Alcoholic liver disease (ALD) encompasses a spectrum of injury, ranging from simple steatosis to frank cirrhosis and is the oldest form of liver injury known to mankind. The pathophysiology of ALD is quite complex: encompassing factors related to genetics, gender, ethnicity, consumption patterns and co-morbid conditions. The diagnosis of ALD is based on a combination of features, including history of ‘significant’ alcohol intake, clinical evidence of liver disease, and supporting laboratory abnormalities such as Alanine aminotransferase (ALAT), Aspartate aminotransferase (ASAT), Hepatic imaging, Full blood count and liver biopsy. Treatment and management of alcoholic liver disease are abstinence from alcohol, Liver Transplantation and Therapy for Alcoholic Hepatitis which includes Nutrition Therapy, and Steroids.
Alcoholic liver disease (ALD) encompasses a spectrum of injury, ranging from simple steatosis to frank cirrhosis and is the oldest form of liver injury known to mankind. The pathophysiology of ALD is quite complex: encompassing factors related to genetics, gender, ethnicity, consumption patterns and co-morbid conditions. The diagnosis of ALD is based on a combination of features, including history of ‘significant’ alcohol intake, clinical evidence of liver disease, and supporting laboratory abnormalities such as Alanine aminotransferase (ALAT), Aspartate aminotransferase (ASAT), Hepatic imaging, Full blood count and liver biopsy. Treatment and management of alcoholic liver disease are abstinence from alcohol, Liver Transplantation and Therapy for Alcoholic Hepatitis which includes Nutrition Therapy, and Steroids.
Chronic renal failure or chronic kidney disease management, pharmacist role, medical management objectives, goals of the therapy .
What are the risk factors of chronic renal failure, clinical manifestations of chronic renal failure, renal failure complications, pathophysiology of chronic renal failure.
Acute kidney injury (AKI), also known as acute renal failure (ARF), is a sudden episode of kidney failure or kidney damage that happens within a few hours
CKD is a condition in which the kidneys are damaged and cannot filter blood as well as they should. Because of this, excess fluid and waste from blood remain in the body and may cause other health problems, such as heart disease and stroke.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
1. Uric acid in health and disease
Dr Lalit Agarwal
Woodlands Hospital
Kolkata
2. Normal Uric acid metabolism
• Food
– Organ meat (liver, kidneys), Beer,
other alcoholic beverages, Yeast,
Legumes (dried beans, peas),
Mushrooms, spinach, cauliflower
• Normal level of serum uric acid
(sUA)- 6.8mg/dl (M) 6mg/dl (F)
Purines
Xanthine
hypoxanthine
Uric acid
Diet Synthesized
de novo
Xanthine
oxidase
Xanthine
oxidase
5C-sugar,P,N base
Purine A,G or
pyrimdine C,T & U
APRT & HGPRT
3. Abnormal Uric acid metabolism:
Cardiovascular
events and mortality
Dietary purinesTissue nucleic
acids
Endogenous purine
synthesis
URATE
Overproduction Underexcretion
HYPERURICEMIA
Silent tissue
deposition(tophi)
GOUT Renal
manifestations
Prevalence 15.9%
About 2/3 rd of such individuals remain asymptomatic
90%
4. Asymptomatic Hyperuricemia:
Pharmacologic Intervention?
• Nearly 67% (2/3rd of patient) are asymptomatic
and hence untreated
• Not recommended, unless:
– Uric acid is persistently >13 mg/dL in men and
>10 mg/dL in women
– Patient to receive chemotherapy or radiation
therapy with potential for tumor lysis syndrome
– Daily urinary uric acid >1100 mg (due to 50%
risk of uric acid calculi)
5. • Old belief : UA is unlikely to be a risk factor
for vascular and renal disease.
• Does Hyperuricemia cause or increase the
risk of cardiovascular disease, hypertension
and CKD- this complex interaction was
incompletely understood ?
6. • The paradigm of the causative association
of hyperuricemia with cardiovascular and
renal diseases seems to have progressed
from skepticism to increasing evidence of
a true relationship.
• Recent preclinical and clinical evidence
suggests that chronic hyperuricemia is an
independent risk factor for hypertension ,
metabolic syndrome and CVdisease
8. Accelerated tissue breakdown
Overproduction/ overexcretion of uric acid
Renal tubular obstruction by urate and uric acid crystals
Acute oligoanuric renal failure
Acute uric acid nephropathy
Malignancy (leukemia, lymphoma): cell lysis due to chemotherapy or
radiation therapy
9. Acute Uric Acid Nephropathy
• Common/rare causes
• C/F: AKI in appropriate clinical setting and
marked hyperuricemia, uric acid crystals in
urine, release of other intracellular
constituents
• Prevention and treatment: Hydration,
Rasburicase, XO inhibitor, Avoid
Sodabicarbonate, Hemodialysis
10. Uric acid and new onset CKD
(cause of CKD)
Uric acid is independent risk factor for development
of incident CKD through several mechanisms:
Direct endothelial toxicity to kidneys (uricotoxicity)
Hyperuricemia is risk factor for hypertension,
diabetes or metabolic syndrome. These chronic
diseases lead to CKD over time.
Epidemiologic studies suggest this association by
Weiner et al, Obermeyer et al.
11. Uric acid and new onset CKD
• Uric acid levels between 7 to 9 mg/dl
doubles the risk for incident kidney disease
• Uric acid levels more than 9 mg/dl triples
the risk of incident kidney Disease
12. Uric acid and new onset CKD
• Hyperuricemia is an independent risk factor
for renal dysfunction and cardiovascular
events, with 18.4% women and 25.8% men
with Hyperuricemia also suffering from
chronic renal failure
• A meta-analysis of 13 studies containing
190,718 participants showed a positive
association between Hyperuricemia and
CKD.
13. Gouty nephropathies are very uncommon nowadays as
hyperuricemia well managed.
Severe tophaceous gout and hereditary disorder of purine
metabolism.
Deposition of sodium urate crystals in medullary
interstitium, chronic inflammatory response,interstitial
fibrosis and CKD.
C/F of Chronic urate nephropathy is non specific..
Hyperuricemia out of proportion to degree of renal failure
c/w modest hyperuricemia of kidney diseases.
Chronic urate nephropathy
14. Uric acid and progression of CKD
A 14% increase in the risk of kidney disease
progression was demonstrated for each 1 mg/dL
increase in uric acid levels in the Cardiovascular
Health Study.
? Slow progression by Urate lowering therapy:
• Goicoechea et al Allopurinol slows down
progresison of CKD.
• Sircar et al Febuxostat slowed the progression
of CKD stages ¾.
15. Uric acid as a marker of kidney function.
(Effect of ckd)
• 90% cases of hyperuricemia is due to renal
under-excretion(genetic or acquired) of uric
acid.
• Waste product accumulating in renal
dysfunction like other nitrogenous waste
products.
• At what level causes toxicity (renal &extra
renal (CVS),so when to give treatment is
unknown in CKD
16. Uric acid and CKD
Still these data are insufficient to provide any
recommendations to treat asymptomatic
hyperuricemia in CKD
17. Uric acid nephrolithiasis
• 5 to 10 percent of all renal calculi. however, UA stones seen in
40 % or more in areas with hot, arid climates.
• a high urine uric acid concentration and an acid urine pH
promote pptn.
• Gout, UA overproduction, Chronic diarrhea, Diabetes and
metabolic syndrome
• Diagnosis. asymtomatic or symptomatic
• ●Alkalinization of the urine (ph 6-7)●Increased fluid intake
●Reduction of uric acid production with reduced purine intake
and xanthine oxidase inhibitors.
• XO inhibitors can reduce urine uric acid excretion by 40-50%.
18. Gout
Results from increased body pool /loadof urate with hyperuricemia
Occurring predominantly in men
Characterized by (episodic acute arthritis) painful inflammation of joints; big
toe (most common), feet, hands etc
Chronic arthritis: results in deformity
Caricature ‘The gout’ by James Gillray (1799)
19. Risk factors:
• Age and gender
Comorbidities
• Hypertension
• Cardiovascular disease
• Chronic renal failure
• Diabetes mellitus
• Dyslipidemia
• Metabolic syndrome
Number of metabolic syndrome components
Juan García Puig; Curr Opin Rheumatol. 2008;20(2):187-191.
21. Gouty Arthritis: pathology
• Elevated serum urate with local factors leads to crystal deposition in
joints
• At > 6.8mg/dl concentrations (MSU) crystals precipitates & released into
the joint space initiate an acute inflammatory response
– Self limiting, but crystals and low level inflammation persists
• Chronic crystal presence leads to low grade inflammation and damage
joints
• Lowering serum urate to 4-6mg/dl can reduce crystals and tophi, resulting
eventually in fewer attacks and less joint damage.
• Uric acid level may not correlate with the severity of articular disease
22. Acute attack/flare
• Abrupt onset, severe inflammation,
often single joint (mono or polyarticular)
• Untreated attack subside: 3-10days
• Most common- big toe (90%)
• Other common sites: ankle, feet, knees
• Least common sites: elbow, wrist,
fingers
• Extraarticular manifestations
• 50% of patients with acute gout will
have normal serum uric acid levels.
• Pptating factors – dietary excess,trauma
surgery, excessive ethanol, hypouricemic
therapy, medical illness.
24. Advanced gout
• Chronic low grade inflammation due to MSU crystals
• Clinically detectable tophaceous deposits
• Chronic inflammation: erosion and joint damage (visible on X-ray,
MRI)
Chronic
inflammation
Tophus
Courtesy of American college of Rheumatology slide
26. Gout- tophus at other sites
Solid urate deposits in tissues: Irregular destructive nodularity produced
Courtesy of American college of Rheumatology slide
27. Diagnosing gout
• Inflamed joint fluid aspirate or in
tophus
• Needle shaped crystals
• Yellow or blue in color
Uric acid crystals as seen under
polarizing microscope
Courtesy of American college of Rheumatology slide
28. Treatment goals
• Treat acute arthritic attack promptly by colchicin, steroid,
NSAIDs (ULT has no role in acute attack)
• Prevent recurrence of acute gouty arthritis give ULT +
prophylaxis (3-6 months)
• Lower urate levels by ULT(don’t change, start, stop during
attack)
• All hyperuricemic pts with 3 gouty attacks, tophi,
nephrolitiasis should receive ULT. Lifelong treatment
• Prevent or reverse co-morbid conditions like obesity,
Hypertension and triglyceridemia and renal complications
and less commonly myeloproliferative states, Lesch-
Nyhan syndrome and drugs.
29. Comorbidities Associated
with Hyperuricemia
• Renal
manifestations1
• Obesity2
• Metabolic syndrome3
• Diabetes mellitus4
• Heart failure5
• Hyperlipidemia2
• Hypertension6
• Cardiovascular
disease7
1. Vazquez-Mellado et al. Best Pract Res Clin
Rheumatol. 2004;18:111-124
2. Nakakanishi et al. Int J Epidemiol. 1999;28:888-893
3. Ford et al. JAMA. 2002;287:356-359.
4. Boyko et al. Diabetes Care. 2000;23:1242-1248.
5. Anker et al. Circulation. 2003;107:1991-1997.
6. Gavin et al. Am J Cardiovasc Drugs. 2003;3:309-314.
7. Niskanen et al. Arch Intern Med. 2004;164:1546-1551.
30. Hyperuricemia and
Diabetes Mellitus
• Diabetics have a significantly higher uric acid
level compared to non-diabetic subjects.
• Considering that the prevalence of obesity and
thus metabolic syndrome/ insulin resistance is
rising across the globe, it is very likely that the
number of type 2 diabetic patients with
Hyperuricemia will also increase.
31. Studies demonstrating some associations with
Hyperuricemia and Cardiovascular outcomes
Alderman M, Aiyer KJ. Uric acid: role in cardiovascular disease and effects of losartan. Curr Med Res Opin. 2004 Mar;20(3):369-79.
33. In some of the countries like Japan,
treatment of asymptomatic
hyperuricemia is recommended to
prevent non- gout diseases like
hypertension, CAD, and CKD .
34. Japanese Guidelines
• Hyperuricemia- Serum Uric Acid > 7.0 mg (Male or
Female)
• Life style modification- Serum Uric Acid 7-8 mg.
• Drug Therapy – Serum Uric Acid 8-9 mg.
> 9 mg. definitely requires drug therapy
• In gout –Serum Uric Acid should be lower 6.0 mg %
35. • Patients with asymptomatic
Hyperuricemia with an SU level 9
mg/dL or greater should be treated with
urate lowering drugs.
• Drug therapy should be considered in
those with a level between 8 and 9
mg/dl only if they have Hyperuricemia-
associated comorbidities like obesity,
diabetes mellitus, hypertension,
ischemic heart disease, or dyslipidemia.
• Patients over 50 years of age with an SU
level >7 mg/dl and comorbidities
should be treated
Key recommendations of the ISN
position paper on Hyperuricemia
36. Key recommendations of the ISN
position paper on Hyperuricemia
• Serum urate measurement should be
included in the list of investigations for
the evaluation of CVD.
• Patients with chronic renal failure
should be screened for Hyperuricemia,
which, if detected, must be treated.
• The use of Febuxostat is
recommended instead of allopurinol,
as the latter is more toxic and the risk
of life-threatening Steven-Johnson
Syndrome in CKD patients is higher.
37. Take Home Message
• Hyperuricemia increases the risk for HTN,
CKD, risk of CVD, morbidity and mortality.
• There are lots of studies concerning uric acid
and possible links to hypertension, renal disease
and cardiovascular disease.
• Despite such evidence, there is no global
consensus for treatment of asymptomatic
hyperuricemia to reduce cardiovascular & renal
risk.
• CKD markedly increases the risk for
hyperuricemia and gout due to under excretion
of uric acid.
38. Conclusion
• Need to gather Indian data --- To develop
Indian specific guidelines for the management
of Hyperuricemia.
• In the absence of any recommendation at
present– we may follow Japanese guideline.
• Need to arrive at common consensus, weather
or not to treat cases of Asymptomatic
Hyperuricemia before the Development of
complication like Gout, diabetes, CVD, CKD,
Nephrolithiasis