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Severe and permanent conditions 39 womens health questions answers 20mg female cialis with amex,900 to women's health bikini body meal plan purchase female cialis online now 63 women's health center knoxville tn purchase 10 mg female cialis overnight delivery,900 these injuries will be the most severe and will include where the movement of the elbow is restricted due to menopause vs pregnancy buy cheap female cialis online the ligament or muscle damage. Dislocation Some injuries require open reduction of the dislocation rather than the more common closed reduction. Complications can arise where vein damage also occurs due to swelling and the need to hold the elbow in a fexed position following reduction. Minor 21,200 to 40,700 these injuries will have substantially recovered and may have required the joint to be replaced back into the original position. Moderate 37,400 to 70,800 these injuries will have required manipulation of the joint back into normal position and may have taken longer to recover with treatment but with a full recovery expected. Upper Limb Injuries (cont’d) Severe and permanent conditions 55,400 to 75,300 these injuries will have required manipulation of the joint back into normal position and may have included more invasive treatment or even surgery to keep the joint in the position. Fracture – Radius and Ulna Bones It is more common to encounter fractures of both forearm bones rather than isolated fractures of either the ulna or radius. If caused by direct trauma the fracture line usually occurs at the same level in both bones. Minor 22,100 to 38,300 A simple fracture to either the radius, or the ulna, with no joint involvement which has substantially recovered. Moderate 37,700 to 40,000 Fractures to either bones, or more complex fracture to one of the bones or a displaced fracture with a full recovery expected with treatment. Moderately Severe 39,200 to 81,700 Multiple fractures that include joint which have resolved but with ongoing pain and stiffness which impacts on movement of the elbow joint or the wrist. Serious and permanent conditions 57,200 to 83,700 Complex and multiple fractures to the radius and ulna which required extensive surgery and extended healing but may result in an incomplete union and the possibility of having or has achieved arthritic changes and degeneration of the elbow or wrist joint which may affect the ability to use the arm. Wrist Soft Tissue Like other sprains, wrist sprains are sometimes classifed in grades: mild sprains involve some stretching of ligaments; moderate sprains involve partial rupture of a ligament while severe sprains involve complete rupture of a ligament. Although the injury may last for several months, a full recovery is the most common outcome. Minor up to 27,800 Minor sprains are mild injuries where there is no tearing of the ligament and often no wrist movement is lost, although there may be tenderness and slight swelling which has substantially recovered. Moderate 21,900 to 32,900 Moderate sprains are caused by a partial tear in the ligament. These sprains are characterised by obvious swelling, extensive bruising, pain, diffculty gripping, and reduced function of the wrist with a full recovery expected. Severe and permanent conditions 41,200 to 67,500 Severe sprains are caused by complete tearing of the ligament or a rupture, where there is severe pain, loss of joint function, widespread swelling and bruising, and the inability to bear weight. Dislocation the more complicated dislocations will involve serious and permanent conditions as well as treatment such as open reduction. They may have complications such as medial nerve compression and result in a permanent condition. Minor 19,800 to 43,500 these injuries will have substantially recovered and may have required the joint to be replaced back into the original position which has substantially recovered. Moderate 35,000 to 75,500 these injuries will have required manipulation of the joint back into normal position and will have taken longer to recover with extensive treatment but with a full recovery expected. Severe and permanent conditions 54,400 to 77,600 these injuries will have required manipulation of the joint back into normal position and may have included more invasive treatment or even surgery to keep the joint in the position. Upper Limb Injuries (cont’d) Fracture the wrist contains many bones (radius, ulna and eight carpal bones) all of which make up the wrist joint. In view of this complexity and variety it is diffcult to provide very specifc ranges for each “wrist fracture”. Fractures that involve the joint are usually considered more complicated than others due to the increased impact on movement. Minor 19,300 to 36,800 Simple non-displaced fracture to any of the bones of the wrist which has substantially recovered. Moderate 35,000 to 45,000 Simple or minimally displaced fractures with a full recovery expected with treatment. Moderately Severe 54,200 to 70,100 Multiple fractures that have resolved but with ongoing pain and stiffness which impacts on movement of the wrist. Severe and permanent conditions 68,400 to 78,000 Complex and multiple fractures to the bones within the wrist which required extensive surgery and extended healing but may result in an incomplete union and the possibility of having or has achieved arthritic changes and degeneration of the wrist and may affect the ability to use the hand. Hand Soft Tissue Like other sprains, hand sprains are sometimes classifed in grades: mild sprains involve some stretching of ligaments; moderate sprains involve partial rupture of a ligament while severe sprains involve complete rupture of a ligament. The injury may last for several weeks or several months but a full recovery is the most common outcome. Minor up to 21,700 Minor sprains are mild injuries where there is no tearing of the ligament, and often no movement is lost, although there may be tenderness and slight swelling which has substantially recovered. Moderate 21,900 to 43,700 Moderate sprains are caused by a partial tear in the ligament. These sprains are characterised by obvious swelling, extensive bruising, pain, diffculty gripping, and reduced function of the wrist and a full recovery is expected. Severe and permanent conditions 41,200 to 67,500 Severe sprains are caused by complete tearing of the ligament or a rupture, where there is severe pain, loss of joint function, widespread swelling and bruising and the inability to grip. Fractures Fractures to the hand (the metacarpal bone(s)) are described according to the site of the fracture. Minor 14,600 to 32,200 Simple fracture non-displaced fracture with no joint involvement which has substantially recovered. Moderate 30,200 to 64,800 Fractures to multiple bones in the hand or a displaced fracture with a full recovery expected with treatment Severe and permanent conditions 49,600 to 67,700 Complex and multiple fractures to the bones in the hand which required extensive surgery and extended healing but may result in an incomplete union and the possibility of having or has achieved arthritic changes and degeneration in the hand and may affect the ability to use the hand. Thumb and Fingers Soft Tissue Like other sprains, hand sprains are sometimes classifed in grades: mild sprains involve some stretching of ligaments; moderate sprains involve partial rupture of a ligament while severe sprains involve complete rupture of a ligament. Although the injury may last for several months a full recovery is the most common outcome. Thumb Minor up to 21,200 Minor sprains are mild injuries where there is no tearing of the ligament, and often no function is lost although there may be tenderness and slight swelling which has substantially recovered. Moderate 24,100 to 48,700 Moderate sprains are caused by a partial tear in the ligament. These sprains are characterised by obvious swelling, extensive bruising, pain, diffculty gripping and reduced function of the thumb with a full recovery expected. Severe and permanent conditions 35,600 to 57,300 Severe sprains are caused by complete tearing or rupture of the ligament, where there is severe pain, loss of thumb function, widespread swelling and bruising and the inability to bear weight. Finger(s) Minor up to 19,100 Minor sprains are mild injuries where there is no tearing of the ligament, and often no function is lost although there may be tenderness and slight swelling which has substantially recovered. Moderate 21,700 to 40,100 Moderate sprains are caused by a partial tear in the ligament. These sprains are characterised by obvious swelling, extensive bruising, pain, diffculty gripping, and reduced function of the fnger(s) with a full recovery expected. Severe and permanent conditions 33,800 to 51,300 these injuries will include multiple fngers of one or both hands to fall within this category. Severe sprains are caused by complete tearing or rupture of the ligament, where there is severe pain, loss of grip, widespread swelling and bruising and the inability to grip or have useful beneft of the fngers. Otherwise, it is most common for reduction to be attempted by closed means where the dislocation is manipulated and pushed back into its normal place. Thumb Minor 14,400 to 26,100 these injuries will have substantially recovered and may have required the joint to be replaced back into the original position. Moderate 28,900 to 50,600 these injuries will have required manipulation of the joint back into normal position and will have taken longer to recover with extensive treatment but with a full recovery expected. Severe and permanent conditions 41,400 to 59,000 these injuries will have required manipulation of the joint back into normal position and may have included more invasive treatment or even surgery to keep the joint in the position. Finger(s) Minor 12,800 to 22,400 these injuries will have substantially recovered and may have required the joint to be replaced back into the original position. Moderate 17,300 to 40,700 these injuries will have required manipulation of the joint back into normal position and will have taken longer to recover with extensive treatment but with a full recovery expected. Severe and permanent conditions 29,300 to 51,900 these injuries will have required manipulation of the joint back into normal position and may have included more invasive treatment or even surgery to keep the joint in the position. Fracture Most thumb and fnger fractures are simple fractures and are treated non operatively. Whether the fracture is open (breaks the skin) or closed will have a bearing on the compensation given. Complications such as non-union of fractures are rare but mal-union does sometimes occur with deformity and restriction of function.

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Metabolic acidosis women's health center methuen ma generic 10 mg female cialis visa, (Retrospective review; 32 patients) rhabdomyolysis pregnancy symptoms purchase female cialis 10 mg amex, and cardiovascular collapse after prolonged 148 breast cancer quotes of hope safe 20mg female cialis. Acute neurologic complications of drug and alco for the treatment of refractory status epilepticus pregnancy 0-9 months discount female cialis 10 mg with amex. The lack of effcacy trial; 36 patients) of phenytoin in the prevention of recurrent alcohol-related 132. Barbiturate anesthe Pathophysiology, differential diagnosis, evaluation, and sia in the treatment of status epilepticus: clinical experience treatment. Regarding prehospital care of the patient with letins of the American College of Obstetricians and Gynecolo seizures, which of the following statements is gists. The main priorities are airway management, blind study; 1687 patients) intravenous access, and protecting the 173. National High Blood Pressure Education Program Working Group Report on High Blood Pressure in Pregnancy. These patients have a signifcantly higher presents after a seizure mortality than the general population. He appears to have and no history of seizure disorder presents af responded to a 4 mg loading dose of lorazepam ter witnessed jerking of her extremities. What is the frst initial step in is the most important step in this patient’s this patient’s management Lock in your low subscription price today and continue to receive all these great benefts for up to fve years at the discounted price! With your paid renewal, you also receive the “Emergency Medicine Practice Audio Series Vol. Each section condenses the information you need to know into easily digestible 15-minute sessions. Target Audience: this enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents. Objectives: Upon completion of this article, you should be able to: (1) distinguish between generalized convulsive and refractory status epilepticus; (2) recognize alcohol withdrawal seizures; and (3) choose appropriate pharmacologic therapy for various seizure states. Discussion of Investigational Information: As part of the journal, faculty may be Practice now for $279 presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to (a savings of $50 off our promote off-label use of any pharmaceutical product. Toscano, and their related parties report no signifcant fnancial organized at the same time. Commercial Support: this issue of Emergency Medicine Practice did not receive any Call us at 1-800-249-5770 and use commercial support. Additional Policies: For additional policies, including our statement of confict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit. It covers a highly technical and complex subject and should not be used for making specifc medical decisions. This publication is intended for the use of the individual subscriber only and may not be copied in whole or part or redistributed in any way without the publisher’s prior written permission — including reproduction for educational purposes or for internal distribution within a hospital, library, group practice, or other entity. If there are fewer questions on your issue than listed here, leave the additional 5. Response codes: 5=strongly agree; 4=agree; 3=neutral; 2=disagree; 1=strongly disagree 1. E-mail address: We respect your privacy, and we hate spam as much as you do! It is characterised by the tendency to have repeated seizures that start in the brain. There are many diferent types of seizures, and their efects may difer from one person to another. If you spend tme with someone with epilepsy, for example if they are in your class or you are assessing the potental impact of their seizures and the support they may need, it is important to know about their seizures. It is also useful to know how to recognise their seizures and know what to do to best help them. Knowing how to help someone during and afer an epileptc seizure may help you feel more confdent if a seizure happens. The following informaton gives general guidance about how to help someone during a seizure, depending on the type of seizure and what is happening to the person. Having more details from the person themselves, such as what specifcally happens during a seizure, how they feel aferwards and what they would like you to do, helps you to best help them. How to help during a focal seizure In a simple focal seizure the person is conscious (awake) and aware of what is happening to them. The seizure could be twitching of one limb or part of a limb, an unusual smell or taste, a strange feeling such as a ‘rising’ sensaton in the stomach or ‘pins and needles’ in part of the body, or a sudden intense feeling of fear or joy. In a complex focal seizure the person’s consciousness is afected and they may be confused. You might notce them wandering around or behaving strangely and they may not know what they are doing. They may pick objects up for no reason, fddle with their clothes or make chewing movements with their mouth. Gently guide them away from any danger (such as walking into the road) and speak quietly and calmly so that they are not startled. They may be confused, so if you speak loudly or act forcefully this may confuse them more. They may mistake your help for being hostle, and be upset or respond in an aggressive way. It is a good idea to stay with them untl they have recovered and can safely return to what they were doing before the seizure. Call us for a large print version 1 How to help during a secondarily generalised seizure If a focal seizure develops into a generalised seizure (a secondarily generalised seizure) the person will become unconscious and will usually have a tonic clonic seizure. Generalised seizures In a generalised seizure the person usually becomes unconscious, and aferwards will not remember what happened during the seizure. How to help during an absence If the person becomes blank and unresponsive for a few seconds, and is not aware of what they are doing or what is happening around them. If necessary, gently guide them away from any danger, for example, if they are walking they may contnue to walk, but will not be aware of what they are doing. How to help during tonic and atonic seizures If the person’s muscles suddenly become stf (tonic seizures) they are likely to suddenly fall backwards. If the person’s muscles suddenly lose tone (atonic seizures) they are likely to suddenly fall forwards. Aferwards, it may be helpful to reassure them, and to check whether they have been injured and need medical help. How to help during myoclonic seizures Myoclonic seizures are brief jerks of a limb or part of a limb, and ofen happen shortly afer waking up from sleep. How to help during convulsive seizures In convulsive seizures the person may suddenly go stf and fall to the ground (a tonic clonic seizure). However, sometmes the person will not stfen at the start of the seizure (clonic seizure). Their breathing can be afected and they may go pale or blue, partcularly around their mouth. Although this can be frightening to see, these seizures are not usually a medical emergency. Usually, once the jerking has stopped, the person recovers and their breathing goes back to normal. During the seizure: • try to stay calm; • check the tme to see how long the seizure is going on for (because there may be a risk of status); • move objects, such as furniture, away from the person if they might hurt themselves; • only move them if they are in a dangerous place; for example, at the top of stairs or in the road; 2 • put something sof (like a jumper) under their head, or cup their head in your hands, to stop it hitng the ground; • do not restrain them, allow the seizure to happen; • do not put anything in their mouth – there is no danger of them swallowing their tongue during the seizure; and • try to stop other people from crowding around. When the jerking (convulsing) has stopped: • roll them on to their side into the recovery positon (see right); • wipe away any spit and if their breathing is difcult check their mouth to check nothing is blocking their airway, such as food; • try to minimise embarrassment. If they have wet themselves, deal with this as privately as possible; and • stay with them, giving reassurance, untl they have fully recovered. Some people recover quickly from a tonic clonic seizure but more ofen they will be very tred, want to sleep and may not feel ‘back to normal’ for several hours or sometmes days. Usually when a person has an epileptc seizure there is no need to call an ambulance.

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Establishing court watchers composed of lawyers and other members of the public to menstrual cycle chart discount female cialis 10mg fast delivery monitor serious crime cases can support 97 apolitical prosecutions pregnancy 37 weeks order 10mg female cialis fast delivery. Leading expert on issues of transnational organized crime Vanda Felbab-Brown cautions against opportunistic menstruation 7 days early order 20 mg female cialis overnight delivery, non-strategic law enforcement approaches to menstruation 10 days buy cheap female cialis 20mg on line drug interdiction. She writes: It is important to realize that indiscriminate and uniform application of law enforcement – whether external or internal – can generate several undesirable outcomes: First, the weakest criminal groups can be eliminated through such an approach, with law enforcement inadvertently increasing the efficiency, lethality, and coercive and corruption power of the remaining criminal groups operating in the region. Second, such an application of law enforcement without prioritization can indeed push criminal groups into an alliance with terrorist groups – the opposite of what should be the purpose of law enforcement and especially outside policy 98 intervention in West Africa (and elsewhere). Felbab-Brown’s warning highlights the importance of the softer side of counternarcotics efforts. Although a focus on interdiction with elite units and extraditions may bring short-term victories, they are not the only requirements necessary to bring about the systemic change needed to make African nations inhospitable for drug trafficking. The longer-term democracy, rights and governance programming implemented by development agencies has a crucial role to play in 95 Senate Committee on Foreign Relations, Confronting Drug Trafficking in West Africa: Hearing before Senate Committee on Foreign Relations, Subcommittee on African Affairs, Testimony by Michael Braun, 111th Congress, June 23, 2009. These broader reform efforts also address the underlying factors that facilitate illicit economic activities in general, helping to ensure that another illicit economy does not simply take the place of drug trafficking in the aftermath of successful counternarcotics efforts. An examination of unintended consequences could include the potential risk to civil society activists and journalists speaking out against the drug trade or the risk of perceived discrimination of changing eligibility criteria for political candidates. Other unintended consequences could include exacerbating human rights violations from prison crowding as a result of greater enforcement of drug laws that target only the low-level traffickers or heightened tensions affecting other aspects of U. Ameliorate Impacts the socio-economic impacts of drug trafficking, described in more detail in the section on identifying the development challenge of drug trafficking, include: (1) decreased economic growth due to drug trafficking-related instability or poor governance, (2) market distortions from drug money, (3) problematic drug use and associated health and societal problems, and (4) street crime. To ameliorate the economic impacts of drug trafficking, development efforts can focus on decreasing the circulation of drug proceeds in the country. Development efforts can generate support for anti-money laundering legislation. In addition to addressing money laundering, development efforts can support the development of accompanying banking and other sector regulations and improved supervision of relevant organizations. Development efforts can also help create a financial and regulatory environment that supports legitimate business development. Development actors also can play a central role in addressing the social impacts of drug trafficking. Especially where retail distribution and problematic drug use affect their current programming, Missions should consider new or modified programming to ameliorate these impacts. Development efforts to reduce demand entail education efforts to prevent drug consumption along with support to clinics, hospitals and community groups for treatment programs. Efforts to foster inclusion, reduce marginalization, and promote education, particularly among youth, can also help in problematic drug use prevention. Development efforts can also work to reduce individual-level violence related to the retail sales of drugs. Such efforts can include gang prevention and rehabilitation efforts, community policing, citizen security programs, and harm and demand reduction efforts. Similarly, if Missions are working to empower youth in communities affected by drugs, they may need to discuss the harms of drug abuse and offer drug counseling to youth. Missions should examine the potential unintended consequences for drug trafficking of their current and planned efforts and seek ways to mitigate any negative impacts. Development efforts could unintentionally foster drug trafficking by: (1) bolstering the power of those complicit in drug trafficking, (2) de incentivizing opposition to drug trafficking, (3) facilitating the movement of drugs, and (4) facilitating money laundering. To address these unintended consequences, Missions need to first understand the potential risks. In places with substantial drug trafficking, Missions need to be aware of the government institutions and officials who are complicit in drug trafficking through an assessment, basic research or discussions with U. In some instances, the programming may create such a significant crime risk that Missions may choose not to implement programming for infiltrated institutions. In other cases, the Mission may decide that the development gains from the programming outweigh the crime costs and may implement the program. In other situations, Missions may modify programs in a way to not bolster complicit actors or institutions. Some crime sensitivity efforts entail adding on a program component that explicitly considers the risks and engages stakeholders in mitigating it. Figure 6 below provides an example of each of these risks for unintended consequences and mitigation strategies. It is not just an issue in countries fraught with serious governance challenges like Guinea-Bissau but also in countries considered models of good governance in the region like Ghana and Mali, where drug trafficking exacerbated instability. Left unaddressed, the corrosion of governance could also result in future instability and hamper economic growth. In addition, the growing retail market of hard drugs in Africa can create significant social problems. Interdiction Alone Will Not Solve the Problem Although improved interdiction of drugs transiting through Africa plays an important role in addressing drug trafficking, interdiction alone will not solve the problems caused by the trade. First, efforts focused solely on interdiction may actually increase the prices of drugs and thus encourage 100 more drug trafficking. Interdiction must be accompanied by demand reduction efforts to help counteract the potential increased profitability from decreasing the supply of drugs. To effectively disrupt drug trafficking networks, attention must be given to ensure appropriate levels of political will, legal frameworks that facilitate an interdiction leading to the arrest of higher-level traffickers, and capacity within the criminal justice system to prosecute the individuals involved. Development Practitioners Need to “Get Smart” About Drug Trafficking Many development actors working in Africa have limited knowledge of the issue of drug trafficking in the region; however, the significant threats the trade poses to development cannot be ignored. Government to better understand the nature of the drug trafficking threat in their particular country. In particular, this type of information may be critical to adhering to “do no harm” principles by incorporating crime sensitivity in implementing procurement reform. Greater awareness of the issue of drug trafficking also can inform the Country Development Cooperation Strategy development process. These tools should be adapted for the specific context, and interview protocols and stakeholder lists should be developed in coordination with relevant Embassy colleagues. Early Identification of the Problem and Prevention Efforts are Critical Early identification of the problem and corresponding prevention efforts are critical to contain the threat. Africa can learn much from the experiences of instability in Guinea-Bissau and northern Mali as well as other places with longer histories of drug trafficking and consumption problems, including Latin America and the United States. In addition to the broader threats to political instability posed by drug trafficking, Africa’s demographic trends, including rapid urbanization and a youth bulge, concurrent with increased flows of drugs across the continent, raise serious concerns about the risks of increased levels of problematic drug use, violence and gang activity. Although it is difficult to garner support for these issues before they erupt as has occurred in Central America, early investments to prevent the spread of a retail drug market could significantly contribute to Africa’s future stability and prosperity. In addition, once the situation has escalated to instability and conflict as seen in Guinea-Bissau and northern Mali, development assistance will have a more limited impact. The situation in the Sahel highlights the importance of early diagnosis and response to the issue of drug trafficking, and calls for analysis of the issue in countries in the region. Political Will Must Drive the Counternarcotics Approach the level of political will within a country to address drug trafficking is a key determinant of the counternarcotics approach. Whereas Missions can support efforts to increase demand for counternarcotics measures without accompanying political will, they should only pursue supply-side efforts to improve governance where there is corresponding political will. When the highest levels of government are involved in drug trafficking, then there is little sense in investing in supply-side security sector or democracy, rights and governance programs that address the issue head on. In these contexts, direct counternarcotics efforts should focus on fostering political will to address the issue, including raising the awareness and capacity of civil society actors to advocate for counternarcotics efforts and diplomatic pressure. Efforts to build political will should address both the demand side by working with local populations and civil society organizations and the supply side by working with government officials. Initiatives designed to bolster political will – such as the Kofi Annan Foundation’s recently formed Commission on Drug Trafficking, Governance, Security and Development in West Africa – may also help strengthen national leaders’ resolve to address drug trafficking. In contexts where there is some government involvement in drug trafficking but pockets of political will, a careful analysis is needed to determine whether some institutions merit supply-side support. In particular, support for improved oversight within government institutions – targeting pockets of political will in the executive, legislative, or judicial branches – may make sense in this scenario. National or regional task forces, roundtables on drug trafficking, or emerging leaders programs may also be useful to strengthen the stance of reform proponents, depending on the context. Working with opposition parties who advocate counternarcotic measures may appear to be an attractive option, but is likely to be too sensitive for U. When drug trafficking involves mostly lower-level government officials, a range of supply and demand-side programs could be appropriate provided there is U. Government support for skills training, institutional strengthening, equipment, legal reform, and improved accountability measures could help reduce drug trafficking activity in a country.

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It has been reported that oxidative stress-induced changes in thalassemic erythrocytes can be attenuated by vitamin E [13] menstruation blood color purchase online female cialis. N-Acetylcysteine amide menopause yoga poses discount female cialis 10mg overnight delivery, a novel cell-permeating thiol was reported to women's health clinic gawler cheapest generic female cialis uk restore cellular glutathione and protect human red blood cells from oxidative stress [26] menopause 54 buy female cialis online. Oxidative stress is greatly increased in thalassemia because of the prolonged exposure to iron accumulation. Jetawattana Thalassemias, disorders of hemoglobin synthesis 18 Experimental design to test the hypothesis From the evidence of several studies, it is clearly indicated that oxidative stress, at least some parts, plays an important role in pathophysiologic status of thalassemia disease. In order to reveal and understand whether free radical initiated oxidative damage plays an important role in thalassemia, the research strategy should directly measure the levels of free radials and oxidative damage in blood components of normal and thalassemic mice. The correlations between free radical levels and oxidative damage will provide a clue underlying pathophysiology of the disease. More information underlying the mechanism of oxidative damage in thalassemia is needed. A long-term study of free radicals exposure to normal and thalassemic mice may help to determine the adverse effects of a certain levels of free radicals that develop severity of anemia and other complications. It might be useful to measure the levels of free radicals, oxidative products in vivo in thalassemia transgenic mice at different age to see whether free radicals and oxidative stress levels are influenced by age. A decrease in antioxidant enzyme has been detected in thalassemic patients suggesting that a deficient activity of antioxidant enzymes may play important role in at lease some thalassemia case. Increasing antioxidant activity will hopefully reduce oxidative stress down to minimal level. The mechanism of oxidative damage in thalassemia is likely to be complex, involving iron overload. Utilizing a case-control study design, determine the status of antioxidant, lipid peroxides in the presence or absence of iron chelating agent might provide information of mechanism which contributes to iron overload. Vitamin E is a major lipid-soluble antioxidant, and is the most effective chain-breaking antioxidant within the cell membrane where it protects membrane fatty acids from lipid peroxidation. These results suggest that providing appropriate nutritional supplements to the patients may prevent any complications from hemolytic red blood cells including significantly decreased need for blood transfusions. Therefore, it might be useful to investigate whether various kinds of supplementary antioxidants, such as vitamin C, E, beta-carotene, and the resultant antioxidant plasma status of these nutrients are associated with regression of oxidative damage of red blood cells. Jetawattana Thalassemias, disorders of hemoglobin synthesis 20 Summary the fundamental abnormality in thalassemia is impaired production of either the alpha or beta hemoglobin chain. Several theories of pathogenesis and severity of thalassemia disease have emerged including free radicals induce oxidative stress. Patients with severe thalassemia who receive regular blood transfusions become iron overloaded, which increases damaging free radical activity and lowers antioxidant levels in their bodies. General treatment strategies of thalassemia are blood transfusion and iron chelation. Besides the promising treatment of stem cell transplantation and gene therapy, an imbalance in the antioxidant protective mechanisms leading to oxidative stress in blood components suggests a new era of antioxidant therapy for thalassemia disease. However, more attempts to put forth the evidence for involvement of free radicals in pathophysiology of thalassemia and the potential of treatment with antioxidant and scavenger substances are still needed and required a combination of a multitude of disciplines. Kassab-Chekir A, Laradi S, Ferchichi S, Haj Khelil A, Feki M, Amri F, Selmi H, Bejaoui M, Miled A. Suthutvoravut U, Hathirat P, Sirichakwal P, Sasanakul W, Tassaneeyakul A, Feungpean B. G enetic servicesin H aw ai‘iare provided by board certi ed clinical geneticists, genetic counselors, and allied health providers. Haw ai‘iCom m unity G enetics Providespediatric and adultclinicalgenetic services Specialm ultidisciplinary clinicsinclude H em oglobinopathy and M etabolic Clinics. Box 28807 2083 Nicosia Cyprus Phone: (357) 22-319129 Nondiscrim ination in Service: F ax: (357) 22-314552 the Haw ai‘iDepartm entof Health providesaccessto itsactivitiesw ithoutregard to race, color, nationalorigin (including language), age, sex, religion, ordisability. M icroscopic red cellm orphology changesassociated Hem oglobin StructuralD efects w ith thalassem ia: analysisof data from H aw ai‘iThalassem ia Project. In casesw ith docum ented iron de ciency, iron therapy should be m onitored to avoid excessive treatm ent. M oderately severe form s of thalassem ia (Hb H disease, thalassem ia interm edia, and som e Hb E / thalassem ias) require ongoing m edicalcare. Yet, m any individualsw ho are fam iliarw ith anem ia caused • Im portantconsiderationsinclude adm inistering supplem entalfolic acid, avoiding oxidantdrugs by iron de ciency m ay notbe aw are of thalassem ia leading to anem ia. The patient • Sickle cellanem ia can be identi ed by hem oglobin electrophoresisalone, w hile m ay also develop sym ptom atic gallstonesand/orleg ulcers. Therefore, itisim portantto understand the strengthsand lim itationsof the differenttesting F orsevere form s of thalassem ia, therapeutic considerations include regulartransfusion m ethodsavailable forthe hem oglobinopathies. The detection and follow up forhem oglobinopathiesisa signi cantissue forH aw ai i. O ne should also be aw are • Allpatientsw ith these severe form sshould be cared thatindividualscan potentially inheritm ore than one type of hem oglobinopathy, leading to forby physiciansw ith expertise in the m anagem entof m ore severe sym ptom sand health outcom es. Ideally, centersthatprovide hem oglobinopathiesisessentialforhealth care providersin H aw ai i. The m aterialisbroadly organized into three m ain sections: • G enetic counseling fordecision-m aking assistance should be nondirective and objective. There are num erous laboratoriesnationw ide thatoffergenetic testing forthe hem oglobinopathies, including the Q ueen’s • Abnorm alred blood cellindicesshow anem ia G eneticsLaboratory located in H onolulu. Providing instructionsforhow to orderthese testsisbeyond the scope of this • Potentialhealth problem s protocolasgenetic technology israpidly advancing and localand nationallaboratory procedures and guidelineschange overtim. W e recom m end you contactthe appropriate clinicalgenetics • Regular, yearly appointm entsw ith the hem atologist health providerslisted in the resourcessection form ore inform ation once an individualw ith a hem oglobinopathy hasbeen identi ed in yourpractice. G enetic counseling strongly recom m ended forindividualsconsidering pregnancy Beta Thalassem ia M ajor a. Regularconsultation w ith hem atologiststrongly recom m ended • F am ily planning optionsavailable to personsaffected w ith beta thalassem ia. Hem oglobin C Trait • Clinically benign, no anem ia Positive screen resultfora hem oglobinopathy 4. Sickle CellTrait Results: • Nota disease • O ccursin about10% of AfricanAm ericans Recom m ended • Sickle celltraitisnotassociated w ith anem ia. F lighttravelisnotdiscouraged as ightcarrier cabinsare reportedly pressurized to 4,000-5,000 feet. PrenatalScreening and F am ily Planning • Com m on typesof eventsthatcan affectillnessinclude dehydration, alcoholconsum ption, high Thalassem iasand structuralhem oglobin variantsare m ore dif cultto diagnose orexclude during pregnancy altitudes, extrem e tem peratures, stress, and depression. A m ore thorough description of anem ia butcould potentially have a child w ith sickle celldisease. Sickle cellanem ia isthe m ostcom m on form of sickle celldisease, but otherform sof sickle celldisease exist. Thisisbelieved to be due to pastendem ic m alaria occurring in these areassuch thatindividualsw ith som e abnorm alhem oglobinsare m ore resistantto m alaria and m ore likely to survive. Alpha thalassem ia occursw hen one orm ore of the alpha globin genes S and hem oglobin C W orking G ene Non-w orking G ene • Alpha thalassem ia isdetected on the new born screen. Itisrecom m ended thatotherfam ily m em bersbe m ade aw are of theirrisk forinherited anem ia and thattheirfam ily seek geneticsservicesto discussthese concernsfurther. Thissection closesw ith intended • E lectrophoresisisusually H bE F (H bF E in new borns). H ydropsF etalis • Personsw ith beta thalassem ia traithave one gene forproduction of the usualam ountof beta chains 2. Alpha Thalassem ia Trait • Can be confused w ith iron de ciency because of m icrocytosis 5. Alpha Thalassem ia + AnotherH em oglobinopathy o M ild anem ia (H b 1-2g below norm al) 7. S-H ereditary Persistence of F etalH em oglobin • Usually seen in SoutheastAsiansorM editerraneans 4. Sickle Beta0 Thalassem ia • Such personshave one gene forthe production of hem oglobin S and one gene fordecreased production of beta chains. Beta m any people in H aw ai`iare of m ixed ethnic backgrounds, itisim portantto assessindividualsforalpha thalassem ia m ajorresultsw hen both copiesdo notw ork. O ver70 differentbeta chain thalassem ia using laboratory testsin addition to ethnic m arkers. Beta Thalassem ia M ajor • Inherited defectin beta chain synthesisresulting in a decreased 1. Hem oglobin H D isease • Anem ia isgenerally severe and the patientisdependenton chronic transfusion and chelation therapy.

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