Order etodolac on line
Sometimes arthritis in fingers nhs purchase 400mg etodolac visa, plasma cells are present in impressive numbers and the condition is then termed plasma cell mastitis arthritis knee medication etodolac 200 mg generic. Occasionally arthritis definition deutsch buy cheap etodolac 200 mg line, there may be obliteration of the ducts by fibrous tissue and varying amount of inflammation and is termed obliterative mastitis. M/E There is disruption of the regular pattern of lipocytes with formation of lipid-filled spaces surrounded by neutrophils, lymphocytes, plasma cells and histiocytes having foamy cytoplasm and frequent foreign body giant cell formation. The mammary duct is obstructed and dilated to form a thin-walled cyst filled with milky fluid. Its incidence has been reported to range from 10-20% in adult women, most often between 3rd and 5th decades of life, with dramatic decline in its incidence after menopause suggesting the role of oestrogen in its pathogenesis. As such, fibrocystic change of the female breast is a histologic entity characterised by following features: i) Cystic dilatation of terminal ducts. Presently, the spectrum of histologic changes is divided into two clinicopathologically relevant groups: A. The usual large cyst is rounded, translucent with bluish colour prior to opening (blue-dome cyst). Frequently, there is apocrine change or apocrine metaplasia in the lining of the cyst resembling the cells of apocrine sweat glands. Fibrosis There is increased fibrous stroma surrounding the cysts and variable degree of stromal lymphocytic infiltrate. The latter condition, lobular hyperplasia, must be distinguished from adenosis (discussed separately) in which there is increase in the number of ductules or acini without any change in the number or type of cells lining them. M/E Epithelial hyperplasia is characterised by epithelial proliferation to more than its normal double layer. In general, ductal hyperplasia is termed as epithelial hyperplasia of usual type and may show various grades of epithelial proliferations (mild, moderate and atypical) as under, while lobular hyperplasia involving the ductules or acini is always atypical. Mild hyperplasia of ductal epithelium consists of at least three layers of cells above the basement membrane, present focally or evenly throughout the duct. Moderate and florid hyperplasia of ductal type is associated with tendency to fill the ductal lumen with proliferated epithelium. Such epithelial proliferations into the lumina of ducts may be focal, forming papillary epithelial projections called ductal papillomatosis, or may be more extensive, termed florid papillomatosis, or may fill the ductal lumen leaving only small fenestrations in it. Of all the ductal hyperplasias, atypical ductal hyperplasia is more ominous and has to be distinguished from intraductal carcinoma. The proliferated epithelial cells in the atypical ductal hyperplasia partially fill the duct lumen and produce irregular microglandular spaces or cribriform pattern. Atypical lobular hyperplasia is closely related to lobular carcinoma in situ but differs from the latter in having cytologically atypical cells only in half of the ductules or acini. The lesion may be present as diffusely scattered microscopic foci in the breast parenchyma, or may form an isolated palpable mass. G/A the lesion may be coexistent with other components of fibrocystic disease, or may form an isolated mass which has hard cartilage-like consistency, resembling an infiltrating carcinoma. The histologic appearance may superficially resemble infiltrating carcinoma but differs from the latter in having maintained lobular pattern. Simple fibrocystic change or nonproliferative fibrocystic changes of fibrosis and cyst formation do not carry any increased risk of developing invasive breast cancer. Identification of general proliferative fibrocystic changes are associated with 1. Multifocal and bilateral proliferative changes in the breast pose increased risk to both the breasts equally. Within the group of proliferative fibrocystic changes, atypical hyperplasia in particular, carries 4 to 5 times increased risk to develop invasive breast cancer later. Since the male breast does not contain secretory lobules, the enlargement is mainly due to proliferation of ducts and increased periductal stroma. Such excessive oestrogenic activity in males is seen in young boys between 13 and 17 years of age (pubertal gynaecomastia), in men over 50 years (senescent gynaecomastia). G/A One or both the male breasts are enlarged having smooth glistening white tissue. Proliferation of branching ducts which display epithelial hyperplasia with formation of papillary projections at places. Though it can occur at any age during reproductive life, most patients are between 15 to 30 years of age. Clinically, fibroadenoma generally appears as a solitary, discrete, freely mobile nodule within the breast. G/A Typical fibroadenoma is a small (2-4 cm diameter), solitary, wellencapsulated, spherical or discoid mass. The cut surface is firm, grey-white, slightly myxoid and may show slit-like spaces formed by compressed ducts. Less commonly, a fibroadenoma may be fairly large in size, up to 15 cm in diameter, and is called giant fibroadenoma but lacks the histologic features of cystosarcoma phyllodes. The arrangements between fibrous overgrowth and ducts may produce two types of patterns which may coexist in the same tumour. Intracanalicular pattern is one in which the stroma compresses the ducts so that they are reduced to slit-like clefts lined by ductal epithelium or may appear as cords of epithelial elements surrounding masses of fibrous stroma. Pericanalicular pattern is characterised by encircling masses of fibrous stroma around the patent or dilated ducts. Occasionally, the fibrous tissue element in the tumour is scanty, and the tumour is instead predominantly composed of closely-packed ductular or acinar proliferation and is termed tubular adenoma. If an adenoma is composed of acini with secretory activity, it is called lactating adenoma seen during pregnancy or lactation. Juvenile fibroadenoma is an uncommon variant of fibroadenoma which is larger and rapidly growing mass seen in adolescent girls but fortunately does not recur after excision. G/A the tumour is generally large, 10-15 cm in diameter, round to oval, bosselated, and less fully encapsulated than a fibroadenoma. The cut surface is grey-white with cystic cavities, areas of haemorrhages, necrosis and degenerative changes. M/E the phyllodes tumour is composed of an extremely hypercellular stroma, accompanied by benign ductal structures. Thus, phyllodes tumour resembles fibroadenoma except for marked stromal overgrowth. The histologic criteria considered to distinguish benign, borderline and malignant categories of phyllodes tumour are based on following cellular features of stroma: i) frequency of mitoses; ii) cellular atypia; iii) cellularity; and iv) infiltrative margins. About 20% of phyllodes tumours are histologically malignant and less than half of them may metastasise. G/A Intraductal papilloma is usually solitary, small, less than 1 cm in diameter, commonly located in the major mammary ducts close to the nipple. Less commonly, there are multiple papillomatosis which are more frequently related to a papillary carcinoma. M/E An intraductal papilloma is characterised by multiple papillae having well-developed fibrovascular stalks attached to the ductal wall and covered by benign cuboidal epithelial cells supported by myoepithelial cells. In the United States, carcinoma of the breast constitutes about 25% of all cancers in females.
Buy etodolac visa
The ventral surface of the proximal nail fold adheres closely to hip arthritis definition cheap etodolac master card the nail for a short distance and forms a gradually desquamating tissue arthritis in feet help order online etodolac, the cuticle arthritis in the knee teenager etodolac 200 mg line, made up of the stratum corneum of both the dorsal and the ventral sides of the proximal nail fold. The cuticle seals and protects the nail cul-de-sac against irritants, solvents, and other agents that might disturb matrix function and hence, nail growth. The rate of nail growth peaks between the ages of 10 and 14 and begins an inexorable decrease with age after the second decade, Rate of growth of the nail plate is usually undertaken as a simple measure of longitudinal elongation, using the lunula as a reference structure. The nail bed that has parallel longitudinal ridges extends from the lunula to the hyponychium. However, in contrast to the matrix, the nail bed has a firm attachment to the nail plate and avulsion of the overlying nail denudes the nail bed. Colorless but translucent, this highly vascular connective tissue containing glomus organs transmits a pink color through the nail. The distal margin of the nail bed which has a contrasting hue in comparison with the rest of the nail bed is called the onychocorneal band. Its color or presence may vary with disease, or with compression, which influences the vascular supply. Distally, adjacent to the nail bed, lies the hyponychium, an extension of the volar epidermis under the nail plate, which marks the point at which the nail separates from the underlying tissue. The distal nail 20 Pediatric Nail Disorders Downloaded by [Chulalongkorn University (Faculty of Engineering)] at groove, which is convex anteriorly, separates the hyponychium from the fingertip. The hyponychium and the onychodermal band may be the focus or the origin of subungual keratosis in some diseases. The proximal matrix is also supplied by a branch of the digital artery coming off at the midportion of the middle phalanx and proceeding directly to the matrix, providing a collateral circulation. The normal nail fold capillary network in children resembles that observed in adults with some differences, such as a lower number of loops per millimeter, a higher subpapillary venous plexus visibility score, and a higher frequency of atypical loops. This information is important for the diagnostic evaluation of children in the context of autoimmune rheumatic diseases. Longitudinal branches of the dorsal collateral nerves supply the terminal phalanx of the fifth digit and also the thumb. The nail bed, richly innervated, contains VaterPacini corpuscles, Meissner corpuscles, and MerkelRanvier endings. Enthesis is defined as the site of insertion of a tendon, ligament, or joint capsule to bone. Among its multiple functions, the nail provides counter pressure to the pulp that is essential for the touch sensation involving the fingers and for the prevention of hypertrophy of the distal soft tissue leading to anterior ingrown nails. Anatomic relationship of the proximal nail matrix to the extensor hallucis longus tendon insertion. Downloaded by [Chulalongkorn University (Faculty of Engineering)] at 3 Nail Contour Variations Robert Baran Congenital and hereditary nail dystrophies are classified according to the defects occurring in the nail matrix, the nail field, or the nail bed. Proliferation of the nail bed will produce a thickened nail which, as in pachyonychia congenita, is not evident until early childhood (Table 3. Physical Signs Ainhum (Amniotic Syndrome) Ainhum presents as a painful constricting band, which, most often, encircles the fifth toe with eventual spontaneous amputations (Figure 3. It affects the black population of the subtropical regions of America, Africa, and Asia. The condition often leads to an abnormality in the foot vessels producing an abnormal blood supply, alone or in combination with chronic trauma and infection. Similar changes occur in pseudoainhum caused by constriction of external forces, such as hair or threads encountered in children, or mentally deranged adults. Often, there are rudimentary nails on some digits; therefore, there is frequently only a quantitative difference between anonychia and hyponychia, and they often occur together in a patient. Rudimentary nails of 12 mm long with a thin plate and even thinner free margin can be observed. Isolated anonychia without other symptoms can be inherited as an autosomal dominant or recessive trait or acquired (Table 3. If an X-ray is undertaken, absence of bone or underlying bone abnormality is generally found in congenital cases. In the isolated type, it may be associated with the total or partial absence of the distal bony phalanx. Normally, the interaction of mesoderm and ectoderm simultaneously infers the epidermal thickening producing the nail and the mesenchymal condensation producing the distal phalanx. In patients with brachydactyly, syndactyly, zygodactyly (union of digits by soft tissues without bony fusion of the phalanges), the nails are sometimes malformed or absent. When the distal phalanges are involved, the nails are longitudinally convex and/or broad. Skeletal changes are also found in syndromes with ectodermal dysplasia and with chromosomal anomalies. Disorders associated with brachyonychia include cartilagehair hypoplasia, acroosteolysis (Table 3. Acroosteolysis may also be acquired in bitten nail or associated with bone resorption in scleroderma, hyperparathyroidism, psoriatic arthropathy, and frostbite9 associated with shortening of the nail (Figure 3. In these conditions, acroosteolysis is present radiologically with longitudinal acroosteolysis and leads to a "pencilling" like deformity in contrast to idiopathic acroosteolysis. Of note, two children have developed latent epiphysial destruction in the middle and distal phalanges after frostbite, with one case developing brachyonychia. The appearance of a racquet thumb nail can be improved in narrowing the nail and creating lateral nail folds: an excision of both sides of the thumbnail and lateral segments of the matrix is performed, followed by creation of lateral nail folds after back-stitching is performed on the lateral soft aspects of the distal phalanx that have been dissected from the bone. These patients also have growth and mental retardation, and multiple facial abnormalities. Circumferential Fingernail Circumferential fingernail is an extremely rare congenital malformation associated with other bony and soft tissue abnormalities of the affected limb. In normal individuals, the opposition of the dorsum of two fingers from opposite hands delineates a diamond-shaped "window" formed at the base of the nail beds. Early clubbing obliterates this window and creates a prominent distal angle between the ends of the nails. In addition to clubbing, hypertrophic pulmonary osteoarthropathy is associated in adolescence with acromegalic limb changes, pseudoinflammatory symmetric large joint arthropathy, bilateral proliferative periostitis, peripheral cyanosis and paresthesia, local pain, and swelling. It may be associated with characteristic facial features such as prominent skinfold on the forehead and cheeks. In a 5-year-old girl with bronchiectasis, avulsion of the nail plate revealed atrophy of the nail bed instead of hypertrophy observed in true clubbing. Curved Nail of the Fourth Toe Curved nail of the fourth toe is often bilateral (Figure 3. There are cases without other anomalies of the extremities, but sometimes hypoplasia of the bone and soft tissues are present. Congenital curved nail of the fourth toe18 is inherited in an autosomal recessive manner. Dolichonychia Normally the quotient between the length and the width of the nail is 1 ± 0. Double Little Toenail (Inherited Accessory Nail of the Fifth Toe) A rudimentary accessory or double nail of the little toe is not rare (Figure 3.
Purchase cheap etodolac online
Chronic form is due to arthritis in feet generic 300 mg etodolac mastercard foci of ischaemic necrosis throughout body arthritis swelling feet treatment purchase cheap etodolac online, especially the skeletal system arthritis medication philippines buy generic etodolac on line. Ischaemic necrosis may be due to embolism perse, but other factors such as platelet activation, intravascular coagulation and hypoxia might contribute. During labour and in the immediate postpartum period, the contents of amniotic fluid may enter the uterine veins and reach right side of the heart resulting in fatal complications. The amniotic fluid components which may be found in uterine veins, pulmonary artery and vessels of other organs are: epithelial squames, vernix caseosa, lanugo hair, bile from meconium, and mucus. The cessation of blood supply may be complete (complete ischaemia) or partial (partial ischaemia). Inadequateclearanceofmetabolites which results in accumulation of metabolic waste-products in the affected tissue. These causes are discussed below with regard to different levels of blood vessels: 1. Causes in the heart Inadequate cardiac output resulting from heart block, ventricular arrest and fibrillation from various causes may cause variable degree of hypoxic injury to the brain as under: i) If the arrest continues for 15 seconds, consciousness is lost. Causes in the arteries the commonest and most important causes of ischaemia are due to obstruction in arterial blood supply as under: i) Luminalocclusion ofartery(intraluminal): a) Thrombosis b) Embolism ii) Causesinthearterialwalls (intramural): a) Vasospasm. Causes in the veins Blockage of venous drainage may lead to engorgement and obstruction to arterial blood supply resulting in ischaemia. Causesinthemicrocirculation Ischaemia may result from occlusion of arterioles, capillaries and venules. Anatomic pattern the extent of injury by ischaemia depends upon the anatomic pattern of arterial blood supply of the organ or tissue affected. General and cardiovascular status the general status of an individual as regards cardiovascular function is an important determinant to assess the effect of ischaemia. Typeoftissueaffected Vulnerability of the tissue of the body to the effect of ischaemia is variable. The following tissues are more vulnerable to ischaemia: i) Brain (cerebral cortical neurons, in particular). Rapidity of development Sudden vascular obstruction results in more severe effects of ischaemia than if it is gradual. Degreeofvascularocclusion Complete vascular obstruction results in more severe ischaemic injury than the partial occlusion. However, there are a few other noteworthy features in infarction: i) Most commonly, infarcts are caused by interruption in arterial blood supply, called ischaemicnecrosis. General Pathology Section I ii) Less commonly, venous obstruction can produce infarcts termed stagnanthypoxia. Accordingtotheirage: Recentorfresh Oldorhealed Derangements of Homeostasis and Haemodynamics 3. Accordingtopresenceorabsenceofinfection: i) Bland, when free of bacterial contamination ii) Septic, when infected. This is because lungs receive blood supply from bronchial arteries as well, and thus occlusion of pulmonary artery ordinarily does not produce infarcts. G/A Pulmonary infarcts are classically wedge-shaped with base on the pleura, haemorrhagic, variable in size, and most often in the lower lobes. Cut surface is dark purple and may show the blocked vessel near the apex of the infarcted area. M/E the characteristic histologic feature is coagulative necrosis of the alveolar walls. Initially, there is infiltration by neutrophils and intense alveolar capillary congestion, but later their place is taken by haemosiderin, phagocytes and granulation tissue. Majority of them are caused by thromboemboli, most commonly originating from the heart such as in mural thrombi in the left atrium, myocardial infarction, vegetative endocarditis and from aortic aneurysm. Characteristically, they are pale or anaemic and wedge-shaped with base resting under the capsule and apex pointing towards the medulla. Generally, a narrow rim of preserved renal tissue under the capsule is spared because it draws its blood supply from the capsular vessels. M/E the affected area shows characteristic coagulative necrosis of renal parenchyma i. The margin of the infarct shows inflammatory reaction-initially acute but later macrophages and fibrous tissue predominate. They are characteristically pale or anaemic and wedge-shaped with their base at the periphery and apex pointing towards hilum. Section I General Pathology G/A Ischaemic infarcts of the liver are usually anaemic but sometimes may be haemorrhagic due to stuffing of the site by blood from the portal vein. Infarcts of Zahn (non-ischaemic infarcts) produce sharply defined red-blue area in liver parenchyma. M/E Ischaemic infarcts show characteristics of pale or anaemic infarcts as in kidney or spleen. Infarcts of Zahn occurring due to reduced portal blood flow over a long duration result in chronic atrophy of hepatocytes and dilatation of sinusoids. Osmotic pressure exerted by the chemical constituents of the body fluids has the following features except: A. For causation of oedema by decreased osmotic pressure, the following factor is most important: A. Pulmonary oedema appears due to elevated pulmonary hydrostatic pressure when the fluid accumulation is: A. Pathologic changes between sudden decompression from high pressure to normal levels and decompression from low pressure to normal levels are: A. It is a body defense reaction in order to eliminate or limit the spread of injurious agent, followed by removal of the necrosed cells and tissues. Acute inflammation is of short duration (lasting less than 2 weeks) and represents the early body reaction, resolves quickly and is usually followed by healing. Chronic inflammation is of longer duration and occurs after delay, either after the causative agent of acute inflammation persists for a long time, or the stimulus is such that it induces chronic inflammation from the beginning. These alterations include: haemodynamic changes and changes in vascular permeability. Irrespective of the type of cell injury, immediate vascular response is of transient vasoconstriction of arterioles. Next follows persistent progressive vasodilatation which involves mainly the arterioles, but to a lesser extent, affects other components of the microcirculation like venules and capillaries. Progressive vasodilatation, in turn, may elevate the local hydrostatic pressure resulting in transudation of fluid into the extracellular space. Slowing or stasis of microcirculation follows which causes increased concentration of red cells, and thus, raised blood viscosity. Stasis or slowing is followed by leucocytic margination or peripheral orientation of leucocytes (mainly neutrophils) along the vascular endothelium. Lewis induced the changes in the skin of inner aspect of forearm by firm stroking with a blunt point. The reaction so elicited is known as triple response or red line response consisting of the following: i) Red line appears within a few seconds after stroking and is due to local vasodilatation of capillaries and venules.
Buy etodolac in united states online
Preparation of a calibration graph for use with a filter colorimeter what does arthritis in your neck look like purchase generic etodolac line, 158 Hematology requires the use of a secondary blood standard arthritis in lower back and pelvis generic etodolac 200 mg on line, i arthritis neck esophagus order etodolac 300mg on line. The absorbance of the solution is measured as oxyhemoglobin in a filter colorimeter using a yellow-green filter or at wavelength 540nm. Methemoglobin and carboxyhemoglobin are not accurately detected but these are normally present only in trace amounts and are not oxygen-carrying forms of hemoglobin. Preparation of calibration graph for HbO2 technique A series of dilutions are prepared form a whole blood or standard hemolysate of known hemoglobin value, 159 Hematology preferable between 140-160g/l. Prepare a 1 in 201 dilution of the standard blood or hemolysate in the ammonia water diluting fluid as follows: · · Dispense 20ml of diluting fluid into a screw cap container. Measure carefully 20µl of capillary or well-mixed venous blood and dispense into 3. Disadvantage · · Certain forms of Hb are resistant to alkali denaturation, in particular Hb-F and Hb Bart. Standard A mixture of chromium potassium sulphate, cobaltous sulphate and potassium dichromate in aqueous solution. Acid Hematin Method (Sahli-Hellige) this visual comparative method of estimating hemoglobin although still used in some health centers and hospitals is not recommended because of its unacceptable imprecision and inaccuracy. Most of the problems associated with the Sahli method are due to the instability of acid hematin, fading of the color glass standard and difficulty in matching it to the acid hematin solution. HbF is not converted to acid hematin and therefore the Sahli method is not suitable for measuring hemoglobin levels in infants up to 3 months. Principle 163 Hematology Hemoglobin in a sample of blood is converted to a brown colored acid hematin by treatment with 0. Materials Sahli hemoglobinometer Sahli pipette Stirring glass rod Dropping pipette Absorbent cotton 0. Fill the graduated tube to the '20' mark of the red graduation or to the 3g/dl mark of the yellow graduation with 0. Blow the blood from the pipette into the graduated pipette into the graduated tube of the acid solution. Compare the color of the tube containing diluted blood with the color of the reference tube. If the color of the diluted sample is darker than that of the reference, continue to dilute by adding 0. Depending on the type of hemoglobinometer, this gives the hemoglobin concentration either in g/dl or as a percentage of 'normal'. Hemoglobin color scale Many color comparison methods have been developed in the past but these have become obsolete because 165 Hematology they were not sufficiently accurate or the colors were not durable. A new low-cost hemoglobin color scale has been developed for diagnosing anemia which is reliable to within 10 g/l (l g/dl). It consists of a set of printed color shades representing hemoglobin levels between 4 and 14 g/dl. The color of a drop of blood collected onto a specific type of absorbent paper is compared to that on the chart. Validation studies in blood transfusion centers have shown the scale to be more reliable and easier to use than the copper sulphate method in donor selection checks. Copper Sulphate Densitometery this is a qualitative method based on the capacity of a standard solution of copper sulphate to cause the suspension or sinking of a drop of a sample of blood as a measure of specific gravity of the latter and corresponding to its hemoglobin concentration. The method is routinely utilized in some blood banking laboratories in the screening of blood donors for the presence of anemia. Normal hemoglobin reference range: Children at birth children 2 y 5 y Children 6 y 12 y Adult men Adult women Pregnant women 135-195 g/l 110-140 g/l 115-155 g/l 130-180 g/l 120-150 g/l 110-138 g/l 167 Hematology Review Questions 1. What are the two most commonly applied color comparison methods for measurement of hemoglobin in a sample of blood? How do you check the linearity of the spectrophotometric method of hemoglobin quantitation in the laboratory? It is one of the simplest, most accurate and most valuable of all hematological investigations. It is of greater reliability and usefulness than the red cell count 169 Hematology that is performed manually. There are two methods of determination: microhematocrit method and macrohematocrit (Wintrobe) method. Microhematocrit method Materials required · Capillary tubes these need to be plain or heparinized capillaries, measuring 75mm in length with an internal diameter of 1mm and wall thickness of 0. The plain ones are used for 171 Hematology anticoagulated venous blood while the heparinized ones (inside coated with 2 I. Test method 1 Allow the blood to enter the tube by capillarity (if anticoagulated venous blood, adequate mixing is 173 Hematology mandatory) leaving at least 15mm unfilled (or fill 3/4th of the capillary tube). It is increased in hypochromic anemia, macrocytic anemia, sickle cell anemia, spherocytosis and thalassemia. Advantages of the Microhematocrit Method · It enables higher centrifugation speeds with consequent shorter centrifugation times and superior packing. Blood samples for microhematocrit measurements should be centrifuged within 6 hours of collection. When it contains an increased amount of bilirubin (as occurs in hemolytic anemia) it will appear abnormally yellow. If the plasma is pink-red this indicates a hemolyzed sample (less commonly hemoglobinemia). When white cell numbers are significantly increased, this will be reflected in an increase in the volume of buffy coat layer. The method uses a Wintrobe tube which can also be used to determine the erythrocyte sedimentation test. It has two graduation scales in millimeters and with the centimeters marked by numbers. One side is graduated from 0 to 10cm (0-100mm) from the bottom to the top, while the other side is graduated from 10 to 0cm (100-0mm) from bottom to top. The hematocrit is read from the scale on the right hand side of the tube taking the top of the black band of reduced erythrocytes immediately beneath the reddish gray leucocyte layer. Reference ranges vary in different populations and in different District laboratories should check the reference ranges with their nearest Hematology 178 Hematology Reference Laboratory. Increased values are found in dengue hemorrhagic fever and in all forms of polycythemia. The first step in finding the cause is to determine what type of anemia the person has. These formulas were worked out and first applied to the classification of anemias by Maxwell Wintrobe in 1934. Abnormal 182 Hematology hemoglobins, such as in sickle cell anemia, can change the shape of red blood cells as well as cause them to hemolyze. Cells of normal size are called normocytic, smaller cells are microcytic, and larger cells are macrocytic. Cells with a normal concentration of hemoglobin are called normochromic; cells with a lower than normal concentration are called hypochromic. Because there is a physical limit to the amount of hemoglobin that can fit in a cell, there is no hyperchromic category.
Etodolac 200 mg without prescription
After approximately 8 days rheumatoid arthritis usmle discount 400 mg etodolac, the egg capsules hatch nymphs that mature over the next 8 days into adult lice rheumatoid arthritis in feet symptoms discount etodolac 300 mg online. They move about by crawling and are transmitted by close person-to-person contact arthritis feet ice order etodolac 300mg without prescription. Clinical manifestations of head, body (pediculosis corporis), and pubic (pediculosis pubis) lice include intense itching and small, erythematous maculopapular lesions with excoriations at the site of bites. Pubic lice typically survive for up to 36 hours away from a host, but may live for 10 days under ideal conditions. For the 4-month-old infant in the vignette, the best option for treating head lice is over-thecounter permethrin because none of the other topical agents are recommended for young infants (Item C155). Lindane shampoo no longer is recommended for treating children because of neurologic adverse effects and widespread resistance. Pediculicides used to treat pediculosis capitis and corporis can also be used to treat pediculosis pubis. After each treatment, the hair and body should be checked for nits and lice with a nit comb. Bedding and clothing should be washed in hot water, and close contacts should be monitored for lice and treated if infested. After administration of an analgesic and cleansing of these burns, debridement of the ruptured blister on his upper chest is the next best step in management. Pediatric providers should be familiar with the initial assessment and management of burns. Burns may arise from contact with hot objects or liquids, sun exposure, radioactivity, electricity, chemical exposure, or friction. Thermal injuries that occur commonly in children include scald and contact burns sustained from cooking or spilling hot foods or liquids. Scald burns related to bathing are a particular risk in infancy and the toddler years. Contact burns from hot objects such as space heaters, grills, stoves, ovens, irons, hair appliances, campfires, and fireworks are also seen fairly frequently. Fortunately, only a few burns in children require hospitalization; most can be managed on an outpatient basis. Burn injuries are classified into 3 main types, based on the depth of tissue injury: · First-degree (ie, superficial) burns: these burns involve injury to the epidermis only, without involvement of the dermis. Clinical features include erythema and mild inflammation of the epidermis, without blister formation. These burns may be painful, but generally resolve within a few days without scarring. Although the injured epidermis often peels within a few days of a superficial burn injury, new epidermal cells will be regenerated. Blister formation typically occurs, as well as tissue edema arising from increased capillary permeability. These burns are generally painful because of exposure of intact sensory nerve receptors in the injured dermis. Superficial partial thickness burns typically heal within 2 weeks without scarring. Deeper partial thickness burns may involve damage to most of the dermis and may have a paler, drier appearance than more superficial partial thickness burns. Deeper partial thickness burns may be difficult to differentiate from full thickness burns. Full thickness burns may appear pale and "waxy" or charred, and often have a leathery appearance. Skin affected by full thickness burns is nontender because of destruction of the cutaneous nerves, though surrounding partial thickness burns may be very painful. Full thickness burns cannot re-epithelialize because of destruction of the entire dermal layer, and skin grafting is often required. Minor partial thickness burns can be cleansed with mild soap and water, diluted povidone-iodine solution, chlorhexidine gluconate, or saline. The burn wound should be dressed promptly to help reduce pain associated with convection of air across the wound. Minor partial thickness burns should be dressed with a topical antimicrobial agent such as bacitracin ointment or silver sulfadiazine and covered with a sterile gauze dressing. Caregivers should be advised to gently cleanse minor burn wounds daily with a clean cloth or gauze in the shower or bathtub, and then to redress the wounds. Providing adequate analgesia is an essential component in the outpatient care of minor burns. Pediatricians should administer appropriate analgesia before performing the initial burn wound assessment and care, and anxiolytic agents may even be required in some children. Regarding the management of blisters associated with minor partial thickness burns, those that are intact provide protection for the underlying tissue and should be left intact, as long as they do not cross joints or otherwise limit activity. Once blisters rupture, they should be debrided, because devitalized tissue could serve as a nidus for infection. Although providing adequate analgesia is an essential component in caring for children presenting with burns, application of a topical lidocaine gel to burned areas is not recommended for children with burns of any degree. There is a scarcity of evidence supporting the effectiveness and safety of this practice. In addition, the use of topical lidocaine preparations on burned skin places children at risk for systemic lidocaine toxicity, which could result in serious complications, including methemoglobinemia, central nervous system toxicity, and cardiotoxicity. A course of oral cephalexin would not be the best next step in management for the boy in the vignette, who displays no signs of systemic infection. There is no role for the empiric administration of systemic antibiotics after burn injuries. Systemic antibiotics should only be administered to children with clear evidence of infection on physical examination or on culture of the burn wound. Reporting of the injuries sustained by the boy in the vignette to child protective services is not warranted, given that the reported mechanism of injury is consistent with his developmental stage, and that his pattern of burns is not suspicious for inflicted injury. Pediatric burn injuries associated with a delay in seeking care or isolated scald or contact burns to the hands, feet, genitalia, or buttocks without a plausible mechanism should raise suspicion for inflicted injury. Burns to the hands and feet with a "stocking and glove" pattern (clearly demarcated borders without surrounding splash burns) can arise from intentional immersion of the hands or feet in scalding liquid, and should raise suspicion for child abuse. Scald burns to the buttocks and thighs in toddlers can result from forced submersion in a tub of hot water, often following a toilettraining mishap. Suspicious patterns of contact burns with hot objects (such as burning cigarettes, hot irons, cooking pans, hair appliances, or heaters) that do not seem to correlate with the reported history should prompt a thorough evaluation for abuse. If concern for an inflicted burn injury exists, reporting to child protective services and referral of the injured child to a pediatric burn center are indicated. A topical antimicrobial agent such as bacitracin ointment should be applied, and the wound should be covered with a gauze dressing. The pregnancy was unremarkable, including a normal anatomy scan at 18 weeks of gestation. The mother presented in labor, with artificial rupture of the membranes 3 hours before delivery, revealing clear amniotic fluid. The newborn emerged vigorous and has been exclusively breastfeeding since delivery.
Cedarwood (Eastern Red Cedar). Etodolac.
- Dosing considerations for Eastern Red Cedar.
- Are there safety concerns?
- How does Eastern Red Cedar work?
- What is Eastern Red Cedar?
- Cough, bronchitis, rheumatism, venereal warts, and skin rash.
- Are there any interactions with medications?
Proven 400mg etodolac
You probably should not carry anything heavier than the baby for the first week or two arthritis pain pregnancy order etodolac 200 mg online. Do not use a Jacuzzi until the vaginal discharge stops or bathe after a cesarean section until the incision is healed (usually 5-7 days) rheumatoid arthritis diet mercola buy cheap etodolac 400 mg on line. Intercourse is permissible after the vaginal discharge and bleeding stop arthritis prevention purchase etodolac 200mg without prescription, usually at three to four weeks. Condoms should be used with a water-soluble lubricant such as K-Y jelly or Astroglide. Vaginal Delivery After delivery, you will experience bleeding and a discharge for 4 to 6 weeks. If you had a vaginal tear or episiotomy, your vaginal area may be swollen or sore. Taking sitz baths or a warm bath 2 to 3 times a day will help with the discomfort and promote healing. Cesarean Section Cesarean section incisions have many layers that heal at the same time. Call the office for an appointment if your incision opens, has a large amount of discharge or bleeding, or if it becomes red or painful. If you are breast-feeding and took prenatal vitamins during your pregnancy, continue them while nursing. Fiber supplements and stool softeners (Colace) are available without a prescription. If you become constipated with no bowel movement for a few days, you may need a laxative such as Miralax, Ducolax or Senakot. Medications You may also continue to use the same medications used during your pregnancy. Anti-inflammatory Medication Ibuprofen and Naprosyn are nonprescription pain relievers that reduce cramping, bleeding and discomfort. The usual dose of Ibuprofen (Advil, Nuprin, Motrin) is 600 mg every 6 hours, not to exceed 2400 mg in 24 hours and Naprosyn (Aleve) is 220 mg, 2 initially, then 1 every 6-8 hours, not to exceed 1100 mg in 24 hours. Tylenol is also useful for pain relief and can be taken with Ibuprofen and Naprosyn as they work differently. Narcotics Percocet, Vicodin, or Tylenol #3 are narcotics that may be prescribed by your physician if you have had a cesarean section. Ibuprofen and Naprosyn work synergistically with the narcotic so that you need less of it. Continue the anti-inflammatory medication after you stop taking the narcotic to continue with pain relief. Symptoms to Report · Excessive bleeding, soaking a pad in one hour with bright red blood, or passing large clots (call immediately). The second is watery-pink, lasting for 1-3 weeks, and the third is yellowish-white, lasting another 3-6 weeks. Clots can be bright red, dark red, small or large and are frequently associated with severe cramping. Call for excessive bleeding, soaking one pad per hour with bright red blood or continuing to pass large clots. The edges of the incision may be more swollen than the center because of knots used to close the layers located at the sides of the incision. The top of the incision frequently hangs over the lower edge during the healing process until the lymphatic system begins to function normally. Call the office if the incision becomes red, more inflamed, more tender, or begins to leak fluid. Constipation Hormonal changes, dehydration, breast-feeding and inactivity cause constipation. Try increasing the fiber in your diet, drinking more water, and using stool softeners. We recommend changing your position often, emptying your bladder often, using a heating pad, and taking Ibuprofen to help with the contractions. Depression and Emotional Changes It is normal to feel overwhelmed, exhausted, and sleep deprived. The lifestyle changes, exhaustion, and fluctuating hormones frequently cause anxiety and feelings of helplessness. The demands of a new baby and inadequate sleep may lead to feelings of depression. Resting, maintaining a good diet, and planning time for you away from baby are important. If depression persists longer, or seems more severe, please do not hesitate to schedule an appointment with your doctor. Engorged Breasts Try using ice packs and wearing a sports bra or nursing bra all the time. If you are nursing, your body should regulate the engorgement within the first few weeks. Episiotomy 69 Use ice packs the first 1-2 days and Ibuprofen as needed for swelling and discomfort. Taking a warm bath, using a sitz bath, a spray bottle, or a rubber ring/donut to sit on may also help. Hair Loss Thinning hair is normal postpartum, with the most noticeable change 5-6 months after delivery. Hormonal Changes It is common after delivery to experience hot flashes, night sweats, mood swings, and vaginal dryness similar to what women experience in early menopause. Your estrogen level drops with delivery and is reduced until you finish nursing and your regular menses resumes. If the symptoms are troublesome, you can discuss estrogen replacement with your physician. A small dose of oral or transdermal (patch) estrogen will reduce the vasomotor symptoms of hot flashes and night sweats. The body treats nursing like menopause with all the same symptoms due to lack of estrogen. Starting a combination oral contraceptive pill or using an estrogen patch usually helps decrease the symptoms. Sex If you had a cesarean section or a vaginal delivery without an episiotomy, you may attempt intercourse four weeks after delivery. If you had a vaginal delivery with an episiotomy or laceration, wait until after your postpartum visit. You may need to use lubrication (Astroglide or K-Y Jelly), especially if you are breastfeeding. If vaginal dryness persists, vaginal estrogen cream can be prescribed by your physician. Urinary Leakage Urinary stress incontinence is caused by decreased perineal muscle tone and lack of estrogen.
- Warm skin
- U.S. Centers for Disease Control and Prevention - www.cdc.gov/ncbddd/dd/ddcp.htm
- Indifference (apathy)
- Damage to the electrical conduction system of the heart during surgery (causing an irregular heart rhythm)
- Decrease or loss of vision
- Grows to a height that is double the length at birth
Etodolac 300 mg visa
Simple and highly effective treatment for ingrowing nail- Gutter treatment with acrylic fixation arthritis vs gout purchase etodolac master card, acrylic artificial nail and taping arthritis knee range of motion cheap 200 mg etodolac visa. Treatment of ingrowing nail in children complete arthritis health diet guide and cookbook buy etodolac with american express, acrylic affixed gutter splint, sculptured nail and taping. Simple and effective non-invasive treatment methods for ingrown nail and pincer nail including acrylic affixed gutter splint, anchor taping, sculptured nails, shape memory alloy and plastic nail braces as well as 40% urea paste. Anchor taping method for the treatment of ingrown nail, nail trauma and other nail disorders. Surgical pearl: Nail splinting by flexible tube-A new noninvasive treatment for ingrown toenails. Sodium bicarbonate attenuates pain on skin infiltration with lidocaine, with or without epinephrine. Pain tolerance, especially during the local anesthesia, is the cornerstone of any surgical procedure. Fortunately, the indications of a nail biopsy in a child are very limited and should be done only for specific purposes. Indications of Nail Biopsy in Children Contrary to adults, nail biopsy is rarely performed in children, unless necessary. Indeed, the scope of nail conditions in children is different from the one in adults and hopefully, many pediatric nail diseases are clinically recognizable. The latter is aggressive and should be diagnosed as soon as possible to avoid any permanent scarring. Nail psoriasis is much less often biopsied as there are in most cases clues to help the diagnosis, such as plaques on the body or scalp or a familial history of psoriasis. Moreover, there are no dystrophic sequelae from the disease and the treatment mostly remains topical. The lesion is biopsied because it has an unusual location or an unusual presentation5 (Figure 19. In some rare instances of dominant dystrophic epidermolysis bullosa, the nail abnormalities may be the only sign of the condition over several generations. One should remember that the stress of the parents is very easily transmitted to the child. Older children should be included in the discussion and a simple, clear, and reassuring explanation should be given to them. There are no specific studies on nail surgery procedures in children, but one may get good information from publications on venous puncture and dental procedures in this age group. Several studies compared different regimens: those with midazolam, chloral hydrate, hydroxyzine, and mepiridine, respectively. It is amazing to discover how parents are unable to carry out this kind of dressing. A demonstration on how to perform an adequate occlusion (with any cream) during the preoperative consultation is of great help. Time of occlusion should be respected, too, at least 2 hours prior to the procedure for fingers or toes. It is a cost-effective and efficacious alternative to conscious sedation or general anesthesia for minor pediatric surgical procedures. Managing the Child during the Biopsy Pain from the Needle As previously mentioned, children mostly fear the needle. However, it is sometimes impossible to apply before the procedure (parents forgot, waited too long, did not do it properly) and other tips should be used to overcome the discomfort from the needle insertion. Pain is highly subjective, and it is neurologically proven that stimulation of large diameter fibers using cold, rubbing, pressure, or vibration can close the neural "gate" so that the central perception of pain is reduced. The mother (or the nurse) may be asked to firmly press on the point of injection for at least 5 minutes before the needle prick. Another option is to use a vibrating tool for several minutes, at the location of the future injection, until the child finds that the area is becoming numb (Figure 19. This was demonstrated as an effective method to decrease pain during local anesthesia. Downloaded by [Chulalongkorn University (Faculty of Engineering)] at Pain from Dilation Once the needle is inserted painlessly, the infusion of the anesthetic may start. The subungual space is very limited, and excessive pressure on the Vater-Pacini corpuscules within the distal soft tissue will trigger pain. The injection should be extremely slow, thus performing a very slowly progressive swelling. It is not unusual to spend more time performing the anesthesia than the surgical procedure itself. If the child moves a little bit, showing some discomfort from the infusion, the surgeon should stop injecting for a few seconds, then start again. Buffering it (1 volume of bicarbonate for 9 volumes of lidocaine) dramatically reduces pain during infusion. Keeping the anesthetic out of the fridge or at body temperature in a water bath will render the infusion less painful. The best way to reduce pain from infusion is to inject warmed, buffered lidocaine. Distraction is a very commonly used trick, called talkesthesia, which was known to work well with children. A Cochrane database showed that there is strong evidence supporting the efficacy of distraction for needle-related pain and anxiety in children and adolescents (Figure 19. However, there is no evidence that any one technique among the ones used (parents coaching, blowing out air, memory alteration, distraction, and suggestion) is superior to another. There is insufficient evidence of the analgesic effects of sweet-tasting solutions or substances during painful procedures. Dealing with Postoperative Pain Once the procedure is done, the first two questions of the parents will be "When will the anesthetic effect stop? This will be painless because of the previous lidocaine block and this will also act as a volumetric tourniquet by pressing on the digital proper arteries, thus limiting the risk of postoperative bleeding. Ropivacaine is now considered as the reference drug for regional anesthesia in pediatric patients, mainly because it is less toxic than bupivacaine and provides excellent postoperative analgesia even when used at low concentrations. The first thing to explain to the parents is that the limb should be kept elevated for the next 2 days. The type and power of painkiller will depend upon the procedure performed, the age of the patient, and his/her tolerance to pain. This is why the immediate postoperative dressing should be adapted to nail surgery. Applying large amounts of ointment covered with nonadherent dressing, such as petrolatum-coated gauze (Tulle gras, Bactigras, Adaptic, Jelonet) will protect the wound from drying and will allow an easy and painless removal. Mepitel is a porous, semitransparent, low-adherent, flexible polyamide net coated with soft silicone. It is not absorbent, but contains apertures of approximately 1 mm in diameter that allow the passage of exudate into a secondary absorbent dressing.
Buy discount etodolac on line
Mesoderm-derived connective tissue gives rise to arthritis relief home remedies order etodolac 400mg on-line structures in the dental papilla symptoms of arthritis in horses feet 200 mg etodolac. Outer margin of the dental papilla differentiates into odontoblasts arthritis gelling order etodolac 200mg with mastercard, which continue with ameloblastic epithelium; odontoblasts secrete dentin. Diets rich in carbohydrates do not require much chewing and thus the soft and sticky food gets clung to the teeth rather than being cleared away, particularly in the areas of occlusal pits and fissures. G/A the earliest change is the appearance of a small, chalky-white spot on the enamel which subsequently enlarges and often becomes yellow or brown and breaks down to form carious cavity. There is evidence of reaction of the tooth to the carious process in the form of secon dary dentin, which is a layer of odontoblasts laid down under the original dentin. Less common causes of these lesions are fracture of tooth and accidental exposure of pulp by the dentist. Besides inflammation, other diseases associated with gingival swelling are leukaemia, scurvy, fibrous hyperplasia and epulis. Pregnancy, puberty and use of drugs like dilantin are associated with periodontal disease more often. M/E Untreated chronic marginal gingivitis slowly progresses to chronic periodontitis or pyorrhoea in which there is inflammatory destruction of deeper tissues. At this stage, progressive resorption of alveolar bone occurs and the tooth ultimately gets detached. It arises consequent to inflammation following destruction of dental pulp such as in dental caries, pulpitis, and apical granuloma. Most often, radicular cyst is observed at the apex of an erupted tooth and sometimes contains thick pultaceous material. The cyst wall is fibrous and contains chronic inflammatory cells (lymphocytes, plasma cells with Russell bodies and macrophages). Dentigerous cysts are less common than radicular cysts and occur more commonly in children and young individuals. M/E Dentigerous cyst is composed of a thin fibrous tissue wall lined by stratified squamous epithelium. Thus, the cyst may resemble radicular cyst, except that chronic inflammatory changes so characteristic of radicular cyst, are usually absent in dentigerous cyst. The cyst arises from remains in the midline during closure of mandibular and branchial arches. G/A the tumour is greyish-white, usually solid, sometimes cystic, replacing and expanding the affected bone. M/E Ameloblastoma can show different patterns as follows: i) Follicular pattern is the most common. The tumour consists of follicles of variable size and shape and separated from each other by fibrous tissue. The tumour epithelium is seen to form irregular plexiform masses or network of strands. The tumour is commonly associated with an unerupted tooth and thus closely resembles dentigerous cyst radiologically. The wall of cyst contains scanty fibrous connective tissue in which are present characteristic tubulelike structures composed of epithelial cells. It is seen commonly in 4th and 5th decades and occurs more commonly in the region of mandible. M/E the tumour consists of closely packed polyhedral epithelial cells having features of nuclear pleomorphism, giant nuclei and rare mitotic figures. The stroma is often scanty and appears homogeneous and hyalinised in which small calcified deposits are seen which are a striking feature of this tumour. It resembles ameloblastoma but can be distinguished from it because ameloblastic fibroma occurs in younger age group (below 20 years). There are 3 subtypes: i) Complex odontoma is always benign and consists of enamel, dentin and cementum which are not differentiated. The major salivary glands are the three paired glands: parotid, submandibular and sublingual. The minor salivary glands are numerous and are widely distributed in the mucosa of oral cavity. M/E the salivary glands are tubuloalveolar glands and may contain mucous cells, serous cells, or both. The secretory acini of the major salivary glands are drained by ducts lined by: low cuboidal epithelium in the intercalated portion, tall columnar epithelium in the intralobular ducts, and simpler epithelium in the secretory ducts. It occurs commonly due to: stomatitis, teething, mentally retarded state, schizophrenia, neurological disturbances, increased gastric secretion and sialosis. Viral infections the most common inflammatory lesion of the salivary glands particularly of the parotid glands, is mumps occurring in children of school-age. It is characterised by triad of pathological involvement-epidemic parotitis (mumps), orchitisoophoritis, and pancreatitis. Bacterial and mycotic infections Bacterial infections may cause acute sialadenitis more often. M/E Acute viral sialadenitis in mumps shows swelling and cytoplasmic vacuolation of the acinar epithelial cells and degenerative changes in the ductal epithelium. Chronic and recurrent sialadenitis is characterised by increased lymphoid tissue in the interstitium, progressive loss of secretory tissue and replacement by fibrosis. Majority of parotid gland tumour (65-85%) are benign, while in the other major and minor salivary glands 35-50% of the tumours are malignant. Most of the salivary gland tumours originate from the ductal lining epithelium and the underlying myoepithelial cells; a few arise from acini. They are broadly classified into 2 major groups-pleomorphic and monomorphic adenomas. Pleomorphic adenoma is the commonest tumour in the parotid gland and occurs less often in other major and minor salivary glands. The tumour is commoner in women and is seen more frequently in 3rd to 5th decades of life. G/A Pleomorphic adenoma is a circumscribed, pseudoencapsulated, rounded, at times multilobulated, firm mass, 2-5 cm in diameter, with bosselated surface. Epithelial component may form various patterns like ducts, acini, tubules, sheets and strands of cells of ductal or myoepithelial origin. The ductal cells are cuboidal or columnar, while the underlying myoepithelial cells may be polygonal or spindle-shaped resembling smooth muscle cells. Stromal elements are present as loose connective tissue, and as myxoid, mucoid and chondroid matrix, which simulates cartilage (pseudocartilage). However, true cartilage and even bone may also be observed in a small proportion of these tumours. The main factors responsible for the tendency to recur are incomplete surgical removal due to proximity to the facial nerve, multiple foci of tumour, pseudoencapsulation, and implantation in the surgical field. The cut surface shows characteristic slit-like or cystic spaces, containing milky fluid and having papillary projections. M/E the tumour shows 2 components: Epithelial parenchyma is composed of glandular and cystic structures having papillary arrangement and is lined by characteristic eosinophilic epithelium.
Best buy for etodolac
Primary tubular diseases that include tubular injury by ischaemic or toxic agents i arthritis essential oil blends buy discount etodolac 400 mg on line. Tubulointerstitial diseases that include inflammatory involvement of the tubules and the interstitium i rheumatoid arthritis inflammation diet buy etodolac 200 mg amex. Shock (post-traumatic arthritis in fingers relief buy cheap etodolac 300mg on-line, surgical, burns, dehydration, obstetrical and septic type). Non-traumatic rhabdomyolysis induced by alcohol, coma, muscle disease or extreme muscular exertion (myoglobinuric nephrosis). M/E Predominant changes are seen in the tubules, while glomeruli remain unaffected. Eosinophilic hyaline casts or pigmented haemoglobin and myoglobin casts in the tubular lumina. Disruption of tubular basement membrane adjacent to the cast may occur (tubulorrhexis). In general, cases that follow severe trauma, surgical procedures, extensive burns and sepsis have much worse outlook than the others. General poisons such as mercuric chloride, carbon tetrachloride, ethylene glycol, mushroom poisoning and insecticides. Drugs such as sulfonamides, certain antibiotics (gentamycin, cephalosporin), anaesthetic agents (methoxyflurane, halothane), barbiturates, salicylates. Epithelial cells of mainly proximal convoluted tubules are necrotic and desquamated into the tubular lumina. The regenerating epithelium, which is flat and thin with few mitoses, may be seen lining the tubular basement membrane. The bacteria gain entry into the urinary tract, and then into the kidney by one of the two routes: 1. The common pathogenic organisms are inhabitants of the colon and may cause faecal contamination of the urethral orifice, especially in females in reproductive age group. Ascending infection may occur in a normal individual but the susceptibility is increased in patients with diabetes mellitus, pregnancy, urinary tract obstruction or instrumentation. After having caused urethritis and cystitis, the bacteria in susceptible cases ascend further up into the ureters against the flow of urine, extend into the renal pelvis and then the renal cortex. The role of vesico-ureteral reflux is not a significant factor in the pathogenesis of acute pyelonephritis as it is in chronic pyelonephritis. Haematogenous infection Less often, acute pyelonephritis may result from blood-borne spread of infection. This occurs more often in patients with obstructive lesions in the urinary tract, and in debilitated or immunosuppressed patients. G/A Well-developed cases of acute pyelonephritis show enlarged and swollen kidney that bulges on section. M/E Acute pyelonephritis is characterised by extensive acute inflammation involving the interstitium and causing destruction of the tubules. Generally, the glomeruli and renal blood vessels show considerable resistance to infection and are spared. The acute inflammation may be in the form of large number of neutrophils in the interstitial tissue and bursting into tubules, or may form focal neutrophilic abscesses in the renal parenchyma. Papillary necrosis Papillary necrosis or necrotising papillitis develops more commonly in analgesic abuse nephropathy and in sickle cell disease but may occur as a complication of acute pyelonephritis as well. Pyonephrosis Rarely, the abscesses in the kidney in acute pyelonephritis are extensive, particularly in cases with obstruction. This results in inability of the abscesses to drain and this transforms the kidney into a multilocular sac filled with pus. Perinephric abscess the abscesses in the kidney may extend through the capsule of the kidney into the perinephric tissue and form perinephric abscess. Refluxnephropathy Reflux of urine from the bladder into one or both the ureters during micturition is the major cause of chronic pyelonephritis. Reflux results in increase in pressure in the renal pelvis so that the urine is forced into renal tubules which is eventually followed by damage to the kidney and scar formation. Obstructive pyelonephritis Obstruction to the outflow of urine at different levels predisposes the kidney to infection. Recurrent episodes of such obstruction and infection result in renal damage and scarring. G/A the kidneys are usually small and contracted (weighing less than 100 gm) showing unequal reduction, which distinguishes it from other forms of contracted kidney. The surface of the kidney is irregularly scarred; the capsule can be stripped off with difficulty due to adherence to scars. There is generally blunting and dilatation of calyces (calyectasis) and dilated pelvis of the kidney. Xanthogranulomatous pyelonephritis is an uncommon variant characterised by collection of foamy macrophages admixed with other inflammatory cells and giant cells. Dilated tubules may contain eosinophilic colloid casts producing thyroidisation of tubules. The patients present with clinical picture of chronic renal failure or with symptoms of hypertension. Sometimes, the patients may present with features of acute recurrent pyelonephritis with fever, loin pain, lumbar tenderness, dysuria, pyouria, bacteriuria and frequency of micturition. The renal lesions in tuberculosis may be in the form of tuberculous pyelonephritis or appear as multiple miliary tubercles. G/A the lesions in tuberculous pyelonephritis are often bilateral, usually involving the medulla with replacement of the papillae by caseous tissue. The clinical presentation is extremely variable but it should always be considered as a possibility in a patient in whom there is persistent sterile pyouria, microscopic haematuria and mild proteinuria after effective antibiotic therapy for urinary tract infection. Functional renal impairment in multiple myeloma is a common manifestation, developing in about 50% of patients. The pathogenesis of myeloma kidney is related to excess filtration of Bence Jones proteins through the glomerulus, usually kappa (k) light chains. These light chain proteins are precipitated in the distal convoluted tubules in combination with Tamm-Horsfall proteins, the urinary glycoproteins. M/E There are some areas of tubular atrophy while many other tubular lumina are dilated and contain characteristic bright pink laminated cracked or fractured casts consisting of Bence-Jones proteins called fractured casts. Most commonly, it develops as a complication of severe hypercalcaemia such as due to hyperparathyroidism, hypervitaminosis D, excessive bone destruction in metastatic malignancy, hyperthyroidism, excessive calcium intake such as in milk-alkali syndrome and sarcoidosis. M/E Nephrocalcinosis due to hypercalcaemia characteristically shows deposition of calcium in the tubular epithelial cells in the basement membrane, within the mitochondria and in the cytoplasm. The cause of obstruction may lie at any level of the urinary tract-renal pelvis, ureters, urinary bladder and urethra. The obstruction at any of these anatomic locations may be intraluminal, intramural or extramural as under: A. There are three important anatomic sequelae of obstruction, namely: hydronephrosis, hydroureter and hypertrophy of the bladder.