Regis W. Haid Jr., MD

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We also wanted to demonstrate that late decrease in thyroid hormone levels accompany worse outcome menstruation 4 days early discount estradiol online master card. Materials and Methods: After Institutional Review Board Approval we conducted our retrospective study on a population of 184 patients who underwent heart transplantation between 2015 women's health clinic dufferin lawrence discount 1 mg estradiol overnight delivery. Trendelenburg position is a common maneuver used by practitioners a standard protocol1 womens health eugene oregon purchase estradiol visa. The purpose of this study was to determine 1)the effects (Figure 1A and B) and subjected to a gradient of enzymatically induced hypoxia2 breast cancer lumpectomy cheap estradiol online american express. Before (5h) human monocytes using proteome profling chemokine arrays (R&D systems) menstruation graph 1mg estradiol for sale. In this case we describe the lesion was detected by intraoperative transesophageal echocardiography menstruation krampfe buy cheapest estradiol. The transthoracic echocardiography showed bicuspid aortic valve and moderate aortic regurgitation. Induction with thiamylal 250 mg, fentanyl 60 ug, lidocaine 60 mg and cisatracurium 10 mg. The operating fnding confrmed the quadricuspid aortic valve with an enlarged left atrium and left ventricle. On the same day, the patient was successfully extubated and transferred to the general ward on the next day of surgery. The Hurwitz & Roberts divided the lesion into A to G types according to the size of the extra leafet. The case is the most common type B (three equal-sized and an additional smaller leafet). Nearly 30% of quadricuspid aortic valve is associated with other congenital anomalies such as coronary abnormalities, atrial or ventricular septal defects, Tetralogy of Fallot, and mitral regurgitation. We present a surgical case in which intraoperative 3-D echo was cardiovascular adverse events and mortality. Therefore, early diagnosis and useful in delineating the intramural course and guiding the surgical repair of an initiation of appropriate treatment are essential. We used the sensitivity and specifcity of the cut-off to calculate the positive ostium augmenting blood infow. It is recommended in cardiac surgery to assessing Faculty of Medicine Universidad Complutense Madrid (Spain) adequacy of a valvular repair. Case 1: 72-year-old study was to assess the continuity of the effect of short-term esmolol therapy in an female scheduled for elective mitral valve replacement. In the postoperative period, patient develops right empiema, mediastinitis hypertensive rat). It was treated by placement of endoscopic esophageal the end of the treatment, a week and a month after the administration, systolic prostheses. He was placed an esophageal Results and Discussion: Esmolol produces decreasing in blood pressure, heart prosthesis. Further studies are needed (histological and myocardial metabolism echocardiography-induced esophageal perforation. References : Learning points: this complication has a low incidence and high mortality. Early regression of left ventricular hypertrophy quick diagnosis is essential for an effective treatment. When a patient develops after treatment with esmolol in an experimental rat model of primary a hemodynamic disorder and infammatory makers increase we should consider hypertension. For readings < 10 cm2, 200 ml colloid was given and increase in the thoracic aneurysm than in the general population (42% vs. Signifcant number of Background and Goal of Study: Nasal bone fracture reduction surgery is normally patients after surgery experience deterioration in diastolic function. Due to the bleeding control, patients suffer from pain and require further analgesics treatments. This study aimed to evaluate the effect of fentanyl-soaked packing as a method to control pain after nasal surgeries by a prospective, randomized, double-blind controlled trial. Materials and Methods: 65 Patients that have undergone closed nasal bone fracture reduction surgery were set as the study group. To analyze the relative nasal pain control effect of fentanyl, Numeric Rating Scale, Patient Satisfaction, and Ramsay Sedation Scale were used. Patients were closely monitored to check for the degree of adverse symptoms such as headache or sore throat and cardiopulmonary-relevant indicators were monitored. Results and Discussion: Fentanyl group displayed a signifcantly lower Numeric Rating Scale and higher patient satisfaction for most of the time periods after operation (p<0. Symptoms of headache and sore throat were also signifcantly reduced and the Ramsay Sedation Scale scores improved compared to the control group (p<0. No remarkable differences in cardiopulmonary relevant indicators between the two experimental groups were observed (p>0. Conclusions: Fentanyl soaked packing displayed a signifcant postoperative pain reducing effect with no observable adverse effects. Based on the experimental result, we suggest the method of topical fentanyl application to nasal packing as an effective method to reduce pain after closed nasal bone fracture reduction surgery. Mean numeric rating pain scores were recorded daily in Materials and Methods: A single center, double-blinded, randomized controlled the frst fve postoperative days. Exclusion criteria were contraindications for intrathecal injections intercept and slope, were developed to explain the variations in postoperative or for any of the study medication. The infuences of potential predictors of postoperative pain in which patients received a single shot of intrathecal 12. Both groups received standardized general anesthesia and the same infuential factors of pain trajectories, patients receiving chest and lower extremity post-operative analgesic regimen. Primary outcome was the decrease in the Quality surgery tended to have less and more baseline pain, respectively, than those with of Recovery-15 (QoR-15) questionnaire on postoperative day 1. Male and elderly had less baseline pain as well effects of intrathecal morphine were secondary outcomes. Moreover, patients older, lighter or receiving Results and Discussion: 155 patients were analysed, from which 76 received chest surgery tended to have milder decreasing trends in pain trajectories. Patients in the intervention group had less decrease in QoR-15 that higher infusion rate was associated with elevated baseline level and smoother (-12. Moreover, the variations in postoperative pain trajectories and more explanatory variables should intervention group used less rescue medication. Pruritus was more common in be considered to elucidate the mechanisms behind the transitions of pain scores the intervention group (47. For Group A, the background trend of daily pain score, lower abdomen surgery tended to steepen the slope (p infusion rate was set to 2 ml/h and the bolus dose to 0. For Group P, the background infusion rate was set to 6 ml/h, the longer anesthesia time tended to fatten the slope parameter (p < 0. If the patient pressed the bolus button, the background infusion pain trajectories. Data collected included demographics, surgery type, infusion duration, pain scores, analgesic consumption and adverse effects. However, the cephalic vein and thoracoacromial artery identifed and analyzed separately. Conclusion: this single-center retrospective study over 10 years confrms the Productivity: A cross-sectional study. Clinical importance of changes in chronic pain intensity measured 2 on an 11-point numerical rating scale. The goal of this study was to investigate both the prevalence approach for continuous brachial plexus block for of pain in outpatients in a Spanish Teaching Hospital and its relationship with Quality of Life and Work Productivity in active workers. The Case 2: A 23-year-old male presented with right elbow arthritis and stiffness after R for this linear regression was 0. It is planned for him to receive surgical manipulation accurately predict the loss of productivity in more than 40% of our population. However, his motor and sensory blockage prevalence of pain is similar to that of general population, the quality of life indexes was incomplete. The linear regression model confrms the very high implication of pain complete motor and sensory blockage. Estimating means from medians [1] risks false analyses of postoperative analgesics and may reduce quality of evidence [1]. Ratio assumptions about the underlying data, whilst reporting in a narrative synthesis may of means has been proposed as an alternative to mean differences [2] and such risk excluding important data from analyses, with resultant errors in effect estimates relative measures may reduce statistical heterogeneity. Although ratio of means2 Results and Discussion: the overall result reported in the meta-analysis showed did improve I values, considerable heterogeneity still exists and therefore ratio of2 statistically signifcant beneft (p=0. The overall effect p value increased when analysed using Edgington?s in meta-analyses of postoperative analgesics [1]. The proportion of Conclusions: Re-analysing meta-analyses using ratio of means does not appear statistically signifcant individual studies was 36% (4/11) when reported as means to resolve statistical heterogeneity in meta-analyses of postoperative analgesics. When the overall results included studies References: reported as medians using meta-analysis of p values, the overall p value increased 1. These results have implications for reducing consumption may explain between-study heterogeneity in meta-analyses of type 1 errors in overall results and publication bias tests. However, the limitations of adjuvant analgesics and improve precision and accuracy of effect estimates. Ratio of means for analyzing continuous 1 errors in effect estimates and publication bias tests and therefore sensitivity outcomes in meta-analysis performed as well as mean difference methods. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. Pre-emptive and preventive opioids for postoperative pain in adults undergoing all types of surgery. The goal is here to collect data of the current situation about post-operative pain, treatments and protocols and to identify the variables associated with opioids use. Results and Discussion: the median most severe pain score was 7 on an elevenpoints scale. Interference of pain on activities has a median of 6 and side-effects scored a median under 5. Patient satisfaction and participation in the treatment of post-operative pain have a median of 8 and 9 respectively. A bivariate analysis showed that age, length of surgery, intra-operative and post-operative use of opioids have a signifcant (P<0. Further univariate analysis (Spearman Rank test) confrm that more opioids are used during longer operations and graphical multivariable modelling suggests the occurrence of opioid-induced hyperalgesia. Conclusions: Most severe pain scores and interference with activities remain high, even in satisfed and participating patients. Outcomes are associated with opioids use suggesting the development of complementary approaches. An e-health application, PainCoach app, was developed to guide patients in pain control and opiate use. PainCoach-app group got access to the app to be used Results and Discussion: For the separate testing there was constant overrating of whenever the patient wanted. In response to patient?s input of the pain experienced, pain, however there was high agreement for the whole scale. Secondary, data on drug use other than opiates, experiences with executed exercises, pain acceptance, function and quality of life were obtained. Data were collected in both groups by questionnaires; preoperatively, daily the frst two weeks and after 1 month. Opiate use is substituted by acetaminophen Acknowledgements: We thank Mr Jack Harich for the permission to use his scale use. Active use of this app leads to further reduction of Personalized therapy of acute postoperative pain opiate use and improved pain control during activity and at night. In outpatient failure is mostly due to uncontrolled/catastrophized pain and questions 100% patients had: degenerate diseases of cervical, thoracic and lumbar spine and on postoperative care. We developed a Comprehensive Acute Pain Anchoring Scale for Outpatients lumbar zone (lidocaine-1mg*kg-1, dexamethasone 0. A French version of this scale (Figure 1) was tested in 2 groups 2-nd stage of T were: 1gr. Another group (n=57) rated their agreement for each anchor looking at the plexite 11,1% (1/9), lumbago in 2 gr. An Leuven (Belgium) epidemiological study that analyzes pain intensity in the frst 24 hours places it in ninth place out of 176 surgical procedures. The aim of our study is to analyze the evolution of indicators of because it can be used without technical restrictions. Search terms included anesthesia, anesthesia is performed with hyperbaric bupivacaine 0. Based on these records, level of pain post therapy from ?severe to ?moderate or ?moderate to ?light. No objectif conclusion can be drawn Table 1: Intensity of postoperative pain at any time during admission from this literature review. Therefore, prompt acute pain relief is of paramount some patients show diverged results. Types of surgery were laparotomy (6 cases), laparoscopy (4 cases), symptoms and physical symptoms. We evaluated the proportion of diverged results, thoracotomy (1 cases), and t extremities surgery (4 cases). However, it was really useful for our one psychological test, we may be able to determine the factors by using other patients. Background and Goal of Study: the aim of this study was to compare a multimodal Silva R. Patients concerning despite technically challenging and high morbi-mortality potential.

Syndromes

• Interstitial cystitis
• Depression or feelings of sadness
• Delayed walking
• Tell the person not to rub the eye. Wash your hands before examining it.
• Lumpectomy is when only the breast cancer and tissue around the cancer are removed. This is also called breast conservation therapy or partial mastectomy. Part of your breast will be left.
• Permanent spinal cord injury (very rare)
• Fluids by IV
• Take your drugs your health care provider told you to take with a small sip of water.
• Head tilting
• Baby formula with iron

Back to Top Date Sent: 3/24/2020 423 these criteria do not imply or guarantee approval women's health issues in thrombosis and haemostasis 2013 generic estradiol 1mg on line. Unless there are medical contraindications to therapy menstrual massage order 1 mg estradiol, patients should undergo feminizing hormone therapy aimed at decreasing androgen effects prior to hair removal to enhance efficacy and prevent additional/recurrent terminal hair growth womens health 31 meals in 31 days recipes buy online estradiol. History of prior gonadectomy Note: Patients who have not had gender reassignment surgery (gonadectomy or vaginoplasty) should continue hormone/anti-androgen therapy unless contraindicated during and after hair removal to prevent recurrence menopause 24 buy 2mg estradiol with mastercard. Back to Top Date Sent: 3/24/2020 424 these criteria do not imply or guarantee approval menstruation yeast infection discount estradiol 1 mg mastercard. Age 18 years or older (Note: age requirement will not be applied to mastectomy in Female-toMale patients if the surgeon menopause urine changes purchase 1mg estradiol free shipping, the primary care provider, and the qualified mental health professional unanimously document the medical necessity of earlier intervention) B. If significant medical or mental health concerns are present, they must be reasonably well controlled. The health plan may require a second opinion regarding the patient?s stability prior to surgery if in question. Twelve months of living in a gender role that is congruent with their gender identity (real life experience). If the referring medical provider or mental health provider requests surgical intervention prior to the patient?s completion of 12 months of living in desired gender, the surgeon, the primary care provider, and the qualified mental health professional must submit evidence of medical necessity and clear rationale for the proposed surgical intervention to be done early. The three providers must submit written documentation to the plan that includes: a. Clear rationale for the variation from the 12-month period of living in desired gender; and c. The plan will determine authorization and consent to care based on medical necessity from the documentation outlined in A-F above. Age 18 years or older (Note: age requirement will not be applied to augmentation in Male-toFemale patients if the surgeon, the primary care provider, and the qualified mental health professional unanimously document the medical necessity of earlier intervention) E. The health plan may require a second opinion regarding the patient?s stability prior to surgery if in question; and F. Twelve months of living in a gender role that is congruent with their gender identity (real life experience) and G. Twelve months of continuous hormone therapy as appropriate to the member?s gender goals. If the referring medical provider or mental health provider requests surgical intervention prior to the patient?s completion of 12 months of hormone therapy and/or living in desired gender, the surgeon, the primary care provider, and the qualified mental health professional must submit evidence of medical necessity and clear rationale for the proposed surgical intervention to be done early. A comprehensive, coordinated treatment plan with evidence that all treatment plan criteria for surgery and treatment goals have been met; and b. Clear rationale for the variation from either the 12-month period of hormone therapy and/or living for 12 months in desired gender; and c. Patient understands the treatment plan, risks and benefits of surgery prior to completing the 12month period; and d. The plan will determine authorization and consent to care based on medical necessity from the documentation outlined in A-G above. Back to Top Date Sent: 3/24/2020 425 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History the criteria above apply for only initial male to female augmentation mammaplasty, any additional breast augmentation after an initial mammaplasty is considered a cosmetic procedure, and therefore, a contract exclusion. Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male to-female): A. Two referral letters from qualified mental health professionals*, one in a purely evaluative role. Requirements for genital reconstructive surgery (Vaginectomy, colpectomy, metoidioplasty, vaginoplasty, colovaginoplasty, penectomy, clitoroplasty, labioplasty, phalloplasty, scrotoplasty, urethroplasty, testicular prosthesis (expanders and implants), penile prosthesis. Two referral letters from qualified mental health professionals*, one in a purely evaluative role (At least one letter should be an extensive report. Twelve months of continuous hormone therapy as appropriate to the member?s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); and G. Member has the capacity to make fully informed decisions and to consent to treatment. If significant medical or mental health concerns are present, they are reasonably well controlled. Member has a current referral letter for laryngochrondroplasty surgery or other gender reassignment surgery from a qualified mental health professional who has independently assessed the patient. For providers working within a multidisciplinary specialty team, the assessment and recommendation can be documented in the patient?s chart. The duration of the mental health professional?s relationship with the client, including the type of evaluation and therapy or counseling to date. An explanation that the criteria for surgery have been met and a brief description of the clinical rationale for supporting the patient?s request for surgery. Back to Top Date Sent: 3/24/2020 426 these criteria do not imply or guarantee approval. A statement about the fact that the patient has the capacity to provide informed consent. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this. Member has had a mental health evaluation and a medical evaluation and has been deemed to have no medical or psychological contraindications for surgery. Electrolysis, except for facial hair removal and as needed for genitourinary reconstructive surgery. Facial feminization surgery including but not limited to: facial bone reduction and facial plastic reconstruction. Reversal of genital surgery or reversal of surgery to revise secondary sex characteristics. All other cosmetic procedures that do not meet medical necessity * Characteristics of a Qualified Mental Health Professional: 1. Master?s degree or equivalent in a clinical behavioral science field granted by an institution accredited by the appropriate national accrediting board. The professional should also have documented credentials from the relevant licensing board or equivalent; and 2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Disease for diagnostic purposes; and 3. Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; 4. Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria; and 5. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria. Back to Top Date Sent: 3/24/2020 427 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History Gender Dysphoria refers to discomfort or distress that is caused by a discrepancy between a person?s gender identity and that person?s sex assigned at birth. Transgender individuals usually present to the medical profession with a sophisticated understanding of their identity, and a desired course of treatment, including hormone therapy and potentially gender-realignment surgery. The therapeutic approach to gender dysphoria consists of three elements: hormones, real life experience and, finally, surgery for some patients. The use of hormone therapy and surgery for gender transition/affirmation is based on many years of experience treating transgender people. Research on hormone therapy is providing us with more and more information on the safety and efficacy of hormone therapy, but all of the long-term consequences and effects of hormone therapy may not be fully understood. A vital part of the long-term diagnostic therapy is the so-called real-life experience, in which the patient lives as a member of the desired gender continually and in all social spheres in order to accumulate necessary experience. Hormone therapy and gender-realignment surgery are superficial changes in comparison to the major psychological adjustments necessary in affirming gender identity. One aspect of treatment should concentrate on the psychological adjustment, with hormone therapy and gender-realignment surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Many providers and organizations are moving to an informed consent model for hormones, but surgery still needs involvement of psychology and psychiatry. Psychiatric care may need to be continued for many years after gender-realignment surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the patient, and the support from family, friends, employers and the medical profession. Evidence and Source Documents There was no evidence review conducted for these criteria. Back to Top Date Sent: 3/24/2020 428 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 429 these criteria do not imply or guarantee approval. Genetic tests for cancer are only a covered benefit for a beneficiary with a personal history of an illness, injury, or signs/symptoms thereof. A person with a personal history of a relevant cancer is a clinically affected person, even if the cancer is considered cured. Predictive or pre-symptomatic genetic tests and services, in the absence of past or present illness in the beneficiary, are not covered under national Medicare rules. Back to Top Date Sent: 3/24/2020 430 these criteria do not imply or guarantee approval. Medicare does not cover a genetic test for a clinically affected individual for purposes of family planning, disease risk assessment of other family members, when the treatment and surveillance of the beneficiary will not be affected, or in any other circumstance that does not directly affect the diagnosis or treatment of the beneficiary. The results of the genetic test must potentially affect at least one of the management options considered by the referring physician in accordance with accepted standards of medical care (e. Pre-test genetic counseling must be provided by a qualified and appropriately trained practitioner. Back to Top Date Sent: 3/24/2020 431 these criteria do not imply or guarantee approval. The member is at clinical risk for a genetic condition because of current documented symptoms being displayed or a strong family history of the condition. The results will directly affect a member?s clinical management or reproductive decisions. After appropriate clinical work-up, and informed consent by the appropriate practitioner, the genetic test is indicated. Genetic testing is not covered for the medical management of a family member who does not have Kaiser Permanente coverage. Back to Top Date Sent: 3/24/2020 432 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 433 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 434 these criteria do not imply or guarantee approval. Results have the potential to directly impact clinical decision-making and clinical outcome for the patient 3. Clinical presentation does not fit a well-described syndrome for which single-gene or targeted panel testing is available 6. Back to Top Date Sent: 3/24/2020 435 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 436 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 437 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 438 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 439 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 440 these criteria do not imply or guarantee approval. Genetic screening is only appropriate when the natural history of the disease is understood; the screening tests are valid and reliable; sensitivity, specificity, false-negative, and false-positive rates are acceptable; and effective therapy is available. A sufficient benefit must be derived from a screening program to justify its cost. It is thus recommended that any identified nodule measuring one centimeter or more in diameter be diagnostically evaluated. It can identify approximately 50% of malignant nodules and 70% of benign nodules without the need to perform a diagnostic surgery. Most patients with indeterminate lesions or lesions suspicious for malignancy, according to the Bethesda classification* system, are referred to surgery for both diagnostic and therapeutic purposes. Thus, a large proportion of these patients may undergo unnecessary partial or complete thyroidectomy with its potential surgical complications and risk of long-term morbidity (Alexander 2012, Duick 2012, Walsh 2012, Ali 2013, Labourier 2015, Sacks 2016). Molecular markers and assays have been investigated for their ability to preoperatively classify the indeterminate thyroid nodules. Ideally a molecular marker or panel of markers is accurate in differentiating benign from malignant in any lesion that is considered suspicious or indeterminate. Molecular tests should also be simple to use, reproducible by the different institutions/laboratories, and cost-effective. Molecular genetic testing for cytologically indeterminate thyroid nodules fall in two approaches: the ?rule in and the ?rule-out disease approach. Tests that rule-out the disease on the other hand, should have a high sensitivity and negative predictive value in order to exclude malignancy when the test results are benign. Because a majority of nodules with indeterminate cytology are found to be benign on surgical resection, a test that can preoperatively rule-out malignancy may spare a subset of these patient?s unnecessary diagnostic surgeries (Alexander 2012, Kouniavsky 2012, Ward 2013, Chaudhary 2016. It represents the ?rule-out approach by preoperatively identifying the benign thyroid nodules and ruling-out malignancy. Back to Top Date Sent: 3/24/2020 441 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History of surgically proven benign and malignant thyroid nodules.

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Then came the discovery of mosquito hosts for filariae by Manson (1877 -1878) and Plasmodia by Laveran in 1880 women's health xmas kekse order discount estradiol online, transmission of babesiosis by ticks by Smith and Kilburne in 1894 menstrual 3 times a month generic 2 mg estradiol free shipping, trypanosomes and their transmission by tsetse flies by Bruce (1895 1896) pregnancy ultrasounds order estradiol uk, and mosquito transmission of plasmodia by Ross (18971898) pregnancy kit buy estradiol discount. With the aid of microscopes breast cancer jokes trusted 2mg estradiol, morphological characters of various parasites were first studied and species and group characteristics were determined breast cancer 2a discount estradiol 1 mg. Then several stages of the organisms were related to one another in life-cycle sequence. This provided important information on extrinsic as well as intrinsic development and paved the way for epidemiologic studies. Moreover, the relationship between parasite to host provided a background for studying the pathogenesis of infection in man and reservoir hosts and, indirectly, for understanding clinical aspects. Parasitology 8 Recent investigations have been largely concerned with the ecology of parasitic infections, anatomy and physiology as revealed by electron microscopy, metabolism of the parasite in its host, immunologic phenomena, and the rationale of chemotherapy. Meanwhile, practical methods are being developed to control these infections and to reduce human exposure to them. A landmark of great significance was the publication in 1978 of a twovolume work by B. Russell, which brought together in English translation as the articles on the major discoveries and earliest descriptions by workers in tropical medicine and parasitology. Having set the historical background; now we will see the importance and the scope of Parasitology. Parasitology is a science that deals with an organism that lives in or on another organism in order to have shelter and /or nutrition. Medical parasitology study parasites that is capable of causing disease in humans. In the context of this ecture note, the term parasite refers to organisms, which belong to protozoa. A lot of economic loss occurs as a result of infection of domestic animals by parasite, which causes diseases such as fascioliasis and trypanosomiasis. The study of parasitology has more importance to developing countries where the social and economic conditions require great deal of improvement in terms of better clothing, shelter, food, provisions of wells Parasitology 9 and latrines and sewages and other waste disposal facilities together with the means of controlling vectors. The tropical or the semi-tropical nature of places where most of the people of the developing nations live not only provides better environmental conditions for larval development of parasites than that of temprate regions where most of the developed countries are found, but also provides better conditions for the multiplication of vectors. This lecture note will discuss specific parasite of medical importance, including the information necessary to assist in the diagnosis. Parasitology 10 General Objectives Understand the concepts of parasitism, the relationships between parasites and hosts, between parasites and environment and the cultural and socioeconomic factors affecting the transmission of parasites Know the general epidemiological aspects of parasites that affect human Apply simple preventive measures for specific parasites Know the life cycle of specific parasites and identify the important parasitic agents affecting human health Be able to prepare reagents necessary for parasitology lab. List the various environmental, cultural and socioeconomic factors that affect the distribution of parasites 4. Explain mode of transmission, source of infection, and portal of entry of parasites 1. Parasite:is an organism living temporarily or permanently in or on another organism (host) from which is physically or physiologically dependant upon other. Association of Organisms When there is an association between two organisms their relation will be one of the following type: 1. Symbiosis:Permanent association between two different organisms, so dependant on each other, that their life part is impossible. Commensalism:When the parasite benefited from the host while the host neither benefited nor harmed. Parasitism:-One organism live at the expense of the other, the later usually suffers from the association. Permanent (obligate) parasites: the parasite depends completely upon its host for metabolites, shelter, and transportation. Temporary (facultative) parasite: the parasite is capable of independent existence in addition to parasitic life. Non-Pathogenic (commensal) parasite:-The parasite derives food and protection from the host without causing harm to the host. Opportunistic parasites:Parasites which cause mild disease in immunologically healthy individuals, but they cause severe disease in immuno-deficient hosts. Pneumocystis carnii, Toxcoplasma gondii, Isospora belli Host :Hosts are organism which harbors the parasite. Definitive host:Depending on the parasitic species, it is either a host which harbors the adult stage of a parasite or most highly developed form of the parasite occurs; or sexually mature stages of a parasite and fertilization takes place in it. When the mature or most highly developed form is not obvious the definitive host is the mammalian host. Intermediate host:Is a host harboring sexually immature or larval stage of a parasite and in which no fertilization takes place in it. Cow is the intermediate host for Taenia saginata Parasitology 14 Amplifier hostIntermediate hosts in which parasites under go multiplication. Reservoir host:A wild or domestic animal which harbors a parasite and acts as sources of infection to humans. Carrier host:A host harboring and disseminating a parasite but exhibiting no clinical sign. Accidental (Incidental) host:Infection of a host other than the normal host species. Vector:Any arthropod or other living carrier which transports a pathogenicmicroorganisms from an infected to non-infected host. Anopheles (Vector of Plasmodium), Phlebotomus (Vector of Leishmania), Glossina (vector of Trypanosoma), Simulium (Vector of Onchocerca), etc. Mechanical (Parathenic or transport) Vectors: They are passive carriers of parasites, not essential in the life cycle. Infective Stage:the stage of parasite at which it is capable of entering the host and continue development within the host. Infection:Invasion of the body by any pathogenic organism (except )arthropods and the reaction of the hosts tissue to the presence of the parasite or related toxins. Parasitology 15 Infestation:the establishment of arthropods upon or within a host. Biological Incubation (Prepatent) Period:It is time elapsing between initial infection with the parasite and demonstration of the parasites or their stages in excreta, blood, aspirate and other diagnostic material. Clinical Incubation Period:It is the interval between exposure and the earliest manifestation or infestation. Autoinfection:An infected individual acts as a source for hyperinfection to himself. Superinfection (Hyperinfection):When an individual harboring the parasite is reinfected by the same parasite. Contaminated soil:Soils polluted with human excreta is commonly responsible for exposure to infection with Ascaris lumbricoides, S. Contaminated water:Water may contain (a) Viable cysts of Amoeba, flagellates and T. Insufficiently cooked meat of pork and beef which contains infective stage of the parasite. Herbivores animals commonly constitute the source for human infection with Trychostrongylus species. Human beings:-Another person his clothing, bedding or the immediate environment that he contaminated are directly responsible for all or a considerable amount of infection with a pathogenic amoeba E. Horizontal Direct Mode of Transmission: Transmission is mainly effected through:Feco-oral route: Most intestinal parasites transmitted in this way. Vertical Direct Mode of Transmission: Transmission of the parasite is from the mother to child through: Congenital / transplacental Transmammary (breast milk) 1. Host Susceptibility Factors Not all parasitic infection causes disease of clinical significance. Metabolic process of the parasite, particularly the nature of any waste products or toxins produced by the parasite during its growth and reproduction. Escape mechanism of parasite from the immune system That parasitism is wide spread in almost all species of animals would imply that parasites have developed the capacity to escape or render ineffective the host internal defense mechanisms. Molecular mimicry: Certain parasites are recognized as self and consequently do not stimulate immunologic reactions in their host. Thus Schistosome worms are capable of masking their foreigners by acquiring a surface layer of host antigens which possibly protect them from antibody damage. These are called ?eclipsed antigens, since these antigens by resembling those of the host are not recognized as foreign and therefore are hidden Parasitology 21 from the immune recognition. This phenomenon of antigen sharing between a parasite and a host is called Molecular mimicry. This sometimes, results in an increase in the severity of any viral or bacterial infection also present. Immuno-supression is due to production by the parasite of large quantities of soluble antigens which: 3. Induce B or T-cell tolerance either by blocking antibody forming cells or by depleting the stock of mature antigenspecific lymphocites ( clonal exhaustion ). Indirect Life Cycle: When a parasite requires an intermediate host or vector to complete its development. Although common names are frequently used for this purpose, these are not universally understood, partly because of language barriers and partly because of a common name not necessarily applied to the same organism in different countries. To overcome this difficulty, a binomial scientific name is used, consisting of a generic and a specific designation based on the International Code of Zoological Nomenclature. The first name in the binomial is that of the genus to which the organism belongs, and the second is that of the species. This combination of in designating an animal or plant species is termed binomial nomenclature. Taxonomic classification of medically important parasites of man belong to the kingdom of Animalia and most parasites are members of three phyla: Phylum Protozoa Phylum Platyhelminths and Phylum Nemathelminths. Parasitology 24 Basic Classification of Parasites of Medical Importance Kingdom Animalia I I I I Sub-kingdom Protozoa Metazoa I I I I I I I Phylum Protozoa Platyhelminthes I Arthropoda I I Nemathelminthes I Class I 1) Trematoda I I I 2)Cestoda I 1) Insecta, 1) Rhizopoda 2) Arachnid, 2) Zoomastigophora I etc. Discuss the characteristics of each class of protozoan parasite in general and each parasite in particular. Apply the necessary procedures for the diagnosis of protozoan parasites and be able to identify them in the procedures used. Introduction Protozoa consists of a vast assemblage of single cell micro-organisms that are placed in the subkingdom, or phylum protozoa. They are made of a mass of protoplasm differentiated in to cytoplasm and nucleoplasm. The ectoplasm function in protection, locomotion, ingestion of food, excretion, respiration. The protozoa of medical importance to humans include Amoebas, Flagellates, Ciliates, Coccidia, sporozoa and Microsporidia. For this reason the laboratory technician must be familiar with characteristic of pathogenic as Parasitology 27 well as non-pathogenic species. Protozoa may colonize or infect intestinal tract, pharynx, and the uro-genital tract of humans. The majority of this parasite belongs to the Amoeba or Flagellate; however infection with Ciliate, Coccidian or Microsporidian parasite may also be encountered. These organisms are generally of world wide distribution and almost are acquired by fecaloral contamination. In review of stool specimens examined for intestinal parasite in United State, non pathogenic protozoa were detected in 10. The protozoa of blood and tissues include the sporozoan parasites Plasmodium, Babesia and Toxoplasma gondii; the hemoflagellates Leishmania and Trypanosoma; and the free living amoeba Naegleria and Acathamoeba. The protozoa causing tissue infections cause significant damage to specific organs such as the eyes (toxoplasmosis, acanthamoeba, keratitis), the brain (toxoplasmosis, amoebic meningoencephalitis, African sleeping sickness), the heart (toxoplasmosis, chagas disease),or gastrointestinal tract (chagas disease). Pneumocystis carnii primarily causes pneumonia; however invasion of other sites such as the eye have been reported. As a parasite protozoa play a double role; they can attack man and cause disease or they can affect him economically by attacking domestic Parasitology 28 animals. The general procedures utilized for diagnosis of the protozoa vary according to where the parasite is found in the body. The malarial parasites and blood or tissue flagellates (Trypanosome or Leishmania) are usually detected in stained smears of blood or tissue. In the case of the blood or tissue flagellates cultivation procedures and animal inoculations are often important tools. The intestinal and atrial parasites, with few exceptions, may be found in stool as a motile trophozoite stage or a non-motile, resistant cyst stages. One of them is found in the oral cavity and the remaining six species are found in the large intestine, these include: Entamoeba histolytica, E. Coli, Endolimax nana, Iodamoeba butschlii and Entamoeba polecki; of these only one, i. All human intestinal amoebae have: 1) a trophozoite from which is motile organism, feed, and reproduce, and, 2) a cystic form which is the nonfeeding, non motile, dormant stage of protozoa. The trophozoite stage consists of a shapeless mass of moving cytoplasm which is divided into granular endoplasm and clear ectoplasm. Before going into structural details here for each of them, their nuclear character for identification is considered: E. Habitat:-Trophozoite:Large intestine, liver abscesses and other extraintestinal organs Cyst:found in the stools of chronic dysenteric patients and carriers. Motility:Active, Progressive, directional amoeboid motility in fresh warm stool specimen. Stored food: Sausage shaped chromatoidal bars with blunt ends and glycogen mass in immature cysts with one or two nuclei. Life cycle: Entamoeba histolytica requires a single host to complete its life cycle. When mature tetra-nucleated cyst from contaminated food or drink or form hands contaminated with feces is ingested it excysts in the small intestine to produce metacystic trophozoite by a process of binary fission. The immature trophozoites migrate to the colon and grow to become mature trophozoite stage, multiply by binnary fission to invade the mucus membrane of the large intestine.

Diseases

• Necrotizing fasciitis
• Dominant cleft palate
• Kostmann syndrome
• Glaucoma, congenital
• White matter hypoplasia corpus callosum agenesia mental retardation
• Cardiomyopathy cataract hip spine disease
• Encephalopathy progressive optic atrophy
• Abdallat Davis Farrage syndrome