Arthritis Australia

By N. Gorn. Drury University. 2018.

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The drop in blood glucose produces a craving for food order requip 0.25mg with amex, particularly foods that quickly elevate blood glucose generic 2 mg requip with amex, such as sugar and more alcohol. Increased sugar consumption aggravates the reactive hypoglycemia, particularly in the presence of alcohol. Hypoglycemia aggravates the mental and emotional problems of the alcoholic, producing such symptoms as sweating, tremor, anxiety, hunger, dizziness, headache, visual disturbance, decreased mental acuity, confusion, and depression. Although many of the nutritional problems of alcoholics relate directly to the effects of alcohol, a major contributing factor is that alcoholics tend not to eat, instead substituting alcohol for food. As a result, the alcoholic has to deal not only with nutritional deficiencies caused by excessive alcohol consumption but also with deficiencies due to inadequate intake. These metabolic abnormalities then lead to the common disorders of alcohol dependence: • Night blindness • Skin disorders • Cirrhosis of the liver • Slow skin healing • Decreased testicular function • Impaired immune function Vitamin A supplementation inhibits alcohol consumption in female rats (though this effect is inhibited by testosterone administration and removal of the ovaries). Antioxidants Alcohol consumption increases the formation of damaged fats (lipid peroxides) in both the liver and the blood. Matters are made even worse by the fact that alcoholics are typically deficient in key antioxidant nutrients, particularly vitamin E, selenium, and vitamin C, that protect against lipid peroxide formation. Carnitine The usual nutritional compounds that support liver function, such as choline, niacin, and cysteine, appear to have little value in improving liver function in the alcoholic. It has been suggested that chronic alcohol consumption results in either a reduced manufacture of carnitine or an increased need. It serves a critical role in the transport of fatty acids into the mitochondria, the energy-producing structures of the cells. Correction of this disturbance greatly aids the alcoholic, especially when there are signs or symptoms of cirrhosis or depression. Correction of the imbalances probably requires seeing a nutritionally oriented physician for proper analysis and treatment. That said, the branched-chain amino acids—valine, isoleucine, and leucine—can be of significant benefit for an alcoholic with cirrhosis. Vitamin C Vitamin C deficiency is common in alcohol-related disease—in one study, a deficiency of vitamin C was found in 91% of patients. It also decreases the formation of thiamine into its most active form, and this effect may also contribute to the development of functional thiamine deficiency. In addition, evidence indicates that a thiamine deficiency results in greater intake of alcohol, suggesting that thiamine deficiency is a predisposing factor for alcohol dependence. In fact, one study found deficiency in as many as 60% of alcoholics and a strong link to delirium tremens (a state of confusion and trembling during alcohol withdrawal). This deficiency is due primarily to a reduced magnesium intake coupled with alcohol-induced excessive excretion of magnesium by the kidneys, which continues during withdrawal despite low serum magnesium levels. Alcoholic cardiomyopathy, often associated with thiamine deficiency, may instead be due to a magnesium deficiency. Glutamine Supplementation of the amino acid glutamine (1 g per day) has been shown to reduce voluntary alcohol consumption in uncontrolled human studies and experimental animal studies. This is unfortunate, as the results were promising and showed the supplement to be safe and relatively inexpensive. Psychosocial Aspects Psychological and social measures are critical in the treatment of alcohol dependence, as it can be a chronic, progressive, and potentially fatal disease. Although strict abstinence may not be absolutely necessary, at this time it appears the safest and most effective choice. In some cases depressed individuals become alcoholic (primary depressives), while others become alcoholic first and later develop a depressive condition in the context of their alcohol dependence (secondary depressives). Alterations in the metabolism of brain chemicals such as serotonin and the availability of its precursor, tryptophan, have been implicated in some forms of depression, while other forms have been linked to alterations in catecholamine metabolism and tyrosine availability. As mentioned above, alcoholics have severely depleted levels of tryptophan, which may explain both the depression and the sleep disturbances common in alcohol dependence, since brain serotonin levels depend on circulating tryptophan levels. Another factor influencing tryptophan uptake into the brain is competition from amino acids that share the same transport mechanism, especially tyrosine and phenylalanine, which are elevated in malnourished alcoholics. Alcoholics have significantly depressed ratios of tryptophan to these amino acids when compared with normal controls, with depressed alcoholics having the lowest ratios. This mechanism is probably the cause of the abnormalities of the small intestine commonly found in alcoholics. Alcohol ingestion also increases intestinal permeability to endotoxins and large particles that can activate the immune system adversely. Improved fitness may allow more effective responses to emotional upset, thereby reducing the likelihood of resorting to alcohol when the patient is involved in conflict. Botanical Medicines Kudzu Kudzu (Pueraria lobata) was one of the earliest medicinal plants used in traditional Chinese medicine.

These vacuoles represent cytoplasmic vacuoles in association with clusters of the ballooning degeneration of the squamous epithe- small vacuoles purchase requip 2mg on-line. These cytoplasmic vacu- cell nucleus appears pyknotic and pushed to one edge oles often contain small order requip 1mg, pale eosinophilic inclusions of the cell, often appearing as if pushed beyond the with oil immersion examination of Wright’s stained cell margin. A secondary septic inflammatory response is lipomas resembles the cytoplasm of the lipocytes and often associated with ulcerated pox lesions. These clear, round, fat droplets usually partially dissolve in the alcohol- Cytology of the Cornea and Conjunctiva based stains (eg, Wright’s stain) but are easily seen in the water-soluble stains such as new methylene Normal conjunctival scrapings provide poorly cellu- blue. The nor- The cytology of feather cysts varies, depending upon mal cytology of the cornea is also poorly cellular and the chronicity of the lesion (see Color 24). Early consists of occasional noncornified squamous epithel- stages of feather cyst development reveal a marked ial cells. Inflammatory lesions involving the cornea number of red blood cells in the sample. Often and conjunctiva reveal inflammatory cells and in- erythrophagocytosis can be found. The comes more chronic and caseous exudation develops, epithelial cells often demonstrate degenerative the cytology resembles that of mixed-cell inflamma- changes, such as cytoplasmic vacuolation, karyolysis tion with a marked amount of background debris and or karyorrhexis. Chronic lesions may also reveal the presence of cornified squamous epi- Cutaneous and subcutaneous malignant neoplasms thelial cells that are not normally found in the con- are rare in birds, but can be detected on cytologic junctiva or cornea (Figure 10. Lymphoid neoplasia produces a highly cellular sample of immature lymphocytes (Color 10. These lymphoblasts and prolymphocytes are Cytology of Synovial Fluid large, round cells that exfoliate as single cells. They The amount of fluid in synovial joints of most birds is have large nuclei with fine chromatin and multiple normally too small for sampling; however, an abnor- or large prominent nucleoli. The cytoplasm stains mal accumulation of joint fluid may provide enough basophilic. The cells are mononuclear cells, rep- lymphoid tissue, such as lymphoid neoplasms, typi- resenting either synovial lining cells or mononuclear cally contains small, irregular, blue cytoplasmic frag- leukocytes. Cytologic evaluation should also be performed whenever lesions involving these organs are found on postmortem examinations. Avian lymphoid tissue appears as lym- phoid aggregates in the walls of the intestines, inter- nal organs (especially the spleen and liver) and skin. The cloacal bursa of young birds is a sac-like lym- phoid nodule found in the dorsal wall of the proc- todeum of the cloaca (see Figure 5. Cytologic evaluation of conjunctiva scrap- ings may have been helpful in determining an etiology for this lymphocytes, lymphoblasts and plasma cells nor- bird’s problems. Lymphoid hyper- An increase in the inflammatory cells and change in plasia causes an increase in the lymphoid tissue the color, clarity, and viscosity of the fluid is indica- mass; however, the cytology appears normal with the tive of inflammatory joint lesions (see Figure 12. Lymphoid neoplasia produces a background material, suggesting a decrease in mucin marked increase in the number of immature lympho- content. Erosion of the articular cartilage may result cytes, especially lymphoblasts, in the cytologic speci- in the presence of multinucleated osteoclasts in the men. An increase in the number of inflammatory cells, Cytologic samples of the liver are usually highly especially heterophils, is also seen with traumatic cellular with a predominance of hepatocytes, eryth- arthritis. Depending upon the location phagocytosis is supportive of a cytodiagnosis of hem- of sampling, there may be numerous lymphocytes arthrosis. Hepatocytes are large epithelial cells that occur in sheets or clusters or as single cells. Normal Articular gout produces a cream-to-yellow-colored hepatic cytology reveals uniform-appearing hepato- deposit in affected joints (see Color 21). These cells have an abundant, basophilic, of this material reveals numerous, needle-shaped finely granular cytoplasm and a round-to-oval, crystals (monosodium urate) (Color 10. Hepatocytes are easily ruptured during occasionally stain eosinophilic with Wright’s stain. Normal hematopoiesis is occasionally found because the liver is a common location for ectopic hematopoi- esis. It is are schizogony of Haemoproteus and Leukocytozoon, important not to confuse normal ectopic granulopoi- sporozoites of Atoxoplasma and microfilaria. If developing stages of the heterophils can be found, the cytology is Normally, cytology of the spleen shows a marked representative of granulocytopoiesis (see Chapter 9). The hepatocytes also present and occasionally contain iron pigment may demonstrate degenerative changes in the pres- from erythrophagocytosis of senescent red cells. The tions often cause a marked increase in the number of cytology reveals numerous macrophages and mult- splenic plasma cells. De- nowsky stain, the background of the smear contains velopmental stages of blood parasites may also be numerous large bacterial rods that do not stain. Systemic bac- Likewise, macrophages may contain numerous bact- terial or fungal infections may result in an increase erial rods that do not stain (Color 10. Because in the number of inflammatory cells, especially ma- mycobacterium have a waxy cell wall, they do not ture heterophils, in the spleen.

Once the candidate diagnosis pericardial effu- sion cheap 0.25 mg requip with amex, the patient should be admitted for observation and management to watch for cardiac tamponade order requip 1mg with visa. The candidate should still consider other differentials such as pulmonary embolism or myocardial infarction by reviewing risk factors such as family history of cardiac disease and recent travel history. Pericarditis may be caused by viral or bacterial illnesses, malignancy, radia- tion, or a variety of other causes. Patients often present with chest pain, made worse with lying down and improved with sitting forward. Additional symptoms can include dysphagia, dyspnea, and intermittent low-grade fevers. A friction rub heard over the left side of the chest is the most frequently encountered physical fnding. Test such as laboratory tests, chest radiographs, and echocardiogram can aid in ruling out other causes of chest pain. Patient appears stated age, confused, garbled response to questions, with obvi- ous facial droop on right side. She has a history of hyperten- sion, high cholesterol, diabetes, and hypothyroid disease. She suffers from mild dementia and forget- fulness, but is otherwise active, walks frequently, and is usually alert and con- versational. Upon questioning she states she took her regular medications but did not eat breakfast because she had a doctor’s appointment at 1 p m. If D50 is not given, patient will continue to be confused with focal neurological fndings c. No dextrose – patient remains confused Case 61: Altered Mental status 263 Figure 61. Eyes: pale conjunctivae, extraocular movement intact, pupils equal, reactive to light d. No dextrose – facial droop with garbled speech, does not cooperate with examination, refexes normal, Babinski refex normal, withdraws to pain q. Option 3: octreotide 50 to 125 mcg subcutaneously Case 61: Altered Mental status 265 b. This is a case of altered mental status with neurological defcits as a result of hypoglycemia. Hypoglycemia (low blood glucose) can mimic stroke syndromes presenting with weakness and confusion, and can typically be reversed with the administration of dextrose. The hypoglycemia in this scenario is due to not eating breakfast after taking a diabetes medicine (glipizide, a sulfonylurea). Obtaining an immediate blood glucose level is crucial to the diagnosis in this case. With the ingestion in this case, further action is required beyond a rapid correction of blood glucose with dextrose in the case. Blood sugar levels must be maintained because sulfonylurea drugs can cause delayed or rebound hypoglycemia for many hours. Feeding fuids with dextrose, or octreotide are all adequate options for this, with two or all three sometimes required. Symptoms of hypoglycemia are due to both the effects on the brain and a refex sympathetic surge. Neurological effects include confusion, altered mental sta- tus, agitation, unresponsiveness, and symptoms that may mimic acute stroke such as focal neurological defcits. Peripheral effects due to a sympathetic out- put of catacholamines cause anxiety, irritability, vomiting, palpitations, tremor, and sweating. One amp of D50 is about 100 calories, which is insuffcient to maintain adequate blood glucose beyond a few minutes. Rapid blood glucose determination is essential in all patients with altered men- tal status. The elderly and severely malnourished (ie, alcoholics) can present with hypo- glycemia in the absence of sympathetic signs or even awareness of hypoglyce- mia, often mimicking intoxication, unresponsiveness, or stroke. They had arrived 2 days before to go skiing for the week and the symptoms started yesterday morning after waking up. This morning, they were planning to go skiing but the patient complained of worsening headache and unsteadiness; no chest pain, shortness of breath, palpita- tions, vomiting, diarrhea, fever, or blurry vision. Nobody else with similar symp- toms; arrived yesterday to the mountains by helicopter, ascended 10 000 feet. Social: lives with wife at home, smokes one pack of cigarettes a day for 20 years, denies alcohol, drugs, not sexually active; works as an investment banker g. Travel history: arrived yesterday to the mountains by helicopter, ascended 10 000 feet G. Eyes: extraocular movement intact, pupils equal, reactive to light, no papille- dema on fundoscopic examination d. Neuro: intact refexes throughout, ataxic on tandem gait, poor fnger to nose, positive Romberg’s test, no focal weakness, no sensory defcit p. Our patient pres- ents with fu-like symptoms a day after rapid ascent to a mountain by heli- copter, commonly seen with acute mountain sickness.