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Iron requirements The amount of iron required each day to compensate for losses from the body and growth varies with age and sex purchase cialis with american express erectile dysfunction treatment lloyds; it is highest in pregnancy and in adolescent and menstruating females order cialis visa erectile dysfunction specialists. These groups, therefore, are particularly likely to develop iron deficiency if there is additional iron loss or prolonged reduced intake. Causes Chronic blood loss, especially uterine or from the gastrointestinal tract is the dominant cause. Half a liter of whole blood contains approximately 250mg of iron and, despite the increased absorption of food iron at an early stage of iron deficiency, negative iron balance is usually in chronic blood loss. Increased demands during infancy, adolescence, pregnancy, lactation an in menstruating women account for the prevalence of latent iron deficiency (absent iron stores without anemia) and a consequent high risk of anemia in these particular clinical groups. It has been estimated to take 8 years for a normal adult male to develop iron deficiency anemia solely due to a poor diet or malabsorption resulting in no iron intake at all. Bone marrow iron • Bone marrow examination is not essential to assess iron stores except in complicated cases, but iron staining is carried out routinely on all bone marrow aspirations that are performed for any reason. Anemia of Chronic disorders One of the most common anemias occurs in patients with a variety of chronic inflammatory and malignant diseases. The anemia is only corrected by successful treatment of the underlying disease and does not respond to iron therapy despite the low serum iron. Sideroblastic anemia This is a refractory anemia with hypochromic cells in the peripheral blood and increased marrow iron; it is defined by the presence of many pathological ring sideroblasts in the bone marrow. These are abnormal erythroblasts containing numerous iron granules arranged in a ring or collar around the nucleus instead of the few randomly distributed iron granules seen when normal erythroblasts are stained for iron. In the hereditary forms, the anemia is characterized by a markedly hypochromic and microcytic blood picture. In the hereditary and primary acquired diseases, 15% or more of marrow erythroblasts are ring sideroblasts. Ring sideroblasts also occur with lesser frequency in the marrow disorders, especially the other types of myelodysplasia, the myeloproliferative diseases, acute myeloid leukemia 252 Hematology and myeloma. They may also occur in the bone marrow of patients taking certain drugs, excess alcohol or with lead poisoning. The anemia may be hypochromic or predominantly hemolytic, and the bone marrow may show ring sideroblasts. Clinically they are divided into hydrops fetalis, β- thalassemia major, which is transfusion dependent, thalassemia intermedia characterized by moderate anemia usually with splenomegaly and iron overload, and thalassemia minor, the usually symptomless carrier. As there is duplication of the α-globin gene, deletion of four genes is needed to completely suppress α chain synthesis. Since the α chain is essential in fetal as well as in adult hemoglobin, deletion of both α genes on both chromosomes leads to failure of fetal hemoglobin synthesis with death in utero (hydrops fetalis). Hemoglobin electrophoresis is normal but occasionally Hb H bodies may be observed in reticulocyte preparations. Beta-thalassemia syndromes Anemia in β–thalassemia is a result of (1) decreased synthesis of the β-globin chains of hemoglobin and (2) precipitation and subsequent removal of excess α-globin chains, which in turn lead to ineffective erythropoiesis and hemolysis. Hypochromia, microcytosis, fragmented forms, and basophilic stippling are found in blood from thalassemia patients. The hypocrhomia is a result of decreased 254 Hematology cellular content of hemoglobin, a major defect in thalassemia. The production abnormality is due to ineffective erythropoiesis, that is, destruction of immature erythroid cells in the bone marrow. Several forms of macrocytosis are not accompanied by megaloblastic changes and some of these are relatively common. It is to be distinguished from the swelling of the red cell membrane that accounts for target cell in some patients with obstructive jaundice. Some authors 255 Hematology believe that it is the result of the reticulocytosis that accompanies the hemolytic component of the anemia associated with liver dysfunction. Similarly, macrocytosis, often in the absence of anemia, is seen in patients who consume large amounts of alcohol, and this is sometimes used as a criterion for the diagnosis of chronic alcoholism. Anemia associated with hypothyroidism can have various morphologic characteristics, but is sometimes macrocytic in nature, for reasons that are not entirely clear. The postsplenectomy state is often associated with mild macrocytosis, in addition to the formation of some target cells and acanthocytes; these changes are due to the fact that young red cells normally undergo a process of surface remodeling, with loss of some of their redundant red cell membrane, with the spleen, and thus splenectomy may be associated with cells containing excessive plasma membrane material. Erythrocytes during the neonatal period are normally macrocytic and are then replace by cells of normal size. In the presence of high serum levels of erythropoietin 256 Hematology stimulated by anemia and the attendant hypoxemia, there is early release of immature red blood cells from the bone marrow, that is, a “shift” of immature bone marrow reticulocytes into the peripheral blood. Macrocytosis of mild degree is often seen as well in conditions in which the anemia is due to a decease in erythropoietic tissue in the bone marrow, for example, aplastic anemia, pure red cell aplasia, or the bone marrow suppression caused by chemotherapy. In these situations there is also a high titer of erythropoietin in the plasma, and this causes a rapid rate of ingress of young red blood cells into the peripheral blood. Major causes of macrocytic anemia that are megaloblastic in nature are vitamin B12 or folic acid deficiency, both of which have multiple causes. This result in ineffective erythropoiesis, that is, death of immature erythyroid cells before release from the bone marrow, associated with some early destruction of circulating erythrocytes as well. It is known that a state of unbalanced growth exists in the marrow 259 Hematology cells of patients with megaloblastic anemia. Although most anemias characterized by megaloblastic erythropoiesis are due to either vitamin B12 or folic acid deficiency, there are several other causes of megaloblastic hematopoiesis. Laboratory findings • Pancytopenia : As a result of ineffective erythropoiesis, 260 Hematology granulopoiesis, and thrombopoiesis, and premature destruction of defective cells in the peripheral blood, it is unusual to find a patient with megaloblastic anemia who does not have depression of all three cell lines in the peripheral blood. Occasionally it is 2 to 3 percent, but the reticulocyte production index is low, a reflection of a functionally defective marrow. It has been suggested that these abnormalities result from 261 Hematology fragmentation of the abnormal large red cells as they pass through small arterioles. As the megaloblastic anemia becomes more sever, bizarre shapes such as triangles and helmets increases proportionately. Normally no more than 1 percent of polys have six nuclear lobes, but in megaloblastic anemia many have six or more, even ten, lobes. Despite hemolysis the reticulocyte production index is reduced because of the ineffective erythropoiesis in the bone marrow. Morphologically, the megaloblastic erythropoiesis is characterized by the presence of large cells, with asynchronism between nuclear and cytoplasmic development. Vitamin B12 Since vitamin B12 is common in human diets, almost all deficiencies of vitamin B12 are a result of malabsorption. This structure is analogous to the porphyrin structure of heme, with position of the heme iron being occupied by a cobalt atom. The vitamin B12 synthesized by microbes is deposited in animal tissues, such as liver, eggs, and 263 Hematology milk, and is therefore plentiful in fish and meat products.

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It is the means by which food cheap 5 mg cialis visa erectile dysfunction diabetes medication, oxygen cialis 5 mg erectile dysfunction young living, water and other requirements are conveyed to the tissue calls, and their waste products are carried away. It is about the size of a person’s clenched fist and weighs around 300 gm in a man and 250gm in a woman. The right and left sides of the heart are totally separated by a muscular wall and there is no communication between them. The right side of the heart receives the deoxygenated (impure) blood collected from the different parts of the body through small and big veins, which enters the lungs. In the lungs the blood is oxygenated and carbon­di­oxide and metabolic waste are removed The left side of the heart receives (pure) blood from the lungs and supplies it to the entire body through the major blood vessel (aorta) and its numerable branches (arteries and capillaries). The left ventricle generates greater pressure than the right ventricle to enable the bold to be pumped throughout the body. The coronary arteries branch out (left and right coronary arteries) from the root of the aorta near its origin from the left ventricle. Both the coronary arteries branch of into smaller vessels, which are distributed all over the surface of the heart. For efficient pumping, it is necessary for the heart to beat at a reasonable rate of 60 – 90 beats per minute, which is achieved through controlled electrical impulses (conductive system). Plasma is important for the life of the tissue cells, conveying to them water and nourishment, and carrying away their waste products. They are very tiny disc with no nucleus, and are filled with haemoglobin, which is made from iron and protein. They can change shape and squeeze through the small bood vessel walls in order to fight gems that have entered the tissues. In acute infection many more leucocytes are produced to help in the fight (leucocytosis) 2) Lymphocytes are produced in the spleen and lymph glands. They are found mainly grouped together in the neck, axilla, and groins and in the pelvic and abdominal cavities. Functions of Lymph: Lymph glands help to protect the body from infection by 1) Filtering the lymph to prevent germs from getting into the blood stream, and fighting to overcome them. Once the food is digested, it must be transferred to the blood stream and the process by which this transfer occurs is called absorption. The Alimentary Canal: The alimentary canal is a long muscular digestive tube extending through the body. Functions of Digestive System: 1) Break down the food substances into small particles 2) Digestion of food substances. The alimentary canal,which is a continuous, passage way beginning at the mouth, where the food is taken in and terminating at the anus where the solid products of digestion, which are not absorbed, are expelled from the body. The accessory organs – which are vitally necessary for the digestive process, do not happen to be the part of the alimentary canal. They are: 1) Mouth – with the help of saliva from three pairs of salivary glands, 2) Stomach – with the help of gastric juice from the stomach wall and 3) Small intestine – with the help of pancreatic juice from the pancreas bile juice from the liver and the intestinal juice from the small intestine. They are (1) Molars – 12 (2) Pre molars – 8 (3) Canines – 4 (4) Incisors – 8 The teeth help to break down the food substances into small particles. The tongue has on its surface a number of taste buds by means of which we can differentiate sensation of taste. Later by associating the sight and smell of food with its taste, the child learns that the food has certain qualities and these very qualities are after wards capable of eliciting salivary secretion. Digestion in the mouth The food is chewed; and saliva the first of the digestive juices acts on it, softens it so that it can be easily swallowed. Both ends of the stomach are guarded by valves which normally permit the passage of substances in only one direction. The proximal end is guarded by cardiac sphincter and the distal end of the stomach is guarded by pyloric sphincter. Digestion in the Stomach The food material after being broken down by mechanical grinding and having been converted into a bolus with the saliva reaches the stomach, which pours a large quantity of gastric juice every day. Bile Juice: 1) In the absence of bile, fats are not digested properly which results in fatty diarrhea. The bile is concentrated and sent to the duodenum through the cystic duct when chime from the stomach enters the duodenum. Due to liver damage or obstruction of the bile duct, bilirubin collects in excess quantities in bleed and changes the colour of the skin and the eyes. Besides these enzymes pancreatic juice contains large quantities of sodium bicarbonate which neutralizes the hydrochloric acid present in the gastric juice secreted by the stomach. The Spleen: This is a dark purple organ situated in the left side of the upper abdomen, behind the stomach. Small Intestine The small intestine is about 600cm long in adult extending from the pyloric sphincter of the stom­ ach to intestine. The first 25cm or 30cm of the small intestine is called the duodenum followed by the jejunum and the remainder is the ileum. Digestion in the Small Intestine: The food in the stomach is partially digested by the gastric juice, but the small intestine is the organ in which the completion of the digestion and absorption occurs. Bile is not primarily a digestive juice because it contains no enzyme but it helps in the digestion of fats. They are: 1) Pancreatin: converts carbohydrates into simple sugars like amylase glucose, fructose and galactose. This trypsinogen is converted into active trypsin by action of enterokinase which is secreted in the small intestine. The final product of digestion of the carbohydrates is glucose while the proteins are amino acids and fats are fatty acids and glycerol. Large Intestine The large intestine is as the name implies has the larger diameter than the small intestine. Rectum and anal canal: The descending colon of large intestine opens into last part, the rectum and anal canal. The narrow portion of the distal part of the large intestine is called the anal canal, which leads to the outside through an opening called the anus. Absorption of Food: Absorption is the process by which water, minerals, vitamins and end products of digestion are absorbed through the mucosa of alimentary canal (especially the small intestines) into blood stream either directly or via lymphatic vessels. The main absorption occurs in small intestines especially in the lower (ileum) part, the upper part of the small intestine is mainly associated with the process of digestion. Both monosaccharide and amino acids are absorbed by a positive pressure gradient between the intestinal content and the blood as well as by an active process involving enzymatic reactions and transported in the blood stream to the liver via the hepatic portal system. The excess amount of glucose is converted into glycogen and stored in the liver, when need arises glycogen is converted into glucose and is utilized by the body. Large quantities of water are however absorbed from the large intestine and the fluid content of the small intestine are converted into the pasty consistency and ejected through the opening called the anus. Movements of the gastro intestinal tract: Deglutition is the process by which the masticated food is transported across the pharynx and reaches the stomach.

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On the anterior surface of the older adult sacrum discount cialis 5mg mastercard impotence and high blood pressure, the lines of vertebral fusion can be seen as four transverse ridges cheap cialis online amex erectile dysfunction at age 35. On the posterior surface, running down the midline, is the median sacral crest, a bumpy ridge that is the remnant of the fused spinous processes (median = “midline”; while medial = “toward, but not necessarily at, the midline”). Lateral to this is the roughened auricular surface, which joins with the ilium portion of the hipbone to form the immobile sacroiliac joints of the pelvis. Passing inferiorly through the sacrum is a bony tunnel called the sacral canal, which terminates at the sacral hiatus near the inferior tip of the sacrum. The anterior and posterior surfaces of the sacrum have a series of paired openings called sacral foramina (singular = foramen) that connect to the sacral canal. Each of these openings is called a posterior (dorsal) sacral foramen or anterior (ventral) sacral foramen. These openings allow for the anterior and posterior branches of the sacral spinal nerves to exit the sacrum. The superior articular process of the sacrum, one of which is found on either side of the superior opening of the sacral canal, articulates with the inferior articular processes from the L5 vertebra. The coccyx, or tailbone, is derived from the fusion of four very small coccygeal vertebrae (see Figure 7. The fused spinous processes form the median sacral crest, while the lateral sacral crest arises from the fused transverse processes. Intervertebral Discs and Ligaments of the Vertebral Column The bodies of adjacent vertebrae are strongly anchored to each other by an intervertebral disc. This structure provides padding between the bones during weight bearing, and because it can change shape, also allows for movement between the vertebrae. Although the total amount of movement available between any two adjacent vertebrae is small, when these movements are summed together along the entire length of the vertebral column, large body movements can be produced. Ligaments that extend along the length of the vertebral column also contribute to its overall support and stability. Intervertebral Disc An intervertebral disc is a fibrocartilaginous pad that fills the gap between adjacent vertebral bodies (see Figure 7. Because of this, intervertebral discs are thin in the cervical region and thickest in the lumbar region, which carries the most body weight. In total, the intervertebral discs account for approximately 25 percent of your body height between the top of the pelvis and the base of the skull. Intervertebral discs are also flexible and can change shape to allow for movements of the vertebral column. It forms a circle (anulus = “ring” or “circle”) and is firmly anchored to the outer margins of the adjacent vertebral bodies. It has a high water content that serves to resist compression and thus is important for weight bearing. This causes the disc to become thinner, decreasing total body height somewhat, and reduces the flexibility and range of motion of the disc, making bending more difficult. The gel-like nature of the nucleus pulposus also allows the intervertebral disc to change shape as one vertebra rocks side to side or forward and back in relation to its neighbors during movements of the vertebral column. Thus, bending forward causes compression of the anterior portion of the disc but expansion of the posterior disc. If the posterior anulus fibrosus is weakened due to injury or increasing age, the pressure exerted on the disc when bending forward and lifting a heavy object can cause the nucleus pulposus to protrude posteriorly through the anulus fibrosus, resulting in a herniated disc (“ruptured” or “slipped” disc) (Figure 7. The posterior bulging of the nucleus pulposus can cause compression of a spinal nerve at the point where it exits through the intervertebral foramen, with resulting pain and/or muscle weakness in those body regions supplied by that nerve. The most common sites for disc herniation are the L4/L5 or L5/S1 intervertebral discs, which can cause sciatica, a widespread pain that radiates from the lower back down the thigh and into the leg. Similar injuries of the C5/C6 or C6/C7 intervertebral discs, following forcible hyperflexion of the neck from a collision accident or football injury, can produce pain in the neck, shoulder, and upper limb. Ligaments of the Vertebral Column Adjacent vertebrae are united by ligaments that run the length of the vertebral column along both its posterior and anterior aspects (Figure 7. These serve to resist excess forward or backward bending movements of the vertebral column, respectively. The anterior longitudinal ligament runs down the anterior side of the entire vertebral column, uniting the vertebral bodies. Protection against this movement is particularly important in the neck, where extreme posterior bending of the head and neck can stretch or tear this ligament, resulting in a painful whiplash injury. Prior to the mandatory installation of seat headrests, whiplash injuries were common for passengers involved in a rear-end automobile collision. The supraspinous ligament is located on the posterior side of the vertebral column, where it interconnects the spinous processes of the thoracic and lumbar vertebrae. In the posterior neck, where the cervical spinous processes are short, the supraspinous ligament expands to become the nuchal ligament (nuchae = “nape” or “back of the neck”). The nuchal ligament is attached to the cervical spinous processes and extends upward and posteriorly to attach to the midline base of the skull, out to the external occipital protuberance. This ligament is much larger and stronger in four- legged animals such as cows, where the large skull hangs off the front end of the vertebral column. You can easily feel this ligament by first extending your head backward and pressing down on the posterior midline of your neck. Then tilt your head forward and you will fill the nuchal ligament popping out as it tightens to limit anterior bending of the head and neck. The posterior longitudinal ligament is found anterior to the spinal cord, where it is attached to the posterior sides of the vertebral bodies. This consists of a series of short, paired ligaments, each of which interconnects the lamina regions of adjacent vertebrae. The ligamentum flavum has large numbers of elastic fibers, which have a yellowish color, allowing it to stretch and then pull back. In the posterior neck, the supraspinous ligament enlarges to form the nuchal ligament, which attaches to the cervical spinous processes and to the base of the skull. The thickest portions of the anterior longitudinal ligament and the supraspinous ligament are found in which regions of the vertebral column? Chiropractors focus on the patient’s overall health and can also provide counseling related to lifestyle issues, such as diet, exercise, or sleep problems. They will perform a physical exam, assess the patient’s posture and spine, and may perform additional diagnostic tests, including taking X-ray images. They primarily use manual techniques, such as spinal manipulation, to adjust the patient’s spine or other joints. They can recommend therapeutic or rehabilitative exercises, and some also include acupuncture, massage therapy, or ultrasound as part of the treatment program. In addition to those in general practice, some chiropractors specialize in sport injuries, neurology, orthopaedics, pediatrics, nutrition, internal disorders, or diagnostic imaging. To become a chiropractor, students must have 3–4 years of undergraduate education, attend an accredited, four-year Doctor of Chiropractic (D. The clavicular notch is the shallow depression located on either side at the superior-lateral margins of the manubrium. The manubrium and body join together at the sternal angle, so called because the junction between these two components is not flat, but forms a slight bend.