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More than 20 five-lobed cells/100 WBCs suggest incip- ient megaloblastic anemia discount 260 mg extra super avana mastercard erectile dysfunction pump nhs, and a six-lobed or seven-lobed poly is virtually diagnostic cheap extra super avana 260mg line erectile dysfunction gnc. In bands or stabs, the connection between the lobes of the nucleus is by a thick band; in segs, by a thin filament. A band is defined as a connecting strip wide enough to reveal two distinct margins with nu- clear material in between. For practical purposes, a left shift is present in the CBC when more than 10–12% bands are seen or when the total PMN count (segs plus bands) is greater than 80. Left Shift: Bacterial infection, toxemia, hemorrhage Right Shift: Liver disease, megaloblastic anemia, iron deficiency anemia RETICULOCYTE COUNT • Collection: Lavender top tube The reticulocyte count is not a part of the routine CBC. The count is used in the initial workup of anemia (especially unexplained) and in monitoring the effect of hematinic or ery- thropoietin therapy, monitoring the recovery from myelosuppression or monitoring engraft- ment following bone marrow transplant. Normal bone marrow responds to a decrease in erythrocytes (shown by a decreased hematocrit) with an increase in the production of reticulocytes. Lack of increase in a reticu- locyte count with an anemia suggests a chronic disease, a deficiency disease, marrow re- placement, or marrow failure. CBC DIFFERENTIAL DIAGNOSIS • See Tables 5–2 and 5–3 for normal age and sex-specific ranges. Calculated by 5 Hemoglobin (g / L) MCH = 6 RBC (10 / µL) Increased: Macrocytosis (megaloblastic anemias, high reticulocyte counts) Decreased: Microcytosis (iron deficiency, sideroblastic anemia, thalassemia) MCHC (Mean Cellular [Corpuscular] Hemoglobin Concentration) • 33–37 g/dL (SI:330–370 g/L) The average concentration of hemoglobin in a given volume of red cells. Calculated by the formula Hemoglobin (g / dL) MCHC = Hematocrit Increased: Very severe, prolonged dehydration; spherocytosis Decreased: Iron deficiency anemia, overhydration, thalassemia, sideroblastic anemia MCV (Mean Cell [Corpuscular] Volume) • 76–100 cu µm (SI: fL) The average volume of red blood cells. Increased: Sudden exercise, after trauma, bone fracture, after asphyxia, after surgery (espe- cially splenectomy), acute hemorrhage, polycythemia vera, primary thrombocytosis, 5 leukemias, after childbirth, carcinoma, cirrhosis, myeloproliferative disorders, iron deficiency Decreased: DIC, ITP, TTP, congenital disease, marrow suppressants (chemotherapy, alco- hol, radiation), burns, snake and insect bites, leukemias, aplastic anemias, hypersplenism, infectious mononucleosis, viral infections, cirrhosis, massive transfusions, eclampsia and preeclampsia, prosthetic heart valve, more than 30 different drugs (NSAIDs, cimetidine, as- pirins, thiazides, others) PMNs (Polymorphonuclear Neutrophils) (Neutrophils) • 40–76% • See also the “Left Shift” page 100. Severe exercise, last months of pregnancy, labor, surgery, new- borns, steroid therapy Pathologic. Bacterial infections, noninfective tissue damage (MI, pulmonary infarction, pancreatitis, crush injury, burn injury), metabolic disorders (eclampsia, DKA, uremia, acute gout), leukemias Decreased: Pancytopenia, aplastic anemia, PMN depression (a mild decrease is referred to as neutropenia, severe is called agranulocytosis), marrow damage (x-rays, poisoning with benzene or antitumor drugs), severe overwhelming infections (disseminated TB, sep- ticemia), acute malaria, severe osteomyelitis, infectious mononucleosis, atypical pneumo- nias, some viral infections, marrow obliteration (osteosclerosis, myelofibrosis, malignant infiltrate), drugs (more than 70, including chloramphenicol, phenylbutazone, chlorpro- mazine, quinine), B12 and folate deficiencies, hypoadrenalism, hypopituitarism, dialysis, fa- milial decrease, idiopathic causes RDW (Red Cell Distribution Width) • 11. Increased: Many anemias (iron deficiency, pernicious, folate deficiency, thalassemias), liver disease LYMPHOCYTE SUBSETS Specific monoclonal antibodies are used to identify specific T and B cells. Lymphocyte sub- sets (also called lymphocyte marker assays, or T- and B-cell assay) are useful in the diagno- sis of AIDS and various leukemias and lymphomas. The designation CD (“clusters of differentiation”) has largely replaced the older antibody designations (eg, Leu 3a or OKT3). Absolute CD4 count is used to initiate therapy with antiretrovirals or prophylaxis for PCP (see page 75). The CDC includes in the category of AIDS any patient with a CD4 count < 200 who is HIV-positive. General terms include poikilocytosis (irregular RBC shape such as sickle or burr) and anisocytosis (irregular RBC size such as microcytes and macrocytes). Sickling: Sickle cell disease and trait Spherocytes: Hereditary spherocytosis, immune or microangiopathic hemolysis, severe burns, ABO transfusion reactions Target Cells (Leptocytes): Thalassemia, hemoglobinopathies, obstructive jaundice, any hypochromic anemia, after splenectomy WBC MORPHOLOGY DIFFERENTIAL DIAGNOSIS The following gives conditions associated with certain changes in the normal morphology of WBCs. Activated Clotting Time (ACT) • 114–186 s • Collection: Black top tube from instrument manufacturer This is a bedside test used in the operating room, dialysis unit, or other facility to docu- ment neutralization of heparin (ie, after coronary artery bypass, heparin is reversed. Decreased: Autosomal-dominant familial AT-III deficiency, PE, severe liver disease, late pregnancy, oral contraceptives, nephrotic syndrome, heparin therapy (>3 days) Increased: Coumadin, after MI Bleeding Time • Duke, Ivy <6 min; Template <10 min • Collection: Specialized bedside test performed by technicians. A small incision is made, and the wound is wicked with filter paper every 30 s until the fluid is clear. In vivo test of hemostasis that tests platelet function, local tissue factors, and clotting factors. Nonsteroidal medications should be stopped 5–7 d before the test because these agents can affect platelet function. Nearly all of the coagulation factors ap- parently exist as inactive proenzymes (Roman numeral) that, when activated (Roman numeral + a), serve to activate the next proenzyme in the sequence. Increased: DIC, thromboembolic diseases (PE, arterial or venous thrombosis) 5 Fibrin Degradation Products (FDP), Fibrin Split Products (FSP) • <10 µg/mL • Collection: Blue top tube Generally replaced by the fibrin D-dimer as a screen for DIC Increased: DIC (usually >40 µg/mL), any thromboembolic condition (DVT, MI, PE), hepatic dysfunction Fibrinogen • 200–400 mg/dL (SI:2. Fibrinogen is cleaved by thrombin to form insoluble fragments that polymerize to form a stable clot. Increased: Inflammatory reactions, oral contraceptives, pregnancy, cancer (kidney, stomach, breast) Decreased: DIC (sepsis, amniotic fluid embolism, abruptio placentae), surgery (prostate, open heart), neoplastic and hematological conditions, acute severe bleeding, burns, venomous snake bite, congenital Lee-White Clotting Time • 5–15 min • Collection: Draw into plain plastic syringe; clotting time measured in sepa- rate tube Increased: Heparin therapy, plasma–clotting factor deficiency (except Factors VII and XIII). Most commonly used to monitor heparin therapy Increased: Heparin and any defect in the intrinsic coagulation system (includes Fac- tors I, II, V, VIII, IX, X, XI, and XII), prolonged use of a tourniquet before drawing a blood sample, hemophilia A and B Prothrombin Time (PT) • 11. The use of INR instead of the Patient/Control ratio to guide anticoagulant (Coumadin) ther- apy is becoming standard. INR provides a more universal and standardized result be- cause it measures the control against a WHO standard reference reagent. Most useful in serial measurement to follow the course of disease (eg, polymyalgia rheumatica or temporal arteritis).

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Specifically cheap 260mg extra super avana visa erectile dysfunction medication side effects, can high frequency encoding be understood as a place code where the frequency content of a stimulus is determined from a spatial map of frequency established by the biomechanical transduction properties of the peripheral sensors buy 260 mg extra super avana fast delivery impotence thesaurus, or, can the fine timing of neural activity, a temporal code, account for pitch perception? Most likely, these mech- anisms work in combination with predominance in different ranges of the percep- tual spectrum. As a solution to this challenge to temporal coding, Wever proposed the volley principle, suggesting that while any given neuron might not follow every cycle of a stimulus, different subpop- ulations within a group of neurons could fire in a phase-locked manner to different © 2005 by Taylor & Francis Group. The top graph shows a frequency tuning curve for a trigeminal unit, constructed by counting all evoked inter-spike intervals (ISIs), a measure that is functionally equivalent to the mean firing rate. The lower graph shows the count of ISIs at the driving period, indicating fine temporal following of the neuron. Numbers adjacent to each curve indicate the amplitude of vibrissa stimulation applied. Frequency tuning was observed in both the mean firing rate and in the fine timing of neural evoked activity. An increased mean firing rate was observed for stimuli ≥32 µm, while temporal following at the driving frequency was present only for larger amplitudes of stimulation, ≥48 mm. This finding parallels similar observations made in the primate somatosensory system. A graph of the incidence of ISIs at the fundamental resonance frequency, plotted as a function of the amplitude of stimulation (yellow indicates increased incidence) for the example in A. At larger amplitudes of stimulation, only firing at the fundamental resonance frequency was observed, as shown by the exclusive presence of ISIs at ~7 msec at 80 µm stimulation. In contrast, lower amplitudes of stimulation evoked ISIs at multiples of the driving period. A plot from a different single-unit trigeminal recording, showing the mean firing rate (red) and power at the driving frequency (blue). As in the example shown in A and B, temporal following provides a more precise tuning function at frequencies surrounding the vibrissa resonance frequency. First, that phasic excitation of the system occurred; second, that a given stimulus drove multiple nerve fibers; and third, that subpopulations of the driven nerve fibers were tuned for different aspects of the stimulus presented. Peripheral neurons respond in a phasic fashion to frequency-varying stimuli, and multiple fibers from a given follicle respond to a given vibrissa. Specifically, when a vibrissa is deflected by a high-frequency sinusoid, high-velocity transients are present on the ascending and descending phase of each cycle of stimulation and each of these high velocity transients occurs in an opposite direction. As discussed previously, the vibrissa sensory system is more sensitive to velocity transients than to the peak amplitude of vibrissa motion. As such, each single cycle of a high-frequency stimulus actually contains two events that the vibrissa sensory system will be optimally sensitive to, namely, two high-velocity transients in opposite directions. Both of these stimuli should drive neural activity in subpopulations of trigeminal ganglion neurons tuned for motion in opposite directions, and a given frequency of stimulation applied to the system should lead to a frequency doubling of the response in downstream representations where the inputs from these two neural subpopulations converge. This framework differs from the proposal made for the volley principle in hearing only in the sense that the vibrissa sensory system is less concerned with the frequency of the peak amplitude of motion of a vibrissa stimulus, and more sensitive to the frequency and direction of high-velocity transients in that stimulus. That said, fre- quency doubling has also been reported in the auditory nerve in response to low- frequency, high-intensity tones. The summed output of two neurons with these kinds of opposing tuning properties would provide a total of 250 Hz input to a downstream neuron that received input from both channels. The sharp directional tuning of trigeminal neurons obviously has several other consequences for stimulus encoding including enhancing the sensitivity of the system to high frequency changes in the direction of vibrissa motion. The firing pattern of a trigeminal single unit evoked by a 500 msec duration sinusoidal stimulus (125 Hz) is shown. On 2 separate trials, stimulation was initiated in either a dorsal or ventral direction: the red trace is the response to the initial dorsal deflection, the blue trace to the ventral. The responses of this unit are highly directionally tuned for motion in the dorsal direction, leading to precise firing in phase with stimulation in that direction. The previously demonstrated existence of a population of dorsal- and ventral-tuned trigeminal neurons suggests that a high frequency stimulus presented to the vibrissa will ultimately lead to a frequency doubling in the temporal input transmitted to higher neural centers. As such, a volley principle may exist for the transmission of information by the trigeminal nerve. Vibrissa Resonance and SI Temporal Coding Do these high-fidelity temporal signals reach SI? The most commonly reported effect of vibrissa stimulation in the 0–40 Hz range is profound adaptation of the mean firing rate in SI neurons. Two examples of this tuning are shown for neurons recorded in SI during high-frequency stimulation. In both examples, the mean firing rate response (top panel) was more broadly tuned than the vector strength (2nd panel, blue) around the vibrissa resonance (2nd panel, gray), suggesting an improvement of temporal coding at an amplitude level where saturation in rate coding has occurred. This cortical finding is in agreement with the sharper temporal tuning observed in trigem- inal responses (Figure 2. Further, there was limited evidence for frequency doubling, or vector strength at half the stimulation period (2nd panel, red), providing support for the description of the volley principle in the vibrissa sensory system described above. The finding of high-frequency fidelity in the response of fast-spiking units is in agreement with previous studies reporting higher firing rates and more precise following in thin spike neurons86 and suspected inhibitory neurons. VIBRISSA RESONANCE AND INTRINSIC NEURAL FREQUENCY TUNING Several studies have demonstrated the presence of intrinsically generated high- frequency oscillations (~200–600 Hz) in SI local field potentials that can be entrained to tactile input.

One study found Health study cautioned that garlic supplements could that DHEA had no effect on lymphocytes or p24 anti- reduce levels of a protease inhibitor that is used to treat gen levels purchase extra super avana 260 mg on line erectile dysfunction medication nhs. However purchase extra super avana 260mg overnight delivery erectile dysfunction treatment melbourne, a 2002 study found that it was as- AIDS patients, so patients should discuss using garlic sociated with a significant increase in measures that in- supplements with their physicians. One study of pregnant women with AIDS found able as soap, dental floss, toothpick, and mouthwash. Another study that patients who use marijuana had increased food in- found that 60 mg of vitamin A had no effect on CD4 take and weight gain. Vitamin A has been associated with tetrahydrocannabinol is licensed for treating AIDS faster disease progression. Beta-carotene supplementation has led tal state can have a direct impact on disease severity and to elevation in white blood cell counts and changes in quality of life. These include: carotene supplementation led to an increase in deaths • massage due to cancer and heart disease. AIDS pa- Antiretroviral treatment tients took a tablet that contained 31 herbs that was In recent years researchers have developed drugs based on the formulas Enhance and Clear Heat. The drugs are used in symptoms were reduced in the herbal treatment group as combination with one another and fall into four classes: compared to the placebo group. These drugs Herbals used in treating AIDS include: work by interfering with the action of HIV reverse tran- • Maitake mushroom extract. Patients with low white blood cell counts may be (ddC, Hivid), stavudine (d4T, Zerit), abacavir (Ziagen), given filgrastim or sargramostim. Protease inhibitors are effective Treatment in women against HIV strains that have developed resistance to Treatment of pregnant women with HIV is particu- nucleoside analogues, and often are used in combina- larly important because antiretroviral therapy has been tion with them. These compounds include saquinavir shown to reduce transmission to the infant by 65%. Three are avail- ment stresses aggressive combination drug therapy when able, nevirapine (Viramune), efavirenz (Sustiva), and possible. These drugs are less common, ex- initely using these and other drug therapies to boost the pensive and difficult to use. They block infection early immune system, keep the virus from replicating, and by preventing HIV from fusing with and entering a ward off opportunistic infections and malignancies. Patients with AIDS-related lym- change as new medications are developed and intro- phomas of the central nervous system die within two to duced. Department of Health and three months of diagnosis; those with systemic lym- Human Services revised its guidelines for the use of phomas may survive for eight to ten months. In America, these agents to help clinicians better choose the best the successful treatment of AIDS patients with HAART combinations. The new guidelines offer a list of suggest- has actually led to a growing number of people living ed combination regimens classified as either “preferred” with HIV. A recent study shows Most AIDS patients require complex long-term that HAART therapy substantially reduces risk of AIDS- treatment with medications for infectious diseases. This related pneumonia (PCP), although PCP still remains the treatment often is complicated by the development of re- most common AIDS-defining illness among opportunis- sistance in the disease organisms. Other recent studies show that these pro- nancies in the central nervous system usually are treated tease inhibitors may result in high cholesterol and put with radiation therapy. Most clin- Prophylactic treatment for opportunistic infections icians would say the benefits outweigh the risks anyway. AIDS patients with a history of Pneu- Prevention mocystis pneumonia; with CD4+ counts below 200 As of 2000, there is no vaccine effective against cells/mm3 or 14% of lymphocytes; weight loss; or thrush AIDS. Several vaccines to prevent initial HIV infection should be given prophylactic medications. In 2002, reports drugs given are trimethoprim-sulfamethoxazole, dap- showed a new “library” vaccine showed potential. In the cause many patients with AIDS suffer from abnormally same year, the British government worked with five low levels of both red and white blood cells, they may be African countries in a trial to find an effective gel that given medications to stimulate blood cell production. The study 38 GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 leaders believed if they could find a lotion that could be (AIDS). Stamford, CT: Apple- transmission, they would give women the ability to bet- ton & Lange, 1997. Acute retroviral syndrome—A group of symptoms Lymphoma—A cancerous tumor in the lymphatic resembling mononucleosis that often are the first system that is associated with a poor prognosis in sign of HIV infection. AIDS dementia complex—A type of brain dysfunction Macrophage—A large white blood cell, found pri- caused by HIV infection that causes difficulty thinking, marily in the bloodstream and connective tissue, confusion, and loss of muscular coordination. Antigen—Any substance that stimulates the body Mycobacterium avium (MAC) infection—A type to produce antibody. Hairy leukoplakia of the tongue—A white area of Pneumocystis carinii pneumonia (PCP)—An op- diseased tissue on the tongue that may be flat or portunistic infection caused by a fungus that is a slightly raised. It is caused by the Epstein-Barr virus major cause of death in patients with late-stage and is an important diagnostic sign of AIDS. Hemophilia—Hereditary blood clotting disorders Progressive multifocal leukoencephalopathy occurring almost exclusively in males. CD4 lymphocytes are a subset of T lympho- sue that produces painless purplish red (in people cytes.

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Figure 13-2 shows all the cate- ney removes excess water purchase 260 mg extra super avana free shipping impotence young male, acid purchase 260mg extra super avana fast delivery erectile dysfunction juicing, electrolytes, and urea gories of formed elements in a blood smear, that is, a (a nitrogen-containing waste). The liver removes blood blood sample spread thinly over the surface of a glass pigments, hormones, and drugs, and the lungs elimi- slide, as viewed under a microscope. For ex- of functions, including the formation of bone (calcium and ample, the level of glucose, a simple sugar, is maintained at phosphorus), the production of certain hormones (such as a remarkably constant level of about one tenth of one per- iodine for the production of thyroid hormones), and the cent (0. The plasma proteins in- Other materials transported in plasma include vita- clude the following: mins, hormones, waste products, drugs, and dissolved gases, primarily oxygen and carbon dioxide. The ancestors of The remaining 1% of the plasma consists of nutrients, all the blood cells are called hematopoietic (blood-form- electrolytes, and other materials that must be transported. Carbon monoxide is a byproduct of the incomplete burning of fuels, such as gasoline and other petroleum products and coal, wood, and other car- Erythrocytes bon-containing materials. The need for constant blood cell re- the hormone erythropoietin (eh-rith-ro-POY-eh-tin) placement means that normal activity of the red bone (EPO), which is released from the kidney in response to marrow is absolutely essential to life. Erythrocytes are different from other cells in that the mature form found in the circulat- Leukocytes The leukocytes, or white blood cells ing blood lacks a nucleus (is anuclear) and also lacks most (WBCs, or white cells), are different from the erythro- of the other organelles commonly found in cells. Occurring at a concentration in the red cells to hemoglobin (he-mo-GLO-bin), a pro- of 5,000 to 10,000 per cubic millimeter of blood, leuko- tein that contains iron (see Box 13-1, Hemoglobin: Door cytes are outnumbered by red cells by about 700 to 1. Therefore, the blood that goes from the lungs to the tissues is a bright red because it carries a great supply of oxygen; in contrast, the blood that returns to the lungs is a much darker red because it has given up much of its oxygen to the tissues. THE BLOOD ✦ 267 Box 13-1 A Closer Look Hemoglobin: Door to Door Oxygen DeliveryHemoglobin: Door to Door Oxygen Delivery he hemoglobin molecule is a protein made of four chains Hemoglobin allows the blood to carry much more oxygen Tof amino acids (the globin pzmolecule), each of which than it could were the oxygen simply dissolved in the plasma. This protein in red blood cells consists of four etary protein and iron are still essential to maintain hemoglo- amino acid chains (globins), each with an oxygen-binding bin supplies. They are present in all basic dyes and show lavender granules white blood cells, but they are more easily stained and ◗ Eosinophils (e-o-SIN-o-fils) stain with acidic dyes more visible in some cells than in others. The relative per- (eosin is one) and have beadlike, bright pink granules centage of the different types of leukocytes is a valuable ◗ Basophils (BA-so-fils) stain with basic dyes and have clue in arriving at a medical diagnosis (Table 13-2). Because the nuclei of the Table 13•2 Leukocytes (White Blood Cells) neutrophils have various shapes, these RELATIVE cells are also called polymorphs (mean- PERCENTAGE ing “many forms”) or simply polys. CELL TYPE (ADULT) FUNCTION Other nicknames are segs, referring to 54%–62% Phagocytosis the segmented nucleus, and PMNs, an Granulocytes 1%–3% Allergic reactions; defense against abbreviation of polymorphonuclear neu- Neutrophils parasites Eosinophils trophils. Before reaching full maturity 1% Allergic reactions; inflammatory re- and becoming segmented, the nucleus of actions Basophils the neutrophil looks like a thick, curved 25%–38% Immunity (T cells and B cells) band (Fig. An increase in the Agranulocytes 3%–7% Phagocytosis number of these band cells (also called Lymphocytes Monocytes stab or staff cells) is a sign of infection and the active production of neutrophils. They squeeze be- tween the cells of the capillary walls and proceed by ameboid (ah-ME- boyd), or amebalike, motion to the area of infection where they engulf the invaders. When foreign organisms invade, the bone marrow and lymphoid tissue go into emergency production of A Mature neutrophil B Band cell white cells, and their number in- (immature neutrophil) creases enormously as a result. A mixture of dead and living THE BLOOD ✦ 269 Bacterium Leukocyte Lysosome Bacterium Vesicle Lysosome Blood Digestive products Erythrocyte Capillary wall Epithelial cell Residue A B Figure 13-6 Phagocytosis. Hemostasis (he-mo-STA-sis) is the process that prevents blood loss from the circulation when a blood vessel is Checkpoint 13-8 What are the types of granular leukocytes? Activated platelets be- tiny structures are not cells in them- selves but rather fragments constantly Platelets released from giant bone marrow cells called megakaryocytes (meg-ah-KAR- Erythrocytes e-o-sites) (Fig. Serum contains all the com- The many substances necessary for blood clotting, or co- ponents of blood plasma except the clotting factors, as ex- agulation, are normally inactive in the bloodstream. A pressed in the formula: balance is maintained between compounds that promote clotting, known as procoagulants, and those that prevent Plasma serum clotting factors clotting, known as anticoagulants. The final step in these reac- ◗ Blood Types tions is the conversion of a plasma protein called If for some reason the amount of blood in the body is se- fibrinogen (fi-BRIN-o-jen) into solid threads of fibrin, verely reduced, through hemorrhage (HEM-eh-rij) (ex- which form the clot. One possible measure to tion are described below and diagrammed in Figure 13-8: take in such an emergency is to administer blood from ◗ Substances released from damaged tissues result in the another person into the veins of the patient, a procedure formation of prothrombinase (pro-THROM-bih-nase), called transfusion. There are many types of such than the lining of a blood vessel, for example, a glass or proteins, but only two groups are particularly likely to cause a transfusion reaction, the so-called A and B anti- gens and the Rh factor. Injury or removal of blood from vessels The ABO Blood Type Group There are four blood types involving the A and B antigens: Preliminary steps in clotting A, B, AB, and O (Table 13-3). THE BLOOD ✦ 271 Table 13•3 The ABO Blood Group System BLOOD RED BLOOD REACTS WITH PLASMA CAN TAKE CAN TYPE CELL ANTIGEN ANTISERUM ANTIBODIES FROM DONATE TO A Anti-A Anti-B A, O A, AB B Anti-B Anti-A B, O B, AB AB A, B Anti-A, Anti-B None AB, A, B, O AB O None None Anti-A, Anti-B O O, A, B, AB Testing for Blood Type Blood sera containing anti- Anti-A serum Anti-B serum bodies to the A or B antigens are used to test for blood type. Blood serum containing antibodies that can agglutinate and destroy red cells with A antigen is called anti-A serum; blood serum containing antibodies that can destroy red cells with B antigen is called anti-B serum. When combined with a blood sample in the laboratory, each antiserum Type A causes the corresponding red cells to clump together in a process known as agglutination (ah-glu-tih-NA-shun). In an emergency, type O blood can be given to any ABO type because the cells lack both A and B antigens and will not react with either A or B antibodies (see Table 13-3). Con- versely, type AB blood contains no antibodies to agglutinate red cells, and people with this blood type can therefore re- Type O ceive blood from any ABO type donor. People with this antigen are said to be Rh there is loss of a large volume of blood, for example: positive; those who lack this protein are said to be Rh neg- ◗ In the treatment of massive hemorrhage from serious ative. If Rh-positive blood is given to an Rh-negative per- mechanical injuries son, he or she may produce antibodies to the “foreign” Rh ◗ For blood loss during internal bleeding, as from bleed- antigens.

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The studies have to be buy extra super avana 260 mg low cost impotence urinary, at best discount extra super avana 260mg erectile dysfunction medications drugs, single blind, as a trained acupuncturist must do the needling. Difficulties also arise in determining an appropriate placebo for the control group. This factor is important, since as many as 30% of subjects may respond positively to some placebos. There is little consistency in the literature pertaining to the criteria used for acupuncture research. Sham acupuncture is commonly used for the control treatment in research trials involving acupuncture, but it presents a unique problem as a placebo. The well-outlined energy channels of the acupuncture meridian systems cover the entire body, linking Wei- Qi (defence Qi), Rong-Qi (growth and development Qi) and Yuan-Qi (the original Qi inherited at birth). As the meridian systems affect the entire body, the sham acupuncture does have some acupuncture effects. To try to address this difficulty, a placebo acupuncture needle has been developed. The placebo acupuncture needle retracts back into the handle of the acupuncture needle and does not 24 penetrate the skin. Chronic pain 25 Richardson and Vincent reviewed 27 controlled studies of acupuncture for treating acute and chronic pain, as well as several large uncontrolled studies. Of the patients, 50– 80% showed that short-term data made assessment of long-term effectiveness difficult. In a metaanalysis of 14 randomized controlled trials of acupuncture for chronic pain in adults, Patel and colleagues found that, while few of the individual trials demonstrated statistically significant benefit from acupuncture, the pooled results for several subgroups 26 attained statistical significance in favor of acupuncture. Acupuncture and traditional Chinese medicine 143 Low back pain Low back pain is not well defined, but involves a non-specific category of complaints of various causes. In a meta-analysis of 12 randomized controlled trials, acupuncture was found to be superior to various control interventions for the management of low back 27 pain. A randomized controlled trial of acupuncture versus TENS for chronic low back pain in the elderly revealed that both were equally effective. A randomized controlled study of 50 patients with low back pain showed that a significant decrease in intensity of pain occurred at 1 and 3 months in the acupuncture groups, compared with the placebo group. There was a significant improvement in return to work, quality of sleep and analgesic intake in subjects treated 29 with acupuncture. A recent randomized controlled study revealed significant improvement from traditional acupuncture in chronic low back pain as compared to routine care (physiotherapy), but not compared to sham acupuncture. The improvements included pain intensity, pain disability and psychological distress at the end of 12 weeks of treatment. At the 9-month follow-up, the superiority of acupuncture over the control 30 condition had lessened. Headache Acupuncture therapy for migraine headaches has also been reported to be effective in 31,32 several adult studies. A systematic review of 22 trials, including 15 migraine, six tension and one mixed, involving a total of 1042 patients, concluded that the existing 33 evidence suggests that acupuncture has a role in the treatment of recurrent headaches. In a randomized controlled trial of 168 women with migraine, acupuncture was shown to be adequate for migraine prophylaxis. Relative to flunarizine, acupuncture treatment 34 exhibited greater effectiveness in the first months of therapy and superior tolerability. Our experience also indicates that acupuncture can be a useful complementary therapy 35 for the management of pediatric headache. Temporomandibular joint dysfunction Three randomized controlled trials, involving 205 patients, of acupuncture treatment of temporomandibular joint dysfunction were all positive. Neck pain Several clinical reports have suggested that acupuncture might be useful for patients with neck pain. Fourteen randomized controlled trials involving 724 subjects with various causes of neck pain did not provide significant evidence in support of acupuncture for the 37 treatment of neck pain. There are too few trials of chronic neck pain of sufficient quality and homogeneity to be able to draw conclusions as to the effectiveness of the 38 treatment. A randomized controlled study of 177 patients with chronic neck pain were randomly allocated to five treatments over 3 weeks with acupuncture (n=56), massage (n=60), or sham laser Complementary therapies in neurology 144 acupuncture (n=61). Acupuncture was shown to be an effective short-term treatment for patients with chronic 39 neck pain. Myofascial pain syndrome Acupuncture may be useful for the treatment of chronic myofascial pain. In an uncontrolled study, Lewit reported immediate relief in 87% of cases and long-term 40 benefit in at least 92 of 288 cases. Melzack and colleagues reported a 71% correlation 41 between acupuncture points and trigger points used in the treatment of myofascial pain.

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