Condet

JOHN C.ACHERMANN, MD

• Lecturer in Endocrinology, UCL Institute of Child Health,
• University College, London, United Kingdom

Recent evidence suggests that monounsaturated fats (olive oil and canola oil) are preferable to polyunsaturated fats for preventing heart disease menopause 34 symptoms provera 10mg amex. When polyunsaturated fats are transformed from the cis to the trans form women's health nutrition tips order provera 5mg with amex, as when margarine is hardened into stick as opposed to tub form women's health big book of exercises walmart discount provera 5 mg with visa, the fats appear to become more atherogenic women's health center groton ct cheap 5 mg provera with amex. Eat at least seven servings of a combination of vegetables and fruits and at least six servings of a combination of unrefined starches and legumes (beans, peas). Preferred carbohydrates include fresh fruit, green and yellow vegetables, whole-grain breads and cereals, beans, baked potatoes, and other unrefined starches. These foods, which are good sources of fiber and antioxidants such as beta-carotene and vitamin C, substances that may protect against certain cancers, should be substituted for foods with higher energy density such as fats and simple sugars, which are conducive to obesity. The evidence for an inverse association of vegetable and fruit intake with certain cancers (especially lung cancer) is strong and consistent. High vegetable and fruit intake, which has been associated with reduced urinary calcium excretion, may also be beneficial for the prevention of bone loss. Sufficient quantities of complex carbohydrates, with their naturally high nutrient and fiber content, may obviate the need for vitamin and fiber supplements. On average, Americans consume about 10 to 12 g of salt per day, 31 about 20 times their requirement of less than 0. Evidence that high sodium intake is associated with greater calcium and bone loss adds further impetus to achieve this goal, especially for women at risk for osteoporosis. However, since 80% of dietary sodium generally comes from manufactured and restaurant-prepared foods, patients should be encouraged to read labels and avoid packaged and canned foods that have high sodium contents. At about 100 to 140 g/day, the average intake of protein in this country is well in excess of need, which is closer to 40 to 60 g/day for the average adult. Most adults can achieve an adequate intake with a diet that contains a variety of vegetables and starches, even without the use of animal products. Animal protein (such as from meat, poultry, and fish) causes increased loss of calcium in the urine and, when taken in excessive amounts, could contribute to osteoporosis. Red meat has also been associated with an increased risk of colon and other cancers, as well as with coronary artery disease. Two to three servings per day of low-fat dairy products such as milk, yogurt, and cheese should be consumed. The optimal intake of calcium remains uncertain, and recommendations have varied from 800 to 1500 mg/day. To achieve these levels by diet would necessitate liberal use of dairy products. However, recommendations regarding the liberal use of dairy products must be tempered by several caveats: (1) Adult populations in countries with low bone fracture rates generally consume few dairy products and actually have low calcium intake by our standards. Thus it is possible that a reduction in the incidence of bone fractures may be more appropriately approached with dietary modifications other than the use of liberal amounts of dairy products; modifications might include a reduction in animal protein and salt intake, liberal use of vegetables and fruits, and if deemed appropriate, calcium supplementation. One ounce or less of pure alcohol should be consumed per day (equivalent to two cans of beer, two small glasses of wine, or two average cocktails). Although moderate alcohol intake is associated with a lower risk of coronary artery disease, drinking poses other risks that may offset any potential advantages. Because alcohol is high in energy density (7 kcal/g or 200 kcal/oz of ethanol), alcoholic beverages may contribute significantly to total calorie intake. Evidence is accumulating that for some persons, supplementation with certain vitamins may be beneficial. For example, folic acid will reduce certain congenital abnormalities, and both folic acid and vitamin B6 reduce homocysteine levels and hence may reduce the risk of coronary disease. However, the most desirable approach for the general public is to obtain the recommended levels of nutrients by eating a variety of whole foods, as described previously. When the diet is optimal, routine use of nutritional supplements may be of little benefit to most people, and unprescribed daily use of selenium and fat-soluble vitamin supplements such as beta-carotene and vitamin E in amounts exceeding the recommended dietary allowances should be avoided. These data indicate that our meals should be based mainly on whole grains, legumes (beans, peas), other vegetables, and fruit. If consumed, poultry and fish should be taken in moderation; red meat and eggs should be used no more than several times per week. It is less clear but likely that a healthful diet may also include low-fat dairy products in moderation and, if desired, small amounts of alcohol. Health is increasingly dependent on lifestyle, and associations between diet and many specific diseases are becoming more clear. In this context, physicians should routinely provide nutrition counseling and/or referral to qualified nutritionists as part of routine health evaluations or whenever possible as part of a medical encounter.

Hypernatremia also may complicate use of normal saline solutions when the endogenous osmolar solute load is high and renal concentrating ability is limited women's health clinic kitchener purchase provera 10 mg fast delivery. Patients with diabetic ketoacidosis breast cancer 30 year old woman best 10mg provera, who are generally young pregnancy 4th week purchase provera 10mg visa, have sufficient urinary concentrating ability that hypernatremia does not occur when normal saline solutions are used to treat ketoacidosis menopause kit gag gift buy 5mg provera mastercard. In contrast, the non-ketotic hyperglycemic syndrome generally occurs in elderly patients, who can have partial impairment of urinary concentrating power. In this setting, hypernatremia can occur during therapy with normal saline solutions. This complication can be avoided by treating with half-normal saline and thus providing sufficient solute-free water for urinary elimination of the osmolar glucose load. In such circumstances, the urine volumes are large, the urinary osmolality is low, and the net rate of solute excretion is low, in contrast to individuals undergoing osmotic diuresis, in whom rates of urinary solute excretion are elevated. Striking water losses also may occur with excessive sweating, particularly during rigorous physical activity by untrained individuals exercising in high humidity. A common example in modern clinical practice involves injudiciously administering large amounts of carbohydrate or amino acids by nasogastric tube, coupled with limited amounts of water, to stroke patients unable to communicate thirst. Because two thirds of body water is intracellular, primary water losses tend to have modest effects on circulating volume unless fluid losses are profound. The degree of symptomatology varies with the degree of hypertonicity and with the rate at which hypertonicity develops. To treat acute hypernatremia, normal saline solutions are initially given intravenously. In the highly volume-contracted patient with severe hypernatremia, administering isotonic saline solutions has two advantages. Moreover, the isotonic salt solution, which is hypotonic with respect to the hypertonic patient, avoids an unnecessary rapid fall in the serum sodium level. Because accumulation of idiogenic osmoles by brain cells is a compensatory mechanism for preserving brain volume in hypertonic disorders, a normal serum osmolality may be relatively hypotonic to brain cells that have accumulated idiogenic solutes. A useful guide to circumventing this difficulty is to reduce the serum sodium level by no more than 1 mEq/L during every 2 hours of the first 2 days of treatment. Study of patients with hyponatremia secondary to compulsive water drinking demonstrating that it is safe to reverse the neurologic sequelae by rapid correction of serum sodium level by 15 mEq/kg H2 O followed by more gradual correction of the remaining hyponatremia. Discusses the pathophysiology, assessment, and treatment of hyponatremia and hypernatremia syndromes. Authors call attention to increased morbidity and mortality with hyponatremia especially in children and menstruant women. Easy to understand therapeutic approach is given to asymptomatic and symptomatic hyponatremia. An account of factors causing hyponatremia in hospitalized patients with affective disorders. Clear discussion on potential complicating factors in formulating a therapeutic plan for treatment of hyponatremia. Literature review of severe diuretic-induced hyponatremia showing that severity of hyponatremia as well as too-rapid correction was associated with higher mortality. Thiazide diuretics were associated with severe hyponatremia much more frequently than loop diuretics. Hyponatremia of either cause was associated with increased morbidity and mortality. Whereas the plasma potassium concentration is influenced by total body potassium stores, it should be recognized that factors influencing the distribution of potassium between extracellular and intracellular spaces are important determinants of plasma potassium concentration. In potassium-depleted states with normal acid-base status, a 1 mEq/L fall in the serum potassium level reflects the loss of about 300 mEq of potassium; hence, the bulk of external potassium loss comes from the cellular compartment. In this situation, cellular uptake of potassium obviously occurs and prevents greater increases in the serum potassium concentration. This ability of cells to accumulate potassium can be enhanced strikingly by chronic administration of high-potassium diets. Insulin also reduces sodium permeability; the resultant cellular hyperpolarization of cells produces a passive driving force for potassium accumulation within cells. Thus, hyperkalemia may be the sensor that stimulates release of insulin, which then serves as an effector for potassium entry into cells.

Because the movement of small molecules and enzymes is dependent on the presence of water womens health 15 minute arm workout discount provera 10 mg with mastercard, active growth depends on a relatively high percentage of moisture in the environment breast cancer 0 stage treatment cheap provera 10 mg mastercard. As saprobes menopause queasy cheap provera 5 mg with mastercard, fungi help maintain a sustainable ecosystem for the animals and plants that share the same habitat menstrual 5 days late provera 5 mg discount. In addition to replenishing the environment with nutrients, fungi interact directly with other organisms in beneficial, and sometimes damaging, ways (Figure 24. While some shelf fungi are found only on dead trees, others can parasitize living trees and cause eventual death, so they are considered serious tree pathogens. When both members of the association benefit, the symbiotic relationship is called mutualistic. Fungi form mutualistic associations with many types of organisms, including cyanobacteria, algae, plants, and animals. Fungus/Plant Mutualism One of the most remarkable associations between fungi and plants is the establishment of mycorrhizae. Mycorrhiza, which comes from the Greek words myco meaning fungus and rhizo meaning root, refers to the association between vascular plant roots and their symbiotic fungi. Somewhere between 80 and 90 percent of all plant species have mycorrhizal partners. In a mycorrhizal association, the fungal mycelia use their extensive network of hyphae and large surface area in contact with the soil to channel water and minerals from the soil into the plant. In exchange, the plant supplies the products of photosynthesis to fuel the metabolism of the fungus. Ectomycorrhizae ("outside" mycorrhiza) depend on fungi enveloping the roots in a sheath (called a mantle) and a Hartig net of hyphae that extends into the roots between cells (Figure 24. In a second type, the Glomeromycete fungi form vesicular­arbuscular interactions with arbuscular mycorrhiza (sometimes called endomycorrhizae). In these mycorrhiza, the fungi form arbuscules that penetrate root cells and are the site of the metabolic exchanges between the fungus and the host plant (Figure 24. Orchids are epiphytes that form small seeds without much storage to sustain germination and growth. Their seeds will not germinate without a mycorrhizal partner (usually a Basidiomycete). After nutrients in the seed are depleted, fungal symbionts support the growth of the orchid by providing necessary carbohydrates and minerals. Endophytes release toxins that repel herbivores, or confer resistance to environmental stress factors, such as infection by microorganisms, drought, or heavy metals in soil. Coevolution of Land Plants and Mycorrhizae Mycorrhizae are the mutually beneficial symbiotic association between roots of vascular plants and fungi. A well-accepted theory proposes that fungi were instrumental in the evolution of the root system in plants and contributed to the success of Angiosperms. The bryophytes (mosses and liverworts), which are considered the most primitive plants and the first to survive on dry land, do not have a true root system; some have vesicular­arbuscular mycorrhizae and some do not. They depend on a simple rhizoid (an underground organ) and cannot survive in dry areas. Vascular plants that developed a system of thin extensions from the rhizoids (found in mosses) are thought to have had a selective advantage because they had a greater surface area of contact with the fungal partners than the mosses and liverworts, thus availing themselves of more nutrients in the ground. The first association between fungi and photosynthetic organisms on land involved moss-like plants and endophytes. The fungi involved in mycorrhizae display many characteristics of primitive fungi; they produce simple spores, show little diversification, do not have a sexual reproductive cycle, and cannot live outside of a mycorrhizal association. The plants benefited from the association because mycorrhizae allowed them to move into new habitats because of increased uptake of nutrients, and this gave them a selective advantage over plants that did not establish symbiotic relationships. They cover rocks, gravestones, tree bark, and the ground in the tundra where plant roots cannot penetrate. Lichens can survive extended periods of drought, when they become completely desiccated, and then rapidly become active once water is available again. Generally, neither the fungus nor the photosynthetic organism can survive alone outside of the symbiotic relationship. The body of a lichen, referred to as a thallus, is formed of hyphae wrapped around the photosynthetic partner. The photosynthetic organism provides carbon and energy in the form of carbohydrates. Some cyanobacteria fix nitrogen from the atmosphere, contributing nitrogenous compounds to the association.

In the villous adenoma women's health clinic ottawa hospital discount provera 10 mg fast delivery, finger-like projections of neoplastic epithelium project toward the bowel lumen menopause 1 ovary purchase provera 10mg on line. About 60% of adenomas are tubular menstrual calendar premium buy cheap provera 5mg on line, 20 to 30% are tubulovillous womens health elkins wv buy cheap provera 5 mg, and about 10% are villous. All adenomas are dysplastic, and dysplasia in adenomas may be graded into mild, moderate, and severe. This classification is based on the presence of cytologic (mainly nuclear) abnormalities and glandular architectural changes. In the normal adult, the epithelial tissue of the colon actively renews itself with a turnover period of about 3 to 8 days. Normally cells replicate and migrate up the crypt, subsequently to be exfoliated from the mucosal surface. Colonic adenomas appear to have malignant potential: (1) the epidemiology of adenomas and carcinoma is similar; (2) adenocarcinomas and adenomas occur in the same anatomic distribution in the colon; (3) residual adenomatous tissue is observed quite commonly in small cancers; (4) the incidence of cancer increases as the size of the adenoma increases; (5) the adenoma-to-cancer transition has been observed in familial polyposis, hereditary nonpolyposis colorectal carcinoma, and in experimental animals treated with a carcinogen; (6) the risk for colorectal cancer is higher in patients with a history of adenomas and is significantly lessened if the adenoma is removed; (7) a period of approximately 5 years elapses between the diagnosis of adenoma and the development of carcinoma. Several important factors in this transformation can be identified, especially size, histologic type, and epithelial dysplasia. The frequency of cancer in adenomas under 1 cm is 1 to 3%; in those between 1 to 2 cm, 10%; and in those over 2 cm, more than 40%. Invasive neoplasm has been found in 40% of the villous tumors, in fewer than 5% of the tubular adenomas, and in 23% of the tubulovillous variety. The malignant potential of adenomas also increases with increasing degrees of dysplasia. Most adenomas smaller than 1 cm show only mild dysplasia and have a low malignant potential. Cancer in adenomas is usually well differentiated and occurs most commonly in the tip of a pedunculated adenoma without invasion of the muscularis mucosae. Occasionally cancers in adenomas invade the muscularis mucosae, grow down the stalk, invade lymphatic vessels and adjacent lymph nodes, and metastasize. The roles of autocrine factors, tumor suppressor genes, and oncogenes in the development of adenomas and their malignant transformation are currently under study. Some adenomatous polyps are diagnosed after the detection of occult blood loss in asymptomatic individuals who are screened for colon cancer. Adenomas may also be detected by fiberoptic sigmoidoscopy or colonoscopy or by double-contrast barium enema examination. Because of the association of adenomas with the development of adenocarcinomas, colonic polyps should usually be removed or destroyed. Pedunculated polyps, even if large, can be removed by electrocautery snare, whereas small sessile polyps (1 to 8 mm) should be biopsied and destroyed with the "hot biopsy" forceps. For sessile polyps with a wide-based attachment to the colonic wall, several electrocautery sessions may be required for complete excision. Endoscopic removal may not be safe or possible if a lesion is in a relatively inaccessible location. The endoscopic appearances that suggest carcinomatous invasion include ulceration, an irregular surface contour, firm consistency, and friability. If a diagnosis of malignancy is made after polypectomy, a decision has to be made about the adequacy of the polypectomy. In the presence of poorly differentiated histologic features, penetration of the muscularis mucosa, vascular or lymphatic invasion, or a resection margin containing cancer, the risk of regional lymph node involvement is approximately 5%. The mortality from surgical resection is less than 2% in patients aged 50 to 69 years and 4. Ideally, all adenomas should be removed from the colon at the time of the initial colonoscopy. A follow-up colonoscopy is appropriate at 3 years to evaluate for the presence of any lesions missed at the previous procedure or to discover new lesions. If the colon is free of polyps at this examination, an interval of 3 years is appropriate before the next colonoscopy. The polyposis syndromes account for approximately 1% of colorectal cancer, whereas the nonpolyposis inherited conditions may be responsible for up to 6%. Almost all patients with familial polyposis develop carcinoma of the colon by age 40 years if the colon has not been removed.

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