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By G. Stejnar. Peace College.

This may be a quantitative or 474 Chapter 12: Haematology and clinical immunology functional abnormality of any of the membrane proteins Incidence (spectrin cheap metformin 500mg, ankyrin 500mg metformin otc, protein 4. These cells are more rigid than normal and As HbF synthesis is normal, it presents at 6 months. Sex Clinical features M = F Spherocytosis may present as neonatal jaundice or anaemia with chronic malaise and splenomegaly. Nor- Geography mal infections cause a relative increase in haemolysis and Occurs most frequently in Africa, Middle East, India and may result in jaundice. Aetiology Investigations Apoint mutation on chromosome 11 results in a sub- Anaemia is usually mild. A blood film will demonstrate stitution valine for glutamine at the sixth codon on the the spherocytes, but this cell morphology is not diagnos- β globin chain to form haemoglobin (Hb)S. Thediagnosiscanbeconfirmedbydemonstratingthe dehydration, hypoxia and cold may precipitate a sickle osmotic fragility of the red blood cells. Patients are given Pathophysiology pneumococcal vaccinations and prophylactic antibiotics HbS molecules, when deoxygenated tend to aggregate post splenectomy. The red blood cells become inflex- ible and sickle shaped and become trapped in the mi- Haemoglobinopathies crocirculation, especially within bones, resulting in mi- Haemoglobinopathies are abnormalities in the nor- crovessel occlusion. Normal haemoglobin is made up of four polypeptide chains Clinical features each containing a haem group. HbA is the main adult Sickle cell trait (the carrier state) is asymptomatic, but form comprising two α chains and two β chains. Sickle cell also have a minor haemoglobin HbA2,which makes up anaemia is a clinical spectrum ranging from asymp- around 2% of the circulating haemoglobin and con- tomatic to severe haemolytic anaemia and recurrent sists of two α chains and two δ chains. Painful vascular occlusive crises typically haemoglobins result from: produce symptoms of bone pain and pleuritic chest pain r Abnormal globin chain production such as thalas- with a low-grade fever. Other patterns of crisis: r Acute sequestration (pooling of blood in liver and Sickle cell anaemia spleen) requires transfusion for apparent hypo- Definition volaemia. Autosomal recessive condition in which there is abnor- r Pulmonary infarction may occur in association with mal structure of the globin chain. Chapter 12: Haemoglobin disorders and anaemia 475 Complications syndrome or cerebral infarction require exchange blood Patients have a susceptibility to infections including transfusionstoremovesicklecells. Transfusionsmayalso streptococcal infections and osteomyelitis often due be indicated in patients with regular severe crises and to salmonella. Prognosis Retinal detachment and proliferative retinopathy may Thereismarkedvariationintheseverityofthecondition, result in blindness. See also complications of haemolytic some patients have a relatively normal life span with few anaemia (page 473). Blood film shows a α-Thalassaemia high reticulocyte count and sickle shaped red blood cells. Definition r Sickle screening tests use a reducing solution, which Inherited haemoglobinopathy with defective synthesis causes HbS to precipitate. Aetiology r X-ray of the tubular bones may show destruction and α-Thalassaemia is caused by gene deletions. There are medullary sclerosis together with periosteal bone for- four copies of the α gene, two on each chromosome 16. Management Clinical features Treatment is largely symptomatic with prophylactic an- r Deletion of all four copies of the α gene (–/–) prevents tibiotics,folicacidandpneumococcalvaccination. This disorder agement of a painful crisis includes oxygenation, ade- is also termed haemoglobin Bart’s (γ4)hydrops syn- quate hydration and analgesia. Acute se- r Deletion of three genes (–/α-) causes HbH disease (a questration requires blood transfusion, as patients be- moderate anaemia with splenomegaly and the pro- comeshocked. Normal Investigations Full blood count shows microcytosis with or without Sickle Trait anaemia. These mutations may result in no β chain production Investigations (β0)orveryreducedproduction (β+). The reticulocyte count is noproductionofβ globinandhavetheclinicalpicture raised and there are nucleated red cells. Management Excess α chains precipitate in the red blood cells r Thalassaemiaminordoesnotrequiretreatment;how- or combine with δ resulting in increased HbA2, and ever, iron supplements should be avoided unless γ resulting in increased levels of fetal haemoglobin co-existent iron deficiency has been demonstrated. The partners of women with thalassaemia minor r If there are defects in both β and δ genes, patients shouldbescreenedtoallowappropriategeneticcoun- have thalassaemia intermedia (homozygous) or tha- selling. Homozygous combined β, γ and δ are in- r Thalassaemia major and symptomatic thalassaemia compatible with life. This Clinical features aims to suppress ineffective erythropoesis and pre- r Thalassaemia minor/trait is asymptomatic with a vent bony deformity, while allowing normal growth mild hypochromic microcytic anaemia. Iron overload is prevented by the r Thalassaemia intermedia causes symptomatic mod- use of the chelating agent desferrioxamine, which is erate anaemia with splenomegaly. Splenectomy should be considered in patients ure to thrive and recurrent infections. Bone the production of fetal haemoglobin ceases and the marrow transplantation has been used successfully patient becomes symptomatic with a severe anae- in young patients with severe β-thalassaemia major.

Acute obstruction (acute urinary retention) causes se- vere discomfort 500 mg metformin fast delivery, due to a wish to void urine buy discount metformin 500 mg on line, without Sex the ability to do so. There is complete anuria, although there may be small amounts of urine voided due to overflow in- Aetiology continence. However, polyuria and/or nocturia may Pathophysiology be symptoms of the loss of concentrating ability of the Androgens appear to act on the periurethral area of the tubules, which can occur in long-standing obstruc- prostate ‘McNeal’s transition zone’ to stimulate hyper- tion. At 30–40 years there is microscopic evidence, by 50 years it Macroscopy is macroscopically visible, by 60 years the clinical phase Dilation above the obstruction. The obstruction is due to both direct impingement Complications of the enlarged prostate on the urethra and also the dy- As aresultofchronicobstruction,thebladderdilatesand namic smooth muscle contraction of the prostate, pro- fails to empty fully, defined as >50 mL residual urine static capsule and bladder neck. Nodules Management formedofhyperplasticglandularacinidisplaceandcom- Relief of the obstruction is usually by insertion of a uri- press the true prostatic glands peripherally forming a nary catheter, followed by treatment of the underlying false capsule. Chapter 6: Disorders of the bladder and prostate 263 Microscopy symptoms than α-blockers. It seems to be more effec- Benign epithelial proliferation with large acini, smooth tive in those with very large prostates and its effects muscleandfibroblastproliferation. The procedure involves removal Complications of prostatic tissue using electrocautery via a resecto- Bladder decompensation – due to chronically increased scope from within the prostatic urethra, under general residualvolumes(urineretainedaftervoiding),theblad- or spinal anaethesia. Post-operatively patients require der may become less contractile, lowering flow rates fur- a three-way catheter and continuous bladder irrigation ther. Obstruction may lead to dilated ureters and kid- to reduce the risk of clot retention until haematuria is ney(hydroureter,andhydronephrosis). Investigations Antibiotic prophylaxis is usually given to prevent Itisimportanttoexcludeothercausesof bladderoutflow urinary tract infection. Between10and15mL/second,combined bladder neck contracture or urethral stricture requir- pressure/flow studies may be done to exclude those ing surgery or dilatation, incontinence. The disad- Other options (not widely available) include: vantage of the latter, is that urinary catheterisation is r Stent which is cost-effective in those with a short required. Definition r Finasteride is a 5 alpha reductase inhibitor which in- Urinary incontinence is the involuntary loss of urine hibits the conversion of testosterone to dihydrotestos- from the urethra. It is also useful, but generally less effective for and functional impact on the individual. This is mainly due to detrusor instability/over- 30% of women <65 years but only up to 5% of men <65 activity. Rates are much higher in certain settings such as care of r Overflow incontinence is continual or unprecipitated the elderly institutions (up to 45%) and psychiatric care leakage without urge. Bladder outflow obstruction may lead Age to overflow incontinence due to bladder decompen- Increases with age. Rare causes include spinal cord compression affecting the sacral segments (S2, 3 and 4) or the conus medullaris. F > M Acomprehensive examination is important and can avoid the need for specialist tests. It is important to as- Aetiology sess fluid balance, mobility, cognitive ability and relevant Incontinence has been associated with many conditions neurology. Rectal examination for constipation, rectal and risk factors such as chronic cough, depression, de- masses and vaginal speculum examination for atrophy, mentia, pregnancy, vaginal delivery (particularly with masses, cystocele or rectocele. Toremaincontinentthere r Avoiding diary is useful to record the time, volume must be: and relevant events, e. This is due to poor sphincter func- Stress incontinence: Initially non-surgical options tion. This r Pelvic floor (Kegel) exercises (with or without weigh- may be precipitated by the sound of running water, tedcones) may be used but are dependent on the Chapter 6: Urinary tract infections 265 motivation of the patient. Systemic or topical oestro- r Inspinalcordcompressionemergencydecompression gen therapy may be of benefit. Ring tions intermittent self-catheterisation is the preferred pessaries are useful for those with uterine prolapse. For vaginal cys- Urinary tract infections toceles (where the bladder herniates into the vaginal canal), a transvaginal approach may be used to re- pair the cystocele but this is generally less effective. In females, vaginitis is another syndrome Urge incontinence: unlike stress incontinence, be- which commonly overlaps. Surgery (clam cystoplasty to increase the size of the blad- Age der using bowel) is rarely successful. In patients with cognitive awareness of bladder Sex filling and the ability to independently toilet, bladder F > M training is used to learn methods of deliberately sup- pressing the urge to pass urine. In patients without cognitive awareness or lack of motivation to remain Aetiology dry, scheduled or prompted voiding reduces the num- Most frequently due to bacteria, in particular E. These and Histoplasma capsulatum), parasites (the protozoan tend to cause a dry mouth and may cause constipa- Trichomonas vaginalis and the fluke Schistosoma haema- tion and/or urinary retention. Pathophysiology Combined stress and urge incontinence may be treated r Bacterialvirulencefactors:Criticaltothepathogenesis with behavioural therapy with or without medical ther- of bacteria is adherence to the uroepithelium as infec- apy. Surgicaltreatmentappearstobelesseffectivethanin tions ascend from the urethral orifice to the bladder pure stress incontinence. Proteus), duction of urease, causes the alkalinisation of urine, so it hydrolyses urea and increases ammonia, which fa- that phosphate, carbonate and magnesium are more cilitates bacterial adherence.

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Scientifc validation of phar- macological activity of age-old drugs used in Ayurveda reinforces faith in the traditional system buy generic metformin 500 mg line, in which plants are selected only on the basis of experience metformin 500mg on-line. This review provides information on Indian herbal drug biodiversity, supply and demand, use of herbal drugs in the pharmaceutical industry and quality control methods required for the modern drug industry. Mostly this increase is in the developing or un- der-developed countries, 80 % of whose population still relies on a traditional system of medicine based on herbal drugs. Goyal are readily available in neighbourhood, cheap, and without side effects, having been time tested. The demand for medicinal plants is continuously increasing not only in developing countries, but also in developed countries as drug, food supplements (nutraceuticals) and cosmetics [1]. Tyler defnes herbal medicines as “crude drugs of vegetable origin utilised for the treatment of diseased state often of a chronic nature or to attain or maintain a condition of improved health” [2]. If we look at the socio-economic scenario of Asian and African countries, modern medicine is neither affordable nor within the reach of many villagers and tribes inhabiting remote areas and deep forests. There are certain pockets in a country like India where the tribal people have no access to mod- ern amenities like roads, telecommunications or electricity, and therefore, these communities rely only on their traditional knowledge of medicine for day-to- day requirements [3]. It is well established that industrialisation has many direct and indirect ef- fects on the human population. Increased stress is the most evident, although this is offset by increased health awareness among the people and better medical facilities. Men learnt to use plants as healers of different ailments with the beginning of civilisation. One of the oldest Pharmacopoeia describing the appearance, properties and use of many plants is by the Greek physician Galen (A. The great civilisations of India, China and North Africa have developed this science to perfection, and written records are available dating back up to 3000 years B. There are many examples where medicines have been obtained from plants known to traditional healers. With the development of modern analytical tools, interest in natural product chemistry has led to the isolation by Serturner of morphine alkaloid from opium, a mixture of plentiful alka- loids. This in turn was obtained from the opium poppy (Papaver somniferum) by processes that have been used for over 5000 years. Quinine isolated from the Cinchona tree had its origin in the Royal household of South American Incas. Long before the frst European explorers arrived, the native people of South America had developed medical systems with complete diagnosis and treatment of various maladies. The leaves of the coca tree have been primarily chewed by Andean people to obtain well-known benefts. In 1860, Carl Koler isolated cocaine from the coca tree, the chemical responsible for its biological activity, and has become infamous as a drug of abuse. Similar are stories of the de- velopment of many modern drugs such as pilocarpine from the alkaloid-rich oil of the zaborandi tree (Pilocarpus zaborandi) used to treat glaucoma, anti- infammatory agents from the pineapple (Ananas comosus), which was used by the American Indians of Guadeloupe. India is a very large country (3,280,483 km2) with diverse geoclimatic zones and biodiversity. Although there are many excellent centres of natural products chemistry, still many plants are yet to be explored for their phytochemical and pharmacological properties, for example Chlorophytum borivilianum. Earlier, Chapter 18 The Indian Herbal Drugs Scenario in Global Perspectives 327 this plant was collected from forests, but it is now cultivated in several thousand hectares and consumed in tonnes, but nothing is known about its chemistry and pharmacology [5,6]. In India we often wake up to our therapeutic wis- dom only after recognition about a plant material or its active ingredient comes from the West [7]. This can be well illustrated by the cases of Rauwolfa ser- pentina [8] and Withania sonmifera, both of which are used traditionally in the Indian system of medicine, where Indian reports were ignored and the plants attained importance only after publications by Western scientists [9]. In India, it is mainly the central government departments that fund the re- search on medicinal plants; the contribution of private partnership is almost insignifcant. The research and development activity of large traditional Indian pharmaceutical frms is mainly in-house activity. The plants under cultivation are utilised in both the domestic and foreign markets as raw material for drugs and perfumery. These nodal agencies have their own priorities based on their own mandate, and a comprehensive common list of medicinal plants of Indian national priority is yet to be evolved. Ayurveda texts like “Charak Sam- hita” and “Sushruta Samhita” were documented about 1000 years B. It deals elaborately with measures for healthful living during the entire span of life and its various phases. In ad- dition, dealing with principles for maintenance of health, it has also developed Chapter 18 The Indian Herbal Drugs Scenario in Global Perspectives 329 a wide range of therapeutic measures with which to combat illness. These prin- ciples of positive health and therapeutic measures relate to the physical, men- tal, social and spiritual welfare of human beings. In fact, of the 6599 hymns and around 700 prose lines that comprise Atharva Veda, a substantial part relates to the human body, its dis- orders and possible cures, which included recitation of prayers and magical invocations.

After the year 2000 programs were created using Latvias Field of Rehabilitation own experience and resources (nutritionists) buy 500mg metformin visa. It was decided not to make any speciffc Latvian model when the system of rehabilitation was frst made cheap metformin 500 mg free shipping, but to use ex- The support in the feld of inclusive education has different aspects perience of more developed countries. It concerns the physical, psychic as there is some inconsistencies in making of the system with the well as social factor in enabling the persons to be part in the social physical medicine. In the feld of art For Latvia with it’s less than 2,000,000 populations this is a rela- therapeutic support it works in a playful way with inner images, tively suffcient number for the development of multiproffesional stress release, resources by using the artistic expression as a means rehabilitation. Conclusion: Development system for education of for getting in contact with the own abilities as well as with others. Referring to three different cases some different aspects tries has to be assessed. Republic of Srpska (B&H Entity) The art therapeutic intervention is related to support the feeling of coherence and self-esteem. In relation to neurosciences it supports new ways of stimulating the inner learning abilities and is part of Introduction: In year 2014. Keyword: inclusive education, art fare in Republic of Srpska (B&H entity) passed new By-law, ap- therapeutic support, coherence, neurosciences, case studies. More time is given to rehabilitation of vascular patients and patients with post- Objective: The goal of this study is to determine if a difference in operative/posttraumatic conditions. Information was collected from for seven (7) subspecialist trainings, as follows: assessment of oc- Quebec Trauma Registry. The independent variables collected were cupational/working ability, angiology, epidemiology of non-com- socio-demographic, helmet status, clinical and neurological patient municable diseases, baromedicine, balneoclimatology, children information. No dif- tients with consequences of chronic non communicable diseases, ferences in costs were found for inpatient rehabilitation (p =0. However, the median total costs for patients with diagnostics, traditionally performed by other specialists. It is of oral health care contribute to the prevention and improvement intended to support the continuation of the quality improvement of of aspiration pneumonia. For example, there are fve questions about patients’ for inpatients has been recognized, but the care activity has not participation: “I am able to deal effectively with everyday life ac- been standardized. Therefore, we describe mouth and pharynx rehabilita- generally able to do things I need to do without major barriers. We provided services condition was evaluated with a total grade (4-16) of these four that address the individual impairments, activity limitations, partici- items. The patients with a poor oral condition (more than 8 in total) pation restrictions, environmental needs. Patients, family members, were performed oral cleaning by ward nurses and oral hygienists. The interaction and communication was doing ing and cleaning, 800 inpatients in July 2006 and 1951 inpatients well and consensus was reached on predicted outcomes and treat- between April 2007 and March 2008 were investigated with the ment plan. The differences in the incidence of patients vidual based on goals and outcomes to achieve the most appropriate between these two periods were compared using the chi-square setting for the patients. Results: The incidence of patients who underwent screening ing relationships with community systems. The incidence of patients who underwent oral clean- of rehabilitation services and continuity of care after patients were ing increased signifcantly (p<0. Before the oral care, the total grade of four items answer of these fve questions was 75%, 89. The percentage of the patients who thought they had met the conditions improved signifcantly (the total grade ranged from 4 to needs they came our hospital for increased from 86. In all patients, the aspiration pneumonitis Conclusion: Hearing the voice of experience offered by patients is did not occur. Conclusion: Taking these results into consideration essential to establish and improve the quality of services. This study was performed to compare isometric mus- tions in Rehabilitation therapy. Material & sometimes we have to have the frst walking exercises with no Methods: Ten subacute hemiplegic subjects with Poor~Fair quadri- exams. Zhang ple size and follow-up period to determine if the improvement in Shanghai No. Ozgirgin 360C, was used for the relaxing and analgesic effect, for joint un- loading, musculoligamentous stretching, combating joint stiffness Ankara Physical Medicine and Rehabilitation Training and Re- and gait reeducation. All patients were applied the same conventional rehabilitation program 5 times a week for 4 Medical Rehabilitation in a Case with Severe Clinical weeks. Cioara 1University of Oradea, Faculty of Medicine and Pharmacie, Baile groups (all p<0. Compared with baseline, all of sensorimotor defcit, without loss of consciousness.