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The commonest type of psoriasis order caverta 50 mg on-line impotence aids, presenting with typical plaques of psoriasis of the extensors surfaces like knee order 100mg caverta fast delivery erectile dysfunction protocol hoax, pretibial area elbows and trunk, back and scalp. Flexural psoriasis (psoriasis inversa): lesions are present over the flexors and intertriginous areas (axilla, groin, umbilical region, inframammary folds) the lesions may be moist and lack the typical scaling. Generalized pustular psoriasis may occur as an explosive eruption of generalized pustules with systemic disturbances. Localized pustular psoriasis usually presents with persistent pustular eruptions of the hands and feet. The commonest type is asymmetrical oligoarthritis, other types are: symmetrical seronegative rheumatoid- like disease , distal interphalangeal involvement( most characteristic, but relatively rare), axial skeletal involvement, and a destructive mutilating form (arthritis mutilans) The typical lesions of psoriasis have the following features; The lesions are very well marginated with distinct border and are raised above the surface. The lesions are covered with silvery white, mica-like, loosely adherent scales which, on removal may reveal punctate bleeding points (Auspitz sign) Symmetry: the lesions are symmetrically disposed on extensor surfaces of the body. Management of psoriasis Topical therapy is generally indicated when psoriasis is limited to less than 20% of the body surface. Either alone or in combination with coal tar or topical corticosteroids, salicylic acid (2% to 10%) helps to soften and remove psoriatic scale. Coal tar 5-10% Ultraviolet Radiation although coal tar has been used to treat psoriasis for decades, its mechanism of action is still not well understood. Moisturizer (Emollients) help to hydrate, soften, and loosen psoriatic plaques A strong topical steroid once or twice daily, cover with salicylic acid 2- 10 if necessary. Vitamin D3 analogues: Calcitriol and Calcipotriol, act by regulating keratinocyte proliferation and maturation. Therapy usually is given 2-3 times per week on an outpatient basis, with maintenance treatments every 2-4 weeks until remission. Systemic corticosteroids are generally contraindicated, and they can exacerbate a very severe type of psoriasis called pustular psoriasis, which has a high rate of mortality 3. In the acute and sub acute phases, there is rapid onset of generalized vivid red erythema and fine branny scales; the patient feels hot and cold, shivers, and has fever. There is a loss of scalp and body hair, the nails become thickened and separated from the nail bed (onycholysis), and there may be hyperpigmentation or patchy loss of pigment in patients whose normal skin color is brown or black. The most frequent preexisting skin disorders are (in order of frequency) psoriasis, eczematous dermatitis (atopic, allergic contact, seborrheic), adverse cutaneous drug reaction, lymphoma, and pityriasis rubra pilaris. Drugs most commonly implicated in erythroderma are found In 10 to 20% of patients it is not possible to identify the cause by history or histology. Large amounts of warm blood are present in the skin due to the dilatation of capillaries, and there is considerable heat dissipation through insensible fluid loss and by convection. Also, there may be high output cardiac failure; the loss of scales through exfoliation can be considerable, up to 9 g/m2 of body surface per day, and this may contribute to the reduction in serum albumin and the edema of the lower extremities so often noted in these patients. Thickening leads to exaggerated skin folds; scaling may be fine and branny, and may be barely perceptible or large, up to 5 cm, and lamellar. Palms and Soles Usually involved, with massive hyperkeratosis and deep fissures in pityriasisrubra pilaris, Sézary’s syndrome, and psoriasis. General Examination Lymph nodes generalized, rubbery, and usually small; enlarged in Sézary’s syndrome. Despite the best attention to all details, patients may succumb to infections or, if they have cardiac problems, to cardiac failure (“high output” failure) or to the effects of the prolonged glucocorticoid therapy that may be required. Management This is an important medical problem that should be dealt with in a modern inpatient dermatology facility with experienced personnel. The patient should be hospitalized in a single room, at least for the beginning workup and during the development of a therapeutic program. The hospital room conditions (heat and cold) should be adjusted to the patient’s needs; most often these patients need a warm room with many blankets. Presenting with atypical presentation, more disseminated disease, or being resistant to conventional therapies and patient having related disorders eg candidiasis, H. The eruption, which is characterized by widespread inflammatory and hyperkeratotic lesions in seborrhoeic areas, may progress to erythroderma in some patients. In some instances, pre-existing psoriasis may become more severe with disseminated plaques and pustules.

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Similar picture 183 develops if more than 40% of total blood volume is lost if the bleeding occurs more slowly from one to several hours buy discount caverta 100 mg on-line injections for erectile dysfunction video. High altitude promotes increased red cell production and causes a mild polycythemia cheap 50mg caverta fast delivery erectile dysfunction quick remedy; people living at more than 4700 m have red cell count of 6-8 million per cu mm of blood. Acclimatization to high altitude also increases vascularity of the tissues that lowers total peripheral resistance and tries to counteract high red cell count and increased peripheral resistance. In plycythemia vera, the bone marrow becomes malignant and hematocrit may rise from a normal value of 40 – 45% to even 70 –80% blood viscosity rises sharply, peripheral resistance increases, and cardiac output falls. Anemia decreases viscosity, and together with the vasodilatation due to tissue hypoxia, causes a fall in total peripheral resistance and an increase in cardiac output, so that tissue at rest get enough oxygen, But heart has no reserve to use for the demands of exercise and severe exercise may result in heart failure. Blood Vessels The cardiovascular system is designed to provide widely varying metabolic needs under changing physiological circumstances, without overburdening the heart. These two factors: • Control blood flow and consequently regulate the cardiac output • Are influenced by such factors that control extra cellular fluid volume Microcirculation Microcirculation is the organization of the micro-size blood vessels that are present between the arterioles and venules; their number and size of these vessels vary significantly in deferent vascular beds, many of which have specialized features befitting 184 a special function. The vessels included in the microcirculation are: • Terminal arterioles • Meta -arterioles • Arterioles • Arteriovenous anastomoses • Capillaries • Post capillary venules The terminal arterioles are narrow muscular vessels, having a diameter of 35-50 microns and conduct blood directly into the meta arterioles; both the terminal arterioles are the resistance vessels of the microcirculation. Capillaries • Are the thin-walled exchange vessels forming a network linkage between narrow meta arterioles and wide-lumen venules. Fenestrated Capillaries: Have a very thin area of endothelial membrane stretched between adjacent endothelial cells. These fenestrations are not open holes but are closed by a thin diaphragm; these types are found in the capillary tuft /glomerulus of the kidney, in endocrine glands, and in the intestine providing very high permeability. There is no diaphragm between the adjacent endothelial cells that ensures rapid passage of substances through the capillaries e. Sinusoids: are more wide, more irregular in size and shape than capillaries; sinusoid structure is present in liver and the spleen; in the liver, the sinusoids are lined by an incomplete layer of fenestrated endothelial cell, which increases permeability still preventing passage of many small molecules, such as albumin. Postcapillary venules collect blood from the capillaries, have no muscle and elastic tissue like the capillaries; are wider than the capillaries (15-20 microns); some exchange seems to occur in these vessels; these vessels are very susceptible to inflammation. Viscosity and laminar flow According to the Poiseuille’s Law, viscosity is one of the parameter of resistances to flow. Laminar flow is a characteristic of blood flow in large vessels of the circulation; the laminae move parallel to each other in longitudinally oriented concentric sleeves, each sleeve moving at a different rate. In leukemia and polycythemia, blood viscosity may rise markedly, increasing systemic and pulmonary resistance and consequently raising blood pressure. The bore of the vessel also affects viscosity; it decreases as the vessel diameter falls below 150 micron. This 186 is increase in viscosity as blood velocity decreases, an effect probably due to increased adherence of the red cells to each other. Turbulent blood flow If the velocity of flow is very high, or if the blood has to pass an obstruction vessel, flow becomes turbulent so that eddy currents are formed. Cross-sectional area and flow velocity The mean velocity of blood flow is inversely proportional to the cross-sectional area provide that the total volume of fluid flowing through each segment is constant. Blood volume distribution & blood pressure Blood volume is very unevenly distributed through the various vascular segments even though the volume flowing through is relatively constant. Thick, elastic arteries and arterioles contain 18%, capillaries hold only 3-4 percent of blood volume, while the heart contains about 7% blood pressure is almost inversely proportional to volume distribution and vascular resistance. There is little change in pressure in large arteries, but resistance increases rapidly in small arteries, causing the pressure to drop to about 70 mm Hg at the beginning of the arterioles. The arterioles have the greatest resistance of the systemic circulation, so that by the time blood reaches the capillaries, pressure has dropped to about 30 mmHg. Direct methods 1 Mercury manometer The principle behind manometry is that the vertical column of manometer fluid exerts a downward Pressure which opposes the blood pressure. When the column reaches a stable height (h), the blood pressure must be equal to the pressure at the bottom of the column, namely ρgh (fluid density ρx force of gravity g x h). Electronic pressure transducer To record the pressure wave form, a fast-responding electronic pressure transducer is needed. The transducer contains a metal diaphragm which deforms slightly when arterial pressure is applied to it via a catheter. The deformation of the diaphragm alters the resistance of a wire Connected to it and the resistance is recorded. Indirect methods Auscultator method (sphygmomanometry) The mercury manometer is used in medical practice throughout the world to measure human blood pressure, by an indirect method called sphygmomanometry.

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The method uses a Wintrobe tube which can also be used to determine the erythrocyte sedimentation test generic 50mg caverta fast delivery new erectile dysfunction drugs 2012. One side is graduated from 0 to 10cm (0-100mm) from the bottom to the top order caverta 50 mg overnight delivery erectile dysfunction treatment edmonton, while the other side is graduated from 10 to 0cm (100-0mm) from bottom to top. The hematocrit is read from the scale on the right hand side of the tube taking the top of the black band of reduced erythrocytes immediately beneath the reddish gray leucocyte layer. District laboratories should check the reference ranges with their nearest Hematology 178 Hematology Reference Laboratory. These formulas were worked out and first applied to the classification of anemias by Maxwell Wintrobe in 1934. Abnormal 182 Hematology hemoglobins, such as in sickle cell anemia, can change the shape of red blood cells as well as cause them to hemolyze. Cells of normal size are called normocytic, smaller cells are microcytic, and larger cells are macrocytic. Cells with a normal concentration of hemoglobin are called normochromic; cells with a lower than normal concentration are called hypochromic. Because there is a physical limit to the amount of hemoglobin that can fit in a cell, there is no hyperchromic category. When examined under a microscope, normal red blood cells that contain a normal amount of hemoglobin stain pinkish red with a paler area in the center. It is a measurement of the degree of anisocytosis present, or the degree of red cell size variability in a blood sample. Moderate elevations are common in active inflammatory disease such as rheumatoid arthritis, chronic infections, collagen disease, and neoplastic disease. An initial period of a few minutes (approximately 10 minutes) during which rouleaux formation takes place 2. A period of approximately 40 minutes during which settling or sedimentation occurs at a more or less constant rate. A slower rate of fall (last 10 minutes) during which 192 Hematology packing of the sedimented red cell column occurs. Venous blood is diluted accurately in the proportion of one volume of citrate to four volumes of blood. The tube is placed in a strictly vertical position in the Westergren stand under room temperature conditions not exposed to direct sunlight and away from vibrations and draughts. After 1 hour read to the nearest 1mm the height of the clear plasma above the upper limit of the column of sedimenting red cells. A poor delineation of the upper layer of red cells, the so-called ‘stratified sedimentation’, has been attributed to the presence of many reticulocytes. Advantages of the method It more reliably reflects the clinical state and is the most sensitive method for serial study of chronic diseases, e. Disadvantages of the method 194 Hematology It requires a large amount of blood and involves dilution which may be one source of error. Interpretation of results Reference value Men: 0-15mm/hr; Women: 0-20mm/hr There is a progressive increase with age because of the decline in plasma albumin concentration. Enough blood to fill the Wintrobe tube (approximately 1ml) is drawn into a Pasteur pipette having a long stem. The Wintrobe tube is then filled from the bottom up 195 Hematology (so as to exclude any air bubbles) to the "0" mark. Advantages of the method • The method is simple, requires a small amount of blood and there is no dilution. Red cells possess a net negative charge (zeta potential) and when suspended in normal plasma, rouleaux formation is minimal and sedimentation is slow. Alterations in proportions and concentrations of various hydrophilic protein fractions of the plasma following tissue injury or in response to inflammation reduce the zeta potential and increase the rate of rouleaux formation and the size of the aggregates thus increasing the rate of sedimentation. Albumin which tends to counteract rouleaux formation diminishes in concentration (hypoalbuminemia) further increasing the sedimentation rate. However, plasma viscosity may increase to the extent of masking the rouleaux forming property of the plasma proteins. Effect of red cell factors Efficient rouleaux formation depends on the red cells having normal shape and size. Anisocytosis and poikilocytosis will reduce the ability of the red cells to form large aggregates thus reducing the sedimentation rate. Anemia by altering the ratio of red cells to plasma encourages rouleaux formation and accelerates sedimentation.

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