Loading

← teresacarles.com

Vardenafil


"Order vardenafil with visa, erectile dysfunction doctor malaysia."

By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

Serum prolactin levels should be measured in the identification of other pituitary tumors or processes patients with low testosterone levels may have important clinical implications for the patient combined with low or low/normal luteinizing beyond testosterone deficiency erectile dysfunction workup aafp purchase discount vardenafil. Of these four men impotence with lisinopril buy vardenafil 20 mg online, two literature fails to erectile dysfunction 3 seconds buy vardenafil from india support any specific level of prolactin 180 were known to erectile dysfunction kidney stones discount vardenafil generic have pre-existing gynecomastia. An evaluation for a prolactinoma Finally, a randomized trial of 76 men (mean age 50. There was only 1 reported case should undergo a baseline measurement of Hb/Hct of gynecomastia in the treatment arm (n=35) at follow (Appendix C). If the Hct exceeds 50%, clinicians should up compared to no cases in the placebo group consider withholding testosterone therapy until the (n=35). In men with elevated Hct and high oninterested in fertility should have a treatment testosterone levels, dose adjustment should reproductive health evaluation performed be attempted as first-line management. Participants (N=451) received 5-10g of 1% 190 A 2005 meta-analysis by Calof et al. Clinicians should inform testosterone deficient 249, 251, 255, 257, 260, 262-265, 267-289 as compared to men with patients that low testosterone is a risk factor normal testosterone levels. Patients should be informed that testosterone therapy may result in improvements in Currently available literature has consistently shown erectile function, low sex drive, anemia, bone that low testosterone levels are associated with an mineral density, lean body mass, and/or increased incidence of major adverse cardiac events depressive symptoms. This may underestimate the true and explained, can increase their Hb and/or Hct levels benefits of therapy as long-term prospective data while on testosterone therapy. At the present time, compared to 15-19% (explained 19%, unexplained there are insufficient data available to predict which 15%) on placebo. Whether the changes in both these which included measures of both desire and erectile studies represent a clinically meaningful improvement function, improvements in 10/12 measures of sexual is unclear. Patients should be informed that the evidence testing, such as parathyroid hormone, calcium, and is inconclusive whether testosterone therapy vitamin D levels, may be required. Testosterone therapy has demonstrated indeterminate benefits for several symptoms that are associated with Lean Body Mass. In men with testosterone testosterone deficiency, including cognitive function, deficiency, testosterone therapy results in increased measures of diabetes, energy, fatigue, lipid profiles, lean muscle mass and reduced fat mass, but no overall and QoL measures. Although there were an insufficient number of studies to confirm statistically Cognitive Function. Overall, only one of the trials (N=22) months’ duration reported non-significant demonstrated a significant improvement in a single improvements (0. Despite clinical experience that some depressive indices with no impact on anxiety. Overall, Compared to placebo, no significant changes were seven studies reported no benefits on QoL in men using noted with testosterone therapy, including when the testosterone therapy compared to placebo,199, 205, 212, 225, data were evaluated as a continuous or dichotomous 226, 230, 303, 318 while five studies demonstrated (fi4 point change) variable. The long-term impact of exogenous change regarding energy level, men receiving testosterone on spermatogenesis should be testosterone were significantly more likely to rate discussed with patients who are interested in changes as a little or much better compared to placebo future fertility. Evidence Level: Grade A) these findings highlight the limitations of standardized questionnaires in the assessment of energy. In both While the vast majority of healthy men with normal trials, scores in the placebo cohort increased by a testosterone levels will recover sperm production after relatively large amount (placebo: 6. This is a relatively study population, the spermatogenesis results might common condition that affects approximately 1:500 not be generalizable to patients with testosterone 332 males and is characterized by hypergonadotropic deficiency. The need to be made aware of the highly variable time controversy surrounding prostate cancer and course to recover sperm in the ejaculate and the testosterone stems from the work of Dr. Charles variable degree to which spermatogenesis returns after 331, 333 Huggins who discovered that treating metastatic stopping exogenous testosterone. Intratesticular 31 Copyright © 2018 American Urological Association Education and Research, Inc. At the end of study the total number of prostate cancer in the untreated patient or recurrence in the related events was significantly greater in the treated patient. When individual prostate accumulating evidence against a link between events were analyzed separately, there was not a testosterone therapy and prostate cancer development. At therapy is not safe for use in prostate cancer patients, the end of follow-up, 10 men who were on testosterone the decision to commence testosterone therapy in men treatment (n=1,372) were diagnosed with prostate with a history of prostate cancer is a negotiated cancer, compared to 9 men in the placebo arm decision based on the perceived potential benefit of (n=1,136). Morgentaler is based on the concept that prostate Another meta-analysis by Calof et al. From a clinical cause prostate events in men who were on exogenous standpoint, it dictates that there is a testosterone testosterone treatment as compared to men who were threshold beyond which prostate cells (benign or on placebo. In-vitro experiments physiologic levels of testosterone or if participants were have shown that prostate cancer cells fail to proliferate using androgens other than testosterone. Three of the treatment group versus 8/49 in the reference group these men were brachytherapy patients alone, did not (p=0. There has been a concern that testosterone on testosterone therapy do not experience recurrence therapy might cause progression of previously existing, of prostate cancer. At the conclusion of the study, no Another retrospective study (Morgentaler 2011) men who were on testosterone therapy had a major followed 13 men (mean age 58. Patients should be informed that there is no infarction, stroke, cardiovascular-related definitive evidence linking testosterone death, all-cause mortality). Men who are on randomized, double-blind, placebo-controlled study that testosterone therapy should be advised to report the showed that men who received transdermal occurrence of any possible cardiovascular symptoms, testosterone (n=106) were significantly more likely to such as chest pain, shortness of breath, dizziness, or have a cardiac related event than those on placebo transient loss of consciousness, during routine follow-up 194 (n=103). At the end of the study, total testosterone increased in both Given the conflicting nature of the evidence, the Panel groups with neither group deriving more benefit than cannot definitively state that there is an association the other (p fi 0. All men with testosterone deficiency should be levels than men who underwent calorie reduction or counseled regarding lifestyle modifications as 378, 379 exercise programs alone. Treatment of Testosterone Deficiency Clinicians should counsel patients that lifestyle modifications should be undertaken for the benefit of 22. A study of 118 the Panel recommends that patients on all modalities overweight and obese men with normal total of testosterone have their symptoms/signs re-evaluated testosterone levels (>350 ng/dL) placed subjects on within three months after the commencement of 36 Copyright © 2018 American Urological Association Education and Research, Inc. In the uncommon circumstance the 300 mg and 600 mg weekly doses (producing nadir where men have prior available off-therapy testosterone levels in the range of 1,800-3,300 ng/ testosterone laboratory data considered reliable (early dL). The final analysis suggested old healthy men (n=3690) in Perth, Australia that the effects of testosterone alone on established a reference range of 283-454 ng/dL (mean 381 spermatogenesis varied widely. The general trend 361 ng/dL) while other randomized trials of indicated that higher doses of testosterone were more testosterone therapy in older men have achieved onlikely to result in azoospermia than lower doses, treatment mean total testosterone levels in the range 202, 226, 229 however a dose-response effect was not consistently of 430-600 ng/dL. A larger study that examined the contraceptive efficacy of testosterone-induced azoospermia in men was 37 Copyright © 2018 American Urological Association Education and Research, Inc. Its use is also associated with liver toxicity, study subjects (n=390) and 157 men became including abnormal liver function tests, cholestasis, and azoospermic during the 12-month follow-up period jaundice. Several case of studies that evaluate cardiovascular risk associated reports have identified virilization and precocious with testosterone therapy, most of which have excluded puberty in children as well as hyperandrogenism in men who had a history of a cardiovascular event within women following accidental exposure to topical the preceding three to six months. Methyltestosterone is an oral androgen 38 Copyright © 2018 American Urological Association Education and Research, Inc. The authors report that clomiphene resulted in significantly higher serum testosterone levels than anastrozole, but anastrozole resulted in significantly higher T:E ratios than clomiphene. Thus, thromboembolic events hypothalamic pituitaryincluding deep venous gonadal gonadotropin release thrombosis and stroke is increased. Considerable variation in testosterone and the subsequent decrease in dosages and in ingredients results. Although steady-state levels are generally potencies ranging from 68-268% of labeling claims. Two pharmacies provided samples Panel recommends that this be completed no earlier with >20% of the prescribed dose, while one contained than three to four cycles. As such, even such a strategy is convenience for patients and if consistent testosterone levels could be achieved, clinicians, although such timing has no ability to define providers issuing prescriptions for compounded peak and trough levels. Similarly, in the event patients testosterone (testosterone undecanoate) should have have unexplained anemia that improves on blood work tested once steady state levels have been testosterone therapy, continuation can be considered achieved. Testosterone undecanoate is typically reeven in the absence of other symptom improvement. The first testosterone measurement should be obtained two to four weeks after initial implant to determine if the number of inserted pellets needs to be increased or decreased to achieve the appropriate therapeutic level. Given anecdotal concerns about clomiphene citrate-associated tachyphylaxis, it is recommended that patients using this therapeutic approach have total testosterone measured as outlined previously. Testing intervals are the expert opinion of the Panel and are provided as a guide to aid clinicians in the follow-up of such patients. Clinicians should discuss the cessation of testosterone therapy three to six months after commencement of treatment in patients who experience normalization of total testosterone levels but fail to achieve symptom or sign improvement.

In trials involving children and adolescents (ages < 18 years) short term erectile dysfunction causes purchase vardenafil discount, microbiological eradication was less likely with short-course treatment impotence of organic nature vardenafil 10 mg on-line. Adverse events rates did not signifcantly differ between compared groups (Falagas erectile dysfunction meds vardenafil 10 mg discount, 2008) impotence of organic origin meaning proven 20mg vardenafil. A 1993 study of 47 children (ages 4 to 17) with pharyngitis and a positive throat culture for group A streptococci found that 17 (36. However, 39 (83%) of the patients became "culture negative" within the frst 24 hours. If not treated with antibiotics, it is reasonable for children to return to school after they are 24 hours fever free without antipyretic treatment. Rheumatic fever recurrence can also occur when a symptomatic infection is optimally treated. Additional treatments that may help with throat pain include lozenges, sipping warm or cold beverages, eating cold or frozen desserts and eating soft foods. It is not clear that salt water works to relieve pain, but it is unlikely to be harmful. Return to Algorithm Return to Table of Contents Reevaluation Patients whose symptoms do not improve require reevaluation to determine if the treatment plan is appropriate, if a complication has occurred, or if an alternative diagnosis should be considered. Mononucleosis If clinically indicated, testing for mononucleosis may be appropriate. Newly infected patients typically present with fever, sore throat, pharyngitis, lymphadenopathy, malaise or fatigue. Patients may also have headache, hepatomegaly, splenomegaly, palatal petechiae, periorbital edema and rashes. Morbilliform rash is more common following the administration of ampicillin or amoxicillin (occurring in up to 95% of patients with such drug exposure) and other beta-lactam antibiotics (40-60%) (Luzuriaga, 2010). Patients with peritonsilllar abscesses typically have progressive sore throat, pain on swallowing typically becoming unilateral, ear pain, malaise and trismus. Examination typically reveals tonsillar exudates and asymmetric, indurated peritonsillar swelling with deviation of the tonsil and uvula towards the midline. Other common fndings are tender and enlarged cervical lymph nodes, trismus, muffed voice and fever. Recent evidence suggests that Fusobacterium necrophorum pharyngitis occurs as often as streptococcal pharyngitis in patients ages 15 to 30 (Centor, 2009). The infection begins in the oropharynx with thrombosis of the tonsillar veins followed by involvement of the parapharyngeal space and is associated with jugular venous thrombophlebitis and the dissemination of infection by septic emboli. Patients typically present acutely ill with fever (> 39fiC) and rigors, often accompanied by respiratory distress and worsening of pharyngitis symptoms with neck swelling (Centor, 2009). Major criteria include carditis, arthritis, chorea, erythema marginatum and subcutaneous nodules. A detailed discussion on how to use these criteria to make the diagnosis is outside the scope of this guideline. The risk of developing rheumatic fever is about 3% under epidemic conditions and approximately 0. Acute rheumatic fever remains very rare in Western countries at less than 1 per 100,000 children (Van Brusselen, 2014). Please see the "Reevaluation" section for more detailed discussion of the clinical presentation of peritonsillar abscess. Prompt recognition is important to prevent further complications such as airway obstruction, abscess rupture, extension of infection into the neck or mediastinum (Galioto, 2017). It primarily occurs in the developing world in areas in which the population has been exposed to poor nutritional support and inadequate general sanitation. These conditions likely result in an immunocompromised state and a dysregulated response to infections. Post-streptococcal glomerulonephritis is caused by prior infection with specifc nephritogenic strains of group A beta-hemolytic streptococcus. The clinical presentation varies from asymptomatic, microscopic hematuria to acute nephritic syndrome, characterized by red to brown urine, proteinuria edema, hypertension and acute kidney injury. Non-Infectious Rhinitis Causes Rhinitis is the presence of one or more of the following symptoms: nasal congestion, rhinorrhea (anterior and posterior), sneezing and nasal itching (Wallace, 2008). Allergic rhinitis is an allergen-driven infammation caused by infammatory cells and other mediators, such as cytokines (Wallace, 2008). Examples of allergic rhinitis triggers include the following: pollen (tree, grass, weed), molds, house dust mites, animal dander and cockroaches. Non-allergic rhinitis is characterized by perennial or periodic symptoms that are not from IgE-dependent events (Wallace, 2008). Examples of non-allergic rhinitis include hormonal (such as rhinitis of pregnancy), vasomotor rhinitis with sensitivity to smells and temperature changes, non-allergic rhinitic eosinophilic syndrome, rhinitis medicamentosa from regular use of topical nasal decongestants, and atrophic rhinitis. Other examples of triggers are smoke, fumes (such as from cleaning solutions, pool chlorine, car exhaust or other chemicals), strong odors (perfumes, hair sprays and some cleaners), medications (particularly antihypertensive agents), foods, alcohol, bright light, emotional upset, and snorting or inhaling illicit drugs or substances. There are also a number of conditions that need to be included in the differential diagnosis. Deviated nasal septum, deformity of nasal bones, nasal turbinates or nasal cartilage may be detected on physical examination and may cause signifcant obstruction. In the pediatric population, unilateral nasal obstruction and/or rhinorrhea require that an intranasal foreign body be ruled out. Family History: • Asthma • Rhinitis • Atopic dermatitis Social and Environmental History: • Occupational exposures • Home exposures • Active and passive smoking exposures • School exposures • Illicit drug exposures Return to Algorithm Return to Table of Contents Suspicion of a cerebrospinal fuid leak as the cause of nasal discharge can be confrmed by testing for glucose in the discharge. If cerebrospinal fuid leak is seriously being considered, this would fall in the realm of specialty diagnosis, and a consultation should be obtained as soon as possible. In young children, foreign body in the nares and gastroesophogeal refux (in both children and adults) should also be considered as potential causes of rhinitis. Nose: • Swollen nasal turbinates (may be boggy, bluish or pale, hyperemic or purplish red); note size and color • Clear, cloudy or colored rhinorrhea • Nasal septal deviation or structural abnormality Return to Algorithm Return to Table of Contents A 2013 prospective observational study involving 108 patients found that patient symptoms, physical examination and nasal endoscopy are not reliable predictive tools for diagnosis of allergic rhinitis. This study demonstrated signifcant inter-rater variability of common nasal examination fndings (Eren, 2013). While often the diagnosis is made clinically, specifc diagnostic testing is recommended if a defnitive diagnosis is needed. Clinical relevance is established when exposure to an allergen to which the patient has evidence of allergen-specifc IgE. There are two major reasons to consider allergy testing: to differentiate allergic from non-allergic rhinitis, and to identify specifc allergens causing allergic rhinitis. Skin tests require experience in application and interpretation, and carry the risk of anaphylactic reactions. The precise sensitivity of specifc IgE immunoassays such as radioallergosorbent tests compared with prick/puncture skin tests is approximately 70-75% (Wallace, 2008). Therefore, skin tests are presently the preferred test for the diagnosing of IgE-mediated sensitivity. It may be a useful adjunct if the diagnosis of allergic rhinitis is not straightforward from the history, physical and IgE testing (Wallace, 2008). Serum eosinophilia has little diagnostic value in the evaluation of nasal allergies and is generally not helpful in the differential diagnosis. Nasal endoscopy and/or rhinomanometry may be reserved for particular situations (Wallace, 2008). Return to Algorithm Return to Table of Contents Treatment for Allergic Rhinitis Education on Avoidance If the clinical diagnosis is obvious, symptomatic treatment should be initiated. Symptomatic treatment includes both education on avoidance and medication therapy. Some avoidance activities require signifcant fnancial investment or substantial lifestyle changes by the patient. Before recommending such measures, it may be useful to recommend skin testing or limited radioallergosorbent testing to confrm the diagnosis and to identify the specifc allergen.

Order vardenafil 20 mg. Natural Cures for Erectile Dysfunction - Cure Erectile Dysfunction.

order vardenafil 20 mg

Complications the major complication is a pathological fracture of the Relief femoral neck or the femoral shaft erectile dysfunction queensland buy vardenafil american express. Pathology Precise pathology unknown erectile dysfunction in your 20s buy discount vardenafil 20 mg on line, but nerve root lesions have Summary of Essential Features and Diagnostic been described erectile dysfunction treatment bangkok cheap 10 mg vardenafil amex, and spinal cord damage doctor for erectile dysfunction in dubai quality vardenafil 10mg. There is usually tenderness in the groin and increased pain on internal and external rotaReferences tion. Differential Diagnosis the differential diagnosis includes upper lumbar plexoNathan, P. Psychiatry, 41 (1978) pathy, avascular necrosis of the femoral head, and septic 934-939. Definition Usual Course Pain in the limbs, usually constant and aching in the feet, Unremitting. Pathology Site Degenerative changes appear in the dorsal root ganglion the distal portion of the limbs, more often in the feet cells or motor neurons of the spinal cord with resulting than in the hands, and across the joint spaces. Cold, damp, and changes in the weather appear to cause an increase in the symptom. Rest, simple analgesics the pain arises in association with peroneal muscular such as paracetamol (acetaminophen) and nonsteroidal atrophy. Age anti-inflammatory drugs, and transcutaneous electrical of Onset: the illness normally appears in childhood and stimulation help to ease the pain. Relief is also associadolescence, with a reported age range for prevalence ated with warmth, massage, lying down, sleep, and disfrom 10-84 years. The sex linked form is less common than the other Conduction velocities in motor nerves may be detypes. Pain Quality: pain is relatively rare in the disease, creased, or denervation may be evident. It may be continuous or intermittent but is aggraEssential Features vated by activity, stress, cold, and damp. This aching Pain in the relevant distribution in patients affected by pain appears most often as a complication of surgical the typical muscle disorder. Anxiety and Pain affecting joints only fatigue appear in association with the pain. There is Pain affecting the belly of the muscle distal muscle wasting with the “classical” inverted 205. Definition System Severe, sharp, or aching pain syndrome arising from Musculoskeletal system. The patient characteristically finds it impossible to sleep on the affected side. Cases are often secondary to systemic Aggravated by climbing stairs, extension of the back inflammatory disease, such as ankylosing spondylitis, from flexion with knees straight. Relief Usual Course Injection into the ischial bursa with local anesthetic and Usually of sudden onset. The pain tends to be severe and steroid; “doughnut” cushion as used for treatment of persistent. Local infiltration of local anesthetic and steroid into the area of the greatest tenderness produces excellent pain Pathology relief. Essential Features Recurring pain in ischial region aggravated by sitting or Pathology lying, relieved by injection. Inflammatory process of bursa caused by repeated trauma or generalized inflammation such as rheumatoid Differential Diagnosis arthritis. X3 Local pain aggravated by climbing stairs, extension of the back from flexion with knees straight. Aching or burning pain in the high lateral part of the thigh and in the buttock caused by inflammation of the Code 634. Definition Pain due to primary or secondary degenerative process involving the hip joint. Treatment with quiPain due to a degenerative process of one or more of the nine, calcium supplements, diphenhydramine, diphenyl three compartments of the knee joint. X8 ology, aggravating and relieving features, signs, usual course, physical disability, pathology, and differential diagnosis as for osteoarthritis (I-11). Main Features Pain with insidious onset in the plantar region of the System foot, especially worse when initiating walking. Main Features Signs Severe aching cramps in the calves of the legs, often Tenderness along the plantar fascia when ankle is dorsipreventing the patient from sleep or waking him or her flexed. Page 206 Radiographic Findings Pathology Often associated with calcaneal spur when chronic. Fifteen percent have some form of systemic rheumatic disease, usually a seronegative form of spondylarthritis. Relief Arch supports, local injection of corticosteroid, oral nonDifferential Diagnosis steroidal anti-inflammatory agents. Many of the terms were already esprocess by which the terms were first delivered and the tablished in the literature. The “The usage of individual terms in medicine often terms have been translated into Portuguese (Rev. Dehen, vided that each author makes clear precisely how he Lexique de la douleur, La Presse Medicale 12, 23, employs a word. Nevertheless, it is convenient and help[1983] 1459-1460), and into Turkish (as Agri Terimleri, ful to others if words can be used which have agreed translated by T. A supplementary note was added to these meetings during the period 1976-1978, the present pain terms in Pain (14 [1982] 205-206). The definitions are inadditions were prepared by a subgroup of the Committended to be specific and explanatory and to serve as an tee, particularly Drs. Devor, the other tions was provided by the reports of a workshop on Orocolleagues just mentioned, and Dr. We hope that they will the versions now presented are based upon some prove acceptable to all those in the health professions subsequent discussions by correspondence. Not only are they a limited selection the definitions and notes at this point has been the refrom available terms, but it is emphasized that except for sponsibility of the editor (H. It would be difficult pain itself, they are defined primarily in relation to the now to single out individual contributions, but the editor skin and the special senses are excluded. They may be remains heavily indebted to those five members of the used when appropriate for responses to somatic stimulaoriginal Subcommittee on Taxonomy who sustained this tion elsewhere or to the viscera. Except for Pain, the work in the form of an Ad Hoc group and whose names arrangement is in alphabetical order. Their knowlIt is important to emphasize something that was imedge and patience was repeatedly provided freely and plicit in the previous definitions but was not specifically with good will. The original comclinical practice rather than for experimental work, ments provided as an introduction to the terms are given physiology, or anatomical purposes. These were forexcept for very slight alterations in the wording of the merly labeled Reflex Sympathetic Dystrophy and definitions of Central Pain and Hyperpathia. Two new Causalgia, and the discussion of Sympathetically Mainterms have been introduced here: Neuropathic Pain and tained Pain and Sympathetically Independent Pain is Peripheral Neuropathic Pain. The terms Sympathetically Maintained Pain and Changes have been made in the notes on Allodynia Sympathetically Independent Pain have also been emto clarify the fact that it may refer to a light stimulus on Page 210 damaged skin, as well as on normal skin. A sentence tabulation of the implications of some of the definitions, has been added to the note on Hyperalgesia to refer to curthe words lowered threshold have been removed from rent views on its physiology, although as with other definithe features of Allodynia because it does not occur regutions, that for Hyperalgesia remains tied to clinical criteria. Small changes have been made to better Last, the note on neuropathy has been expanded. Note: the inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons.

generic vardenafil 10mg with amex

The patented Fill-trigger electrode ensures that the test starts only when enough blood is applied popular erectile dysfunction drugs best vardenafil 10mg, so the potential for error due to homemade erectile dysfunction pump generic 10mg vardenafil “short” samples is minimised erectile dysfunction gabapentin order 10mg vardenafil otc. Each box of strips come with a FreeStyle Optium Neo H test strips are unique calibration stick erectile dysfunction remedies natural cheap vardenafil 20mg line. Move the meter and test strips to a location Logbook or too cold for the meter to where the temperature is within the test strip work properly operating range. Check the expiration date on the test strip foil Control Solution Test Test strip error packet. Repeat the calibration using the calibrator that came with the test strip you are using. Check that you are using the correct test strip for Venous blood mark used, or the meter does not this meter. Blood Glucose and Ketone Monitoring System Abbott Diabetes Care Customer Service 1800 801 478 FreeStyle Optium range of products are used in the testing or monitoring of blood glucose and blood ketone levels for people diagnosed with diabetes. Cover Photo: MotherCare Project Acknowledgments As anemia persists in being a health concern throughout the world, we have attempted to write a manual that can be used by laboratory and health workers in many settings. The manual was sent to two locations in Indonesia and to Kenya and Tanzania for review by people familiar with various methods of detecting anemia under difficult working conditions. We would like to thank the following people for contributing to the development of the manual by thoroughly and thoughtfully reviewing its contents, sharing their insights regarding testing for anemia, and offering suggestions so that the manual addresses the realities faced by laboratory and health workers in low-resource settings: Indonesia Dr. Gatot, Sunaryoto, Aris Winata, Agus Supriyono, Nur Listyarini, and Joko Bidiyono Kenya Dr. Jane Carter, Orgenes Lema, Christine Adhiambo, Viterlis Sitati, Vitali Kangero, Paul Kitenge, Clement Ngando, Crispus Matano, Melda Wafula, David Makau, and Emmanuel Shungu Tanzania David Ocheng, Vincent Mgaya, J. A manual aimed at helping administrators select tests appropriate to their situations, Anemia Detection in Health Services: Guidelines for Program Managers, was published in 1996. Chapter 1 provides basic but essential information on waste disposal, quality assurance, and record keeping as relevant to anemia detection. Anemia is most commonly detected by measuring hemoglobin (the oxygen-carrying component in red blood cells) or by determining the hematocrit (the volume of red blood cells expressed as a percentage of the total blood volume). Centers for Disease Control for calculating hemoglobin based on altitude, where altitude is known, is included in the Appendix. One half of the pregnant women in the world are anemic: in developing countries between 55% and 60% of pregnant women are affected while only 18% are affected in developed countries. Maintenance of Equipment Routine maintenance of the equipment used to detect anemia is crucial to obtain accurate and consistent results. If instruments require calibration, this must be done on a regular basis using standard calibrating devices. It is important that a record book be kept of maintenance activities that include the date, type of maintenance, and any follow-up required. Waste should always be rendered noninfectious by autoclaving or incineration, or buried in a specified and safe site when no other options are available. These items should be placed in a cardboard container before being incinerated or buried. Immediately after completing the screening tests, the work area must be disinfected with 0. Good Laboratory Practices Good laboratory practices include using established guidelines to ensure that standard laboratory and safety procedures are followed. Laboratory surfaces and floors should be made of materials that can be easily cleaned and disinfected. Quality Assurance Quality assurance is a concept that covers all aspects that can influence the quality of a product or a process. Internal Quality Control to Ensure Test Standardization Internal quality control measures are performed within the laboratory to ensure test-to-test consistency. The anemia detection methods described in this manual are standardized using a calibrator or reference standard. A calibrator is a device that conforms to a reference standard and is used to calibrate, or adjust, an instrument so that its readings are accurate. Reference standards, which are blood samples with a known hemoglobin concentration, are used to ensure that equipment and reagents are functioning correctly and that personnel are performing the procedures correctly and maintaining accuracy. It is helpful if laboratory personnel are familiar with basic statistical concepts, such as calculating means, standard deviations, and coefficients of variation. Each time the reference standard is used, its value should be plotted on the chart. Trends can be easily seen to determine 3 Chapter 1 General Considerations in Anemia Testing whether errors are random or whether readings have a tendency to rise or fall. Anemia detection tests must be done with care, and tests with questionable results should be repeated. It is important to provide training so that laboratory personnel are able to recognize when results are not precise. To determine the accuracy of simple anemia detection devices, a portable instrument capable of providing precise and accurate measurements, such as a hemoglobinometer, can be used as the standard method. Record Keeping Proper record keeping is essential in any laboratory as it helps to ensure accuracy in diagnosing anemia and determining if treatment is effective. Blood specimens must be labeled with the date of collection and with either an identification number or the patient’s name, depending on the system used. It is important to keep a daily record of test results in a bound laboratory notebook in a central place in the laboratory, as loose reports are easily misplaced. The notebook should contain the following details: date; laboratory record number; patient’s name, age, sex and residence; tests performed; the person who performed the tests; and test results. It is important to note any unusual findings on the specimen, such as the presence of clotted blood or lipid, as this may influence the result. That is, the health care worker should avoid direct contact with any body fluid including blood specimens. Health care workers must be trained in the safe collection, handling, and disposal of blood products and items with blood on them, as described below. Health care workers should always wear a fresh, disposable pair of gloves when obtaining blood samples from patients, regardless of the method used to obtain the blood sample. This will protect both the health care worker and the patient from accidental contamination with blood from a previous patient. Always wash hands and other skin surfaces immediately after contact with blood or body fluids. In the case of accidental puncture with a used sharp object, immediately wash the affected area gently in running water while squeezing to ensure a free flow of blood. Record all accidents, however minor, in the accident book and report them immediately to your supervisor. Venous blood samples are collected by venipuncture for other tests and placed in tubes containing anticoagulant. Capillary Blood Collection Capillary blood is obtained in adults and children from the fingertip or earlobe. To ensure an adequate amount of blood from a fingerprick, run warm water over the fingertip, vigorously rub the fingertip, or shake the wrist to improve blood flow prior to capillary blood collection. With children, especially those who are malnourished, health care workers may obtain the specimen from the earlobe because this area is not as sensitive as the finger tip. Neither the lancet nor the blood are visible to the child if the worker stands behind the child while taking the specimen. Required Supplies • 70% alcohol and cotton wool (to clean the skin) • sterile, dry lancets (to make the incision) • capillary tubes or Sahli blood pipette (to collect the blood sample) • rubber tubing if using the Sahli blood pipette (to draw up the blood) • beaker of saline solution (for flushing Sahli blood pipette after use) Procedure 1. Using a sterile, dry lancet, puncture the skin deeply enough so that large drops of blood emerge slowly but spontaneously (Figure 3). Wipe away the first drop of blood, as it is contaminated with skin particles, oil, and sweat. If using the Sahli blood pipette, fill the tube to the level required for the test. Attach a piece of rubber tubing with a knot at one end of the pipette and draw up the blood by gently squeezing the rubber tubing. Have the patient sit comfortably at a table with the arm extended to form a straight line. Introduce the needle bevel side up at a 15-degree angle into the skin and through the top wall of the vein.