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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Barbara Caldwell, MS, MT(ASCP)SHCM
At this time the increased peristaltic movement helps in the transport of sperms into the fallopian tubes allergy forecast new hampshire buy discount aristocort 4 mg on-line. The peristaltic movements diminish during the luteal phase under the effect of progesterone and help in implantation of the fertilized egg allergy testing documentation discount aristocort 4 mg otc. The contractions or these movements in the subendometrial zone have important bearing on reproductive process allergy medicine during ivf order aristocort 4mg on-line. They help in the rapid transport of sperms to the fallopian tubes within a few minutes during ovulation allergy testing overland park ks generic 4 mg aristocort, but help in implantation during the luteal phase allergy and asthma center generic aristocort 4mg on line. Regeneration Regeneration of the denuded epithelium is already in progress before the menstrual bleeding has stopped and is completed 48 h after the end of menstruation allergy to yellow 5 symptoms order 4 mg aristocort free shipping. Repair is brought about by the glandular epithelium growing over the bare stroma (Figure 2. It is not uncommon for relics of crenated glands to be found in the endometrium during the first 2 days following menstruation, and one of the great characteristics of the endometrium at this time is the presence of a large number of lymphocytes in the stroma. The relation of the cyclical changes between the ovaries and the endometrium is discussed in Chapter 3. The Decidua of Pregnancy In the early weeks of pregnancy, the structure of the endometrium is very similar to that found in the late secretory phase. The division into compact and spongy zones of the functional layer is more clearly defined. The basal layer can still be identified, but its glands, although staining more deeply than the hypertrophied glands of the spongy layer, show some degree of crenation and contain secretion. The lymphoid islands of the basal layer are not easily identified, for in the early weeks of pregnancy lymphocytes are disseminated extensively into the stroma of the spongy layer. The glands of the spongy layer retain the general form found in the late secretory phase, but they are much more crenated, so much that the impression is given that they have increased in number. The cells lining the glands are irregular in shape and tend to be elongated with irregular processes projecting into the lumina of the glands and discharging secretion. It is not uncommon for small papillae to be formed which project into the glands, but in spite of the activity of the epithelium, the basement membrane remains well defined. Activity is not restricted to the immediate vicinity of the implanted ovum, but is distributed uniformly throughout the endometrium of the body of the uterus. The decidual cells are derived from stroma cells: they are stellate in shape, contain glycogen and are surrounded by an intercellular fibrillary ground substance and by lymphocytes (Figure 2. Decidual reaction has been demonstrated in various ectopic situations in the pelvis. The best example of ectopic decidual reaction is found on the surface of the ovaries during pregnancy, when small irregular reddish areas are easily recognized with the Figure 2. Progesterone is secreted by the corpus luteum, and the absence of progesterone in the premenstrual phase denotes anovulation. Androstenedione gets converted peripherally into oestrone through aromatization in the fat tissue. After menopause, ovarian oestrogen level falls as Graafian follicles disappear, and progesterone fails to be produced. The increased stromal cells of the menopausal ovary continue to produce some androstenedione which gets converted into oestrone. Though a weak oestrogen, oestrone is capable of exerting oestrogenic effect on the target tissues. Obese women have therefore more oestrone than a lean woman and hence a greater tendency to endometrial hyperplasia and malignancy. They are always surrounded by lymphocytes and the cells fuse with an intercellular matrix (3110). In the ovaries, the decidual reaction is limited to the surface with very little invasion of the cortex. Ectopic decidual reaction is always very wellmarked beneath the peritoneum of the back of the uterus in the pouch of Douglas. It has been demonstrated in adenomyomas, in the walls of chocolate cysts, on the uterovesical fold of peritoneum and in the omentum. Decidual reaction can invariably be demonstrated in the isthmical region of the endometrium during pregnancy, but only rarely is the typical reaction found in the glands of the cervical canal. Decidual reaction occurs in the fallopian tube in an ectopic pregnancy, but it is incomplete and deficient. A thick decidua develops in hydatidiform mole under the influence of the hormones. The decidual reaction is controlled by the corpus luteum, but it is unknown why only cells with this curious distribution respond to the stimulus. Pregnancy In some cases of uterine and ectopic pregnancies, the endometrium shows intense adenomatous and hypersecretive activity within the glandular epithelium. The cells are enlarged; epithelial nuclei show mitosis, hyperchromasia, polyploidy and atypical cell types. These changes are focal and often associated with decidual reaction in the stroma. The atropic endometrium is susceptible to infection resulting in senile endometritis, and postmenopausal bleeding. In rare cases, the endometrium becomes hyperplastic under the influence of extragenital oestrogen (oestrone) produced in the peripheral fat from epiandrostenedione. Endometrial hyperplasia and polyp also occur when tamoxifen is administered to a woman with breast cancer. Vaginal Epithelium the upper portion of the lateral vaginal epithelium displays cyclic changes in response to the ovarian hormones. These changes can be studied cytologically by scraping this portion of the vaginal epithelium and staining it with Shorr stain. Ovarian Function Apart from producing an ovum monthly, ovaries produce hormones responsible for maturation of the Graafian follicle, ovulation, menstruation and maintenance of pregnancy in the early weeks of gestation. A drop of cervical mucus spread and dried on a glass slide in the preovulatory phase (oestrogenic phase) presents a palm leaf or fern type of reaction, due to the presence in it of sodium chloride (Figure 2. Under the influence of progesterone, the cervical mucus becomes thick and tenacious and impenetrable to sperms and bacteria. In pregnancy, however, adenomatous hyperplasia may occur, and decidual changes are seen in 10% of the patients. Lately, an increased incidence of endocervical carcinoma has been observed in young women who have been on hormonal contraception use. Key Points n Process of Fertilization Certain changes are necessary before the primary oocyte can mature for fertilization. Oogonia that enter the prophase of the first meiotic division are known as primary oocytes. Whereas those oogonia which do not begin the first meiotic division and those not surrounded by granulosa layer undergo atrophy. This secondary oocyte completes its second meiotic division only after fertilization, and gives out second polar body. Thus, the first stage of maturation of the oocyte occurs within the Graafian follicle, but the second division occurs only after the fertilization in the fallopian tube. Further meiotic division results in secondary spermatocytes, spermatids and a mature sperm. The seminiferous tubule is surrounded by myofibroblasts which contract and propel the sperms into rete testis. These are reduced to about 400,000 at puberty and of these around 400 are available during the reproductive lifespan. Cyclic changes in the Graafian follicle-leading to ovulation, corpus luteum formation and menstruation- are under the control of the hypothalamus, which controls the release of gonadotropins from the anterior pituitary. Progesterone is responsible for secretory transformation of the endometrium rendering it favourable for implantation of the fertilized ovum. In present-day practice, serial ultrasound monitoring of the Graafian follicle is used to detect ovulation in patients undergoing treatment for infertility. Endometrial histology is required to diagnose endometrial tuberculosis, endometrial cancer and hormonal dysfunction. Describe the microscopic appearance of the endometrium during the proliferative phase. It is now well established that a normal menstrual cycle depends on cyclical ovarian steroid secretions, which in turn are controlled by the pituitary and the hypothalamus and, to some extent, are influenced by the thyroid and adrenal glands. Hypothalamus regulates the functions of the anterior pituitary gland through portal vessels by releasing both the stimulatory and the inhibitory hormones that in turn influence the functions of the target tissues through the systemic circulation (Figure 3. These hormones in turn are controlled by positive and negative feedback loops from ovarian hormones. Hypothalamus is located at the base of the brain behind optic chiasma and below the thalamus above the pituitary and forms the base of the third ventricle. The base of the hypothalamus forms tuber cinereum, which merges to form the pituitary stalk. The origin of this stalk is known as median eminence, which is rich in capillary loops as well as nerve endings. Median eminence is an important site of storage of chemical signals, which get transferred into portal circulation to reach the anterior pituitary gland. During late pregnancy and lactation, a low or absent inhibitory factor leads to a high secretion of prolactin that initiates and maintains lactation. Hypothalamus is also responsible for secretion of thyrotropin releasing factor, corticotropin releasing factor, insulinlike growth factor and melanocyte releasing factor. Hypothalamus is connected to the anterior pituitary gland through special hypophysis pituitary portal system of vessels but connected directly to the posterior pituitary gland (neurohypophysis) by the supraoptic and paraventricular nuclei (Figure 3. It is released in a pulsatile manner into the portal vessels and reaches the anterior pituitary gland. The pulsatility and amplitude of its release vary with the various phases of the menstrual cycle. Its suppressive effect on ovulation is also being tried as a contraceptive, but the drug has proved expensive as of today. Hypothalamus can be influenced by the higher cortical centres, especially the temporal lobe. Until puberty, the hypothalamus is in a dormant state under the inhibitory influence of adrenal cortex, and the higher cortical centres, or it may be insensitive and nonresponsive to these stimuli. In the follicular phase, with low oestrogen (E2) level, pulsatility is every 90 min, and with rise in E2 level, the frequency rises to every 60 min. The b-cells secrete the gonadotropins that control the ovarian function and menstrual cycles. Whereas a-fraction is identical in all (contains 92 amino acids), b-fraction is specific in its action. Its activity builds up as the bleeding starts to cease reaches a peak around the seventh day of the cycle (40 ng/mL) and then declines to disappear around the 18th day. Another small peak occurs after ovulation, perhaps as a result of a fall in the level of oestrogen in the premenstrual phase. Prolonged administration over 6 months can cause oestrogen deficiency and osteoporosis, and therefore the therapy should be used on a short-term basis. This peptide is degraded in the gastrointestinal tract and is therefore given intravenously, subcutaneously or intranasally. Following ovulation, it produces luteinization of the granulosa and the theca cells and initiates progesterone secretion. Today, for diagnostic and therapeutic purposes, a rapid, visual semiquantitative enzyme immunoassay dipstick test, n n n Pituitary Gland (Adenohypophysis) Pituitary gland lies in the sella turcica. It comprises the anterior pituitary gland (adenohypophysis) and the posterior pituitary gland (neurohypophysis). The anterior pituitary gland measuring 30 3 6 3 9 mm in size is located at the base of the brain in a bony cavity called sella turcica below the hypothalamus. Interleukin-1 is a cytokine with antigonadotrophic activity and it prevents luteinization of granulose cells. Posterior Pituitary Gland (Neurohypophysis) Oxytocin and vasopressin are nonapeptides formed in the hypothalamus and released directly into the posterior pituitary gland. Oxytocin is produced by the paraventricular nucleus and vasopressin by the supraoptic nucleus of the hypothalamus. Oxytocin Oxytocin acts mainly on the smooth muscle of the uterus, causing contraction of the muscles and controlling the bleeding in the third stage of labour. By intermittent uterine contractions and relaxation, it induces and enhances the labour pains, in the first and second stage of labour. It causes contraction of the myoepithelial cells lining the mammary ducts and ejects milk during suckling.
Ideally in vitro susceptibility tests to determine the allergy medicine 2 years aristocort 4 mg low price, bacterial sensitivity to the drugs should be carried out before and during the therapy allergy forecast league city cheap 4 mg aristocort overnight delivery. Apart from doing audit for efficacy of treatment allergy shots toronto generic aristocort 4 mg without prescription, patients should be monitored for possible serious toxicity of drugs allergy symptoms burning skin generic 4mg aristocort overnight delivery. Induction of autoimmune thrombocytopenia by R allergy medicine 15 month old buy 4 mg aristocort, impaired vision by E or H and gouty arthritis by Z mandate their withdrawal allergy forecast kansas buy aristocort 4mg on line. The usual dose of H, R, Z can be given in renal failure as they are eliminated in bile or metabolised to nontoxic products. Tuberculosis during pregnancy: this should be treated with H + R + Z + E together with pyridoxine for 9 months. Adjuvant therapy: If the tuberculosis is very extensive or is complicated by marked pulmonary insufficiency secondary to emphysema, chronic bronchitis or pulmonary fibrosis, oxygen or ventilatory assistance or both may be required. Cleansing of bronchopulmonary secretions, and a tracheostomy if necessary may be life saving. Secondary respiratory infection must be promptly treated with appropriate antibiotics; so also associated diseases like diabetes mellitus. Light sedation is advisable but over-suppression of the cough reflex favours atelectasis. Failure to obtain reversal of infectiousness (sputum or tracheobronchial secretions free of tubercle bacilli after smear and culture) after 3 months of therapy or closure of cavities, after 4 or 6 months demands revision in chemotherapy Failure of drug therapy is likely to . In such patients, the proportion of bacilli still susceptible to standard anti-tuberculous drugs may be usually high. Bacteriological relapse after completion of a regimen containing H + R is due to late replication of persisters, which have escaped the effect of the drugs by remaining dormant. Until the results of such susceptibility tests are available, which need 1-3 months, a four-drug regimen, is started depending on the history of drugs used earlier and reported evidence of drug resistance in the health care setting. If needed, either: clofazimine, linezolid, amoxicillin/clavulanate, thioacetazone, clarithromycin or imipenem may be added. However, addition of only one new drug at a time to an ineffective regimen must be avoided as resistance to that drug is bound to develop. Reserve drugs used to treat the resistant cases are less effective and more toxic; they need daily administration. Hepatic toxicity of pyrazinamide and the psychoses caused by cycloserine may occur at any time during the treatment. Persistent cavitation in the presence of positive sputum after 6 months of secondary chemotherapy or relapse calls for surgical intervention. It involves 6-9 months of intensive therapy with 6 drugs (K + Levofloxacin + Et + Z + E + Cycloserine), followed by 18 months of continuation phase with 4 drugs (Levofloxacin + Et + E + Cycloserine). The continuation phase is started if the 4th or 5th month culture shows negativity; else the intensive phase is extended by a month. The change from intensive phase to continuation phase is done only after achieving conversion i. Bone marrow suppression and anaemia can occur due to linezolid and capreomycin is nephrotoxic. Hence frequent monitoring of hemogram, serum creatinine along with liver function tests with chest X-ray is needed. Other Forms of Tuberculosis Drug regimens proven effective in pulmonary tuberculosis are effective in extrapulmonary tuberculosis as well. Some authorities, however, advocate that short courses should not be used to treat severe extra-pulmonary forms of tuberculosis. Severe forms of tuberculosis like tuberculous meningitis, tuberculous pneumonia, tuberculous pericarditis and acute miliary tuberculosis may require longer treatment with three or four drugs for 18-24 months. Tuberculous meningitis: H + S + R + Z is the preferred initial combination in this disease. Steroids should be used in all severely ill patients, in those with a suggestion of cerebrospinal block and probably also in children under 1 year of age. The initial adult dose of prednisolone is 80 mg per day (1 mg per kg in children) in 4 equally divided doses. The dose should then be gradually reduced till a maintenance level of 25 to 30 mg daily is reached within 2 to 3 weeks. The same regime including steroids is also applicable to miliary tuberculosis, tuberculous pericarditis and tuberculous pneumonia. Tuberculous lymphadenitis: this condition which is often due to atypical mycobacteria usually responds unsatisfactorily to chemotherapy (see later). If no progress is apparent within 6 to 8 weeks, the glands may be removed surgically. Streptomycin and ethambutol are retained in patients with renal failure and must be used with caution. For ocular tuberculosis, topical and systemic glucocorticoid therapy may be required in addition to systemic chemotherapy. Glucocorticoids in Tuberculosis Glucocorticoids are known to impair host defence mechanism and promote dissemination of infection. They are useful when the excessive inflammatory reaction of the body is likely to threaten life or is likely to lead to extensive fibrosis on healing. Use of glucocorticoids in abdominal tuberculosis, may be dangerous as it may lead to intestinal perforation. Moreover, it must be emphasised that surgical removal of the lesion does not mean that the disease is completely eradicated. The patient must, therefore, be treated with adequate chemotherapy before, during and after such procedures. Chemoprophylaxis of Tuberculosis Chemoprophylaxis of tuberculosis means the use of anti-tuberculous drugs for its prevention. This is particularly important in tuberculin positive children under the age of 5 years in whom the disease and its complications can be severe. Secondary chemoprophylaxis is also justified (a) in individuals showing recent tuberculin conversion from negative to positive, and (b) in ex-tuberculous patients, in whom the disease appears inactive at present, during treatment with glucocorticoids or immunosuppressants, and times of stress such as pregnancy puerperium, surgery and, serious intercurrent illness. Healing occurs gradually thereafter, but the papule may be detectable upto a period of 12 months. After vaccination, the tuberculin test becomes positive within 6 to 12 weeks indicating the development of immunity. This should be treated with chemotherapy in the usual way Just an enlargement of lymph nodes needs no. Still rarer is the occurrence of fatal disseminated tuberculosis mainly in children with hypogammaglobulinemia. The protection, is "not complete, nor permanent, nor predictable, nor measureable". It stimulates the reticuloendothelial system and increases resistance against bacterial and viral infections. Its administration can prevent the growth and cause regression of transplanted tumours in animals. It activates the natural killer cells and the production of hemopoietic stem cells. Nontuberculous Mycobacterial Infections these infections are caused by organisms such as M. The atypical mycobacteria are frequently resistant to many of the commonly used drugs. Whenever possible, surgical removal of the infected tissue is recommended, followed by chemotherapy M. Ciprofloxacin is used in the dose of 750 mg bid and levofloxacin in the dose of 500 mg/once a day. It is readily absorbed and tissue levels are 5-10 times higher than plasma concentration. It is mainly eliminated in bile and no dose adjustment is needed in the presense of kidney damage. It is more potent than azithromycin but the latter has better intracellular penetration. Many experts prefer rifabutin, clofazimine, fluoroquinolone or amikacin as third or fourth agent. Therapy needs to be continued for life if clinical and radiological improvement is observed. Although the leprosy bacillus was discovered by Hansen in 1873, almost 12 years before the discovery of tubercle bacillus, the progress in the chemotherapy of leprosy has been much slower than in that of tuberculosis. This is because, until recently it was not possible to culture the leprosy bacillus. Further, unlike tuberculosis, human leprosy cannot be transmitted to animals so easily. Human leprosy bacillus from nasal washings and skin biopsies has now been cultivated successfully in the foot pads of mice; and the disease has been successfully transmitted to some species of armadillo. The infected armadillo tissues contain a large number of leprosy bacilli, thus, providing a good experimental model of human leprosy. Later, ulceration occurs with marked tissue destruction involving eyes, nose and larynx. The typical tuberculoid lesion is a large, flat, atrophic, hairless, hypopigmented skin area, with red, raised margin showing marked impairment of sensation. Although 70% of leprosy skin lesion have diminished sensation, 30% of lesion are non-anaesthetic in patients with multi-bacillary disease (see later). Histologically the lesion consists of focal masses of epitheloid cells and giant, cells with lymphocytic infiltration. Since this picture resembles to that seen in tuberculosis, it is called tuberculoid leprosy. In the field classification, the presence of more than five skin patches is treated as multibacillary. The diagnosis of leprosy is essentially clinical, supported by bacteriological evidence from smears from the lesions, nodules, earlobes, or from scrapings of the nasal mucosa. All patients with active leprosy should be treated with chemotherapy It is, however. This not only exposes the patient to prolonged therapy with potentially toxic drugs but can also cause severe psychological trauma. In case of doubtful diagnosis, it is better to wait for definite diagnosis because little harm can be done by waiting. They are, however, very useful in the treatment of leprosy because the doses needed are very small. Mechanism of action: Sulfones are essentially bacteriostatic and act by inhibiting the de novo synthesis of folic acid by M. Sulfones have bacteriostatic action also against other bacteria susceptible to sulfonamides and against the tubercle bacilli. They are, however, not used in the treatment of other infections because of their toxicity. They are distributed throughout the body fluids and tissues and can be detected in the tissues upto 3 weeks after stoppage of therapy Sulfones get concentrated more in the. These compounds are metabolised in the liver and excreted in urine as glucuronic acid conjugates. They are also excreted in large quantities in bile; this portion however, is reabsorbed. Fatal exfoliative dermatitis (Stevens-Johnson syndrome) associated with drug fever, hepatitis and psychosis can rarely occur. Although the list of toxicity is formidable, sulfones are remarkably well tolerated by most of the leprosy patients in the dosage recommended. Other uses of sulfones: Dermatitis herpetiformis is a chronic disease characterised by intensely itching papules, urticaria-like lesions, vesicles and bullae on the extensor surfaces of the body A gluten-sensitive enteropathy is observed in many patients with this. Dapsone, in the dose of 50 mg orally daily increased by 25 mg (daily dose) once in, 10-15 days to 25 mg three to four times daily rapidly controls the skin lesions. If the patient, adheres strictly to the gluten-free diet, the dose of dapsone can be reduced. Its introduction has revolutionised the management of leprosy It is bactericidal and given. Supervised administration of 600 mg of rifampicin single dose once a month is equally effective as daily administration. It is expensive and more toxic than dapsone but perhaps has faster bactericidal action against M. It is principally retained in tissues of the reticuloendothelial system and concentrated by macrophages of the skin. It imparts a reddish black hue to the skin of patients, which persists for several months. Clofazimine is also deposited in the intestine where it may cause segmental thickening leading to crampy pain and diarrhoea. In the dose of 100 mg three times a day it is useful in lepra reactions because of its, simultaneous bactericidal and anti-inflammatory actions. It can effectively relieve the agonising pain in lepra reactions in tuberculoid leprosy It is also claimed that the drug. Studies indicate that 100 mg of minocycline with 500 mg of clarithromycin given daily produces beneficial effects. The medical treatment of leprosy can be wholly undertaken by practitioners or by trained medical auxilliaries in the majority of patients. Some knowledge about the natural history of the disease, details about the drug therapy and a compassionate outlook towards the patient are all that is necessary for managing the patients. The disease is transmitted by prolonged and intimate contact with untreated, open lepromatous patients whose cutaneous lesions and mucosal discharges teem with leprosy bacilli.
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