Paul E. Szmitko, MD
- Chief Medical Resident, Division of General
- Internal Medicine, St. Michael? Hospital
- University of Toronto
- Toronto, Ontario, Canada
The moderate consumption of alcoholic beverages is defned as one to two drinks per day (one drink is 1 can erectile dysfunction cause infertility discount viagra super active american express. Consuming a glass of red wine a day for women and two glasses a day for men may provide a variety of benefts for your heart erectile dysfunction pills viagra viagra super active 50 mg discount. If you have high cholesterol erectile dysfunction treatment penile implants cheap viagra super active 25mg line, you may have plaque buildup in your arteries erectile dysfunction research viagra super active 25 mg line, which can cause them to harden erectile dysfunction red pill buy cheap viagra super active 25mg line. Because it is good for your arteries enlarged prostate erectile dysfunction treatment buy generic viagra super active 50 mg on-line, it also helps to bring oxygen and blood to your skin. Exercise It is important to adopt an exercise program that suits your level of ftness and experience. Jumping head-frst into a difcult exercise routine could result in frustration (and going back to old habits), and pushing the body too hard can be dangerous for anyone, but particularly someone with a heart condition. How you feel will guide how long and hard you should exercise and what activities you should do. Apply the talk test: Choose a level of exertion that allows you to still talk while you exercise. You should be able to talk in short sentences, but will likely not be able to sing. Experts recommend at least two and a half hours of moderate activity (such as brisk walking) a week. You could walk briskly for at least 30 minutes a day or work up to 10,000 steps a day, fve days a week or more. It works practically all of the muscles in the body and builds cardiovascular ftness and endurance. Exercising in water is perfect for people who have a hard time with land-based physical activities, because your weight in water is about one tenth of your weight on land. Even of moderate intensity, swimming can help reduce high blood pressure in some people. It benefts your heart and lungs, has low impact on joints, increases strength, and is refreshing and invigorating. M anaging Stress Although human beings have evolved over thousands of years, instinctual bodily responses to perceived danger have persisted. Either fghting or feeing involves physical activity; therefore the body raises the blood pressure and the heart rate in order to increase the blood supply to the muscles. Any event that is perceived as stressful (or any event that causes anxiety, frustration, anger, hostility, or depression, to name a few) can trigger this response in varying degrees. W hen the perceived danger or other stressful event is over, the elicited response should resolve spontaneously. W hen you are under stress, your brain releases signals to your body through the nerves and hormones. The nerves can either cause the arteries to relax or put more tension on their walls, narrowing them. There is still the same number of cars (the same amount of blood), but there is less space for it to fow through. It takes more energy to get the blood through the arteries, and so your heart has to work harder with each beat. W hen your heart has to work harder in conjunction with a higher heart rate, high blood pressure (hypertension) is the result. There are various activities that can help you to better deal with day-to-day stress by eliciting what is called a relaxation response as opposed to a fght or fight response. Yoga and M editation Yoga exercises encompass the practices of yoga postures, meditation, and pranayama (specialized yogic breathing). These practices are believed to infuence the autonomic nervous system balance and our hormonal system. In general, meditation techniques have been widely believed to be benefcial in reducing stress as well. M editation practices can be added to other lifestyle modifcations such as regular aerobic exercise and a low-sodium diet. Yoga can be practiced as part of your daily exercise program for stress reduction and general well-being. W e do, however, recommend that you consult with your health care provider, because some postures should only be assumed with the guidance of qualifed teachers. It is believed that these modalities result in better stress management by favorably afecting the autonomic nervous system as well as the hormonal system. It involves a series of movements performed in a slow, focused manner and accompanied by deep breathing. Each posture fows into the next without pause, ensuring that your body is in constant motion. Tai chi is a low-impact form of exercise and puts minimal strain on muscles and joints, making it safe for all ftness levels. The health benefts often mentioned in connection with tai chi are relaxation, improved circulation, strengthening, balance, and mind-body coordination. One caveat about tai chi: if you have musculoskeletal or neurological concerns or have an issue with your balance, you should not try tai chi as there is a risk of falling. M any gyms, community centers, and senior centers ofer classes in eastern practices including tai chi, yoga, and meditation. These classes can be an enjoyable and low-impact way to get ft and meet new people. For those who prefer to practice on their own, there are videos available that walk you through the basic steps and allow you to learn at your own pace. So if you are ready to get started, here is a plan to improve your chances for success. It is a lot more satisfying to make life changes when you focus on the positive rewards that motivate you. So today, make a list of all the benefts you will experience by tossing out those cigarettes. Think of the money you will save, and the benefts to your health (and to the health of those around you). W rite down any personal benefts you can think of and keep your rewards list handy. A common practice is wearing a rubber band around your wrist; whenever you have the urge to smoke, snap it. If you still have the craving, go for a walk or engage in some other new activity. The craving to smoke will not last forever, and once you get past the frst weeks, you will be well on your way to better health. Contact the following for m ore inform ation about the risks of sm oking: Sm okefree. It can do a lot to speed your recovery and reduce your chances of future heart problems. Everything you need to know to stay healthy is in one place, and medical staf is on hand at all times. During the rehabilitation program, you will exercise using a treadmill, a bike, or a rowing machine, or on a walking/jogging track. As you build strength, you will move into a more intensive program, with the goal of returning you to your home and to independent living. Follow-up Be sure to call and m ake a follow-up appointm ent with your cardiologist one to two weeks after your procedure. If you have symptoms such as chest pain, palpitations, shortness of breath, or difculty breathing, immediately call your doctor, call 911, or go to the closest emergency room. If you are going to have an elective invasive procedure or surgery, you should call 212-241-8315 in advance to get instructions on when to stop taking aspirin, Plavix, Efent, or Brilinta. It is important to discuss whether you need to discontinue any medications sooner, as it may not be safe to do so. In most cases, patients are instructed to stop Plavix fve days prior to surgery and resume two days after surgery. Once arriving in New York, patients and visitors can take public transportation (see below); taxicabs are available for hire from the station. M etered parking on streets bordering the M ount Sinai Hospital campus is also available. From the west side of M anhattan Travel the W est Side Highway to the 96th Street exit. From Brooklyn and parts of Q ueens (Brooklyn Bridge) From the Brooklyn-Queens Expressway, take the Brooklyn Bridge exit. From Staten Island (Brooklyn Battery Tunnel) Take the Verrazano Bridge (Staten Island only) to the Brooklyn-Queens Expressway. Follow signs to the Brooklyn Battery Tunnel and make a right turn out of the tunnel. From Upstate New York Take the New York State Thruway (I-87 South), which will turn into the M ajor Deegan Highway. Exit at 96th Street and travel across 96th Street through Central Park to M adison Avenue. Other accommodations within a short distance of the M ount Sinai Hospital include: Courtyard by M arriott Franklin Hotel M anhattan/Upper East Side 164 East 87th Street (between Lexington and Third Avenues) 410 East 92nd Street 212-369-1000 or 800-607-4009 (between First and York Avenues) Check availability and make reservations Hotel Newton through M ount Sinai Guest Services 2528 Broadway to receive discount rates. The M arm ara M anhattan O n the Ave Hotel Luxury Hotel & Residence 2178 Broadway at 77th Street 301 East 94th Street 212-651-3351 or 800-497-6028 (between First and Second Avenues) * Request special M ount Sinai rates. Sharma Family Foundation Cardiac Catheterization Laboratory volume 30003,000 for all types of interventions over the past fve 20002,000 years. Our lab rose to the top position among New York State hospitals in 2005 and has 10001,000 continued to deliver interventional care to the 00 greatest number of patients compared to other 2008 2009 2010 2011 2012 New York State hospitals for the last eight years, the Mount Sinai Hospital according to New York State Department of North Shore Hospital Health statistics. Limaye, M D Sameet Usman Baber, Jefrey Bander, M D ichael Alan Palkhiwala, M D D, M S Sicat, M D Daniel Sofer, M D Jose M eller, M D azullah Johnny Lee, M D Paul C. M ittal, M D Asim Hameedi, M D Vinod Patel, M D Anuj Shah, M D Vishal Kapur, M D Lynne Glasser, M D 36 Sam in K. Sharma is well known for complex coronary interventions, performing over 1,500 each year with an extremely low complication rate. Kini performs over 1,000 coronary interventions annually (the highest number by a female interventionalist in the United States) with an extremely low complication rate of <0. Sharm a Fam ily Foundation Cardiac Catheterization Laboratory at M ount Sinai Heart is: To im prove outcom es and safety of our interventional patients by using a team concept to deliver clinical innovations, unrivaled research, and personalized clinical care. Chronic Heart Failure is generally defned as the inability of the heart to supply enough blood fow to meet the needs of the body. The diagram below illustrates the sequence of events and the vicious cycle that often occurs. The heart is unable these hormones also to cope with the cause blood vessels extra fuid, and to become narrower, weakens further. The heart muscle swelling around the gradually becomes enlarged, just ankles and lungs, and like any muscle does when it weight gain. Your ability to exercise is determined by how well your heart and lungs are able to supply blood and oxygen to the working organs and muscles. Heart failure may also impair your ability to perform daily activities such as household chores, showering or shopping. Listed below are examples of how heart failure can also lead to other problems throughout your body. Who can I talk to about starting an exercise It is never too late to start regular exercise. Exercise Specialist about assessing the appropriate amount and types of A physiotherapist or an accredited exercise you can do. If you are already exercise physiologist with expertise active, keep up the good work and in heart failure can help develop perhaps add a new physical activity to your exercise program. You may also perform some light Start slowly and build up gradually as stretches for your major muscles.
The primary antiphospholipid syndrome characterized by recurrent thromboembolic phenomena and feta loss is triggered by the reaction of autoantibodies with a complex of fi2-glycoprotein turns up again as an abundant component of atherosclerotic plaques and there is increasing attention to the idea that autoimmunity may initiate or exacerbate the process of lipid deposition and plaque formation in this disease erectile dysfunction world statistics purchase viagra super active 50mg overnight delivery, the two lead candidate antigens being heat-shock protein 60 and the low-density lipoprotein erectile dysfunction medication names viagra super active 50mg sale, apoprotein B erectile dysfunction treatment natural remedies purchase 50 mg viagra super active free shipping. The erosions of cartilage and bone in rheumatoid arthritis are mediated by macrophages and fibroblasts which become stimulated by cytokines from activated T cells and immune complexes generated by a vigorous immunological reaction within the synovial tissue erectile dysfunction caverject injection buy generic viagra super active 100mg on-line. The complexes can arise through the self-association of IgG rheumatoid factors specific for the Fcy domains erectile dysfunction treatment in egypt discount viagra super active generic, a process facilitated by the striking deficiency of terminal galactose on the biantennary N-linked Fc iligosaccharides (Figure-11) xatral impotence cheap viagra super active master card. However, it is difficult to identify a role for the T cell as a pathogenic agent as distinct from a T-helper function in the organ-specific disorders. This is particularly true of developing thymic T cells (thymocytes) that fail to be eliminated by a subset of self peptides (self epitopes). Many autoantigens, when injected with adjuvants, make autoantibodies in normal animals, demonstrating the presence of autoreactive B cells, and it is possible to identify a small number of autoreactive B cells. Autoreactive T cells are also present in normal individuals, as shown by the fact that it is possible to produce autoimmune lines of T cells by stimulation of normal circulating T cells with the appropriate autoantigen. Autoimmunity is antigen driven Given that autoreactive B cells exist, the question remains whether they are stimulated to proliferate and produce autoantibodies by interaction with autoantigens or by some other means, such as non-specific polyclonal activators or idiotypic interactions (Figure-14). Evidence that B cells are selected by antigen comes from the existence of high affinity autoantibodies which arise through somatic mutation, a process which requires both T cells and autoantigen. Additonally, autoantibodies to epitope clusters occur on the same autoantigenic molecule. Apart from the presence of autoantigen itself, it is very difficult to envisage a mechanism that could account for the co-existence of antibody responses to different epitopes on the same molecule. A similar argument applies to the induction, in a single individual, of autoantibodies to organcelles. The most direct evidence for autoimmunity being antigen driven comes from studies of the Obese strain chicken which, as described earlier, spontaneously develops thyroid autoimmunity. If the thyroid gland (the source of antigen) is removed at birth, the chickens mature without developing thyroid autoantibodies (Figure-13). Furthermore, once thyroid autoimmunity has developed, later removal of the thyroid leads to a gross decline of thyroid autoantibodies, usually to undetectable levels. In organ-specific disorders, there is ample evidence for T cells responding to antigens present in the organs under attack. But in non-organ-specific autoimmunity, identification of the antigens recognized by T cells is often inadequate. In this scheme, autoantibodies are produced normally at low levels by B cells using germline genes. However, infection with a microbe bearing antigens that cross-react with the cryptic self epitopes. Cross reactive antigens which share B cell epitopes with self molecules can also break tolerance but by a different mechanism. The autoimmune process may persist after clearance of the foreign antigen if the activated B cells now focus the autoantigen on their surface receptors and present it to normally resting autoreactive T cell which will then proliferate and act as helpers for fresh B-cell stimulation. A disease in which such molecular mimicry operates is rheumatic fever, in which autoantibodies to heart valve antigen can be detected. These develop in a small proportion of individuals several weeks after a streptococcal infection of the throat. Carbohydrate antigens on the streptococci cross-react with an antigen on heart valves, so the infection may bypass T-cell self tolerance to heart valve antigens. One might therefore expect autoimmune responses to arise not infrequently through activation of these cells by molecular mimicry. For example, lipopolysaccharide or Epstein-Barr virus causes direct B-cell stimulation and some of the clones of activated cells will produce autoantibodies, although in the absence of T-cell help these are normally of low titer and affinity. However, it is conceivable that an activated B cell might pick up and process its cognate autoantigen and present it to a naive autoreactive T cell. Furthermore, this is not due to any stimulating animals show even higher uptakes of iodine (Figure-21). Interestingly, the Cornell strain (from which the Obese strain was derived by breeding) shows even higher uptakes of iodine, yet these animals do not develop spontaneous thyroiditis. This could be indicative of a type of abnormal thyroid behavior which in itself is insufficient to induce autoimmune disease but does contribute to susceptibility in the Obese strain. Other situations in which the production of autoantigen is affected are diabetes, in which one of the genetic risk factors is associated with a microsatellite marker lying within a transcription factor controlling the rate of insulin production, and rheumatoid arthritis, in which the agalacto IgG glycoform is abnormally abundant. Particularly relevant to the present discussion is the finding of upregulated hasp60 expression at such critical sites even in a 5-month-old child (Figure22). Again, one must re-emphasize the considerable importance of multiple factors I the establishment of prolonged autoimmunity. A particularly good example is the test for mitochondrial antibodies, used in diagnosing primary biliary cirrhosis (Figure-23). Exploratory laparotomy was previously needed to obtain this diagnosis, and was often hazardous because of the age and condition of the patients concerned. For instance, individuals testing positively for antibodies to both insulin and glutamic acid decarboxylase have a high risk of developing insulin-dependent diabetes. In pernicious anaemia, metabolic correction is achieved by injection of vitamin B12, and in myasthenia gravis by administration of cholinesterase inhibitors. Where function is completely lost and cannot be substituted by hormones, as many occur in lupus nephritis or chronic rheumatoid arthritis, tissue grafts or mechanical substitutes may be appropriate. In the case of tissue grafts, protection from the immunological processes which necessitated the transplant may be required. The potential of cyclosporine and related drugs such as rapamycin has yet to be fully realized, but quite dramatic results have been reported in the treatment of type 1 diabetes mellitus. As we understand more about the precise defects, and learn how to manipulate the immunological status of the patient, some less well-established approaches may become practicable (Figure-24). This suggests that stimulating normally suppressive functions, including the idiotype network, could be promising. Other symptoms included fatigue, a low-grade fever, a weight loss of 2 kg, and some mild chest pain. Past medical history of note was a mild autoimmune haemolytic anaemia 2 years previously. On examination Miss Jacob had a non-specific maculopapular rash on her face and chest and patchy alopecia (hair loss) over her scalp. In the normal thyroid space (cs) into which they secrete thyroglobulin, which is broken down on demand to provide thyroid hormones (cap=capillaries containing and blood cell). In the Hshimoto gland (2), the normal architectrure is virtually destroyed and replaced by involving cell (2), which consist essentially of lyphocytes, macrophages and plasma cells. A secondary lymphoid follicle (sf), with a germinal centre (gc) and a mantle of small lymphoctes (m), and small regenerating thyroid follicles (rf) are present. Figure-3 Autoimmune diseases may be classified as organ-specific or non-organspecific depending on whether the response is primarily against antigens localized to particular organs, or against widespread antigens. Short-term influence of prednisone and phenobarbital on thyroid function in euthyroid dogs. The vague and non-specific clinical signs of hypothyroidism and the fact that numerous factors can influence thyroid function test results are major contributors to the difficulty in diagnosing this disease. Thyroid physiology, canine hypothyroidism, specific diagnostic tests and factors influencing thyroid homeostasis will be described in chapter 1. Changes in thyroid hormone concentrations induced by drugs or disease can be confusing and lead to an erroneous diagnosis of hypothyroidism resulting in inappropriate life long treatment. These medications alter the synthesis, secretion, transport, or metabolism of thyroid hormones. Species differences exist in all areas of the thyroid axis, therefore it is not surprising that drug-thyroid interactions will vary among species. In humans, several drugs may cause marked changes in the results of thyroid function tests, leading to difficulty in interpretation, but only rarely lead to clinical features of thyroid dysfunction. Therefore, chapters 2 and 3 will focus on the effects of some very commonly used drugs in canine practice on thyroid function test results. To further assess the possible influence of some very common clinical situations on thyroid function test results, the possible effects of obesity and weight loss on canine thyroid function will be assessed in chapter 4. Indeed, clinical evaluation of thyroid function in dogs is not always straightforward. First, numerous factors such as the presence of systemic disease or the administration of drugs can affect thyroid homeostasis and frequently used thyroid function tests. Second, clinical manifestations of hypothyroidism, such as lethargy, alopecia and obesity, are nonspecific. The aim of this study is to clarify, if and how, some commonly observed clinical situations could affect thyroid homeostasis, in order to avoid an erroneous diagnosis of hypothyroidism resulting in inappropriate treatment. Specific aims: 1/ To evaluate the effects of some very commonly prescribed drugs on canine thyroid function test results. To evaluate the effects of prednisone and phenobarbital on canine thyroid function. To evaluate the effects of acetylsalicylic acid and ketoprofen on canine thyroid function test results. Obesity and weight loss have been shown to alter thyroid hormone homeostasis in humans. The symmetrical alopecia described in canine recurrent flank alopecia can easily mislead one to a diagnosis of hypothyroidism. Department of Medicine and Clinical Biology of Small Animals, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium And 1 2 2. Physiology of the hypothalamic-pituitary-thyroid axis An understanding of the basic physiology of the hypothalamic-pituitary-thyroid axis is critical to appreciating the various ways in which diseases or drugs can interact with this system and influence thyroid hormone concentrations. Figure 1 shows a schematic representation of the hypothalamic-pituitary-thyroid axis. Dogs have plasma iodide concentrations of 5 to 10 Pg/dl, which are 10 to 20 times concentrations in human plasma. In the thyroid gland, iodide is concentrated or "trapped" by active transport mechanisms of the thyroid follicular cell resulting in intracellular iodide concentrations, which are 10 to 200 times those of serum. Thiocyanate is a metabolic product of some naturally occurring compounds in plants. Another naturally occurring goitrinogen is goitrin found in plants of the genus Brassica (Ferguson, 2001). Oral administration of perchlorate after the administration of a tracer dose of radioiodine can be used to diagnose congenital defects in the thyroidal organification of iodide (Taurog, 1996). Thyroid hormone synthesis Thyroglobulin (Tg), an iodinated glycoprotein with a molecular weight of 660,000 daltons, serves as a synthesis and storage site for thyroid hormone and its precursors in the thyroid follicle. However, in iodine-deficient states and impending thyroid failure, the intrathyroidal synthesis of T3 is preferred over that of T4. By this autoregulation, the thyroid gland produces the most active thyroid hormone (T3 is 3 to 10 times more potent than T4) while using less iodide (Taurog, 1996). This inhibitory effect may represent a mechanism by which the organism is protected from massive thyroid hormone release after a large dietary iodine load. In puppies, increasing the iodine content of the diet results in a fall in total and free T4 concentration (Castillo et al. Thyroid hormone secretion Thyroid hormone secretion is initiated as the epithelial follicular cells take up thyroglobulin in colloid droplets by a process called pinocytosis. Some of this iodine is recycled internally for iodination of new tyrosine residues in thyroglobulin, but in carnivores much iodine is released to the circulation. As a result, although the T4:T3 ratio stored in the gland is 12:1 in the canine thyroid, the ratio of secreted products is 4:1. Production rates of the thyroid hormones in the dog have been estimated to be 8 Pg/kg/day for T4 and 0. Hypothalamic-pituitary-thyroid axis Thyrotropin, a glycoprotein produced in the thyrotropes of the pituitary pars distalis, has a stimulatory effect on thyroid hormone synthesis and secretion. Thyrotropin has a molecular weight of about 30,000 and consists of an D and E subunit. The D subunit is identical to the D subunit of the other glycoprotein pituitary hormones. Circulating T4 taken up by the pituitary gland is the preferred source of T3 in the pituitary gland, at least in the rat (Larsen et al. Metabolism of thyroid hormone the metabolically active thyroid hormones are the iodothyronines, T4 and T3. Therefore, although it also has intrinsic metabolic activity, T4 has been called a "prohormone" because of its conversion to the more potent T3 in a step regulated by peripheral tissues (Belshaw et al. This enzyme is now known to be a selenoenzyme requiring trace quantities of selenium for optimal activity. Plasma hormone binding of thyroid hormone and free hormone fraction Thyroxine and T3 are water insoluble lipophilic compounds. Thyroid hormone binding proteins provide a hormone reservoir in the plasma and "buffer" hormone delivery into tissue. These transport proteins act to provide a continuously available source of hormone while keeping the free or active fraction of the hormone within a tight range.
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Conditions initiating transient bacteraemia erectile dysfunction commercial buy generic viagra super active 50mg online, septicaemia destructive acute infection of the endocardium by highly and pyaemia erectile dysfunction webmd discount 25mg viagra super active. Bacteraemia erectile dysfunction hormonal causes purchase cheap viagra super active line, septicaemia and pyaemia: Bacteria gain entrance previously diseased heart and has a gradual downhill course to the bloodstream causing transient and clinically silent in a period of 6 weeks to a few months and sometimes years erectile dysfunction doctors los angeles discount 100mg viagra super active overnight delivery. Some of the common and subacute forms has been largely discarded because the examples are: clinical course is altered by antibiotic treatment erectile dysfunction treated by purchase viagra super active with a visa, still a few i) Periodontal infections such as trauma from vigorous important distinguishing features are worth describing brushing of teeth erectile dysfunction injection medication generic viagra super active 25 mg on-line, hard chewing, tooth extraction and other (Table 16. Virulence of Highly virulent Less virulent following: organisms i) Chronic rheumatic valvular disease in about 50% cases. Previous condition Usually previously Usually previously ii) Congenital heart diseases in about 20% cases. Clinical features Features of acute Splenomegaly, iii) Other causes are syphilitic aortic valve disease, systemic infection clubbing of fingers, atherosclerotic valvular disease, floppy mitral valve, and petechiae prosthetic heart valves. The vegetations are shown on the mitral valve (left upper diagram) as viewed from the left atrium, while those on the aortic valve (left lower diagram) are shown as seen from the left ventricle. Opened up chambers and valves of the left heart show presence of irregular, soft, elevated grey white friable vegetations on the atrial (superior) surface of the mitral valve (arrow). The circulating bacteria are lodged much more frequently may appear flat, filiform, fungating or polypoid. Conditions producing haemodynamic stress on the valves underlying valve leaflet, or may produce myocardial are liable to cause damage to the endothelium, favouring abscesses. Another alternative hypothesis is the occurrence of noni) the outer layer or cap consists of eosinophilic material bacterial thrombotic endocarditis from prolonged stress which composed of fibrin and platelets. Valves commonly Mitral alone; mitral Mitral, tricuspid Mainly mitral; less often Mitral; aortic; combined affected and aortic combined aortic and tricuspid mitral and aortic 2. Macroscopy Small, multiple, warty, Medium-sized, multiSmall but larger than Often large, grey-tawny grey brown, translucent, ple, generally do not those of rheumatic, to greenish, irregular, firmly attached, generally produce significant single or multiple, single or multiple, produce permanent valvalvular deformity brownish, firm, but typically friable vular deformity more friable than those of rheumatic 4. Microscopy Composed of fibrin with Composed of fibrinoid Composed of degenerated Composed of outer superimposed platelet material with superimvalvular tissue, fibrineosinophilic zone of fibrin thrombi and no bacteria, posed fibrin and platelet platelets thrombi and no and platelets, covering Adjacent and underlying thrombi and no bacteria. The underlying colonies of bacteria and endocardium shows the underlying endovalve shows swelling of deeper zone of non-specific oedema, proliferation of cardium shows fibrinoid collagen, fibrinoid change, acute and chronic inflamcapillaries, mononuclear necrosis, proliferation of proliferation of capillaries matory cells. The underlying inflammatory infiltrate capillaries and acute and but no significant inflamendocardium may show and occasional Aschoff chronic inflammatory matory cell infiltrate. B, Section of the mitral valve shows fibrin cap on luminal surface, layer of bacteria, and deeper zone of inflammatory cells, with prominence of neutrophils. In either case, their origin is due to toxic or involvement of extra-cardiac organs. Both these have their pathogenesis in circulating immune complexes (hypersensitivity A. Though tubercle bacilli are entering the systemic circulation affect organs like the spleen, bacteria, tuberculous endocarditis is described separate from kidneys, and brain causing infarcts, abscesses and mycotic the bacterial endocarditis due to specific granulomatous aneurysms. It is characterised by ii) Emboli arising from right side of the heart enter the presence of typical tubercles on the valvular as well as mural endocardium and may form tuberculous thromboemboli. Rarely, endocardium may be maculopapular lesions on the pulp of the fingers called infected with fungi such as from Candida albicans, Histoplasma capsulatum, Aspergillus, Mucor, coccidioidomycosis, cryptothe major forms of vegetative endocarditis involving the 449 coccosis, blastomycosis and actinomycosis. Others along with the fungal infections like candidiasis and aspergillosis are seen consequences of these valvular diseases in the form of more commonly in patients receiving long-term antibiotic stenosis and insufficiency of the heart valves are described therapy, intravenous drug abusers and after prosthetic valve below. Rheumatic heart disease is mitral valve in stenosis varies according to the extent of the most common form of acquired valvular disease. Generally, the valve leaflets are diffusely of the left side of the heart are involved much more frequently thickened by fibrous tissue and/or calcific deposits, than those of the right side of the heart. There are fibrous affected most often, followed in descending frequency, by adhesions of mitral commissures and fusion and the aortic valve, and combined mitral and aortic valves. Infective endocarditis (page 445) atrial pressure from the normal of 12 mmHg to about 25 3. Non-bacterial thrombotic endocarditis (page 444) mmHg leading to dilatation of the left atrium. Libman-Sacks endocarditis (page 444) left atrial pressure, in turn, raises pressure in the pulmonary 5. Syphilitic valvulitis (page 401) veins and capillaries, reducing the pulmonary function and 6. Calcific aortic valve stenosis causing exertional dyspnoea which is the chief symptom of 7. Normal mitral valve (A) contrasted with mitral stenosis (B) and mitral insufficiency (C). Normal-sized or atrophic left ventricle due to reduced as well as pressure since the left ventricle cannot empty inflow of blood. As a consequence of left atrial hypertension, backward transmission of elevated left artial pressure which pulmonary hypertension occurs resulting in pulmonary causes: oedema and right heart failure. In symptomatic cases of i) chronic passive congestion of the lungs; mitral insufficiency, the major symptoms are related to ii) hypertrophy and dilatation of the right ventricle; and decreased cardiac output. Features of pulmonary hypertension such as: insufficiency occurs more often in men (75%). Subsequently, i) chronic passive congestion of the lungs; mitral insufficiency is associated with some degree of mitral ii) hypertrophy and dilatation of the right ventricle; and stenosis. About 80% patients of valve syndrome), rupture of a leaflet or of the chordae symptomatic aortic stenosis are males. A few other conditions non-calcific and calcific type, the latter being more common. Calcific aortic stenosis is more rigidity, deformity and retraction of the valve leaflets and common type. These fusion of commissures as well as shortening and fusion include healing by scarring followed by calcification of aortic of chordae tendineae (Fig. The aortic cusps show in the aged, there is irregular, stony-hard, bead-like characteristic fibrous thickening and calcific nodularity thickening in the region of mitral annulus without any of the closing edges. Normal aortic valve (A) contrasted with aortic stenosis (B) and aortic insufficiency (C). The lesions are characteristically located 451 valve orifice is reduced to 1 cm2 from its normal 3 cm2. The major effect carcinoid tumour with hepatic metastasis, there is increased of aortic stenosis is obstruction to the outflow resulting in blood level of serotonin secreted by the tumour. Later, when increased concentration of serotonin reaches the right side cardiac failure supervenes, there is dilatation as well as of the heart and causes the lesions but serotonin is inactivated hypertrophy of the left ventricle (eccentric hypertrophy). Exertional bradykinin may play contributory role in carcinoid heart dyspnoea results from elevation of pulmonary capillary disease. Angina pectoris usually results from elevation of in experimental animals has not succeeded in producing pulmonary capillary pressure and usually develops due to cardiac lesions; hence the exact pathogenesis of carcinoid increased demand of hypertrophied myocardial mass. Other causes include syphilitic leaflets of the valves of the outflow tracts of the right heart valvulitis, infective endocarditis, congenital subaortic result mainly in pulmonary stenosis and tricuspid stenosis (congenitally bicuspid aortic valve), myxomatous regurgitation, and to a lesser extent, pulmonary regurgitation degeneration of aortic valve (floppy valve syndrome), and tricuspid stenosis. There Myxomatous or mucoid degeneration of the valves of the is generally distension and distortion of the ring heart is a peculiar condition occurring in young patients (Fig. The condition is also known by other increase of the left ventricular end-diastolic volume. Failure of the left ventricle some cases it may be genetically determined collagen increases the pressure in the left atrium and eventually disorder. Others have noted myxomatous the characteristic physical findings in a patient of aortic degeneration in cases of Ehlers-Danlos syndrome and in insufficiency are awareness of the beatings of the heart, myotonic dystrophy. However, the myxomatous valvular poundings in the head with each heartbeat, low diastolic and high pulse pressure, rapidly rising and collapsing water changes seen in the aged patients are not related to this entity. Any cardiac valve may be murmur heard over the femoral artery when it is lightly involved but mitral valve is affected most frequently. Sometimes, angina pectoris disease is usually most severe and most common in the occurs due to increased myocardial demand or due to posterior leaflet of the mitral valve. Infective granulomatous myocarditis is recognised during life by the characteristic mid-systolic 5. Rickettsial myocarditis incompetent mitral valve caused by the mitral valve prolapse. Fungal myocarditis superimposed infective endocarditis, mitral insufficiency and arrhythmias. Its exact incidence is difficult to ascertain as the Viral myocarditis usually appears after a few days to a few histological examination has been largely confined to autopsy weeks of viral infections elsewhere in the body. Reports from different studies have estimated the to the myocardium is caused either by direct viral cytotoxiincidence of myocarditis in 1 to 4% of all autopsies. Regardless of the A number of classifications of myocarditis have been type of virus, the pathologic changes are similar. There may be focal or patchy areas whether the inflammation is confined to interstitial tissue or of necrosis. Specific and non-specific type, depending upon whether the Initially, there is oedema and infiltration of the interstitial inflammation is granulomatous or non-specific type. Later, there is Acute, subacute and chronic type, depending upon the necrosis of individual myocardial fibres and the infiltrate duration of inflammatory response. However, currently most commonly used is etiologic classification given in Table 16. Pyogenic bacteria, According to this classification, myocarditis is divided chiefly Staphylococcus aureus or Streptococcus pyogenes, which into 4 main etiologic types described below. A number of infectious agents such as bacteria, viruses, protozoa, parasites, fungi, rickettsiae and spirochaetes may Grossly, There are either abscesses in the myocardium cause myocarditis by direct invasion or by their toxins. Microscopically, the exudate chiefly consists of neutrophils, admixed with lymphocytes, plasma cells and 1. These include: candidiasis, aspergillosis, blastomycosis, actinomyosis, Grossly, the appearance is similar to that seen in viral cryptococcosis, coccidioidomycosis and histoplasmosis. The cardiac chambers Tuberculosis, brucellosis and tularaemia are some examples are generally dilated and sometimes show hypertrophy. Tuberculous myocarditis is rare described: diffuse type and giant cell (idiopathic and occurs either by haematogenous spread or by extension granulomatous) type. It is distinguished from idiopathic granulomatous (giant cell) characterised by diffuse non-specific inflammatory infilmyocarditis (described later). Late stage consisting of granulomatous inflammation which is more shows healing by fibrosis. The gummas may consisting of macrophages, lymphocytes, plasma cells and affect the conduction system of the heart. Some have suggested relationship of this condition with sarcoidosis but sarcoid granulomas are Microscopically, there is interstitial oedema and focal or known to occur in the myocardium secondary to patchy infiltration by inflammatory cells which include generalised sarcoidosis. The pathologic changes frequently attacks myocardium besides involving the skeletal in the heart muscle are similar to the changes seen in other muscle and the central nervous system. Toxoplasmosis organs in these conditions as described elsewhere in relevant caused by intracellular protozoan, Toxoplasma gondii, chapters. The organisms physical and chemical agents, drugs and metabolic are found in the muscle fibres. Physical agents like contusion of the and Trichinella spiralis are the two intestinal helminths which myocardium, heat stroke, cardiac surgery and irradiation can may cause myocarditis. The features consist of an cyst in the myocardium while the larvae of Trichinella in infiltrate of neutrophils, eosinophils and mononuclear cells trichinosis cause heavy inflammation in the myocardium as and shows contraction-band necrosis of the myocardial well as in the interstitial tissue. However, the term cardiomyopathy has fifi been loosely used by various workers for myocardial diseases 1. Idiopathic hypertrophic cardiomyopathy amyloid cardiomyopathy, ischaemic cardiomyopathy etc. Idiopathic restrictive (or obliterative or infiltrative) cardiomyopathy a) primary cardiomyopathy; and i) Cardiac amyloidosis b) secondary cardiomyopathy i. Toxic chemicals such as arsenic, phosis subdivided into the following 3 pathophysiologic phorus and carbon monoxide cause focal areas of categories (Fig. Changes similar to those induced by chemical poisons are produced by certain drugs such as phenothiazine Idiopathic Dilated (Congestive) Cardiomyopathy compounds, sulfonamides, catecholamines and cytotoxic compounds. This type of cardiomyopathy is characterised by gradually progressive cardiac failure along with dilatation of all the 4. The condition occurs more often ataxia, and progressive muscular dystrophies initiate a state in adults and the average survival from onset to death is less of autoimmunisation against the myocardium resulting in than 5 years. Though the etiology is unknown, a few focal myocardial degeneration and necrosis with secondary hypotheses based on associations with the following inflammatory reaction. Uraemia, hypokalaemia and coxsackievirus B) with dilated cardiomyopathy, due to shock are associated with degeneration and necrosis of the presence of viral nucleic acids in the myocardium, has been myocardial fibres, oedema of the interstitial tissue and nonnoted. Cardiomyopathy literally means disease of the heart muscle iii) Inherited mutations have been implicated due to occurrence but the term was originally coined to restrict its usage to of disease in families.
Actual coping efforts to manage the problem and emotional regulation give rise to the eventual outcomes of the coping process ritalin causes erectile dysfunction buy 100mg viagra super active amex. Recent adaptations of coping theory propose that positive psychological states should also be taken into account erectile dysfunction age 33 viagra super active 25 mg. Community Organisation Although a gamut of new approaches and change models have been developed and adapted by health behaviour change professionals in recent years impotence remedies cheap viagra super active online amex, the principles and practices loosely referred to as Community Organisation remain an important focus xyzal impotence buy line viagra super active. Community Organisation can be defined as the process through which community groups are assisted to identify common problems or goals impotent rage definition purchase cheapest viagra super active, mobilise resources and develop and implement strategies for achieving these goals erectile dysfunction and icd 9 discount 50mg viagra super active overnight delivery. An important construct in Community Organisation is empowerment, explained by Rappaport [20] as an enabling process through which individuals or communities grasp control of their lives and their environment. The founder of community organising practice Murray Ross stated that Community Organisation could not be considered to have taken place unless community competence or problemsolving ability had increased during the process [21]. Diffusion of Innovations Diffusion of Innovations is a theory of that seeks to explain the spread of new ideas; the how, why and at what rate innovations (an idea, practice, or object that is perceived as new by an individual or other unit of adoption) spread throughout societies. The concept was first examined by sociologists and anthropologists around the turn of the 20th century [23-24]. Rogers [25-26] proposed four main elements that influence the spread of a new idea: the innovation, communication channels, time and a social system. Under this model, diffusion can be described as the process by which an innovation is communicated through certain channels over a period of time among the members of a social system. Rogers identified a five-step adoption process: knowledge, persuasion, decision, implementation and confirmation. Within the adoption process there is a point at which an innovation reaches critical mass, meaning that enough people have adopted it to make it self-sustaining. Rather, it provides a framework for applying theories so that the most suitable intervention strategies can be identified and implemented. Although originally developed for service programmes delivered in practice settings, the framework may be as useful to researchers and practitioners delivering health behaviour change programmes. It is based upon the premise that, just as in medicine, a diagnosis precedes a treatment plan, educational diagnosis precedes an intervention plan. The model addressed some concerns that health education focused too little on the design of interventions [30]. Social Ecological Model the Social Ecological Model is a framework that examines the multiple effects and correlations of social elements in an environment. Each system of influence contains roles, norms and rules that shape psychological development. Each of the levels has obvious synergies with social marketing which can act in each arena [33]. The model has been used in interventions on adolescent physical activity using social marketing [34]. Behavioral Ecological Model the Behavioral Ecological Model [35] is an extension of previous behaviour models that focus on the role and influence of selectionist and environmental factors on behaviour, such as the ecological model of health behaviour proposed by McLeroy et al [36]. The model features the integration of public health and behavioural science and places precedence on the function of behaviour, such as the consequences produced by a particular behaviour, over the type or topography of behaviour. The Behavioral Ecological Model also places emphasis on environmental influences on behaviour. The Behavioral Ecological Model assumes an interaction between physical and social contingencies to explain and control health behaviour. Theory of Reasoned Action, Theory of Planned Behavior and the Integrated Behavioral Model. Intervention mapping: Designing theory and evidence based health promotion programs. Promoting Nutrition and Physical Activity through Social Marketing: Current Practices and Recommendations. Prepared for the Cancer Prevention and Nutrition Section, California Department of Health Services, Sacramento, California. The behavioral ecological model: Integrating public health and behavioral science. Establishing early warning and surveillance early warning of emerging zoonoses in the Netherlands. This was the conclusion of the Health ces between the veterinary and medical infectious disease Council advice in 2004. This is a prerequisite for two-year research programme with the aim to develop a an effective implementation of the human-veterinary early blueprint for an early warning and surveillance system in warning system in the Netherlands, with a clear description animal reservoirs in the Netherlands, under the condition of duties, responsibilities and mandates for this signalling that the main institutes involved in veterinary medicine infrastructure. In 2007, the consortium, consisting of partners this report is the combined result of the collaborative from the Faculty of Veterinary Medicine, University of institutes and other experts outside the consortium. Next Utrecht, Animal Sciences Group and Central Institute of to the results described, the establishment of a collaborative Animal Diseases Control, Wageningen University and framework consisting in experts from different institutes Research Centre, the Animal health services in Deventer working together in this field, is an achievement in itself. Activities in the programme can be subdivided into activities that give direction to early warning and Prof. Technology assessment & data-sharing for the purpose of early warning signalling 28 2. Blueprint for the early warning signalling and surveillance in the Netherlands (later) 32 D. Technology assessment and data-sharing for the purpose of early warning signalling 51 2. Het ultieme doel van aangaande de selectie van pathogeen-reservoir combinaties EmZoo was het ontwikkelen van een blauwdruk voor die voor early warning en surveillance in aanmerking een effectief early warningen signaleringssysteem voor komen, werd een geprioriteerde lijst van emerging microbiele bedreigingen die relevant zijn voor zowel de zoonotische pathogenen opgesteld. Om dit doel the ingericht bestaande uit 86 pathogeen-gastheer-vectorbereiken was een gezamenlijke inspanning nodig van combinaties en een prioriteringssysteem werd ontwikkeld belangrijke instituten op het terrein van diergezondheid en op basis van een multi-criteria-analyse. Hiertoe is een consortium lijst geeft niet aan welke agentia het meest waarschijnlijk gevormd bestaande uit de Faculteit Diergeneeskunde van opduiken, maar welke de grootste bedreiging vormen. De tussen de verschillende emerging zoonotische agentia en consortium-partners werkten samen in een achttal projecten deze ranking kan gebruikt worden voor besluitvorming. Bovendien kan deze Inventarisatie van de huidige early warningen website professionals behulpzaam zijn bij risicoschatting surveillance-systemen voor de verschillende dierpopulaties en bij wetenschappelijk onderzoek naar de prioritering van en voor de humane populatie, die relevant zijn voor de bedreigingen voor de volksgezondheid. Het huidige Middels een inventarisatie van beschikbare diagnostische systeem bij landbouwhuisdieren is goed ingericht en kan methoden werd het mogelijk om direct the bepalen of aangepast worden om zoonotische agentia the signaleren die diagnostische methoden voor prioritaire surveillancegeen klinische aandoeningen veroorzaken. De bestaande systemen beschikbaar zijn of nog ontwikkeld moeten structuren bij landbouwhuisdieren en de mens lijken worden. Alle aanpassingen the doen voor het monitoren van nieuw86 pathogenen op de lijst werden bediscussieerd maar opduikende (emerging) zoonotische agentia. Voor wild, aanbevelingen aangaande specifieke surveillance-systemen exotische dieren, gezelschapsdieren en paarden zijn geen voor geprioriteerde pathogenen moeten nog nader worden early warning-systemen aanwezig. De recente oprichting van behulpzaam the zijn voor risk assessment van emerging het Dutch Wildlife Health Centre en het Centrum voor vectoroverdraagbare pathogenen. De afwezigheid van structurele surveillance-activiteiten Om een blauwdruk op the leveren van een effectieve bij exotische dieren, gezelschapsdieren en paarden, is infrastructuur, bestaande uit samenwerkende sleuteleen belangrijke omissie bij de surveillance van emerging personen uit de veterinaire en humane gezondheidszorg, zoonosen. Surveillance-systemen zijn nodig in deze voor early warning en surveillance van emerging dierpopulaties om informatie the verzamelen over de aanof zoonosen in Nederland, werden eerst de veterinaire afwezigheid van geprioriteerde zoonosen. Ervaringen met de en volksgezondheidssystemen in zeven andere landen ontwikkeling van een systeem voor syndroomsurveillance beschreven, hetgeen al aangeeft dat interactie tussen de twee in de humane sector werden geevalueerd met het oog op domeinen in verschillende landen op verschillende wijzen de ontwikkeling van een syndroomsurveillance-systeem is georganiseerd. Voor de Nederlandse situatie werden de voor gezelschapsdieren en paarden, maar implementatie verschillende taken en verantwoordelijkheden beschreven van een identiek systeem lijkt nu niet mogelijk the zijn. Een van de belangrijkste instituten die betrokken zijn bij stapsgewijze benadering wordt aanbevolen. De inrichting signalering, surveillance en bestrijding van infectieziekten van een helpdesk, waar ongebruikelijke gebeurtenissen bij dier en mens. Zolang incidenten plaatsvinden in een van beide domeinen en niet domeinBinnen het programma is een aantal communicatieoverschrijdend zijn, levert dat geen probleem op. Communicatie tussen het humane en van geschikte maatregelen, wie verantwoordelijk is voor veterinaire domein is essentieel. Het verder werken met besluitvorming en welke communicatie naar welke partijen de ontwikkelde communicatie-tools wordt dan ook van en organisaties nodig is. Samenwerking dient domein over de rolverdeling met betrekking tot plaats the vinden tussen alle partijen die betrokken zijn bij de signalering en bestrijding van zoonosen, zowel de uitvoering van surveillance. Eveneens is afstemming met inzake uitvoerende aspecten als ten aanzien van het beleid noodzakelijk. Het EmZoo-consortium van samenwerkende instituten kan de basis vormen van deze signaleringsgroep met toevoeging van andere relevante partners. De coordinatie van de activiteiten van deze gezamenlijke signaleringsgroep dient neergelegd the worden op een plek voor een langere tijdsperiode en voorwaarden voor het functioneren van deze signaleringsgroep, met betrekking tot een mandaat voor verdere actie en communicatie tussen professionals in de twee domeinen, dienen duidelijk vastgelegd the worden. The ultimate objective of EmZoo was seven comprehensive criteria, differs considerably between to develop a blueprint for an effective early warning and the different emerging zoonotic agents and this ranking signalling system in the Netherlands for threats of relevance can be used for decision making. To reach this aim, the flexible method, new information can readily be included collaborative effort of key institutes involved in veterinary and analysed. A web-based Emerging Zoonoses Information and public health in the Netherlands was requested. In addition, this website can also assist professionals and collaborated in eight projects serving the following for risk assessment purposes and scientific research into the three aims: prioritisation of public health threats. An inventory of current early warning and surveillance General recommendations about the arbitrary top twentysystems for different animal populations and humans five of the ranked zoonoses are provided. All 86 pathogens relevant for public and veterinary health showed that on the list were discussed but recommendations about suitable systems are in place for timely recognition of specific surveillance systems for prioritised pathogens need clinical signals of (emerging) zoonotic diseases in humans to be further defined. The current system in farm animals is well equipped Scenario studies, including modelling and risk mapping, and could be adapted to register zoonotic agents that do not of vector borne diseases proved to be helpful for risk cause clinical signs. Moreover, the existing structures in assessments of emerging vector-borne pathogens. Such farm animals and humans appear flexible enough to adjust approaches should receive more support in monitoring to monitoring newly identified emerging zoonotic agents, programmes of pathogens in vector populations in when deemed necessary. For wildlife, exotic animals, connection with studies of the ecology of pathogen companion animals and horses, no early warning systems transmission. The same holds for registering early warning and methodologies for monitoring, analysis and prevention signals of the emergence of zoonoses via vectors such and control in humans, animals and their vectors. The recent establishment the absence of structural surveillance activities in exotic of the Dutch Wildlife Health Centre and Centre Monitoring animals, companion animals and horses is a major gap Vectors are essential first steps to a signalling infrastructure in the surveillance of emerging zoonoses. Experiences with of pathogen-reservoir combinations for early warning the development of a syndromic surveillance system in and surveillance, a prioritised list of emerging zoonotic the human sector were considered for the development of pathogens for the Netherlands was developed. A database syndromic surveillance in companion animals and horses consisting of 86 pathogen-host-vector combinations was but implementation of an identical system seems to be not established and a priority setting system, based on a multiyet possible. The EmZoo-programme provided clear tools and a blueprint Within this programme, several tools for communication for an integrated veterinary-human infrastructure for were developed, especially an email service to share the signalling, risk assessment and control of emerging information between veterinarians and public health zoonoses in the Netherlands. Therefore, sustaining the developed tools is signalling and control of zoonoses, in executive aspects considered of utmost importance in order to facilitate the as well as in risk management, policy making and risk signalling, risk assessment and communication of zoonotic communication. An agreement should be made that takes and communication to professionals, is needed. Cooperation away existing barriers for the exchange of (research) should take place between all parties involved in the execution data among the various institutes and groups. Further development collaborating institutes can be the basis for this national and establishment of a joint signalling structure is zoonoses signalling group, with the addition of other recommended. However, before the human-veterinary group with regard to its mandate for further actions signalling structure can be further developed and routinely and communication between professionals in the two implemented, a clear description of duties, responsibilities domains should be clearly identified. In the Netherlands, the different duties and responsibilities were described for the key institutes involved in signalling, surveillance and control of infectious diseases in animals and humans. As long as events take place in one of these domains and not in both, this does not pose a problem. About 75% of the recognised that the impact of emerging zoonoses can be emerging diseases in humans appears to be zoonotic minimised through a well-prepared and strong public health (1). In 2007, zoonoses, which were already known like system, but only with similar systems developed in the Q-fever and psittacosis, have had serious direct and indirect livestock, wildlife and food safety sectors. A wide emerging zoonoses effectively, preparedness plans, early variety of animal species, both domesticated and wild, can warning systems and response capacity must be strengthened act as reservoirs for these pathogens. To achieve these objectives, effective cross-jurisdictional, In Europe, zoonoses originating from wildlife reservoirs and/ intersectoral and interdisciplinary collaboration is required or transmitted by arthropods are expected to become more (8). Climate and ecological changes may the negative effects of zoonotic events for public health, favour already existing arthropods expanding to other regions trade in animal and animal products and animal health and and thus introducing new pathogens to native areas in Europe wellbeing.