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The best food sources are animal foods such as egg yolks rogaine 2 60 ml sale, organ meats such as liver discount rogaine 2 60 ml without prescription, whole milk and milk products order rogaine 2 60 ml otc, small fish with the liver intact buy cheap rogaine 2 60 ml, fish purchase rogaine 2 60 ml line, cod liver oil, butter, and ghee. The mother’s secretion of vitamin A into breastmilk is related to her own vitamin Astatus. The best plant sources of vitamin A are dark orange or dark yellow fruits and vegetables such as papayas, mangos, pumpkins, carrots, and yellow or orange sweet potatoes, and dark green vegetables such as spinach and kale. Food fortification This involves adding one or more vitamins and minerals to commonly consumed foods, especially those for children, with the purpose of preventing or correcting a demonstrated deficiency. It is difficult to fortify foods in Ethiopia because no staple food has been identified as widely consumed in the entire country. However, efforts are underway to fortify oils that are being produced in some of the larger factories. You read how to conduct testing of the salt that families consume in Study Session 4. Supplementation of iodine capsules to populations in areas where iodine deficiency in very common As a short-term strategy in highly endemic areas, iodised oil capsules should Iodine capsule dosages are: be distributed on a one-time basis to individuals. This will cover the recipients One capsule for pregnant women for one to two years until salt iodisation processes are in place. The strategy for the reduction of iron deficiency anaemia should be holistic and sustainable. For this to happen there is a need to involve relevant stakeholders from agriculture, education, information and other relevant 89 sectors in planning and implementation of priority programs. The main strategies are the following: Supplementation of iron and folic acid for pregnant and lactating women Pregnant women require a much higher amount of iron than is met by most diets and therefore it is important that they routinely receive iron supplements. In places where anaemia is high, supplementation should continue into the postpartum period to enable them to acquire adequate stores of iron. Six months during pregnancy where anaemia prevalence is less than 40% Folic acid: 400 mcg/day. Six months during pregnancy and three months postpartum where anaemia prevalence is equal to or more than 40%. If it is not possible for women to take iron and folic acid for six months in pregnancy, supplementation should continue into the postpartum period or the dose should be increased to 102 mg/day Supplementation for children and adolescents Many children from six to 24 months of age need more iron than is available in breastmilk and common complementary foods. Infants with low birth weight have fewer iron stores, and are thus at a higher risk for deficiency after two months of age. In areas where iron fortified complementary foods are not available for regular consumption, children should routinely receive supplements in the first year of life. In areas where anaemia prevalence in young children is 40% or more, delivery of iron supplements should continue through the second year of life, and also be given to adolescent girls. For example early on, during postnatal care and the well baby visits, you can talk to the mother about this. Other opportunities include school health programmes that you might advise on, or when you are providing family planning services and doing home visits. Treatment of severe anaemia If anaemia is diagnosed by clinical examination (extreme pallor of the palms Children with severe acute of the hands) or by laboratory tests at health centre, treatment is as set out in malnutrition should be assumed to be severely anaemic. Populations should be encouraged to produce and consume iron-rich foods throughout the country at all times. Health Extension Practitioners can play a significant role in promoting the introduction of iron-rich foods and improving consumption and storage of such foods. As you can read, the way food is processed and cooked has an impact on how well iron is absorbed. Animal sources of iron Plant sources of iron Animal products (meat, organs and The best plant sources of iron include blood) provide the best food sources of dark green leafy vegetables and legumes. If these are available, Legumes are also excellent sources of children six to 24 months of age and folic acid. Consumption of foods which pregnant women should have priority to are rich in vitamin A will also prevent include small amounts in their diet. Food processing techniques Animal products provide iron that is such as cooking, germinating, absorbed easily.

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Recently buy 60 ml rogaine 2 with mastercard, district surveys were carried out in India rogaine 2 60 ml amex, in the states of Maharashtra order 60 ml rogaine 2 mastercard, Tamil Nadu rogaine 2 60 ml with mastercard, and Karnataka effective 60 ml rogaine 2. Only well designed state level surveys, sampling new and previously treated cases separately, will be able to assist in ascertaining a baseline prevalence in these populations at the state level. India is developing a plan to conduct nationwide surveillance of drug resistance by state, starting with two states this year and gradually adding and re-surveying states over time, as has been done in China and is planned in Brazil. Prevalences of resistance among new cases from the first and third surveys were similar; however, the second survey found considerably higher prevalence of resistance among new cases. Resistance among previously treated cases (surveyed only in the last two surveys) decreased. Bangladesh constitutes another important gap in drug resistance information in the region and nationwide surveillance there should be a priority. The human and financial capacity of the national reference laboratory needs to be enhanced before proficiency testing can take place and a nationwide survey implemented. China has a progressive surveillance policy and has surveyed six of 31 provinces in the country, with a repeat survey completed in Henan, and repeat surveys planned in Guangdong, Zhejiang, and Shandong provinces. New surveys are under way in Inner Mongolia and Hunan, surveys of Beijing and Shanghai cities are due to start shortly, and surveys are planned in Xinjiang, Heilongjiang, and Chongqing. In both settings, misclassification was difficult to avoid because of previous policies, and this underlines the importance of rechecking records and reinterviewing patients during the course of a survey. Proficiency testing of provincial laboratories that have conducted or are preparing to conduct surveys takes place annually, even after the survey has been completed. Japan provided data from a 1997 nationwide sentinel survey and Mongolia from a 1999 nationwide survey, both showing relatively low prevalences of drug resistance. Resistance in Australia, New Zealand, and the South Pacific islands appears to be largely of foreign origin and low in magnitude at this time. This finding highlights the importance of giving greater attention to this group of patients in terms of treatment, reporting, and representative drug resistance surveillance. In general, the ecological analysis was inconclusive with the exception of the above finding. Despite the inherent weakness in ecological analysis of aggregate data, the conceptual model can constitute a step forward for more reliable and individual data collection. Ultimately the magnitude of the problem rests on the ability of a country to treat patients effectively. Failure to do so will result in a situation where a substandard level of care and irrational use of second-line drugs will continue to perpetuate the transmission of, and potentially amplify further, highly drug-resistant isolates of tuberculosis. The network has completed nine rounds of proficiency testing since 1994; cumulative results over the nine rounds generally indicate overall high performance of the network. Following an evaluation by the supranational laboratory, a decision is made on whether to carry out the survey or repeat proficiency testing. The network has recently agreed such criteria and details will be published in the coming year. Preliminary research has shown that at least one of the apparently borderline isolates was in fact a mixed culture containing one drug-resistant and one susceptible isolate; however, further exploration is warranted. There is a need for these costs to be met internationally to stabilize and enhance the network. The Laboratory Strengthening Subgroup seeks to assess and develop plans for improvement of entire national laboratory networks, with an emphasis on sputum smear microscopy. Improved laboratory networks will translate into improved diagnostic and treatment capacity, and more accurate surveillance of drug resistance. This is not always true of the data from individual sites, where the number of cultures examined is less than 1000, given that some drug resistance types show prevalences of 0. The total number of isolates examined is sufficiently high to guarantee statistical significance of both new cases and previously treated cases, even though all settings within some regions such as the Eastern Mediterranean and South-East Asia are not necessarily representative of the regions as a whole. The consistency of the findings argues for the robustness of the following conclusions. In patients with drug-resistant tuberculosis, additional drug resistance may develop if a prescribed multidrug regimen includes the drugs these patients are already resistant to. In this situation, some of these patients may end up effectively receiving monotherapy.

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Much of the blood pooled in the legs is displaced from the intrathoracic vascular area during quiet prolonged standing buy cheap rogaine 2 60 ml on line. This significantly reduces the volume of blood in the heart and the pulmonary circulation order rogaine 2 60 ml otc. Stroke volume and cardiac output fall significantly - a 20% decrease in cardiac output purchase 60 ml rogaine 2 amex. Abrupt fall in cardiac output is compensated by the cardiovascular responses best 60 ml rogaine 2; first purchase rogaine 2 60 ml online, by a reflex stimulation of heart rate through the sympathetic nerves, and secondly, by strong vasoconstriction in the splanchnic and skin area, that results in increasing the blood shunting to the thoracic area, and increasing peripheral resistance. However, these cardiovascular responses alone cannot fully 182 compensate for a change to standing position. The action of muscle pump is needed to exert external pressure on the veins and push the venous blood toward the heart. The rhythmic contraction and relaxation of skeletal muscles characteristic of vigorous running, cycling, jogging, or skiing are especially effective in activating the skeletal muscle pumping action of the legs. Aldosterone causes the retention of salt and water by the kidneys, which increases plasma volume and compensates to some extent for the fall in arterial blood pressure. At the same time, there is about 20% decrease in blood flow to the brain during prolonged standing, and in case the muscle is not kept contracting rhythmically, fainting is more likely to occur. During prolonged bed rest the entire body is affected by gravitational forces, often resulting in a temporary inability to changes in posture. Blood Volume and viscosity Blood volume normally remains constant, but decreases following hemorrhagic or traumatic shock; there is sharp drop in circulating volume, a fall in venous return, and a pronounced decrease in cardiac output and blood pressure. A rapid loss of 25% of the total blood volume in hemorrhage will reduce cardiac output to almost zero, causing circulatory shock. This results in inadequate tissue perfusion, resulting in progressive tissue damage. The damage involves the cardiovascular system as well as the other tissues of the body, so that the cardiac muscle, the blood vessels, and the vasomotor system degenerate, initiating a vicious cycle where by deterioration cardiovascular system becomes progressively incapable to supply the tissues with blood. Similar picture 183 develops if more than 40% of total blood volume is lost if the bleeding occurs more slowly from one to several hours. High altitude promotes increased red cell production and causes a mild polycythemia; people living at more than 4700 m have red cell count of 6-8 million per cu mm of blood. Acclimatization to high altitude also increases vascularity of the tissues that lowers total peripheral resistance and tries to counteract high red cell count and increased peripheral resistance. In plycythemia vera, the bone marrow becomes malignant and hematocrit may rise from a normal value of 40 – 45% to even 70 –80% blood viscosity rises sharply, peripheral resistance increases, and cardiac output falls. Anemia decreases viscosity, and together with the vasodilatation due to tissue hypoxia, causes a fall in total peripheral resistance and an increase in cardiac output, so that tissue at rest get enough oxygen, But heart has no reserve to use for the demands of exercise and severe exercise may result in heart failure. Blood Vessels The cardiovascular system is designed to provide widely varying metabolic needs under changing physiological circumstances, without overburdening the heart. These two factors: • Control blood flow and consequently regulate the cardiac output • Are influenced by such factors that control extra cellular fluid volume Microcirculation Microcirculation is the organization of the micro-size blood vessels that are present between the arterioles and venules; their number and size of these vessels vary significantly in deferent vascular beds, many of which have specialized features befitting 184 a special function. The vessels included in the microcirculation are: • Terminal arterioles • Meta -arterioles • Arterioles • Arteriovenous anastomoses • Capillaries • Post capillary venules The terminal arterioles are narrow muscular vessels, having a diameter of 35-50 microns and conduct blood directly into the meta arterioles; both the terminal arterioles are the resistance vessels of the microcirculation. Capillaries • Are the thin-walled exchange vessels forming a network linkage between narrow meta arterioles and wide-lumen venules. Fenestrated Capillaries: Have a very thin area of endothelial membrane stretched between adjacent endothelial cells. These fenestrations are not open holes but are closed by a thin diaphragm; these types are found in the capillary tuft /glomerulus of the kidney, in endocrine glands, and in the intestine providing very high permeability. There is no diaphragm between the adjacent endothelial cells that ensures rapid passage of substances through the capillaries e. Sinusoids: are more wide, more irregular in size and shape than capillaries; sinusoid structure is present in liver and the spleen; in the liver, the sinusoids are lined by an incomplete layer of fenestrated endothelial cell, which increases permeability still preventing passage of many small molecules, such as albumin. Postcapillary venules collect blood from the capillaries, have no muscle and elastic tissue like the capillaries; are wider than the capillaries (15-20 microns); some exchange seems to occur in these vessels; these vessels are very susceptible to inflammation. Viscosity and laminar flow According to the Poiseuille’s Law, viscosity is one of the parameter of resistances to flow.

Effect on Skin The deficeiency causes dryness and roughness of skin developing keratosis of hair folliciles with concomitant deficiency of Vit-B complex buy rogaine 2 60 ml without prescription. Osteoclastic activity is also hampered buy discount rogaine 2 60 ml line, causing defective bone formation Effect on general Metabolism Zinc is necessary to maintain normal plasma concentration of Vit A generic 60 ml rogaine 2 free shipping. This vitamin is also necessary for the conversion of trioses to glucose perhaps indirectly through adrenal cortex that synthesizes hormones concerned with Gluconeogenesis discount rogaine 2 60 ml with mastercard. It is a photolytic process involving no enzyme and slows down with aging because of the decrease of 7- dehydrocholesterol rogaine 2 60 ml sale. Hydroxylation at C21 takes place in the endoplasmic reticulum of hepatocytes in a non-regulating process. It crosses cell membrane bind to cytoplasmic receptor to form a complex, which is translocated to the nucleus. Ricketes is characterized by the production of soft pliable bones due to defective mineralization secondary to calcium deficiency. Vit D deficiency is also characterized by low concentration of calcium in blood in association with increased serum alkaline phosphatase. In adults the deficiency produce Osteomalacia due to decreased absorption of calcium and phosphorous, maintains a low plasma level resulting in weak mineralization of bones. Functions The main function of Vit E is as an antioxidant, in particular a membrane antioxidant associated with lipid membrane structure. It provides protection from the action of peroxides by converting them to a product that is conjugating with glucuronic acid and excreted in bile. Source: The richest source is vegetable oil, and nuts 180 Deficiency Vit E deficiency is a rare but found in complication of prolonged and severe steatorrhoea, and of prolonged parenteral nutrition. Deficiency of Vit E causes anemia in children with cystic fibrosis of pancreas are found to be tocopherol deficient as a result of stetorrhoea. It is required for post translational modifications of several proteins required in the coagulation cascade. Activation is carried out by the carboxylation of specific glutamate residues on the prothrombin by Vit K dependent enzyme. The presence of a second carboxyl group on the glutamate (γ- 181 carboxy glutamate) side chain confers phospholipids binding properties on the Prothrombin in 2+ the presence of Ca. However, it is found in patients suffering from Liver diseases (obstructive jaundice), in new born infants and in patients with malabsorption. The placenta is inefficient at passing maternal Vit K to the fetus and immediately after birth the circulation concentration drops, but recovers on absorption of foods. In addition the gut of the new born is sterile, so that the intestinal micro flora does not provide a source of vit K for several days after birth. This is the reason why adults who are on prolonged antibiotic treatment require supplementation of Vit. Warfarin, which inhibit the action of Vit K - probably via the mechanisms involved in the regeneration of the active hydroquinone. Tests to asses Vitamin K status include the prothrombin time-an important test in the investigation and management of jaundiced patients and of those on anticoagulant treatment. Sodium and Potassium: They are important in cell, muscle physiology, transmission of messages and other biological processes. Hyponatremia: It is common in patients who are in diuretics or excessive sweating, kidney disease, diarrhea and congestive heart failure. Other causes are decreased excretion by the kidney, diseases like Anuria, tissue damage or Diabetes Mellitus. Hypokalemia: Low potassium is not due to dietary deficiency but due to conditions like vomiting, diarrhea. Calcium and Phosphate: Major parts (90%) of them are found in the form of crystal lattice in the bone. People, who get enough sunlight, exercise regularly, on high protein diet, require 300- 400mgs per day. Clinical conditions: Hyper- calcemia; may be due to hyper parathyroidism, endocrine causes, renal failure and malignancies.

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