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Vitamins for chronic disease related quality of life of an elderly institutionalized popula- prevention in adults: scientifc review order 100caps gasex free shipping gastritis and esophagitis. Postprandial glycemia purchase gasex australia gastritis diet , glycemic index purchase 100 caps gasex with amex gastritis olive oil, Oral health, nutrient intake and dietary quality in the very and the prevention of type 2 diabetes. Food avoidance and expenditure and heart disease risk factors during weight food modifcation practices of older rural adults: associa- loss. Food-drug ciated with the coronary disease epidemic in Central and interactions: Careful drug selection and patient coun- Eastern Europe. Folate and vitamin B(6) intake and risk of acute myo- medication management for older adult clients. Association nisms relating to obesity, diabetes, and cardiovascular dis- between fsh consumption and all-cause and cause-specifc ease. The emphasis is on an integrated policy approach to investment and enterprise development. The term “country” as used in this study also refers, as appropriate, to territories or areas. The designations employed and the presentation of the material do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. In addition, the designations of country groups are intended solely for statistical or analytical convenience and do not necessarily express a judgment about the stage of development reached by a particular country or area in the development process. Rows in tables have been omitted in those cases where no data are available for any of the elements in the row. Reference to “dollars” ($) means United States dollars, unless otherwise indicated. Annual rates of growth or change, unless otherwise stated, refer to annual compound rates. Details and percentages in tables do not necessarily add to totals because of rounding. The material contained in this study may be freely quoted with appropriate acknowledgement. It aimed at assisting developing countries to participate as effectively as possible in international investment rulemaking at the bilateral, regional, plurilateral and multilateral levels. Issues of transparency, predictability and policy space have come to the forefront of the debate. It is the purpose of the sequels to consider how the issues described in the first-generation Pink Series have evolved, particularly focusing on treaty practice and the process of arbitral interpretation. Compared to the first generation, the sequels will offer a greater level of detail and move beyond a merely informative role. The sequels are finalized through a rigorous process of peer reviews, which benefits from collective learning and sharing of experiences. Attention is placed on ensuring involvement of a broad set of stakeholders, aiming to capture ideas and concerns from society at large. The sequels are edited by Anna Joubin-Bret, and produced by a team under the direction of Jörg Weber and the overall guidance of James Zhan. The members of the team include Bekele Amare, Suzanne Garner, Hamed El-Kady, Jan Knörich, Sergey Ripinsky, Diana Rosert, Claudia Salgado, Ileana Tejada, Diana Ruiz Truque and Elisabeth Tuerk. It has to be interpreted in the light of general principles of treaty interpretation. Comparing treatment: treatment “in like circumstances”, identifying better treatment. It is therefore, a relative standard and must be applied to similar objective situations. It also reviews arbitral awards against the background of the cases that have followed the Maffezini v. With some notable exceptions, arbitral tribunals have generally been cautious in importing substantive provisions from other treaties, particularly when absent from the basic treaty or when altering the specifically negotiated scope of application of the treaty. Spain itself, focused on the elimination of a preliminary requirement to arbitration. Such awards have further strengthened the debate, particularly given the fact that tribunals have been rather inconsistent in their reasoning and conclusions. Consequently, States began reacting or expressing concern about the growing uncertainty. So far, arbitral tribunals have taken different and sometimes inconsistent approaches. This would allow States to: • Make better-informed decisions for drafting and negotiating purposes (more precise scope, wording, exceptions, etc. This benefit granted to foreign investors is of extraordinary legal nature insofar as it derogates from customary international law, which requires that any acts or measures taken by the State must be challenged before the national jurisdictions of the State. Only after the investor has exhausted local remedies can the State from which it derives its nationality file an action against the host State, but never the investor himself. It may not be within the role of investment tribunals to enforce commitments or secure their compliance. International and national frameworks for investment have generally evolved towards more certainty and predictability in the conditions relating to the entry and operation of foreign investors in host countries. In the context of arbitration, both States and investors would have reason for concern when seeing that the same argument may succeed one day and fail the next. It will also look into arbitral awards against the background of the cases that have followed the Maffezini v. The early clauses were quite broad, applying to a wide range of issues such as “rights, privileges, immunities and exceptions” with respect to trade, commerce and navigation, or to “duties and prohibitions” with respect to vessels, importation or exportation of goods, as illustrated by the examples in box 1. Amity, Navigation and Commerce Treaty (the Jay’s Treaty) between the United States and Great Britain (1794) Article 15 It is agreed, that no other or higher Duties shall be paid by the Ships or Merchandize of the one Party in the Ports of the other, than such as are paid by the like vessels or Merchandize of all other Nations. Nor shall any other or higher Duty be imposed in one Country on the importation of any articles, the growth, produce, or manufacture of the other, than are or shall be payable on the importation of the like articles being of the growth, produce or manufacture of any other Foreign Country. Nor shall any prohibition be imposed, on the exportation or importation of any articles to or from the Territories of the Two Parties respectively which shall not equally extend to all other Nations […]. These early clauses were often conditional, meaning that the benefits granted by one State were dependant on the granting of the same concessions by the beneficiary State. The unconditional approach emerged during the second half of the eighteen century. The Treaty of Commerce signed in 1869 between Great Britain and France (the Chevalier-Cobden Treaty) is a prominent example. The draft articles explore, inter alia, matters concerning definitions, scope of application, effects deriving from the conditional or unconditional character of the clause, source of treatment and termination or 2 suspension. Foreign investors seek sufficient assurance that there will not be adverse discrimination which puts them at a competitive disadvantage.
Control convulsions with diazepam (see section onSeizure Disorders) Table 19-1: Guidelines for the Treatment of the Patient with Fever Complaints Diagnosis Action * (See Appropriate * (See appropriate section) section) Rigors order gasex 100 caps with mastercard gastritis diet soy milk, fever (occasionally * Malaria * Take a blood film or perform periodic) buy 100caps gasex visa gastritis jello, sweating discount 100 caps gasex with visa symptoms of gastritis and duodenitis, general rapid diagnostic test for malaria malaise, joint pains parasites and treat appropriately Rigors, fever, sweating, * Cerebral Malaria * Take a blood film or perform general malaise, altered rapid diagnostic test for malaria sensorium parasites and treat appropriately Headache, vomiting, * Meningitis * Do not delay treatment while drowsiness, stiff neck, awaiting results of lumbar seizures puncture. Tuberculosis is spread through airborne droplets when a patient coughs, spits or sneezes. Empirical antibiotic treatment for pneumonia may be prescribed while awaiting the sputum smear result. This may be subsequently changed to oral therapy with significant clinical improvement. The bacteria which are spread by the faeco-oral route invade the intestinal wall and spread through the bloodstream to all organs. They may continue to be present in the stool of asymptomatic carriers, who are persons who have recovered from the symptoms of the disease but continue to carry the bacteria. Public education on good personal hygiene, hand washing and appropriate disposal of solid waste would often prevent the disease. Screening of food handlers by carrying out stool cultures to exclude carrier status and safe handling of food, fruits and vegetables are also helpful preventive measures. Adults 200 mg 12 hourly Children 10 mg/kg 12 hourly Note Ciprofloxacin should be used with caution in children. At the first sign of pain or inflammation, patients must discontinue treatment and alternative treatment (e. It follows the introduction of protozoan malaria parasites into the blood stream by the bite of a female Anopheles mosquito. Malaria is a major cause of significant morbidity and mortality especially among children under 5 years of age, pregnant women (sometimes with adverse foetal and maternal outcomes), patients with sickle cell disease and visiting non-resident Ghanaians and expatriates. However, for a definitive diagnosis to be made laboratory tests must demonstrate the malaria parasites or their components since the clinical presentation of the condition is similar in many respects to other common diseases such as typhoid fever, urinary tract infection, septicemia, Pneumonia and meningitis in both adults and children and measles, otitis media, tonsillitis, etc. Rapid diagnostic tests may be used to confirm a diagnosis if microscopy (blood film) is not available. Preventive measures in the community mainly target elimination of the insect vector or prevention of mosquito bites while additional chemoprophylaxis is required for vulnerable individuals. The development of resistance of malaria parasites to anti-malarial medications is a matter of major public health concern. It is therefore necessary to obtain laboratory confirmation of a diagnosis of malaria. Exceptions to this guideline are children under 5 years and cases of suspected severe malaria where laboratory confirmation is not immediately possible. A combination of anti-malarial drugs is preferred to monotherapy as this helps to prevent the development of drug resistance. A complete course of medications at the correct dosages must be given in all cases of malaria. The events causing most deaths in severe malaria are related to cerebral involvement (cerebral malaria), severe anaemia, hypoglycaemia, severe dehydration, renal failure and respiratory acidosis. The diagnosis of severe malaria is based on clinical features and confirmed with laboratory testing. While confirmation of the diagnosis is necessary treatment must be started promptly and not withheld while confirming the diagnosis. To prepare this, draw 2 mls of Quinine 600 mg and add 4 mls of sterile water or saline (not dextrose). Repeat infusion 8 hourly until patient can swallow, then change to Quinine, oral, 10mg/kg (maximum dose 600 mg), 8 hourly to complete 7 days treatment. Note Artemether should not be given in the first trimester of pregnancy unless there are no suitable alternatives. In most other respects, however, the treatment of severe malaria in pregnancy shall be the same as the treatment of severe malaria for the general population. Appropriate drug treatment, as shown in the tables (19-8, 19-9, and 19-10), must be initiated prior to transferring the patient. Note The drug of choice for uncomplicated malaria for pregnant women in the first trimester is oral Quinine. However their use should not be withheld in cases where they are considered to be life saving, or where other antimalarials are considered to be unsuitable. Fourth Dose: May be given, provided it is at least one month after the last dose and at least one month before anticipated delivery. Poor hygiene or contact of bare skin with soil in which the worm or its eggs live predisposes individuals to infestation. It is important to prevent this condition by examining the eyes of all sick and malnourished children. The foreign body may be either in the conjunctival sac, on the cornea or inside the eyeball (intraocular). A history of the likely nature of the foreign body aids in its detection and removal. The foreign body may be seen by careful inspection of the cornea or conjunctival sac. Good light is needed and a magnifying glass may be required to detect corneal foreign bodies. Acute red eye may have a history of injury to the eye or there may be no history of injury. There may be a foreign body on the cornea or on the conjunctiva, under the eyelid. A blunt injury may cause a subconjunctival haemorrhage or bleeding into the anterior chamber (hyphaema). Corneal ulcer • 1% Tetracycline eye ointment and refer to the specialist immediately. Also refer acute conjunctivitis which shows no improvement after 48 hours of treatment. The different types of conjunctivitis are: • Bacterial Conjunctivitis • Viral Conjunctivitis • Trachoma • Allergic Conjunctivitis e. Glaucoma may produce severe loss of vision and blindness without prior warning symptoms and must therefore be screened for in all adults beyond the age of 40 years, especially those with a positive family history. This occurs when there is an obstruction of the upper airway from the nasopharnyx down to the trachea and main bronchi. The disease tends to run an extremely rapid course (4-6 hours) to respiratory failure and death. It is more common in children, however, the incidence has reduced due to the current immunisation schedule with the pentavalent vaccine. However, it is important to diagnose streptococcal pharyngitis since it may give rise to abscesses in the throat (retropharyngeal and peritonsillar abscess) as well as complications that involve organs like the kidneys and the heart. Streptococcal throat infections require treatment with antibiotics in order to reduce the complications noted above. This infection does not occur in children less than 6 years because their air spaces are not well developed.
Cana- Med 2010 discount 100caps gasex otc chronic gastritis surgery;362:1575–1585 Early referral to specialist nephrology services dian Ophthalmological Society evidence-based 32 discount generic gasex uk gastritis nausea. Tight for preventing the progression to end-stage kid- clinical practice guidelines for the management blood pressure control and risk of macrovascu- ney disease 100 caps gasex visa gastritis diet 21. Oph- Effects of losartan on renal and cardiovascular tes Care 1995;18:258–268 thalmology 1996;103:1815–1819 outcomes in patients with type 2 diabetes and 50. Am J Kidney Dis 1998;31: 20-year prospective study of childbearing and inhibition on diabetic nephropathy. N Engl J 947–953 incidence of diabetes in young women, control- Med 1993;329:1456–1462 51. Diabetes 2007;56:2990–2996 antagonist irbesartan in patients with nephropa- Studies. Preliminary report on effects of photo- 345:851–860 effects of medical management on the progres- coagulation therapy. Photocoagulation for Suppl 2012;2:337 Ophthalmology 2014;121:2443–2451 diabetic macular edema: Early Treatment Dia- 37. Diabetes Control and Complications Trial Re- betic Retinopathy Study report number 1. The effect of intensive treatment of Ophthalmol 1985;103:1796–1806 diovascularand microvascularoutcomes in peo- diabetes on the development and progression 69. N Engl J Med 1993;329: uating ranibizumab plus prompt or deferred la- 355:253–259 977–986 ser or triamcinolone plus prompt laser for S98 Microvascular Complications and Foot Care Diabetes Care Volume 40, Supplement 1, January 2017 diabetic macular edema. Ophthalmology 2010; diabetes during the Epidemiology of Diabetes and active-controlled study of T-type calcium 117:1064–1077. Mitchell P, Bandello F, Schmidt-Erfurth U, Diabetes Care 2010;33:1090–1096 peripheral neuropathic pain. Ophthalmology 2012;119:789–801 of glycemic control strategies on the progres- ogy 2006;67:1411–1420 73. Writing Committee for the Diabetic Reti- sion of diabetic peripheral neuropathy in the 100. Curr Med Res Opin 2011;27: Rep 2014;14:528 abetes Metab Syndr Obes 2013;6:79–92 151–162 75. Neuropathy and related Pharmacotherapy for neuropathic pain in randomized withdrawal, placebo-controlled findings in the Diabetes Control and Complica- adults: a systematic review and meta-analysis. Evidence- with chronic painful diabetic peripheral neurop- 2014;37:31–38 based guideline: treatment of painful diabetic athy. Clinicalguideline:managementofgastro- Care 2017;40:136–154 the American Academy of Physical Medicine and paresis. Neurology 2011;76:1758–1765 quiz 38 diabetic etiology: differential diagnosis of diabetic 90. Pharmacologic interventions for painful Therapy for Diabetes Mellitus and Related Dis- 78. Diabetes Care 2008;31:1679–1685 cations Trial/Epidemiology of Diabetes Inter- safety, and tolerability of pregabalin treatment 106. J Am Coll Cardiol for painful diabetic peripheral neuropathy: find- Themanagementofdiabeticfoot:aclinicalpractice 2013;61:447–454 ings from seven randomized, controlled trials guideline by the Society for Vascular Surgery in 80. The diagnostic utility of Sudoscan 31:1448–1454 Association and the Society for Vascular Medicine. Ann lin in patients with inadequately treated painful bet Foot Ankle 2016;7:29758 Neurol 1995;38:869–880 diabetic peripheral neuropathy: a randomized 108. Clin J Pain 2014;30:379–390 madeorthesisandshoesinastructuredfollow-up diabetes therapy on measures of autonomic 95. Duloxetine program reduces the incidence of neuropathic nervous system functioninthe DiabetesControl and pregabalin: high-dose monotherapy or their ulcers in high-risk diabetic foot patients. Pain 2013;154:2616–2625 clinical practice guideline for the diagnosis and ingthe DiabetesControlandComplicationsTrial 96. A randomized double-blind, placebo-, Dis 2012;54:e132–e173 Diabetes Care Volume 40, Supplement 1, January 2017 S99 American Diabetes Association 11. C c Screening for geriatric syndromes may be appropriate in older adults experi- encing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management and be related to health-related quality of life. C c Annual screening for early detection of mild cognitive impairment or dementia is indicated for adults 65 years of age or older. B c Older adults ($65 years of age) with diabetes should be considered a high- priority population for depression screening and treatment. It should be assessed and managed by adjusting glycemic targets and pharmacologic in- terventions. B c Older adults who are cognitively and functionally intact and have significant life expectancy may receive diabetes care with goals similar to those devel- oped for younger adults. C c Glycemic goals for some older adults might reasonably be relaxed using indi- vidual criteria, but hyperglycemia leading to symptoms or risk of acute hyper- glycemic complications should be avoided in all patients. C c Screening for diabetes complications should be individualized in older adults. Particular attention should be paid to complications that would lead to func- tional impairment. C c Treatment of hypertension to individualized target levels is indicated in most older adults. C c Treatment of other cardiovascular risk factors should be individualized in older adults considering the time frame of benefit. Lipid-lowering therapy and as- pirin therapy may benefit those with life expectancies at least equal to the time frame of primary prevention or secondary intervention trials. E c When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E c Consider diabetes education for the staff of long-term care facilities to im- prove the management of older adults with diabetes. E c Patients with diabetes residing in long-term care facilities need careful assess- ment to establish glycemic goals and to make appropriate choices of glucose- lowering agents based on their clinical and functional status. E c Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E Suggested citation: American Diabetes Asso- Diabetes is an important health condition for the aging population; approximately ciation. In Standards of one-quarter of people over the age of 65 years have diabetes (1), and this pro- Medical Care in Diabetesd2017. Older adults with diabetes also are at greater risk than other for profit, and the work is not altered. More infor- older adults for several common geriatric syndromes, such as polypharmacy, cog- mation is available at http://www. S100 Older Adults Diabetes Care Volume 40, Supplement 1, January 2017 Screening for diabetes complications in simplify drug regimens and to involve older adults for cognitive dysfunction older adults should be individualized and caregivers in all aspects of care. Hypoglycemic screening tests may impact therapeutic with a decline in cognitive function events should be diligently monitored approaches and targets. Older adults are (11), and longer duration of diabetes and avoided, whereas glycemic targets at increased risk for depression and worsens cognitive function.
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The extensively disseminated disease in the abdominal cavity that especially affects the small intestine may prevent radical surgery gasex 100caps low price gastritis drugs. If the tumour is not completely resected from the abdominal cavity during the cytoreductive surgery generic gasex 100caps with amex gastritis ginger ale, the chemotherapeutic agent will not eliminate the disease gasex 100 caps overnight delivery viral gastritis diet. The cytoreduction is considered complete when residual tumour nodules are sized under 0. The administration of a chemotherapeutic agent is timed after complete cytoreductive surgery is finished but before the construction of any anastomoses. Perfusion drains are placed through the abdominal wall at specific sites: the right subdiaphagmatic space, the left subdiaphagmatic space, and two in the pelvis (Figure 6). One additional spiral- ended (Tenckhoff) catheter is positioned within the abdomen. The Coliseum technique involves the elevation of the edges of the abdominal incision onto the self-retaining retractor by a running suture. A plastic sheet is then sewed to that suture and a cavity for chemotherapy is consequently formed. An incision in the plastic sheet is made and a portal is then attached, which allows manual access into the cavity (Figure 7). The perfusion is then performed for 90 min (Figure 8) and the surgeon secures the distribution of chemotherapeutic agent manually during that time. There are at least three reasons, why chemotherapy solution should be heated: the tissue penetration of the chemotherapeutics is increased, the cytotoxicity of the chemotherapeutics is increased, and also because of the inherent anti-tumour effect of heat itself [49]. The manual 22 distribution of chemotherapeutic agent for 90 minutes affords several advantages: all surfaces of the abdomen and pelvis are uniformly affected by the chemotherapeutic agent and heat, diuresis can easily be monitored during the administration of agents that can affect renal functioning, hyperthermic therapy lasting 90 minutes causes mechanical disruption of cancer cells within blood clots and fibrin accumulations, and the moderately long time allows the normalization of many physiological parameters (temperature, haemodynamics, coagulation, etc. Non-surgical complications include inter alia neutropenia, sepsis, pleural effusion, respiratory insufficiency, and thromboembolism. Surgical complications include anastomotic leakage, bowel perforation, haemorrhage, fistula formation, bile leakage, abscess formation, and wound dehiscence. Events that resulted in a return to the operating room were recorded for 40 (11%) of the procedures. The distribution of causes for return to the operating room was as follows: fistula 29%, anastomotic leak 19%, compartment syndrome 19%, postoperative bleeding 18%, pancreatitis 3%, bile leak 3%, fascitis 3%, urine leak 3%, and negative exploration 3%. Not only are deep venous thromboses encountered, pulmonary embolisms and portal vein embolisms also occur. Special attention should be paid to anti-thrombotic treatment during the perioperative course. The wearing of anti-embolic pump stockings in combination with intensified low-molecular weight heparin are offered with the purposes of avoiding such complications. Even so, a 39% incidence of neutropenia was reported after such therapy by Lambert and co-workers in 2009 [62]. Despite this, neutropenia was not found to be associated with an increased risk of operative mortality or increased 29 hospital stay. The only infection type neutropenia was associated with was urinary tract infection, but no other types were associated with neutropenia upon univariate analysis. The construction of any anastomoses is postponed till after the intraperitoneal chemotherapy has finished in order to avoid these complications. Even so, there are specific differences in chemotherapy protocol, histological classification of the tumour, follow-up time, reporting of the surgical completeness, and so forth. The study is not only the smallest series in the compared investigations, it is also the oldest and thus represents the early era of combined modality treatment. The survival outcomes are not fully comparable because of the heterogeneity of the patient populations. Despite the lack of uniformity in the patient demographics of the different series, the conclusion of the comparison is clear. The survival of patients treated by serial debulking may sometimes be rather favourable as well. The histopathological grade of the tumour has also been reported to affect survival in many studies [20, 64, 67]. Those authors used a Cox proportional hazard model and found that only the surgical outcome had an impact on survival. Physical examination may reveal new tumour deposits in the scars or the abdomen, abdominal distension, or newly-onset hernias. Patients may have abdominal complaints that are related to relapse or to disease progression. Consequently, there will be reference images stored to compare with during the follow-up. Follow- up visits should be biannual in the first year and yearly in the subsequent years. In the case of a suspected relapse, the examinations should be immediately performed regardless of the protocol [23]. The subsequent follow-up visits are repeated every six months for up to two years and they include the same examinations as for the six- month follow up visits. The total duration of the subsequent follow-up is considered individually for each patient and varies from five to ten years. Our aim is to optimize the balance with minimizing radiation, coping with hospital resources, and early detection of relapses. The tumour causes organ malfunctioning, mostly by compression as the disease progresses. The classic surgical approach was to debulk the tumour iteratively until further surgery becomes impracticable. They underwent surgery or consideration concerning surgery between 1984 and 2011 in Helsinki University Central Hospital. Study I included 33 consecutive patients treated by the classic approach of serial debulking between the years 1984 and 2008. Those patients with malignant peritoneal mesothelioma and benign cystic mesothelioma were also excluded. Complete tumour resection was the aim, particularly in the initial surgery, but only for those cases for which the disease was amenable for that procedure. A modified version of the Coliseum technique was used for administering the chemotherapeutic solution [48]. The target temperature of intraperitoneal solution was 42 - 43ºC and the duration was for 90 minutes. The grading was performed according to the Clavien-Dindo classification of surgical complications published by Dindo et al. The streamlined classification is as follows: - Grade I refers to any deviation from the normal postoperative course that does not need intervention.
Xerostomia is noa synonym for hyposalivation since imay also occur with the changes in the quality of saliva discount 100caps gasex mastercard gastritis natural treatment, while the amounof saliva stay unchanged buy gasex 100 caps lowest price gastritis diet . This is the reason thapeople sometimes complain of dry mouth buhave proper salivation [3] gasex 100caps low cost definition of gastritis in english. Therefore, a pa- tiencomplaining of dry mouth cannoautomatically be assumed to have salivary dysfunction, while oral dryness may have many causes [20]. Any individual may experience xerostomia with or withouhyposalivation, experience hyposalivation with or withouxerostomia or may have an average salivary fow and normal sen- sation [17]. Oral dryness is one of the moscommon and mosunpleasanoral symptom which adversely afects all oral functions and compromise oral health in any afec- d person. Ileads to numerous oral sequelae including mucosal dryness, difculty in chewing, swallowing and speaking, burning and pain of oral mucosa, propensity to damage of oral mucosa and infection, increased fungal infection, demineraliza- tion of eth and increase in caries, dysgeusia, halitosis and difculty in wearing dentures. Therefore, for the maintaining good oral and general health, saliva should be secred in an adequa quantity and quality [27]. However, the prevalence reaches almos100% in patients with Sjogren�s syn- drome and those who are receiving radiation therapy for head and neck cancer [29]. Ihas been shown thathe prevalence increases with age and thaxerostomia is more prevalenin postmenopausal women compared to men [16,30]. Iis estimad thaabou30% of the population older than 65 sufer from xerostomia [29]. Altho- ugh previous opinion thasalivary function declines with aging process, iis now accepd thasalivary fow as well as salivary constituens are both age-stable in the 72 Rad 514 Medical Sciences, 38(2012) : 69-91 M. Mravak-Stipetic: Xerostomia - diagnostics and treatmenabsence of major medical problems and medications. Since there is no evidence thaxerostomia is likely to resulfrom the aging pro- cess alone ican be concluded thathe condition is a side-efecof various diseases and the drugs used to treathese diseases [29,33]. In general, causes may be gro- uped into two cagories [34]: a) primary or direccauses comprise conditions thadirectly afecsalivary glands and cause decreased salivary production [35]. The prevalence of Sjogren�s syndrome is 1% to 4% in older adults and is more common in postmenopausal women [36]. Authors conclu- de thathese observations are relevanfor identifying patients who would moslikely beneffrom inrvention treatment. When an autoimmune disease is suspecd, a minimally invasive chnique of minor salivary gland biopsy of the lower lip should be made with the dermination of serum antibodies [38]. In Sjogren�s syndrome the progressive lymphocytic infltration gradually de- stroys the secretory acini of the major and minor salivary glands which results in hyposalivation and fnally in xerostomia. Another explanation for the loss of glan- dular function may be relad to an inhibition of nerve stimuli of the glands [39]. Mravak-Stipetic: Xerostomia - diagnostics and treatmenThe hypofunction of egzocrine glands causes dryness of mucosal surfaces, mosnoticeable of the mouth and eyes [36]. Irradiation and cytostatic drugs lead to sialoa- denitis which in turn may lead to irreversible damage of acinar cells of major and minor salivary glands and resulin hyposalivation and permanenxerostomia [1]. Long-rm morbidity in patients receiving combined radiation and chemotherapy is signifcanbecause of salivary gland hypofunction, radiation-induced xerostomia, mucositis and severe dysphagia [20]. Although radiotherapy was earlier considered the moscommon cause of sali- vary gland hypofunction and xerostomia, in recenyears medications have emer- ged as the moscommon cause, particularly in elderly people. Ihas been shown thaamong the moscommonly prescribed drugs 80% of them cause xerostomia with more than 500 medications causing an adverse efecof dry mouth [2,16,20,40]. The moscommon medications causing hyposalivation are those with an- ticholinergic activity, sympatomimetics and benzodiazepines [2]. The risk for xerostomia will increase the synergistic efects of xerogenic medications, multiple medications (polypharmacy),higher dose of medication and the time of starting the medication. This is the main reason thathe prevalence of medication-induced xe- rostomia is highesin the elderly. Mravak-Stipetic: Xerostomia - diagnostics and treatmenDehydration of the organism can secondarily afecsalivation, and changes in the quantity of war in the body can afecthe wetness of oral mucosa which may crea a feeling of dry mouth [2,20,29,34]. The feeling of dry mouth can occur also due to the change in cognitive abilities of the central nervous sysm following a cerebral vascular acciden(stroke) (48) and sensory disturbances in the mouth. Al- rations in autonomic innervation of salivary glands with predominansympathetic stimulation, during episodes of acu anxiety or stress, cause changes of salivary composition thacreas sensation of oral dryness. There are also psychological conditions thalead to feeling of oral dryness such as depression and insomnia as well [2, 29, 33, 34, 48]. Drugs associad with dry mouth (2) Drugs thadirectly damage salivary glands Cytotoxic drugs Drugs with anticholinergic activity Anticholinergic agents: atropine, atropinics and hyoscine Antirefux agents: proton-pump inhibitors (e. Mravak-Stipetic: Xerostomia - diagnostics and treatmenquality of life, requireing careful planning of long-rm dental and oral care. Parotid glands exposed to doses of grear than 60 Gy sustain permanendamage with no recovery in salivary hypofunction with time [20]. Frequently seen acu accompanying oral side efects include mucositis, dysphagia, erythema and desquamation of oral mucosa. La complications are resulof cronic injury on exposed tissue; mucosa, vasculature, salivary glands, connective tissue and bone. The type and severity of these changes are relad directly to total dose adminisred, fraction size and duration of the treatmenas well as on volume of irradiad tissue. Qualitative changes in saliva include increased viscosity, increased organic component, alred pH, decreased transparency, and yellowbrown discolo- ration [50]. The assessmenof the severity of xerostomia in patients with head and neck cancers afer radiotherapy and its efecon quality of life (QoL) over a period of 6 months, in a study of Kakoei eal. Iwas also shown when multiple daily treatments are given in small fractionad doses (<1,8-2 Gy) this does noincreae the incidence of xerostomia [20]. Iis obvious thathe quality of life in patients who underwenradiotherapy in the head and neck region is strongly infuenced by xerostomia and all its consequ- ences. Patients usually sufer from dry, vulnerable and painful oral mucosa, have difculties in all oral functions (chewing, swallowing and particularly speech), per- 76 Rad 514 Medical Sciences, 38(2012) : 69-91 M. Mravak-Stipetic: Xerostomia - diagnostics and treatmenception of tas is alred or even partially lost. The risk for dental caries increases secondary to number of factors: shif to cariogenic fora, reduction of salivary pH, and loss of mineralizing components. The reduction in salivary fow may contribu to the risk of fungal infection and osonecrosis of the mandible. All these secon- dary efects of radiation-induced xerostomia contribu to the so-called xerostomia- syndrome [54]. Patients with xerostomia may be asymptomatic withoucomplaints, or more frequently, complain of dry mouth and develop various complications. Pati- ents usually experience difculties while speaking, chewing, swallowing (dyspha- gia) and wearing dentures [1-3,15,20,34]. Oral mucosa is dry and sensitive, prone to injuries, fungal infection and in- fammation, painful with burning sensations, tas is alred and halitosis is pre- sent. In patients with Sjogren�s syndrome in which exocrine glands and the connec- tive tissue is afecd patients complain abouthe dryness of the eyes. These initial changes may precede clinical eviden- ce of mucosal changes or measurable reduction in salivary gland function [36]. In the patienwith dentures and insufciensaliva, the lack of lubrication can re- sulin traumatic ulcerations of the mucosa, and increased susceptibility to oral fun- gal infection, candidosis.
