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Cell adhesion molecules facilitate leukocyte adhesion by binding to a single cell surface glycoprotein found on activated monocytes 50mg avanafil visa erectile dysfunction medication south africa, fibroblasts and vascular endothelial cells order avanafil 100 mg visa erectile dysfunction prevents ejaculation in most cases. Chemotaxis – directional movement of phagocytic cells, mediated by a series of chemical messengers a. Diapedesis – passive escape of erythrocytes – may be facilitated by chemotactic leukocyte migration. Monocytes and macrophages appear after 4 hours and peak 16-24 hours after injury occurs. They have greater killing potential and have a role in preparing the tissue for healing and repair. Adherence between the phagocyte and unwanted material is the first step in the process of phagocytosis. Opsonins, which facilitate adherence of opsonin coated substances to receptors on phagocytes. Specific surface receptors are present on phagocytes for immunoglobulin molecules, C3b and fibronectins – note that not all bacteria bind fibronectins and adhere to phagocytes through non-specific mechanisms. Antibody-mediated opsonization can be enhanced by activation of complement, and is critical if non-specific opsonization is not effective. Activated macrophages are larger, have more mitochondria and Lysosomes, and a greater amount of hydrolytic chemicals. Coagulation factors (factor V and thromboplastin) Note that some bacteria still survive – e. Microbicidal function - chronic granulomatous disease of childhood Clinical manifestations of acute inflammation: 1. Redness caused by arteriolar dilatation and increased vascularity – congestion may progress to stasis leading to reduction of haemoglobin 2. Heat due to increase blood flow – central body temperature may also be elevated 3. Processes contained within rigid structures may not swell, but can occlude structures. Pain due to physical tension and swelling, as well as the release of bradykinin 5. Note that deliberate motion and function may promote the spread of the injurous process through tissue planes and lymphatics. Endocrine change – an increase in glucocorticoid steroid hormone production due to stress • Chronic Inflammation Chronic inflammation is a prolonged process in which destruction and inflammation are proceeding at the same time as attempts at healing. After repeated bouts of acute inflammation with intervals of healing – gall bladder, kidney and large intestine 3. Immune reactions Mononuclear cells are the characteristic features of chronic inflammation: 1. Activated macrophages, which are motile, capable of phagocytosis, stimulate fibroblasts to divide and are hardy and long lived. B and T lymphocytes may be involved also, along with plasma cells, eosinophils and fibroblasts The histological hallmarks of chronic inflammation are: 1. Hyperplasia of mononuclear/phagocytic cells in lymph nodes, spleen, liver and bone marrow b. Non-specific complaints include fatigue, anorexia, low grade fever A granulomata is a focal chronic inflammatory reaction, with macrophages and epithelioid cells in compact masses surrounded by lymphocytes. Modified macrophages are characteristic: Epithelioid cells are specialised for secretion over phagocytosis – seen in tuberculosis and sarcoidosis Multinucleate giant cells are formed by fusion of macrophages or epithelioid cells – they may be seen in chronic inflammation without granulomatas. Non-immune – foreign body may attract macrophages without epithelioid cells or cell-mediated immune response. Inhalation/ingestion of organisms Æ acute reaction Æ organism survives (waxy coat) 2. Immune status change Æ reactivation of dormant bacteria Pathogenesis of syphilis: 1. Bone and skin – gumma necrosis (extensive, few giant cells) • Healing by Regeneration and Repair Regeneration is the replacement of lost cells by those of the same type – the capacity of tissues for regeneration depends on the presence of stem cells: 1. Axons of peripheral nerve cells may regenerate slowly if the nerve sheath is not damaged – a displaced sheath may produce a traumatic neuroma. Satellite cells at the basement membrane of skeletal muscle cells can differentiate into myocytes to replace those that have necrosed.

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In one review of the evidence of B vitamin influence on mood discount avanafil 100 mg overnight delivery impotence fonctionnelle, the authors concluded discount avanafil 100 mg visa impotence at 35, “On the basis of current data, we suggest that oral doses of both folic acid (800 microg daily) and vitamin B12 (1 mg daily) should be tried to improve treatment outcome in depression. One particular form—C677T—is found in significantly higher numbers in psychiatric populations. Psychiatric signs of deficiency include concentration difficulties, confusion, irritation, impaired memory, dementia, irritability, depression, personality changes, and psychosis. Psychiatric symptoms may exist despite the absence of typical blood or neurologic symptoms common with B12 deficiency. Psychosis may respond to supplementation, even after a prolonged period of cobalamin deficiency. B12-related mental disorders can manifest even with low-to-moderate B12 serum levels. If homocysteine or methylmalonic acid levels are elevated, despite “normal” B12 levels, a deficiency could be indicated. This is a particular issue with the elderly, who commonly experience B12 deficiency, in part due to a scarcity of intrinsic factor, a glycoprotein that aids in B12 absorption (Sabeen 2009). For these patients, injected B12 may prove more effective than supplements taken orally. It should be noted that some non-elderly also do not produce sufficient intrinsic factor and are at risk for psychiatric symptoms due to B12 deficiency, as are vegans and vegetarians. Recent research suggests that B12 supplementation may reduce the risk of Alzheimer’s disease. In Finland 271 people, age 65 to 79, were selected who did not have dementia at the start of the study. B12 has been found as a marker of how well people will respond to treatment for depression. In another Finnish study, researchers monitored 115 patients suffering from depression over a six-month period and grouped them according to how Nutritional Treatments in Psychiatry | 51 well they responded to treatment. The patients who responded fully to treatment had higher concentrations of vitamin B12 in their blood at both the start and the end of the study than those for whom treatment was less effective. Results confirmed the conclusions of a similar study on elderly patients (Hintikka 2003). These observations suggest that B12 can be a helpful complement to any treatment regimen for depression. Vitamin B6 Vitamin B6, or pyridoxine, is another critical element of the methylation cycle. One of its many tasks is to convert tryptophan to serotonin and to assist in the making of norepinephrine and melatonin. A lack of B6 or a metabolic failure to process it correctly can cause nervousness, irritability, depression, difficulty concentrating, and short-term memory loss. B6 has been found in a multitude of studies to be twice as effective as placebo in improving symptoms of premenstrual syndrome when taken in doses of 50-100 mg per day. Pyridoxine may also be helpful in autism and related disorders, many studies suggest. It’s been found that when 100 mg of B6 is administered daily for two weeks, then twice a day after that, children with pervasive developmental disorder see an 11. As a result, supplementation with this nutrient has been found helpful for depression when taken alone or as an adjunct to medication. Not all patients, however, are deficient in methylation, so one has to be alert to a negative response to methylation supplementation and discontinue supplementation if necessary. Fatty Acids In the past decade we have seen a plethora of studies showing the effectiveness of fatty acids in the treatment of a range of mental disorders. Like the elements of the methylation cycle, fatty acids have their own chemical pathway, which also requires specific substrate materials which must be in adequate supply for normal physiological response to occur. Of particular interest to mental health professionals has been the omega-3 fatty acids—so-called because the molecule has 3 hydrogen atoms at the end of a carbon chain. An epidemiological study found improved outcomes for schizophrenia patients in countries where diets are high in unsaturated fatty acids. A review of 18,411 women in Sweden found that those who ate fish 3–4 times per week were 53% as likely to experience high- level psychotic symptoms as women who ate no fish at all.

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H R E S H R Iceland Countrywide 2005 Surveillance 7 7 100 0 0 discount 200 mg avanafil free shipping erectile dysfunction drug has least side effects,0 0 0 generic avanafil 50 mg otc impotence groups,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Ireland Countrywide 2005 Surveillance 200 194 97,0 6 3,0 6 3,0 1 0,5 1 0,5 1 0,5 5 2,5 5 2,5 0 0,0 Israel Countrywide 2005 Surveillance 211 165 78,2 46 21,8 32 15,2 12 5,7 13 6,2 41 19,4 15 7,1 2 0,9 0 0,0 Italy Half of the country 2005 Surveillance 485 438 90,3 47 9,7 30 6,2 11 2,3 4 0,8 29 6,0 30 6,2 15 3,1 1 0,2 Kazakhstan Countrywide 2001 Survey 359 154 42,9 205 57,1 153 42,6 56 15,6 89 24,8 185 51,5 50 13,9 11 3,1 1 0,3 Latvia Countrywide 2005 Surveillance 873 560 64,1 313 35,9 270 30,9 94 10,8 92 10,5 273 31,3 80 9,2 37 4,2 0 0,0 Lithuania Countrywide 2005 Surveillance 1293 980 75,8 313 24,2 262 20,3 128 9,9 234 18,1 62 4,8 109 8,4 60 4,6 0 0,0 Luxembourg Countrywide 2005 Surveillance 36 32 88,9 4 11,1 3 8,3 0 0,0 0 0,0 2 5,6 3 8,3 2 5,6 0 0,0 Malta Countrywide 2005 Surveillance 11 9 81,8 2 18,2 0 0,0 0 0,0 0 0,0 2 18,2 2 18,2 0 0,0 0 0,0 Netherlands Countrywide 2005 Surveillance 709 650 91,7 59 8,3 46 6,5 10 1,4 3 0,4 26 3,7 39 5,5 26 3,7 5 0,7 Norway Countrywide 2005 Surveillance 193 150 77,7 43 22,3 20 10,4 3 1,6 4 2,1 31 16,1 32 16,6 9 4,7 0 0,0 Poland Countrywide 2004 Surveillance 2716 2. Sweden Countrywide 2005 Surveillance 425 373 87,8 52 12,2 42 9,9 3 0,7 2 0,5 9 2,1 50 11,8 40 9,4 1 0,2 Switzerland Countrywide 2005 Surveillance 326 311 95,4 15 4,6 14 4,3 3 0,9 0 0,0 0 0,0 13 4,0 12 3,7 1 0,3 Turkmenistan Dashoguz Velayat 2002 Survey 105 73 69,5 32 30,5 16 15,2 4 3,8 2 1,9 26 24,8 22 21,0 6 5,7 0 0,0 (Aral Sea Region) Ukraine Donetsk 2006 Survey 1003 604 60,2 399 39,8 311 31,0 180 17,9 30 3,0 284 28,3 148 14,8 69 6,9 12 1,2 United Kingdom Countrywide 2005 Surveillance 3428 3. India Raichur District, 1999 Survey 278 217 78,1 61 21,9 52 18,7 7 2,5 9 3,2 20 7,2 43 15,5 34 12,2 0 0,0 Karnataka State India North Arcot District, 1999 Survey 282 204 72,3 78 27,7 66 23,4 8 2,8 13 4,6 35 12,4 47 16,7 36 12,8 0 0,0 Tamil Nadu State India Ernakulam district, 2004 Survey 305 220 72,1 85 27,9 27 8,9 11 3,6 8 2,6 72 23,6 64 21,0 8 2,6 3 1,0 Kerala State India Gujarat State 2006 Survey 1571 1. Cambodia Countrywide 2001 Survey 638 572 89,7 66 10,3 41 6,4 4 0,6 1 0,2 32 5,0 54 8,5 30 4,7 3 0,5 China Guandong Province 1999 Survey 461 401 87,0 60 13,0 43 9,3 16 3,5 11 2,4 28 6,1 37 8,0 22 4,8 2 0,4 China Beijing Municipality 2004 Survey 1043 856 82,1 187 17,9 91 8,7 44 4,2 43 4,1 95 9,1 113 10,8 35 3,4 11 1,1 China Shandong Province 1997 Survey 1009 831 82,4 178 17,6 114 11,3 38 3,8 17 1,7 123 12,2 99 9,8 38 3,8 6 0,6 China Henan Province 2001 Survey 1222 858 70,2 364 29,8 208 17,0 117 9,6 53 4,3 271 22,2 190 15,5 40 3,3 17 1,4 China (3) Liaoning Province 1999 Survey 818 474 57,9 344 42,1 207 25,3 93 11,4 31 3,8 279 34,1 177 21,6 44 5,4 4 0,5 China Heilongjiang 2005 Survey 1574 1. H R E S H R New Zealand Countrywide 2006 Surveillance 250 224 89,6 26 10,4 17 6,8 1 0,4 1 0,4 18 7,2 17 6,8 8 3,2 0 0,0 Northern Mariana Is Countrywide 2006 Surveillance 18 4 22,2 4 22,2 3 16,7 2 11,1 0 0,0 2 11,1 1 5,6 0 0,0 0 0,0 Philippines Countrywide 2004 Survey 965 767 79,5 198 20,5 130 13,5 44 4,6 41 4,2 115 11,9 122 12,6 57 5,9 4 0,4 Rep. Vanuatu Countrywide 2006 Surveillance 29 28 96,6 1 3,4 1 3,4 0 0,0 0 0,0 0 0,0 1 3,4 1 3,4 0 0,0 Viet Nam Countrywide 2006 Survey 1619 1. The reduction would be 106 Mono % Mono % Mdr % Hr % Hre % Hrs % Hres % Poly % He % Hs % Hes % Re % Rs % Res % Es % E S 0 0,0 9 3,6 1 0,4 0 0,0 0 0,0 0 0,0 1 0,4 8 3,2 0 0,0 8 3,2 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 1 5,6 2 11,1 2 11,1 0 0,0 0 0,0 0 0,0 1 5,6 0 0,0 1 5,6 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 1 0,1 60 6,2 39 4,0 10 1,0 5 0,5 5 0,5 19 2,0 37 3,8 5 0,5 21 2,2 8 0,8 1 0,1 0 0,0 0 0,0 2 0,2 7 0,3 26 1,0 71 2,7 24 0,9 33 1,3 4 0,2 10 0,4 47 1,8 16 0,6 26 1,0 3 0,1 1 0,0 1 0,0 0 0,0 0 0,0 2 0,2 23 2,6 2 0,2 0 0,0 0 0,0 0 0,0 2 0,2 12 1,3 2 0,2 9 1,0 1 0,1 0 0,0 0 0,0 0 0,0 0 0,0. Ethiopia Countrywide 2005 Survey 76 39 51,3 37 48,7 19 25,0 11 14,5 11 14,5 29 38,2 21 27,6 4 5,3 1 1,3 Gambia Countrywide 2000 Survey 15 15 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Guinea Sentinel sites 1998 Survey 32 16 50,0 16 50,0 16 50,0 9 28,1 6 18,8 11 34,4 3 9,4 3 9,4 0 0,0 Kenya Nearly Countrywide 1995 Survey 46 29 63,0 17 37,0 17 37,0 0 0,0 0 0,0 3 6,5 14 30,4 14 30,4 0 0,0 Lesotho Countrywide 1995 Survey 53 35 66,0 18 34,0 16 30,2 3 5,7 2 3,8 9 17,0 11 20,8 9 17,0 0 0,0 Madagascar (2) Countrywide 2007 Survey 51 45 88,2 6 11,8 5 9,8 3 5,9 0 0,0 2 3,9 2 3,9 2 3,9 0 0,0 Mozambique Countrywide 1999 Survey 122 67 54,9 55 45,1 50 41,0 5 4,1 1 0,8 30 24,6 27 22,1 22 18,0 1 0,8 Rwanda Countrywide 2005 Survey 85 66 77,6 19 22,4 9 10,6 9 10,6 10 11,8 16 18,8 10 11,8 0 0,0 1 1,2 Senegal Countrywide 2006 Survey 42 29 69,0 13 31,0 10 23,8 7 16,7 7 16,7 12 28,6 4 9,5 1 2,4 0 0,0 Sierra Leone Nearly Countrywide 1997 Survey 13 5 38,5 8 61,5 8 61,5 3 23,1 1 7,7 3 23,1 4 30,8 4 30,8 0 0,0 South Africa Countrywide 2002 Survey 1465 1. Costa Rica Countrywide 2006 Survey 21 20 95,2 1 4,8 1 4,8 1 4,8 1 4,8 0 0,0 0 0,0 0 0,0 0 0,0 Cuba Countrywide 2005 Sentinel 19 12 63,2 7 36,8 2 10,5 1 5,3 0 0,0 6 31,6 6 31,6 1 5,3 0 0,0 Dominican Republic Countrywide 1995 Survey 117 56 47,9 61 52,1 43 36,8 37 31,6 15 12,8 30 25,6 26 22,2 12 10,3 10 8,5 Ecuador Countrywide 2002 Survey 185 104 56,2 81 43,8 56 30,3 62 33,5 10 5,4 38 20,5 24 13,0 5 2,7 11 5,9 El Salvador Countrywide 2001 Survey 100 78 78,0 22 22,0 12 12,0 13 13,0 3 3,0 9 9,0 12 12,0 3 3,0 5 5,0 Guatemala Countrywide 2002 Survey 155 70 45,2 85 54,8 56 36,1 45 29,0 31 20,0 67 43,2 34 21,9 6 3,9 3 1,9 Honduras Countrywide 2004 Survey 73 45 61,6 28 38,4 18 24,7 15 20,5 5 6,8 11 15,1 16 21,9 7 9,6 5 6,8 Mexico Baja California, 1997 Survey 107 63 58,9 44 41,1 35 32,7 30 28,0 15 14,0 20 18,7 16 15,0 11 10,3 2 1,9 Sinaloa, Oaxaca Nicaragua Countrywide 2006 Survey 103 66 64,1 37 35,9 30 29,1 9 8,7 9 8,7 21 20,4 18 17,5 11 10,7 1 1,0 Paraguay Countrywide 2001 Survey 51 41 80,4 10 19,6 6 11,8 6 11,8 1 2,0 2 3,9 7 13,7 3 5,9 4 7,8 Peru Countrywide 2006 Survey 360 210 58,3 150 41,7 109 30,3 95 26,4 33 9,2 107 29,7 52 14,4 13 3,6 8 2,2 Puerto Rico Countrywide 2005 Surveillance combined only. H R E S H R Iceland Countrywide 2005 Surveillance 1 1 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Ireland Countrywide 2005 Surveillance 10 8 80,0 2 20,0 2 20,0 1 10,0 0 0,0 0 0,0 1 10,0 1 10,0 0 0,0 Israel Countrywide 2005 Surveillance 3 3 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Italy Half of the country 2005 Surveillance 79 50 63,3 29 36,7 24 30,4 14 17,7 8 10,1 23 29,1 9 11,4 4 5,1 0 0,0 Kazakhstan Countrywide 2001 Survey 319 57 17,9 262 82,1 216 67,7 196 61,4 173 54,2 246 77,1 26 8,2 3 0,9 1 0,3 Latvia Countrywide 2005 Surveillance 182 86 47,3 96 52,7 90 49,5 66 36,3 63 34,6 93 51,1 9 4,9 3 1,6 0 0,0 Lithuania Countrywide 2005 Surveillance 440 176 40,0 264 60,0 250 56,8 212 48,2 239 54,3 141 32,0 27 6,1 14 3,2 2 0,5 Luxembourg Countrywide 2005 Surveillance 0 0 0 0 0 0 0 0 0 0 Malta Countrywide 2005 Surveillance 0 0 0 0 0 0 0 0 0 0 Netherlands Countrywide 2005 Surveillance 30 25 83,3 5 16,7 3 10,0 2 6,7 0 0,0 2 6,7 3 10,0 1 3,3 1 3,3 Norway Countrywide 2005 Surveillance 8 8 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Poland Countrywide 2004 Surveillance 522 428 82,0 94 18,0 71 13,6 51 9,8 12 2,3 55 10,5 39 7,5 17 3,3 7 1,3 Portugal Countrywide 2005 Surveillance 172 127 73,8 35 20,3 26 15,1 19 11,0 10 5,8 18 10,5 14 8,1 6 3,5 2 1,2 Republic of Moldova Countrywide 2006 Surveillance 2054 605 29,5 1. Serbia Countrywide 2005 Surveillance 121 107 88,4 14 11,6 7 5,8 8 6,6 6 5,0 6 5,0 7 5,8 2 1,7 1 0,8 Slovakia Countrywide 2005 Surveillance 56 46 82,1 10 17,9 10 17,9 4 7,1 1 1,8 3 5,4 3 5,4 3 5,4 0 0,0 Slovenia Countrywide 2005 Surveillance 28 24 85,7 4 14,3 3 10,7 1 3,6 1 3,6 3 10,7 2 7,1 1 3,6 0 0,0 Spain Galicia 2005 Surveillance 68 59 86,8 9 13,2 5 7,4 1 1,5 1 1,5 6 8,8 6 8,8 2 2,9 0 0,0 Spain Aragon 2005 Surveillance 26 21 80,8 5 19,2 5 19,2 4 15,4 2 7,7 2 7,7 1 3,8 1 3,8 0 0,0 Spain Barcelona 2005 Surveillance combined only. Kerala State India Gujarat State 2006 Survey 1047 562 53,7 485 46,3 385 36,8 190 18,1 105 10,0 274 26,2 220 21,0 122 11,7 10 1,0 India Tamil Nadu State 1997 Survey new only. H R E S H R Japan Countrywide 2002 Surveillance 417 312 74,8 105 25,2 79 18,9 46 11,0 35 8,4 60 14,4 49 11,8 26 6,2 2 0,5 Malaysia Peninsular Malaysia 1997 Survey 16 13 81,3 3 18,8 0 0,0 1 6,3 0 0,0 2 12,5 3 18,8 0 0,0 1 6,3 Mongolia Countrywide 1999 Survey new only. New Zealand Countrywide 2006 Surveillance 16 15 93,8 1 6,3 1 6,3 0 0,0 0 0,0 0 0,0 1 6,3 1 6,3 0 0,0 Northern Mariana Is Countrywide 2006 Surveillance new only. Philippines Countrywide 2004 Survey 129 81 62,8 48 37,2 40 31,0 33 25,6 12 9,3 22 17,1 17 13,2 10 7,8 5 3,9 Rep. Korea Countrywide 2004 Survey 278 201 72,3 77 27,7 67 24,1 47 16,9 27 9,7 16 5,8 29 10,4 20 7,2 7 2,5 Singapore Countrywide 2005 Surveillance 105 94 89,5 11 10,5 4 3,8 3 2,9 1 1,0 7 6,7 9 8,6 2 1,9 2 1,9 Solomon Islands Countrywide 2004 Survey combined only. Viet Nam Countrywide 2006 Survey 207 85 41,1 122 58,9 90 43,5 44 21,3 30 14,5 105 50,7 38 18,4 8 3,9 2 1,0 (1) Several countries conducting routine diagnostic surveillance do not routinely test for streptomycin. The reduction would be 112 Mono % Mono % Mdr % Hr % Hre % Hrs % Hres % Poly % He % Hs % Hes % Re % Rs % Res % Es % E S 1 0,2 20 4,8 41 9,8 6 1,4 6 1,4 10 2,4 19 4,6 15 3,6 3 0,7 6 1,4 3 0,7 1 0,2 0 0,0 2 0,5 0 0,0 0 0,0 2 12,5 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0. Costa Rica Countrywide 2006 Survey 284 264 93,0 20 7,0 10 3,5 6 2,1 14 4,9 0 0,0 7 2,5 5 1,8 1 0,4 Cuba Countrywide 2005 Sentinel 198 177 89,4 21 10,6 3 1,5 2 1,0 0 0,0 19 9,6 19 9,6 1 0,5 1 0,5 Dominican Republic Countrywide 1995 Survey 420 236 56,2 184 43,8 103 24,5 86 20,5 26 6,2 94 22,4 104 24,8 38 9,0 31 7,4 Ecuador Countrywide 2002 Survey 997 753 75,5 244 24,5 145 14,5 121 12,1 20 2,0 130 13,0 123 12,3 34 3,4 26 2,6 El Salvador Countrywide 2001 Survey 711 654 92,0 57 8,0 20 2,8 20 2,8 5 0,7 32 4,5 42 5,9 6 0,8 10 1,4 Guatemala Countrywide 2002 Survey 823 505 61,4 318 38,6 128 15,6 73 8,9 83 10,1 260 31,6 190 23,1 14 1,7 8 1,0 Honduras Countrywide 2004 Survey 530 447 84,3 83 15,7 45 8,5 25 4,7 13 2,5 49 9,2 55 10,4 18 3,4 7 1,3 Mexico Baja California, 1997 Survey 441 350 79,4 91 20,6 59 13,4 42 9,5 25 5,7 44 10,0 51 11,6 25 5,7 4 0,9 Sinaloa, Oaxaca Nicaragua Countrywide 2006 Survey 423 344 81,3 79 18,7 51 12,1 12 2,8 13 3,1 46 10,9 51 12,1 24 5,7 2 0,5 Paraguay Countrywide 2001 Survey 286 250 87,4 36 12,6 21 7,3 14 4,9 7 2,4 14 4,9 23 8,0 10 3,5 7 2,4 Peru Countrywide 2006 Survey 2169 1. H R E S H R Iceland Countrywide 2005 Surveillance 8 8 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Ireland Countrywide 2005 Surveillance 273 260 95,2 13 4,8 13 4,8 3 1,1 2 0,7 3 1,1 9 3,3 9 3,3 0 0,0 Israel Countrywide 2005 Surveillance 217 171 78,8 46 21,2 32 14,7 12 5,5 13 6,0 41 18,9 15 6,9 2 0,9 0 0,0 Italy Half of the country 2005 Surveillance 585 504 86,2 81 13,8 57 9,7 26 4,4 13 2,2 52 8,9 44 7,5 22 3,8 2 0,3 Kazakhstan Countrywide 2001 Survey 678 211 31,1 467 68,9 369 54,4 252 37,2 262 38,6 431 63,6 76 11,2 14 2,1 2 0,3 Latvia Countrywide 2005 Surveillance 1055 646 61,2 409 38,8 360 34,1 160 15,2 155 14,7 366 34,7 89 8,4 40 3,8 0 0,0 Lithuania Countrywide 2005 Surveillance 1739 1. Papua Province Myanmar Countrywide 2003 Survey 849 741 87,3 108 12,7 79 9,3 52 6,1 10 1,2 74 8,7 33 3,9 9 1,1 0 0,0 Nepal Countrywide 2007 Survey 930 776 83,4 154 16,6 101 10,9 41 4,4 43 4,6 113 12,2 80 8,6 27 2,9 0 0,0 Sri Lanka Countrywide 2006 Survey 624 613 98,2 11 1,8 6 1,0 3 0,5 1 0,2 5 0,8 9 1,4 4 0,6 2 0,3 Thailand Countrywide 2006 Survey 1344 1. New Caledonia Countrywide 2005 Survey 5 4 80,0 1 20,0 1 20,0 0 0,0 0 0,0 1 20,0 0 0,0 0 0,0 0 0,0 New Zealand Countrywide 2006 Surveillance 266 239 89,8 27 10,2 18 6,8 1 0,4 1 0,4 18 6,8 18 6,8 9 3,4 0 0,0 Northern Mariana Is Countrywide 2006 Surveillance new only. Philippines Countrywide 2004 Survey 1094 848 77,5 246 22,5 170 15,5 77 7,0 53 4,8 137 12,5 139 12,7 67 6,1 9 0,8 Rep. The reduction would be 118 Mono % Mono % Mdr % Hr % Hre % Hrs % Hres % Poly % He % Hs % Hes % Re % Rs % Res % Es % E S 3 0,1 164 5,3 60 1,9 8 0,3 9 0,3 13 0,4 30 1,0 45 1,4 3 0,1 27 0,9 7 0,2 1 0,0 2 0,1 4 0,1 1 0,0 4 0,4 26 2,6 1 0,1 0 0,0 0 0,0 0 0,0 1 0,1 5 0,5 0 0,0 5 0,5 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0. Puerto Rico Surveillance 132 18 13,6 3 2,3 158 19 12,0 8 5,1 166 18 10,8 3 1,8 193 26 13,5 5 2,6 165 15 9,1 3 1,8 175 13 7,4 1 0,6 Uruguay Survey. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimi- tation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.

It provides basic information on different aspects of diabetes so that they participate in early case detection 50mg avanafil mastercard erectile dysfunction diabetes permanent, case management and prevention of complications as front line health workers discount 100 mg avanafil visa erectile dysfunction doctor denver. Directions for using the module Before starting to read this module, please follow the instruction given below. Self- Monitoring of glucose Many patients (especially those with type 1(insulin- dependent diabetes mellitus)) now regularly monitor their own blood glucose concentrations on the advice of their health care provider, using reagent test strips and reflectance meter. Several companies manufacture reagent test strips for monitoring blood glucose, and most of these companies make reflectance meters to be used to electronically read the test result. The strips used for these tests are impregnated with the enzyme glucose oxidase, enzyme peroxidase and an indicator to give a color change that is detectable. Urine Glucose determinations Chemical screening tests for glucose (dextrose) are generally included in every routine urinalysis. The occurrence of glucose in the urine indicates that the metabolic disorder diabetes mellitus should be suspected, although several other conditions result in glycosuria (glucosuria). It is possible to use both enzymatic technique and oxidation- reduction technique to determine urine glucose 2. Glucose oxidase will oxidize glucose to gluconic acid and at the same time reduce atmospheric oxygen to H2O2. The hydrogen peroxide formed will, in the presence of the oxidized form, which is indicated by the color change of an oxidation- reduction indicator. Note: The glucose oxidase, peroxidase and the reduced form of the Oxidation- Reduction indicator are all impregnated on to a dry reagent strip. After one minute read the result by matching the color on the strip with the color on the reagent strip container 7. Determination of ketone bodies in urine ketone bodies are a group of three related substances: acetone, aceto acetic acid, and β – hydroxyl butyric acid. When ever fat (rather than carbohydrate) is used as the major source of energy, ketosis and ketonuria may result. The two out standing causes of ketone accumulation are diabetes mellitus and starvation In diabetes mellitus, the body is unable to use carbohydrate as an energy source and attempts to compensate by resorting to fat catabolism, which results accumulation of ketone more than normal, that the body is unable to utilize it. The clinical result is an increased concentration of ketones in the blood (ketonemia) and in the urine (ketonuria. After collecting the urine sample from the patients, transfer into a clean, dry and free of disinfectant test tube 2. Read the result by comparing the color produced with the standard on the strip container Note acetone and aceto acetic acid can be detected by different dip stick tests, but there is no reagent strip test for β - hydroxyl butyric acid 115 4. Determination of urine protein Microalbuminuria • Diabetes mellitus causes progressive changes to the kidneys and ultimately results in diabetic renal nephropathy. This complication progresses over a period of years and may be delayed by aggressive glycemic control • An early sign that nephropathy is occurring is an increase in urinary albumin • It is thought that the early development of renal complications can be predicted by the early detection of consistent micro albuminuria. And this early detection is desirable, as better control of blood glucose levels may delay the progression of renal disease 4. Tests that are based on the precipitation of protein by chemical or coagulation by heat - This test will detect all proteins, including albumin, glycoproteins, globulins, Bence Jones protein & hemoglobin 4. The general recommendation include consumption of a balanced health diet composed of the following • 50% to 60% of calories be derived from carbohydrates • Less than 30% from fat & • The remaining 10% to 20% from protein *Food which diabetic should avoid (rapidly absorbed carbohydrate) 1) Sugar, honey, jam, marmalade &candy 2) Cakes & sweat biscuits 3)Soft drink (Fanta, cocacola etc) 4) Alcohol (Cognac, tej, arki, whisky) There are alcohols, which are allowed in moderation, that is, less sweat drinks i. Exercise - Is extremely important in the management of diabetes because of its effect on lowering blood glucose and reducing cardiovascular risk factors -Lowers blood glucose level by increasing the uptake of glucose by body muscles and by improving insulin utilization - Pre or post exercise snack may be required to prevent hypoglycemia after exercise - Patients should be thought to do regular, moderate exercise at the same time (preferably when blood glucose level are at their peak) and in the same amount for at least 30 minutes each day. Monitoring of Glucose and Ketones Blood glucose level and urine for ketone and glucose should be assessed frequently by self or by having follow up in the health unit Pt education -about Insulin Injection - Insulin injections are administered into the subcutaneous tissue - Equipment: - Insulin - Short acting insulin is clear in appearance and long acting insulin are cloudy and white - The long acting must be mixed (gently inverted or rolled in the hands) before use o - Before injection it should have room T which may require rolling it in the hands or removing it from a refrigerator for a time before the injection - If a frosted, adherent coating is present, some of the insulin is bound and should not be used Syringes - should be matched with the insulin concentration - 1 ml syringes – hold 100 units - ½ ml syringes – hold 50 units - 3/10 ml syringes – hold 30 units Administering the injection -Avoid use of alcohol for cleansing - Four main areas • Abdomen • Arms (posterior surface) • Thighs (anterior surface) • Hips 120 Absorption is greatest in abdomen and decreases progressively in the arm, thigh, and hips Rotation - Rotation of injection site is required to prevent lipodystrophy, localized changes in fatty tissue, Pt is instructed as: - 1. Systemic allergic reaction - are rare - local skin reaction that gradually spreads in to generalized urticaria Treatment:- desensitization , gradually increasing the amount of insulin 3. High-risk individuals should be encouraged to • Maintain a normal body mass index • Engage in regular physical exercise No specific intervention is proven to prevent type 2 diabetes mellitus. Braunwald, Fauci, Kasper, Hauser, Longo, Jameson:Harrison’s Principles of th Internal medicine, 15 Edition 12. Links or references to nonfederal organizations mentioned in this book or in the resource list are provided solely as a service to our users.