Sanjeev Bhalla, MD

• Associate Professor of Radiology
• Washington University
• Mallinckrodt Institute of Radiology
• Chief, Cardiothoracic Imaging Section
• Barnes Jewish Hospital
• St. Louis, Missouri

Ring X and other structural X chromosome abnormalities: X inactivation and phenotype medicine for bronchitis order pirfenex no prescription. Care of girls and women with Turner syndrome: a guideline of the Turner Syndrome Study Group symptoms xylene poisoning order discount pirfenex line. The similarity of phenotypic effects caused by Xp and Xq deletion in the human female: a hypothesis symptoms thyroid buy pirfenex 200 mg on-line. Karyotype-phenotype correlations in gonadal dysgenesis and their bearing on the pathogenesis of malformations medicine 1920s cheap 200 mg pirfenex mastercard. New natural inactivation mutations of the follicle-stimulating hormone recep to r: correlations between recep to r function and phenotype treatment purchase pirfenex with paypal. Mechanisms of disease: single gene mutations resulting in reproductive dysfunction in women symptoms anemia discount pirfenex 200 mg free shipping. Hypogonadism and mineralocorticoid excess: the 17-hydroxylase deficiency syndrome. Clinical review 78: aromatase deficiency in women and men: would you have predicted the phenotypesfi Aromatase deficiency in a female who is compound heterozygote for two new point mutations in the P450arom gene: impact of estrogens on hypergonadotropic hypogonadism, multicystic ovaries and bone densi to metry in childhood. Testicular and ovarian resistance to luteinizing hormone caused by inactivating mutations of the luteinizing hormone-recep to r gene. Naturally occurring mutations of the luteinizing hormone recep to r gene affecting reproduction. Endocrine and neurologic outcome in childhood craniopharyngioma: review of effective treatment in 42 patients. Prevalence, phenotypic spectrum and modes of inheritance of gonadotropin-releasing hormone recep to r mutations in idiopathic hypogonadotropic hypogonadism. Brief report: delayed puberty and hypogonadism caused by mutations in the follicle-stimulating hormone (beta)-subunit gene. Primary amenorrhea and infertility due to a mutation in the beta-subunit of follicle-stimulating hormone. Effects of childhood leukemia and chemotherapy on puberty and reproductive function in girls. Hyperprolactinemia and delayed puberty: a report of three cases and their response to therapy. Abnormalities of development associated with hypothalamic calcification after tuberculous meningitis. Hyperprolactinemia as a cause of delayed puberty: successful treatment with bromocriptine. The risk of death in pregnancy achieved through oocyte donation in patients with Turner syndrome: a national survey. Pregnancy success following surgical correction of imperforate hymen and complete transverse vaginal septum. The bicycle seat s to ol in the treatment of vaginal agenesis and stenosis: a preliminary report. Primary ovarian insufficiency: a more accurate term for premature ovarian failure. Premature ovarian failure: a systematic review on therapeutic interventions to res to re ovarian function and achieve pregnancy. Familial premature ovarian failure due to interstitial deletion of the long arm of the X chromosome. A human homologue of the Drosophila melanogaster diaphanous gene is disrupted in a patient with premature ovarian failure: evidence for conserved function in oogenesis and implications for human sterility. Genetic and phenotypic heterogeneity in ovarian failure: overview of selected candidate genes. Recent developments in identifying genetic determinants of premature ovarian failure. Reduced ovarian function in long-term survivors of radiation and chemotherapy-treated childhood cancer. A new syndrome of amenorrhea in association with hypergonadotropism and apparently normal ovarian follicular apparatus. Galac to se-1-phosphate uridyl transferase activity associated with age at menopause and reproductive his to ry. Aetiology, previous menstrual function and patterns of neuro-endocrine disturbance as prognostic indica to rs in hypothalamic amenorrhea. Menstrual cycles: fatness as a determinant of minimum weight for height necessary for their maintenance or onset. Comparison of flutamide and spironolac to ne in the treatment of hirsutism: a randomized controlled trial. Clinical efficacy and safety of cyproterone acetate in severe hirsutism: results of a multicentered Canadian study. Patient-tailored conventional ovulation induction algorithms in anovula to ry infertility. An extended regimen of clomiphene citrate in women unresponsive to standard therapy. Aromatase inhibi to rs for female infertility: a systematic review of the literature. Over 900 oocyte cryopreservation babies born with no apparent increase in congenital anomalies. Ovarian cryopreservation and transplantation for fertility preservation for medical indications: report of an ongoing experience. Careful cardiovascular screening and follow-up of women with Turner syndrome before and during pregnancy is necessary to prevent maternal mortality. Matthew Peterson Hyperandrogenism most often presents as hirsutism, which usually arises as a result of androgen excess related to abnormalities of function in the ovary or adrenal glands. By contrast, virilization is rare and indicates marked elevation in androgen levels. Deficiency of 21-hydroxylase is responsible for more than 90% of cases of adrenal hyperplasia resulting from an adrenal enzyme deficiency. Patients with severe hirsutism, virilization, or recent and rapidly progressing signs of androgen excess require careful investigation for the presence of an androgen-secreting neoplasm. Amenorrhea without galac to rrhea is associated with hyperprolactinemia in approximately 15% of women. In patients with both galac to rrhea and amenorrhea, approximately two-thirds will have hyperprolactinemia; of those, approximately one-third will have a pituitary adenoma. In more than one-third of women with hyperprolactinemia, a radiologic abnormality consistent with a microadenoma (>1 cm) is found. The most common thyroid abnormalities in women, au to immune thyroid disorders, represent the combined effects of the multiple antibodies produced. The classic triad of exophthalmos, goiter, and hyperthyroidism in Graves disease is associated with symp to ms of hyperthyroidism. The endocrine disorders encountered most frequently in gynecologic patients are those related to disturbances in the regular occurrence of ovulation and accompanying menstruation. Other conditions leading to ovula to ry dysfunction, hirsutism, or virilization, and common disorders of the pituitary and thyroid glands associated with reproductive abnormalities, are reviewed in this chapter. Hyperandrogenism Hyperandrogenism most often presents as hirsutism, which arises as a result of androgen excess related to abnormalities of function in the ovary or adrenal glands, constitutive increase in expression of androgen effects at the level of the pilosebaceous unit, or a combination of the two. By contrast, virilization is rare and indicates marked elevations in androgen levels. An ovarian or adrenal neoplasm that may be benign or malignant commonly causes virilization. Hirsutism Hirsutism, the most frequent manifestation of androgen excess in women, is defined as excessive growth of terminal hair in a male distribution. This refers particularly to midline hair, side burns, moustache, beard, chest or intermammary hair, and inner thigh and midline lower back hair entering the intergluteal area. The response of the pilosebaceous unit to androgens in these androgen responsive areas transforms vellus hair (fine, nonpigmented, short) that is normally present in to terminal hair (coarse, stiff, pigmented, and long). Androgen effects on hair vary in relation to specific regions of the body surface. The hair of the limbs and portions of the trunk exhibits minimal sensitivity to androgens. Pilosebaceous units of the axilla and pubic region are sensitive to low levels of androgens, such that the modest androgenic effects of adult levels of androgens of adrenal origin are sufficient for substantial expression of terminal hair in these areas. Follicles in the distribution associated with male patterns of facial and body hair (midline, facial, inframammary) require higher levels of androgens, as seen with normal testicular function or abnormal ovarian or adrenal androgen production. Scalp hair is inhibited by gonadal androgens, in varying degrees, as determined by age and genetic determination of follicular responsiveness, resulting in the common frontal-parietal balding seen in some males and in virilized females. Hirsutism results from both increased androgen production and skin sensitivity to androgens. Hair demonstrates cyclic activity between growth (anagen), involution (catagen), and resting (telogen) phases. The durations of both the growth and resting phases vary according to region of the body, genetic fac to rs, age, and hormonal effects. The cycles of growth, rest, and shedding are normally asynchronous, but when synchronous entry in to telogen phase is triggered by major metabolic or endocrine events, such as pregnancy and delivery, or severe illness, dramatic (although transient) hair loss may occur in the following months (telogen effluvium). What is normal in one setting may be considered abnormal in others; social and clinical reactions to hirsutism can vary significantly, reflecting ethnic variation in skin sensitivity to androgens and cultural ideals. Androgen-dependent hair (excluding pubic and axillary hair) occurs in only 5% of premenopausal white women and is considered abnormal by white women of North America, whereas considerable facial and male pattern hair in other areas may be more common and more often considered acceptable and normal among such groups as the Inuit and women of Mediterranean background. Hypertrichosis and Virilization Two conditions should be distinguished from hirsutism. Hypertrichosis is the term reserved for androgen-independent terminal hair in nonsexual areas, such as the trunk and extremities. This may be the result of an au to somal-dominant congenital disorder, a metabolic disorder (such as anorexia nervosa, hyperthyroidism, porphyria cutanea tarda), or medications. Although hirsutism accompanies virilization, the presence of virilization indicates a high likelihood of more serious conditions than are common with hirsutism alone and should prompt evaluation to exclude ovarian or adrenal neoplasm. Although rare, these diagnoses become likely when onset of androgen effects is rapid or sufficiently pronounced to produce the picture of virilization. The his to ry should focus on the age of onset and rate of progression of hirsutism or virilization. A rapid rate of progression or virilization is associated with a more severe degree of hyperandrogenism and should raise suspicion of ovarian and adrenal neoplasms or Cushing syndrome. This is true whether rapid progression or virilization occurs before, during, or after puberty. Anovulation, manifesting as amenorrhea or oligomenorrhea, increases the probability that there is underlying hyperandrogenism. Hirsutism occurring with regular cycles is more commonly associated with normal androgen levels and thus is attributed to increased genetic sensitivity of the pilosebaceous unit and is termed idiopathic hirsutism. In determining the extent of hirsutism, a sensitive and tactful approach by the physician is manda to ry and should include questions regarding the use and frequency of shaving and/or chemical or mechanical depila to ries. Most physicians arbitrarily classify the degree of hirsutism as mild, moderate, or severe. Objective assessment is helpful, especially in establishing a baseline from which therapy can be evaluated. It is a scoring scale of androgen-sensitive hair in nine body areas rated on a scale of 0 to 4 (2). Although widely used, this scoring system has limitations, one of which is the fact that the scale does not include the sideburn, but to cks, and perineal areas. Substantial hirsutism may be confined to one or two areas without exceeding the cu to ff value in to tal hirsutism score. Each of the nine body areas most sensitive to androgen is assigned a score from 0 (no hair) to 4 (frankly virile), and these separate scores are summed to provide a hormonal hirsutism score. In addition to drugs that commonly cause hypertrichosis, anabolic steroids and tes to sterone derivatives may cause hirsutism and even virilization. During the physical examination, attention should be directed to obesity, hypertension, galac to rrhea, male pattern baldness, acne (face and back), and hyperpigmentation. With virilization, the presence of an androgen-producing ovarian neoplasm or Cushing syndrome must be considered. A moon-shaped face, upper body obesity, muscle weakness, and the development of a pad of fat between the shoulder blades are particularly notable to both patients and diagnosticians considering the diagnosis of Cushing syndrome. Biosynthesis begins with the rate-limiting conversion of cholesterol to pregnenolone by side-chain cleavage enzyme. In a parallel fashion, progesterone undergoes transformation to androstenedione in the fi-4 steroid pathway.

A randomized controlled trial of goserelin and medroxyprogesterone acetate in the treatment of pelvic congestion symptoms 9 days after ovulation order pirfenex amex. A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion treatment magazine buy pirfenex 200mg with visa. Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management treatment 002 buy cheap pirfenex on-line. Pathologic findings and outcomes of a minimally invasive approach to ovarian remnant syndrome treatment 12mm kidney stone purchase pirfenex 200mg on-line. Prevalence and characteristics of irritable bowel syndrome among women with chronic pelvic pain symptoms 11dpo buy pirfenex toronto. Recognition and treatment of irritable bowel syndrome among women with chronic pelvic pain medical treatment 80ddb purchase pirfenex without a prescription. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. The role of the urinary epithelium in the pathogenesis of interstitial cystitis/prostatitis/urethritis. The potassium sensitivity test: a new gold standard for diagnosing and understanding the pathophysiology of interstitial cystitis. Pharmacologic management of painful bladder syndrome/interstitial cystitis: a systematic review. Dyspareunia response in patients with interstitial cystitis treated with intravesical lidocaine, bicarbonate, and heparin. Percutaneous sacral nerve root neuromodulation for intractable interstitial cystitis. Anterior abdominal wall nerve and vessel ana to my: clinical implications for gynecologic surgery. Pudendal neuropathy involving the perforating cutaneous nerve after cys to cele repair with graft. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurological fac to rs in chronic pelvic pain: trigger points and the abdominal pelvic pain syndrome. A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Changes in personality profile associated with laparoscopic surgery for chronic pelvic pain. A randomized clinical trial for women with vulvodynia: cognitive-behavioral therapy vs. A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. Chronic pelvic pain treated with gabapentin and amitriptyline: a randomized controlled pilot study. Physical therapy evaluation of patients with chronic pelvic pain: a controlled study. Availability of a multidisciplinary pelvic pain clinic and frequency of hysterec to my for pelvic pain. The effect of different types of hysterec to my on urinary and sexual functions: a prospective study. Severe or deeply infiltrating endometriosis should be managed in a facility with the necessary expertise to provide treatment in a multidisciplinary context, including advanced laparoscopic surgery and laparo to my. Classification systems for endometriosis are subjective and correlate poorly with pain symp to ms, but have some value in determining the prognosis and management of infertility. Suppression of ovarian function for 6 months reduces pain associated with endometriosis. Hormonal drugs are equally effective in reducing pain but have differing side effects and cost. Ablation of endometriotic lesions plus adhesiolysis in minimal to mild endometriosis is more effective than diagnostic laparoscopy alone in improving fertility. Suppression of ovarian function is not effective in improving subsequent fertility in patients with endometriosis. Endometriosis is defined as the presence of endometrial tissue (glands and stroma) outside the uterus. The most frequent sites of implantation are the pelvic viscera and the peri to neum. Endometriosis varies in appearance from a few minimal lesions on otherwise intact pelvic organs, to massive ovarian endometriotic cysts that dis to rt tubo-ovarian ana to my and extensive adhesions involving bowel, bladder, and ureter. It is estimated to occur in 10% of reproductive-age women and is associated with pelvic pain and infertility. Considerable progress in understanding the pathogenesis, spontaneous evolution, diagnosis, and treatment of endometriosis has occurred. Epidemiology Prevalence Endometriosis is found predominantly in women of reproductive age but is reported in adolescents and in postmenopausal women receiving hormonal replacement (2). Estimates of the frequency of endometriosis vary widely, but the prevalence of the condition is assumed to be around 10% (3,4). Although no consistent information is available on the incidence of the disease, temporal trends suggest an increase among women of reproductive age (4). In women with pelvic pain or infertility, a high prevalence of endometriosis (from a low of 20% to a high of 90%) is reported (5,6). In women with unexplained subfertility with or without pain (regular cycle, partner with normal sperm), the prevalence of endometriosis is reported to be as high as 50% (7). First, it may vary with the diagnostic method used: laparoscopy, the operation of choice for diagnosis, is a better method than laparo to my for diagnosing minimal to mild endometriosis. Second, minimal or mild endometriosis may be more thoroughly evaluated in a symp to matic patient given general anesthesia than in an asymp to matic patient during tubal sterilization. Third, the interest and experience of the surgeon is important because there is a wide variation in the appearance of subtle endometriosis implants, cysts, and adhesions. Protective fac to rs against the development of endometriosis include multiparity, lactation, to bacco exposure in utero, increased body mass index, increased waist- to -hip ratios and exercise, and diet high in vegetables and fruits (20). Endometriosis and Cancer Several publications link endometriosis with an increased risk for certain gynecologic and nongynecologic cancers (24,25). These associations are controversial and no data exist to inform clinicians regarding the best management of patients who might be at risk of developing such cancers (1). Endometriosis should not be considered a medical condition associated with a clinically relevant risk of any specific cancer (26). Data from large cohort and case-control studies indicate an increased risk of ovarian cancers in women with endometriosis. Evidence from clinical series consistently demonstrates that the association is confined to the endometrioid and clear cell his to logic types of ovarian cancer (28). A causal relationship between endometriosis and these specific his to types of ovarian cancer should be recognized, but the low magnitude of the risk observed is consistent with the view that ec to pic endometrium undergoes malignant transformation with a frequency similar to its eu to pic counterpart (29). Etiology Although signs and symp to ms of endometriosis were described since the 1800s, its widespread occurrence was acknowledged only during the 20th century. Three theories were proposed to explain the his to genesis of endometriosis: Ec to pic transplantation of endometrial tissue Coelomic metaplasia the induction theory No single theory can account for the location of endometriosis in all cases. Transplantation Theory the transplantation theory, originally proposed by Sampson in the mid-1920s, is based on the assumption that endometriosis is caused by the seeding or implantation of endometrial cells by transtubal regurgitation during menstruation (30). Retrograde menstruation occurs in 70% to 90% of women, and it may be more common in women with endometriosis than in those without the disease (8,32). The presence of endometrial cells in the peri to neal fluid, indicating retrograde menstruation, is reported in 59% to 79% of women during menses or in the early follicular phase, and these cells can be cultured in vitro (33,34). The presence of endometrial cells in the dialysate of women undergoing peri to neal dialysis during menses supports the theory of retrograde menstruation (35). The menstrual reflux theory combined with the clockwise peri to neal fluid current explains why endometriosis is predominantly located on the left side of the pelvis (refluxed endometrial cells implant more easily in the rec to sigmoidal area) and why diaphragmatic endometriosis is found more frequently on the right side (refluxed endometrial cells implant there by the falciform ligament) (37,38). Endometrium obtained during menses can grow when injected beneath abdominal skin or in to the pelvic cavity of animals (39,40). Endometriosis was found in 50% of Rhesus monkeys after surgical transposition of the cervix to allow intra-abdominal menstruation (41). Women with shorter intervals between menstruation and longer duration of menses are more likely to have retrograde menstruation and are at higher risk for endometriosis (45). Deeply infiltrative endometriosis, with a depth of at least 5 mm beneath the peri to neum, can present as nodules in the cul-de-sac, rec to sigmoid, and bladder area and occurs with other forms of peri to neal or ovarian endometriosis (52). According to ana to mic, surgical, and pathologic findings, deep endometriotic lesions originate intraperi to neally rather than extraperi to neally. The lateral asymmetry in the occurrence of ureteral endometriosis is compatible with the menstrual reflux theory and with the ana to mic differences of the left and right hemipelvis (37). This observation, to gether with evidence from the development and spontaneous evolution of endometriosis in baboons, supports the notion that endometriosis starts as peri to neal disease and that the three different phenotypes and locations of endometriosis (peri to neal, ovarian, and deep) represent a homogenous disease continuum with a single origin. Extrapelvic endometriosis, although rare (1% to 2%), may result from vascular or lymphatic dissemination of endometrial cells to many gynecologic (vulva, vagina, cervix) and nongynecologic sites. The latter include bowel (appendix, rectum, sigmoid colon, small intestine, hernia sacs), lungs and pleural cavity, skin (episio to my or other surgical scars, inguinal region, extremities, umbilicus), lymph glands, nerves, and brain (56). Coelomic Metaplasia the transformation (metaplasia) of coelomic epithelium in to endometrial tissue is a proposed mechanism for the origin of endometriosis. One study evaluating structural and cell surface antigen expression in the rete ovarii and epoophoron reported little commonality between endometriosis and ovarian surface epithelium, suggesting that serosal metaplasia is unlikely in the ovary (57). The results of another study involving the genetic induction of endometriosis in mice suggest that ovarian endometriotic lesions may arise directly from the ovarian surface epithelium through a metaplastic differentiation process induced by activation of an oncogenic K-ras allele (50). Induction Theory the induction theory is an extension of the coelomic metaplasia theory. It proposes that an endogenous (undefined) biochemical fac to r can induce undifferentiated peri to neal cells to develop in to endometrial tissue. This theory is supported by experiments in rabbits but is not substantiated in women or nonhuman primates (58,59). Genetic Fac to rs Increasing evidence suggests that endometriosis is partially a genetic disease. The induction of humanlike endometriosis by genetic activation of an oncogenic K-ras allele lends further support to the genetic basis of this disorder (50). Population Studies the risk of endometriosis is seven times greater if a first-degree relative is affected by endometriosis (61). Because no specific Mendelian inheritance pattern is identified, multifac to rial inheritance is postulated. In another study of twins, 51% of the variance of the latent liability to endometriosis may be attributable to additive genetic influences (63). Other investiga to rs reported that 14 monozygotic twin pairs were concordant for endometriosis, and two pairs were discordant (64). A relationship was shown between endometriosis and systematic lupus erythema to sus, dysplastic nevi, and a his to ry of melanoma in women of reproductive age (65,66). Genome-wide association studies show that the risk of endometriosis is associated with a mutation on the short arm of chromosome 7 (7p15. Genetic Polymorphisms and Endometriosis A number of studies investigated genetic polymorphisms as a possible fac to r contributing to the development of endometriosis. About 50% of the studies in one review demonstrated positive correlations between different polymorphisms and endometriosis (71). This relation was seen most clearly in groups 1 (cy to kines and inflammation), 2 (steroid-synthesizing enzymes and de to xifying enzymes and recep to rs), 4 (estradiol metabolism), 5 (other enzymes and metabolic systems), and 7 (adhesion molecules and matrix enzymes). Group 8 (apop to sis, cell-cycle regulation, and oncogenes) seemed to be negatively correlated with the disease, whereas groups 3 (hormone recep to rs), 6 (growth fac to r systems), and especially 9 (human leukocyte antigen system components) showed a relatively strong correlation. As many results were contradic to ry, the review concluded that genetic polymorphisms might have a limited value in assessing possible development of endometriosis (71). Future studies should include large numbers of women with laparoscopically and his to logically confirmed endometriosis and women with a laparoscopically confirmed normal pelvis as controls, taking in to account ethnic variability. Aneuploidy Epithelial cells of endometriotic cysts are monoclonal on the basis of phosphoglycerate kinase gene methylation, and normal endometrial glands are monoclonal (72,73). In another study, trisomies 1 and 7, and monosomies 9 and 17 were found in endometriosis, ovarian endometrioid adenocarcinoma, and normal endometrium (78).

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Since fire burns upward and the heart and lungs are located above the liver, this In terms of lifestyle, many Western clinicians to day are aware pathological heat may also accumulate in the heart and/or of the mind-body connection that plays such a large role in lungs, disturbing either or both heart and lung function. Therefore, they may recommend some form of stress reduction, counseling, or possibly psychotherapy. Other symp to ms may include chest and abdominal erning vessel and harmonize yin and yang, open the orifices glomus and oppression, sticky, foul-smelling, dark-colored or and quiet the spirit, extinguish wind, support the righteous, bright yellow s to ols with burning around the anus, hot, and free the flow of the network vessels. The second group of points treat the root of the dis ease, linking with the pattern discrimination. Therefore, this pattern rarely presents in this pure form in draining, and transforms Western patients. Therefore, treatment for damp heat is usually secondary or tertiary to other treatment principles. For atrophy, wilting, weakness, (Radix Stephaniae) 9g numbness, and/or insensitivity of the lower extremities, add (Radix Achyranthis Bidentatae) 9g (St 31), (St 32), (St 34), (Rhizoma Dioscoreae Hypoglaucae) 9g (St 36), (St 37), and/or (St 41). For weakness of the feet or plements the kidneys and strengthens the sinews and bones. If damp heat has damaged yin, add nine grams weakness of the sinew vessels of the foot tai yang and foot each of (Radix Dioscoreae), Bei (Radix shao yang, add (Bl 60), (Bl 62), Glehniae), and (Radix Trichosanthis). For talipes valgus due is liver-kidney vacuity, add 15 grams of (cooked to weakness of the sinew vessels of the foot tai yin and foot Radix Rehmanniae) and nine grams of (Cortex shao yin add (Sp 4), (Sp 6), (Ki Acanthopanacis). In the early stage, there is abnormal sen, and sitivity, heaviness, and a cumbersome sensation or numbness clear heat and eliminate dampness. This is then followed by wilting and weak limbs, drooping of the hands and feet, and loss of use of the Please see pattern #1 above. X-ray generally reveals ease characterized by loss of articular cartilage and hypertrophy narrowing of the joint space, increased density of the sub of the bone producing osteophytes or bone spurs. It is the chondral bone, osteophyte formation at the periphery of the most common articular disorder. Almost all persons by age 40 have some out other diseases with similar symp to ms, such as rheuma pathological changes in weight-bearing joints, although rela to id arthritis and gout. Muscle relaxants may be tem Osteoarthritis is divided in to two broad categories: primary porarily prescribed to relieve pain arising from muscle (, idiopathic) and secondary. However, drug ically involves the distal and proximal interphalangeal joints, therapy comprises only 15% of a to tal treatment program the first carpo-metacarpal joint, the intervertebral disks and and is the least important aspect of optimum management. These include osteo to my, and to tal joint replacement, may be used when congenital joint abnormalities, genetic defects, infectious, conservative therapy fails. Morning stiffness fol External contraction of wind, cold, lows inactivity but lasts less than 15-30 minutes and lessens damp evils and bodily weakness due to former heaven natu with movement. Proliferation of cartilage, bone, ligament, ten Due to habitual bodily vacu don, capsules, and synovium, along with varying amounts of ity weakness, the defensive exterior may fail in its duty. If joint effusion, ultimately produces the joint enlargement wind, cold, and/or damp evils take advantage of this vacuity characteristic of this disease. For swelling in the joints, add the yin and yang of the kidneys as well as former heaven 15 grams of (Rhizoma Atractylodis) and essence, is the meeting point of the marrow. If there is severe pain or a cold sensation in Supplementing it boosts the marrow, is the meeting the joints, add three grams of (Herba Asari). Draining cold limbs, low back and knee soreness and weakness, fre the local points free the flow of the network vessels in the quent copious urine, nocturia, a pale to ngue, and a deep, affected area. Because osteoarthritis occurs mainly in older patients, it network vessels usually manifests as a mixed vacuity and repletion pattern. Therefore, there may be pronounced qi, blood, yin, or yang (True Warrior Decoction with vacuities. When impediment is complicated by either kidney yin or yang (Radix Astragali) 20g vacuity, this is called recalcitrant impediment. Recalcitrant (Ramulus Cinnamomi) 20g impediment is then divided in to heat recalcitrant impedi (Ramulus Mori) 20g ment if there is yin vacuity and cold recalcitrant impediment e (Radix Achyranthis Bidentata) 20g if there is yang vacuity. Of course, yin and yang vacuities may processed (Radix Aconiti Carmichaeli) 12g exist simultaneously. When these occur, qi (Poria) 9g rectifying and blood-quickening medicinals should be added mix-fried (Radix Glycyrrhizae) 9g to the formula. Appropriate blood-quickening medicinals include (Caulis Spatholobi), (Radix, and Salviae Miltiorrhizae), (Radix Angelicae Sinensis), to gether warm and supplement kidney yang (Rhizoma Chuanxiong), (Radix and diffuse impediment. In addition, warms the ves Paeoniae Rubrae), (Olbanum), (Myrrha), sels, frees the flow of the 12 vessels, and and (Radix No to ginseng). The former works on the lower complicated by spleen qi, liver blood and kidney yang part of the body, while the latter works on the upper part of vacuities (but without damp or vacuity heat). Antinuclear antibodies are found in a few patients, terized by inflamma to ry and degenerative changes in the most often in those with another simultaneous connective muscles. Serum muscle enzymes, such as the transami affect the skin, then it is called derma to myositis. It is less common than these two diseases, but it is from long remissions and even apparent recovery to poten not rare. In general, polymyositis and derma to myositis are categorized as, wilting the onset of this condition may be either acute or insidious. Patients may Constructive and defensive insecurity have trouble raising their arms over their heads, climbing with invasion of wind, cold, damp external evils or liver-kid stairs, or getting up from a sitting position, eventually ney yin depletion with damp heat becoming wheelchair-bound or bedridden. In the Due to the constructive and late chronic stage, there may be contractures of the limbs. The skin rash may be slightly elevated and flesh where it causes skin redness and muscular pain. Such rash commonly occurs on the endures, it may consume the qi and damage the blood, in forehead, the vee of the neck and shoulders, chest and back, which case, the qi becomes vacuous and the blood becomes forearms and lower legs, elbows and knees, medial malleoli, depleted. It is also possi and dorsum of the proximal interphalangeal and matecar ble for there to be liver-kidney yin depletion with either exter pophalangeal joints. In addition, the base and sides of the nally invading or internally engendered damp heat. Visceral involve and blood become depressed and stagnant and the sinew ves ment is relatively rare. In addi a fine, bowstring or soggy, bowstring pulse tion, clears the s to mach and with eliminates dampness. If spleen vacuity is pronounced, add nine grams each of (Radix Astragali) 15g (Radix Codonopsitis) and (Rhizoma Atractylodis (Rhizoma Pinelliae) 12g Macrocephalae). For severe counterflow of the s to mach, (Radix Bupleuri) 9g add 12 grams each of (Folium Eriobotryae) and (Herba Artemisiae Scopariae) 9g (Rhizoma Imperatae). For concomitant food (Radix Paeoniae Albae) 9g stagnation, add nine grams each of (Fructus (Rhizoma Cyperi) 9g Crataegi) and (Fructus Germinatus Hordei). For (Poria) 9g severe rib-side distention and pain, add nine grams each of (Fructus Immaturus Aurantii) 6g (Fructus Toosendan) and (Tuber (Pericarpium Citri Reticulatae) 6g Curcumae). For fixed, stabbing pain in the s to mach, add mix-fried (Radix Glycyrrhizae) 3g 12 grams each of (Rhizoma Corydalis) and (uncooked Rhizoma Zingiberis) 3 slices (Radix Salviae Miltiorrhizae). Together, they dis disinhibits dampness and heat and treats a bitter taste in the inhibit the qi mechanism and harmonize upbearing and mouth. Draining clears the s to mach and dis If complicated by heat, charges depressive heat of the yang ming. If and clears and harmonizes the s to mach, heat is even more severe, add three grams of downbears counterflow, and s to ps vomiting. If complicated by food stagnation, add six grams each of (Massa Medica For concomitant spleen qi Fermentatae). The docu ment is based on a comprehensive literature review and expert consensus on relevant diagnostic methods. However, it does not include didactic information on human parasite life cycles, organism morphology, clinical disease, pathogenesis, treatment, or epidemiology and prevention. As greater emphasis is placed on ne glected tropical diseases, it becomes highly probable that patients with gastrointes tinal parasitic infections will become more widely recognized in areas where para sites are endemic and not endemic. Although the document is not designed for reference or research labora to ries, it is important for general clinical labora to ries to be aware of all relevant procedures, even those for which specimens are submitted to a reference labora to ry. The document is the result of a comprehensive literature review and expert con sensus relevant to the to pics under discussion; it also supports the education and training of microbiologists in clinical labora to ries. However, it is not intended to provide didactic training related to human parasite life cycles, organism morphology, clinical disease, pathogenesis, treatment, or epidemiology and prevention. Most procedures performed in diagnostic parasi to l ogy require a great deal of judgment and interpretation and are classified by the Clinical Labora to ry Improvement Amendments of 1988 (1) as high-complexity proce dures. The majority of these procedures are not au to mated and require considerable practice to produce accurate, clinically relevant results. We have had extensive actual bench experience and bring to this project our accumulated knowledge and awareness of the many requirements necessary for excellence within a clinical labora to ry. Although it is important to realize that not every January 2018 Volume 31 Issue 1 e00025-17 cmr. Clinical Microbiology Reviews labora to ry will perform each procedure in exactly the same way, it is very important to understand the pros and cons of clinical procedure modifications. The presentations of these parasi to ses vary depending on the infecting parasite, as well as on a variety of host fac to rs that are incompletely under s to od. However, it is clear that the patients with severely compromised immune responses usually have more-severe disease. These patients are also at risk for infec tions by parasites that do not commonly cause disease in immunocompetent individ uals (11). The duration of parasi to sis and the load of parasites also affect the clinical manifestations of disease. Infections of the gastrointestinal tract in the form of gastroenteritis, enteritis, or enterocolitis are common for certain intestinal parasites, such as Giardia lamblia (Giardia duodenalis, Giardia intestinalis), Cryp to spo ridium parvum or Cryp to sporidium hominis, and Entamoeba his to lytica, among others. These infections usually manifest with some degree of abdominal pain, bloating, and diarrhea. There are some gastrointestinal parasitic pathogens that may cause invasive disease, whereas there are others that, even in profoundly immunocom promised individuals, are usually not associated with tissue invasion. Ascarid parasites from other hosts, such as anisakids, burrow in to the mucosa, which causes severe localized abdominal pain (14). This condition is essentially a more localized form of visceral larva migrans, since the nema to de is in a biologically inappropriate host and wanders. Less commonly, the worm may penetrate through the muscularis propria and adventitia of the s to mach or small intestine, causing a perforation. The worms in such instances may be found free in the abdominal cavity or embedded in the omentum. Nema to des that have an indirect life cycle are by their nature invasive when the larvae penetrate the intestinal tract on their transpulmonary passage back to the intestines. Strongyloides stercoralis, however, establishes a chronic infection, which includes par thenogenic production of larvae that recapitulate the transpulmonary migration. This chronic infection is also usually subclinical, unless the infected individual becomes immunocompromised, and this subclinical condition includes the diminished immune response that occurs during normal aging. Strongyloides hyperinfection syndrome is a disease wherein there is uncontrolled replication of these helminths (15). Hyperinfection results in a substantial number of migrating larvae through the lungs and other organs, which, even with aggressive therapy, may result in death. The amoebae may also be transported to the liver via the portal January 2018 Volume 31 Issue 1 e00025-17 cmr. Less commonly, a fistula may form between the hepatic abscess and the diaphragm and create a connection to the right pleural space, producing an amoebic empyema. Nutritional depletion is another un to ward consequence of gastrointestinal parasitic infections. The depletion of water and electrolytes is a danger in individuals with severe diarrhea. Immunocompromised individuals with infections caused by Cryp to sporidium, Cys to isospora, and Giardia lamblia (G. Other intestinal parasites compete with the human host for the absorption of nutrients. The classic example is that of pernicious anemia caused by vitamin B12 deficiency that results from the absorption of this nutrient by the large fish tapeworm, Diphyllobothrium latum (18). In other instances, it may be the competition for a variety of nutrients in food, which manifests as malnutrition (19). The effects include stunted growth, wasting, hunger, and more-specific signs of micronutrient deficiency. Malnu trition is more likely to occur in individuals with large burdens of worms that consume a substantial amount of the nutrients that are digested. Unfortunately, the individuals with the largest worm burdens are often people, commonly children, in resource-poor countries who already lack access to the recommended daily intake of food. Hookworms pose a particular problem, as these helminths attach to the mucosa and access by means of teeth or cutting plates the highly vascular lamina propria of the intestine. As noted above, the individuals most likely to have a greater hookworm load are also those who live in resource-limited settings and who likely also do not receive the recommended daily allowance of protein and other iron-containing substances in their diets.

These exercise-induced cramps may the second is myoedema symptoms 6 months pregnant order pirfenex once a day, which is a localized mus be secondary to dehydration symptoms narcolepsy generic pirfenex 200mg otc, electrolyte shifts medicine go down order pirfenex 200mg amex, or cle contraction caused by mechanical irritation or accumulation of metabolites in exercised muscle medications vascular dementia purchase pirfenex in united states online, dis to rtion of the muscle treatment research institute order pirfenex line. On examination treatment xanax withdrawal cheap pirfenex 200 mg fast delivery, percus although defining the difference has remained elu sion of the muscle may produce this hard knot. In a study comparing marathon runners who Myoedema is produced by an electrically silent con developed cramps during a race and those who did tracture (discussed later). The third symp to m expe not, there was no difference in plasma volume, se rienced by those with hypothyroidism is true cramps, rum sodium, or serum potassium levels. These heat in this disease than in other lower mo to r neuron cramps81 are well-recognized in miners, s to kers, diseases. Patients with heat cramps show evidence of quent fasciculations), 8 of 9 of their original group volume depletion and hyponatremia. Taking salt of patients were unable to work because of these tablets during the work may help prevent heat symp to ms. The gests that heat cramps are caused by both volume specificity of these afterdischarges remains un contraction and hyponatremia. Nearly one rum antibodies to voltage-gated potassium channels third of patients undergoing hemodialysis complain were recently found in some patients meeting crite of muscle cramps. Similar to other patients end of dialysis, and may be relieved by volume ex with cramps, carbamazepine is effective in treating pansion with either hyper to nic dextrose or saline the cramps. However, it remains unclear exactly how solutions, implying that volume expansion rather different these patients are from those with cramps than shifts in sodium concentration are the most with no apparent cause. We have seen one case in although adult-onset cases have also been de which severe cramps occurred during intravenous scribed. An au to immune etiology has been suggested, and some cases respond well to Medications. The first Similarly, patients with frequent muscle cramps of challenge in evaluating a patient with spasms or unknown cause do not have frequent fasciculations. Disturbance of the central nervous system, 1991, Tahmoush and colleagues described patients peripheral nervous system, or muscle can cause with both fasciculations and cramps under the rubric symp to ms refiected in muscle discomfort or spasms. Although often uncomfortable, With muscle weakness these occupational cramps are not usually associated Infiammation (polymyositis, derma to myositis) with the violent seizing-up and pain characteristic of Infection Trichinosis a true cramp. Myo to nia may be associated with in Toxoplasmosis voluntary muscle contractions, but these are not usu Poliomyelitis, West Nile virus infection ally painful. Viral syndrome Muscle pain associated with contraction of mus Secondary to bacterial to xin. The most common scenario is the focal Potassium deficiency muscle spasm around an injured or infiamed skele Acute alcoholic myopathy tal structure. Low back pain often fits in to this cate Total parenteral nutrition (essential fatty acid deficiency) gory. Palpation of the lower back of those suffering Necrotic myopathy secondary to malignancy from a recent increase in their pain often reveals Hypothyroid myopathy Medications hardened, tight paraspinal muscles on the most af Carnitine palmityltransferase deficiency fected side. In all cases, spasms will need to Infiammation Sarcoidosis (nodular form) be described further. Localized nodular myositis Muscle pain without contractions is referred to as Proliferative myositis myalgia. Generalized myalgias have a broad differen Pseudomalignant myositis ossificans tial (Table 3), from benign postexertional pain in Eosinophilic fasciitis those unaccus to med to exercise to an infiamma to ry Ischemia Muscle necrosis following relief of large artery occlusion disorder of muscle. Determining whether weakness Diabetes (infarction of thigh muscle) is present helps distinguish the various etiologies. In Embolism spite of some overlap, focal muscle pain often leads Azotemic hyperparathyroidism to a different set of diagnoses (Table 4). The tempo Toxic and metabolic disorders of onset of focal pain and the presence of swelling or Acute alcoholic myopathy Exertion muscle damage induration helps to distinguish these disorders. These occupational No swelling or induration cramps are best considered focal dys to nias rather Exertional myalgia Normal persons than cramps. Agonist and antagonist muscles con Vascular insuficiency (intermittent claudication) tract simultaneously to prevent the performance of a Metabolic myopathies specific task, despite the agility, strength, and sensa Acute brachial neuritis tion to perform other manual mo to r tasks of similar Parkinsonism dificulty. The spasms and stiffness of unit hyperactivity that derive from the Greek word this syndrome are often most prominent in the axial tetanos, referring to muscular spasm, and both con muscles. Simultaneous contraction of both abdomi ditions could be confused with muscle cramps. Tet nal muscles and back extensors is typical of this any is associated with electrolyte disturbances, either central disorder, which is often associated with anti hypocalcemia or alkalosis, and is caused by sponta bodies to glutamic acid decarboxylase. Hypocalcemic tetany was common in the are predisposed to true muscle cramps, but the other 19th and early 20th centuries because of dietary clinical manifestations of this disorder of continuous vitamin D deficiency. The full manifestation of the muscle fiber activity are usually even more promi syndrome is now rare; the clinical features of an nent. Ab and peripheral extremities, increases in intensity, normal postures of the limbs identical to carpal or and spreads proximally. Then a sensation of spasm pedal spasm are characteristic and may be either or tension follows the same pattern as the tingling, persistent or intermittent. Laryngeal muscles are commonly involved to nia, and increased rather than decreased stiffness early. This disorder of children extremities, the thumb and fingers adduct and re and young adults progresses insidiously, and is asso main straight except for fiexion at the metacarpo ciated with the presence of serum antibodies to volt phalangeal joints. Immunomodulation In the lower extremities, the to es and foot fiex with is helpful in some cases, and carbamazepine or phe an equinovarus deviation at the ankles. Exercise-induced contractures are the hallmark developing countries, especially in infants. Persistent spasm of masseter muscles leading contractures are typically associated with exercise to jaw closure (trismus) and dysphagia are the typical induced muscle pain, weakness, elevated serum cre presenting complaints. Unlike tremely painful, are caused by sudden contraction of cramps, these contractures never occur outside the opposing muscles that last for a few seconds, but setting of exercise. They may be either disorder causing exercise-induced painless impair localized or generalized and are often triggered by ment of muscle relaxation, stiffening, cramping, and sensory stimuli, movement, or emotion. Biochemical studies have revealed reduced tetanus consists of supportive care, usually in an calcium uptake and calcium adenosine triphos intensive care unit, and administering anti to xin. Having de cause reuptake of calcium is important for skeletal termined that a patient is suffering from true cramps muscle relaxation after contraction, this defect rather than another syndrome, the next challenge is seems to account for the clinical symp to ms, includ to try to determine their cause. Widespread cramps dur Reversing an underlying metabolic or structural dis ing the day, provoked by only minimal activity would order responsible for the cramps is clearly impor raise more concern for mo to r neuron disease. Unfortunately, the underlying cause often is ever, most of these cases are also benign, in the not evident or not reversible, and thus other treat absence of muscle weakness and atrophy. This method helps may occur with any of the disorders associated with to s to p most cramps. Hereditary cramping syn ened muscles, stretching was also tried as a preven dromes are uncommon, but a family his to ry of tive strategy. This simple, low-risk treatment whether there is weakness and loss of muscle bulk, should be suggested first in all patients with cramps. Sensory loss may suggest a polyneuropathy, method to prevent cramps during exercise, although which is sometimes associated with cramps. Thyroid disorders are sometimes suggested by the Strengthening training in elderly patients has shown physical examination, although screening labora to ry clear improvement in strength. Mild to moderate exercise Ancillary tests in evaluating a patient with cramps may help prevent the cramps occurring during preg depend on the individual patient. Adding so ilarly help to demonstrate the extent of lower mo to r dium (50 mmol/L) to fiuid replacement has been neuron loss or further define a neuropathy. The old mainstay of and such a finding does not necessarily imply a pharmacological treatment for cramps is quinine primary muscle disease. As discussed earlier, we do sulfate, although the concerning side-effect profile not screen for voltage-gated potassium channels as may change that practice. The initial single the pathophysiology of cramps as just described blinded study demonstrated excellent relief. In 1995, Man-Son-Hing and Wells52 theoretically be effective, although these medica provided a meta-analysis of six double-blind, cross tions have not been formally studied for preventing over trials. They found that patients ing quinine sulfate with 12 patients receiving lido treated with quinine sulfate compared with placebo caine injections in to the calf showed equal reduction had roughly eight fewer cramps and about one third in cramp frequency in both groups. They reached the the anticonvulsant gabapentin proved particularly same general conclusion: quinine sulfate reduces effective for muscle cramps, with all patients cramp cramps compared with placebo. Supplemental calcium, sodium, and magne out of the various studies and had a greater number sium have all been tried, and the best evidence of side-effects, especially tinnitus. A recent trial of 98 favors supplemental magnesium for preventing patients in general practice centers in Germany also cramps,18,89 although this is based on a single, supports the beneficial effect of quinine sulfate over randomized, placebo-controlled trial. Ber to lasi and col ban over-the-counter formulations of quinine sulfate leagues demonstrated decreased cramping after bot in 19945 and then recommended against its use for ulinum to xin injection in to the calf and foot muscles cramps in 1995, arguing that the risk/benefit ratio of a small group of patients with an inherited cramp was to o high. Symp to ms include temporary difference between the two groups in terms of he visual and hearing disturbances, dizziness, fever, ma to crit, hemodynamic shifts, or electrolytes. Blindness may be sion of l-carnitine may also be beneficial for hemo permanent in some cases when the levels exceed 10 dialysis-associated cramping. In effect profile discussed earlier, although for severe patients with liver disease and cirrhosis, Konikoff et cramps its use may still be warranted. Replacement with also have side-effects (some of them severe) and the oral vitamin decreased the cramp frequency. In alysis patients, vitamin E was as effective as quinine pregnant patients, a trial of magnesium may be war sulfate in treating leg cramps. Therapies and side-effects are summarized in cebo-controlled study of 27 patients with nocturnal Table 5. Building on 31 the observations of others10,50 that cramps may be currently treated. Unlike other symp to ms such as fasciculations, which are often not bothersome, electrically induced in normal subjects, S to ne et al. The four main drugs being used for quency; that is, the frequency of repetitive stimula tion that produces a cramp in a given subject. In a survey recording two trials on 3 separate days, they demon on their eficacy, patients rated baclofen, pheny to in, strated excellent intrasession (0. This finding gives promise for effective If electrically induced cramps could be produced treatment even with a placebo, but also emphasizes in labora to ry animals, this might provide an excel the need for well-designed, double-blind, random lent model for quickly testing various therapeutic ized, placebo-controlled trials in choosing therapies. Given the well ing exercises three times daily, especially before go documented pathology and disease course in these ing to bed and before exercise. Despite the lack of animals, correlating changes in physiology of cramps studies, maintaining passive stretching of the calves over time may yield insights in to the pathophysiol while sleeping should be effective and devices worn ogy of cramps. Nonpharmacologic treatments Stretching before exercise and before bedtime Good hydration/nutrition, especially surrounding exercisefi Gastrointestinal distress Side effects are not intended to be a complete list and this table is not intended as a prescribing guide. Cirrhosis and muscle cramps: evidence of a the muscle cramp may also be determined. Intravenous gamma from further studies to better define the pathophys globulin therapy of Sa to yoshi syndrome. Used by permission of Oxford University study in skeletal muscle and cultured muscle cells and the Press, Inc. Analysis of to nic muscle monohydrate treatment alleviates muscle cramps associated activity and muscle cramps during hemodialysis. Electromyography in amyotrophic lateral sclero blind, placebo-controlled, parallel-group, multicentre trial. Newsom-Davis J, Buckley C, Clover L, Hart I, Maddison P, exercise with common beverages and water.

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References

• Svanes K, Ito S, Takeuchi K, Silen W. Restitution of the surface epithelium of the in vitro frog gastric mucosa after damage with hyperosmolar sodium chloride. Morphologic and physiologic characteristics. Gastroenterology 1982;82:1409.
• Eversole LR. Malignant epithelial odontogenic tumors. Semin Diagn Pathol 1999;16:317-324.
• Lim F, Morris CP, Occhiodoro F, Wallace JC. Sequence and domain structure of yeast pyruvate carboxylase. J Biol Chem 1988;263:11493.
• Neri RO. Antiandrogens. Adv Sex Horm Res 1976;2:233-262.