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By: Thomas Richard Gehrig, MD

  • Associate Professor of Medicine


Which of the following sets of values for repeat analyses of a sample (target value of 100) shows the least bias? Patient preparation and proper collection and handling of specimens are important preanalytical steps to anxiety xanax and copd proven 50 mg fluvoxamine ensure the validity of a test result anxiety pregnancy generic fluvoxamine 100mg amex. Automated instrumentation includes numerous algorithms to anxiety symptoms quitting smoking order cheap fluvoxamine online detect potential sources of error and alert the operator anxiety 25 mg zoloft order fluvoxamine 50mg without a prescription. Preanalytical errors are those that occur during sample collection anxiety symptoms weak legs buy fluvoxamine overnight delivery, transport or processing prior to anxiety questionnaire buy online fluvoxamine the analysis step. It is important that patients follow these instructions so that the test result can be compared in a meaningful way to the reference interval. For example, the reference interval for triglycerides is based on a specimen collected after 8?12 hours of fasting (no food or drink other than water). If a patient eats a meal or snack shortly before the blood sample is taken, the triglycerides may be higher than the reference range, erroneously suggesting that the patient demonstrates dislipidemia (abnormal concentration of a lipid fraction). Prolonged tourniquet application time can lead to unrepresentative amounts of certain substances in the specimen. These are mostly high molecular weight substances such as proteins, lipids and protein bound substances like calcium. Use of the wrong anticoagulant for a blood sample, or the wrong preservative for a urine sample, may lead to inaccuracies, either due to a failure to stabilize the analyte or by direct interference in the testing step. A patient specimen collected using a diferent type of tube may produce inaccurate results. For example, if 24-hour urine samples for calcium or magnesium testing are not adequately acidifed by the addition of hydrochloric acid or other acceptable preservatives, insoluble salts of these metal ions may form and precipitate out of solution. Since the test only measures the ions remaining in solution, the result will underestimate the actual amount. Some samples can be stabilized by refrigeration, some may require freezing, others may need protection from light, and still others might require analysis within limited timeframes. If a blood sample is not immediately placed on ice, the continued formation of ammonia during transport may cause falsely high results suggesting liver disease when no disease is present. Glucose, on the other hand, is consumed by blood cells when a sample of whole blood is stored at room temperature. Signifcant amounts of glucose can disappear in a matter of 30?60 minutes, risking a failure to recognize high glucose or to falsely identify someone as havingFigure 5-1. Sometimes it is not discovered that an assay is out of control until after patient samples have been analyzed. If the method fails to meet performance standards (?out of control), the results from testing patient samples will be erroneous. In this case, the cause of the problem must be identifed and corrected and then the patient samples retested. Part of the evaluation of test method accuracy includes evaluation of the efect of potential interferents. The indices representing these conditions are abbreviated by the letters H, I and L. Hemolysis results in the sample appearing red; icterus as yellow to brown; and lipemia results in a milky or turbid appearance. Qualitative visual scales, ranging from 1+ to 4+, indicate the relative degree of each of these conditions. E ect of the Presence of H, I or L the color or turbidity of the interferent can alter the readings taken by a spectrophotometer so the absorbance signal does not refect the true concentration of analyte. By taking absorbance measurements at the seven photometric measurements of absorbance at several diferent wavelengths. A mathematical algorithm can designated wavelengths, the concentrations of each of these then be used to compute the relative amount of each interferent and provide a semiquantitative estimate. This estimate can be made during the background reading time, before any active reagents are added, or as a separate test. For example, if the test for potassium has been found to be elevated when H > 2+, but not when L or I are elevated, the laboratory may decide not to report potassium results if H > 2+, or it may choose to report the result with a conditional statement indicating the result is likely to be overestimated because of the high H index. The presence of these antibodies (called heterophile antibodies) can lead to a falsely high or falsely low result. Patients may develop heterophile antibodies if they receive immunotherapies, a vaccine containing serum from another species, or even through environmental exposure. If a provider questions the result, it is possible to repeat the test adding an anti-heterophile antibody or a blocking substance that will bind to the heterophile antibody in the sample before analysis. The anti-heterophile antibody or blocking substance binds to the heterophile antibody in the patient sample and prevents it from interfering in the test. Some immunoassays include anti-heterophile antibodies or blocking agents in the reagents for the test, to reduce the possibility of interferences from heterophile antibodies in the patient sample. This approach is acceptable when only knowing that a result is elevated is sufcient for medical management. In such cases the usual approach is to dilute the sample and reanalyze a diluted aliquot of the sample, mathematically correcting the measured result by a dilution factor. For example, if the original sample is diluted by taking 1 mL of sample and adding 9 mL of an appropriate diluent (a term for the solution used for making dilutions), the measured result in the diluted sample will be multiplied by 10 to give the value for the original sample. Manual dilution and reanalysis steps are often undesirable because they are subject to human error such as mismeasurement, miscalculation and use of the wrong diluent. Some tests are sensitive to the diluent so the proper diluent and water, saline or even the zero calibrator may be required for specifc tests. Manual dilution and reanalysis can also introduce inefciencies such as delayed reporting of results and delays to other sample testing. Automated chemistry analyzers often include automatic dilution for determining the concentrations of out-of-range samples without human intervention. If the diluted sample gives a result that is in range, the instrument performs a calculation to correct the reported result with the dilution factor. While this process takes additional time for the dilution and reanalysis, it ofers the advantage of minimizing errors and promptly addressing the issue and providing a quantitative result for the sample within minutes. Two diferent read windows, the routine reaction read window and an earlier read window, may be monitored to observe the reaction rate. If the sample has a high concentration of analyte, the added enzymatic substrate reagent is quickly consumed, resulting in substrate depletion. The reaction no longer refects the true enzyme quantity or activity and cannot be measured. The result is reported as greater than linearity (too high to measure) or in some cases, if substrate depletion is not detected, as a falsely low result. This illustration explains the use of two read windows, a main or routine read window, and an earlier read window, to accurately determine the enzyme activity. For example, if less than three linear data points fall within the main read window, the system will use the earlier read window to calculate the result. FlexRate Extends Linearity of Enzymes By read window can use an algorithm to calculate the concentration of enzyme activity while the reaction is stillUsing 2 Absorbance Read Time Windows in the linear range. Early Rate Read Time Main Read Time 1 1 = Low Enzymatic Activity 3 2 2 = Medium Enzymatic Activity 3 = High Enzymatic Activity Photometric Reads Figure 5-4: Use of alternate read windows to extend linearity of enzymes FlexRate Description: 1. If the values are nonlinear, then FlexRate uses the absorbance from an earlier read (Flex) window to calculate the patient result. Examples of random errors include air bubbles or particulate matter in the sample resulting in pipetting a too small volume of sample. Fortunately, many automated analyzers are programmed to recognize the presence of bubbles, microclots, low sample volume or other random errors. Random Error From Bubbles, Foam or Precipitates for analysis can sense when the sample is not fowing at the expected rate, as it might be if impaired by the presence of a microclot, and generate a pressure monitoring error for the analysis. Instruments can recognize if the absorbance signal is not demonstrating the expected steady increase or decrease during the reaction time and is instead showing some random high or low values, as would be seen with a bubble or particle foating through the light path. When bubbles or clots or other random events lead to unexpected sampling or signal patterns, the instrument can alert the operator that this test result is suspect and needs to be retested. Panel A Panel B Read Read Window Window Time Time Expected absorbance increases are smooth, regular curves (Panel A). The presence of bubbles, foam or particle in the photometric window will cause sporadic high or low values (Panel B). A Test method incorrectly calibrated B Collection of blood in wrong kind of tube C Presence of interfering substance in specimen D Delay in sending the report to the provider 2. Which type of analytical error can be prevented by a good quality control program? A Instrument not properly calibrated B Presence of interfering substances in sample C Presence of bubbles in the light path of a photometric method D Analyte concentration so high it depletes the active reagent 3. A Instrument not properly calibrated B Presence of interfering substances in sample C Presence of bubbles in the light path of a photometric method D Analyte concentration so high it depletes the active reagent 4. What option(s) might be employed if a test result is above the upper limit of the test measurement range? Clinical chemistry tests measure a wide variety of analytes that refect many diferent organ systems and diseases. Some test results are specifc indicators for a single organ system or disease; others are general indicators of a disease or disorder, but do not pinpoint the specifc organ or disease process. Some tests help diagnose a disease, others monitor the course of the disease progression or efectiveness of therapy, and still others are used to screen for risk of developing a disease. This section gives only a sampling of some of the more common analytes that are measured in the clinical laboratory. These range from ions to small molecules to proteins (macromolecules) to lipids and lipoproteins that circulate in complexes containing hundreds of molecules and macromolecules. Reference ranges or expected results for healthy adult individuals are provided as a guide for discussion in this chapter. These values were sourced from the 5th edition of Tietz Fundamentals of Clinical Chemistry unless otherwise stated. These values may difer with diferent patient populations, regions of the world and assay methodologies, and should be verifed by laboratories prior to use. They are found in all body fuids both inside of cells and in extracellular fuids. They maintain osmotic pressure (pressure across membranes or between diferent fuid compartments) and fuid balance, and play an important role in many metabolic processes. These tests are most often ordered together to assess overall electrolyte balance often in critical care settings as well as in routine settings. Some conditions in which electrolyte balance is of concern include edema, weakness, confusion, cardiac arrhythmias, high blood pressure, heart failure, liver disease and kidney disease. Electrolyte panels often include a calculated value termed ?anion gap that may indicate the presence of unmeasured anions in the blood. Like the electrolytes, these ions are found in many diferent tissues and serve many diferent metabolic functions. Every living organism uses molecules as sources of energy, as building blocks for cells and tissue, and as metabolic sensors to control metabolism. Thousands of small molecules (for this section we will consider small as below a molecular weight of 1,000) are created and destroyed in metabolic processes every day. Those that circulate in blood or that are excreted in urine can be useful indicators of how well the body is functioning whether the patient is using and storing energy efciently, eliminating waste products, and is healthy. Several commonly measured small molecules include those that refect nutritional status, those that refect the elimination of waste products and those that refect metabolic control. Most proteins are large with molecular weights ranging from 30,000 to more than 500,000. Proteins that are the focus of clinical chemistry analyses are primarily those that circulate in the blood. These include plasma proteins, transport proteins, defense proteins and clotting proteins, which function primarily in the circulation and extracellular fuid. Most of these proteins are made by the liver, with the exception of immunoglobulins, which are made by immune cells (specifcally B lymphocytes). Other proteins sometimes found in blood are proteins whose primary functions are intracellular. They may have leaked from the inside of the cells where they were made and their presence in blood often refects some kind of damage to the cell. They recognize specifc antigenic structures on proteins, viruses or bacteria, bind to these and initiate a series of reactions (termed immune response) designed to disable and destroy the antigen. Monoclonal immunoglobulins are produced by a single line of white blood cells (T-cells) and all have exactly the same chemical composition, sequence and structure. Polyclonal refers to the aggregate collection of monoclonal immunoglobulins produced by many diferent T-cells lines. Increased levels of polyclonal immunoglobulins are found in infections and infammations, refecting a widespread immune response to the infecting agent. In these conditions, a single clone of T-cells has become malignant and produces excessive amounts of a single version of an immunoglobulin molecule. Complement tests are usually ordered to determine the possible cause of frequent infections or high levels of autoimmune activity. These tests, which do not measure specifc molecules involved in clotting, are usually not performed in the clinical chemistry section of the lab, but rather the coagulation laboratory. However, there are a few tests that measure specifc proteins in the clotting cascade. Their presence in blood is usually the result of enzymes leaking from damaged cells. The presence of these proteins can be used for screening, helping with diagnosis, staging of disease, monitoring efectiveness of therapy and providing evidence of recurrence. Most are used primarily for monitoring treatment and watching for evidence of recurrence. Tumor markers are typically measured using immunoassays and reference intervals are method specifc. Some of the analytes in the lipid risk profle may be elevated as a result of other underlying diseases like hypothyroidism, diabetes or kidney disease. It is important to rule out these possible causes of lipid abnormalities before treating these solely as cardiovascular risk factors.

The most likely exception to anxiety symptoms light sensitivity order 50mg fluvoxamine visa this is those genetic illnesses determined by genetic error anxiety symptoms 4 weeks buy fluvoxamine 50mg cheap, but even with these there is a chance that the overall medical condition of the patient will be better for a certain toning up of cellular metabolism anxiety symptoms red blotches generic fluvoxamine 50mg otc, such as Aloe can bring anxiety back pain order 50 mg fluvoxamine with mastercard. Some of the papers on the subject report that 100% of patients responded to anxiety yoga discount fluvoxamine 100 mg with mastercard Aloe or very nearly so anxiety symptoms for hiv buy fluvoxamine without a prescription. How does Aloe relate to specific Disciplines within Alternative and Complementary Medicine? Nutritional Medicine For the Practitioner whose prime field is Nutritional Medicine, Aloe vera can be seen in the role of a quite unique adjunct of the Therapy. Although Aloe is often advocated for its content of nutrients, this is not really a key point, nor even a very significant point at all about Aloe. Naturally, Aloe, being a plant juice, contains some protein, carbohydrate and lipid, contains minerals, such as calcium, magnesium, sodium and potassium, and some of the vitamins, but the amounts of these are low. Because Aloe is the juice of a plant which is adapted to water-storage, its juice is very dilute, the gel containing about 0. Given these low concentrations, and the modest volumes of the juice which are used for therapy, the quantities of nutrients taken in with a daily dose of Aloe, are very small compared to dietary intakes. These are substances which interact with living cells in very small amounts, producing significant changes to cell metabolism and cell behaviour. These substances interact with specialized receptors on the cell surface to produce these changes, in a way which might be described as ?pharmacological. Any practitioner who is a purist and, perhaps, does not much like the use of the word ?pharmacological in this connection, can rest assured that Man has always been exposed to active substances of this kind in his foods. Aloe itself, of course, is not a food, but pharmacologically active substances of the same general type are well distributed among unprocessed whole foods. None of our foods contain the same range of active cell-stimulating constituents as Aloe in the same proportions, but the principles involved in using Aloe are much the same as when one uses some foods as medicines. Naturally, much of what one does when using foods as medicines involves selecting the foods for their nutrient content. Unlike Aloe, we eat enough of various individual foods, or can do, to contribute significantly to the dietary supply of specified vitamins, minerals etc. The other aspects of food therapy, but one which is often forgotten, due to focusing primarily upon the nutrients, is the way that the various whole unprocessed foods contribute pharmacologically active substances which constantly stimulate or otherwise modify the behaviour and metabolism of our cells. We are used to the idea that food processing can damage our food by causing extensive losses of nutrients but, almost certainly, there is another huge area of understanding one which we are only just beginning to glimpse at the present time which concerns the way in which the processing of food damages these pharmacologically active substances which are in natural, unprocessed foods but which may be absent, or nearly so, from processed foods. The presence of special bioactive substances in plant-derived foods is the subject of two important books by Jean Carper the Food Pharmacy, 1989 and Food Your Miracle Medicine, 1993. Some of the components she identifies are nutrients and others simply have very powerful anti-oxidant effects, but is seems rather clear than some of them exert actions of a pharmacological kind. Just because the pharmacologically active substances in Aloe, and also those in foods, interact with cell surface receptors, and because drugs also do the same thing, there is no need whatsoever to regard these substances as being drug-like in their action. Not only do these natural therapeutic agents leave no residues in the tissues, but, since there are some such substances in foods, it is true to say that Man has evolved with a certain level of exposure to these substances as his normal experience. That is an experience which must have ranged over at least three million years of the history of Man. Indeed, the flowering plants (Angiosperms), which are the principal source of foods for mammals and Man today, themselves evolved over a somewhat longer time-scale from the Cretaceous period of some 100 120 million years ago. It is therefore very arguable that the tissue cells of Man have developed under conditions in which exposure to such stimulatory biochemicals has been expected, normal, and perhaps entirely necessary to survival. If so, the partial withdrawal of such substances from the diet, which is inherent in the switch to processed food, may well be catastrophic to the health of Man. The consumption of fresh fruit and vegetables, which is shown in national statistics of diet and food consumption, is actually very unevenly distributed between individuals. It is by no means surprising, therefore, if we find today that people in countries with a western lifestyle, Aloe, which has unique powers, and possibly other herbs also, where they contain concentrates of bioactive substances, are very badly needed to offset the loss of these actively stimulatory compounds from the food. Even more so, of course, they are needed to effect cures from chronic diseases among people who have followed the western lifestyle for many years. Aloe, of course, must be classified as an adjunct to the Nutritional Therapist, simply because Aloe itself is not a food. But it is a powerful one, containing more potent stimulatory substances than any food, in its own unique combination. The writer is both a practitioner of Nutritional Medicine and is engaged in the training of Nutritional Medicine Practitioners. His student / Practitioners almost all understand and most use the powers of Aloe. Its cleansing effect, which is so completely in accord with the precepts of the Western Naturopathic system of thought, is most probably mediated through the effects of Aloe upon the immune system and those which it exerts upon the alimentary system. The healing action depends partly upon the direct stimulatory effect upon fibroblasts and other cell types and partly upon the consequences of the tissues being better cleansed. For the dedicated naturopathic it is obvious to use a potent cleansing herb to augment the benefits of their other cleansing procedures. Herbalism To a herbalist Aloe is home ground, as it is unquestionably a herbal remedy. Herbalists should also note all that has been said above about the relative lack of nutrients in Aloe. It usually takes either foods or concentrated nutritional supplements to deliver a significant amounts of nutrients and the claim to do so with small doses of herbs is almost always misleading. Most active herbs, like Aloe, depend for their action upon pharmacologically active compounds present in small concentrations. The herbalist therefore needs to be aware of using the herbs for these specific biomedical effects which depend upon interactions between the living cell and the active compounds. In my experience, herbalists may be mainly scientific in their emphasis, or mainly naturopathic, using the herbs within either of these appropriate concepts. Whichever way the herbalist leans, he or she will usually be happy with the information about Aloe and the way in which it is very readily justified in either the scientific or the naturopathic mode. Iridology Iridology is a purely diagnostic discipline which only makes any sense when it is naturopathically interpreted, since the iris only yields information in naturopathic terms. Iridologists are therefore almost always either naturopathic, nutritional or herbal Practitioners who are used to using these various disciplines as a means of therapy once the iridology diagnosis has been reached. They will almost certainly find that Aloe has the strongest possible appeal to them as a powerful therapeutic tool, which will make real changes in the iris signs, which signify progress being made in identifiable parts of the body with cleansing, healing and the relief of inflammation. The writer is both a Practitioner of Iridology and is engaged in the training of Iridologists. Osteopathy And Massage Physical therapists obviously treat conditions which manifest as physical problems. These may arise from injuries or from metabolic deterioration of structural parts. Conditions which arise without any influence from outside physical trauma and are hence internally generated, usually have underlying causes from nutritional deficiencies or imbalance, toxicity and/or subtle energy imbalances. When osteopaths or masseurs treat a patient for a condition which results from injury they are faced with both damage and inflammation. Both the healing and anti-inflammatory actions of Aloe can be engaged at once to assist in these cases. It is, perhaps, in an adjunct role to the main therapy of the Practitioner, but in most cases it will be found to be a very potent and worthwhile adjunct. When the complaint is internally generated, osteopathy itself is likely to provide helpful treatment, without, perhaps, touching the metabolic disorders which lay at the foundation of the trouble. To deal with this problem some osteopaths and masseurs embrace naturopathic means of treatment as well as their main therapy. It should appeal to physical practitioners whether or not they have already adopted a naturopathic approach to aspects of their treatment. Its use calls for no additional training and, by its cleansing action and its various cell-stimulating actions, it will tend to help metabolic problems, even though the nutritional defects should never be ignored. Practitioners of therapeutic massage who do massage directed to the purpose of lymphatic drainage, have a particular reason for seeking the help of Aloe as an adjunct of their treatment. The cell-types of the lymphatic system are one and the same with those of the immune system. When the flow of the lymphatic vessels is stimulated by the massage, the flow through the lymph glands is necessarily improved. These important concentrations of lymphatic cells are thereby helped in their cleansing by the massage and if Aloe is used at the same time, then these two actions, both aiming at essentially the same end, will augment one another and the benefits may well be synergistic. Much that has been said in this section could also be said about other physical therapies, including the often distinctly non-Alternative field of Physiotherapy. Some Physiotherapists have nonetheless embraced some aspect of Alternative and Complementary therapy and hence may be able to gain in the same way from the use of Aloe. Acupuncture And Homeopathy these therapies are considered together here because they are prime energy therapies of great importance within the field as a whole. Aloe, so far as we know, does not become directly involved in the correction of subtle energy imbalances, but rather does so indirectly through relieving the Life Force from some of the burdens of toxicity and enhancing vitality through its stimulating actions upon tissue cells of different types. Therapists who are primarily subtle energy therapists will therefore regard Aloe as working upon a different level. Not all training courses for acupuncturists and homeopaths stress sufficiently the way that the flow of energy, whilst being helped by these therapies, can also be synergistically facilitated by employing nutritional means. Therefore some of these Practitioners may not have got into using Nutrition as the valuable adjunct which it is. Those who have not done so, or whose patients simply ?do not want to know about diet and vitamin supplements may well find Aloe an easy option to introduce, so far as patient acceptance is concerned, and should be well pleased most of the time, with the results. Those energy medicine Practitioners who do use diet and supplements as well should gain even more of a fillip to their treatments from employing Aloe as well. One needs to remember here that Aloe does not replace any aspect of Nutrition, so the benefits of Aloe plus Nutrition are generally found to be additive. The same observations I have made about acupuncturists and homeopaths apply also to those osteopaths who use cranial osteopathy and, through that version of their therapy, work directly upon the subtle energies of the patient. These Practitioners will probably want to ask, through their diagnostic techniques, whether Aloe should be used. The known effects of Aloe are, as we have seen in previous NewsLetters, so broad spectrum in their relationship to pathologies, that probably there will be few who are not diagnosed as requiring or benefiting from Aloe. Perhaps, however, these methods will be able to pick out the most prime cases for concentrating upon Aloe treatment. However, one can go much further and say that these diagnostic procedures will very frequently find labeled conditions for which treatment must then be found. If the diagnosed labeled condition is inflammatory, involves damage and therefore requires healing, involves the digestive system or else a need for fighting infection or tumours or requires cleansing action, then Aloe is likely to have a role. These Practitioners will either employ their technique and/or their equipment to help them decide, or may decide to use Aloe anyway, once the cause of the problem has been found. Much of what has been said in this section could also be applied to Practitioners who work via Dowsing and/or Radionics, in relation to their likely use of Aloe. They find sites of previously unsuspected chronic inflammation, disorders of the digestive system which were, perhaps, not clearly diagnosable before, and find organs which may be struggling with chronicity for reasons connected with nutrition, toxicity and subtle energy imbalances. Application of Aloe by these Practitioners is likely to have much in common with that of Practitioners of other diagnostic approaches, like the kinesiologists. They will be able to apply Aloe to conditions they have uncovered and make the Aloe synergize with their main therapy. Colonic Irrigation Any cleansing therapy can synergize with the cleansing action of Aloe. Aloe being taken by mouth during the same period when colonic washout therapy is being applied will strengthen cleansing effect simply by combining these two approaches to cleansing which operate in different ways, one, the Aloe, internally and the other essentially externally, bearing in mind that the colonic lumen is regarded as being outside the body. The benefits here will be much the same as those of combining Aloe with any other, distinctly different approach to cleansing, and the effects are almost certain to be synergistic. The colonics therapist can use Aloe directly in the washout fluid, or leave the Aloe containing fluid in contact with the bowel lining for a time, to work directly upon inflammatory conditions itself. Aromatherapy the effects of Aromatherapy are presumed to be partly subtle and partly physiological. The subtle energy effects of the Therapy will interact with Aloe indirectly, rather than directly, as in the case of energy therapies, acupuncture and homeopathy. Insofar as the effects of Aromatherapy are physiological, they will interact directly with Aloe, working at the same material level to augment cleansing and re-establishment of balance within the body. Of course, whichever of the above disciplines one practices, the use of Aloe is an addition to the rest of the therapy you are giving. It is something which the patient must do for themselves when they are not with you. For the osteopathic, massage, acupuncture or reflexology patient that might be a new departure since the main treatment is something which the practitioner does to them. For patients of nutritional medicine, herbalism and homeopathy, they are all used to the idea that the treatment involves regular administration of remedies or nutrients to themselves. The introduction of Aloe into treatment should not give any difficulty for any of these groups, since the administration is very easy, involving, in the case of Whole Leaf Extract, only measuring out and taking a small quantity of liquid one, two or three times per day. Topical Use the use of Aloe vera Whole Leaf Extract will be the usual form of treatment, since internal administration is usually required. However, application to the surface is a secondary form of application which will be wanted fairly often either instead of internal use or in addition to it. For application of Aloe to the skin, or to the accessible mucous membranes, creams and ointments have a long-standing role, both in home treatment and in hospital applications. Alternatively the concentrated Whole Leaf Extract can be applied topically also using either cotton wool pads, or other means. The ointments and creams are manufactured with ?body which helps them to adhere to the surface, but this very fact means that they usually have a lower Aloe content. Selection Of the Right Aloe Products For Practitioner Use Any user of Aloe should bear in mind the recent history of Aloe, which is that whilst it has marvellous credentials as a curative herbal remedy, it has been much abused by the unscrupulous acts of certain suppliers.

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The risk of scarring is an important factor when considering the type of treatment anxiety panic attack symptoms purchase 100 mg fluvoxamine free shipping. Try to anxiety symptoms tingling discount fluvoxamine 100mg with mastercard eat at least five servings of vegetables per day and at least one serving of fruit per day anxiety scale 0-10 buy generic fluvoxamine 50 mg on-line. Fried foods and trans fats such as milk anxiety after eating order fluvoxamine in india, milk products anxiety symptoms blood pressure discount 50 mg fluvoxamine mastercard, margarine anxiety ocd purchase 50 mg fluvoxamine visa, shortening, and other hydrogenated vegetable oils should be eliminated. Foods containing healthy omega-3 oils such as ground flaxseeds and sardines should be increased. Some people find that chocolate, caffeine, carbonated beverages, iodized salt, shellfish, wheat and/or milk products aggravate acne. Some people may benefit from a one to four-week liver detox diet based on fresh vegetables and fruit. Vitamins & Nutritional Supplements Vitamin A Vitamin A may help to reduce sebum production. However, high doses of vitamin A can carry a risk of decreased bone density, birth defects, headache, and muscle and joint pain. Like the modified vitamin A prescription drugs, vitamin A can cause birth defects. Vitamin A supplementation may not be necessary if there is adequate intake of beta-carotene, vitamin E, and zinc, all necessary for vitamin A formation. Decreasing unhealthy fats such as margarine, hydrogenated oils, processed foods, and other sources of trans fats can also improve absorption. Zinc Zinc, especially in the form of zinc gluconate or zinc sulfate, can help prevent acne. Zinc helps heal blemishes, reduces inflammation, and reduces androgenic hormonal effects on the skin. Two studies comparing zinc to the antibiotic tetracycline found zinc to be as effective as tetracycline. This vitamin is essential for the proper metabolism of steroid hormones and can reduce the sensitivity of skin to the effects of testosterone. Herbs An herbal blend that can help with acne consists of equal parts of the herbal extracts of sarsaparilla, yellow dock, burdock, and cleavers. Half a teaspoon per day of this blend can be taken three times per day combined with a healthy diet. Tea tree oil applied to acne lesions may help to eliminate bacteria and reduce inflammation. It can help to increase circulation and lymphatic drainage and speed the healing of blemishes. Allergies occur when the immune system overreacts to a normally harmless substance, such as pollen. Although there are many different Types: of allergies, including food and skin allergies, here we are talking specifically about allergies to airborne particles, known medically as allergic rhinitis. See a doctor immediately if you begin wheezing or have difficulty breathing, which could be signs of an asthma attack. Although it often begins with itching of the eyes or face, within minutes it can progress to such severe swelling that makes it difficult to breathe and swallow. How Diet Can Help the foods you eat can boost your immune system and prevent symptoms. A Japanese study assessed the possible protective effect of the traditional Japanese diet on allergies. They looked at 1002 Japanese pregnant women, and found that calcium, magnesium, and phosphorus were associated with a decreased prevalence of allergies. Getting enough calcium in your diet People with allergies may also have sensitivity to certain foods. For example, several studies have found that people allergic to grass pollens also react to tomatoes, peanuts, wheat, apple, carrot, celery, peach, melon, eggs and pork. To find out which foods aggravate symptoms of allergies in a particular individual, an elimination-and-challenge diet is recommended. This diet involves the removal of suspected foods from the diet for at least a week followed by systematic re-introduction of those foods in order to isolate the foods that may aggravate certain symptoms. How Herbs and Supplements Can Help Bromelain Bromelain is an enzyme found naturally in the stem of the pineapple plant. Precautions: If it is taken with water between meals on an empty stomach (one hour prior to or two hours after a meal), bromelain is believed to have an anti-inflammatory effect, which can help to decrease mucus and other allergy symptoms. Side effects, while rare, may include nausea, vomiting, diarrhea, and abnormal menstrual bleeding. Nettle Leaf (Urtica dioica) Nettle leaf, also called stinging nettles, are a popular remedy for allergies. In a double blind, randomized study of 69 people, 58 percent rated a nettle extract effective in relieving symptoms after one week. In addition, 48 percent found it equally or more effective than previous medicine. Dosages: A typical dosage for allergies is 300 mg one to three times a day of a freeze-dried nettle extract. Quercetin Quercetin is a compound found naturally in vegetables, such as onions and berries. People with allergies may benefit from quercetin because it has been found to inhibit the release of histamine and reduce inflammation. Quercetin is believed to work by stabilizing cell membranes so they are less reactive to allergens. Butterbur (Petasites hybridus) A randomized, double-blind study, 330 hay fever patients at 11 clinics in Switzerland and Germany received either a tablet of butterbur herbal extract three times a day (providing a total of 8 mg of the active petasine a day), the antihistamine Allegra once a day, or a placebo. The researchers found that the butterbur was as effective as the antihistamine at relieving sneezing, nasal congestion, itchy eyes, and other hay fever symptoms. How Acupuncture Can Help A German study published in the journal Allergy found that acupuncture may an effective and safe option for people with seasonal allergies. Patients who received the acupuncture and herbal treatment noticed an 85 percent improvement on a global assessment of change scale compared to 40 percent in the control group. However, for the over 14 million Americans who suffer from anxiety, there is a pervading sense of unease and even fear that diminishes their quality of life. Typically, people feel tension, worry, irritability, frustration, or hopelessness. The sympathetic nervous system (fight-or-flight) is activated, causing symptoms such as poor concentration, fatigue, poor sleep, and restless, irritable, feeling tense or on edge, and muscle tension. People may also notice changes in physical health such as headaches, jaw pain, dry mouth, chest tightness, poor digestion, irritable bowel, acne, sexual dysfunction, and heart palpitations. Other areas may be impaired the combination of chronic stress, poor sleep, poor diet, use of stimulants such as coffee, and long work hours can deplete the body and lead to condition holistic doctors call "adrenal fatigue". Decreased levels of the stress hormone cortisol, fatigue, dark under eye circles, weakness, frequent colds and flu, thin skin, and accelerated aging, and the feeling burned out characterize it. Treatments Conventional treatment center on anti-anxiety drugs such as Xansa or BuSpar. There is significant clinical evidence showing that it can be all that is needed in some cases. Other nutritional supplements used for anxiety include pantothenic acid, calcium, magnesium, and vitamin B complex. Herbs Kava Kava (Piper methysticum) is an herb that is used widely in Europe for nervous anxiety, tension, agitation, and insomnia. Native to Polynesia, kava appears to work in a similar way to prescription benzodiazepine drugs such as Xanax and Valium, with similar effectiveness. Nevertheless, it is best to use caution until you know the extent of its effects on you. The benefits are often noticeable within weeks, but some people notice improvement after as little as a week. Valerian Valerian is an herbal tranquilizer that is best known as a remedy for insomnia. People with serious health conditions, or who are taking prescription drugs for mood or neurological disorders should consult a qualified professional before taking Valerian. In an acute flare-up, the skin of the foot is red or white with scales, cracks, inflammation, cuts, and blisters. The fungus lives off dead skin cells and thrives in warm, damp environments, such as the floors around gym locker rooms and indoor swimming pools. Treatments: the tinea fungus is contagious and once it takes hold, it can be quite tenacious, so it is important to take the following steps to prevent re-infection. Tea tree oil can be applied directly to the skin three times a day, covering the affected area. Continue for two weeks after the fungal infection seems to have disappeared to ensure that it is eradicated. About 4 ounces of aloe vera gel to 1/2 teaspoon of tea tree oil can be combined in a spray bottle and applied twice daily. Grapefruit seed extract Grapefruit seed extract, which is available at health food stores, is reported to have significant anti-fungal effects. Apply this mixture to the feet every morning and night and cover them with old socks (tumeric will stain sheets and socks). After two weeks, if there are signs of improvement, continue with a once a day application of this mixture for another week. If there has been any discoloration of the skin due to the tumeric, it will fade within two weeks. The surrounding muscles constrict and mucus is produced, which both cause airways to narrow. It consists of shallow-breathing exercises designed to help people with asthma breathe easier. Description: the Buteyko Breathing Technique is based on the premise that raising blood levels of carbon dioxide through shallow breathing can treat asthma. A study involving 60 people with asthma compared the effects of the Buteyko Breathing Technique, a device that mimics pranayama (a yoga breathing technique), and a placebo. Researchers found people using the Buteyko Breathing Technique had a reduction in asthma symptoms. The use of inhalers was reduced in the Buteyko group by two puffs a day at six months, but there was no change in the other two groups. There have been several other promising clinical trials evaluating this technique. Omega Fatty Acids the primary inflammation-causing fat in our diets is called arachidonic acid. A German study examined data from 524 children and found that asthma was more prevalent in children with high levels of arachidonic acid. A study examining food diaries of 68,535 women found that women who had a greater intake of tomatoes, carrots, and leafy vegetables had a lower prevalence of asthma. Butterbur Butterbur is a perennial shrub that grows in Europe, Asia and North America. The active constituents are petasin and isopetasin, which are believed to reduce smooth muscle spasm and have an anti-inflammatory effect. Researchers at the University of Dundee, Scotland, evaluated the effects of the herb butterbur in people with allergic asthma who were also using inhalers. Another study examined the use of butterbur root extract in 80 people with asthma for four months. The number, duration, and severity of asthma attacks decreased and symptoms improved after using butterbur. More than 40 percent of people using asthma medication at the start of the study reduced their intake of medication by the end of the study. The butterbur plant contains pyrrolizidine alkaloids, which can cause liver damage. Only extracts in which the pyrrolizidine alkaloids have been removed should be used. Bromelain Bromelain is an extract from pineapples that is believed to be a natural anti-inflammatory. Researchers at the University of Connecticut found that bromelain reduced airway inflammation in animals with allergic airway disease. Boswellia the herb boswellia, known in Indian Ayurvedic medicine as Salai guggal, has been found to inhibit the formation of compounds called leukotrienes. A double blind, placebo-controlled study of forty patients, 40 people with asthma were treated with a boswellia extract three times a day for six weeks. According to the National Institutes of Health, back pain is the second most common neurological disorder in the United States?only headache is more common. If you have back pain, the first step is to be properly assessed by your primary care provider. Back pain has many causes, from muscle strain to more serious conditions such as a herniated disc, spinal stenosis, spondylosisthesis, osteoporosis, or a tumor, so it is important to find out what is causing the back pain. Acupuncture Research: A study conducted at Sheffield University in the United Kingdom looked at the long-term symptom reduction and economic benefits of acupuncture for persistent low back pain. Averages of eight acupuncture treatments were given to 159 people, while 80 people received usual care instead. After one year, people receiving acupuncture had reduced pain and reported a significant reduction in worry about their pain compared to the usual care group. After two years, the acupuncture group was significantly more likely to report that the past year had been pain free. According to traditional Chinese medicine, pain results from blocked energy along energy pathways of the body, which are unblocked when acupuncture needles are inserted along these invisible pathways. A scientific explanation is that acupuncture releases natural pain-relieving opioids, sends signals that calm the sympathetic nervous system, and releases neurochemicals and hormones.

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Overall 15 physicians contributing 211 patients (Genomic Prostate Score group 124 anxiety jealousy symptoms cheap fluvoxamine 50 mg without prescription, baseline group 87) participated in the chart review anxiety kit buy fluvoxamine 100 mg online. With Genomic Prostate Score the relative increase in active surveillance recommended was 22% (baseline 50% and Genomic Prostate Score 61% anxiety symptoms brain fog discount 50 mg fluvoxamine fast delivery, absolute increase of 11%) and the relative increase in use of active surveillance was 56% (baseline 43% and Genomic Prostate Score 67% symptoms anxiety 4 year old purchase fluvoxamine australia, absolute increase of 24%) anxiety symptoms 4 days order 50mg fluvoxamine visa. Treatment recommendations for active surveillance were directionally consistent with assay reported risk anxiety lack of sleep fluvoxamine 100 mg fast delivery. The relative increase in recommendations for active surveillance was 24% (absolute change 41% to 51%). The area under the receiver 184/512 Tumor Markers Medical Clinical Policy Bulletins | Aetna operating characteristic curve improved from 0. The study was conducted at a single large urology group practice and enrolled patients with a single insurance carrier. Oncotype Dx Prostate testing improves health outcomes in the investigational setting. The assessment stated: Published evidence is sparse and insufficient to draw conclusions on the. Also, the need for tissue which has previously been fixed for histological analysis is of some concern. The assessment observed that this is the most obvious reason for the relatively high number of patients for whom a valid test results could not be obtained. European Association of Urology (2015) prostate cancer guidelines state that genomics on the tissue samping appear "promising," but "further study data will be needed before such markers can be used in standard clinical practice. Although full assessment of their clinical utility requires prospective, randomized clinical trials, which are unlikely to be done, the panel believes that men with clinically localized disease may consider the use of tumor-based molecular assays at this time. Although full assessment of their clinical utility requires prospective, randomized clinical trials, which are unlikely to be done, the panel believe that men with low or favorable intermediate risk disease may consider the use of Decipher, Oncotype Dx Prostate, Prolaris, or ProMark during initial risk stratification. Future comparative effectiveness research may allow these tests and others like them to gain additional evidence regarding their utility for better risk stratification of men with prostate cancer. Selective use of these ancillary tests in patients with discordant clinical and/or pathologic findings may be appropriate. The guidelines also indicate that tissue based genomic biomarkers are not necessary for followup. The guidelines state that the Oncotype Dx Prostate test has not been validated as providing substantial benefit in the active surveillance population. These investigators reported on outcomes in the first 297 patients enrolled in the study with valid 17-gene assay results and decision change data. Secondary end-points included perceived utility of the assay and 188/512 Tumor Markers Medical Clinical Policy Bulletins | Aetna patient decisional conflict before and after testing; 1-year results were available on 258 patients. Shift between initial recommendation and shared decision occurred in 23 % of patients. This study was based on an interim analysis of the first 297 patients enrolled in a large (n = 1,200), multi-center prospective trial, and should thus be considered preliminary. Another drawback of the study was that patients were treated during an era when definitive treatment was standard of care with little adoption of active surveillance. First, some patients followed to 6 months had no follow-up data at 12 months, which may be due to patients seeking care elsewhere, an insurance change, or a small risk of mortality between 6 and 12 months. Charts from 6 months post-biopsy were reviewed for both cohorts to compare management received in the untested and tested cohorts. Patient characteristics were generally similar in the untested and tested cohorts. The untested cohort included a significantly larger proportion of intermediate-risk patients. The primary study outcome was biopsy up-grading, defined as an increase in the Gleason score from 3 + 3 to 3 + 4 or greater, which was analyzed by Cox proportional hazards regression. In addition, biopsy and prostatectomy specimens were evaluated locally without central review. An accompanying editorial asked "how do we know that similar improvements in decisional conflict could not have been achieved through the use of free, publically-available decision aids? The editorialists noted that the authors acknowledged that this study did not include men who elected active surveillance. Odds ratios considered strong in the research setting are not adequate for discriminating between subjects who do and do not experience the outcome at an individual level. The editorialists also observed that once challenge to tests such as Oncotype Dx Prostate that report on a continuum of risk is the lack of a clear, singular threshold that can rule in or rule out the projected outcome. The editorialist suggested that future studies report threshold values with very high specificity and sensitivity observed in the study population. The proprietary combination of antibodies used to capture circulating tumor cells is a potential limitation. Whether other methods of isolating prostate-cancer cells would yield similar results should be determined. Their prespecified statistical plan required a sample size of 36 taxane-treated men. These molecular alterations may indicate the emergence of treatment resistance and may be targeted for the development of novel agents for prostate cancer. In the last 8 years, many androgen receptor splice variants have been identified and characterized. Increasing evidences highlighted the concept that variant expression could be used as a potential predictive biomarker and a therapeutic target in advanced prostate cancer. Moreover, they stated that continued examination of this biomarker in prospective studies will further aid clinical utility. These investigators stated that prospective trials to validate these findings and further elucidate clinical utility are currently in development. An accompanying editorial (Montgomery and Plymate, 2016) noted that the assay used in this study may be less sensitive and 201/512 Tumor Markers Medical Clinical Policy Bulletins | Aetna specific than the assay used in the previously described studies by Antonorakis, et al. Relationships with survival were analyzed using multi variable Cox regression and log-rank analyses. In addition, it will be important to establish the biological explanation for these findings. Moreover, these researchers stated that a limitation of this study was that patients were not prospectively randomized to treatment based on the biomarker results, addressed in part through the use of risk scores in the analysis to mitigate confounding between treatment and underlying patient risk for which latent, unknown imbalances might not be captured by the included features. Studies must correlate response to treatment with assay positivity, and not just survival data, to ensure that the assay is not simply a prognostic biomarker. The authors searched in the Medline and Cochrane Library database from the literature of the past 10 years. Prostavysion ProstaVysion (Bostwick Labs) is a prognostic genetic panel for prostate cancer (Raman, et al. By examining these two markers, ProstaVysion is able to provide a molecular analysis of prostate cancer aggressiveness and long-term patient prognosis. Each subtype responds differently to standard therapies, and knowing the subtype allows doctors to tailor treatment for each patient. Assay performance characteristics of the commercially available version of the test indicate high reproducibility. The briefing also noted that the populations included in the patient cohorts included in these clinical validation studies. However, there is a lack of evidence establishing the clinical utility of this test in colorectal cancer. Recurrence risks at 3 years were 12 %, 18 %, and 22 % for predefined low, intermediate, and high recurrence risk groups, respectively. The assay was performed on formalin-fixed, paraffin embedded primary cancer tissue. Studies of the Decipher genetic test have evaluated its correlation with tumor characteristics (Den, et al. The impact of Decipher was evaluated in a clinical utility study where 21 uro-oncologists were presented 24 patient cases (12 potential candidates for adjuvant and 12 for salvage external beam radiation therapy) and were asked for treatment recommendations with and without information from the genetic test (Badani, et al. The recommendation changed in 43% of the adjuvant cases and 53% in the salvage setting, suggesting a potentially significant impact on treatment decisions after radical prostatectoy. In that study, 43% of patients shifted to observation based on information of Decipher genomic classifier after radical prostatectomy. It should be noted, however, that participants were community-based physicians rather than those with appointments at academic/research centers, and treatment strategies may deviate from standard practice. Consensus is emerging that long-term, prospective studies in diverse settings will optimize generalizable knowledge to inform best practices for such technologies. This approach and other recommendations for evidence development was recently recommended by a diverse and independent group of researchers, insurers, and policy-makers addressing the challenges of translating the promise of tumor biology research into practice. Using clinical 212/512 Tumor Markers Medical Clinical Policy Bulletins | Aetna information alone, observation was recommended in 42% of decisions made by urologists versus 23% by radiation oncologists (P <. Each urologist was asked to provide treatment recommendations on 10 cases randomly drawn from a pool of 100 case histories. However, the long-term impact of these changes in management is unknown (Bostrom et al, 2015). Spratt et al (2017) performed an individual patient-level metaanalysis of the performance of the Decipher genomc classifier in high-risk men after prostatectomy to predict the development ofmetastatic disease. Five studies (975 total patients, and 855 patients with individual patient-level data) were eligible for analysis, with a median follow-up of 8 years. The authors concluded that the Decipher test can improve prognostication of patients postprostatectomy. The authors stated that future study of how to best incorporate genomic testing in clinical decision-making and subsequent treatment recommendations is warranted. Dalela et al (2017) aimed to develop and internally validate a risk stratification tool incorporating the Decipher score, along with routinely available clinicopathologic features, to identify patients who would benefit the most from postoperative adjuvant radiation therapy. Pathologic T3b/T4 stage, Gleason score 8-10, lymph node invasion, and Decipher score > 0. The future will tell if this additional information is considered sufficient by the urologic and prostate cancer patients to change practice (Bostrom, et al. The guidelines state that the Decipher test has not been validated as providing substantial benefit in the active surveillance population. Future comparative effectiveness research may allow these tests and others like them to gain additional evidence regarding their utility for better stratification of men with prostate cancer. Klein et al (2016) evaluated the ability of the Decipher genomic classifier in predicting metastasis from analysis of prostate needle biopsy diagnostic tumor tissue specimens. A Cox multivariable proportional hazards model and survival C-index were used to evaluate the performance of Decipher. With a median follow-up of 8 years, 8 patients metastasized and 3 died of prostate cancer. The authors concluded that biopsy Decipher predicted the risk of metastasis at 10 years post-radical prostatectomy. These researchers stated that while further validation is needed on larger cohorts, pre-operative knowledge of Decipher risk derived from biopsy could indicate the need for multi modality therapy and help set patient expectations of therapeutic burden. This may reflect the fact that the test was originally developed to specifically predict for distant metastasis and generally only a minority of biochemical recurrences will lead to distant metastasis. The highest-grade core was sampled and Decipher was calculated based on a locked random forest model. With a median follow-up of 6 years among censored patients, 34 patients developed metastases and 11 died of prostate cancer. For predicting metastasis 5-year post-biopsy, Cancer of the Prostate Risk Assessment score had a c-index of 0. These researchers stated that the cohort size of this study was limited by access to biopsy tissue from community and referral health centers; 93 % of the unavailable cohort were either unavailable or had inadequate tissue and 7. Such information would be useful to guide decisions about treatment versus active surveillance. Finally, research is ongoing to determine the concordance between Decipher scores derived from biopsy versus prostatectomy samples, which has been reported in prior small studies to be 64 %, 75 %, and 86 %. Providers submitted a management recommendation before processing the Decipher test and again at the time of receipt of the test results. First, they were presenting interim data regarding treatment recommendations, which may not correlate with the actual treatment received. Final analysis of the current study will identify treatments received within 12 months of Decipher testing. Second, patients were their own controls; these researchers did not include a group unexposed to Decipher testing. Patients who have additional time to consider their clinical and pathological characteristics may have decisional effectiveness changes parallel with the current study findings. Spratt et al (2018) noted that it is clinically challenging to integrate genomic-classifier results that report a numeric risk of recurrence into treatment recommendations for localized prostate cancer, which are founded in the framework of risk groups. These investigators developed a novel clinical-genomic risk grouping system that can readily be incorporated into treatment guidelines for localized prostate cancer. Two multi-center cohorts (n = 991) were used for training and validation of the clinical-genomic risk groups, and 2 additional cohorts (n = 5,937) were used for re-classification analyses. Time-dependent c-indices were constructed to compare clinicopathologic risk models with the clinical genomic risk groups. In contrast, the 3-tier clinical genomic risk groups had 10-year distant metastasis rates of 3. The authors concluded that a commercially available genomic classifier in combination with standard clinicopathologic variables could generate a simple-to-use clinical genomic risk grouping that more accurately identifies patients at low-, intermediate, and high-risk for metastasis and can be easily incorporated into current guidelines to better risk-stratify patients. First, although these men have poor oncologic outcomes, there is a lack of consensus for the definition of very-high-risk disease and thus, it was not included in 220/512 Tumor Markers Medical Clinical Policy Bulletins | Aetna American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology 2017 guidelines. Lastly, a potential source of bias that was present in this retrospective cohort was that the samples analyzed were typically older than 10 years. Thus, it was possible that samples with larger tumor burden were more likely to be analyzed successfully.


  • https://ehjcimaging.oxfordjournals.org/content/ejechocard/10/1/i11.full.pdf
  • https://web.duke.edu/pathology/siteparts/avaps/05.10.1_Pathology_of_Ischemic_Heart_Disease_Final.pdf
  • https://www.intersocietal.org/echo/standards/IACAdultEchocardiographyStandards2017.pdf
  • https://www.quinnipiaclawjournals.com/content/dam/qu/documents/sol/law-journals1/law-review/volume-34/consolidated-pdf/quinnipiac-law-review-volume-34-issue-4.pdf
  • http://solaci.org/_files/esc2019/complete-articulo-original.pdf

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