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The level of specific enzyme activity in the plasma frequently correlates with the extent of tissue damage cheap oxybutynin 2.5 mg fast delivery symptoms for mono. Thus buy oxybutynin amex medications you can take while breastfeeding, the degree of elevation of a particular enzyme activity in plasma is often useful in evaluating the diagnosis and prognosis for the patient discount 2.5 mg oxybutynin with mastercard jnc 8 medications. Measurement of enzymes concentration of mostly the latter type in plasma gives valuable informatio0n about disease involving tissues of their origin. The plasma lipase level may be low in liver disease, Vitamin A deficiency, some malignancies, and diabetes mellitus. It is present in pancreatic juice and saliva as well as in liver fallopian tubes and muscles. The plasma amylase level may be low in liver disease and increased in high intestinal obstruction, mumps, acute pancreatitis and diabetes. They are found in bone, liver, kidney, intestinal wall, lactating mammary gland and placenta. In bone the enzyme is found in osteoblasts and is probably 20 important for normal bone function. Serum alkaline phosphatase levels may be increase in congestive heart failure result of injury to the liver. It is present in high concentration in liver and to a lesser extent in skeletal muscle, kidney and heart. It is widely distributed with high concentrations in the heart, skeletal muscle, liver, kidney, brain and erythrocytes. The enzyme is increased in plasma in myocardial infarction, acute leukemias, generalized carcinomatosis and in acute hepatitis. Estimation of it isoenzymes is more useful in clinical diagnosis to differentiate hepatic disease and myocardial infarction. Measurement of serum creatine phosphokinase activity is of value in the diagnosis of disorders affecting skeletal and cardiac muscle. Carbohydrates in general are polyhydroxy aldehydes or ketones or compounds which give these substances on hydrolysis. Chemistry of Carbohydrates Classification and Structure Classification There are three major classes of carbohydrates • Monosaccharides (Greek, mono = one) • Oligosaccharides (Greek, oligo= few) 2-10 monosaccharide units. The most abundant monosaccharides in nature are the 6-carbon sugars like D- glucose and fructose. One of the carbon atoms is double bonded to an oxygen atom to form carbonyl group. Structure of Glucose Open chain D-glucose α-D –glucose α-D –glucose (Fisher formula) (Haworth formula) Fig. Monosaccharides having aldehyde groups are called Aldoses and monosaccharides with Ketone group are Ketoses. Depending on the number of carbon atoms, the monosaccharides are named trioses (C3), tetroses (C4), pentoses (C5), hexoses (C6), heptoses (C7). No of carbon atoms Generic name Aldose family Ketose family 3 Triose Aldotriose Ketotriose Eg. Asymmetric Center and Stereoisomerism Asymmetric carbon is a carbon that has four different groups or atoms attached to it and having optically activity in solution. All the monosaccharides except dihydroxyacetone contain one or more asymmetric or chiral carbon atoms and thus occur in optically active isomeric forms. Monosaccharides with n number n of asymmetric centers will have (2 ) isomeric forms. The designation of a sugar isomer as the D- form or of its mirror images the L- form is determined by the spatial relationship to the parent compound of the carbohydrate family. When a beam of plane- polarized light is passed through a solution of carbohydrate it will rotate the light either to right or to left. Depending on the rotation, molecules are called dextrorotatory (+) (d) or levorotatory (-) (l). When equal amounts of D 25 and L isomers are present, the resulting mixture has no optical activity, since the activities of each isomer cancel one another. Epimers When sugars are different from one another, only in configuration with regard to a single carbon atom (around one carbon atom) they are called epimers of each other. The resulting six membered ring is called pyranose because of its similarity to organic molecule Pyran. This five membered ring is called furanose because of its similarity to organic molecule furan Fig 2. Glycosidic bond is formed when the hydroxyl group on one of the sugars reacts with the anomeric carbon on the second sugar. Maltose is hydrolyzed to two molecules of D- glucose by the intestinal enzyme maltase, which is specific for the α- (1, 4) glycosidic bond. Structure of Maltose Lactose Lactose is a disaccharide of β-D galactose and β-D- glucose which are linked by β-(1,4) glycosidic linkage. Lactose acts as a reducing substance since it has a free carbonyl group on the glucose. Since the anomeric carbons of both its component monosaccharide units are linked to each other. Structure of sucrose α-(1, 2) β-Glycosidic bond Polysaccharides Most of the carbohydrates found in nature occur in the form of high molecular polymers called polysaccharides. These are: • Homopolysaccharides that contain only one type of monosaccharide building blocks. Homopolysaccharides Example of Homopolysaccharides: Starch, glycogen, Cellulose and dextrins. It is especially abundant in tubers, such as potatoes and in seeds such as cereals. Starch consists of two polymeric units made of glucose called Amylose and Amylopectin but they differ in molecular architecture. Amylose is unbranched with 250 to 300 D-Glucose units linked by α-(1, 4) linkages Amylopectin consists of long branched glucose residue (units) with higher molecular weight. The branch points repeat about every 20 to 30 (1-4) linkages Glycogen - Glycogen is the main storage polysaccharide of animal cells (Animal starch). Cellulose is a linear unbranched homopolysaccharide of 10,000 or more D- glucose units connected by β-(1, 4) glycosidic bonds. Humans cannot use cellulose because they lack of enzyme (cellulase) to hydrolyze the β-( 1-4) linkages. Figure: Structure of Cellulose 30 Dextrins These are highly branched homopolymers of glucose units with α-(1, 6), α-(1, 4) and α-(1, 3) linkages. Since they do not easily go out of vascular compartment they are used for intravenous infusion as plasma volume expander in the treatment of hypovolumic shock. Hetero polysaccharides These are polysaccharides containing more than one type of sugar residues 1. They have the special ability to bind large amounts of water, there by producing the gel-like matrix that forms the basis of the body’s ground substance.
Though exposure is one of the most powerful ways to overcome almost any fear discount oxybutynin medications with dextromethorphan, the process isn’t easy cheap oxybutynin 5mg with amex 714x treatment. If you have a history of passing out upon expo- sure to blood purchase oxybutynin 2.5mg amex medicine man aurora, injections, and related situations, there is a risk of fainting during your exposure practices. Also, chapter 6 is devoted to the topic of preventing fainting during exposure prac- tices. Many people have a great sense of satisfaction and even excitement following each practice, especially when they start to notice their 74 overcoming medical phobias fear decreasing as a result of exposure. A sense of free- dom may also emerge as you begin to realize that situa- tions that were previously off-limits are now a possibility. For most people, the temporary increase in discomfort is manageable, and it’s almost always well worth it. It’s only after a few weeks of regular exercise that you start to notice the benefits, including more energy, increased strength, weight loss, and a decreased risk of various illnesses. If you can tolerate some initial discomfort, you’ll quickly start to see the benefits—including a reduction in fear and anxiety and an increase in the range of things that you can do comfortably. In fact, more than half the peo- ple who have these phobias have a history of fainting in the feared situation. However, if you do have a history of fainting, we have a few additional recommendations: Make sure you read chapter 6 before trying the exposure practices described in this chapter. Although exposure alone is an effective treatment for fears of blood, needles, doctors, and dentists, combining the exposure strategies with the muscle tension exercises described in chapter 6 will help to prevent fainting during your practices. For most people, fainting on occasion in a controlled situation is perfectly safe. However, if you have certain medical conditions (for example, cardiac disease), fainting may be risky. If you have a history of fainting, we recommend clearing this treatment with your family doc- tor before beginning your exposure practices. If you have a history of fainting, all exposures should be done with someone else in the room, particu- larly early in your treatment when the risk of fainting is still an issue. If you do fall over and are on your back, your helper should roll you onto your side (just in case you vomit). Chances are that your previous experiences with exposure to your feared situations have been negative—filled with anxiety, fear, embarrassment, and perhaps fainting. Fortu- nately, there are important differences between the types of exposure experiences you may have had in the past and the ways in which exposure is carried out in therapy. This section provides a number of guidelines for ensuring that exposure works for you. Schedule your exposure practices on your calen- dar, just as you would an appointment. If your practices require you to have contact with your doctor or dentist, you’ll need to arrange that in advance. If you’re practicing at home, make sure that potential distractions are eliminated. For example, if you have young children, schedule your practices when they are away, asleep, or otherwise occupied. Practicing confronting your fear 77 easier items for longer (and taking steps more gradually) has some advantages: The anxiety and fear you experi- ence during your practices will probably be more manage- able. However, there are also disadvantages to going slowly: The slower you take steps, the longer it will take you to overcome your fear. And because you’ll notice changes more slowly, you may start to lose motivation to push yourself. If you push yourself to work out more strenuously, you’ll see bigger changes in your fitness level, and the changes will occur more quickly. If you lift lighter weights and spend less time on the treadmill, you’ll still notice changes, but they’ll take longer and be more modest. As mentioned in chapter 1, many people with blood and needle phobias are able to over- come their fears with just a few hours of exposure. If you push yourself to practice the items on your hierarchy more quickly, or to practice items that are more difficult, you’ll see changes more quickly. The worst thing that may happen is that you’ll feel more anxiety and fear (and if you have a history of fainting, you may also increase the likelihood of fainting). If an item is too difficult, you can always change the practice to something easier. There’s no danger in taking steps quickly, other than the possibil- ity of feeling more uncomfortable. For example, if you were afraid of snakes and some- one surprised you by throwing a snake at you, that kind of exposure wouldn’t work! On the other hand, if you were told that there was a harmless snake in a nearby room and you had the opportunity to approach it gradu- ally, at your own pace and with no surprises, your fear would slowly decrease. For example, before start- ing an exposure practice with a dentist, it’s good to know how long the appointment will take, what’s going to hap- pen, and what each procedure is likely to feel like. Mak- ing the exposure predictable is especially important early in your treatment. You can always test yourself later with some less predictable exposures, such as having a dental appointment and not asking any questions at the start. The problem with brief exposures is that they can sometimes strengthen a person’s fear by reinforcing the belief, “When I’m in the confronting your fear 79 situation I feel terrible, and when I leave I feel much better. For example, if you’re fearful of getting an injection, it’s difficult to stretch the experience beyond a minute or two. However, it will be easy to extend the length of the exposure for other practices. Here are some ways to extend your exposure practices: 7 Watch a video of an injection over and over again until your feelings of anxiety, disgust, and faintness have subsided. We are not simply suggesting that spacing exposures closer together leads to faster improvements (though it does). What we’re suggesting is that spacing exposures close together actually leads to better out- comes. For example, exposures scheduled once per day for five days will work better than exposures scheduled once per week over five weeks. It may be difficult to get an injection every day, but most other types of exposure are easier to schedule on a more regular basis. If exposures are too spread out, each practice will be like starting over; however, exposure practices scheduled close together build on one another. Ideally, you should try to practice at least several times perweekuntilyourfearhasdecreased. Forexample,if you’re fearful of getting a physical, you’ll see more improvement if you schedule three or four physicals in a single week than if you have a physical every couple of weeks over a period of a few months.
Delayed tear clearance may lead to an increase in ocular surface irritation oxybutynin 2.5mg on line shinee symptoms mp3, inflammation and pain B discount oxybutynin 2.5 mg with mastercard hb treatment. Delayed Thear Clearance in Patients with Conjunctivochalasis Is Associated With Punctal Occlusion order oxybutynin in united states online medications covered by blue cross blue shield. Amniotic Membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Scarring with obliteration of lacrimal ducts and atrophy of lacrimal gland i) Mucous membrane pemphigoid ii) Stevens-Johnson syndrome iii) Trachoma iv) Radiotherapy v. Primary Sjögren syndrome i) Aqueous tear deficiency (keratoconjuctivitis sicca) and/or, ii) Decreased salivary gland flow (xerostomia), and/or iii) Lymphocytic infiltration of lacrimal and salivary glands, and/or iv) Presence of serum autoantibodies. Decreased mucin production from destruction of conjunctival goblet cells, conjunctiva a. Interpalpebral and/or inferior corneal staining, using fluorescein, rose bengal, or lissamine green c. Thear film break up time less than 10 seconds (See Thear film evaluation: static and dynamic assessments; tear break-up time, Schirmer) Aqueous tear deficiency a. Hyperosmolarity (> 308 mOsms/L recommended as threshold for most sensitive detection of dry eye) b. Loss of epithelial integrity: punctate epithelial erosions or large epithelial defect B. Obtain care for dry mouth and oral complications of xerostomia Additional Resources 1. Production and activity of matrix metalloproteinase-9 on the ocular surface increase in dysfunctional tear syndrome. Filaments are composed of degenerated epithelial cells and mucus in variable proportions 2. Seen in various corneal conditions which have in common an abnormality of the ocular surface and altered tear composition B. Common symptoms include: foreign body sensation, ocular pain (may be severe), photophobia, blepharospasm, increased blink frequency, and epiphora 2. Symptoms tend to be most prominent with blinking and alleviated when the eyes are closed C. Filaments stain with fluorescein and rose bengal dyes, facilitating identification 2. Often a small, gray, subepithelial opacity will be present beneath the site of corneal attachment 4. Associated with superior limbic keratoconjunctivitis, ptosis, or other causes of prolonged lid closure b. Associated with keratoconjunctivitis sicca, pharmacologic dry eye, or exposure keratopathy ii. Filaments after penetrating keratoplasty typically reside on the graft, at the graft-host interface or at the base of the suture on donor side 6. Any condition associated with irregularity (including desiccation) of the ocular surface 1. Mechanical removal of filaments (temporary measure; care should be taken not to disrupt underlying epithelium) 2. Superior conjunctival resection or cauterization if secondary to superior limbic keratoconjunctivitis V. Mechanical removal of filaments - epithelial defect with secondary infection, may serve as a receptor site for new filaments 1. Removal of filaments/use of mucolytics may be successfully employed, but are not definitive treatments C. Continue with aggressive topical lubrication (if not possible to eliminate underlying process) Additional Resources 1. Meibomian gland dysfunction is a result of progressive obstruction and inflammation of the gland orifices 2. Seborrheic blepharitis is a chronic inflammation of the eyelid, eyelashes, forehead and scalp skin 3. Rosacea is a skin disease characterized by dysfunction of meibomian glands and/or other cutaneous sebaceous glands of the skin of the face and chest B. It mainly develops in patients between ages 30 and 60 years but can affect all age groups including children 2. Abnormal meibum after expression of glands (with slight pressure on lid margin with Q tip or finger) h. Masquerade syndrome (eyelid neoplasm - rare, but should be considered in chronic unilateral blepharitis) D. Daily eyelid hygiene (warm compresses, eyelid massage, and eyelid scrubbing) with commercially available pads, washcloth or cotton-tipped applicators soaked in warm water +/- dilute baby shampoo 2. Complications of topical corticosteroids, if used (including glaucoma and cataract) B. Side effects related to systemic tetracyclines, if used (ex: enamel abnormalities in children, photosensitivity) V. The international workshop on meibomian gland dysfunction: report of the clinical trials subcommittee. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. The international workshop on meibomian gland dysfunction: report of the diagnosis subcommittee. The international workshop on meibomian gland dysfunction: report of the subcommittee on tear film lipids and lipid-protein interactions in health and disease. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. The international workshop on meibomian gland dysfunction: report of the definition and classification subcommittee. Occur near the limbus, bulbar conjunctiva, plica, caruncle Rarely in the fornix or tarsal conjunctiva e. Typically noted in the first two decades of life, stable, unlikely to develop into malignancy i. May increase in size and pigmentation with hormonal changes (puberty, pregnancy, menopause) f. May result from inflammation, ocular surface surgery, infection, chalazion, foreign body 4. Dilated lymph channels seen as sausage like clear or hemorrhagic conjunctival cystic lesions b. May be associated with local venous hypertension (thyroid eye disease, orbital apex syndrome, cavernous sinus thrombosis, carotid-cavernous fistula), increased vascular permeability (allergy), local lymphatic scarring 6. Consists of irregular cyst like channels with clear fluid or intralesional hemorrhage (chocolate cysts) 7.
