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By K. Irmak. College of Saint Mary.

Later buy viagra 25 mg visa, features of subacute combined degen- inactive nucleus (maturation arrest) in a relatively eration of the cord may develop discount viagra 25 mg line. There is an increased incidence presence denotes vitamin B12 or folate deciency, of gastric carcinoma. Vasculitis and drug hypersensitivity Causes of lymphopenia (low lymphocyte count). Parasitic infestation of gut or other tissues (muscles, subcutaneous tissues, liver, urinary tract). Uro- bilinogen is present in the urine as a result of reduced red cell survival and ineffective erythropoiesis. Anti- bodiestoparietalcellsarepresentin>90%ofpatients and to intrinsic factor in approximately 55%. Patients with pernicious anaemia treated with vitamin B12usually have normal peripheral blood and a normal marrow within 24h. Treatment Vitamin B12 as hydroxocobalamin 1mg is given ve times at 2-day intervals and then every 3 months for life. The response of the marrow to therapy is very rapid with an early reticulocyte response maximal on the fourth to sixth day. The rapid pro- duction of cells with therapy may reveal an associated deciencyof,and demandfor,iron,potassiumor folic acid and supplements should be given where necessary. Neurological features of B12 deciency usually im- prove to some degree; sensory abnormalities more completely than motor, and peripheral neuropathy morethanmyelopathy. Blood transfusion contains enough B12 to correct the marrow and to make interpretation of serum B12 levels difcult. It may precipitate heart failure and deathsomeauthoritiesbelievethattransfusionmust never be given to patients with pernicious anaemia. In the tropics it is often seen in association with multiple deciencies and with gut infection and infestation. If sufciently severe, vitamin B12 and folate Haemolysis results in increased red cell formation, deciencies produce depression of all the marrow which requires folate more than B12. Phenytoin therapy interferes isusuallysomehaemolysiswitharaisedunconjugated with folate metabolism. Haematology 327 Hereditary haemolytic anaemias Haemolytic anaemia These are caused by defects in the red cell membrane or specic red cell enzyme deciencies. Haemolysis Hereditary spherocytosis is characterised by jaundice with a raised unconjugat- ed serum bilirubin, increased urobilinogen in urine An autosomal dominant disorder that causes in- and stools, increased haptoglobins and reticulocyto- creased osmotic fragility and produces spherocytes sis. There is no bile pigment in intermittent jaundice, which may be confused with the urine (the jaundice is acholuric). Gall- appearanceofchromium-taggedredcellsgivesamore stones, leg ulcers, splenomegaly and haemolytic or accurate measure of the rate of haemolysis. Spleno- aplastic crises during intercurrent infections may megalyandpigmentstonesmayoccur. During adult life the b- the X chromosome (affected males always show clin- globin variants combine with a-globin chains to form ical manifestations but females will have variable adult haemoglobin (HbA). Sickle-cell anaemia is usually drug-induced (sulphonamides, primaquine) caused by a point mutation, which involves substi- or occur during acute infections. Other features are tution of T for A in the second nucleotide of the sixth neonatal jaundice and favism. Sickle-cell haemoglobin (HbS) possesses two a- This is an acquired clonal disorder of haematopoiesis and two abnormal b-chains. Thisaccountsfortheincreasedsensitivityof red cells to complement, which forms the basis of Sickle-cell disease is found in Africa, the Middle East, Hams acid lysis test. Sickle-cell trait occurs in who develop paroxysmal haemolysis (with anaemia, heterozygotes (HbAHbS) whose haemoglobin con- macrocytosis, reticulocytosis, haemoglobinuria and tains characteristically 60% HbA and 40% HbS. Pa- haemosiderinuria) and life-threatening venous tients with the trait are usually symptom-free except thromboses. Normal adult haemoglobin is made up of two poly- This leads to the sickling phenomenon and to abnor- peptide chains, the alpha- and beta-chains, which are mal sequestration with thrombosis in small arterioles. Repeated renal infarction causes Haematology 329 tubular damage and failure to concentrate urine, Marrow disorders compounding sickle-cell crises. Median be given and penicillin prescribed to reduce mortality survival in both essential thrombocythaemia and from pneumococcus. Hydroxyurea can help by in- polycythaemia vera exceeds 15 years and the 10-year creasing HbF production. Bone marrow transplanta- risk of developing either myelobrosis or acute mye- tion is curative but limited by availability of well loid leukemia is relatively low. Polycythaemia vera presents in late middle age (5060 years), most commonly as a chance haem- Thalassaemia atological nding.

Widal test for O and H antigens The O (somatic) antigen shows active infection whereas the H (flagellar) antigen could be indicative of past infection or immunization for typhoid cheap 50 mg viagra free shipping. Limitations of Widal test It is non specific and a positive test could be due to Infection by other salmonellae (as the antigen used for the test is also shared by other salmonellae) Recent vaccination for typhoid Past typhoid (already treated) The demonstration of 4- fold rise in titer on paired sera is not useful for the treatment of acute cases cheap viagra 100 mg without prescription, as this requires waiting for the convalescence phase of the disease and at this stage if the patient is lucky recovery will occur. These drugs can be given either orally or intravenous, depending on patient condition (able to take orally or not), severity of the disease. One should note that fever may persist for 4-6 days despite effective antibiotic treatment 20 Internal Medicine Oral drugs First Line Nowadays 4-amino quinolones are the drugs of choice because of their effectiveness on multidrug resistant typhoid, and low relapse and carrier rates. Dose should be reduced to 2g/d when fever starts to decrease (usually after 5 - 6 days), and continued to complete 2 weeks treatment. This is a drug of choice for patients that need parenteral therapy especially in Ethiopia (mainly for cost reason). Hence if resistance is suspected in an area, the preferred treatment would be with quinolones, azithromycin or third generation cephalosporins 21 Internal Medicine Early use of antibiotics is associated with high rate of relapse (up to 20%) as compared to untreated cases (where the relapse rate is 5 - 10%). This is due to inhibition of adequate development of immune response by early therapy. Co-trimexazole (160/800mg twice a day) plus Rifampicin 600mg orally/d for 6 weeks. Identify the different features of the two types of borrelia and their clinical manifestations 7. Design appropriate methods of prevention and control of relapsing fever Definition Relapsing fever is an acute febrile illness caused by Borrelia species, presenting with recurrence of characteristic febrile periods lasting for days alternating with afebrile periods. Borrelia demonstrates remarkable antigenic variation and strain heterogeneity which help the parasite to escape the immune response of the host and result in recurrence of febrile episodes. In Ethiopia the diseases affects mostly homeless men living crowded together in very unhygienic circumstances especially during rainy seasons. Pathophysiology In humans, borreliae after entering the body multiply in the blood and circulate in great number during febrile periods. Severity is related to spirocheatal density in blood but systemic manifestations are related to release of various cytokines. The disease is characterized by sub capsular and parenchymal hemorrhage with infarcts of spleen, liver, heart and brain is seen. Thus, patients will have enlarged spleen and liver with variable edema and swelling of brain, lung and kidneys. Complications:- Life threatening complications are unusual in otherwise healthy persons if the disease is diagnosed and treated early. Without treatment, symptoms intensify over 2-7 days period and subside with spontaneous crisis during which borrelia disappear from the circulation. Such cycles of febrile periods alternating with afebrile periods may recur several times. Define rickettsial diseases with Special Emphasis on Epidemic and Endemic Typhus 2. Identify the clinical manifestations of the different types of rickettsial diseases 8. Describe the most commonly used tests for the diagnosis of rickettsial diseases 10. Refer complicated cases of rickettsial diseases to hospitals for better management 12. Design appropriate methods of prevention and control of rickettsial diseases Definition: Rickettisiae are small intracellular bacteria that are spread to man by arthropod vectors, namely human body lice, fleas, ticks & larval mites. The organisms inhabit the gastrointestinal tract of these arthropods & spread to human host by the direct bite of the vector or the inoculation of the organism contained in the feces of the vector by bite induced body itching. These infections are characterized by persistence in the body, widespread vasculitis (invading endothelial cells of small blood vessels) & multi-system involvement. Except in louse borne typhus humans are accidental hosts in most rickettisial diseases. Classification Rickettsial diseases are classified into five general groups Tick and mite borne spotted fever group Flea and louse borne typhus group Chigger borne scrub typhus Ehrlichiosis Q-fever 29 Internal Medicine Etiology and Epidemiology of Epidemic and Endemic Typhus : Epidemic Typhus (Louse born ): is caused by R. Lice acquire the rickettsia while ingesting a blood meal from an infected patient, the rickettsia multiply in the midgut epithelial cells of the louse and are excreted via louse faeces. The infected louse defecates during a blood meal and the patient autoinoculates the organisms by scratching. Humans and rats are infected when rickettsia laden fleas are scratched in to pruritic bite lesions. Endothelial proliferation coupled with peri-vascular reaction causes thromboses and small hemorrhages. However, tissue and organ injury is commonly due to increased vascular permeability with resulting edema, hypovolemia and organ ischemia. This leads to multi-system involvement with complications such as non-cardiogenic pulmonary edema, cardiac dysrhythemia, encephalitis, renal and hepatic failure and bleeding. Clinical Features Signs and symptoms: Incubation period of 1 week Abrupt onset of illness with prostration, severe headache and rapidly rising fever of 38. Brill-Zinsser disease (recrudescent typhus): This is a mild form of epidemic typhus caused by reactivation of dormant R.

Many are incorporated into programs offered for stress the body discount viagra 100 mg with mastercard, participants are encouraged to management purchase viagra 50mg. While Breathing exercises are the easiest and meditation techniques have been practiced most basic of the relaxation techniques. Progressive Muscle Relaxation has a single subject such as ones breath, an long history in stress management and image, or a sound. There are many 42 techniques and styles of meditating, all and dissociation from other things in the sharing the goal of focusing and quieting environment. For example, in transcendental hypnosis are also usually in a state of meditation, a common form of meditation heightened suggestibility and more likely to practiced in the Western world, accept outside information or instructions 2 participants repeat a word or phrase without question or criticism. Many (called a mantra) to help maintain a hypnosis strategies use this heightened concentrated focus. It refers An important consideration is the to the union of the mind, body and spirit. There is very little spiritual practice, it is now becoming evidence to support this view. Program popular in the West, where it is also being managers are urged to avoid those who used to address some physical disorders may offer hypnosis services, sometimes and support relaxation as well as overall with fee-splitting proposals, as panaceas for health and well-being. As people move muscles are tensed can help them identify through tai chi forms, they are gently the feelings of tension and learn to relax working muscles, focusing concentration, those muscles. In temperature biofeedback, and breathing deeply, all of which lead to sensors are attached to the persons fingers relaxation. Evaluations of yoga interventions have supported their efficacy In addition to these, some consider prayer with regard to improvements in mood, stress, 8 to be a mind-body technique. In addition to studies investigating the effects of mind-body techniques on healthy Evidence Base coping, several studies provide evidence for A recent systematic review of research the use of mind-body techniques to improve conducted with a variety of patient clinical health status of individuals with populations found promising evidence for 10-17 diabetes. Implementation Considerations Research on several of the mind-body The variety of mind-body approaches and approaches and their application to specific providers can make it challenging for audiences, such as those with diabetes, is still administrators to know which services to offer modest. However, as Western medicine and how to tell who is qualified to provide becomes more aware and accepting of such them. Generally, the mind-body techniques approaches, the evidence supporting their are not protected or restricted by licensure or efficacy is growing. Thus, it may be difficult to Several studies have also investigated the evaluate the credentials of those holding effects of mind-body approaches on the health themselves out as expert in yoga, relaxation and well-being of individuals with diabetes. This creates a dilemma 6 study by Surwit suggests that mind-body for administrators. On the one hand, there are approaches to stress management can be individuals with no formal training or meaningful additions to a comprehensive certification for their work who are treatment program for patients with type 2 nevertheless skilled and responsible diabetes. On relaxation training as well as instruction in the the other hand, there are practitioners who are use of cognitive and behavioral skills to poorly trained and poorly skilled who should recognize and reduce physiological stress be avoided. The adverse health consequences of knowledge of the local network of providers stress were reduced as evidenced by to recruit carefully, administrators are well- reductions in hemoglobin A1c. In another advised to recruit carefully from trusted study, Mindfulness Based Stress Reduction, a sources. Because of this and the fact that In programs of the Diabetes Initiative, one site there is little research that one or another partnered with a local fitness center to approach is specifically effective for people incorporate yoga and tai chi into its diabetes with diabetes, decisions about which approach self-management program. At another site, to adopt may be based on factors such as certified diabetes educators referred consumer demand or preference, availability participants to a local clinic where yoga was of people trained in specific approaches, available. General diabetes self-management complexity of adding new dimensions to education and skill building classes programming, upfront costs, resource needs, incorporated mind-body techniques such as etc. Mind-body specific approaches to group versus individual techniques at one site were incorporated into formats; e. Another site guided imagery may be more amenable to a incorporated mind-body techniques through group approach than biofeedback and referral to a nurse-led program that taught hypnosis. Group activities, however, also relaxation and meditation in a weekly series of require larger physical space than strategies group classes. Mindfulness-based stress reduction is associated with improved glycemic control in type 2 diabetes mellitus: a pilot study. Role of mood in outcome of biofeedback assisted relaxation therapy in insulin dependent diabetes mellitus. A brief but comprehensive lifestyle education program based on yoga reduces risk factors for cardiovascular disease and diabetes mellitus. Effects of a randomized controlled trial of transcendental meditation on components of the metabolic syndrome in subjects with coronary heart disease. While spirituality does not necessarily imply participation in are uncomfortable in this realm and feel 15, 16 organized religion or religious practices, many poorly prepared to enter it.