Section 2: Items & services 43 Foot care Part B covers podiatrist (foot doctor) foot exams or treatment if you have diabetes related nerve damage or need medically necessary treatment for foot injuries or diseases medicine for stomach pain buy cheapest haldol, like hammer toe symptoms of dehydration purchase haldol 1.5 mg with amex, bunion deformities symptoms 7 dpo bfp order cheapest haldol, and heel spurs medicine university generic haldol 1.5 mg visa. Medicare doesn?t usually cover routine foot care treatment internal hemorrhoids discount 10mg haldol amex, like cutting or removing corns and calluses treatment 7 february purchase haldol 5mg mastercard, trimming medicine for constipation order generic haldol online, cutting medications prednisone order cheap haldol on-line, or clipping nails, or hygienic or other preventive maintenance, like cleaning and soaking your feet. You pay 20% of the Medicare-approved amount for medically necessary treatment provided by your doctor, and the Part B deductible applies. If you have diabetes, see Terapeutic shoes or inserts on page 104 and Foot care (for diabetes) below. Foot care (for diabetes) Part B covers foot exams if you have diabetic peripheral neuropathy and loss of protective sensations. How often Every 6 months, as long as you haven?t seen a foot care professional for another reason between visits. Section 2: Items & services 45 Gym memberships & ftness programs Medicare doesn?t cover gym membership or ftness programs. Costs You pay 100% for non-covered services, including gym membership and ftness programs. Health education & wellness programs Medicare usually doesn?t cover health education and wellness programs, but it does cover. Hearing & balance exams Part B covers diagnostic hearing and balance exams if your doctor or other health care provider orders them to see if you need medical treatment. Hepatitis B shots Part B covers these shots if you?re at medium or high risk for Hepatitis B. Costs You pay nothing for the shot if your doctor or other qualifed health care provider accepts assignment. Costs You pay nothing for the screening test if your doctor or other qualifed health care provider accepts assignment. Hepatitis C screening tests Medicare covers a screening test if your primary care doctor or other primary care provider orders it and you meet one or more of these conditions. Costs You pay nothing for the screening test if your doctor or other qualifed health care provider accepts assignment. If you?re pregnant, you can get the screening up to 3 times during your pregnancy. Costs You pay nothing for the test if your doctor or other qualifed health care provider accepts assignment. Section 2: Items & services 49 Home health services Part A and/or Part B cover eligible home health services if you meet certain conditions. Custodial or personal care (help bathing, dressing, and using the bathroom) when this is the only care you need. What it is Depending on your terminal illness and related conditions, the plan of care your hospice team creates can include any or all of these services. If your usual caregiver (like a family member) needs a rest, you can get inpatient respite care in a Medicare-approved facility (like a hospice inpatient facility, hospital, or nursing home). You can get respite care more than once, but it can only be provided on an occasional basis. Things to know Hospice care is usually given in your home but may also be covered in a hospice inpatient facility. Original Medicare will still pay for covered benefts for any health problems that aren?t part of your terminal illness and related conditions, but this is unusual. Once you choose hospice care, your hospice beneft will usually cover everything you need. The cost of an oxygen humidifer will be included in the monthly fee for your oxygen equipment. Costs You pay 20% of the Medicare-approved amount, and the Part B deductible may apply. Incontinence supplies & adult diapers Medicare doesn?t cover incontinence supplies or adult diapers. Section 2: Items & services 53 Inpatient hospital care Part A covers inpatient hospital care when all of these are true. Inpatient mental health care in a psychiatric hospital (but not in a Medicare-certifed distinct part psychiatric unit of an acute care or critical access hospital) is limited to 190 days in a lifetime. Things to know this includes care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term care hospitals, and inpatient care as part of a qualifying clinical research study. Your doctor must certify that you have a medical condition that requires intensive rehabilitation, continued medical supervision, and coordinated care that comes from your doctors and therapists working together. This is because your beneft period starts on day one of your prior hospital stay, and that stay counts toward your deductible. You?re transferred to an inpatient rehabilitation facility directly from an acute care hospital. Section 2: Items & services 55 Inpatient rehabilitation care (continued) What it is Inpatient rehabilitation can help if you?re recovering from a serious surgery, illness, or injury and need an intensive rehabilitation therapy program, physician supervision, and your doctors and therapists working together to give you coordinated care. Rehabilitation services, including physical therapy, occupational therapy, and speech language pathology. Personal items, like toothpaste, socks, or razors (except when they?re provided as part of a hospital admission pack). A private room, unless medically necessary Things to know Part B covers doctors services you get while you?re in an inpatient rehabilitation facility. Costs You pay 100% for insulin (unless used with an insulin pump, then you pay 20% of the Medicare-approved amount, and the Part B deductible applies). Things to know Part D may cover insulin and certain medical supplies used to inject insulin, like syringes, gauze, and alcohol swabs. However, if you use an external insulin pump, insulin and the pump may be covered as durable medical equipment under Part B. Other diabetic services and supplies: See Diabetes services and Diabetes supplies on pages 30?31. This is covered if your doctor or other health care provider refers you for the service, and when the service is given by a doctor, certain qualifed non-doctor provider, or certain rural provider. Costs You pay 20% of the Medicare-approved amount per session if you get the service from a doctor or other qualifed health care provider, and the Part B deductible applies. What it is Kidney disease education teaches you how to take the best possible care of your kidneys and gives you information you need to make informed decisions about your care. Tese services are covered if they?re done by the Medicare-certifed hospital where you?ll get your transplant or another hospital that participates in Medicare. Doctors services for kidney transplant surgery (including care before surgery, the actual surgery, and care afer surgery). Medicare will only pay for your transplant drug therapy for 36 months afer the month of the kidney transplant if both of these apply. Section 2: Items & services 59 Kidney transplants (continued) this is because your Medicare coverage will end 36 months afer a successful kidney transplant if you only have Medicare due to permanent kidney failure. Blood (if a transfusion is needed) Part B helps pay for these transplant services. Immunosuppressive drugs (generally for a limited time afer your child leaves the hospital following a transplant). Part A usually pays for inpatient hospital services, and you pay a one-time yearly deductible. What it is Long-term care is a range of services and support for your personal care needs. Instead, most long-term care is help with basic personal tasks of everyday life, sometimes called activities of daily living. This is because your beneft period starts on day one of your prior hospital stay, and that stay counts toward your deductible. Things to know Before your frst lung cancer screening, you?ll need to schedule a lung cancer screening counseling and shared decision making visit with your doctor to discuss the benefts and risks of lung cancer screening. Screening mammograms: You pay nothing for the test if your doctor or other qualifed health care provider accepts assignment. Mental health care (inpatient) Part A covers mental health care services you get in a hospital that require you to be admitted as an inpatient. What it is Mental health care services help with conditions like depression and anxiety. Things to know You can get these services either in a general hospital or a psychiatric hospital that only cares for people with mental health conditions. If you?re in a psychiatric hospital (instead of a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime. A private room, unless medically necessary Section 2: Items & services 65 Mental health care (inpatient) (continued) More information. Talk to your doctor or other health care provider about changes in your mental health. Part B also covers outpatient mental health services for treatment of inappropriate alcohol and drug use. What it is Mental health services help with conditions like depression and anxiety. Things to know Part B covers mental health services and visits with these types of health professionals: psychiatrists or other doctors, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. You pay a percentage of the Medicare-approved amount for each service you get from a doctor or certain other qualifed mental health professionals if your health care professional accepts assignment. What it is Partial hospitalization provides a structured program of outpatient psychiatric services as an alternative to inpatient psychiatric care. Medicare helps cover partial hospitalization services when they?re provided through a hospital outpatient department or community mental health center. Medicare only covers partial hospitalization if the doctor and the partial hospitalization program accept assignment. Support groups that bring people together to talk and socialize (This is diferent from group psychotherapy, which is covered. Cost You pay nothing for this test if your doctor or other qualifed health care provider accepts assignment. Section 2: Items & services 69 Nebulizers & nebulizer medications Part B covers nebulizers (and some medicines used in nebulizers if considered reasonable and necessary). Custodial care helps you with activities of daily living (like bathing, dressing, using the bathroom, and eating) or personal needs that could be done safely and reasonably without professional skills or training. It must be medically necessary for you to have skilled nursing care (like changing sterile dressings). Costs You pay nothing for these preventive services because the Part B deductible and coinsurance don?t apply. Costs You pay nothing for this service if your primary care doctor or other qualifed primary care practitioner accepts assignment. Occupational therapy Part B helps pay for medically necessary outpatient occupational therapy. Costs You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Counseling and therapy services are covered in person and by virtual delivery (using 2-way audio/video communication technology). What it is Part B covers opioid use disorder treatment services including medication-assisted treatment medications, counseling, drug testing, and individual and group therapy. Things to know Talk to your doctor or other health care provider to fnd out where you can go for these services. If you?re in a Medicare Advantage Plan, you may have to switch from your current opioid treatment provider (if they?re not enrolled in Medicare) to a Medicare enrolled opioid treatment provider to make sure your treatment stays uninterrupted. Doctors services associated with heart, lung, kidney, pancreas, intestine, and liver organ transplants. Immunosuppressive (or transplant) drugs, in certain conditions, associated with Medicare-covered transplants. Services for heart, lung, kidney, pancreas, intestine, and liver organ transplants, in certain conditions. Things to know Organ transplants must be performed in Medicare-approved facilities. Stem cell and cornea transplants aren?t limited to Medicare-approved transplant centers. Costs You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Medicare will only pay for orthotic items furnished by a supplier enrolled in Medicare, no matter who submits the claim (you or your supplier). Osteoporosis drugs Part A and Part B help pay for an injectable drug for osteoporosis and visits by a home health nurse to inject the drug if you meet these conditions. Costs You pay 20% of the Medicare-approved amount for the cost of the drug, and the Part B deductible applies. Section 2: Items & services 75 Ostomy supplies Part B covers medically necessary ostomy supplies if you?ve had a colostomy, ileostomy, or urinary ostomy. Medicare covers the amount of supplies your doctor says you need, based on your condition. Outpatient hospital services Part B covers medically necessary diagnostic and treatment services you get as an outpatient from a Medicare-participating hospital. Emergency or observation services, which may include an overnight stay in the hospital or services in an outpatient clinic, including same-day surgery. However, the hospital outpatient copayment for the service is capped at the inpatient deductible amount. In most cases, the copayment can?t be more than the Part A hospital stay deductible for each service. If you get hospital outpatient services in a critical access hospital, your copayment may be higher and may exceed the Part A hospital stay deductible. Outpatient medical & surgical services & supplies Part B covers approved procedures, like X-rays, casts, stitches, or outpatient surgeries. Costs You pay 20% of the Medicare-approved amount for your doctors or other health care providers services. You usually pay the hospital a copayment for each service you get in a hospital outpatient setting. Tere are exceptions for costly surgical procedures (called comprehensive services), like total knee replacements. For these services, you pay 20% for the entire episode of care, including any drugs, laboratory tests, and other services. In most cases, for each service provided, the copayment can?t be more than the Part A hospital stay deductible. The Part B deductible applies, and you pay all costs for items or services that Medicare doesn?t cover. If you own your own equipment, Medicare will help pay for oxygen contents and supplies for the delivery of oxygen when all of these conditions are met. Your doctor says you have a severe lung disease or you?re not getting enough oxygen. Tubing and related supplies for the delivery of oxygen and oxygen contents Costs You pay 20% of the Medicare-approved amount, and the Part B deductible applies. If you have a Medicare drug plan, the plan may also have programs in place, like Medication Terapy Management Programs or Drug Management Programs, to help you use prescription opioid pain medications more safely. For most pain management services, you pay 20% of the Medicare-approved amount for visits to your doctor or other health care provider to diagnose or treat your condition. Section 2: Items & services 79 Pain management (continued) Things to know Tere may be other ways to manage your pain. If this happens, or if your doctor or other health care provider recommends you get services more ofen than Medicare covers, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them. In some cases, Medicare may cover a pancreas transplant even if you don?t need a kidney transplant. Part B will pay for your transplant drugs (also called immunosuppressive drugs) with no time limit if either of these apply. Part B will only pay for your transplant drug therapy for 36 months afer the month of the kidney transplant if both of these apply. This is because your Medicare coverage will end 36 months afer a successful kidney transplant if you only have Medicare due to permanent kidney failure. Section 2: Items & services 81 Pap tests See Cervical & vaginal cancer screenings on pages 17?18. Physical therapy Part B helps pay for medically necessary outpatient physical therapy. Costs You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Costs You pay nothing for pneumococcal shots if your doctor or other qualifed health care provider accepts assignment for giving the shot. Things to know Talk with your doctor or other health care provider to see if you need one or both shots. Section 2: Items & services 83 Prescription drugs (outpatient) Part B covers a limited number of outpatient prescription drugs under limited conditions. A doctor must certify that you can?t give yourself the injection or learn how to give yourself the drug by injection. The home health nurse or aide won?t be covered to provide the injection unless family and/or caregivers are unable or unwilling to give you the drug by injection. Medicare won?t pay for any services or items, including transplant drugs, for patients who aren?t entitled to Medicare. Part D may cover other transplant drugs that Part B doesn?t cover, even if Medicare didn?t pay for the transplant. If you?re worried about paying for them afer your Medicare coverage ends, talk to your doctor, nurse, or social worker. Oral cancer drugs: Medicare helps pay for some oral cancer drugs you take by mouth if the same drug is available in injectable form or the drug is a prodrug of the injectable drug. A prodrug is an oral form of a drug that, when ingested, breaks down into the same active ingredient found in the injectable drug.
Each back blow hand and place the thumb side just above your should be separate from the others medications you should not take before surgery buy haldol overnight delivery. Cover your fist with your other hand and give quick symptoms stomach cancer cheap haldol 1.5mg without a prescription, inward and upward thrusts into the Abdominal thrusts symptoms 0f diabetes haldol 10mg sale. Each abdominal thrust should stand behind the person medications covered by medi cal generic haldol 10 mg fast delivery, with one foot in front be separate from the others medications knee purchase haldol 1.5 mg. After the choking incident is over medications for gout purchase haldol 5mg with amex, even if the person seems fine medicine ethics order discount haldol, he or she should still be evaluated by a healthcare provider to make sure there is no damage to the airway or other internal injuries medicine net order haldol paypal. For step-by-step instructions on giving first aid to an adult or child who is choking, see Skill Sheets 4-1 and 4-2. Table 4-1 describes how to troubleshoot special situations when an adult or child is choking. Use a combination of back blows (A) and abdominal thrusts (B) when an adult or child is choking. To give chest thrusts, position yourself behind the person as you would for abdominal thrusts. The person is obviously pregnant or known to Give chest thrusts instead of abdominal thrusts. Give abdominal thrusts in the same way that you would for a person who is standing. If features of the wheelchair make it difficult to give abdominal thrusts, give chest thrusts instead. Even if you are not able to speak, the open line will cause the dispatcher to send help. Give yourself abdominal thrusts, using your hands, just as if you were giving abdominal thrusts to another person. Alternatively, bend over and press your abdomen against any firm object, such as the back of a chair or a railing. Do not bend over anything with a sharp edge or corner that might hurt you, and be careful when leaning on a railing that is elevated. If the infant is large or your hands are small, you may find it easiest to sit or kneel. Use a combination of back blows (A) and chest thrusts (B) when an infant is choking. Continue sets of 5 back blows and 5 chest thrusts until the infant can cough forcefully, cry or breathe, or the infant becomes unresponsive. After the choking incident is over, even if the infant seems fine, he or she should still be evaluated by a healthcare provider to make sure there is no damage to the airway or other internal injuries. For step-by-step instructions on giving first aid to an infant who is choking, see Skill Sheet 4-3. Continue giving sets of 5 back blows and 5 abdominal thrusts until: the person can cough forcefully, speak, cry or breathe. Continue giving sets of 5 back blows and 5 abdominal thrusts until: the child can cough forcefully, speak, cry or breathe. Verify that the infant is choking by checking to see if the infant is crying or coughing forcefully. Continue giving sets of 5 back blows and 5 chest thrusts until: the infant can cough forcefully, cry or breathe. When a person becomes suddenly ill, you can I help by providing appropriate first aid care; summoning help, if needed; and keeping the person comfortable until help arrives. A chronic illness is an illness that a person lives with on an ongoing basis and that often requires continuous treatment to manage. When a person becomes suddenly ill, it may be the result of an acute illness, or it may be an acute flare-up of a chronic condition. Signs and Symptoms of Sudden Illness the signs and symptoms of sudden illness vary widely, depending on the cause of the illness. Signs and symptoms like trouble breathing, pain that is persistent or severe, problems seeing or speaking, problems feeling or moving, seizures or unresponsiveness require a call to 9-1-1 or the designated emergency number. If you are unsure about the severity of the illness, it is better to call for help early than to wait for the illness to progress. If your initial check of the person reveals any life-threatening conditions (see Chapter 1, Box 1-5), make sure that someone calls 9-1-1 or the designated emergency number right away, and then provide care according to the signs and symptoms that you find and your level of training. Follow the same general guidelines as you would for any emergency: Do no further harm. Respiratory Distress Respiratory distress, or difficulty breathing, is evidenced by signs and symptoms such as shortness of breath, gasping for breath, hyperventilation (breathing that is faster and shallower than normal), or breathing that is uncomfortable or painful. Signs and Symptoms of Respiratory Distress A person who is experiencing respiratory distress is, understandably, often very frightened. Because the person is struggling to breathe, speaking in complete sentences may be difficult. You might hear wheezing, gurgling or high-pitched noises as the person tries to breathe. In some breathing emergencies, the oxygen supply to the body is greatly reduced, whereas in others the oxygen supply is cut off entirely. If breathing stops or is restricted long enough, the person will become unresponsive, the heart will stop beating and body systems will quickly fail. Call 9-1-1 or the designated emergency number and provide appropriate first aid care until help arrives: If you know the cause of the respiratory distress (for example, an asthma attack or anaphylaxis) and the person carries medication used for the emergency treatment of the condition, offer to help the person take his or her medication. Providing reassurance can reduce anxiety, which may also help to make breathing easier. Try phrasing your questions as yes or no questions so the person can nod or shake his or her head in response instead of making the effort to speak. Asthma Many people have asthma, a chronic illness in which certain substances or conditions, called triggers, cause inflammation and narrowing of the airways, making breathing difficult. Common triggers include exercise, temperature extremes, allergies, air pollution, strong odors (such as perfume, cologne and scented cleaning products), respiratory infections, and stress or anxiety. The trigger causes inflammation and swelling, which causes the opening of the airways to become smaller and makes it harder for air to move in and out of the lungs. People who have asthma usually know what can trigger an attack and take measures to avoid these triggers. Long-term control medications are taken regularly, whether or not signs and symptoms of asthma are present. These medications help prevent asthma attacks by reducing inflammation and swelling and making the airways less sensitive to triggers. These medications work quickly to relax the muscles that tighten around the airways, opening the airways right away so that the person can breathe more easily. Both long-term control medications and quick-relief (rescue) medications may be given through an inhaler, a nebulizer (Box 5-1) or orally. The most common way to take long-term control and quick-relief (rescue) medications is by inhaling them. If the person has an asthma action plan (a written plan that the person develops with his or her healthcare provider that details daily management of the condition as well as how to handle an asthma attack), help the person to follow that plan. Encourage the person to use his or her prescribed quick-relief (rescue) medication, assisting if needed and if state or local regulations allow. Stay with the person and monitor his or her condition until the person is able to breathe normally or help arrives. Allergic Reactions and Anaphylaxis Our immune systems help to keep us healthy by fighting off harmful pathogens that can cause disease. But sometimes our immune systems overreact and try to fight off ordinary things that are not usually harmful, like certain foods, grass or pet dander (tiny flakes of skin that animals shed). Common allergens (allergy triggers) include venomous insect stings, certain foods (like peanuts, tree nuts, shellfish, milk, eggs, soy and wheat), animal dander, plant pollen, certain medications (like penicillin and sulfa drugs) and latex. A person who is having a mild to moderate allergic reaction may develop a skin rash, a stuffy nose, or red, watery eyes. The skin or area of the body that came in contact with the allergen usually swells and turns red. If you are alone, help the person administer the medication and then call 9-1-1 or the designated emergency number. While you wait for help to arrive, make sure the person is sitting in a comfortable position, or have the person lie down if he or she is showing signs of shock. If a person is known to have an allergy that could lead to anaphylaxis, he or she may carry an epinephrine auto injector (a syringe system, available by prescription only, that contains a single dose of epinephrine). Devices are available containing different doses because the dose of epinephrine is based on weight (0. Many healthcare providers advise that people with a known history of anaphylaxis carry an anaphylaxis kit containing at least two doses of epinephrine (two auto injectors) with them at all times. This is because more than one dose may be needed to stop the anaphylactic reaction. Have the person administer a second dose only if emergency responders are delayed and the person is still having signs and symptoms of anaphylaxis 5 to 10 minutes after administering the first dose. It is important to act fast when a person is having an anaphylactic reaction because difficulty breathing and shock are both life-threatening conditions. Where state and local laws allow, some organizations (such as schools) keep a stock epinephrine auto injector for designated staff members who have received the proper training to use in an anaphylaxis emergency. Different brands of epinephrine auto injectors are available, but all work in a similar fashion (and some have audio prompts to guide the user). The device must be held in place for the recommended amount of time (5 to 10 seconds, depending on the device) to deliver the medication. Some medication may still remain in the auto injector even after the injection is complete. After removing the auto injector, massage the injection site for several seconds (or have the person massage the injection site). For step by-step instructions on helping a person to use an epinephrine auto injector, see Skill Sheet 5-2. An antihistamine is a medication that counteracts the effects of histamine, a chemical released by the body during an allergic reaction. An organ called the pancreas secretes insulin, a hormone that causes glucose to be moved from the bloodstream into the cells, where it is used for energy. A person with diabetes may manage the condition with insulin injections or oral medications. To keep blood glucose levels within an acceptable range, food intake, exercise and medication must be balanced. A person with diabetes must follow a well-balanced diet, with limited sweets and fats. The timing of meals and snacks relative to exercise and medication is important as well. If the to be under the influence of person is experiencing hyperglycemia, his or her breath may have alcohol. Severe hypoglycemia or hyperglycemia can may slur his or her words or have result in confusion, seizures or loss of consciousness and may be life difficulty walking. Call 9-1-1 or the designated emergency number if the person is unresponsive, not fully awake or having a seizure. For example, if the person is not fully awake, interview bystanders and conduct a head-to-toe check, then put the person in the recovery position. If the person is having a seizure, take steps to keep the person safe while you let the seizure run its course. If the person is known to have diabetes and thinks he or she is having a diabetic emergency, you may be able to help the person by giving him or her some form of sugar. Only offer the person sugar by mouth if the person is responsive, able to answer your questions and able to swallow. Some people may be responsive but not fully awake and therefore not able to safely swallow; in this case, do not attempt to give the person sugar by mouth. You should also call 9-1-1 or the designated emergency number if you are not able to immediately obtain an acceptable form of sugar. Even if the person is experiencing hyperglycemia (too much glucose in the bloodstream), giving the person 15 to 20 grams of sugar will not cause additional harm. If the person is not feeling better in about 10 to 15 minutes, call 9-1-1 or the designated emergency number. Some people with diabetes may have a prescribed glucagon kit that they carry with them to use in case of a severe hypoglycemic emergency. Glucagon is a hormone that stimulates the liver to release glucose into the bloodstream. The glucagon kit is only used when the person is unresponsive or has lost the ability to swallow. Those who spend a significant amount of time with the person (for example, family members, teachers, coaches or co-workers) may receive additional training to learn how to administer a glucagon injection. Seizures A seizure is the result of abnormal electrical activity in the brain, leading to temporary and involuntary changes in body movement, function, sensation, awareness or behavior. One common cause is epilepsy, a chronic seizure disorder that can often be controlled with medication. Other causes of seizure include fever, infection, diabetic emergencies, heat stroke and injuries to the brain tissue. A person having a grand mal seizure loses consciousness and has convulsions (uncontrolled body movements caused by contraction of the muscles). The person experiences a brief, sudden lapse of consciousness, causing the person to momentarily become very quiet and have a blank stare. A person with epilepsy may experience an aura (an unusual sensation or feeling) before the onset of the seizure. If the person recognizes the aura, he or she may have time to tell someone what is happening and sit down before the seizure occurs. First Aid Care for Seizures Although a seizure can be frightening to see, it is easy to care for a person who is having a seizure. Most seizures only last a few minutes, and the person usually recovers fully without any complications. If the person is known to have occasional seizures, it may not be necessary to call 9-1-1 or the designated emergency number. However, under some circumstances, you should call 9-1-1 or the designated emergency number when a person is having a seizure. Call for help if: the seizure lasts more than 5 minutes, or the the person is a young child or infant and the person has multiple seizures in a row. When a person is having a seizure, do not try to hold the person down or stop the seizure from happening. Just let the seizure run its course and take steps to protect the person from injury. The person may be drowsy and disoriented for as long as 20 minutes after the seizure is over. Stay with the person until he or she is fully recovered and aware of his or her surroundings, or until emergency responders arrive. Myth: Put something between the teeth of person who is having a seizure to prevent the person from biting or swallowing his or her tongue. And although the person may bite down on his or her tongue, causing it to bleed, this is a minor problem compared with the problems that can be caused by attempting to put an object in the mouth of a person who is having a seizure. You could chip a tooth or knock a tooth loose, putting the person at risk for choking. The person may also bite down with enough force to break the object and then choke on a piece of the object. Fainting If a person suddenly loses consciousness and then comes to after about a minute, he or she may simply have fainted. For example, being dehydrated (not having enough fluid in the body), being too hot, being in a crowded room or feeling intense emotion can cause a person to faint. Signs and Symptoms of Fainting A person who is about to faint often becomes pale, begins to sweat and may feel weak or dizzy. The person may sense that he or she is about to faint and may attempt to sit down to prevent a fall. First Aid Care for Fainting the person may faint before you even know what is happening, but sometimes it is possible to prevent a fainting spell by having the person sit down with his or her head near his or her knees, or lie down flat on his or her back. If the person does faint, check the person for responsiveness and normal breathing. If the person responds and is breathing normally, check the person from head to toe for injuries that might have happened as a result of the fall. If there are no injuries, place the person in the recovery position and loosen any tight clothing. Although the cause of fainting is not usually serious, the person should still follow up with his or her healthcare provider. Strokes can cause permanent brain damage, but with quick action, sometimes the damage can be stopped or reversed. Although strokes are most common in older adults, a person of any age, even a child, can have a stroke. For this reason, whenever a person experiences signs and symptoms of stroke, even if the signs and symptoms seem to go away, the person should seek immediate medical attention. Signs and Symptoms of Stroke the signs and symptoms of stroke can vary from person to person. First Aid Care for Stroke If you think that a person is having (or has had) a stroke, call 9-1-1 or the designated emergency number immediately. Note when the signs and symptoms first started (or, if you do not know when the signs and symptoms started, note the last time the person was known to be well).
Endocarditis seen on histopathologic examination of cardiac vegetation or intracardiac abscess medications definitions buy genuine haldol on line. Patient has evidence of arterial or venous infection on gross anatomic or histopathologic exam medicine zantac buy generic haldol 5mg on-line. Patient has an abscess or other evidence of oral cavity infection found on invasive procedure medications ibs purchase cheap haldol line, gross anatomic exam medicine 5658 discount 1.5mg haldol free shipping, or histopathologic exam medications are administered to generic 10 mg haldol overnight delivery. Patient has at least one of the following signs or symptoms with no other recognized cause: ulceration treatment group buy cheap haldol line, raised white patches on inflamed mucosa medications quit smoking order haldol canada, or plaques on oral mucosa 911 treatment discount haldol online visa. Note: excludes sputum and tracheal aspirate because these are not upper respiratory specimens. Patient has an abscess on gross anatomical or histopathologic exam or imaging test. Note: excludes sputum and tracheal aspirate because they are not upper respiratory specimens. Patient has evidence of pseudomembranous colitis on gross anatomic (includes endoscopic exams) or histopathologic exam. Patient has an acute onset of diarrhea (liquid stools for > 12 hours) and no likely noninfectious cause (for example, diagnostic tests, therapeutic regimen other than antimicrobial agents, acute exacerbation of a chronic condition, or psychological stress information). Patient has at least two of the following signs or symptoms: nausea*, vomiting*, abdominal pain*, fever (>38. Enteric pathogens identified on culture or with the use of other diagnostic laboratory tests include Salmonella, Shigella, Yersinia, Campylobacter, Listeria, Vibrio, Enteropathogenic or Enterohemorrhagic E. Patient has at least two of the following signs or symptoms compatible with infection of the organ or tissue involved: fever (>38. Consider the requirement for elevated January 2020 17 22 Surveillance Definitions transaminase level(s) met if at least one is elevated as per the normal range provided by the laboratory. Infant has at least one of the clinical and one of the imaging test findings from the lists below: At least one clinical sign: a. Pneumoperitoneum **Note: Bilious aspirate from a transpyloric feeding tube should be excluded 2. Patient has a lung abscess or other evidence of infection (for example, empyema) on gross anatomic or histopathologic exam. Patient has imaging test evidence of abscess or infection (excludes imaging test evidence of pneumonia) which if equivocal is supported by clinical correlation, specifically, physician documentation of antimicrobial treatment for lung infection). Patient has an abscess or other evidence of infection of affected site on gross anatomic or histopathologic exam. Post hysterectomy patient has purulent drainage from the vaginal cuff on gross anatomic exam. Post hysterectomy patient has an abscess or other evidence of infection at the vaginal cuff on gross anatomic exam. Patient has a breast abscess or other evidence of infection on gross anatomic or histopathologic exam. Patient has at least two of the following localized signs or symptoms: pain* or tenderness*, swelling*, erythema*, or heat* And at least one of the following: a. Identification of 2 or more common commensal organisms without a recognized pathogen is not eligible for use. Common Commensal organisms include, but not are not limited to , diphtheroids (Corynebacterium spp. Patient has erythema or drainage from umbilicus And at least one of the following: January 2020 17 28 Surveillance Definitions a. Patient has an abscess or other evidence of infection on gross anatomical exam, during invasive procedure, or on histopathologic exam. It the symptoms of a heart attack may include pain, you with the information you need to understand how heart attacks happen, and what pumps blood through arteries to every part of the pressure, tightness or burning in the chest, pain or the steps are after one occurs. The arteries that carry blood to your heart burning radiating into the neck or jaw, or pain muscle are the coronary arteries. Heart attacks occur for several arteries carry blood rich in oxygen and nutrients pressure or tightness in the center of the upper reasons, but future events can often be prevented by being proactive. Women tend to have more jaw pain, healthy diet, control your portions, and exercise regularly. There are two main coronary arteries: the right coronary artery and Coronary Artery Disease the left coronary artery. Each of these arteries As mentioned above, the arteries that supply branch out into smaller arteries. As a result, A heart attack occurs when the blood supply to blood cannot fow properly through the arteries part of the heart muscle is completely cut off. Because the heart isn?t receiving oxygen, heart cells become damaged and begin to die. Prior to most heart attacks the plaque becomes medicine is safe, and it is non-habit forming. This ruptured plaque It comes in several different forms: A nuclear stress test involves taking two sets of. Tablet (placed under the tongue) images of your heart one set while at rest and. Your nurse will tell you when and how to take this sort of like exercise does; only you don?t have. It is very important that you know the names of your medication(s) and why you take them. It Cardiac catheterization is also called a heart cath, You may be asked to have, or already have had, is a good idea to keep a list of medications with or cardiac cath. The procedure involves inserting a various tests or procedures to determine the you at all times, including the dose, and number of long, thin, fexible tube (catheter) into the heart. Please ask your health Please use the table at the back of this booklet to vessel, usually in the leg or arm. This electrical activity helps set your When the catheter is inside the heart, the doctor by your doctor. The dye allows the x-rays taking any over-the-counter medications, electrical problems with your heart. Do not increase or decrease the dosage of Angina is a sign that the heart may not be getting Echocardiogram (Echo) fows through the coronary arteries that bring your medications, or stop taking them, without enough blood or oxygen. It can be a warning sign An echocardiogram (echo) is a test that checks blood and oxygen to the heart muscle. It uses sound cardiologist uses this information to choose the waves to produce a picture of your heart. It most often feels like a constricting pain in the intake, as alcohol may affect you poorly when is done to help your doctor check: center of the chest. Nuclear Stress Test Medications Finding the Cause of Your Angina A nuclear stress test measures blood fow to your Your doctor will likely prescribe medications to A number of tests are available to help the doctor heart muscle both at rest and while the heart is treat your heart condition to keep it from getting fnd the cause of your angina. During the operation, the surgeon creates heart attack varies from person to person. Sections of veins or arteries are to heal, depending upon the amount of damage to removed from other places in the body where your heart muscle, and the physical condition you they are not needed. During your recovery, you will work to safely regain your strength and stamina, and learn this makes a new route for blood to fow. The lifestyle changes necessary to prevent further surgeon does not remove the diseased coronary problems. Activity After Discharge After leaving the hospital, it is recommended that you exercise every day in order to regain the strength and stamina you lost because of bed rest and inactivity. You also may not be accustomed to exercise and need to build up gradually to establish a regular exercise program. Aerobic Exercise Regular aerobic exercise (walking, cycling, Balloon Angioplasty Balloon Angioplasty With Stents swimming) will help: Balloon angioplasty is a non-surgical, A balloon angioplasty with stents adds invasive treatment used to open one or another step to the above balloon. Following the above procedure: the procedure: the catheter is reinserted with a Your surgeon will make the fnal decision about. The catheter has a small, was just opened, the balloon is There may be other concerns that accompany Be consistent and never quit. Check with your doctor if you have You can exercise any time of the day, but be sure the artery, restoring blood fow to the only a few days, after which most people questions about other procedures that may have to space your sessions evenly throughout the day. Do not exercise outdoors if the temperature is o o below 35 F, above 85 F, or if humidity is greater than 80 percent. Below is a general guide that will help you to know a slow pace and increasing gradually, and end. The energy used during sex Personal Hygiene Don?t with your usual partner is less than it takes to . Avoid any physical activities or intensities that Walking Lifting cause the following: Do. If you are not used to exercise, incision), or intense tiredness during exercise, it begin slowly to make exercise a regular part of could be a sign you are doing too much. Your Plan Ask about whether you can use home exercise Your cardiac rehab specialist believes that walking equipment, such as a bike, treadmill or elliptical, is the right exercise for you at this time. If you become short Regular aerobic exercise, such as walking, will of breath, slow down. Exercise will only your exercise becomes easier, and slowly add hills Rehab centers offer a variety of equipment, have lasting results if you keep it up. Staff will train you to exercise on You can exercise any time of the day, but be increasing slowly) and/or stretch, and 5 to 10 Outpatient cardiac rehabilitation is usually sure to space your sessions equally throughout the equipment that is appropriate for you and minute cool down (gradually slowing your pace recommended after heart surgery, heart attack, or the day. Your cardiopulmonary Wait at least 1 hour after meals and length of exercise increases. Through one-on-one sessions and Do not exercise outdoors if temperature is below Participation in outpatient cardiac rehab promotes demonstrations, staff will teach you what you 35 F, above 85 F, or if humidity is greater than a speedier recovery, longer life, and better health need to know to manage your heart condition and 80 percent. Topics that may be covered Cardiac rehabilitation, or cardiac rehab, provides include: the knowledge, tools, and support you need to Week # 1: Week # 4. At each visit, staff will meet with you to ask about signs and symptoms, 9 9 10 10 and review your progress. Then call a the wrong medicine if you cannot see what To lower your risk, you need to change to a cardiac rehab program near you. Count on family or friends for information blood pressure checked regularly and take about medicines. Learn both the generic name and brand name this chart shows the ideal numbers for each 60 minutes. You Total Cholesterol: Less than 200 medicines, type of surgery or procedure, can help to control stress by exercising, deep doctors names, and emergency numbers. You can still enjoy food when you follow these guidelines in the following tables. The goals are listed > Almonds, peanuts, pecans, walnuts against the walls of the arteries between above. Some specialty rankings are also based on hospital reputation, which is determined by surveying over 125,000 physicians across the country. We cultivate partnerships with other institutions to support global scientifc collaboration and ofer our faculty and staf internal funding opportunities to ignite their research ideas and eforts. We educate and train junior faculty and future leaders in research through our Cardiovascular Research and Entrepreneurship Training program. Trough all of these initiatives, we aim to heighten our culture of collaboration and innovation to better understand cardiovascular disease and discover potential cures. As many of you know, we recently established the Michigan Medicine Provider Portal, a secure, web-based application to help facilitate communication and enable referring physicians and their staf to access Dear Colleagues, patient medical information. This is just one example of the value we place on collaborating with you, our community-based colleagues. We are pleased to present the 2019 Samuel and Jean Frankel Cardiovascular Center Activity and Outcomes Report. We look forward to continuing our partnership with you, our referring to providing exceptional patient care through the work of our experienced faculty physicians, and to providing expanded care opportunities throughout the state. The outcomes presented in this report are a testament to the hard work of more than 200 clinical faculty, over 100 basic science faculty and our dedicated staf members from all disciplines. Together, we deliver collaborative patient care across every facet of heart and vascular disease for the beneft of patients throughout the state and beyond. Our advanced programs provide patients with the latest treatment options for the spectrum of cardiovascular conditions. On these pages are several patient outcomes, including how a young woman was spared a heart transplant when a U-M surgical team was able to create a new left ventricle outfow tract, aortic root and aortic valve, preserve her mechanical mitral valve and perform a bypass graft on her right coronary artery; how a new mother was umcvc. For acute myocardial infarction patients, our Surgical Options time from door to intervention is well below the national goal of 90 Our faculty is renowned for their expertise in a wide variety of minutes, thanks to a team approach that utilizes in-house staf. Even with the declining number of cardiac surgical cases nationwide, our procedure volume continues to grow. Multiple assist devices may be implanted to maintain blood supply Our surgeons perform standard on-pump coronary bypass as well as to the heart tissue during high-risk angioplasty and as a bridge to beating heart, of-pump bypass, with arterial conduits routinely used. During the procedure, a small mesh tube is placed in narrow or blocked arteries to widen and support the walls of the arteries and restore blood fow. Our services include all possible treatment options for valve and structural heart disorders. U-M treats more patients with valvular heart disease than anywhere else in the state and is a national leader in treating this disease. It was a devastating blow to the young After a series of fainting episodes and woman who had dreamed of taking her high another operation to remove surgical school basketball talent to the college level. Today, and referred her to the U-M Frankel the determined 28-year-old is living Cardiovascular Center. Today, she is doing very an infection that had damaged the new well and is living a normal life. Our Mitral Valve Clinic is also a leader in the treatment of mitral regurgitation associated with Tricuspid Valve Disease heart failure from both dilated and ischemic cardiomyopathies. As symptoms progress, treatment may include certain While open-heart surgery is the traditional method of mitral valve medications such as diuretics, which promote urination and the release repair and replacement, our team also performs complex open surgical of excess fuids, and vasodilators, which help open blood vessels. This type of procedure has the potential to shorten a being used to restore the function of failing bioprosthetic tricuspid valves. Tricuspid atresia Our cardiac surgeons and interventional cardiologists work together. A variety of techniques and devices can be used to repair or replace the mitral valve without opening up the heart. The commercially available MitraClip device is indicated for high-risk patients with degenerative, functional or mixed mitral regurgitation. This technique has become the preferred valve replacement option for high-risk surgical patients. We are 8 2019 Activity and Outcomes Report Valve Volume Mitral Valve Volume Isolated Aortic Valve Volume 1200 500 150 1,172 461 1000 993 400 125 963 127 905 378 895 362 800 352 112 339 300 100 104 99 96 600 200 75 400 0 0 0 2014 2015 2016 2017 2018 2014 2015 2016 2017 2018 2014 2015 2016 2017 2018 5 Year Average Mortality 2. Our mortality Danlos Syndrome and Loeys-Dietz Syndrome rates are among the lowest in the country, despite a high volume of complex cases. Tese are lifesaving minimally invasive options for some patients who are not optimal candidates for traditional open repair. Aortic Disease She credits her heart and obstetrics care In the end, she chose to delay surgery. At 28 weeks pregnant, Lowes was fnally able to go home before giving birth four weeks later to her daughter, Graysen Faith. We also specialize in the care of patients with complex implanted cardiac device conditions, including malfunction of devices and leads, infected devices and extraction of leads and devices. We are one of only a few centers in the country with this level of volume and experience. We are also pioneering the use of leadless pacer technology, one of the most remarkable pacing advances of the last decade, as described below. I might not be able to So when he began to experience a faster compete like before, but heart rate and palpitations while training for the cross-country ski-racing season, the I have worked back to a 60-year-old took notice. The cryoballoon catheter is then inserted to cauterize the area where the Afb originates. Our multidisciplinary team of specialists evaluates patients ablation therapy using the FlexAbility Sensor Enabled to determine their eligibility for the device. Ablation Catheter in patients with drug-refractory monomorphic ventricular tachycardia in whom ventricular In addition to catheter ablations and device procedures, we provide tachycardia recurs despite antiarrhythmic drug therapy or cardiac resynchronization in patients with heart failure. We also collaborate with other Michigan Medicine sports-related services and consult with all U-M athletic teams as well as with athletes Sports cardiology patients are athletes or highly active individuals with: from several Michigan schools. The Sports Cardiology Clinic provides comprehensive consultation, evaluation and treatment of all athletes. Our doctors work with patients to understand the full spectrum of their needs and provide targeted services. Enable patients to assume greater responsibility for their care through ognized as an Anticoagulation health education about the safe use of anticoagulants, the physical signs Center of Excellence, illustrating our strong commitment to providing and symptoms of bleeding and the importance of laboratory monitoring. The Antico agulation Centers of Excellence program helps healthcare professionals Safety Measures achieve the best possible outcomes for patients on anticoagulant medi Regardless of the anticoagulation option selected, anticoagulation manage cations. We are leaders in clinical research for inherited cardiomyopathies Our pediatric and adult clinicians work closely with specialists in and have collaborated both nationally and internationally to further electrophysiology, heart failure, interventional cardiology, cardiac our understanding of these complex disease processes. Our team also includes cardiac over 1,400 patients, we ofer access to emerging clinical trials. We trained genetic counselors, nurses and researchers, all dedicated to our are committed to a vision of improved, personalized medicine for mission of caring for patients and families with these conditions. Testing can also identify other family members who may be at risk but Within minutes, emergency responders may not have symptoms. Kwiatkowski was alive and breathing, thanks to the quick action of her husband, Dan, a certifed frst responder. With more than 20 years of experi advanced practice providers ensures safe, collaborative, patient-centered ence, Center For Circulatory Support Program specialists work closely care. The total artifcial heart is often used when end-stage We employ dedicated heart failure trained nurses to provide heart failure afects both sides of the heart and other more common disease-specifc education and telemanagement services to reduce heart-supporting devices are inadequate to keep patients alive. The team is experienced in 14-pound Freedom Driver powers the total artifcial heart with the evaluation of patients with advanced heart failure and is adept precisely calibrated pulses of air. The Frankel Cardiovascular Center at identifying patients whose care is appropriately addressed with is the only Michigan heart program to send patients home with the advanced therapies, such as heart transplantation and mechanical wearable technology.
However treatment that works purchase haldol cheap, we feel that for the purpose of the book this is not a major obstacle treatment kitty colds purchase haldol 5mg otc, and can update the text symptoms 9 weeks pregnancy buy cheapest haldol and haldol, given this is an e-publication medicine 832 quality haldol 10mg. So treatment goals and objectives buy discount haldol 5mg on-line, if our book leads to earlier recognition of patients with hypermobility syndromes and better management medicine 95a pill haldol 10 mg visa, and functions as a practical guide for patients and their families and friends in daily practice medicine quotes haldol 10mg with mastercard, we feel we have met our aim medications safe while breastfeeding order generic haldol on-line. Effect of celiprolol on prevention of cardiovascular events in vascular Ehlers-Danlos syndrome: a prospective randomised, open, blinded endpoints trial. New clinical and molecular data required another revision, which was initiated during the Ehlers Danlos Society International Symposium in New York, May 2016, the results of which have been published in the March 2017 issue of the American Journal of Medical Genetics Part C, Seminars in Medical Genetics. The hypermobile 6 type by far the most common and the classical type comprise more than 90% of all cases. Classification and nosology 5 the New York classification is based on clinical, biochemical and molecular data. In clinical practice, the clinical manifestations guide the choice for further investigations. In young children it is difficult to assess hyperextensibility due Classification and nosology of Ehlers-Danlos syndrome 7 to the abundance of subcutaneous fat. Skin hyperextensibility can also be assessed at the 0 dorsal aspect of the elbow in 90 flection, where the upper limit of normal is 3 cm. In the New York nosology, a score of 5/9 or more defines generalized hypermobility in both sexes, though it is known that joint mobility depends, apart from age, family and ethnic background, also on gender. Not infrequently, the Bulbena mobility score is also used (table 2-4), in which a score of 5/10 or more defines generalized hypermobility in females and 4/10 or more in males. Generalised hypermobility is not 8,9 rare: 5-10% of mainly female secondary school age Caucasian children is hypermobile. Easy bruising is seen as spontaneous ecchymoses, frequently recurring in the same bodily regions, of which long-term signs are often visible as brownish discoloration (haemosiderin), in particular on knees and shins. If it is the predominant presenting sign, child abuse and bleeding disorders need to be considered first. Tissue fragility is manifested in the skin as easy bruising and impaired wound healing with dystrophic scars, which are usually found over pressure points like forehead, chin, elbow, knee and shin and which may have a wide and papyraceous appearance. Internal organs like arteries, lungs, intestines, liver, spleen and uterus may also show fragility, predominantly in the vascular type. Some features are regularly observed, but are not criteria of generalised hypermobility 10 syndromes. In table 2-5 the major and minor diagnostic criteria are shown, minimal criteria for diagnosis and how to verify the diagnosis. A minor criterion is a sign of lesser diagnostic specificity, but its presence supports the diagnosis. However, in the absence of major criteria, minor criteria are not sufficient for a given diagnosis. Minimal diagnostic criteria are the presence of skin hyperextensibility and atrophic scars, plus either generalized joint hypermobility and/or 3 minor criteria (see table 2 11 12 5). It is inherited in an autosomal dominant fashion (see glossary), implying that each child (be it a boy or a girl) of an affected parent (be it father or mother) has a chance of 50% (=? Once the causative mutation has been found in a proband (see glossary), mutation analysis in relatives of the proband is possible. Also, in mild cases of the classical type (partial expression), differentiation from the hypermobile type might be difficult, if not impossible. It is characterised by generalized hypermobility, with a remarkable laxity of finger joints. In contrast with the classical type, its inheritance is autosomal recessive, so most cases are sporadic and some occur in sibships. Diagnosis in children is difficult, particularly in the absence of a family history. Arterial rupture is the most common cause of sudden death and has its peak rd th incidence in the 3 or 4 decade. Acute abdominal and flank pain is a common presentation of an arterial or intestinal rupture and needs urgent investigation and treatment. For women with the vascular type, pregnancy and delivery pose specific risks, which warrant 19 pre-conceptional counselling with an experienced obstetrician and clinical geneticist. As said above, when extensive bruising is the initial presentation and the only sign/symptom, bleeding disorders and child abuse have to be considered. As said, the new diagnostic criteria are more strict than those of the Villefranche criteria and the Brighton criteria (see table 2-5 and chapter 5). Basically, there is no confirmative laboratory test for the hypermobility type, meaning that it is a pure clinical diagnosis. Also, a changing phenotype from one diagnosis into the other in one individual and in some pedigrees 26 the occurrence of both diagnoses argued for this statement. Larsen syndrome, which also features congenital luxations, should be in the differential diagnosis. It is one of the rarest of all types and since only very few cases have been described, possibly this type is characterised by other as yet unrecognised features. The mode of inheritance is autosomal recessive (see glossary), whereby both parents of a patient are healthy carriers and the recurrence risk for siblings is 25% (=? Laboratory tests should start with measurement of the urinary lysyl and hydroxy-lysyl pyridinoline ratio. The mode of inheritance is autosomal recessive (see glossary), whereby both parents of a patient are healthy carriers and the recurrence risk for siblings is 25% (=? Because of severe hypotonia, patients very often undergo a full scale neuromuscular work-up, including a muscle biopsy before the diagnosis is established. The differential diagnosis comprises all other causes of severe hypotonia, including neonatal Marfan syndrome. Minimal diagnostic criteria are thin cornea with or without rupture plus either at least one other major criterion and/or 3 minor criteria (see table 2-5). The urinary lysysl and hydroxylysyl pyridinoline ratio is moderately increased (to approximately 1 compared to normal values of ~ 0. Minimal diagnostic criteria are congenital muscle hypotonia and/or muscle atrophy that improves with age plus either one other major criterion and/or three minor criteria. Among these, one finds not surprisingly other heritable connective tissue disorders like cutis laxa, osteogenesis imperfecta, Stickler syndrome (see chapter 5), Loeys-Dietz syndrome and Marfan syndrome, but also skeletal dysplasias, inborn errors of metabolism, neuromuscular disorders, chromosomal abnormalities and syndromes like Larsen syndrome, Fragile X syndrome and Langer-Giedion syndrome. Like always in clinical practice, the results of history taking, including a family history, and physical examination are the basis for planning additional investigations and finally reaching a diagnosis. This is already standard routine diagnostic practice in some laboratories and will become routine in all in the near future (see chapter 3). Good history taking starts with identifying the exact symptoms and complaints, which compelled the patient to see a physician: when and how did they start and evolve, how were they treated (what were the results, what was advised/prescribed and by whom? Specific questions should elucidate the presence or absence of: Hypermobility and/or (sub)luxations. If (sub)luxation occurred: which joint(s) was/were involved, how often did it occur, was it spontaneous (also the first time) and painful? If so: which ones, when, under which circumstances, exercise related, warm and swollen, if so, for how long? The family history includes drawing a three generation pedigree with specific enquiry regarding hypermobility, easy bruising, abnormal scarring, arterial dissections and organ ruptures. The physical examination is focused on signs relevant for connective tissue disorders: Build and biometry: height, weight, span and others when indicated. On indication, the patient will be referred to an ophthalmologist, cardiologist, orthopaedic surgeon, neurologist and/or others. If there is any reason to believe the phenotype could be the classical-like, tenascin-X deficient type, then there is an indication to perform tenascin-X analysis in serum. In fact, for definite diagnosis molecular confirmation is needed for all types, except the hypermobile type. Genetic counselling (see also chapter 19) Since all the disorders which have been discussed have a genetic background, genetic counselling is an indispensable part of the management of patients and their families. During genetic counselling, information will be given about the mode of inheritance, recurrence risk, variability and penetrance of the disorder, the possibilities of prenatal diagnosis and diagnosis in relatives at risk and management. A social worker should be available to assist whenever a need is perceived or requested. When there is a patient/parent support group, patients/parents should be informed. At the one extreme there is severe stiffness, and at the other severe hypermobility. At the extremes it is likely to find rare monogenic forms, but in between the extremes chances are high to find the more common forms of multifactorial origin. Z -s > +2 o n o r o r s t l a t i ve s (ue l y i a f o r C us c ul o s k a l c o m a t i o n s : n 1. F ur C 2 (bi un S i s ua Classification and nosology of Ehlers-Danlos syndrome 27 Glossary Autosomal dominant Mode of inheritance whereby the disorder often occurs in multiple generations and both sexes are equally affected, because the affected gene is located on an autosome (= chromosomes 1 22; non-sex chromosomes). Generally, in autosomal dominant disorders one allele of a gene pair is mutated and the other allele is normal (heterozygosity). Since a child inherits one allele of a gene pair, the chance for an affected individual of transmitting the mutated allele and having an affected child is 50% (=? Autosomal recessive Mode of inheritance whereby the disorder occurs most often in a single nuclear family and both sexes are equally affected. In autosomal recessive disorders, both alleles of a gene pair are mutated (homozygosity/compound heterozygosity). For an affected individual the chance of having an affected child is usually low (= 1/100 or less), unless the sexual partner is at least carrier of the same abnormal gene. The chance this being the case, is higher when the partner is a relative (consanguinity) Bi-allelic Both alleles (members of a gene pair) of the involved gene are mutated, as occurs in autosomal recessive inheritance. Compound heterozygous/heterozygosity For an autosomal recessive disorder to occur both alleles (members of a gene pair) of the involved gene have to be mutated. Compound heterozygosity exists when these 2 mutations (changes) of the involved gene are not exactly the same. Expression the degree in which an individual is clinically affected by a genetic disease or disorder. Haemosiderin A protein of red blood cells which presents as brownish iron-containing pigment. Haplo-insufficiency relates to the activity of a protein and it means that its activity is reduced to on average 50%. Heterozygous/heterozygosity this is the state where only one of the 2 alleles of a gene pair is mutated, which is the case in patients suffering from an autosomal dominant disorder and in healthy parents (carriers) of a child with an autosomal recessive disorder. Homozygous/homozygosity this is the state where the 2 alleles of a gene have exactly the same mutation, which means disease for the individual in both autosomal dominant and recessive disorders. Multifactorial disorder Disorder which is caused by the contribution of mostly many genes, each having a small effect, and exogenous = non-genetic factors. Null mutation Any mutant allele where the normal gene product is not made or is completely non functional. Penetrance this denotes the percentage of mutation carriers who do have clinical features of the given disorder, i. Proband the first patient in the family in whom a particular disorder has been diagnosed X-linked Mode of inheritance whereby the disorder often occurs in multiple generations and only males are affected. Mothers of affected males are carriers, unless a spontaneous mutation has occurred. Though the majority of carriers are healthy, some do have features of the involved X-linked disorder. An affected male will have healthy children though all his daughters will be carriers, since the causative mutation is on his X chromosome. Spectrum of mucocutaneous, ocular and facial features and delineation of novel presentations in 62 classical Ehlers-Danlos syndrome patients. Spontaneous Ruptured Dissection of the Right Common Iliac Artery in a Patient with Classic Ehlers Danlos Syndrome Phenotype. Recognizing the tenascin-X deficient type of Ehlers-Danlos syndrome: a cross-sectional study in 17 patients. Pregnancy-related deaths and complications in women with vascular Ehlers-Danlos syndrome. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome. Towards a re-thinking of the clinical significance of generalized joint hypermobility, joint hypermobility syndrome, and Ehlers-Danlos syndrome, hypermobility type. Expanding the clinical and mutational spectrum of the Ehlers-Danlos syndrome, dermatosparaxis type. Molecular basis for the progeroid variant of Ehlers-Danlos syndrome: identification and characterization of two mutations in galactosyltransferase I gene. Periodontal Ehlers-Danlos Syndrome is caused by mutations in C1R and C1S, which encode subcomponents C1r and C1s of complement. Ehlers?Danlos syndrome: A showcase of conditions that lead to understanding matrix biology. The evidence-based rationale for physical therapy treatment of children, adolescents, and adults diagnosed with joint hypermobility syndrome/hypermobile Ehlers-Danlos syndrome. The condition is extremely heterogeneous, both at the clinical and the molecular level. An overview of the diagnostic testing possibilities that are currently available will be provided. From genes to proteins Most living organisms consist of cells that originate from one fertilized egg cell through cell division. A male child receives an X chromosome from his mother and a Y chromosome from his father whereas females get an X chromosome from each parent. At each cell division, the two chromosomes are duplicated and one copy of each chromosome separates into the daughter-cells during a process called mitosis. In this way, at the end of the cell division, each of the daughter cells has exactly the same 23 pair of chromosomes as the mother cell. Genes are transmitted from parents to offspring and are considered to be the basic unit of inheritance. Through the transmission of genes physical traits, such as eye colour, are inherited in families. Because each parent gives a child one chromosome of each pair, in general a child has two copies of every gene (except for most of the genes on the X and Y chromosomes in males because males have only one of each). Some characteristics come from a single gene, whereas others come from gene combinations. The sequence of the bases within a gene forms the code that determines which protein is produced. This involves two processes, called transcription and translation, see figure 3-1. During this process, the non-coding introns are removed by nuclear enzymes (splicing). Each gene also contains a code that determines in which cell-type the gene is active. Finally, before a newly synthesized protein can begin its existence as a functional protein, it often undergoes further processing, termed posttranslational modification. These modifications can take a variety of forms such as, for example, combination with other polypeptides to form a larger protein, addition of carbohydrate side chains to the polypeptides etc. An example of a clinically important protein that undergoes considerable posttranslational modification is type I collagen. Genes and hereditary disorders Cells sometimes contain errors in the information in their genes. The errors (mutations) that cause hereditary diseases are usually very small, often confined to the change of only one base in a gene. Heritability A hereditary disorder can be dominant or recessive and autosomal or X-linked (see glossary chapter 2). For a person to have an autosomal dominant disease or disorder, a mutation in only one copy of a gene suffices. However, a person with an autosomal recessive disease or disorder has a mutation on both copies of the gene. If a person has a dominant mutation in a gene implicated in a disease, he or she will usually have the disease. Sometimes a dominant disease occurs in a child of healthy parents; this is caused by a new mutation, which can then be transmitted to the children of that diseased child. People who have a mutation in only one copy of a gene implicated in a recessive disease, are called carriers, and they usually do not have the disease because they still have a normal gene of that pair that can do the job. When two carriers of the same disease have a child together, however, the child has a 1 in 4 (25%) chance of getting the mutated gene from both parents, which results in the child having the disease. This is the basis of the higher prevalence of recessive diseases in children of blood-related or consanguineous. A peculiar situation arises if a disease gene is located on chromosome X (X-linked disorder), because this chromosome is present in one copy in males and two copies in females. In this case, a single mutation will suffice for a male person to get the disorder. Moreover, the mutated gene has always been transmitted to an affected male from his carrier mother, unless the affected male has a new mutation. Females have two copies of chromosome X, of which only one is active in each cell of the organism. Depending on the proportion of cells with an active, mutated gene and the dominant or recessive nature of the disorder, females with a mutation in one copy of a X linked gene will be clinically unaffected or have (a milder presentation of) the disorder. Certain disorders are not caused by mutations in a single gene, but can be triggered by combinations of several variant genes, which interact with each other and often with the environment.
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Request for coverage must be made by a specialist in rheumatology 02473623 Siliq brodalumab 210 mg/1. Request for coverage must be made by a specialist in dermatology 38 02416328 Aubagio teriflunomide 14 mg Tablet 02237770 Avonex interferon beta 1-a 30 mcg Injection 02269201 Avonex interferon beta 1-a 30 mcg/0. Patients will not be permitted to switch from Glatect to another glatiramer acetate product or vice versa, if: 1. Bullous pemphigoid or autoimmune hepatitis for patients who are intolerant of steroids and azathioprine. Grastofil will be the preferred filgrastim option for all filgrastim-naive patients. Preferred means the first infliximab product to be considered for reimbursement for filgrastim-naive patients. Grastofil will be the preferred filgrastim option for all filgrastim-naive patients. Preferred means the first infliximab product to be considered for reimbursement for filgrastim-naive patients. How should intravenous potassium chloride be administered in adults Medicines Q&A 186. Concentrations greater than Maximum infusion rate 20mmol/hr 40mmol/L are painful and may cause severe phlebitis; give via the 2+ Check Mg level (reported automatically if K <2. Also, it is known as aganglionosis because one of the main characteristics in all these patients is that they do not have ganglion cells in the rectum. These babies may present at birth a delay to pass meconium (a dark green poop in newborns) for more 24 hours or have abnormal bowel movements associated with abdominal distention and vomiting. Although congenital aganglionosis always affects the rectum, which is the final part of the large intestine, it can be extended to longer segments or even to the entire large intestine. A wide-range of common problems can sometimes makes it difficult to achieve a timely diagnosis. Some children can improve using laxatives or suppositories and others may require enemas. Moderate to severe cases may present with abdominal distention, fever, vomiting, and dehydration, in a life threating condition named Proliferative Obstructive Colitis or Enterocolitis. During this procedure we take a small fragment of the rectum, obtaining a result in 1 or 2 days. Once we have confirmed the aganglionosis of the rectum, it becomes necessary to perform a radiological study called a Contrast Enema. Note the narrow aganglionic rectum (called distal segment) creating obstruction and, above this segment, observe the obstructed and dilated large bowel (called proximal segment) which contains ganglion cells or called normoganglionic colon. Observe a larger aganglionic distal segment causing obstruction and the proximal normoganglionic dilated colon (named in this case transverse colon). Aganglionosis of rectum, sigmoid, and left large bowel (also called a descending colon). The entire colon is narrow causing obstruction and the small bowel (ileum) is the dilated intestine. The rectal tube is placed into the rectum allowing the gas and stool to come out, also it is used to instill saline solution into the colon. This procedure could be maintained for several days or even weeks until a comprehensive diagnosis is established. Colostomy An intestinal stoma is needed in newborns or infants when a rectal tube does not resolve the obstruction; most commonly, this situation occurs in patients with larger aganglionic segments and usually an abdominal exploration is needed. Ileostomy When a total colonic aganglionosis is suspected or confirmed, the last segment of the small bowel, named ileum, is brought out onto the surface of the skin creating a stoma. Usually, the colon is pulled-through however, the small bowel is connected to the anal canal in patients with total colonic aganglionosis, in these particular patients, some surgeons use a portion of the aganglionic colon to create a mixed tube with small bowel, this is called colon patch. One group of patients, around 30%, will have at any time after the pull through, acute or chronic symptoms of intestinal obstruction (constipation like), abdominal distention, smelly loose stools (diarrhea like), vomiting and fever. These symptoms could be mild to severe and should be treated immediately, or better yet should be prevented. Other groups of patients may suffer fecal incontinence after the pull-through; most of them are diagnosed at 3 to 4 years of age when mothers are aware that their children cannot use normal underwear due to fecal soiling and cannot achieve bowel control. Finally, residual constipation is a problem that other group of patients may suffer after the pull-through. The anal canal is the terminal part of the large bowel located between the rectum and anus. It is a short zone containing the anatomical and physiological elements for fecal continence. The pectinate line is an important anatomical reference of the anal canal, which should be preserved during the anastomosis of the pull through; the normoganglionic bowel is anastomosed (connected) to the anal canal, a few millimeters above this line. For unknown causes, some patients develop acute or chronic obstruction to the outflow causing stasis of stool, bacterial overgrowth and inflammation of the colon named colitis or enterocolitis. In patients with obstructive colitis, colonic irrigations are really useful to remove the stool, to clean (wash out) the colon, to prevent stasis of stool helping to take control of bacterial overgrowth. School of Biomedical and Health Sciences, Victoria University, Werribee Campus, P. Box 14428, Victoria 8001, Australia Article history Abstract Received: 6 October 2011 Interest in consumption of prebiotics and probiotics to improve human gastrointestinal health Received in revised form: is increasing. Consumption of benefcial probiotic bacteria combined with oligosaccharides 3 January 2012 may enhance colonic bacterial composition and improve internal health. The objectives of Accepted:3 January 2012 this article are to review existing literature concerning the effect of synbiotic foods on the Keywords composition and activity of the colonic microbiota, and effciency of functional attributes of synbiotic foods in formulation and development of new dairy products. Prebiotics probiotics synbiotic internal health All Rights Reserved Introduction 1998; Gibson et al. Major classes of dietary fructans found in higher It is well documented that the large intestine plants include inulin, levan, and graminan (Chalmers is one of the most densely populated ecosystem et al. Inulin and Stasse-Wolthuis, 2009) of which bifdobacteria naturally occurs in several plant foods including are generally considered to be health promoting and onion, garlic, chicory, artichoke and leek (Gibson et benefcial (Kimura et al. Inulin is composed of a series of oligo the ecosystem is dynamic and may be negatively and polysaccharides of fructose with (2>1) linkages, affected by aging, daily diet and other environmental where the terminal sugar in most chains is glucose. It is believed that the confguration of the anomeric C2 in fructose the maintenance of the gastro-intestinal bacterial monomers prevents fructans from digestion and population, which mainly contains benefcial species, this is responsible for its reduced caloric value and is important for overall gastro-intestinal health and dietary fbre effects (Coussement, 1996; Kaur and wellbeing (Crittenden, 1999). Prebiotics are non-digestible food ingredients constipation, hyperlipidaemia, hyperglycemia and that pass through the upper gut unchanged and are intestinal cancer (Ziemer and Gibson, 1998; Kaur and selectively fermented by colonic bacteria (Ramirez Gupta, 2002). This leads to specifc changes in effects of prebiotic and probiotic combination on the the composition and activity of the gut microbiota composition and activity of the colonic bacterial fora, that confers benefts upon host health (Cummings et and discusses about functional attributes of synbiotic al. The dietary fructans are particularly well foods in development of new dairy products. However, which may have both positive and negative effects it is important to note that alterations in a single (Gibson, 2004; Lopez-Molina et al. It is biomarker cannot provide explicit proof of a health assumed that Bifdobacterium and Lactobacillus are beneft or reduced risk of disease and more consistent primarily carbohydrate-fermenting bacteria; whereas data on various gut biomarkers and their effects on Bacteroides and Clostridium are mainly proteolytic gut health is required (Meyer and Stasse-Wolthuis and amino acid fermenting (Meyes and Stasse 2009). The frst part of the colon is mostly responsible Synbiotic foods for fermenting substances that cannot be digested Synbiotic food is defned as a mixture of by the host in the upper gut (such as resistant probiotics and prebiotics that benefcially affects the starch, non-digestible carbohydrates like inulin and host by 1) improving the survival and implantation oligosaccharides), while in the lower part of the of live microbial dietary supplements in the gastro colon proteins and amino acids are broken down intestinal tract, and 2) selectively stimulating the (Kolida and Gibson, 2007). The two main types of growth and activity of one or a limited number of fermentation that are carried out in the colon are health-promoting bacteria, and thus improving host saccharolytic and proteolytic (De Preter et al. Saccharolytic fermentation is more preferred to the the synbiotic concept is a promising trend in the host than proteolytic because of the types of metabolic functional food sector as the combination of probiotics end products (Kilda and Gibson, 2007; De Preter et and prebiotics may confer greater benefts to using al. Butyrate is an important reported an overall increase in faecal bifdobacterial source of energy for the colonocytes and has anti numbers in healthy volunteers after the consumption tumour properties. It inhibits cell proliferation and of synbiotic mix of inulin and Bifdobacterium spp. Synbiotic products often are composed of a Lankaputhra and Shah (1997) observed that combination of inulin-type fructans, bifdobacteria, viability of Bifdobacterium infantis in skim milk and lactulose in conjunction with lactobacilli (12% total solids) at pH 4. Currently, and 82% after 12 and 24 days of storage at 4?C, only limited variety of synbiotic products such as respectively. Although more recent study by Bruno et probiotic yoghurt and dairy drinks are available in al. Future market of synbiotic foods not only particularly hi-maize in fermented milks, the viability depends on their effectiveness on human health but of bifdobacteria could be improved. However, more also the increase of consumers awareness about the research needs to be carried out in order to investigate consumption of these products. Probiotics are live micro-organisms defnition of prebiotics overlaps signifcantly with which when administered in adequate amounts in the the dietary fbre defnition; with the exception of diet, deliver health benefts to the host (Fuller, 1991; its selectivity for certain species of the gut bacteria. Among these bacteria, bifdobacteria several hundred strains of anaerobic bacteria, the are believed to have the most benefcial effects for prebiotic concept assumes that there is already improving the gastro-intestinal health (Bruno et al. Bifdobacteria can improve the host immune prebiotics only need to stimulate the growth and functions by suppression the activity of harmful metabolic activities of those bacteria. The most bacteria such as Escherichia coli and Clostridium important functional effects of prebiotics on the gut perfrigens (Yaeshima et al. Some previous studies have shown that the bacterial enzyme activity, and (5) improving gut dairy products may not be an ideal medium for the mucosal permeability (Salminen et al. It is mainly of as they could reduce the problem of keeping the plant origin, whereas some fungi and many bacteria organisms alive during transit through upper gastro are important producers of inulin (Fuchs, 1991). Thus, the prebiotic approach involves the the order Asterales, such as chicory and Jerusalem interaction of a non-digestible food ingredient and artichoke (Vijn and Smeekens, 1999). G is glucosyl unit, F is fructosyl unit and n indicating the most researched prebiotics are non-digestible the number of fructose units linked to the terminal oligosaccharide molecules, containing 3 to 10 glucose unit, and m is an integer number of fructose monosaccharide residues connected by glycosidic units linked to each other in the carbohydrate chain. Inulin is a prebiotic for as a synonym for fructo-oligosaccharide in 1989 which suffcient data has been generated to allow for labelling purposes (Coussement, 1996). Those produced enzymatically hydrolyzed inulin or oligofructose, via partial enzymatic hydrolysis of inulin contain and synthetic fructooligosaccharides (De Leenheer both fructose chains (Fm) and fructose chains with and Hoebregs, 1994). The number of saccharides in the fructans Inulin belongs to a category of carbohydrates molecule is commonly referred to as the degree of known as fructans. It of a fructosyl residue from sucrose to another sucrose is believed that the synthesis and storage of these molecule, leading to the production of a trisaccharide molecules usually occur in the plant vacuole (Vijn 1-kestose (glucosyl-1, 2-fructosyl-1, 2-fructose) and Smeekens, 1999). Laere, 2002), it took more than 30 years before it It is distinguished among the fructan family by its was shown to be correct. In chicory, inulin is stored has been cloned only from Jerusalem artichoke and as a reserve carbohydrate in the feshy tap root and artichoke (Hellwege et al. In terms of inulin constitutes about 42% of root dry weight (Kaur and chain length, it has been suggested that the size of Gupta, 2002). Fungal inulin is generally resistance to digestion by small intestine enzymes assumed to be synthesized by sequential transfer of but are fermented by the bacteria in the large bowel fructosyl residues from fructosyl donor (sucrose) to (Roberfroid, 1993). Chain elongation is mediated fructose linkages, inulin is classifed as a storage by inulosucrase (sucrose 1F fructosyltransferase) carbohydrate (oligo-and polysaccharides) that resists without the presence of any trisaccharide as digestion by mammal digestive enzymes in the upper intermediate. Thus, inulin synthesis in bacteria is gastro-intestinal tract but fermented by the colonic simpler than plant inulin biosynthesis because only microfora. By increasing faecal biomass and water a single biosynthetic enzyme is involved (Vijn and content of the stools, inulin improves bowel habits. For all these reasons, inulin can be considered as As discussed above, inulin is a mixture of poly dietary fbre (Roberfroid, 1993). Inulin is indigestible in the gastrointestinal edible fruits and vegetables like wheat, chicory, tract of all higher animals (Coussement, 1996) due onions, banana, garlic, and leek (Flamm et al. Inulin would the average daily intake of inulin has been estimated be able to selectively enhance the proliferation of gut to be 3-11 g/person/day in Europe and 1-4 g/person/ bifobacteria, decrease pH and lower the oxidation day in the United States. Per 1000 calories, (Vijn and Smeekens, 1999) and store them as a the daily mean intake of inulin ranged from 0. The primary sources lifecycle (Vijn and Smeekens, 1999; Kaur and Gupta, of inulin in the American diet include wheat, onion, 2002). Inulin is present in roots and rhizomes of a garlic and banana with the contribution percentage of number of regularly consumed vegetables, fruits, and 69%, 23%, 3% and 3% to the average daily intake of cereals, including leek, onion, garlic, wheat, chicory inulin, respectively (Moshfegh et al. Despite the high foods were not consumed for the health benefts per inulin content of the aerial parts of many Gramineae se, due to availability, cost and personal preferences. A series of conferences held species are suitable for industrial food applications in Japan in 1982, 1984 and 1986 and more recent (Fuchs, 1999). This may be due to presence of some studies have linked nutritional health changes in interfering components in these plants which inulin humans resulting from eating inulin to changes in the cannot be easily extracted and processed to purifed numbers and varieties of intestinal micro-organism products. In the future, inulin could be classifed as a different segments (duodenum, jejunum, and ileum) of functional food ingredient for disease risk-reduction rat or human small intestine which has been confrmed claims. To study the physiology of the digestive Fructo-polysaccharides such as inulin are non system in humans and to quantify the amount of inulin digestible carbohydrate substrates in the diet that exiting the small intestine, they used the ileostomy target certain components of the gut microbiota in model in both studies. The ileostomy model serves as the human large intestine such as bifdobacteria and the basis for the study of carbohydrate digestion and lactobacilli (Kaur and Gupta, 2002). Different clinical studies have demonstrated types of bacteria in the colon and this stimulation can that this model is making the exact amount of improve the intestinal fora composition, enhance the any substrate passing to ileostomy effuent easily immune system and thereby contribute to the health measurable (Cummings et al. Results of both above studies demonstrate that Results from Kaur and Gupta (2002) have shown 86-88% of the ingested dose of inulin is recovered that ingestion of inulin compared to other sources of in the ileostomy effuent. They concluded that inulin carbohydrate like sucrose, could signifcantly reduce proceeds undigested through the upper part of gastro the count of pathogenic bacteria such as bacteroids, intestinal tract into the colon, and further, there is no fusobacteria and clostridia and increase the count of evidence that inulin is absorbed to any signifcant positive microorganisms such as bifdobacteria (Kaur extent in the small intestine. Similar human studies the small loss of inulin during the passage through in European, Japanese and North American adult the small intestine could be due to fermentation by the populations looking for using different daily doses microbial population colonizing the small intestine of inulin have reported similar results (Gibson et al. These population is known to be up to 100 times greater in study results have suggested that the benefcial effect the people with ileostomy than in normal individuals of inulin could be due to the ability of bifodobacteria (Flamm et al. The prebiotic effect chain carboxylic acid (the end products of glycolysis of inulin has been extensively confrmed by several and anaerobic fermentation) in the small intestine studies. Knudsen and Hessov (1995) conducted a case control trial among seven Fermentibility of inulin in the upper gastro subjects (six females and one male) with a median age intestinal tract of 38 (range 22-73) years and measured the amount Schematically, inulin molecule is comprised of of lactic acid and short chain acids before and after? The non fermentation substrate from starch and non-starch digestibility of inulin has been confrmed by several polysaccharide to inulin. The improved gastro-intestinal tract absorption was associated with decreased pH of Inulin is classifed as a low calorie food ingredient ileal, cecal and colonic contents, resulting in an as it contains less than half amount of calorie content increased concentration of ionized minerals. Therefore, calcium and magnesium absorption in normal rats, inulin can be used as a suitable food ingredient although only magnesium absorption was increased substitute to lower the total calorie content of daily in cecectomized rats. Other study by Coudray et that a diet supplementation with inulin would reduce al. Effect of inulin on glycemia/insulinemia the effect of inulin and oligofructose on glycemia Effect of inulin on constipation and insulinemia are not yet fully understood, and Constipation is a multi-factorial ailment often existing data are contradictory, indicating that these encountered in elderly people. Different reasons may effects may be due to physiological nature of the contribute to the development of constipation such as disease (Kaur and Gupta, 2002). The fermentation of carbohydrate stimulate colonic reduction in glycemic response to saccharose or motility (Roberfroid, 1993; Kleessen et al. When 10 g of artichoke inulin was added to 50 g of wheat-starch Effect of inulin on mineral absorption meal in healthy human subjects, the blood glycemic Some studies have suggested that chicory inulin response was lower, despite no apparent interference as a soluble fbre may increase the body absorption of by inulin on starch absorption (Rumessen et al. This reduction in transit time confrms control rat, despite an increase in total faecal mass. Dairy products such as yoghurts, carbohydrates, by delaying gastric emptying and yoghurt drinks, spreads, fresh cheeses, and milk, shortening small-intestinal transit time. Their selective succinyl-CoA, both of which are specifc inhibitors stimulation of the growth of bifdobacteria and the of pyruvate carboxylase. They are known to be closely related to gluconeogenesis (Lee increasingly used in functional foods, especially dairy et al. The reduction in the activity of lipogenic enzymes, and other commercially available prebiotic (Murphy, in the case of fatty acid synthase via modifcation of 2001; Cummings et al. Addition of oligofructose in bottle-fed babies in the same way as breast-fed in a carbohydrate rich diet reduced the de novo babies (Strohmaier, 1998; Salminen et al. Hepatic glycerol-3 phosphate concentrations the dietary fbre is defned as remnants of plant were signifcantly higher in oligofructose fed rats cells resistant to hydrolysis by the human digestive than in controls. As discussed 3-phosphate content of the liver might be due to its previously, several prebiotic substances such as decreased utilization for fatty acid esterifcation. These effects are related to reduce the Prebiotics in food applications risk of coronary heart disease, colon cancer and other Prebiotics are classifed as food products colonic disorders. The potential interest for using prebiotic in daily foods Resistant starch is related to increased fbre content is mainly due to its low calorie value, hypocariogenic in baked goods and pasta products without any and bifdogenic properties, and dietary fbre effects grainy appearance (Murphy, 2001). When inulin is mixed with water, it forms gels composed of a tri Sugar replacer dimensional gel network of insoluble sub-micron Several types of non-digestive oligosaccharides crystalline inulin particles with large amounts of and polyols can be used as sugar replacers due to their immobilized water. This inulin gel provides the same physiological characteristics such as having minimal texture and mouth feel as fat (Silva 1996; Franck contribution to energy intake and performing bulking 2000). Fat replacement by inulin sugar in various foods, mainly dairy and bakery is successfully applied in most water-based foods products such as chocolate flling biscuits, chewing such as dairy products, frozen desserts, dressings, gums, confectionary, dairy desserts, and ice-cream table spreads, sauces, soups and even meat products, (Franck, 2000). In addition, oligofructose depresses but not in dry foods such as snacks, bakery and the freezing point of frozen desserts and acts as a confectionery products (Murphy, 2001). Typically, binder in nutrition bars, in much the same way as 1 g of fat can be replaced by a 0. Formulating foods sucrose but its sweetness is about 30% of sucrose with inulin also helps to maximize freeze-thaw (Angus et al. In combination with other stability and minimize emulsion separation phased sweeteners such as aspartame, oligofructose can due to its ability to immobilize water and to work provide a desired sweetness and better favour profle with most gelling agents such gelatin, gellan gum, (Weidmann and Jager, 1997; Kaur and Gupta, 2002). Inulin also gives Lactulose carries out some favour enhancing a richer texture to liquid products and spreads and properties similar to sucrose and therefore, it can be provides crispness and expansion to extruded snacks used to replace sucrose in some foods such as yoghurt, and cereals. However, also used as a fat mimetic and a texture enhancer because of its laxative characteristics, lactulose is in low-moisture foods. This is balance and are intended for maintenance of health particularly true in sugar-free confections such as or prevention of disease (Fuller, 1991; Bruno and hard candies, chewing gums and marshmallows, Shah, 2004).
