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O. Enzo, MD
Professor, University of Toledo College of Medicine
It is often associated with absence of ovulation (persistent unovulatory period) When there is no ovulation, there is no corpus luteum formation, this result in inadequate production of progesterone. Deficiency or absence of progesterone in the circulation results in absence of secretary changes in the endometruim. As estrogen levels decrease from degenerating follicles, with drawl bleeding occurs. Emotional disturbance may stimulate hypothalamus and has resultant influence on gonadotrophic hormones. Pelvic peritonitis (abscess):- inflammation of the pelvic peritoneum and puss collections. When cervix is opened for abortion, this will a pave the way for the normal floras of the vagina to ascend. The risk increase with prolonged duration of labor and operative deliveries Organism: - Pollymicrobials (Normal floras of vagina) - Aerobic organism, and - Anaerobic organism. Obstructions in urinary tract (Obstructive Uropathy) Obstructive disorders may cause considerable renal dysfunction, including hemorrhage, renal failure, if they are left untreated. Normally urine is formed by the nephrones in the renal parenchyma, then collected in the renal pelvic to flow through the ureter and reaches urinary bladder. When the bladder becomes full, urethral sphincters are opened then urine passes through urethra to be voided out. Clinical Features - Acute urinary retention - Symptoms of prostatism (frequency, urgency, dribbling, dysuria, etc) - Chronic retention insufficiency. Classification Benign Renal Tumors - Not very common - Includes: Adenoma of renal parenchyma - Papilloma of renal parenchyma - Lipoma, etc - Hematuria and dull pain in the flank are common complaints. Malignant renal tumors - Include: - wilms tumor: - it occurs in children - Renal cell carcinoma: - it occurs in adults - Clinical features - Pain and hematuria are the earliest symptoms. Post procedural urethral stricture:It occurs following urologic procedural like catheterizations. Minor trauma to the urethral mucosa may heal by forming strictures years after the procedure. Urine stasis and back-flow of urine: - Results in hydronephrosis and Renal- failure Symptoms of renal-failure (uremia). Pathophysiologic Effects of Obstructive Uropathy Obstruction to urinary path way (flow) Stasis of urine and back flow Bacterial over growth (pylonephiritis) 200 Pathophysiology Hydronephrosis distension of the renal pelvis. Small increase in one component can be compensated in decrease in volume of one or both of other components of the cranial cavity. Normal fluctuation in intracranial pressure occurs with respiratory movement and activities of daily living such as straining, coughing and sneezing. Example: o An increase in tissue volume results from brain tumors, brain edema, or bleeding into brain tissue. When the pressure in the cranial cavity approaches or exceeds the mean systemic arterial pressure, tissue 205 Pathophysiology perfusion becomes inadequate, cellular hypoxia results and if maintained, neuronal death may occur. The level of consciousness may deteriorate from alertness through confusion, lethargy, obtundation, stupor, and coma. Neurons in vasomotor centre respond directly to ischemia by producing a marked increase in mean arterial blood pressure. Some times up to 270mmHg is accompanied by widening of pulse pressure and a reflex slowing of the heart rate. Types of Brain Edema:208 Pathophysiology There are two types of brain edema:a) Vasogenic Brain Edema:- Increased extra cellular fluid that surrounds brain cells. Infratentorial Herniation Supratentorial Herniation There are three subtypes based on sites. Infratentorial herniation:Results from increased pressure in the brain compartment and often progress rapidly. Cause death because it is likely to involve the lower brain stem centre that control vital function. Brain Injuries Injury to the brain parenchyma:- There are two types of brain injury:a) Primary Head injury b) Secondary Head injury a) Primary Head Injury: 213 Pathophysiology Primary head injury the impact.
Accessory Nerve the accessory nerve supplies the sternocleidomastoid and the trapezius muscles by means of its spinal root. The patient should be asked to rotate the head to one side against resistance, causing the sternocleidomastoid of the opposite side to come into action. Then,the patient should be asked to shrug the shoulders, causing the trapezius muscles to come into action. Lesions of the spinal part of the accessory nerve will result in paralysis of the sternocleidomastoid and trapezius muscles. The sternocleidomastoid muscle will atrophy, and there will be weakness in turning the head to the opposite side. The trapezius muscle will also atrophy, and the shoulder will droop on that side; there will also be weakness and difficulty in raising the arm above the horizontal. Lesions of the spinal part of the accessory nerve may occur anywhere along its course and may result from tumors or trauma from stab or gunshot wounds in the neck. Hypoglossal Nerve the hypoglossal nerve supplies the intrinsic muscles of the tongue and the styloglossus, hyoglossus, and genioglossus muscles. To test the integrity of the nerve, the patient is asked to put out the tongue; if there is a lower motor neuron lesion, the tongue will be observed to deviate toward the paralyzed side. The tongue will be smaller on the side of the lesion, owing to muscle atrophy, and fasciculation may accompany or precede the atrophy. Remember that the greater part of the hypoglossal nucleus receives corticonuclear fibers from both cerebral hemispheres. However, the part of the nucleus that supplies the genioglossus receives corticonuclear fibers only from the opposite cerebral hemisphere. If a patient has a lesion of the corticonuclear fibers, there will be no atrophy or fibrillation of the tongue, and on protrusion, the tongue will deviate to the side opposite the lesion. Glossopharyngeal Nerve the glossopharyngeal nerve supplies the stylopharyngeus muscle and sends secretomotor fibers to the parotid gland. Sensory fibers innervate the posterior one-third of the tongue for general sensation and taste. Isolated lesions of the glossopharyngeal nerve are rare and usually also involve the vagus nerve. A 60-year-old woman was seen as an outpatient because she had suddenly developed double vision. She was watching her favorite television program the day before when it suddenly occurred. After a complete physical examination, it was found that her right eye, when at rest, was turned medially, and she was unable to turn it laterally. A moderate amount of glucose was found in her urine, and she had an abnormally elevated blood glucose level. When closely questioned, she admitted that recently she had noticed having to pass water more frequently,especially at night. Do you think there is any connection between her glucosuria, high blood glucose,polyuria,polydipsia,and weight loss and her eye condition? An 18-year-old man was admitted to the hospital unconscious after a serious motorcycle accident. After a complete physical examination was performed and lateral and anteroposterior radiographs of the skull were taken, it was found that the patient had a fracture involving the anterior cranial fossa. It also was noted that he had a slight but continuous blood-stained watery discharge from his left nostril. Three days later, he recovered consciousness,and a further physical examination revealed that he could no longer smell. This was tested by asking him to recognize the smell of coffee,oil of cloves,and oil of peppermint. Is it possible for normal individuals with an acute sense of smell to be unable to recognize common scents?
These codes do not allow differentiation between attempted suicide and "parasuicide", both being included in the general category of self-harm. The stressor may be an overwhelming traumatic experience involving serious threat to the security or physical integrity of the individual or of a loved person(s). The risk of this disorder developing is increased if physical exhaustion or organic factors. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions, as evidenced by the fact that not all people exposed to exceptional stress develop the disorder. The symptoms show great variation but typically they include an initial state of "daze", with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation (to the extent of a dissociative stupor - see F44. Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within 2-3 days (often within hours). Diagnostic guidelines There must be an immediate and clear temporal connection between the impact of an exceptional stressor and the onset of symptoms; onset is usually within a few minutes, if not immediate. In addition, the symptoms: - 119 - (a)show a mixed and usually changing picture; in addition to the initial state of "daze", depression, anxiety, anger, despair, overactivity, and withdrawal may all be seen, but no one type of symptom predominates for long; (b)resolve rapidly (within a few hours at the most) in those cases where removal from the stressful environment is possible; in cases where the stress continues or cannot by its nature be reversed, the symptoms usually begin to diminish after 24-48 hours and are usually minimal after about 3 days. This diagnosis should not be used to cover sudden exacerbations of symptoms in individuals already showing symptoms that fulfil the criteria of any other psychiatric disorder, except for those in F60. However, a history of previous psychiatric disorder does not invalidate the use of this diagnosis. Typical symptoms include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks") or dreams, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. Commonly there is fear and avoidance of cues that remind the sufferer of the original trauma. Rarely, there may be dramatic, acute bursts of fear, panic or aggression, triggered by stimuli arousing a sudden recollection and/or re-enactment of the trauma or of the original reaction to it. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. The onset follows the trauma with a latency period which may range from a few weeks to months (but rarely exceeds 6 months). In a small proportion of patients the condition may show a chronic course over many years and a transition to an enduring personality change (see F62. Diagnostic guidelines this disorder should not generally be diagnosed unless there is evidence that it arose within 6 months of a traumatic event of exceptional severity. A "probable" diagnosis might still be possible if the delay between the event and the onset was longer than 6 months, provided that the clinical manifestations are typical and no alternative identification of the disorder. In addition to evidence of trauma, there must be a repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams. Conspicuous emotional detachment, numbing of feeling, and avoidance of stimuli that might arouse recollection of the trauma are - 120 - often present but are not essential for the diagnosis. The autonomic disturbances, mood disorder, and behavioural abnormalities all contribute to the diagnosis but are not of prime importance. The stressor may involve only the individual or also his or her group or community. Individual predisposition or vulnerability plays a greater role in the risk of occurrence and the shaping of the manifestations of adjustment disorders than it does in the other conditions in F43. The manifestations vary, and include depressed mood, anxiety, worry (or a mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, and some degree of disability in the performance of daily routine. The individual may feel liable to dramatic behaviour or outbursts of violence, but these rarely occur. None of the symptoms is of sufficient severity or prominence in its own right to justify a more specific diagnosis. In children, regressive phenomena such as return to bed-wetting, babyish speech, or thumb-sucking are frequently part of the symptom pattern. The onset is usually within 1 month of the occurrence of the stressful event or life change, and the duration of symptoms does not usually exceed 6 months, except in the case of prolonged depressive reaction (F43. Grief reactions of any duration, considered to be abnormal because of their form or content, should be coded as F43. Diagnostic guidelines Diagnosis depends on a careful evaluation of the relationship between: (a)form, content, and severity of symptoms; (b)previous history and personality; and (c)stressful event, situation, or life crisis.
We advise checking for the so-called common associated autoimmune conditions (Thyroid-stimulating hormone, Thyroid hormone), and finally tTgA to check the diet adherence. The sensitivity of tTgA for the quality of diet adherence control is not well studied. The key endpoints in the clinical follow-up are normalization of weight, prevention of overweight, and mucosal healing, which means normalization of histology to Marsh 0-1. Dietary adherence guarantees mucosal healing and at least improvement of non-gastrointestinal symptoms. In general, we advise controlling those patients in the out-clinic only once every two years. Moreover, we suggest follow-up until serum values are at satisfying levels or upon indication (bone density deviations, chronic or recurrent diarrhea, or zinc related skin lesions). Therefore, inadvertent gluten intake is discussed during the out-clinic visit, especially in patients with a poor educational state or low-income families. Recently an Israeli study reported about pediatric celiac patients who were lost to follow-up. This is problematic in young patients, who may not reach their growth potential (catch-up growth, etc. Maybe, this selection of patients in the family already had (albeit minor) complaints. We advise offering newly diagnosed celiac patients screening on their first and second family degree family members. It is a herpetiform clustering of extremely itchy urticated papules, especially on the extensor side of the elbows and knees, buttocks, and scalp. Diamonodiphenyl sulfone is almost always indicated and initiated due to rash and the itching. Patients should be monitored for the adverse effects of diamonodiphenyl sulfone, primary hemolytic anaemia, methemoglobinaemia, agranulocytosis, and neuropathy. However, we see major abnormalities in bone density in our population diagnosed above 50 years of age, females as well as males. All of these high-risk patients for bone fractures should be treated with calcium and vitamin D. During our yearly follow-up we measure calcium, alkaline phosphatase, vitamin D, and Parathyroid hormone for a compensatory increase of the bone mass. We repeat bone density investigation in the case of osteopenia in general after an interval of three years. Stabilization or even improvement after 1 2 years would be a strong argument that the patients suffer from gluten ataxia. Unfortunately, the critical number of celiac patients per general physician is insufficient. In the Netherlands, only 25,000 patients are known in a population of 16 million inhabitants. The number of gastroenterologists in the country is 500, so in general, gastroenterologists should control at least 50 celiac patients per doctor. Prompt access for our celiac patients to specialized centers around the country is recommended but not well-organized. However, access to those doctors is limited; the majority of them is each controlling only 150-200 celiac patients per year. Access for patients to a well-trained celiac interested gastroenterologists is limited. It should be noted that this care is not well organized, not only in Europe, but worldwide. Arbitrarily, we vaccinate all celiac patients with a spleen volume below 100cc with Pneumovac. We treat them with slow release budesonide (Entocort) for three months and in the case of a relapse with thiopurines especially tioguanide (thiosix).
Biased homophones to were more likely than newhomophones be spelled according to their least common to interpretation; this priming effect was larger for Korsakoffs than controls, whereasKorsakoffs were severely impaired relative to controls on a subsequentrecognition memory test. In the present paper we focus on indirect tests that are more amenable to comparison with direct memory measures. An important property of studies of reading degraded or geometrically transformedscript is that they permit general benefits fromincreased practice to be separated fromspecific benefits accruing to repeated groupsof wordsor sentences (by comparison of repeated and nonrepeated items as practice progresses). Initial studies of speed of reading mirror-reversedscript (Cohen & Squire 1980; Martone et al 1984) found a general practice effect in amnesics, as well as an item-specific repetition effect; however,whereasthe general practice effect was preservedin amnesics,the item-specific effect was not as large in amnesicsas in normals. Moscovitch et al (1986) argue that the impairment on repeated items occurred because the difficulty of reading mirror-reversed script encourages normalsubjects to use explicit memory speed reading of repeated items (for to a similar argumentsee Horton 1985), a resource not available to the amnesic patients. Kolers 1976), practice effects reading geometrically transformed text are quite durable in memory- Annu. In Cohen& Squire (1980), both general and item-specific effects persisted at a delay of 3 months. A most impressive demonstration of acquisition of problem-solvingability in amnesics has been provided by Cohen et al (1985; see also Cohen1984; Squire & Cohen 1984), using the Tower of Hanoi puzzle. A heterogeneous group of amnesics showed completely preserved practice effects (measured in terms of reduction in number movesto solution) over 16 attempts to solve the problem(4 per day of for 4 days). A direct memory test was constructed by presenting the puzzle in intermediate stages of solution. Someof these configurations were on the optimal 31-movesolution path and would have been encountered previously; others were not on the optimal path and would not have been encountered previously. As in studies of reading transformed text, practice effects on the Towerof Hanoi puzzle are apparently very persistent: Patient H. Curiously, Butters et al (1985) failed to replicate normal learning of the Tower Hanoipuzzle in diencephalic. Korsakoff of syndrome) amnesics; they attribute this failure to a impairment "initiating in and ordering of problem-solving strategies," so that "failure to acquire the. In one experiment, Korsakoffs were found to rate melodies that they had heard before in the experiment as more pleasant than new melodies; this affective bias was the samein Korsakoffs and controls, whereas recognition of old melodies was significantly impaired in Korsakoffs comparedto controls. In another experiment, subjects were given biographical information about two males depicted in photographs; one stimulus person was described in positive terms, the other in negative ones. In this situation, amnesicsdid not showas extreme a bias in favor of the positively characterized stimulus person as did controls. Temporary Change in Brain State Effects of drugs and hypnosis have been cited as dissociating direct and indirect tests. Hashtroudiet al 1984;Kihlstrom1980; Parker et al 1983; Williamsen al 1965); however validity and replicability of these studies et the have been questioned [McKoon al (1986); but see also Nissen et al (1987) et for more recent drug work, and Kihlstrom (1985) for more recent hypnosis work]. Werefer instead to another striking demonstration of this type of dissociation by Squire et al (1985). Recognition memory was took 9 hr to return to a level approaching that shownby controls. Primingwas equivalent for the two types of rehearsal in a subsequent auditory perceptual identification test; however, elaborative rehearsal produced better recognition memory than did rote rehearsal. Consistent with this result, Graf & Schacter (1985) and Schacter &Graf (1986a) showedthat elaborative processing. Similar results were obtained in free-association priming with common idioms and highly related word pairs as study materials (Schacter &Whitfield 1986). Finally, Greene (1986) found no effect on word completion priming of intention to learn study (presumed influence elaborative activity). In the latter four studies to large effects of amountof elaboration on cued recall were observed. Jacoby &Dallas (1981) investigated effects of difficulty of encoding and study time. They showedthat reading a word resulted in as muchpriming of later perceptual identification as did producingthat wordas a solution to an anagram; by contrast, solving anagrams produced muchbetter recognition memory studied items than did reading. Similarly, increasing study time for (by slowing rate of presentation of study words) enhancedrecognition memory but did not affect the magnitudeof priming. Consistent with the latter result, Richardsonand Bjork(1982) found no effect of duration of rehearsal an imaginedvoice on priming of auditory perceptual identification (for both rote and elaborative types of rehearsal), and Greene(1986) obtained a null effect of rehearsal duration on word completionpriming.
