Associate Professor and Consultant in Endocrinology
Center for Pregnant Women with Diabetes
Departments of Obstetrics and Endocrinology
Rigshospitalet
University of Copenhagen
Faculty of Health Sciences
Copenhagen, Denmark
Many following studies were conducted in order to determine the Turkish aphid fauna and were added many new records erectile dysfunction treatment dallas texas generic cialis with dapoxetine 40/60mg overnight delivery. New additions for the aphidofauna of Turkey which have been added from this revision to 2006 were summarized by Remaudiere et al erectile dysfunction and premature ejaculation buy discount cialis with dapoxetine online. Once for all erectile dysfunction doctor dallas purchase cialis with dapoxetine pills in toronto, a checklist of the Turkish aphidofauna have been published by Gorur et al erectile dysfunction doctors in memphis tn quality 20/60mg cialis with dapoxetine. The samples were processed in the labora to ry based on the methods offered by Martin (1983) how to cure erectile dysfunction at young age order cialis with dapoxetine with paypal. The taxonomic status of the species was checked based on Favret (2018) the geographic distribution vacuum pump for erectile dysfunction in dubai order cialis with dapoxetine 20/60mg with mastercard, general characteristcis and biology of the species were given according to Blackman & Eas to p (2018) and Nie to Nafria (2018) erectile dysfunction vacuum device discount cialis with dapoxetine 40/60mg with amex. Also erectile dysfunction only at night purchase cialis with dapoxetine 40/60mg on-line, host plants and distinguishing features of each determined species were given. Voucher samples were s to red at the Biology Department of Ondokuz Mayfis University. Family: Aphididae Subfamily: Aphidinae Tribe: Aphidini Subtribe: Aphidina Genus: Aphis Linnaeus, 1758 Aphis esulae (Borner, 1940) Distinguishing Features: Eyes multifaced. Distribution: Austria, Bulgaria, East Siberia, Hungary, Kazakhistan, (Stekolshchikov et al. Stridula to ry apparatus present and reniform, consisting of a pattern of ridges on ventro lateral areas of abdominal sternites 5 and 6, and a row of short, peg-like hairs on the hind tibia. Material Examined: Samsun, Atakum, Ismet Inonu Boulevard, under leaf of Citrus sp. Aphis rubicola Oestlund, 1887 Distinguishing Features: Smooth head without spicules. Material Examined: Samsun, Carsamba, Agacabey Town, Tilkili Village, on stem of Rubus sp. Distribution: South, Central and East Europea, To East of West Siberia and Transcaucasia (Jorg & Lampel, 1988; Blackman & Eas to p, 2018). Supracaudal process large, conical, extending beyond and usually covering cauda (Blackman & Eas to p, 2018). Material Examined: Samsun, Carsamba, Dikbfiyfik Town, on inflorescence of Oenanthe pimpinelloides, 15. Genus: Megoura Buck to n, 1876 Megoura nigra Lee, 2002 Distinguishing Features: Head smooth with well-developed antennal tubercules, their iner faces divergent. Material Examined: Samsun, Atakum, Mimar Sinan Street, on shoot and stem of Vicia sativa, 19. Genus: Myzus Passerini, 1860 Myzus cornutus Medda & Chakrabarti, 1986 Distinguishing Features: Head capsule with nodulose ornamentation. Antennal tubercules well developed, iner faces are gibbous in dorsal view, withouth a finger-like projection. Spring generations curling, Rolling, twisting or blistering leaves, but not in closed galls (Blackman & Eas to p, 2018). Material Examined: Samsun, Atakum, Mimar Sinan Street, under leaf of Prunus persica, 21. Distribution: India, North-East Pakistan (Naumann-Etienne & Remaudiere 1995; Blackman & Eas to p, 2018). Genus: Si to bion Mordvilko, 1914 Si to bion africanum (Hille Ris Lambers, 1954) Distinguishing Features: Eyes multi-facetted. Distribution: Africa, the Island of Indian Ocean, Yemen (Blackman & Eas to p, 2018). Subfamily: Pterocommatinae Wilson, 1910 Genus: Pterocomma Buck to n, 1879 Pterocomma rufipes (Hartig, 1841) Distinguishing Features: Antennae 6-segmented. Distribution: Canada, East and West Siberia, Iceland, Mongolia, Northwest and Central Europe (Pashtshenko, 1988; Blackman & Eas to p, 2018). Material Examined: Samsun, Vezirkopru, Kunduz Forest, on branch of Pinus sylvestris, 26. Cinara occidentalis (Davidson, 1909) Distinguishing Features: Adult apterae with 6-segmented antennae, at least 0. Turkey has its own characteristic climatic conditions and variability, geographical locations, agricultural crop richness large agricultural landscape and one of the richest flora in Europe with about 31 % endemism, despite that only 2. In addition current number of the Turkey aphid fauna do not reflect real composition compared with neighbouring countries (Gorur et al. It is expected that further studies will reveal new additional aphid species to the Turkish fauna. First record of Cinara curvipes (Patch) (Homoptera, Aphidina, Lachnidae) on Abies concolor in Switzerland. New records of aphid species (Hemiptera: Aphidoidea) for the Turkish fauna from Samsun province. A new genus of Macrosiphini Wilson, 1910 (1887) (Hemiptera: Aphididae) from Rhododendron in Turkey. Trabzon, Rize ve Artvin Illerinin Afit (Homoptera: Aphididae) Faunasfinfin Belirlenmesi. A contribution to the knowledge of the Turkish aphid (Hemiptera: Aphidoidea) fauna. Xerothermophile Aphiden der Schweiz und angrezender Gebiete mit besonderer Berucksichtigung des Kan to ns Wallis. The first record of Cinara curvipes (Patch, 1912) (Homoptera, Aphididae) in Slovenia and its possible economic impact. Two new british aphid introdcutions since 1999, in the contexte of other additions over the preceding thirty years (Sternorrhyncha: Aphidoidea). A commented preliminary checklist of the Aphids (Homoptera, Aphididae) of Pakistan and their host plants. Contribucion al conocimien to de los afidos forestales del genero Cinara Curtis en parte del eje neovolcanico (Distri to Federal, Mexico, Michoacan). Some new records of aphid species (Hemiptera: Aphididae) from the Middle East and the Caucasus. Bowlegged fir aphid Cinara curvipes (Patch) (Aphididae, Homoptera) new pest of Abies concolor in Serbia. Notes on bio-ecology and ethology of Cinara curvipes (Patch), a newly introduced species in to Europe (Aphididae Lachninae). Contribution to the Aphid (Homoptera: Aphididae) species damaging on woody plants in Bartfin, Turkiye. Preliminary screening of selected tropical botanicals as cowpea protectants against cowpea seed bruchid, Callosobruchus maculatus Fabricius (Coleoptrea: Chrysomelidae: Bruchineae). The botanicals included Azadirachta indica, Ekebergia senegalensis, Urginea altissima, Ancistrophyllum secundiflorum, Pseudocedrela kotschyi, Lannea welwitschii, Xylopia parviflora, Usteria guineensis and Antiaris to xicaria. Others were Indigofera arrecta, Hoslundia opposita, Cleome ciliata and Lagerra aurita. The effective botanicals are, therefore, recommended for tropical resource-poor subsistent farmers for use in their small scale cowpea postharvest s to rage and for further studies to elucidate other effective formulations and their active ingredients. Despite its various uses, the post harvest infestation by bruchids, especially the genus Callosobruchus (Coleoptera: Chrysomelidae: Bruchinae) poses a serious threat to its all-year round availability (Tuda et al. The use of plant products to protect s to red products from insect pest infestation is an age-long practice in developing world and is recently receiving a renewed attention as an important component of integrated pest control scheme. The reasons for this renewed interest include their abundance and cost effectiveness. Thirdly, some botanical formulations like powder and ash could be prepared by local resource 390 Mun. Although, a large array of plant species has been documented for their insecticidal properties against bruchids (Dales, 1996; Ileke & Bulus, 2012; Ashamo et al. In this study, powder formulation was used being a preliminary study which was designed to provide baseline information for further studies on the insecticidal properties of the selected botanical species. Interestingly, the selected species are naturally available in many tropical countries. Botanical procurement and preparation Thirteen botanicals were collected from different to wns in south western Nigeria, where they are found in abundance (Table 1). The root and stem bark of the woody species used for the study were exposed to sun drying for 2 days and subsequently air-dried, while the leaves were air-dried under shade until crisp to prevent destroying the thermo-labile compounds in them. Botanical screening for insecticidal potentials the plant powders were screened according to Fa to pe et al. Cowpea seeds (30 g each) were put in a 1 L Kilner jar covered with muslin cloth in to which 3 g plant powder corresponding to 10% (w/w) was added to the cowpea seeds. Six replicates of the setup was maintained for seven days in order to infest the s to ck after which the insects were removed from the s to ck. This bioassay procedure thus allows plant materials with strong, weak or negative grain protectant effects to be identified, irrespective of their mode of action. In this study, all the tested botanicals showed varying levels of protection potentials of cowpea seeds against C. Based on their results, we included the leaf to investigate its bioactivity against the cowpea seed bruchid. The result of this study agrees with previous authors on the efficacy of botanical powders in controlling C. Similar report exists for another member of Annonaceae family (Annona senegalensis) included in Fa to pe et al. Since the formulation investigated in this study was powder, it is necessary to investigate other formulations like organic and inorganic extracts and essential oil. Phy to chemical composition and insecticidal properties of mechanically extracted cas to r seed oil against cowpea seed bruchid (Callosobruchus maculatus Fabricius) infesting bambara groundnut. Combination of Piper guineense essential oil with cowpea varietal resistance in control of cowpea seed beetle, Callosobruchus maculatus Fabricius (Coleoptera: Chrysomelidae: Bruchinae). Comparative bioactivity of three Khaya species (Meliaceae) on Callosobruchus maculatus Fabricus (Coleopteran: Bruchidae). Cowpea weevil bioassay: a simple prescreen for plants with grain protectant effects. Juss) seed oil with varietal resistance for the management of the cowpea bruchid, Callosobruchus maculatus (F. Degradation of azadirachtin A on treated maize and cowpea and the persistence of Azadirachta indica seed oil on Callosobruchus maculatus and Si to philus zeamais. Effect of collection time on phy to chemical profile and insecticidal activity of essential oil from leaf of Ocimum gratissimum grown in Nigeria. Plant species Common Family Part Bioactivity Point of name used information collection Azadirachta indica Neem Meliaceae Leaf Medicinal, Ogbomoso insecticidal Ekebergia Stavewood Meliaceae Leaf Antibacterial Ibadan senegalensis Urginea altissima Tall squill Liliaceae Leaf Medicinal Ibadan Ancistrophyllum Large Benin Arecaceae stem Chewing stick Ogbomoso secundiflorum rattan bark Pseudocedrela Cedar Meliaceae root Antibacterial, Ogbomoso kotschyi mahogany bark chewing stick, Lannea welwitschii Kumbi Anacardiaceae Leaf Antibacterial, Ibadan medicinal, furniture Antiaris to xicaria False iroko Moraceae Stem Insecticidal, Ibadan bark medicinal Xylopia parviflora Bushveld Annonaceae root Medicinal, Alapa bitterwood bark Chewing stick Ilorin Usteria guineensis Loganiaceae Aerial Medicinal Akure Indigofera arrecta Indigo Papilonaceae Leaf Dye Ogbomoso production Lagerra aurita Laggera Asteraceae leaf Antibacterial, Ogbomoso insecticidal Cleome ciliata Wild Capparaceae seed Green Ogbomoso mustard manure, vegetable Hoslundia opposita Hoslundia Lamiaceae Leaf Medicinal, Ilorin insecticidal Table 2. Cowpea grain protectant potentials of the selected botanicals against Callosobruchus maculatus using Bruchid Perforation Index. Plant powder Bruchid Perforation Grain Protectant Index Potentials* Azadirachta indica 2. Male genitalia are not diagnostic, spermathecae are partly diagnostic within the genus Cassida Linnaeus, 1758. Accordingly, ultrastructural investigations of aedeagus and spermatheca are very important to obtain new diagnostic characters in the genus Cassida. It is distributed in Armenia, Greece, South European Russia and Turkey of Western Palaearctic region (Borowiec, 2007a,b; Warchalowski, 2010; Borowiec & Sekerka in Lobl & Smetana (2010)). It has been recorded from 25 provinces in 6 of 7 Turkish regions except for South-East Ana to lian region. It is reported from Amasya, Ankara, Antalya, Balfikesir, Bilecik, Bolu, Burdur, Bursa, Cankfirfi, Corum, Duzce, Erzurum, Eskisehir, Isparta, Istanbul, Izmir, Kastamonu, Kfirsehir, Konya, Kutahya, Sakarya, Samsun, Sivas, Tokat and Usak provinces in Turkey (Ekiz et al. Obtaining observations on ultrastructures of them are presented as follows: Aedeagus: In lateral view, median lobe distinctly curved median foramen to apex. In dorsal view, median lobe at the apex curved to backward and so apex seems like truncated (Figs. The pits located only in lateral parts of terminal part of median lobe in dorsal view (Figs. Dorsal plate and flattened area behind it without ultrastructural pits in dorsal Mun. Also the terminal area from upper margin of orifice to aedeagal apex without ultrastructural pits in dorsal view (Figs. Cornu gradually narrowed to wards to apex and apex of cornu strongly sharpened (Figs. Nodulus, cornu, collum + ramus and spermathecal gland with scattered, irregular and sparsely ultrastructural pits (Figs. Revision of Cassida litigiosa group from southern Africa (Coleoptera: Chrysomelidae: Cassidinae). Aedeagus, the pits on lateral part of terminal part of median lobe in dorsal view. Spermatheca, nodulus, reduced collum + ramus, spermathecal gland, ductus spermatheca. New Distributional Records Of Robber Flies (Insecta: Diptera: Asilidae) From the Darjeeling Himalaya Of West Bengal. Distribution pattern is also included wherever deemed necessary, along with morphology and methodology in aid of understanding the flies of family Asilidae. The diversity response to several ecological process for maintaining the ecosystem stability. The stability of populations and critical ecosystem process is the main phenomenon in community ecology. The most important ecological process is prey-preda to r relationship, where a single species or multiple species by changing the strength of its interaction with co-existing species affect the ecosystem function. Moreover, the pattern and strength of species interactions determine the stability of populations and food webs (May, 1973; De Ruiter et al. Robber flies or assassin flies (Insecta: Diptera: Asilidae), are an important group of preda to rs in all zoogeographical regions. Robber flies are preda to ry, generally catching prey insects on the wing; they are distributed worldwide, with the exception of Antarctica (Bosak & Bartak, 2000). The robber flies are most diverse in warm and arid regions, with species numbers rapidly decreasing to ward the tropics and the temperate regions (Lyneborg, 1965). Adult Asilidae prey on multiple other insect orders and spiders (Wood, 1981; Dennis & Lavigne, 2007). This predaceous mode of life is reflected in the distinctive morphology of the adults, which can be used to identify the family (Lyneborg, 1965). Especially conspicuous are the eyes, which are separated by the sunken vertex and provide forward and backward as well as stereoscopic vision. As diagnostic for the family as the eyes is the so-called mystax, which consists of hairs and bristles that are found in the middle of the face and are thought to protect the eyes from struggling prey. The mystax extends in some cases to the antennal bases and is often found on a protuberance (Wood, 1981). The victims of Asilidae are mostly insects, which are paralyzed by a neuro to xin injected through the hypopharynx (Geller-Grimm, 2003). The liquefied content of the victim is then imbibed through the proboscis of the preda to r (Geller-Grimm, 2003). Asilidae, like most Diptera of the infraorder Asilomorpha, has stages like the egg, three free living larval instar, a pupa inside a puparium (the contracted and hardened integument of the mature third instar lara) and the adult. Information about the early immature stages exists only for 16 species (Musso, 1981) and complete life-cycle descriptions are restricted to four species: Promachus yesonicus Bigot, 1887, Mallophora ruficauda (Wiedemann, 1828), Mallophora media Clements & Bennett, 1969, and Machimus rusticus (Meigen, 1820) (Musso, 1981). Larvae of many genera live in soil while those of the Laphriinae and Laphystiinae usually occur in decaying logs and stumps, where they are preda to rs of the larvae and pupae of other insects (Geller-Grimm, 2003). Much literature on the biology of immature Asilidae is related to their importance as preda to rs (Larsen & Meier, 2004). Populations of such preda to rs may appear to be specialists if they switch to near exclusive use of the most abundant prey type (Mccravy & Baxa, 2011). Due to their habitat specialization and role as to p insect preda to rs, robber flies are becoming increasingly important as a group of special conservation concern (Barnes et al. The specialized habitat associations of some species may also make them valuable as bio-indica to rs (Van Veen & Zeegers, 1998). Despite this high value as a bio-indica to rs, taxonomic studies on the family Asilidae are not sufficiently advanced, and the family is considered one of the least studied in Diptera and neglected as subject of interest (Geller-Grimm et al. As a result, details systematic studies of this group is essential to maintain biodiversity and to be able to react to climate change. On the other hand, by many measures of biodiversity, the eastern Himalayas Region stands out as being globally important. Several fac to rs contribute to the exceptional biological diversity of the eastern Himalayas. Its location at the juncture of two continental plates places it in an eco to ne represented by flora and fauna from both. But unfortunately, most of the available recent studies of geographic distribution and occurrence of Asilid fauna in India had been focused on the southern, Western and northern region (Joseph & Parui, 1987a).
Syndromes
Kidney damage
Abdominal pain and tenderness in the lower abdomen
From mother to child -- a pregnant woman can spread the virus to her fetus through their shared blood circulation, or a nursing mother can transmit it to her baby through her breast milk
The kidneys begin to leak and protein (albumin) passes into the urine.
Reduce your caffeine and nicotine intake. This will often reduce heart palpitations.
Manage behavior problems, confusion, sleep problems, and agitation
Inflammation and infection of the intestines (enterocolitis) may occur before surgery, and sometimes during the first 1-2 years afterwards. Symptoms are severe, including swelling of the abdomen, foul-smelling watery diarrhea, lethargy, and poor feeding.
Heart palpitations
Pregnancy
Definition: age-related dystrophic calcification ketoconazole impotence purchase cialis with dapoxetine 20/60 mg amex, degeneration erectile dysfunction treatment malaysia buy cialis with dapoxetine online pills, and stenosis of the aortic valve c erectile dysfunction type of doctor purchase cheapest cialis with dapoxetine and cialis with dapoxetine. Mitral and aortic valvular fibrosis Valve thickening and calcification Fusion of the valve commissures Chordae tendineae are short erectile dysfunction myths and facts 40/60mg cialis with dapoxetine for sale, thickened impotence from stress buy cialis with dapoxetine 20/60mg lowest price, and fused causes of erectile dysfunction young males discount cialis with dapoxetine amex. Definition: bacterial infection of the cardiac valves erectile dysfunction causes young males purchase cialis with dapoxetine visa, characterized by vegetations on the valve leaflets latest erectile dysfunction drugs generic cialis with dapoxetine 20/60 mg on line, I, b. Risk fac to rs: rheumatic heart disease, mitral valve prolapse, bicuspid aortic valve. Definition: small, sterile vegetations along the valve leaflet line of closure in patients with a debilitating disease c. Presentation: child or adult with hypertension in the upper extremities and hypotension and weak pulses in the lower extremities iii. Treatment: surgical correction Aorta Aorta Ductus Arteriosus Pulmonary Valvular Stenosis Pulmonary Artery Over-riding Aorta Right Ventricular Ventricular Septal Hypertrophy Defect A. Definition: abnormal development of the truncoconal septum results in inversion of the aorta and pulmonary arteries with respect to the ventricles b. Definition: failure to develop a dividing septum between the aorta and pulmonary artery, resulting in a common trunk b. Definition: absence of a communication between the right atrium and ventricle due to developmental failure to form the tricuspid valve b. May produce a jet stream that damages the endocardium and increasesthe risk of infectious endocarditis d. Definition: direct communication between the aorta and pulmonary artery due to days of life due to increased the continued patency of the ductus arteriosis after birth oxygen saturation and b. Definition: cardiac enlargement with dilatation of all four chambers resulting in. Asymmetrical cardiac hypertrophy, which is most prominent in the ventricular septum 11. Definition: uncommon form of cardiomyopathy caused by diseases that produce restriction of cardiac filling during dias to le b. Definition: right-sided endocardial and valvular fibrosis secondary to exposure to sero to nin in patients with carcinoid tumors which have metastasized to the liver b. Plaque-like thickening of the endocardium and valves of the right side of the heart c. Angina pec to ris refers to transient cardiac ischemia (without cell death) resulting in substernal pain. I Variants of angina include stable angina, Prinzmetal variant angina, and unstable angina. Myocardial infarction is a localized area of cardiac muscle necrosis due to ischemia and can occur as. Myocardial infarction often presents with sudden onset of severe "crushing" substernal chest pain that may radiate to the left arm, jaw, and neck. Leftheart failure can complicate ischemic heart disease, hypertension, myocardial diseases, and aortic or mitral valve disease. It is associated with leftventricular hypertrophy and dilatation, passive pulmonary congestion and edema, activation of the renin-angiotensin-aldosterone I system leading to hyperaldosteronism, and cardiogenic shock. Rightheart failure can complicate left heart failure, pulmonary or tricuspid valvular disease, and cor pulmonale. Itcauses jugular venous distension, hepa to splenomegaly, dependent edema, and ascites. Degenerative calcificaortic valve stenosis, the most common valvular abnormality, is an age-related dystrophic calcification,degeneration, and stenosis of the aortic valve that can cause concentric left ventricular hypertrophy, congestive heart failure, and an increased risk of sudden death. Mitralvalve prolapse is a myxoma to us degeneration of the mitral valve that causes the valve leaflets to become enlarged and floppy. Rheumaticfever isa systemic inflamma to ry disease, triggered by a pharyngeal infectionwith Group A beta-hemolytic strep to cocci, that in geneticallysusceptible individualsresults in the produdion of antibodies that cross-react with cardiac antigens. Acute rheumatic heart disease can produce myocarditis, pericarditis,and endocarditis. Chronic rheumatic heart disease can damage the mitraland aorticvalves, secondarily predisposing for mitralstenosis, congestive heart disease, and infectiveendocarditis. Acute endocarditis is caused by high~virulenceorganisms, notably Staphylococcus aureus, and produces large destructive lesions with a high mortality rate. Subacute endocarditis is caused by low-virulence organisms, notably viridans strep to cocci, and usually involves previously damaged valves. Congenital heart disease is the most common cause of childhood heart disease in the United States and may be idiopathic or associated with genetic disease, infection, or drug and alcohol use. Transposition of the great arteries has a poor prognosis without surgery, Truncus arteriosus is a failure to develop a dividing septum between the aorta and the pulmonary artery, resulting in a common trunk. Ventricularseptal defect is the most common congenital heart defect and consists of a direct communication between the ventricular chambers. Atrialseptal defect is a direct communication between the atrial chambers whose most common type involves the ostium secundum. Patent ductus arteriosus is a direct communication between the aorta and pulmonary artery due to the continued patency of the ductus arteriosus after birth. Dilated cardiomyopathy is the most common form of cardiomyopathy and consists of cardiac enlargement with dilatation of all four chambers, resulting in progressive congestive heart failure. Hypertrophic cardiomyopathy is an asymmetric cardiac hypertrophy that is most prominent in the ventricular septum, where it may obstruct the ventricular outflow tract, with resulting increased riskof sudden cardiac death, particularly in young athletes. Restrictivecardiomyopathy is an uncommon form of cardiomyopathy caused by diseases such as amyloidosis and sarcoidosis that produce restriction of cardiac fillingduring dias to le. A 48-year-old man comes to the emergency department 2 hours after experiencing severe chest pain while he was shoveling snow from his driveway. He describes the pain as an "elephant standing on his chest" and says that it radiates to his jaw. A 27-year-old man comes to the emergency department because of fever, chills, and pleu ritic chest pain for the past 2 days. Physical examina tion shows pinpoint lesions in between his to es and a medium-pitched, midsys to lic heart murmur that is best heard at the lower left sternal border. He has multiple hyperpigmented lesions and scars on his inner thighs and upper arms, A chest x-ray shows patchy infiltrates. Compression atelectasis due to fluid, air, blood, or tumor in the pleural space c. Definition: acute inflammation and consolidation (solidification) of the lung due connections between air to a bacterial agent spaces through which b. Organism: Staphylococci, Strep to cocci, Haemophilus inJluenzae, Pseudomonas aeruginosa, etc. Definition: localized collection of neutrophils (pus) and necrotic pulmonary parenchyma b. Aspiration," Most common Tends to involve right lower lobe Mixed oral flora (anaerobic/aerobic) t. Ghon focus: subpleural caseous granuloma above or below the interlobar fis sure ui, Ghon complex: Ghon focus + hilar lymph node granuloma iv. Summary of Obstructive Versus Restrictive Pattern I Variable Obstructive Pattern, Restrictive Pattern. Clinical diagnosis: persistent cough and copious sputum production for at least 3 months in 2 consecutive years b. Definition: destruction of alveolar septa resulting in enlarged air spaces and a loss of elastic recoil b. Proteases (including elastase) are produced by neutrophils and macrophages, which are stimulated by smoke and pollution iii. Antiproteases include a-I-antitrypsin, u-l-rnacroglobulin, and secre to ry leu koprotease inhibi to r Table 13-3. Manifestations Related to Area of Involvement Centriacinar (Centrilobular) Panacinar (Panlobular) Proximal respira to ry bronchioles involved, Entire acinus involved distal alveoli spared Most common type (95%) Associated with smoking a-I Antitrypsin deficiency j Distribution: worst in apical segments of Distribution: entire lung; worse upper lobes in bases oflower lobes c. Allergic (a to pic) Most common type Childhood and young adults; (+) family his to ry Allergens: pollen, dust, food, molds, animal dander, etc. Clinical findings include cough, fever, malodorous purulent sputum, and dyspnea c. Kartagener syndrome iii,I, Au to somal recessive ~j Immotile cilia due to defect of dynein arms Bronchiectasis, sinusitis, situs inversus d. Definition: diffuse damage of alveolar epithelium and capillaries, resulting in pro gressive respira to ry failure that is unresponsive to oxygen treatment c. Causes: shock, sepsis, trauma, gastric aspiration, radiation, oxygen to xicity, drugs, pulmonary infections, and many others d. Clinical presentation: dyspnea, tachypnea, hypoxemia, cyanosis, and use of acces sory respira to ry muscles. Clinical presentation: often normal at birth, but within a few hours develop increasing respira to ry effort, tachypnea, nasal flaring, use of accessory muscle of respiration, an expira to ry grunt, cyanosis. Definition: fluid accumulation within the lungs usually due to disruption of Starling forces or endothelial injury b. Increased hydrostatic pressure: left-sided heart failure, mitral valve stenosis, fluid overload:i" c. Increased capillary permeability: infections, drugs (bleomycin, heroin), shock, radiation. Micro: intra-alveolar fluid, engorged capillaries, hemosiderin-laden macrophages (heart-failure cells) 2. Definition: increased pulmonary artery pressure, usually due to increased vascular resistance or blood flow b. Small artery medial hypertrophy and intimal fibrosis and phentermine have been iii. Cough, sputum production, weight loss, anorexia, fatigue, dyspnea, hemopty sis, and chest pain 11. Obstruction may produce focal emphysema, atelectasis, bronchiectasis, or pneumonia. More commonly seen in women; less closely associated with smoking than squamous cell ii. Micro Invasive nests of squamous cells Intercellular bridges (desmosomes) Keratin production ("squamous pearls") h. Lymph nodes (50%): hilar, bronchial, tracheal, and mediastinal Horner Syndrome 11. Hypertrophic pulmonary osteoarthropathy Periosteal new bone formation Clubbing Arthritis m. Symp to ms: hoarseness, difficulty swallowing, pain, hemoptysis, and eventual respira to ry compromise d. Chylothorax: Chylous fluid in pleural space secondary to obstruction of thoracic duet, usually by tumor 2. Spontaneous: pneumothorax often occurs in young adults due to a rupture of emphysema to us blebs d. Tension: pneumothorax results in a life-threatening shift of thoracic organs across midline 3. Bronchopneumonia causesscattered patchy consolidation centered around bronchioles and can be due to a wide variety of bacterial agents. Lung abscessis a localized collection of neutrophils (pus) and necrotic pulmonary parenchyma and, may occur following aspiration, pneumonia, obstruction, or septic emboli. Atypical pneumonia causes interstitial pneumonitis without consolidation and can be due to viral agents and Mycoplasma pneumoniae. Primary tuberculosis can produce a Ghon complex, characterized by a subpleural caseous granuloma above or below the lobar fissure accompanied by hilar lymph node granulomas. Progressivepulmonary tuberculosis can take the forms of cavitary tuberculosis, miliary pulmonary tuberculosis, and tuberculous bronchopneumonia. Sarcoidosis is a granuloma to us disease of unknown etiology that produces clinical diseasesomewhat resembling tuberculosis. Obstructive airway disease is characterized by increased resistance to airflow secondary to obstruction of airways, whereas restrictive lung disease is characterized by decreased lung volume and capacity. Chronic obstructive pulmonary disease includes chronic bronchitis, emphysema, asthma, and bronchiectasis. Chronic bronchitis is a clinical diagnosis made when persistent cough and copious I sputum production have been present for at least 3 months in 2 consecutive years. Emphysema is associatedwith destruction of alveolar septa, resulting in enlarged air spacesand a loss of elastic recoil, and producing overinflated, enlarged lungs. Asthma is due to hyperreactive airways, resulting I in episodic bronchospasm when triggered by stimuli that may include allergens, respira to ry infections, stress,exercise,cold temperatures, and drugs. Bronchiectasis is an abnormal permanent airway dilatation due to chronic necrotizing infection; most patients have underlying lung diseasesuch as bronchial obstruction, necrotizing pneumonias, cysticfibrosis, or Kartagener syndrome. Adult respira to ry distress syndrome is due to diffuse damage to the alveolar epithelium and capillaries, resulting in progressive respira to ry failure that is unresponsive to oxygen treatment. Causesinclude shock, sepsis,trauma, gastric aspiration, radiation, oxygen to xicity, drugs, pulmonary infections, and many others. I", Respira to ry distress syndrome of the newborn causesrespira to ry distress within hours of birth and I~i: is seen in infants with deficiency of surfactant secondary to prematurity, maternal diabetes, multiple births, or c-sedion delivery. Pulmonary edema is fluid accumulation within the lungs that can be due to many causes,including left-sided heart failure, mitral valve stenosis,fluid overload, nephrotic syndrome, liver disease, infections, drugs, shock, and radiation. Bronchogenic carcinoma isthe leading cause of cancer deaths among both men and women. Major riskfac to rs are cigarette smoking, occupational exposures, and air pollution. Other tumors of importance include bronchial carcinoids, metastatic carcinoma to the lung, and laryngeal squamous cell carcinoma. A previously healthy 19-year-old college student comes to the clinic because of a headache, sore throat, muscle aches, and a constant, irritating, dry cough for the past 4 days. She says that she is "never sick" and has only been to this clinic for her "immunizations. She says that she has been unusually tired lately, frequently going to sleep at 8:30 in the evening. Ultrasound: oligohydramnios u, Potter facies: flattened nose, low-set ears, and recessed chin iii. The cysts are oriented in a radial fashion with their long axis at right angles to the capsule d. May also have multiple hepatic cysts and congenital hepatic fibrosis Clinical Correlate I, 2. Occurs 2-4 weeks after a strep to coccal infection of the throat or skin malaise, periorbital edema, iv. Immunofluorescence: granular depositsof IgG, IgM, and C3 throughout the glomerulus f. Prognosis: poor with rapid progression to acute renal failure and end-stage renal disease 4. There is a possible entrapment of cir disorder culating immune complexes with activation of the alternate complement pathway. Slowly progressive course, resulting in chronic renal failure over the course of 10 years ii. Definition: a rare X-linked disorder caused by a defect in type 4 collagen that is characterized by hereditary nephritis, hearing loss, and ocular abnormalities I -. Electron microscopy: alternating thickening and thinning of basement membrane is seen with splitting of the lamina densa. Alport syndrome is a progressive disease that ultimately results in renal failure E. Initially affects the glomeruli along the medullary border glomeruli are affected d. Immunofluorescence: IgM and C3 deposits in the sclerotic segments Segmental: only a portion of. Definition: the final stage of many forms of glomerular disease and is characterized by progressive renal failure, uremia, and ultimately death 2. Micro: hyalinization of glomeruli, interstitial fibrosis, atrophy of tubules, and a lym phocytic infiltrate 5. Definition: acute renal failure associated with reversible injury to the tubular epi thelium b. Is due to decreased blood flow caused by severe hemorrhage, severe renal vasoconstriction, hypotension, dehydration, or shock d. Definition: bacterial infection involving the renal pelvis, tubules, and interstitium b. Predisposing fac to rs: urinary obstruction, vesicoureteral reflux, pregnancy, urethral instrumentation, diabetes mellitus, benign prostatic hypertrophy, and other renal pathology Clinical Correlate c. Micro: acute inflammation of the interstitium and tubules clues to the diagnosis of pyelonephritis, H. The tumor often invades the renal vein and may extend in to the vena cava and heart.
In a nerve conduction study erectile dysfunction ginkgo biloba order cialis with dapoxetine online now, electrodes are placed in two locations along a nerve; the nerve is stimulated from one electrode erectile dysfunction treatment penile implants discount 40/60mg cialis with dapoxetine visa, and the impulse is recorded from the other electrode erectile dysfunction drugs nhs purchase 20/60 mg cialis with dapoxetine. Tests can be performed on either the median nerve erectile dysfunction 34 order 40/60 mg cialis with dapoxetine with amex, the ulnar nerve erectile dysfunction how can a woman help buy cialis with dapoxetine 20/60 mg with amex, or the radial nerve erectile dysfunction at age 23 purchase cialis with dapoxetine 40/60mg on line, and can assess either mo to r or sensory function erectile dysfunction more causes risk factors purchase cialis with dapoxetine us. The placement of the electrodes in sensory nerve conduction tests can be either orthodromic (stimulating electrodes are placed distal to recording electrodes) or antidromic (stimulating electrodes are placed proximal to recording electrodes) impotence 35 years old purchase cialis with dapoxetine 20/60 mg fast delivery. Other aspects of the nerve impulse such as latency, amplitude and velocity can also be measured. These comparisons are referred to as composite nerve conduction tests (Chapell 2003). Pathological changes in nerves and muscle, including underlying muscle denervation and metabolic abnormalities, may be detected. Imaging tests Imaging tests use a variety of methods to observe the internal ana to my of the body. Using these methods, investiga to rs attempt to measure the size of ana to mical areas within the carpal tunnel or that may be affected by carpal tunnel syndrome. Ulnar nerve the nerve on the medial side of the forearm that innervates the ring and little fingers. Radial nerve the nerve on the lateral side of the forearm that innervates the thumb. Conversely, if the stimulating electrode is proximal to the recording electrode. Electrode Placement Sites Abduc to r pollicus brevis A muscle in the hand that is used to record median mo to r parameters. Onset latency the time in milliseconds between stimulation and recording of an electrical impulse when measured to the beginning of action potential. Peak latency the time in milliseconds between stimulation and recording of an electrical impulse when measured to the largest amplitude of action potential. Inching test A series of nerve conduction tests designed to locate specific areas of nerve slowing. Reporting the evidence: the primary evidence base Table 6 presents summaries and critical appraisal of the 8 diagnostic studies that met 33 the inclusion criteria. In our opinion, these studies represent the best scientific evidence currently available on the 32 this table is adapted from Table 10 in Chapell (2003). Table 7 presents the evidence on the accuracy of specific diagnostic techniques found in these 8 studies. The studies in the evidence base are organized by category (symp to m report, provocative clinical testing, examination-based clinical diagnosis) and within those categories, by descending level of evidence. Whenever possible, we calculated sensitivities, specificities and likelihood ratios for a diagnostic technique from the primary data included in the paper. Sensitivities and specificities were not calculated, and are not included, if the data were not statistically significant. This is both because so many different diagnostic tests have been described, and because the studies themselves are of widely varying methodological quality (Chapell 2003). Each item of his to ry and each item on physical examination represents a diagnostic test, as post-test probabilities are generated that are modified with each new finding (Jaeschke 1994). Taking an additional his to ry to exclude other diagnoses will increase confidence in the initial diagnosis (Stevens 1999). In our systematic review, the Phalen test was most consistently identified as accurate in high quality studies (greatest "coherence" of evidence). The manual carpal compression test appears to be another of the more accurate provocative clinical tests. Although few studies address the issue, combinations of independent tests (models) likely perform better diagnostically than do single tests (Fertl 1998, Katz 1990a, Szabo 1999). A self-administered hand Consecutive the hand diagram is a useful diagnostic to ol and Inter observer reliability was high 1 symp to m diagram for the diagnosis blinded study of may be valuable for occupational and population (Kappa 0. Symp to ms are reported most commonly in to define and select the control verified carpal tunnel syndrome. Methodology used for diagnostic utility paresthesias and pain in almost any distribution in "rating" the hand symp to m of hand symp to m the hand. Inter-rater agreement Blinded study of the most accurate test was the Phalen wrist flexion Inter observer reliability and accuracy 1 and accuracy of clinical tests used in symp to matic test. Good accuracy was demonstrated by pinch were high for Phalen, pinch and wrist the diagnosis of carpal tunnel patients referred and vibration tests. Semmes inter-rater Weinsteim monofiliment testing was very sensitive, agreement and but a high number of false positives occurred when accuracy of "normal" was classified at 2. Reliability and seven clinical accuracy supports their use as components of a tests. Value of clinical Non-blinded Compared to normal controls the Tinel sign and the Calculated sensitivities and 2 provocative tests in carpal tunnel controlled study closed fist test are highly specific; compression test specificities based on comparison to syndrome. Acta Orthopaedica of hands in one is not useful to discriminate between symp to matic asymp to matic controls dropped Belgica 1995. The considerably when a more practice to closed fist test is specific in these situations. The sensitivity and Blinded cross For all the diagnostic tests studied (Phalen Test, this study, which illustrates the effect 2 specificity of tests for carpal tunnel sectional study of Tinel Sign, thenar weakness, thenar atrophy, of spectrum bias on test performance, syndrome vary with the comparison symp to matic abnormal vibration perception, and two point failed to demonstrate any useful subjects. Journal of Hand Surgery patients referred discrimination), the proportion of subjects who had degree of accuracy for any of the (British and European Volume) 1998. The diagnosis of Consecutive Clinical examination by an experienced doc to r the reference standard (expert 3 carpal tunnel syndrome. The Journal blinded study of seems to be sufficient if there are typical symp to ms opinion) was not applied to all of the of Hand Surgery 1997. Compared the arm, wrist or hand, it is important to add a diagnostic utilities neurophysiological examination. The value of diagnostic Non-consecutive, Our findings support the use of clinical his to ry and the study was not blinded. The addition "control" groups were not adequately clinical of nerve conduction studies is unnecessary in most defined, and were likely different from examination tests cases. Sensitivity, Specificity, and Positive and Negative Predictive Values for Carpal Tunnel Syndrome Tests for Group 1 (Definite Carpal Tunnel Syndrome), Group 2 (Other Hand Problems), and Group 3 (Normal Volunteers). They are therefore most applicable to claimants with severe enough symp to ms to warrant such a referral. Test accuracy may change with different mixes of disease severity, different distributions of competing conditions (Jaeschke 1994), varying experience and skill of clinical examiners (MacDermid 1997), or different sets of personal incentives and constraints. It should be noted that both his to ry and physical examination rely on subjective reporting of symp to ms, sensation or pain: there are no objective examination-based clinical tests for median nerve impairment. Examination-based clinical diagnosis of carpal tunnel syndrome is necessary, but not always sufficient, while electrodiagnostic studies alone are never sufficient (Rempel 1998). A small subset of patients may be managed without electrodiagnostic studies (Katz 1990b): in cases where clinical symp to ms and signs are well defined, electrodiagnosis may not be necessary (Graham 2001). If surgery is being 38 contemplated, however, or if there is uncertainty about the clinical diagnosis, electrodiagnostic confirmation of the clinical diagnosis is desirable (Stevens 1999). Use of only electrodiagnostic study findings is not recommended: a positive electrodiagnostic finding in the face of absent symp to ms cannot lead to a diagnosis of carpal tunnel syndrome. In a population with a high prevalence of carpal tunnel syndrome (those referred to an electrodiagnostic center) the positive predictive value associated with this specificity may be acceptable. Among other populations, however, for whom the prevalence of carpal tunnel syndrome is much lower, the false positive rate will be considerably greater, and the positive predictive value will be reduced (Rempel 1998). Electrodiagnostic studies increase or decrease the probability of carpal tunnel syndrome as the correct diagnosis, and their accuracy is good when properly performed. Electrodiagnostic studies are the most objective test available to demonstrate median nerve deficit. In contrast, with the exception of thenar wasting, all examination-based clinical diagnostic to ols rely on subjective input. There are a number of qualifications and technical limits on the interpretation of electrodiagnostic studies. Electrodiagnostic methods are standardized neither in pro to col nor in interpretation, and so like symp to ms and provocative clinical tests they require a stringent review (Massy-Westropp 2000). In addition, test conditions for example, temperature, electrode size, distance between electrodes, and amplifier gain must be controlled (Jablecki 1993). There are gradations of normal nerve function in the general population, for example, and as different clinicians use different normal values, the criteria by which a diagnosis of carpal tunnel syndrome is made may vary from labora to ry to labora to ry. Quality and accuracy varies between labora to ries and neurophysiologists (Katz 1990b). The clinical problem dictates the study strategy (the choice and number of nerves and muscles tested). The clinical usefulness of a diagnostic test is largely determined by the accuracy with which it identifies the target disorder. The predictive value of the diagnostic tests for carpal tunnel syndrome is disputed (Szabo 1999). Our findings, which are based on the evidence provided in the studies that met our inclusion criteria, appear below. The sensitivity of a diagnostic test is the proportion of truly diseased persons, as identified by the diagnostic "gold standard" who are identified as diseased by the test under study. The specificity of a diagnostic test is the proportion of truly nondiseased persons, as identified by the diagnostic "gold standard," who are identified as nondiseased by the test under study. Likelihood ratios indicate by how much a given diagnostic test will raise or lower the probability of the target disorder. The likelihood ratios in this 56 Test information is only valuable if it changes the probability of disease enough to alter diagnosis or treatment. Likelihood ratios, sensitivities and specificities of the diagnostic methods assessed by studies in the primary evidence base are found in Table 7. The diagnostic methods in Table 8 were selected and ordered based on the of level of evidence of the study in which the test appeared, the number of independent studies in the evidence base that cited the test as useful (coherence of evidence), and the size of the likelihood ratios (clinical importance). In our opinion, Table 8 includes the more robust clinical diagnostic methods for carpal tunnel syndrome. Only one study that met the inclusion criteria evaluated electrodiagnostic testing (Gunnarsson 1997). The results of that study indicate that both nerve conduction velocities in the median and ulnar nerves, and palm-wrist/wrist-elbow nerve conduction velocity generate only moderate shifts in pre-post test probability. As indicated by the data in Tables 8 and 9, it is difficult to "rule out" carpal tunnel syndrome. The sensitivities and specificities of the available diagnostic to ols are not very good. In a case of carpal tunnel syndrome, complaints should be localized to the palmar aspect of the first to the fourth fingers and the distal palm (the sensory distribution of the median nerve at the wrist). Numbness predominantly in the fifth finger or extending to the hypothenar eminence or dorsum of the hand should suggest other diagnoses. This more proximal pain should also prompt a careful search for other neurologic diagnoses (eg cervical radiculopathy). The characteristics of the main symp to m (paresthesias) of carpal tunnel syndrome require differential diagnosis from ulnar nerve compression syndromes, thoracic outlet syndrome, hand-arm vibration syndrome, and cervical nerve root compression (Sluiter 2001). Rothman (1986) defined a cause as "an event, condition or characteristic that plays an essential role in producing an occurrence of the disease. Most of epidemiology concerns causality and several types of causes can be distinguished. In epidemiology, it is most often used to express the probability that a particular outcome will follow a particular exposure. A risk fac to r is an environmental, behavioral or biologic fac to r, confirmed by temporal sequence, ideally in longitudinal studies, which, if present, directly increases the probability that a disease will occur, and if absent or removed reduces that probability. Risk fac to rs are part of the causal pathway, or expose the host to the causal pathway (Burt 2001). Carpal tunnel syndrome has an indistinct, multifac to rial etiology: often a single cause cannot be identified. The presence of one risk fac to r does not negate other pathways with other causal roles. The disagreement centers on the relative importance of multiple causal fac to rs of the disease, whether these fac to rs are occupational or non-occupational, and to what degree. At the same time, it is necessary to distinguish between fac to rs that aggravate the symp to ms of carpal tunnel syndrome and fac to rs actually responsible for the development of the condition (Gorsche 2001). Inferring a causal relationship Evaluating epidemiological literature for evidence of a possible causal relationship requires an understanding of the sequence of steps with which causality is generally inferred. The first is that there is an exposure and the second is that there is an outcome of interest. The exposure can be one of any number of biological, physical, chemical or psychological events. While a statistically significant association is a necessary condition for asserting a causal relationship, it is not a sufficient condition. Qualitative considerations about the plausibility of the purported causal relationship are just as important. Before an epidemiological association may be regarded as causal, other possible explanations like chance, bias and confounding must be excluded. To this end, the association may be tested against a set of "characteristics," "conditions," "conventions," or criteria" commonly used to review individual research studies for their likelihood of generating causal inferences (Hill (1966);(1971), modified by Rothman (1986) and Susser (1991)). These "conditions" are designed to elicit specific pieces of empirical evidence that increase the confidence with which one can infer a cause-effect connection. When critically reviewing the epidemiological literature on carpal tunnel syndrome for possible cause-effect connections, we focused on three key criteria: temporality, strength of association, and coherence of evidence. Temporality Temporality, an absolute prerequisite for causality, requires that the cause be present before the effect is observed. If the "cause" did not precede the effect, then it cannot possibly have been a cause. If it cannot be established that the exposure preceded the outcome in time, then it cannot be established that the exposure caused the disease. While prospectively designed studies ensure that the criterion of temporality is strictly adhered to (that is, that exposure preceded adverse health effect), the design of cross-sectional studies does not allow strict adherence to this criterion because both exposure information and adverse health outcome are obtained at the same point in time. Strength of association Strength of association refers to the magnitude of the measure of the association; the larger the summary measure, the more confident one can be that the putative association may be causal 61 (and the less likely the association is spurious). Coherence of evidence the evidence is coherent if a hypothesized causal association is compatible with pre-existing theory and knowledge (Susser 1991). To what extent is the hypothesized causal association compatible with the natural his to ry and biology of disease, with current knowledge of medicine, of statistics, and of biological mechanismsfi How many independent original research studies meeting the inclusion criteria reached a similar conclusionfi Reporting the evidence: the primary evidence base Table 10 presents summaries and critical appraisal of the 14 causation studies that met our 42 inclusion criteria. This set of original research studies forms the primary evidence base on causation of carpal tunnel syndrome. The studies are organized by category (risk fac to rs, task and occupation) and, within those categories, they appear in descending chronological order. The evidence on the causation of carpal tunnel syndrome is of relatively poor quality. This is because of the heterogeneity of the subject matter of the causation studies, the ethical 43 constraints on experimental research in humans, and the lack of longitudinal studies. Studies of disease causation must be observational and are more susceptible to bias and confounding than are experimental studies. Given relatively poor quality of the available evidence on causation of carpal tunnel syndrome, we do not assign numeric levels of evidence to the studies that met the inclusion criteria. We focus instead on their relative strengths and weaknesses, and evaluate the evidence they present based on criteria described in the Causation Evidence Assessment Guide developed 44 specifically for use in this background paper. Because studies of disease causation cannot be experimental, Level 2 is the highest level of evidence these studies can provide, although it may be possible to evaluate preventive strategies experimentally. The genetic contribution of Observational: Previous studies have ignored an underlying In this case control study which attended to carpal tunnel syndrome in women: a blinded case genetic susceptibility that could explain much of the selection bias, no significant association was twin study. Genetic (the study group comprised unselected female twin predisposition appeared to be important. Predic to rs of carpal Longitudinal In 1984 we initiated a study of fac to rs associated Cohort study over 11 years. The electronics, (repetition, heavy lifting, keyboard use, force) did significant drop-out rate of 42% was a major threat plastics) over an not approach conventional levels of statistical to validity of the study. Etiologic and prognostic cohort study which surgery was chosen shows that there are surgically selected population, had no matched role of biological and professional risk some individual fac to rs that not only predispose controlled cohort and no control for surgeons or for fac to rs. This study estroprogestinics, hypothyroidism and viral suffered from a very weak statistical technique. There was no evident statistically significant difference in the parameters for repetitiveness, force, synthetic index or weighted synthetic index in time for professional risk fac to rs. It tunnel syndrome in a large footwear cohort study modern, mechanized footwear fac to ry) were included self-reported and directly observed fac to ry. International Journal of substantially higher than in the general population workstation exposure, but it is not clear that Occupational Medicine and and in other industries. Nonoccupational risk Observational: We examined the relation between non this case control study using an administrative fac to rs for carpal tunnel syndrome. Use of hormone replacement therapy appeared to be associated with a higher rate of requiring carpal tunnel release (80% increase). In addition, we found an unexpected 60% increase in risk of carpal tunnel release in patients taking corticosteroids, even in the absence of evidence for concomitant inflamma to ry arthritis. Comparisons of Observational: the objective of this study of opera to rs in a fish Clearly defined case-control study with multiple measures for quantifying repetition in case-control processing facility was to compare the accuracy of cohorts of small size designed to study different predicting carpal tunnel syndrome. Point prevalence after 6 months significant relationship, and was tentatively exposure would omit all acute cases which are concluded to be the best predic to r. Predictive validity of the Observational: the Strain Index is a job analysis method for this study attempted to identify activity or task Strain Index in manufacturing variant of a determining if workers are exposed to increased versus job specific risks.
These include the Many investiga to rs did not examine each risk absence of nonrespondent bias and fac to r separately but selected study and comparability of study and comparison groups impotence young male purchase 40/60 mg cialis with dapoxetine mastercard. However impotence blood pressure medication buy cialis with dapoxetine online from canada, the results of association erectile dysfunction medication risks order 20/60 mg cialis with dapoxetine with visa, temporal association erectile dysfunction treatment in kl purchase cialis with dapoxetine with mastercard, and many epidemiologic studies can contribute to exposure-response relationship erectile dysfunction biking order cialis with dapoxetine. The exposures examined for the neck and upper this document uses the following framework of extremity were repetition erectile dysfunction johannesburg cheap generic cialis with dapoxetine uk, force erectile dysfunction differential diagnosis 40/60mg cialis with dapoxetine free shipping, extreme criteria to evaluate evidence for causality xatral erectile dysfunction purchase cialis with dapoxetine 20/60mg mastercard. The framework was proposed by Hill [1966; 1971] exposures examined for the low back were and modified by Susser [1991] and Rothman heavy physical work, lifting, bending/twisting, [1986]. The question is whether such studies simply show Temporality no significant association or can be seen as Temporality refers to documentation that the useful estimates of associated risk. Even though the cross-sectional study design Consistency precludes strict establishment of cause and Consistency refers to the repeated observation effect, additional information can be used to of an association in independent studies. If the exposure was directly association is not dependent on measurement measured or observed, it is also unlikely that to ols. Similar studies that yield diverse results the measurement was influenced by the weaken a causal interpretation. Rothman [1986] stated that it is Specificity of Effect or Association important to realize that cause and effect in an this criterion refers to the association of a epidemiologic study or epidemiologic data single risk fac to r with a specific health effect. If this criterion is interpreted to mean example, from a cross-sectional study of that a single stressor can be related to a specific hand/wrist tendinitis and highly forceful, outcome. The researcher can criterion can be interpreted and applied to o also reasonably determine the time of tendinitis simplistically. In hand/wrist tendinitis are likely to seek making this judgement, the investiga to rs employment in jobs that require highly forceful, considered the criteria for causality. The exposure-response relationship relates disease occurrence with the intensity, the evidence of work-relatedness from frequency, or duration of an exposure (or a epidemiologic studies is classified in to one of combination of these fac to rs). For example, if the following categories: strong evidence of long-duration, forceful, repetitive work using work-relatedness (+++), evidence of work the hands and wrists is associated with an relatedness (++), inadequate evidence of increased prevalence of hand/wrist tendinitis, work-relatedness (+/0), and evidence of no this association would tend to support a causal effect of work fac to rs (-). Some have challenged the importance of physical fac to rs as causal agents, Strong Evidence of Work but prospective studies have shown that Relatedness (+++) reduced exposures result in a decreased A causal relationship is very likely between disease [Bigos et al. A demonstration that reduced exposure decreases positive relationship has been observed the incidence of disease. Some studies suggest a In each chapter on neck, shoulder, elbow, relationship to specific risk fac to rs but chance, hand/wrist, and low back disorders, there are bias, or confounding may explain the tables summarizing the risk indica to rs and association. This step involves included in the tables that may not be examination of relevant epidemiologic mentioned in the text. These additional studies information to assess the strength of the are for information purposes only. Appendix C, Summary international authorities, academics, and policy Tables, provides a concise overview of the makers in assessing risk and studies reviewed relative to the evaluation formulating decisions about future research or criteria, risk fac to rs addressed, and other necessary preventive measures. Only reports that have been published or accepted for publication in the openly available scientific literature have been reviewed by the authors. Among these studies are those which fulfill rigorous epidemiologic criteria and appropriately address important issues so that causal inferences can be made. The majority of studies involved working groups with a combination of interacting work fac to rs, but certain studies assessed specific work fac to rs. Each of the studies we examined (those with negative, positive, or equivocal findings) contributed to the overall pool of data for us to use in assessing the strength of the work relatedness using causal inference. The epidemiologic data were insufficient to provide support for the relationship of vibration to neck disorders. At this time, further studies must be done before a decision regarding causal inference is made. The data on intervention provide additional evidence that these disorders are related to workplace risk fac to rs. In the studies, workers were by using both symp to ms and physical categorized only by hand/wrist exposures. For example, workers lower when they are defined using both who may have frequent and rapid awkward symp to ms and physical examination results than postures of the neck but less frequent or when defined using symp to ms alone. In workers in the United States was reported to general, we have given these studies less weight be 4. The discussion within during a cycle), or each fac to r is organized according to the criteria for evaluating evidence for work relatedness in epidemiologic studies using the (2) repeated arm or shoulder motions that strength of association, the consistency of generate loads to the neck/shoulder area. Most of the studies that response relationship, and coherence of examined repetition or repetitive work as a evidence. Therefore, repetitive work was not used to evaluate study quality is presented in necessarily considered the primary exposure Tables 2-1 through fac to r but was considered along with the other 2-6. Few of these studies observed or neck/shoulder area, 35 had participation rates measured: (a) the frequency or duration of of over 70%, 3 had less than 70%, and 8 did tasks pertaining to the neck, (b) the ratio of not report their participation rates. Studies generally address (mainly of the hand/wrist) to workers in repetition as cyclical work activities that occupations without those requirements. In movement for each variable by taking the terms of magnitude of the association, 11 average of the two readings. Studies Meeting the Four Evaluation Criteria the other study that fulfilled the four criteria Of the 27 investigations (see Tables 2-1 and 2 concerned a 3-year prospective study written 2), 2 fulfilled all four evaluation criteria outlined up in a series of articles by Kilbom et al. The investigations workers in highly repetitive tasks with static assessed repetitive work as an independent postural loads to the neck and shoulder areas variable in terms of frequency and duration of were followed over a 3-year period. Three seconds) cycles were compared to 2 referent separate physical exams were carried out at groups: 68 former assembly workers and 64 yearly intervals, the first one initially assessing other workers with no repetitive exposure at tenderness on palpation and pain or restriction their current jobs. Ergonomic perform tasks with a posture requiring an assessments occurred at the outset of the study intermittently flexed neck and elevated arms, and included video analysis of postures and which were abducted intermittently. Workers movements of the head, shoulder, and upper and referents reported neck/shoulder arm. The evaluation recorded work-cycle time symp to m(s) and had physical exams performed and number of cycles per hour; time at rest for by a single examiner. The examiner was blinded the arm, shoulder, and head; to tal number of to exposure status but not completely to group rest periods; and average and to tal duration per status. It included videotaping, observation, designed to study short-cycle repetitive work and analysis of postures, including under visual control. A significant of disorders or remaining healthy in the different association between deterioration of health locations (neck and neck/shoulder) as the two status of the cervicobrachial region between dependent variables. These studies used health outcomes the association between repetitive work related from symp to m surveys and self-reported to the neck and any neck/shoulder diagnoses workplace exposure (no direct observations) was 4. Exposure women from the general population of the same assessment was based on both self-reports and region. Exposure was assessed work-station equipment in conjunction with the through observation and categorization of jobs, user. Authors stated was not statistically significant, although the that the study involved a control group and higher exposure levels were. For this study, the to ok in to account psychosocial fac to rs, but the exposure classification scheme does not allow results were not included in the article. Both separation of the effects of repetition from employment duration and working more than those of force, and there was no precise 30 hours per week were found to be measure of repetitiveness. Data randomly selected from the Swedish insurance entry terminal users, whose tasks required registry. Exposure was obtained by more extensive repetitive work than traditional questionnaire. Gender, immigrant status, work medical secretaries with frequent, significant pace, and current smoking were also analyzed neck pain to those with few episodes based on in the logistic model. A residents for the presence of neck symp to ms in surrogate for repetitive work consisted of hours the past six months. Exposure was based on sitting or working with office machines with high questionnaire responses. Neck case definition required symp to ms and physical examination findings Hales and Fine [1989] compared 89 female that met predetermined criteria. Exposure workers in 7 high exposure jobs to 25 female assessment was based on hand/wrist poultry workers in low exposure jobs assessment of forceful and repetitive jobs. No assessment of neck repetition was Kuorinka and Koskinen [1979] studied performed. Temporary 2-7 workers and Milerad and Ekenvall [1990] compared the self-reported neck and neck/shoulder those with recent trauma were excluded from symp to ms between dentists and pharmacists. Exposure assessment Dentists had been considered the high risk included videotape analysis of scissor maker group because of awkward postures and tasks, however exposure assessed for the hand repetitive use of small hand to ols. The authors examined exposure assessment was conducted on the several covariates and stratified by gender for shop assistants. No difference between groups in interview and physical examination by a leisure time, smoking, systemic disease, and physiotherapist following a standard pro to col. Diagnoses of tension neck syndrome were determined using predetermined criteria [Waris Ohlsson et al. In problem cases, orthopedic and equipment and au to mobile assemblers, physiatric teams determined case status. It is 76 former female assembly workers who quit unclear whether cashiers were excluded from within 4 years and compared these two groups the comparison group in this study as they were to 60 randomly sampled females from the in the Luopajarvi et al. The work 152 female assembly line packers in a food pace was divided in to four classes: (1) Slow: production fac to ry to 133 female shop <100 items/hr; (2) Medium: 100 to 199 assistants in a department s to re. Exposure to items/hr; (3) Fast: 200 to 700 items/hr; repetitive work, awkward hand/arm postures, (4) Very Fast: >700 items/hour. The health assessment of workers with varying exposure to repetitive consisted of interviews and physical tasks. Health outcome was based on symp to ms examinations conducted by a physiotherapist, of shoulder stiffness, dullness, pain, numbness; and diagnoses of tension neck syndrome were pressure measured by strain transducer at which a subject felt pain; and a physical exam. Age, hobbies, and housework were performed then job categorization was were considered in the analysis. Exposure was again based on manipulations, and length of employment, there measurements of job tasks by a representative was not a difference between workers with worker. Opera to rs still working 162 women garment workers and 76 women were compared to those who moved to other hospital workers such as nurses, labora to ry employment in 1991. There was a through a questionnaire asking type of machine low participation rate among the hospital operated, work organization fac to rs, workers. Eighty-six percent of the garment workplace design fac to rs, units produced per workers were sewing machine opera to rs and day, the payment system, and the duration of finishers (sewing and trimming by hand). The exposed to be significantly related to exposure, exposure garment workers likely had more repetitive time, or age, there was a significant drop-out jobs than most of the hospital workers. Subjects significantly higher when performing pear were selected after the bagging than when apple bagging. Confounders were not checked each day with a keyboard machine with a for in this study. In the neck/shoulder area that were both objective same study, comparing the different and independent of the hand/wrist. Several of stereotypic, repetitive jobs in scissor-making, these studies [Baron et al. It is strictly on hand/wrist exposure and not arm, important to note that both the longer-cycled shoulder, or neck exposure. When comparing two groups in which for all work tasks and not specifically focused the level of repetitive exposure may not differ on the neck or neck/shoulder area. It can be used to establish a temporal relationship is reasonable to assume that in those studies, between exposure to repetitive work and neck given the exclusions required by the case or neck/shoulder disorders, the study by definitions, the onset of exposure was prior to Jonsson et al. Many more studies involved workers in introduction of new electronic cash registers repetitive work from a range of industries placed at unsuitable heights. Other studies excluded participants Repetition 2-11 Studies outside the epidemiologic literature give exposure assessments for their analyses and did supportive evidence that repetitive work is not conduct specific neck, shoulder, or upper related to neck/shoulder disorders. Nicholas [1990] reported in his exposure as strenuous work involving the upper discussion on pathophysiologic mechanisms of extremity that generates loads to the trapezius sports injuries that a low-load force with high muscles. Most of the studies that examined repetition results in a gradual deterioration of force or forceful work as a risk fac to r for tissue strength from strain to fatigue to neck/shoulder had several concurrent or deformation, with prefailure symp to ms, such as interacting physical work load fac to rs. Most studies that have dealt with force loading of the neck or stress generated on Conclusions Regarding Repetition the neck structures are from biomechanical the association between neck or studies performed in the labora to ry. In terms of mean static trapezius load in assemblers was magnitude of the association, two studies had reduced from 4. Because so many interventions reported that the findings were statistically were involved in this study, it is not clear to significant at the p<0. However, interviews every 10 weeks to detect symp to ms musculoskeletal sick leave per man-labor years of muscle pain. Interviews concerning exposure at work were also conducted prospectively every 10 weeks Quantification of the muscle load was done by for 1 year. For the initial evaluation, Koskinen [1979] reported statistically observation of work sites were performed. Both studies controlled for age, gender, and length of employment in the Wells et al. Two of the four studies that used an increased load on the shoulder from a estimated hand and wrist exposure mailbag. Letter carriers were compared to gas measurement combinations of force and meter readers (without heavy loads) and postal repetition (but carried out no neck, shoulder, or clerks. A telephone survey was used to obtain upper extremity exposure measurements) found both symp to ms and exposure. This may lead to injury of occupational muscle-related disorders, such as these units, despite the fact that the to tal tension neck syndrome. This hypothesis was recently concerns stress on the trapezius and supported by a longitudinal study by Veiersted surrounding muscles of the neck from heavy et al. Reduced blood flow was found to be performing repetitive assembly work with static correlated with myalgia (muscle pain) and loading of the trapezius muscles [Hagberg and ragged red fibers in 17 patients with chronic Kvarnstrom 1984; Larsson et al. The third pathophysiologic for Force mechanism for muscle pain deals with energy Aaras [1994] reported that by reducing static metabolism disturbance, caused by long-term muscle loading (an indication of force static contractions of the muscles. The psychosocial using a questionnaire survey for case definition work environment was also studied; the based on frequency, duration, and intensity of analysis was stratified for age and gender. Time As part of a longitudinal study, Viikari-Juntura spent on the telephone was associated with an et al. Analysis was study in 1955, and had repeated cross controlled for age, gender, height, psychosocial sectional exams from 1961 to 1963. Exposure consisting of adjustment of office furniture and was also based on survey, asking the amount of equipment was carried out. The study group work with hands overhead, work in forward bent position, and work in twisted or bent was given a short course of basic training on position. Four lessons physical and creative hobbies, with no on relaxation was given by means of exercises. There was a significant decrease in tension neck In a cross-sectional study of machine syndrome among the cases involved in the opera to rs, carpenters were compared to office intervention compared to those workers who workers by Tola et al. The multifac to rial analyses (no numerical results analysis did not control for confounders except were reported). This change would have decreased static previously, compared female industrial workers loading and increased the dynamic pattern of performing repetitive tasks to referents without movements of the workers. Exposure was concerning the electronic workers, reported assessed by job analysis and posture two findings: (1) that the more dynamic the measurements of two representative workers. The same authors found with symp to ms in the neck and neck/shoulder similar results in 1987 when only the symp to ms angle. The article does not mention the body time spent on the telephone increased, so did postures that were measured. We exposure to vibration and to draw any conclude that there is strong evidence for conclusions about their relationship. Therefore, it is important that studies take chance, bias, and confounding can be ruled out in to account when examining the strength of with reasonable confidence.
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