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By E. Keldron. College of Charleston.

Although antimicrosporidial agents (benzimidazole) have been used for controlling microsporidia in insects with variable success discount proscar 5mg, chemical compounds do not pro- vide eVective control of microsporidia in P safe proscar 5 mg. Further studies may prove fruitful; however cheap proscar on line, chemical compounds may not be well suited for controlling microsporidia in phytoseiids. Chemicals are usually added to artiWcial diets or sugar solutions but some arthropods (particularly phytoseiids) cannot be reared successfully on artiWcial diets. Furthermore, it is diYcult to determine how much of the chemical agent is consumed when chemicals are added to food that is eaten. The number of viable microsporidian spores is reduced when microsporidia-infected mites are reared at high temperatures (32 35 C) for several days. Under these conditions, spores that remain in the host tissues are thought to become non-viable because all subse- quent eggs deposited by heat-treated females are microsporidia-free. Spore viability is dependent on environmental factors, including tempera- ture, humidity, and exposure to ultraviolet light (Maddox 1973). Sanitation of rearing facilities and equipment also helps reduce pathogen transmission. Conclusion Although many factors inXuence the outcome of a particular biological control program, the use of pathogen and parasitoid-free natural enemies is the foundation for success. Inver- tebrate pathogens are often overlooked in scientiWc studies and in mass-production systems when things go awry. It is essential to use pathogen-free beneWcial arthropods in scientiWc studies if quality control testing is to have meaning and to avoid the misinterpretation of data (Goodwin 1984). Not all microorganisms are pathogenic; therefore, it is important to correctly identify all microorganisms and determine their impact on host Wtness. Both bacteria and microspor- idia have been reported from mass-reared phytoseiids and some of these cause subtle Diseases of Mites and Ticks 305 symptoms that may be overlooked. Quarantine of introduced or newly-acquired arthropods, in combination with routine microscopic examination of Weld-collected specimens (or specimens otherwise introduced into a mass rearing), is recommended so that invertebrate pathogens are not inadvertently introduced into existing arthropod colonies (Goodwin 1984; Bjrnson and Keddie 1999). Morphology and pathology of the predatory mite, Phytoseiulus persimilis Athias-Henriot (Acari: Phytoseiidae). Biol Control 19:17 27 Bjrnson S, Schtte C (2003) Pathogens of mass-produced natural enemies and pollinators. J Invertebr Pathol 79:173 178 Poinar G Jr, Poinar R (1998) Parasites and pathogens of mites. Acta Entomol Bohemoslov 87:431 434 Kupkov G, Rttgen F (1978) Rickettsiella phytoseiuli and virus-like particles in Phytoseiulus persimilis (Gamasoidea: Phytoseiidae) mites. Biol Control 10:143 149 Veried and potential pathogens of predatory mites (Acari: Phytoseiidae) Conny Schutte Marcel Dicke Originally published in the journal Experimental and Applied Acarology, Volume 46, Nos 1 4, 307 328. Pathogen-free phytoseiid mites are important to obtain high efcacy in biological pest control and to get reliable data in mite research, as pathogens may affect the performance of their host or alter their reproduction and behaviour. Potential and veried pathogens have been reported for phytoseiid mites during the past 25 years. From the latter group four reports refer to Microsporidia, one to a fungus and one to a bacterium. Moreover, infection is not always readily visible as no obvious gross symptoms are present. Monitoring of these entities on a routine and continuous basis should therefore get more attention, especially in commercial mass-production. Special attention should be paid to eld-collected mites before introduction into the laboratory or mass rearing, and to mites that are exchanged among rearing facilities. However, at present general pathogen monitoring is not yet practical as effects of many entities are unknown. More research effort is needed concerning veried and potential pathogens of commercially reared arthropods and those used as model organisms in research. Phytoseiid predatory mites include specialists such as Phytoseiulus persimilis Athias-Henriot, which attack spider mites (Tetranychus spp. Among the 30 species that, by the beginning of this century, are being produced in com- mercial insectaries on a large scale are four phytoseiid species (van Lenteren 2003a, b). The success of biological control programmes is, among other factors, dependent on the health of the benecials that are used. In several cases reports of poor performance in mass-reared phytoseiid mites have raised questions regarding their quality and efcacy in biological control (Steiner 1993a, b; Steiner and Bjrnson 1996; Bjrnson et al. Moreover, phytoseiid mites are used in several research groups for the study of predator prey interactions and foraging behaviour (Yao and Chant 1990; Margolies et al. Pathogens may also alter the behaviour of their host (Horton and Moore 1993), thereby inuencing outcomes of behavioural research. Veried and potential pathogens have been reported in phytoseiid mites collected from the eld (Furtado et al. For the latter two cases it could not be determined whether the entities originated from eld-collected natural enemies or arose in mass-rearing systems as a result of intense and continuous rearing under laboratory con- ditions. Mass-reared host populations may be more susceptible to diseases than eld populations, as genetic variation is lower and immune responses may be compromised by stress factors including sub-optimal climatic conditions, starvation and overcrowding (Lighthart et al. Moreover, in mass-production of arthropods climatic conditions may be better suited for pathogens and horizontal pathogen transmission may be more effective than in natural situations (Sikorowski and Lawrence 1994). These factors may thus enhance disease incidence and the development of novel diseases and/or virulent pathotypes in mass-reared populations. The following review of veried and potential pathogens in phytoseiid mites includes cases with unknown host effects, cases of infection with endosymbiotic bacteria, cases of unidentied diseases and cases of identied diseases, with known pathologies and transmission modes. Diseases of Mites and Ticks 309 Viruses General characteristics of viruses in insects and mites Viruses may be dened as biological macromolecules that have the ability to multiply within living cells. They are reported from mites and virtually every insect order and are the smallest of all entomopathogens. Viral diseases are one of the most widely investigated infections in insects (Tanada and Kaya 1993). Some viruses are occluded at random in proteinaceous occlusion bodies that can be detected under the light microscope, whereas most non-occluded viruses can be detected only with the aid of the electron microscope (Lacey 1997). In general, infection occurs after viruses have been ingested, but transmission may occur via the host egg (=transovarially), through natural body openings (for example spiracles) or through wounds (Tanada and Kaya 1993). Behavioural changes of insects infected by viruses include: changes in level of activity (wandering behaviour) and changes of microhabitat preference, such as elevation seeking behaviour (= tree-top diseases), movement to exposed locations and diurnal behaviour of nocturnal insects (Horton and Moore 1993). Viruses of phytoseiid mites Six reports exist on unidentied viruses of phytoseiid mites (Table 1). In all cases virus-like particles were detected in electron microscopic studies, but host effects have not been studied. Unidentied, non-occluded virus-like particles were observed in the yolk of developing eggs inside N.

Acids are produced on tooth surfaces as an end product of dental plaque bacterial fermentation of simple sugars; 2 order proscar 5mg fast delivery. Acid erosion due to fruit drinks in a xerostomic patient with Sjogren s syndrome (photo courtesy of Dr order proscar 5mg on-line. Effects of Xerostomia on Diet and Nutrition In the absence of saliva buy proscar 5 mg online, it becomes a challenge to chew, swallow, and even taste food (31). Difficulty masticating and lubricating food may make it difficult to eat solid foods. Patients may adapt to a primarily liquid diet that may be low in nutritional value. It is also common that people experiencing dry mouth use items such as hard candies or other slowly dissolving lozenges in an effort to increase salivation. If these items are used frequently and contain sugars, they can be major contributors to increased dental caries incidence. Frequent eating or snacking is a major risk factor for dental caries development that is increased when the oral cleansing effects of saliva are lost. Sufferers may have a dry cough, hoarseness, a decreased sense of smell, and nose bleeds. People may also report having joint or muscle pain (37), low-grade fever, increased fatigue (25), and vasculitis. The new criteria states that a person may be diagnosed as having Sjogren s syndrome if he has at least four of the following six diagnostic tests results (Table 3), including one objective measure (ie, by histopathologic examination or antibody screening) as positive (16,38). Salivary function test: Salivary function tests are used to determine the actual severity of xerostomia (39). Sialometry measures unstimulated salivary flow rate into a calibrated tube for 15 minutes. Salivary gland biopsy: Lip biopsy involves performing biopsy of minor salivary glands in the lower lip. Another test that could be performed for dry eye is the Rose Bengal staining test. Lip biopsy: a small amount of salivary tissue is removed from inside the lip and examined under a microscope for evidence of Sjogrens syndrome Schirmer test for dry eyes: helps determine the dryness of eyes. A small piece of filter paper is placed under the lower eyelid to determine the quantity of tear production Symptom for dry eyes: Patient reports of symptoms of dry eyes are also used to help diagnose Sjogren s syndrome. A positive response to all of the following is considered diagnostic for dry eyes (22): Do you Do your eyes feel dry, gritty or sandy or burn Do you use tear substitutes more than 3x/day? Because the treatment is tailored to the symptoms, each patient s management plan will be different (43). Additionally, a humidifier in the house can be a tremendous help to avoid low humidity conditions. If possible, alternative, non-xerostomic medications should be used as substitutes. Patients should be shown how to avoid any products that can contribute to oral dryness or irritation. Alcohol has a drying effect and should be avoided in both beverages and in oral products such as mouthwashes. Tartar control toothpastes and tooth whitening products should also be avoided as they can be irritating to friable oral tissues. If patients tend to breathe through their mouths, it is often helpful to encourage them to try to increase nasal breathing and check with an otolaryngology specialist if there are impediments to normal nasal breathing. In the presence of xerostomia and decreased immunity, there is often an increase in fungal infections such as oral candidiasis. Eye Palliatives A variety of lubricants are available over the counter and by prescription to lubricate the eyes and minimize eye itching and burning. Oral Palliatives and Therapies (Table 6 (45)) A multitargeted approach is needed for oral care to palliate existing conditions and more importantly, protect oral soft and hard tissues from further damage. Patients should see the dentist at least four times a year for diagnostic evaluations and preventive and palliative treatments. Radiographs should be taken yearly to check for new carious lesions in the dentition. The oral mucosa is often dry and sore as a result of the loss of protective saliva. A saliva substitute can also be used before eating to mimic the effects of actual saliva. Sialogogues are drugs that work by stimulating the M3 receptors stimulating moisture production throughout the body. No serious side effects have been seen but care must be taken if used with concomitant medication or by patients with cardiovascular disease or hypertension (46). Because the loss of protective saliva in xerostomia increases the vulnerability of tooth enamel surfaces, extra effort must be made to protect teeth from demineralization and dental caries. It helps mineralize the outer surfaces of tooth enamel, thereby making enamel destruction more difficult, and impedes the function of the oral bacteria that initiate dental caries. Fluoride is available from a variety of sources from fluoridated drinking water and fluoride dentifrices to over-the-counter and prescription concentrated strength forms. Calcium also has a remineralizing effect on dental enamel and a calcium-containing toothpaste or remineralizing oral rinse may be recommended as well. Antibacterial solutions such as Chlorhexidine and Triclosan are indicated in an effort to reduce the growth of dental caries causing oral bacteria. Because the oral tissues and gums may be sore, the use of a normal soft-bristled toothbrush may be uncomfortable. Table 7 shows the management strategies for patients who develop oral candidiasis. Help these patients to maintain good nutriture despite oral impairment by providing diet suggestions that are well tolerated and high in nutritional value and by providing diet suggestions that do not further irritate oral tissues. Ensure that their dietary habits and patterns do not increase dental caries risk 3. Maintain Good Nutriture Despite Oral Impairment Good nutrition is important to assure the consumption of the nutrients known to be essential for good eye and oral health as well as general health. Many of the oral conditions listed previously conspire to limit food choices for these individuals. The lack of saliva makes it difficult to chew food and move it easily through the mouth in preparation for swallowing. If the oral tissues are sore, the physical form of the food may make it painful to bite or chew. However, when faced with the inability to eat the usual nutritious diet, people may adapt to a soft diet, which can be low in nutritional value. The therapeutic challenge is to provide food choices that help patients overcome the oral impediments while maintaining optimum nutriture. Table 8 provides food choice suggestions from each of the recommended food groups that will be nutritious and yet will help overcome specific oral impediments. These could include soothing beverages with meals, gravies on foods, soups, and soothing smooth deserts like ice cream and gelatin. Ensure That Dietary Habits and Patterns Do Not Increase Risk for Dental Caries The primary focus of dietary prevention of dental caries is to decrease the caries- promoting properties of the diet and enhance its protective qualities.

The initial depolarization of the ventricles starts in the ventricular septum in the same direction as that of the right ventricular wall mass as recorded in V1 and V2 resulting in an initial R-wave deflection in these leads without a Q-wave purchase proscar uk. In patients with right ventricular hypertrophy there may be deviation of the plane of the ventricular septum leading to a small Q-wave with resultant qR pattern in V1 and V2 52 Ra-id Abdulla and D proscar 5 mg visa. Similar to changes leading to an rsR pattern described above cheap proscar online master card, the right ventricular electrical domi- nance may be significant enough to completely mask any left ventricular forces in the right chest leads, resulting in a pure R-wave configuration (Fig. The ventricular septum may deviate secondary to right ventricular hypertrophy thus acquiring an abnormal position within the chest. This will cause an initial downward deflection in the right chest leads, manifesting as a q-wave. This is followed by a prominent R-wave reflecting right ventricular hypertrophy, thus resulting in a qR pattern in the right chest leads. This qR pattern can be also seen in dextrocardia, ventricular inversion, and pectus excavatum, all due to abnormal location of ventricular septum within the chest wall (Fig. Left Ventricle The R-wave in left chest leads represents depolarization of the left ventricle. Left ventricular hypertrophy results in increased depolarization voltages and manifests as a tall R-wave in the left chest leads and a deep S-wave in the right chest leads (Fig. This is typically the result of ventricular hypertrophy or rarely, an abnormal coronary artery origin resulting in inadequate coronary perfusion and myocardial ischemia. Interestingly, the low oxygen saturation from the pulmonary artery blood (70 75%) does not lead to ischemia. It is the low pressure in the pul- monary artery (typically <1/3 systemic pressure) that causes poor perfusion of the anomalous coronary artery which leads to ischemia, followed by infarction. Patients subsequently develop a dilated cardiomyopathy due to the large areas of infarcted left ventricle. Events causing acute insufficiency of coronary blood flow due to mechanical changes not currently well understood lead to compression of the abnormally located left coro- nary artery resulting in stunning of the myocardium and manifesting as syncope or sudden death. Reid Thompson, Thea Yosowitz, and Stephen Stone Key Facts Echocardiography is noninvasive with no known harm to patients. Imaging and interpretation by specialists outside the field of pediatric cardiology is likely to lead to errors. Introduction Echocardiography has become the primary tool of the pediatric cardiologist for diagnosing structural heart disease. It is highly accurate when performed and inter- preted in an experienced laboratory, and in most cases is sufficient for understand- ing the anatomy and most of the hemodynamic consequences of the most W. As miniaturization of ultrasound technology and price points improve, it may eventually become feasible for noncardiologists to purchase portable ultrasound devices and incorporate imaging of the heart into their physical examination. However, due to the level of expertise involved in performing and interpreting a study to rule out congenital heart disease, screening for heart disease currently is still more appropriately done by a careful history and physical examination and will likely remain so for the foreseeable future. Echocardiography in infants and children, performed to diagnose or follow con- genital or acquired heart disease that affects this age group, is technically very different from adult echocardiography and requires specific equipment and exper- tise usually not found in typical adult echocardiography laboratories. This has been recognized by accreditation agencies that have developed specific requirements for quality control of pediatric studies. The pediatrician is often faced with the question of when an echocardiogram should be ordered directly versus requesting a cardiologist consultation at first. There are many indications for echocardiography that are appropriately ordered directly by the generalist, and only if abnormalities are found, would a consultation with the cardiologist be important. In other cases, consultation as the first strategy is more efficient and usually leads to more appropriate testing (Tables 4. An extensive list of situations suitable for echocardiography is included in these guidelines. The following is an outline of situations in which echocardiogra- phy is a valuable and helpful tool to the practitioner. In the neonatal period, echocardiography is indicated in the evaluation of sus- pected patent ductus arteriosus (Fig. It should also be used for screening for cardiac defects in patient with known or suspected chromosomal or other genetic syndrome with cardiac involve- ment (Fig. In uncomplicated cases, an initial echocardiogram should be done at diagnosis, at 2 weeks, and at 6 8 weeks after onset of disease. If the echocardiogram is normal at 6 8 weeks, a follow-up study 1 year later is optional. If abnormalities are detected on any of the echocardiographic studies, additional studies will usually be ordered by the cardiologist, with frequency and length of Fig. Color Doppler echocardio- graphy: parasternal short axis view color Doppler shows direction of blood flow. Typically, the setting is such that red color indicates flow towards the probe, while blue is blood flow away from the probe. The illustration on the left hand shows cardiac anatomy, red and blue color- ing reflects well oxygenated and poorly oxygenated blood in different cardiac chambers. This coloring scheme should not be confused with the red and blue coloring of color Doppler follow-up determined by the severity of the abnormalities. It is important to note that it is difficult to obtain high quality coronary imaging on a fussy infant or young child, which may necessitate the use of sedatives to enable completion of echocardiography. In addition, for any infant or child with 5 days of fever and only 2 3 classic clinical criteria, or elevated inflammatory markers but <3 supplemental lab criteria, an echocardiogram can be used to help make the pre- sumptive diagnosis. In patients with systemic hypertension, the first echocardiogram should include a full anatomy study to rule out aortic coarctation, as well as an assessment of left ventricu- lar wall thickness and function. Subsequent yearly follow-up examinations should be done to look for abnormal increases in left ventricular mass or changes in function. The diagnosis and follow-up of pulmonary hypertension includes the use of echocardiography. In cases of obstructive sleep apnea, the extent to which hypoventilation has affected the heart can be assessed through measurement of Fig. On the other hand, the motion of ventricular walls in the patient in (b) is flat reflecting limited ventricular wall motion 4 Pediatric Echocardiography 61 Fig. The illustration on the left hand shows cardiac anatomy, red and blue coloring reflects well oxygenated and poorly oxygenated blood in different heart chambers. This coloring scheme should not be confused with the red and blue coloring of color Doppler right ventricular pressure (using tricuspid valve Doppler or interventricular septal position), wall thickness, and function. Patients with sickle cell disease and increased pulmonary artery pressure as estimated by echocardiography have higher mortality. Cardiomegaly or other abnormal cardiovascular findings noted on X-ray, espe- cially if associated with other signs or symptoms of potential heart disease should prompt echocardiography. If possible, pericardial effusion is suspected, especially in the setting of hemodynamic compromise possibly representing cardiac tampon- ade, emergency echocardiography is indicated and may be used to assist in pericar- diocentesis (Fig. Patients suspected of having connective tissue disease such as Marfan syndrome or Ehlers Danlos syndrome should have echocardiography. Specifically, echocar- diogram is used to evaluate the aortic root in individuals with suspected Marfan syndrome and to evaluate for Mitral Valve prolapse.

Systemic omega-6 essential fatty acid treatment and pge1 tear content in Sjogren s syndrome patients buy cheap proscar on line. Relation between dietary n-3 and n-6 fatty acids and clinically diagnosed dry eye syndrome in women buy generic proscar 5mg on line. The Effect of an Omega-3 supplement on Dry Mouth and Dry Eyes in Sjogren s Patients purchase proscar mastercard. Correlations between nutrient intake and the polar lipid profiles of meibomian gland secretions in women with Sjogren s syndrome. A new approach to managing oral manifestations of Sjogren s syndrome and skin manifestations of lupus. Inhibition of autoantigen expression by (-)-epigallocatechin-3-gallate (the major constituent of green tea) in normal human cells. Fathalla and Donald Goldsmith Summary The juvenile idiopathic arthritides are a group of heterogeneous disorders characterized by chronic arthritis with frequent extra-articular manifestations. Key Words: Growth delay; juvenile chronic arthritis; juvenile idiopathic arthritis; juvenile rheumatoid arthritis; nutritional impairment 1. Each arthritis subtype has a distinct constellation of clinical manifestations and laboratory features. Chronic arthritis is the most common pediatric rheumatic disease and represents one of the most frequent causes of chronic illness and disability in children. Its clinical spectrum is variable and ranges between arthritis affecting a single joint to a severe systemic inflammatory disease involving multiple joints. Although the etiology of the various types of chronic arthritis in children largely remains unknown, recent advances in the basic understanding of the inflammatory response has led to several breakthroughs in the treatment and management of this group of disorders (1,2). Assessment of nutritional status is a pivotal part of each patient s evaluation (2). In this chapter we present an overview of the subtypes of the chronic arthritides in children From: Nutrition and Health: Nutrition and Rheumatic Disease Edited by: L. He included a section on stiffenes of the limmes a condition that he attributed to exposure to the cold (3 5). Aside from acute rheumatic fever, previously known as acute rheumatism, only a few case reports of chronic arthritis in children were described before the year 1900. Two reports of a relatively large number of patients with chronic arthritis were published at the end of 19th century; the first, in 1891 authored by Diamant-Berger, a French physician and the second in 1897 by George Fredric Still. The latter is considered by many to be a landmark publication in the history of pediatric rheumatology (3 7). Both reports emphasized that chronic arthritis in children was different from adults and that it included several subtypes, perhaps suggesting that various disorders could be operative. Only a few but important benchmark events took place during the first half of the 20th century. The association between Group A hemolytic streptococcal and acute rheumatic fever was established in 1930 (8). The synthesis of cortisone paved the way for the use of corticosteroids in treating several rheumatic conditions including chronic arthritis (3,9). In 1910, Ohm described a child with arthritis who developed chronic iridocyclitis (3,5). As more cases of children with chronic arthritis were identified, several published reports appeared during the early decades of the 20th century. It soon became apparent that the wide spectrum of the presentation of chronic arthritis of children implied that the disorder was quite heterogeneous. This led to a divergence in nomenclature between reports coming out of Europe versus reports from North America. Accordingly, most of the reported case series and studies done before 1993 have used either of these two terms. It is important to note that the primary purpose for establishing uniform classification criteria is to delineate a relatively homogenous group of patients, which will facilitate accurate collection of clinical data between research centers. However, in clinical practice, these classification criteria often provide the framework for a proper diagnosis. The following is a brief review of the main features of each classification system. There are three major subtypes: pauciarticular onset (arthritis involving four or less joints), polyarticular onset (arthritis involving five or more joints), and systemic onset (arthritis with characteristic systemic features such as double quotidian fever and classic rash). These criteria have been widely used, validated, and are easy to apply in clinical practice. It does, however, require the exclusion of other forms of juvenile arthritis that do not have validated classification criteria. Another major difference is the particular application and use of the term rheumatoid. Utilizing the term juvenile idiopathic arthritis several subtypes were identified including an undifferentiated category (14). This international classification was subsequently revised twice, in 1997 (15) and 2001 (16). Those patients who fulfilled more then one subtype criteria or did not fulfill any subtype criteria were categorized under the subtype of undifferentiated arthritis. Tables 1 and 2 provide a summary of the three main classification systems and delineate their major differences. Each of the above seven subgroups has detailed inclusion and exclusion criteria (14 16). Based on analysis of 34 reported epidemiological studies from 1966 to 2002(18), the incidence varies from 0. The major factors contributing to the wide variations included diagnostic difficulties, the use of different definitions, differences in case ascertainment (community-based vs case studies), and definition of the study population. Its most common presentation is monoarthritis affecting one knee, which occurs in almost half of all affected patients. These patients do not usually complain of any significant pain and most often remain quite functional (19,20). Extra-articular manifestations are extremely rare with the exception of chronic uveitis. Some children will develop change in vision, photophobia, or pain and redness in the eyes later in the course. The risk is never absent but uveitis usually develops in the first 5 to 7 years after onset. Patients require regular ophthalmological evaluations so early treatment may be implemented, usually with glucocorticoid ophthalmic drops with or without mydriatic agents. Localized growth disturbance is one of the important complications that require special attention in both this variety and other forms of arthritis. Both are more often seen in females with the former being more common during late childhood and adolescence, whereas the latter is more common during early childhood. Other cosmetic effects such as facial asymmetry or bird face deformity can be seen in chronic disease. However, the initial presentation is often nonspecific and the child is considered to have a fever of unknown origin. Systemic features usually precede the development of arthritis, which prompts extensive assessment to rule out a malignancy or an infectious disease.

A useful approach is to ask open questions that allow the patient to say as much or as little order cheapest proscar and proscar, as s/he wishes purchase proscar master card. These questions allow the index patient to withhold information s/he is not ready to give purchase 5 mg proscar, without seeming rude. As a result, the patient develops a sense of being in control and the health adviser gains insight into the patient s level of resistance without having created conflict. At this stage, most people will be willing to give a first name and describe the type of relationship (regular, ex, casual). Questions about where and how they met (if recent) are usually non-threatening, and can help to develop a 2 relaxed rapport while giving insight into the patient s social and sexual milieu. This is useful: understanding the values, attitudes, language and behaviours associated with transmission networks allows the interviewer to select the right words, questions and 3 4 motivators. Sensitive information about the contact, such as involvement in prostitution, sex clubs or drugs, may be more readily shared before the contact s full name has been given. Using the social context Identifying connections between people can suggest ways of tracing a contact. Learning where people met may uncover key locations that 5 are functional to transmission such as certain pubs, clubs, saunas or drug houses. These 6 7 can then be targeted by additional control efforts, including health promotion and on- 8 9 10 11 12 site screening. Reassurance can be offered by using open questions (such as Who else may be involved? Questions or comments that imply blame or judgement (such as Who might you have given this to? Open question prompts may be repeated until the patient indicates the list is complete. Using memory prompts Memory prompts may help patients with multiple partners to recall forgotten individuals. The interviewee is asked to consider who else s/he has had each type of relationship with during the look- back period. Location cues Require the patient to remember where they met each named contact, then consider who else they have met at each of the places mentioned. Personal timeline cues Involve identifying key events during the look-back period, such as vacations, business trips, time in jail or the end of a relationship. The interviewee is asked to consider whether they have had sex with anyone else known to each named contact. Alphabetic cues Involve asking the patient to recall all recent sexual partners whose names begin with each letter of the alphabet. Brewer & Garrett 14 found that each cue in isolation was moderately effective, particularly alphabetic and location cues, which increased the number of sexual partners recalled by 10% and 12% respectively. When all cues were used together, the impact was much greater, increasing the number of sexual partners recalled by 40% (Evidence Ib). Taking a thorough sexual history Taking a systematic sexual history may reveal some contacts that have not been mentioned because the patient believes they have not been at risk. Specific, exhaustive questioning is recommended, such as Apart from X, Y and Z, who else have you had sexual contact with in the past x months? The symptoms can sometimes take a while to develop, so you could have caught it earlier. The patient may omit to mention partners with whom condoms have been used, in the mistaken belief that there has been no risk of transmission. Protecting contacts from blame The health adviser may protect the contact from blame by stressing the difficulty of knowing how long an infection has been present and the possibility that the source may have been unaware of the infection. Blame is unhelpful because it may put the contact at risk, or be a justification for not notifying that person. Sometimes conditional referral is agreed, whereby provider referral is initiated if the partner has not attended by an agreed time. For patient referral Good practice would include: Preparing the patient It might be helpful to discuss how, when and where the contact might be informed. Potential embarrassment or conflict may be minimised by selecting the most appropriate place, time and words. Typical choices are between: informing face to face, by phone or by post; using a private or a public place; informing immediately by phone or deferring until face to face discussion is possible; disclosing the exact diagnosis or referring vaguely to an infection in the hope that the contact tests negative, and will therefore never know the infection was sexually transmitted. Clarifying the boundaries of confidentiality The patient needs to understand that the contact will not be informed of the patient s diagnosis or other partners, but that the contact is entitled to know his or her own diagnosis, which will also be confidential. Offering a contact slip for each partner The health adviser would offer a contact slip, explaining how and why these are used (see table 2). A system is therefore needed to ensure that medical staff managing the contact will have enough information to give appropriate care. If the contact has attended the clinic before, details can be entered into his or her medical notes. This requires keeping a record of all contacts expected to attend the clinic, together with the index patient details. The need for these contingency measures arises because contacts do not always disclose that they have been asked to attend, and they may leave the service falsely reassured without having had the necessary tests and/or epidemiological treatment. This system is less likely to be useful in cities where the contact has a choice of clinics. Negotiating a back-up plan Contingency measures are useful in case the contact fails to attend: studies have reported that only 11-32% of initial patient referral agreements result in 17 18 contact attendance. Obstacles include the difficulties of locating the person; raising the issue; or convincing the contact that they need to seek care. Since the index patient may not return to the clinic, it is important to negotiate a back-up plan during the first interview, if possible (for example, If he s not been within x days/weeks should I contact him directly, or speak to you again? Re-interviewing the patient A follow-up interview may be necessary if there is no record of the contact having attended. The purpose of this is to check progress, gather any additional data and repeat the offer of provider referral if the index patient is having difficulty. There is evidence that many patients who initially opt to inform their own partners subsequently agree to provider referral at follow-up interviews. For provider referral Good practice would include: Select appropriate method of notifying the contact The contact may be approached by post, telephone or personal visit, although the choice may be restricted if only limited information is available, such as a telephone number. Guidance may be sought from the patient, who is likely to know the contact s individual circumstances, and can alert the health adviser to potential pitfalls (For example: Ring him on his mobile, he works away Don t send anything through the post in case her husband sees it- 32 ring her during the day Send her a hospital letter so she knows its not a wind-up ). Negotiating a back-up plan An alternative approach might be agreed, in case the first choice fails. It may be necessary to arrange to speak to the index patient again, should more information be needed. Clarifying the boundaries of confidentiality The patient would be reassured that the contact would not be given any information that could expose his or her identity: this includes name, gender, area of residence, date of exposure and type of relationship. The patient would also be aware that the contact s subsequent diagnosis is also confidential. However, if the health adviser fails to find the contact, the patient may to be informed so s/he can reconsider patient referral and/or avoid re-exposure.

Treatment of trichorrhexis nodosa (congenital or acquired) involves the avoidance of mechanical or chemical injury to hair discount 5mg proscar. When severe buy proscar with a visa, the entire scalp is affected and patients are totally bald or more often have a sparse covering of short order proscar with paypal, twisted, broken and lusterless hairs. Follicular keratosis and abnormal hairs are found most frequently on the nape and occiput but may affect the entire scalp. Occasionally there is no keratosis pilaris, suggesting that the follicular hyperkeratosis is not important in the genesis of the beaded hairs. The most pathogenic mutations in hHb6 affect either the start of the rod domain at the helix initiation motif or the end of the rod domain at the helix termination motif (2). Both these sites in the rod domain contain a sequence that is very susceptible to point mutation. In fact, patients with autosomal recessive monilethrix appear to have more severe disease than those with an autosomal dominant aetiology with more extensive alopecia and papular rash. Retinoids (4) have been used with variable success and improvement in the condition may be related to resolution of the keratosis. Minoxidil has also been used but the condition may also spontaneously improve over time. Intermittently placed nodes form and the internodes tend to be the site of transverse hair fracture. Excessive weathering of the hairs with uting and disruption of the cuticle is most marked at the internodes. There are case reports of rare associations with mental and physical retardation, abnormal dentition, cataract, syndactyly and koilonychia. The beading is produced as an artifact of mounting hairs on glass slides and is of no signicance. On scanning electron microscopy, the widened beads can be seen to be an optical illusion. They merely represent art factual indentations of the shaft viewed in cross section. In the twisting hair dystrophy known as pilitori, or corkscrew hair, there is irregular thickening of the outer root sheath and attened hairs rotate completely through 180 degrees at irregular intervals. The twists can resemble beads on light microscopy and may be confused with monilethrix. These incomplete twists may occasionally occur in normal hair (seen in African hair and in the pubic/axillary hairs of other races). In pili torti, hair is often normal at birth, but is gradually replaced by abnormal twisted hairs that may be detected as early as the third month. Affected hairs are brittle, fracture easily, and do not grow to any considerable length. Patients present with a sparse and short coarse stubble over the entire scalp and may have a few circumscribed bald patches. A late-onset variant of isolated pili torti that rst pres- ents after puberty with patchy alopecia has also been described. The affected child typically has pale, lax skin and intellectual or neurological impairment secondary to degeneration of cerebral, cerebellar, and connective tissue. Affected males have pili torti, growth retardation and progressive psychomotor retardation. Affected females demonstrate patchy areas of short, broken, and twisted hairs, along Blaschko s lines on their scalp. It is unknown why the abnormality in copper metabo- lism makes the hair twist and defects in copper metabolism have not been demonstrated in other forms of pili torti. Without treatment Menke s patients slowly deteriorate and die within the rst few years of life. Partially treated males may develop long unruly hair that resembles uncombable hair. Trichorrhexis invaginata (also called bamboo hair ) occurs due to intussusception of the distal portion of the hair shaft (which is fully keratinized and hard) into the proximal portion (which is incompletely keratinized) (7). Netherton s syndrome is usually diagnosed in the rst few days after birth with widespread erythema and scaling. These characteristic lesions are seen in three-quarters of reported cases but their extent and persistence is variable. The patient may present primarily with either cutaneous changes or with sparse and fragile hair. Erythroderma and exfoliation may lead to complications of secondary infection, dehydration, or failure to thrive during the rst year. The hair defect may be very obvious on hair microscopic examination or so infrequent that examination of hundreds of hairs is needed to make a diagnosis. If hair-shaft examination is negative but clinical suspicion remains, further hair-shaft examinations at a later date are appropriate. Apart from trichorrhexis invaginata, golf-tee hairs where the distal portion of the bamboo hair fractures, leaving a cupped proximal ragged end is also a feature of Nether- ton s syndrome. It cannot grow to normal lengths, especially in areas most susceptible to friction. In adults, the scalp hair may improve slowly and the bamboo defects may only appear in the eyebrows or limb hair. Shapiro and Callender D D 188 Eyelashes D Alopecia is the clinical manifestation of many diverse causes. This chapter does not address the various etiologies of alopecia nor its varied clinical morphologies. It addresses alternative treat- ments for alopecia since many patients become frustrated with usual therapeutic regimens. In patients with alo- pecia, in whom scarring is evident clinically or histologically, improvement becomes progres- sively unattainable. The lay literature and Internet are replete with suggestions, advertisements, and promises that encourage and often eventually disappoint patients. It is important to be aware of possible alternative treatments and pitfalls in discussing treatments with our patients affected by alopecia. This chapter discusses herbal remedies, dietary supplements and other modalities used for alopecia. To this extent, their manufacture is not rigorously controlled as that of over-the-counter and prescription medicines. Therefore, even if an herbal remedy is useful in alopecia or other disorder, it is difcult to ascer- tain the potency, bioavailability and effectiveness of a given preparation on the market. The enzyme 5D reductase converts testosterone to dihydrotestosterone, which in turn can act on hair receptors to induce miniaturization in androgen-sensitive hair follicles in susceptible patients. When used in benign prostatic hyper- trophy, saw palmetto only relieves the symptoms associated with prostatic enlargement with- out reducing the hypertrophy (1).

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