can be the site of thrombus formation or infectious endocarditis. They can also cause mechanical disruption of red blood cells, resulting in hemolytic anemia with schistocyte formation. Prolapse is the most frequent valvular lesion and is common in young women (Figure 10-3). The lesion is usually benign and asymptomatic but can result in mitral insufficiency. It is often associated with a variety of arrhythmias and predisposes to infective endocarditis. This valve, along with the mitral valve, is frequently involved in rheumatic heart disease and in infective endocarditis. This condition, called degenerative calcific aortic stenosis, is the most common cause of calcific aortic stenosis in persons older than 60 years of age. These patients present with calcific stenosis one to two decades before patients with anatomically normal valves. Infectious endocarditis with arterial embolization is a possible consequence of this very common lesion. This valve is rarely involved alone in rheumatic heart disease but may be involved together with the mitral and aortic valves. This trivalvular involvement accounts for approximately 5% of cases of rheumatic heart disease. This valve is most commonly affected by congenital malformations, occurring either alone or along with other congenital defects, such as in the tetralogy of Fallot. Endocardial cushion defects, which result in atrial and ventricular septal defects and atrioventricular valve deformities, are frequently associated with Down syndrome (trisomy 21). There is an apparent increase in the incidence of patent ductus arteriosus in patients living at high altitudes, suggesting an association with fetal oxygen deprivation. There is strong evidence of a link between maternal rubella during the first trimester of pregnancy and a constellation of fetal defects, known as the congenital rubella syndrome, which includes cardiovascular defects, microcephaly with mental retardation, deafness, cataracts, and growth retardation. Demonstration of antirubella antibodies of the Igm class indicates recent primary infection, whereas demonstration of IgG antibodies indicates either recent primary infection, past infection, or reinfection. Tetralogy of Fallot can cluster in families, probably because of multifactorial inheritance. In atrial septal defects, both pressure and oxygen saturation may be equalized between the two atria. This term refers to diseases of the heart muscle that are noninflammatory and are not associated with hypertension, congenital heart disease, valvular disease, or coronary artery disease. Usually, these diseases are characterized by otherwise unexplained ventricular dysfunction (heart failure unresponsive to digitalis, ventricular enlargement, ventricular arrhythmias). In some cases, dilated cardiomyopathy is related to alcoholism (alcohol cardiomyopathy), thiamine deficiency (beriberi heart), or prior myocarditis. Some forms are associated with mutant cytoskeletal proteins, such as dystrophin or desmin; mutations of sarcomeric proteins, such as cardiac myosin heavy chain; and other muscle proteins, such as actin. Thus far, several genes have been implicated in the genesis of this disorder: genes coding for myosin heavy chain (most common mutation, thus far), cardiac troponins T and I, tropomyosin, myosin-binding protein C, and myosin light chain (Figure 10-4). This myocardial disease most often presents as biventricular heart failure in young persons who do not have valvular, rheumatic, or congenital heart disease. Morphologic characteristics include diffuse myocardial degeneration and necrosis with an inflammatory infiltrate. The interventricular septum is markedly thickened and may cause obstruction of the left ventricular outflow tract. The microscopic view shows the characteristic disoriented, tangled, and hypertrophied myocardial fibers. In parts of South America, myocarditis may be a component of Chagas disease, which is caused by the protozoan Trypanosoma cruzi. It is characterized by production of a clear, straw-colored, protein-rich exudate containing small numbers of inflammatory cells. Purulent or suppurative pericarditis is characterized by a grossly cloudy or frankly purulent inflammatory exudate. It usually results from tumor invasion of the pericardium, but can also result from tuberculosis or other bacterial infection. Characteristics include thickening and scarring of the pericardium with resultant loss of elasticity. This prevents the pericardium from stretching and thus interferes with cardiac action and venous return, often mimicking the signs and symptoms of right-sided heart failure. Congestive heart failure may be failure of the left ventricle, right ventricle, or both. Dyspnea and orthopnea caused by pulmonary congestion and edema regularly occurs (Figure 10-5). Pulmonary vascular congestion and proteinaceous pink staining intra-alveolar fluid can be seen in this manifestation of left-sided heart failure. Edema occurs first in dependent areas and often manifests early as so-called pitting edema of the ankles. Other manifestations of fluid retention include pleural effusion and sometimes ascites. Hydrothorax can be a manifestation of either left-sided or right-sided heart failure. Marked right ventricular hypertrophy secondary to disease of the lung or of the pulmonary vascular system defines this entity. Cor pulmonale is defined as right ventricular hypertrophy and/or dilation secondary to lung disease or primary disease of the pulmonary vasculature, such as primary pulmonary hypertension. Characteristics include pulmonary arterial hypertension, the common characteristic among the entities that lead to cor pulmonale. She states that lowing a myocardial infarct is noteworthy for the chest pain predictably occurs when the special danger of which of the followingfi She is particu(c) Myocardial (pump) failure larly concerned because her mother died of (D) Myocardial rupture a myocardial infarction at 50 years of age. A 10-year-old boy presents with migra(a) Arrhythmia tory polyarthritis involving several large (B) Myocardial infarction joints, fever, and malaise. Physical exami(c) Prinzmetal angina nation reveals a new heart murmur and (D) Stable angina pectoris friction rub on auscultation, and a painless (e) Unstable angina pectoris nodule is detected on the extensor surface of the elbow. Yesterday, a 60-year-old man presented approximately 2 weeks ago, apparently to the emergency department with dyspnea, recovering without antibiotic therapy. Which of the following describes the most When asked to describe the pain, he put likely outcome for this patientfi If the patient unexpectedly dies toms and findings over the next few today, which of the following would almost decades certainly be found on histologic examination (D) Persistence of the current symptoms of the affected myocardiumfi A 9-year-old girl is diagnosed with acute (D) Slight swelling of tissue and change of rheumatic fever. Instead of recovering as color expected, her condition worsens, and she (e) Young fibroblasts and new vessels dies. Which of the following is the most growing into the infarcted tissue likely cause of deathfi A 60-year-old-man is discharged after (B) Endocarditis being observed in the hospital for 4 days fol(c) Myocarditis lowing a myocardial infarction. He returns (D) Pericarditis to his normal activities, which include (e) Streptococcal sepsis 150 chapter 10 the Heart 151 6. At death, the body is emaciated and that he had repeated sexually transmitted cachectic, and gross dissection reveals small diseases in the past, including a painless fibrin deposits arranged around the line of chancre (a hard, round sore) on his penis, closure of the leaflets of the mitral valve. The for which he never sought medical attenvalvular lesions most likely represent tion. The history of untreated syphilis suggests that these tests will most likely detect which of the following abnormalitiesfi The myocardial lesions shown in the figure were observed at the autopsy exami(a) Aortic valvular insufficiency and linear nation of a pediatric patient who died after calcification along the ascending aorta a short illness. During life, which of the (B) Bicuspid aortic valve with aortic following manifestations of his illness was stenosis most likelyfi He has felt well lately and has no past medical history of coronary artery disease, hyperlipidemia, or hypertension, and no family history of myocardial infarction or stroke. Physical examination reveals motor weakness in the left leg, with no other neurologic deficits, and no cardiac murmur. Magnetic resonance imaging of the brain demonstrates a small ischemic infarct in the arterial distribution of the brain correlating with motor control of the left leg. Angiography and echocardiography reveal normal coronary arteries, normal valves with no vegetations, and a small right-to-left shunt. Baltimore, Lippincott Williams & (c) Nonbacterial thrombotic (marantic) Wilkins, 2012, figure 11-29, p.
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Definition: an autoimmune disease characterized by destruction of the lacrimal and salivary glands resulting in the inability to produce saliva and tears b allergy testing greenville sc cheap beconase aq generic. Definition: autoimmune disease characterized by fibroblast stimulation and deposition of collagen in the skin andinternal organs b allergy symptoms 6 year molars trusted 200mdi beconase aq. Definition: inherited immunodeficiency characterized by a developmental failure to produce mature B cells and plasma cells allergy treatment knoxville tn buy discount beconase aq on line, resulting in agammablobulinemia Gamma b allergy nose bleed 200mdi beconase aq sale. Definition: group of disorders characterized by a B-cell maturation defect and Note hypogammaglobulinemia Adenosine ~ inosine b allergy treatment pdf discount beconase aq 200mdi with amex. Definition: embryologic failure to develop the 3rd and 4th pharyngeal pouches allergy medicine alternatives order beconase aq pills in toronto, lymphocytes resulting in the absence of the parathyroid glands and thymus b. Definition: combined deficiency of cell-mediated and humoral immunity often caused by a stem-cell defect b. Patients are immunocompromised due to the immunosuppressive drugs required to prevent rejection of the transplanted organ b. Micro: intimal fibrosis of vessels and interstitial lymphocytes patients is accelerated graft iv. Sexual contact Homosexuals Increasing rate of heterosexual transmission Cofactors: herpes and syphilis 11. Examples of type I hypersensitivity reactions include systemic anaphylaxis following bee stings and drugs. Localized forms of anaphylactic reaction include food allergies, atopy, and asthma. Examples include the complement-dependent cytotoxicity of autoimmune hemolytic anemia, the antibody-dependent cell-mediated cytotoxicity of pernicious anemia, and the antireceptor antibodies of Graves disease. Examples include serum sickness, systemic lupus erythematosus, and glomerulonephritis. I Systemic lupus erythematosus is a chronic systemic autoimmune disease characterized by a loss of self-tolerance and production of autoantibodies. I, Sjogren syndrome (sicca syndrome) is an autoimmune disease characterized by destruction of the i lacrimal and salivary glands resulting in the inability to produce saliva and tears. Scleroderma (progressive systemic sclerosis) is an autoimmune disease characterized by fibroblast I stimulation and deposition of collagen in the skin and internal organs. I Common variable immunodeficiency is a group of disorders characterized by a B-cell maturation defect and hypogammaglobulinemia expressed as increased susceptibility to bacterial infections, I Giardia lamblia, autoimmune diseases,lymphoma, and gastric cancer. I DiGeorge syndrome is an embryologic failure to develop the third and fourth pharyngeal pouches, resulting in the absence of the parathyroid glands and thymus, leading to hypocalcemia with tetany, I T-cell deficiency, and recurrent infections with viral and fungal organisms. Affected infants are susceptible to recurrent infections by bacteria,fungi, viruses,and protozoa. Wiskott-Aldrich syndrome is an X-linked condition characterized by recurrent infections, severe thrombocytopenia, and eczema. Rejection following renal transplantation can occur in three patterns: hyperacute rejection due to ,I preformed antibodies that trigger vascular thrombosis, acute rejection characterized by neutrophilic vasculitis, and chronic rejection characterized by intimal fibrosis of vessels. A 32-year-old woman comes to the physician because of a difficulty swallowing and shortness of breath on exertion. She says that these symptoms started about 6 months ago and have been getting progressively worse. Physical examination shows symmetric skin thickening of the proximal and distal extremities, face, and trunk. A 32-year-old woman comes to the physician because of palpitations and weight loss despite an increased appetite. She says that friends have recently begun to tell her that he eyes look like they are "popping out. Physical examination shows a stare with lid lag, an asymmetrically enlarged, lobular thyroid gland, and plaquelike, thickened lesions on the anterior aspect of her legs. Laboratory studies show an elevated level of thyroxine and an undetectable level of thyroid-stimulating hormone. Apple green birefringence of the amyloid is seen on the Congo red stain under polarized light C. Amyloid is composed of a fibrillaryprotein, amyloid P component, and glycosaminoglycans. The specific composition of the protein varies with each disease producing amyloidosis. Hemodialysis-associated amyloidosis is associated with amyloid protein A~2M and fibrillaryprotein ~2-microglobulin. She says that she used to be able to walk eight blocks without any difficulty, but over the past few months she has noticed that she has difficulty breathing after two blocks. Lately she has been "much more tired than usuaL" She has recently started sleeping with two pillows (up from one pillow), and she frequently has to go over to the window to "catch her breath. She is treated for congestive heart failure, and 2 years later has a myocardial infarction and dies. At autopsy, the pathologist suspects amyloidosis and takes a couple of biopsies from her heart. A 69-year-old man is brought to the physician by his wife because of "forgetfulness. Fifteen Leading Causes of Death in the United States, 2001" i Rank Cause of Death Number of Deathst Percentage I of Total Deaths i 1 Heart diseases 700,142 29. Leading Causes of Death in Children Ages 1-14 in the United States, 2001" I Rank Cause of Death Percentage of Total Deaths 1 Accidents 37. Estimated New Cancer Cases by Site and Sex," Year 2004, in the United States t I Males Females I Site Percentage Site Percentage I, Prostate 33 Breast 32 I I Lung and bronchus 13 Lung and bronchus 12 I! Colon and rectum 10 Colon and rectum 11 i Urinary bladder 7 Uterine corpus 6 I Melanoma of skin 5 Non-Hodgkin lymphoma 4 I Non-Hodgkin lymphoma 4 Ovary 3 I I Kidney 3 Melanoma of the skin 4 I Leukemia 3 Thyroid 3 I Oral cavity 3 Urinary bladder 2 fl I:, I Pancreas 2 Pancreas 2 "Excludes basa! Estimated New Cancer Mortality by Site and Sex, Year 2004, in the United States" ri Males Females! Carcinogenesis is a multistep process involving a sequence of initiation (mutation) followed by promotion (proliferation) b. Proliferation of a mutated cell may lead to accumulation of additional mutations Clinically important chemical carcinogens i. Napthylamine: bladder cancer Potential carcinogens are screened by the Ames test 1. Detects any mutagenic effects of potential carcinogens on bacterial cells in culture ii. Cells in mitosis or the G2 phase of the cell cycle are most sensitive to radiation iii. Immunosurvellience normally destroys neoplastic cells via recognition of "nonself" antigens. Development of all human cancers requires the accumulation of multiple genetic changes I. Protooncogenes are normal cellular genes involved with growth and cellular differentiation b. A change in the gene sequence, resulting in a new gene product (oncoprotern) ii. Loss of gene regulation resulting in overexpression of the normal gene product c. Definition: tumor suppressor genes encode proteins that regulate and suppress cell proliferation by inhibiting progression of the cell through the cell cycle b. Rb prevents the cell from entering S-phase until the appropriate growth signals are present c. May be helpful in confirming the tissue of origin of metastatic or poorly differentiated tumors ll. Tumor markers are usually normal cellular components that are increased in neoplasms but may also be elevated in non-neoplastic conditions b. Natural selection: evolution of a more malignant clone over time due to a selective growth advantage c. Genetic instability: malignant cells are more prone to mutate and accumulate additional genetic defects 7. Lymphatic spread is the most common route of spread for epithelial carcinomas ii. In men, the sites with the highest new cancer rates are (in order of decreasing frequency): prostate, lung and bronchus, and colon and rectum. These same sites have the highest mortality rate, although lung and bronchus cancers more commonly cause death than prostate cancer. In women, the sites with the highest new cancer rate are (in order of decreasing frequency): breast, lung and bronchus, and colon and rectum. These same sites have the highest mortality rate, although lung and bronchus cancers more commonly cause death than breast cancer. The incidence of different cancers can vary with geographic site, racial factors, occupational exposures, age, hereditary predisposition, and acquired preneoplastic disorders. Avariety of chemical carcinogens have been identified that can act as initiators or promoters of specific cancers. Cancer growth can involve either activation of growth promoting oncogenes or inactivation of tumor suppressor genes. Activated oncogenes lack regulatory control and are overexpressed, resulting in unregulated cellular proliferation. Tumor suppressor genes encode proteins that regulate and suppress cell proliferation by inhibiting progression of the cell through the cell cycle. Inactivation of these genes leads to uncontrolled cellular proliferation with tumor formation. I Cancerscan also develop if apoptosis (programmed cell death) is prevented by mutations in genes such as bd-2, bax,bad, and bcl-xS. A diagnosis of cancer requires the examination of cells that may be obtained by complete excision or biopsy of the lesion, fine needle aspiration, or cytologic smears. Immunohistochemistry can be helpful in confirming the tissue of origin of metastatic or poorly differentiated tumors. Serum tumor markers are usually normal cellular components that are increased in neoplasms but may also be elevated in non-neoplastic conditions. They can be used for screening, monitoring of treatment efficacy,and detecting recurrence. Many tumors tend to become more malignant over time as a result of natural selection of more malignant clones and genetic instability of malignant cells. Tumors are also less commonly spread by I i:1 I seeding of body cavities and surfaces and via mechanical manipulations such as surgical incisions and J I I needle tra~~. A 32-year-old woman comes to the physician because of vaginal bleeding after sexual intercourse. She has not been to the doctor in "ages" and has never had a pelvic examination or a Pap smear. He first noticed this "growth" about 4 months ago, and it has been getting progressively darker and larger. A biopsy is taken from the center of the lesion and is sent to pathology for microscopic evaluation. Which of the following markers will be most helpful in establishing the diagnosisfi Definition: fibrosing pulmonary diseases caused by inhalation of an aerosol (mineral dusts, particles, vapors, or fumes) in the workplace b. Carbon pigment (anthracotic pigment) accumulates in macrophages along the pleural lymphatics ii. Industrial Toxins Industrial Toxin Occupation Pathology I Soot (polycyclic English chimney sweeps Scrotal cancer I aromatic hydrocarbons) I Vinyl chloride Plastic industry Angiosarcoma of the liver I I Uranium and radon gas Miners Lung cancer ~-Naphthylamine Dye makers and rubber workers Bladder cancer. Sources: auto emissions, home heaters, byproduct of fires, cigarette smoking,0<" b. Sources: lead paint, lead plumbing, lead pots, and leaded gasoline production by inhibiting c. Wrist and foot drop occur in adults due to peripheral motor nerve demyelination. X-ray: long bones have lead lines (increased bone density) at the epiphyseal growth plates j. Mechanism: cyanide blocks cellular respiration by binding to mitochondrial cytochrome oxidase (cytochrome aa) c. Smoke contains over 4,000 components and over 40 known carcinogens Clinical Correlate I. Increased risk of spontaneous abortions and stillbirths u, Intrauterine growth retardation I. Liver -7 fatty change, alcoholic hepatitis, and micronodular cirrhosis Alcohol induces the ii. Caplan syndrome isthe term used for the combination of pneumoconiosis (due to many different agents) and rheumatoid arthritis. Asbestosiscan cause pulmonary fibrosis, bronchogenic carcinoma, and malignant mesotheliomas. Berylliosis can cause either an acute pneumonitis or granulomatous diseasewith fibrosis of the lungs. A variety of organic and inorganic industrial toxins have been associatedwith specific cancers.
For some patients allergy forecast hamilton purchase beconase aq discount, complementation group testing will not be possible due to these sample limitations allergy hives on legs cheap beconase aq line. Furthermore allergy shots gone wrong beconase aq 200mdi visa, complementation group testing can currently classify patients into 8 of the 13 known complementation groups allergy pro cheap beconase aq generic. Groups that currently can be classifed by complementation group testing include (A allergy medicine 013 order beconase aq 200mdi, B allergy forecast orlando purchase beconase aq 200mdi overnight delivery, C, G, E, F, J, and L). Genes not currently identifable by complementation group testing include D1, D2, I, M, and N. Mutation analysis is necessary to classify individuals into one of these fve groups. In approximately 2-3% of the cases, a complementation group will not be identifed and a gene mutation will not be found in any of the known 13 genes (personal correspondence with Arleen Auerbach, PhD, the Rockefeller University). Mutation analysis is used to confrm the initial complementation group result, to perform other genetic tests such as carrier testing, prenatal testing, and preimplantation genetic diagnosis and, in some cases, to direct medical care and/or enroll in specifc research studies. Genetic testing results Genetic testing Genetic testing results can be used for carrier could show may be inconclusive or testing, prenatal testing, unknown family mutations may not be and preimplantation relationships identified. Genetic testing Family members information can be may not want helpful to family to know information members. Genetic testing results may be used for inclusion in certain research projects or clinical trials. Genetic testing can have many benefts, risks, and limitations and is a personal decision. A detailed conversation and informed consent of the patient and/or legal guardian must be completed prior to undertaking mutation analysis. Genotype-Phenotype Correlations In most cases it is not possible to predict the clinical course of this genetically and clinically heterogeneous disease. Lack of genotype-phenotype correlation is evidenced by siblings with the exact same gene mutations with radically different phenotypic manifestations. Cancer Risks for Fanconi Anemia Carriers the current data collected through the International Fanconi Anemia Registry show that most carriers are not at increased risk of cancer, but several specifc genes and particular mutations do confer cancer risks. Due to the increase in these specifc cancers, Chapter 15: Genetic Counseling 283 recommendations for proper screening and surgical options have been created by the National Comprehensive Cancer Network as described below. Discussion should include reproductive plans, menopausal symptoms, and degree of protection for breast and ovarian cancer. Clinical Breast Exam Seek medical advice for any breast mass, pain or change Mammogram Not typically advised in the absence of other risk factors such as gynecomastia 284 Fanconi Anemia: Guidelines for Diagnosis and Management In addition to screening for cancer, ways to attempt to reduce the risks of cancer include chemoprevention and surgery. Chemoprevention for breast cancer is most commonly achieved using the drug tamoxifen. The use of tamoxifen for fve years has been shown to reduce the incidence of breast cancer by 43% in women who have an increased risk. Carriers should be informed of this potential increased risk and be encouraged to discuss this fnding with their health care providers. Reproductive Issues Reproductive counseling is part of the genetic counseling process. There is always a chance that an error leading to misdiagnosis could occur in the testing or embryological process. It can be a very stressful experience physically, emotionally, and fnancially for couples who undergo the procedure. Risk assessment and genetic counseling for hereditary breast and ovarian cancer: Recommendations of the National Society of Genetic Counselors. Fanconi anemia: another disease of unusually high prevalence in the Afrikaans population of South Africa. Molecular and genealogical evidence for a founder effect in Fanconi anemia families of the Afrikaner population of South Africa. The Ashkenazi Jewish Fanconi anemia mutation: incidence among patients and carrier frequency in the at-risk population. A rapid method for retrovirus-mediated identifcation of complementation groups in Fanconi anemia patients. Association of complementation group and mutation type with clinical outcome in Fanconi anemia. Tamoxifen for the prevention of breast cancer: current status of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. Without indisputable confrmation, there is always the hope that their child will not be severely affected. All families worry that they will not be able to learn enough about the disease to make good decisions for their children. Depending on the age of the parents at the time of the diagnosis, the implications for the family are great. Will they have the physical or the emotional energy, the time, the desire or the fnancial resources to have more childrenfi They may need help thinking through their choices and the implications of those choices. They need information that they can understand to make the best choice given the present state of knowledge. As described in the Damocles Syndrome,1 parents are constantly waiting for the next bad thing to happen. Helping families adjust to living each day to the fullest and to focus on activities apart from the illness are crucial components in day-today coping. The moments that are not driven by medical crises are times for families to learn and stay abreast of salient treatment options and to prepare themselves for the future. Being prepared to take appropriate action, feeling informed, and feeling supported, all help family members to move forward with the necessary tasks during these periods. With some of the very diffcult choices that parents will have to make for and with their children, there is no turning back. Therefore, each major decision requires that families and older patients know all they can prior to making the decision, with an opportunity to integrate the information and refect upon and accept the choices they have made. In certain cases, families will be making decisions about experimental procedures and protocols which have been utilized with very few patients. Families experience a vulnerability and a unique anxiety when they know they are traveling on a road that few have traveled before. One parent may need to learn everything there is to learn to plan strategically for the future, whereas the other may choose to stay focused in the moment. Differences in coping styles as they relate to gender and culture should be recognized so each can be supported for his or her strengths, insight, and ability during the course of the illness. On the other hand, some couples have felt that the strain and the magnitude of the issues they face have made them stronger together. Depression and anxiety are two uncomfortable emotions characteristics that may accompany this disease. Many parents feel anxious or depressed from the onset, unsure of what to anticipate. The ability to contain the anxiety or depression, to make decisions, to enjoy life, and to continue to function are skills to be mastered. Talking to other parents, understanding their decision-making processes, and getting support help parents to maintain the balance they need. These support groups offer parents the opportunity to be parents: to be able to compare their child to other children, to seek companionship of another parent in a similar situation, to brainstorm, to share information, and to join the fght against Fanconi anemia and become empowered in the face of the illness. Families may be viewed incorrectly as aggressive when they advocate in the interests of their children. There may be moments when families and individual physicians do not agree on treatment options and alternatives. The involved professionals must work to make the best decisions with, and not for, families. This strategy will Chapter 16: Psychosocial Issues 295 help minimize potential later regrets for families and professional staff. Helping navigate the course of the illness, and thinking through decisions can help those facing such rare illnesses feel much less isolated. Parents describe having a greater appreciation for the things they do with their children, learning how to experience each day to its fullest. This process can be fnancially, emotionally, and physically draining and in some cases, all-consuming. Families can beneft from talking with others who have been in this situation to help mitigate the intense emotions that can occur during this time. If parents create an environment that allows for questions, discussions, and an expression of feelings, children will feel free to ask their parents about their illness and treatment options and become active participants in the disease management. Children often know much more about what is happening than adults might believe. In addition to what they have been told, they pick up information from ambient conversation, have independent interactions with professionals, and surmise things from the emotional climate around them. They will ask questions when they want to know, and will often shy away from questions to which they do not want the answers. Children are good regulators of their own knowledge base, providing cues to the adults around them at all junctures. Children need to be able to confde in their parents and others when they feel limited physically or socially by Fanconi anemia. At each stage of development, children need age-appropriate explanations of their diagnosis and treatment. Information offered regularly to children will enhance their ability to understand their disease and establish trusting relationships. As they get older and medical problems emerge, groundwork set in earlier years will encourage patients to rely on health care providers. Others may have no known problems but, because of illness-related absence, may need extra assistance. School-age children develop increasingly strong relationships with their peers as they begin to differentiate themselves from their families. Each child and family must fnd a balance in social and family relationships, which allows for a blend of independence and dependence, nurturing and differentiation. They may, therefore, come to understand and deal with issues with which adults may not feel comfortable. Thus, they may seem more mature than their chronological ages and often are more sophisticated than their peers in matters of illness and death. They may also appreciate life, and the meaning of life, more than the adults they encounter. For adolescents, challenging the rules is age-appropriate and functional at times for emotional growth. It allows them to assert themselves as individuals and to begin to learn to take responsibility for their actions. Young adults report stopping their medications, sun bathing, drinking alcohol, smoking, etc. Compliance with medication regimens may be of concern and should be given particular attention at this stage, as should the risk-taking behaviors associated with greater chances of malignancy. As children get older, they need to be involved in assenting, consenting, and participating in actual decisions about their medical care. As their children become more active decision-makers, parents may feel some Chapter 16: Psychosocial Issues 299 relief that they are now making decisions with, rather than for, their children. Yet as children approach young adulthood, parents have expressed anxiety about how their children will learn to make complicated, sophisticated decisions for themselves. For some young adults, the decisions will continue to be made in partnership with their parents. This time of growth for the person with Fanconi anemia also becomes a time of growth for parents. Children of all ages need to be allowed to continue to grow, regardless of the status of their medical conditions. Achievements, great or small, cultivate growth and satisfaction for both children and parents.