Anal sex refers to the activity in which penis is inserted into the anus. Some people found anal sex more joyful, but the fact is that the practice has the downside and it contains so many health risks.
It is prohibited in various cultures especially with regard to religious prohibition. It is a criminal offense in some countries and punishable by corporal or capital punishments. By disparity, people regard it a valid and natural form of sexual activity.
Is Anal Sex Safe?
There are so many health risks associated with the anal sex and anal intercourse, for both partners. Some of the health risks which may affect both homosexual and heterosexual couples are listed below.
Risk of bacterial infection: E. coli is a Gram-negative, facultative anaerobic bacteria, that is commonly found in the lower intestine. Anal sex increases the risk of transmission of E. coli bacteria from anal to your penis, which may cause a severe type of urinary tract infection.
E. coli may cause many bacterial infections, including, urinary tract infection (UTI), meningitis, cholecystitis, cholangitis, bacteremia, and pneumonia.
Hepatitis C Virus (HCV): It may be transmitted through the anal intercourse. Hepatitis C Virus is the cause of fetal liver chronic disease. It is a life-threatening virus and may lead to death.
Human Papilloma Virus (HPV): It may be transmitted through the anal intercourse and may cause to the anal wart. A research showed that some of the strain of HPV have carcinogenic potential. Some strains of HPV cause cancer of the cervix in women and also cause cancer of the throat.
Human immunodeficiency virus (HIV): There is a greater risk of transmission of HIV through anal intercourse. It is a life-threatening virus and leads to death.
Weakening of the anal sphincter: The anal anus is enclosed by the ring-like muscle, called the anal sphincter. The main function of anal sphincter is to hold the feces until you get to the toilet. After the excretion of feces, it tightens. Penetration of something like a penis inside the anal can be difficult and painful. Anal intercourse may lead to the weakening of the sphincter muscles, and make it hard to hold the feces.
Lack of natural lubrication: Naturally, the anal is not made for sex. The anal has lack of lubricant as vagina have, which makes the penetration harder and painful. Penetration can tear the tissues inside the anal and cause the wound, allowing viruses and bacteria to easily enter the bloodstream. Somehow, usage of oil or other lubricants can help in preventing the tearing of tissues inside the anal but doesn't completely.
A research showed that risk of transmission of HIV and HPV is much higher in anal sex and compared to the vaginal sex.
How to Prevent Anal Sex Problems
There is no way to completely eliminate the risk factors of anal sex until you avoid the anal sex. However, you can reduce the risk by the following tips.
- Always use a condom during anal sex.
- Do not enter penis into the mouth after inserting it into the anal.
- Use a sufficient amount of lubricants when penetrating into the anal to reduce the risk of tissue tear. Always use water-based lubricants with condoms.
- Do not lick the anal as it may cause the transmission of bacteria and viruses.
- Take a warm bath before anal sex.
- Lying on your stomach will make the insertion easier.
- Stop if you feel so much pain during anal sex.
- Stop if you experience bleeding or discharge coming from it, go to the hospital as soon as possible.
The Middle East respiratory syndrome (MERS) caused by coronavirus which has a large family of virus. This viral disease first identified in September 2012 in Saudi Arabia. This virus can cause disease ranging from common cold to Severe Acute Respiratory Disease (SARS).
This deadly virus may originate from bats and categorize as a zoonotic virus. Which mean a virus that transmitted from animal to human by direct or indirect contact. Especially dromedary camel which is a reservoir host for this virus.
Which Country Infected By MERS-CoV
Saudi Arabia is the leading country. About 80% of cases have reported. The United Arab Emirates and the Republic of Korea come in second. But specific antibodies that can found in previously infected animal have been identified in Middle East, Africa, and South Asia
*According to WHO, since 2012, 27 countries have reported cases of MERS including Algeria, Austria, Bahrain, China, Egypt, France, Germany, Greece, Islamic Republic of Iran, Italy, Jordan, Kuwait, Lebanon, Malaysia, the Netherlands, Oman, Philippines, Qatar, Republic of Korea, Kingdom of Saudi Arabia, Thailand, Tunisia, Turkey, United Arab Emirates, United Kingdom, United State, and Yemen.
How MERS-Cov virus Spread or Transmitted?
From animal to human. Taking care of infected animal without proper precaution can transmit the virus easily. Eating raw meat or milk without proper preparation can also infect the human.
Secondly, they spread by human to close human contact. For example, unprotected care to a patient in health-care facilities. The facilities provided inadequate prevention and didn’t separate MERS patient with another patient. Traveller whose have infected. Traveling to another country and spread the virus.
However, the exact route is still unknown.
What Are The Symptoms of MERS-CoV
Typical symptoms that infected patient presented are the common cold, cough, and shortness of breath. These are the common/mild symptoms. Pneumonia(not always present), and severe acute respiratory disease which leads to respiratory failure. The patient needs to use mechanical ventilation in intensive care unit (ICU).
Gastrointestinal symptoms also present for example diarrhea. Some of the patients might be asymptomatic meaning absent from clinical symptoms. But they are positive for MERS proved by a laboratory test.
Is There A Possibility For Me To Get Infected?
High-risk people: eating raw contaminated milk and meat. Older people. Low immunity person. Chronic disease patient such as renal disease, cancer, lung disease and diabetes. This person should avoid direct contact with camel, drinking raw camel milk or urine and eating raw meat.
*According to WHO, 750 death related to MERS-Cov since 2012. But there are still patient with mild cases that might miss due to ignorance about the disease. This disease has high mortality rates of 35%.
How Can We Treat MERS-CoV Disease?
Unfortunately, there is no vaccine, or specific treatment is currently available. However, according to WHO, three vaccines currently under development. One vaccine to prevent transmission from animal to human. While the other two for outbreaks of this disease and protection for high-risk people). As for now, we can only treat clinical symptoms and supportive treatment.
What Can We Do To Avoid The Virus?
We can take some precaution. For examples in the farms, market, and barns. The home where dromedary camel and other animals live; we should practice general hygiene measures. Washing hand before and after contact with the animal and avoid visiting sick animal. In health-care facilities, the worker should know or educated in the prevention of disease and applied it. Fortunately, according to WHO, a disease outbreak in healthcare facilities have significant drop compared to previous year.
MERS-CoV is still a threatening virus, and WHO reports the recent case. A male patient 74 years old lives in Batinah, Omani. The disease transmitted when he is taking care of his sick camel. Laboratory confirmed that it is a case of MERS-Cov disease. Take care of ourselves better. Educate yourself and take alert of what happens in our world. The world is getting sicker day by day, and we can change it. Little by little.
- Infants aged less than nine months. But if the infants live in the endemic area, they are required to be vaccinated.
- Pregnant woman except during outbreak of disease.
- People with severe allergies to egg protein.
- People with low immunity due to HIV/AIDs and thymus disorder
- 30 Mar 2018
The medical term for an infection in the vagina is vaginitis. The infection caused by any pathogenic organism such as streptococcus, staphylococcus, Trichomonasvaginalis or maybe Candida. It can happen in a child of age one to five years old, adults and old women.
But How Do You Get Infected?
The organism can transmit from a child or adult by hands or clothes. Sometimes a foreign body such as a pin is inserted by the child into the vagina can cause infection. Wiping your butt from your anus to vagina may transfer organism to the vagina.
A child with a near infection or tonsillitis can transmit bacteria by hand to her genital area as she is touching it.
Sexual abuse is leading to any sexually transmitted disease as gonorrhea.
Or nylon underclothes and harsh soap may cause the infection in your vagina.
So What Are The Symptoms Of Vagina Infection?
- Vaginal discharge. Purulent (pus discharge), blood stained if there is a foreign body or cervical polyp (growth that appear on the cervix look like bulbs on thin stems).
- Irritation, pain, and soreness due to discharge.
- Severe itching of the skin area around genital.
- Pain during peeing like burning sensation and the frequency of peeing is an increase.
How Does Your Genital Look Like If Infected?
The vulva is inflamed, red, tender, sometimes oedematous and bathed in discharge. The labia minora might stick together but can be separated apart leaving inflamed red surfaces.
What Treatment Will You Get?
You need to get proper treatment in the hospital to avoid further infection.
A specific antibiotic is given according to the nature of the organism. For non-specific vaginitis, estrogen cream is applied to the vulva each night for about two weeks. It increases local resistance to infection and relieves soreness.
Any foreign body must be removed. Local washes with warm water and boiling of the underclothes which should be cotton. If one of your child infected, you must isolate from other children to prevent cross infection.
Take extra precaution in sexual activity to avoid sexually transmitted disease which can cause infection to your vagina.
Monitor your daughter during her play time or any changes happen to her. Since prevention is better than cure isn’t it?.
- 28 Mar 2018
Menopause is a phase when you stop getting your period. It marks the end of your menstrual cycles. You stop getting your period for at least six months or one year and confirm with your gynecologist. Woman between 40s to 50s is the age of getting menopause, but in the United States, the average age is 51 years old.
Which Types of Menopause You Could Get?
- Normal or Natural menopause: occurring between the age of 40 and 55 with an average of 50 years
- Premature menopause: Period stop before you hit 40. About 1% of women have menopause below the age of 40
- Delayed menopause: you still have your period until the age of 55
- Artificial menopause: caused by surgical removal of both ovaries or destruction of ovaries by exposure to irradiation
How Menopause Started?
Maybe preceded by the infrequent period, scanty or decrease the amount of your usual period (less than 30ml). Or the length of your period becomes less to two days. A period of dysfunctional uterine bleeding or suddenly your period stop and never return. About 10% of women suddenly their period stop.
What Changes Happen To You During Menopause?
- Your breast might become smaller due to tissue in your breast atrophied or larger due to increase fat deposition
- Your appetite may be decreased or increase which leading to obesity. Constipation and gases accumulate (Fart! Fart! Fart!)
- The tendency to develop menstrual hypertension as the amount of estrogen decrease. Oestrogen can protect you from atherosclerosis
- You gradually have a high risk of coronary heart disease because the level of cholesterol and triglycerides is increased
- Liability to osteoporosis (bone disease which resulted in bone become weak easy to break)
- Mild hirsutism (increase amount of hair in the manly pattern, e.g., in an area where men typically grow hair)
- Psychological changes for examples headaches, irritability and depression
- The pubic hair becomes scanty, grey or white
- The vagina becomes narrow, and the pH becomes neutral or alkaline. This condition will predispose to infection
- The uterus becomes small and atrophic. Senile endometritis may occur (inflammation of uterus)
- The ovaries become small, fibrotic (excess fibrous of connective tissue) and containing no follicles (no egg)
- Bladder becomes small. The condition may lead to going to the bathroom a lot (you pee a lot), inflammation of your bladder and urethra
Symptoms You Might Get With Menopause
Palpitation, hot flushes (sensation of heat felt in the chest, neck, face, head or spread to all over body) and night sweats. About 75% of postmenopausal women have hot flushes. Usually, hot flushes disappear after one or two years even without treatment from a doctor.
The hot flush lasts for seconds, minutes, and rarely for one hour but usually 3 minutes. One or two in 24 hours to one every 15-30 minutes in a day.
However, about 25% of cases will continue to have hot flushes for more than five years.
Lack of concentration, poor memory and insomnia (difficult in sleeping/staying asleep). Insomnia is usually the result of night sweats
Joint pain and backache due to loose ligament and muscle become weak
What Can You Do With Menopause?
Well, menopause is a change in life and not the end of life. You can avoid factors which can cause hot flushes as hot weather, hot bath, nervousness, excessive intake of coffee or tea, excessive blanket and covering during sleep.
Control of diet with less fat to avoid obesity. Increase intake of calcium, i.e., dairy product, green leafy vegetables, nuts or fish where you eat the bones-sardine and pilchards.
There are some treatment or therapy to help you in menopause.
Treatment for symptoms such as depression and palpitation
Estrogen therapy: for a woman without a uterus
Given to women if the symptoms such as hot flushes, senile vaginitis (inflammation of vagina), increase the frequency of peeing and psychological disturbances. Treatment is given for at least one year to prevent recurrence of symptoms
This therapy also is given to premature menopause as this condition predisposes to osteoporosis (bone break easily). Treatment is given at least until the age of 50 years. The treatment reduces the risk of osteoporosis by 50% to 60%
Combined estrogen-progesterone therapy: for a woman with a uterus
To protect against endometrial hyperplasia (womb cancer).
Progesterone alone is given to control hot flushes. Although progesterone less effective than estrogen but it causes a less side effect.
Menopause happens to every woman on earth. It differs in every woman of how it started, the changes in your body, the symptom might present in you and the suitable treatment you can do. Consult your gynecologist for explanation and reassurance of the changes in your life.
Medically reviewed by Dr. Nida Hayat Khan
Editor @ BioScience.pk
- 04 Mar 2018
Have you ever listened about the “Second Brain”?
Yes, you have! whenever you are told to trust your gut instinct. This brain and gut connection is not just metaphorical. An extraordinarily extensive network of neurons (more than 100 million neurons) lines our gut that scientists have named it the Second Brain.
What about the inhabitants of gut including good and bad microbial flora?
Gut microbiota weighs up to 2kg containing trillions of micro-organisms. One-third of these microbiotas is common to all people while others are specific to every individual’s gut depending on the type of diet they take in and their lifestyle.
“Gut flora is a complex community of organisms that inhabit human and animal digestive system”. Relation between humans and gut flora is mutualistic. Bacteria in the digestive system assist in nutrient metabolism, vitamin production, and waste processing. They also aid in the host's immune system response to pathogenic bacteria.
Healthy Microbiota & Healthy Brain
The gut has a bidirectional relationship with the central nervous system referred to as the “gut-brain axis”. Introduction of good bacterial strain reduces anxiety and stress level. Gut-brain axis is used by bacteria to affect the brain function. The most significant factor related to the health of microbiome -- thus, brain – is healthy food. Following are the positive influencing microbiota Lactobacillus that produce lactic acid are found in yogurt. Taking in yogurt will boost mental capacity and relieve stress, it also aids in digestion and relieves constipation. But make sure yogurt is live culture (probiotic). Bifidobacteria feast on chocolate and ferment it causing positive effects on our health and body. Dark chocolate is also very beneficial for the heart because bacteria (Bifidobacterium, LAB, yeast) ferment it into healthful anti-oxidants. Prebiotic foods including raw garlic, raw, and cooked onions allow the healthy microbiota to grow and thrive while inhibits the growth of non-healthy microbiota. Environmental toxins can disturb microbiome and have adverse effects on brain health to save ourselves from these effects, use of home filtered water should be made compulsory. Such filters should be used that remove harmful toxins like chlorine. Fermented foods like pickles, kefir, kimchi etc. are the source of Lactobacillus lactis species and defend against leaky gut. These were some healthy microbial flora and their sources having a positive effect on your body and brain.
Non-Healthy Microbiota & Whacky Gut
There are bidirectional links between stress and microbiota. Irritable Bowel Syndrome (IBS) and Chronic Fatigue Syndrome (CSF) are also related to the gut microbiota. In CSF patients there is an alteration in normal microbiota resulting in symptoms as depression, neurocognitive impairment, pain and sleep disturbance. While IBS is considered as a gut-brain disorder which is worsened by stress. Researchers are investigating whether these unhealthy microbiota resulting in IBS are also the cause of mood disorders. No bacteria can be inherited as bad, when our body is out of balance it takes advantage and proliferates. Some bacteria having a bad reputation are given below Microbial imbalance as a high level of Lactobacillus can also cause mood disturbance and sleep disturbances. Staphylococcus can cause food poisoning, it can be found in unpasteurized milk and can affect when hygiene is poor. Higher levels of the bad clostridium bacteria can cause fatigue by using bidirectional gut-brain axis. By eating junk food firmicutes and bifidobacteria level falls and there is a rise in the level of bacteroidetes causing the lethargic behavior to upshot and immunity problems set in.
Healthy Gut of a Baby
It is believed that when babies are born their guts are sterile, as soon as they encounter the genitourinary tract and mother’s skin, they are exposed to microbial flora. Microbial flora is important to develop in infants or babies for normal functioning. This healthy microbial flora to a baby is also provided by mother through breastfeeding. Milk is a cocktail of healthy microbiota and immunoglobulins causing development and growth of microbial flora in infant’s gut. So it is necessary for mothers to take healthy balanced diets rich in probiotic, prebiotic and fermented foods.
Due to the increased demand for fruits and vegetables, portals like Selly.pk offer a much feasible way of shopping. It takes a lot less effort to buy fruits and vegetables online.
Selly.pk is a welcome initiative if you ask me because the streets and roads are already piling up with fruit & vegetable vendors. More people should realize similar ideas. However, this can be depressing for those conventional vendors if the people start buying online sabzi in Lahore. The status quo always works against change but because this is a good change, we should all work together to make it a successful prospect.
Selly.pk Doing Business with Morals
Fruit market Lahore receives new rates of fruits & veggies daily. In order to comply with a standardized rate, Selly.pk is in touch with fruit officials who know this industry on fingertips. This only gives it an upper hand over the common vendors who are more interested in earning high profits rather than being civil and selling products at a decent price.
In the fruit & vegetable market, the Jin of inflation is still under control but as soon as those items reach private vendors in different localities, the price starts touching the skies. Fruit price in Pakistan should have checks & balances so the vendors can’t get greedy.
Your Online Partner
Selly.pk is one of a kind online fruit shop in Lahore. There are not many online fruit shops in Pakistan, therefore, this is a healthy and productive initiative. Where to order fresh vegetables online? How many of us haven’t thought about this question? It is time, a serious response came through and it has in the form of Selly.pk.
Price Comparable to the Average Market Price
It is a pioneering name regarding online fruit and vegetable shopping. Moreover, one would think the price would be higher because it is online. No, not at all. I do most of my shopping from Selly.pk and the online vegetable rates are lower than most vendors out there.
Every household has a need for a fresh supply of fruits and vegetables daily. Online vegetable shopping is much more time-saving because lives are getting busier every day. It is not easy to stop the car on your way back home from work and buy fruits or vegetables.
Fixed Reasonable Rates – Bargaining Not Required
There is no need to overexert yourself anymore with Selly.pk in town. Online vegetable shopping is simpler rather than spending your brains in bargaining with the vendor at the end of the street. Moreover, the call representatives taking your call are very well-behaved, often stating the list of items to make the selection process easier for you. As soon as you place an order for fresh vegetables online, the processing starts and they promise you to reach within 45 minutes. In my case, they have always been on time. They have met my expectations so far delivering high-quality fruits and vegetables to my doorstep.
Call at your Convenience
Some of us may have trouble ordering through the website due to the fact some of us aren’t technical enough. But you can always call on 0304-111-7355 to place your order.
How Can We Pay?
Cash on delivery is encouraged because we can’t pay by debit or credit cards on the website. Neither is there a card reader with the rider to swipe those cards. These two procedures are something that is lacking in the current order of things.
The riders delivering the goods speak to you in a polite tone without being aggressive or suddenly getting rude.
They have openly declared their return policy. We can instantly return stale fruits or vegetables at the time of delivery and no questions, whatsoever, will be asked.
Fruit and vegetable grocery list – it doesn’t matter how long the list is, Selly.pk is always up for the task delivering them on time. Fresh fruit for sale online, especially in winters is more like a blessing because it’s too cold to go out for shopping anyway. Buy vegetables online easily through Selly.pk because the website is superb. Just keep on tapping the items you want to buy and keep adding them to cart until you are ready to check out.
Fresh vegetables for sale at this website are packed in a luxurious way, unlike those cheap plastic bags we normally see at shops, with a symbol or monogram of Selly.pk attached to each packet.
The Gist of the Matter
Selly.pk provides fresh vegetables near you if you are in Lahore. However, one can consider it as a fresh vegetable market nearby with so many choices to choose from. You only need a working smartphone with an active Wi-Fi connection or mobile data connection. Type in Selly.pk in your browser and you are good to go. Fresh fruits and vegetables delivered to your doorstep in a matter of minutes. Shopping was never so convenient before!
- 11 Feb 2018
- In Archaeogastropods, the Acmaea, the torsion takes place by muscles contraction alone.
- The rotation of 180° is completed in two stages, the first movement takes place by the contraction of larval retractor muscle and second rotation is slower by different growth. It is very common as in Patella, Haliotis etc.
- The rotation of 180° takes place by only differential growth processes like Vivapara.
- Rotation by differential growth processes, with anus coming to a position appropriate to the adult state like Aplysia.
- Torsion is no longer recognizable as a movement of viscera-pallium, the organs in the post-torsional position from their first appearance as in Adalaria.
- Displacement of mantle cavity: The mantle cavity was primarily present on the posterior side. The elongation of the ventral foot which was primarily very small. After torsion, the mantle cavity opens just behind the head and its associated parts are shifted forwards.
- Changes in relative position: Before torsion, the anus, ctenidia and excretory opening were placed on the posterior side and the auricles were placed behind the ventricle but after torsion the anus, ctenidia and excretory opening become anterior and the auricles lie in front of the ventricle. The original posterior face of the visceral sac becomes the anterior face so that the visceral organs morphologically of the original right side change into the left side.
- Looping of alimentary canal: The alimentary canal which was originally straight from mouth to anus, after torsion, it changes into a loop.
- Chiastoneury: The long, uncoiled pleuro-visceral nerve connectives become a figure of "8" after twisting. The right connective with its ganglion passes over the intestine to form the supra-intestinal connective, while the next connective pass under the intestine to form the infra-intestinal connective.
- Endogastric coil: The coil of visceral sac and shell, which was primarily dorsal or exogastric become ventral and endogastric after torsion.
- Loss of Symmetry of Atrophy: The anus changes their original position towards the right side of the pallial cavity so that the original symmetrical condition disturbed.
- 06 Feb 2018
Pearl is secreted by the mantle as a means of protection against a small external particle. When an external particle or body, such as a grain of sand or a small parasite invades in between the mantle and the shell it becomes enclosed in a sac of mantle epithelium which produces irritation. The irritation stimulates the mantle epithelium to secrete thin concentric layers of mother of pearl around the foreign body. The amount of deposition is in direct proportion to the degree of irritation. After several years, a pearl will be formed, usually, it requires 3 to 4 years to produce a pearl of considerable size but a large pearl requires about 7 years. The foreign particles in the pearl are called nucleus whereas the thin nacre layers are concentric and called the mother of pearl.
- 30 Jan 2018
- Towel or soft cloth
- Blackhead removal strips or pads
- Salicylic acid (C7H6O3)
|DISTILLED WATER||REVERSE OSMOSIS (RO) WATER||DEIONIZED (DI) WATER|
|Distillation is employed in the main in laboratories and factories, wherever it's required. Reverse diffusion is widely employed in water treatment plants, each reception and for the manufacture of assorted drinks, drinking water, etc.||
||DI water is as pure because the water or maybe purer|
- 17 Jan 2018
- 28 Sep 2017
- Hyperthyroidism: Elevation of both T4 and T3 values along with decrease of TSH are indicative of primary hyperthyroidism.
- Increased thyroxine-binding globulin: If concentration of TBG increases, free hormone level falls, release of TSH from pituitary is stimulated, and free hormone concentration is restored to normal. Reverse occurs if concentration of binding proteins falls. In either case, level of free hormones remains normal, while concentration of total hormone is altered. Therefore, estimation of only total T4 concentration can cause misinterpretation of results in situations that alter concentration of TBG.
- Factitious hyperthyroidism
- Pituitary TSH-secreting tumor.
- Primary hypothyroidism: The combination of decreased T4 and elevated TSH are indicative of primary hypothyroidism.
- Secondary or pituitary hypothyroidism
- Tertiary or hypothalamic hypothyroidism
- Hypoproteinaemia, e.g. nephrotic syndrome
- Drugs: oestrogen, danazol
- Severe non-thyroidal illness.
- Diagnosis of T3 thyrotoxicosis: Hyperthyroidism with low TSH and elevated T3, and normal T4/FT4 is termed T3 thyrotoxicosis.
- Early diagnosis of hyperthyroidism: In early stage of hyperthyroidism, total T4 and free T4 levels are normal, but T3 is elevated.
- Confirmation of diagnosis of secondary hypothyroidism
- Evaluation of suspected hypothalamic disease
- Suspected hyperthyroidism
- A baseline blood sample is collected for estimation of basal serum TSH level.
- TRH is injected intravenously (200 or 500 μg) followed by measurement of serum TSH at 20 and 60 minutes.
- Normal response: A rise of TSH > 2 mU/L at 20 minutes, and a small decline at 60 minutes.
- Exaggerated response: A further significant rise in already elevated TSH level at 20 minutes followed by a slight decrease at 60 minutes; occurs in primary hypothyroidism.
- Flat response: There is no response; occurs in secondary (pituitary) hypothyroidism.
- Delayed response: TSH is higher at 60 minutes as compared to its level at 20 minutes; seen in tertiary (hypothalamic) hypothyroidism.
Box 864.1 Thyroid autoantibodies
- Hyperthyroidism due to Graves’ disease, toxic multinodular goiter, toxic adenoma, TSH-secreting tumor.
- Hyperthyroidism due to administration of thyroid hormone, factitious hyperthyroidism, subacute thyroiditis.
- Differential diagnosis of high RAIU thyrotoxicosis:
– Graves’ disease: Uniform or diffuse increase in uptake
– Toxic multinodular goiter: Multiple discrete areas of increased uptake
– Adenoma: Single area of increased uptake
- Evaluation of a solitary thyroid nodule:
– ‘Hot’ nodule: Hyperfunctioning
– ‘Cold’ nodule: Non-functioning; about 20% cases are malignant.
|1. TSH Normal, FT4 Normal||Euthyroid|
|2. Low TSH, Low FT4||Secondary hypothyroidism|
|3. High TSH, Normal FT4||Subclinical hypothyroidism|
|4. High TSH, Low FT4||Primary hypothyroidism|
|5. Low TSH, Normal FT4, Normal FT3||Subclinical hyperthyroidism|
|6. Low TSH, Normal FT4, High FT3||T3 toxicosis|
|7. Low TSH, High FT4||Primary hyperthyroidism|
- 28 Sep 2017
|Box 863.1 Terminology in thyroid disorders
|Box 863.2 Thyroid function tests in hyperthyroidism
|Parameter||Primary hyperthyroidism||Secondary hyperthyroidism|
|1. Serum TSH||Low||Normal or high|
|2. Serum free thyroxine||High||High|
|3. TSH receptor antibodies||May be positive||Negative|
|4. Causes||Graves’ disease, toxic multinodular goiter, toxic adenoma||Pituitary adenoma|
|Parameter||Primary hypothyroidism||Secondary hypothyroidism|
|1. Cause||Hashimoto’s thyroiditis||Pituitary disease|
|2. Serum TSH||High||Low|
|3. Thyrotropin releasing hormone stimulation test||Exaggerated response||No response|
|4. Antimicrosomal antibodies||Present||Absent|
Box 863.3 Thyroid function tests in hypothyroidism
- 22 Sep 2017
1. Hypothalamic-pituitary dysfunction:
2. Ovarian dysfunction:
|3. Dysfunction in passages:|
|4. Dysfunction of sexual act: Dyspareunia|
- Regular cycles, mastalgia, and laparoscopic direct visualization of corpus luteum indicate ovulatory cycles. Anovulatory cycles are clinically characterized by amenorrhea, oligomenorrhea, or irregular menstruation. However, apparently regular cycles may be associated with anovulation.
- Endometrial biopsy: Endometrial biopsy is done during premenstrual period (21st-23rd day of the cycle). The secretory endometrium during the later half of the cycle is an evidence of ovulation.
- Ultrasonography (USG): Serial ultrasonography is done from 10th day of the cycle and the size of the dominant follicle is measured. Size >18 mm is indicative of imminent ovulation. Collapse of the follicle with presence of few ml of fluid in the pouch of Douglas is suggestive of ovulation. USG also is helpful for treatment (i.e. timing of coitus or of intrauterine insemination) and diagnosis of luteinized unruptured follicle (absence of collapse of dominant follicle). Transvaginal USG is more sensitive than abdominal USG.
- Basal body temperature (BBT): Patient takes her oral temperature at the same time every morning before arising. BBT falls by about 0.5°F at the time of ovulation. During the second (progestational) half of the cycle, temperature is slightly raised above the preovulatory level (rise of 0.5° to 1°F). This is due to the slight pyrogenic action of progesterone and is therefore presumptive evidence of functional corpus luteum.
- Cervical mucus study:
• Fern test: During estrogenic phase, a characteristic pattern of fern formation is seen when cervical mucus is spread on a glass slide (Figure 862.4). This ferning disappears after the 21st day of the cycle. If previously observed, its disappearance is presumptive evidence of corpus luteum activity.
• Spinnbarkeit test: Cervical mucus is elastic and withstands stretching upto a distance of over 10 cm. This phenomenon is called Spinnbarkeit or the thread test for the estrogen activity. During the secretory phase, viscosity of the cervical mucus increases and it gets fractured when stretched. This change in cervical mucus is evidence of ovulation.
- Vaginal cytology: Karyopyknotic index (KI) is high during estrogenic phase, while it becomes low in secretory phase. This refers to percentage of super-ficial squamous cells with pyknotic nuclei to all mature squamous cells in a lateral vaginal wall smear. Usually minimum of 300 cells are evaluated. The peak KI usually corresponds with time of ovulation and may reach upto 50 to 85.
- Estimation of progesterone in mid-luteal phase (day 21 or 7 days before expected menstruation): Progesterone level > 10 nmol/L is a reliable evidence of ovulation if cycles are regular (Figure 862.5). A mistimed sample is a common cause of abnormal result.
- Measurement of LH, FSH, and estradiol during days 2 to 6: All values are low in hypogonadotropic hypogonadism (hypothalamic or pituitary failure).
- Measurement of TSH, prolactin, and testosterone if cycles are irregular or absent:
Increased TSH: Hypothyroidism
Increased prolactin: Pituitary adenoma
Increased testosterone: Polycystic ovarian disease (PCOD), congenital adrenal hyperplasia (To differentiate PCOD from congenital adrenal hyperplasia, ultrasound and estimation of dihydroepiandrosterone or DHEA are done).
- Transvaginal ultrasonography: This is done for detection of PCOD.
- Infectious disease: These tests include endometrial biopsy for tuberculosis and test for chlamydial IgG antibodies for tubal factor in infertility.
- Hysterosalpingography (HSG): HSG is a radiological contrast study for investigation of the shape of the uterine cavity and for blockage of fallopian tubes (Figure 862.6). A catheter is introduced into the cervical canal and a radiocontrast dye is injected into the uterine cavity. A real time X-ray imaging is carried out to observe the flow of the dye into the uterine cavity, tubes, and spillage into the uterine cavity.
- Hysterosalpingo-contrast sonography: A catheter is introduced into the cervical canal and an echocontrast fluid is introduced into the uterine cavity. Shape of the uterine cavity, filling of fallopian tubes, and spillage of contrast fluid are noted. In addition, ultrasound scan of the pelvis provides information about any fibroids or polycystic ovarian disease.
- Laparoscopy and dye hydrotubation test with hysteroscopy: In this test, a cannula is inserted into the cervix and methylene blue dye is introduced into the uterine cavity. If tubes are patent, spillage of the dye is observed from the ends of both tubes. This technique also allows visualization of pelvic organs, endometriosis, and pelvic adhesions. If required, endometriosis and tubal blockage can be treated during the procedure.
- 22 Sep 2017
2. Hypothalamic-pituitary dysfunction (hypogonadotropic hypogonadism)
3. Testicular dysfunction:
4. Dysfunction of passages and accessory sex glands:
5. Dysfunction of sexual act:
- History: This includes type of lifestyle (heavy smoking, alcoholism), sexual practice, erectile dysfunction, ejaculation, sexually transmitted diseases, surgery in genital area, drugs, and any systemic illness.
- Physical examination: Examination of reproductive system should includes testicular size, undescended testes, hypospadias, scrotal abnormalities (like varicocele), body hair, and facial hair. Varicocele can occur bilaterally and is the most common surgically removable abnormality causing male infertility.
- Semen analysis: See article Semen Analysis. Evaluation of azoospermia is shown in Figure 861.3. Evaluation of low semen volume is shown in Figure 861.4.
- Chromosomal analysis: This can reveal Klinefelter’s syndrome (e.g. XXY karyotype) (Figure 861.5), deletion in Y chromosome, and autosomal Robertsonian translocation. It is necessary to screen for cystic fibrosis carrier state if bilateral congenital absence of vas deferens is present.
- Hormonal studies: This includes measurement of FSH, LH, and testosterone to detect hormonal abnormalities causing testicular failure (Table 861.2).
- Testicular biopsy: Testicular biopsy is indicated when differentiation between obstructive and non-obstructive azoospermia is not evident (i.e. normal FSH and normal testicular volume).
|Follicle stimulating hormone||Luteinizing hormone||Testosterone||Interpretation|
|Low||Low||Low||Hypogonadotropic hypogonadism (Hypothalamic or pituitary disorder)|
|High||High||Low||Hypergonadotropic hypogonadism (Testicular disorder)|
|Normal||Normal||Normal||Obstruction of passages, dysfunction of accessory glands|
- 08 Sep 2017
- Cephalic or neurogenic phase: This phase is initiated by the sight, smell, taste, or thought of food that causes stimulation of vagal nuclei in the brain. Vagus nerve directly stimulates parietal cells to secrete acid; in addition, it also stimulates antral G cells to secrete gastrin in blood (which is also a potent stimulus for gastric acid secretion) (Figure 859.2). Cephalic phase is abolished by vagotomy.
- Gastric phase: Entry of swallowed food into the stomach causes gastric distension and induces gastric phase. Distension of antrum and increase in pH due to neutralization of acid by food stimulate antral G cells to secrete gastrin into the circulation. Gastrin, in turn, causes release of hydrochloric acid from parietal cells.
- Intestinal phase: Entry of digested proteins into the duodenum causes an increase in acid output from the stomach. It is thought that certain hormones and absorbed amino acids stimulate parietal cells to secrete acid.
- Hydrochloric acid (HCl): This is secreted by the parietal cells of the fundus and the body of the stomach. HCl provides the high acidic pH necessary for activation of pepsinogen to pepsin. Gastric acid secretion is stimulated by histamine, acetylcholine, and gastrin (Figure 859.2). HCl kills most microorganisms entering the stomach and also denatures proteins (breaks hydrogen bonds making polypeptide chains to unfold). Its secretion is inhibited by somatostatin (secreted by D cells in pancreas and by mucosa of intestine), gastric inhibitory peptide (secreted by K cells in duodenum and jejunum), prostaglandin, and secretin (secreted by S cells in duodenum).
- Pepsin: Pepsin is secreted by chief cells in stomach. Pepsin causes partial digestion of proteins leading to the formation of large polypeptide molecules (optimal function at pH 1.0 to 3.0). Its secretion is enhanced by vagal stimulation.
- Intrinsic factor (IF): IF is necessary for absorption of vitamin B12 in the terminal ileum. It is secreted by parietal cells of stomach.
- 07 Sep 2017
- Gastric intubation for gastric analysis is contraindicated in esophageal stricture or varices, active nasopharyngeal disease, diverticula, malignancy, recent history of severe gastric hemorrhage, hypertension, aortic aneurysm, cardiac arrhythmias, congestive cardiac failure, or non-cooperative patient.
- Pyloric stenosis: Obstruction of gastric outlet can elevate gastric acid output due to raised gastrin (following antral distension).
- Pentagastrin stimulation is contraindicated in cases with allergy to pentagastrin, and recent severe gastric hemorrhge due to peptic ulcer disease.
- It is an invasive and cumbersome technique that is traumatic and unpleasant for the patient.
- Information obtained is not diagnostic in itself.
- Availability of better tests for diagnosis such as endoscopy and radiology (for suspected peptic ulcer or malignancy); serum gastrin estimation (for ZE syndrome); vitamin assays, Schilling test, and antiparietal cell antibodies (for pernicious anemia); and tests for Helicobacter pylori infection (in duodenal or gastric ulcer).
- Availability of better medical line of treatment that obviates need for surgery in many patients.
- 07 Sep 2017
- Hollander’s test (Insulin hypoglycemia test): In the past, this test was used for confirmation of completeness of vagotomy (done for duodenal ulcer).
Hypoglycemia is a potent stimulus for gastric acid secretion and is mediated by vagus nerve. This response is abolished by vagotomy.
In this test, after determining BAO, insulin is administered intravenously (0.15-0.2 units/kg) and acid output is estimated every 15 minutes for 2 hours (8 post-stimulation samples). Vagotomy is considered as complete if, after insulin-induced hypoglycemia (blood glucose < 45 mg/dl), no acid output is observed within 45 minutres.
The test gives reliable results only if blood glucose level falls below 50 mg/dl at some time following insulin injection. It is best carried out after 3-6 months of vagotomy.
The test is no longer recommended because of the risk associated with hypoglycemia. Myocardial infarction, shock, and death have also been reported.
- Fractional test meal: In the past, test meals (e.g. oat meal gruel, alcohol) were administered orally to stimulate gastric secretion and determine MAO or PAO. Currently, parenteral pentagastrin is the gastric stimulant of choice.
- Tubeless gastric analysis: This is an indirect and rapid method for determining output of free hydrochloric acid in gastric juice. In this test, a cationexchange resin tagged to a dye (azure A) is orally administered. In the stomach, the dye is displaced from the resin by the free hydrogen ions of the hydrochloric acid. The displaced azure A is absorbed in the small intestine, enters the bloodstream, and is excreted in urine. Urinary concentration of the dye is measured photometrically or by visual comparison with known color standards. The quantity of the dye excreted is proportional to the gastric acid output. However, if kidney or liver function is impaired, false results may be obtained. The test is no longer in use.
- Spot check of gastric pH: According to some investigators, spot determination of pH of fasting gastric juice (obtained by nasogastric intubation) can detect the presence of hypochlorhydria (if pH>5.0 in men or >7.0 in women).
- Congo red test during esophagogastroduodenoscopy: This test is done to determine the completeness of vagotomy. Congo red dye is sprayed into the stomach during esophagogastroduodenoscopy; if it turns red, it indicates presence of functional parietal cells in stomach with capacity of producing acid.
- Volume of gastric juice: 20-100 ml
- Appearance: Clear
- pH: 1.5 to 3.5
- Basal acid output: Up to 5 mEq/hour
- Peak acid output: 1 to 20 mEq/hour
- Ratio of basal acid output to peak acid output: <0.20 or < 20%
- 07 Sep 2017
- To determine the cause of recurrent peptic ulcer disease:
• To detect Zollinger-Ellison (ZE) syndrome: ZE syndrome is a rare disorder in which multiple mucosal ulcers develop in the stomach, duodenum, and upper jejunum due to gross hypersecretion of acid in the stomach. The cause of excess secretion of acid is a gastrin-producing tumor of pancreas. Gastric analysis is done to detect markedly increased basal and pentagastrinstimulated gastric acid output for diagnosis of ZE syndrome (and also to determine response to acidsuppressant therapy). However, a more sensitive and specific test for diagnosis of ZE syndrome is measurement of serum gastrin (fasting and secretin-stimulated).
• To decide about completeness of vagotomy following surgery for peptic ulcer disease: See Hollander’s test.
- To determine the cause of raised fasting serum gastrin level: Hypergastrinemia can occur in achlorhydria, Zollinger-Ellison syndrome, and antral G cell hyperplasia.
- To support the diagnosis of pernicious anemia (PA): Pernicious anemia is caused by defective absorption of vitamin B12 due to failure of synthesis of intrinsic factor secondary to gastric mucosal atrophy. There is also absence of hydrochloric acid in the gastric juice (achlorhydria). Gastric analysis is done for demonstration of achlorhydria if facilities for vitamin assays and Schilling’s test are not available (Achlorhydria by itself is insufficient for diagnosis of PA).
- To distinguish between benign and malignant ulcer: Hypersecretion of acid is a feature of duodenal peptic ulcer, while failure of acid secretion (achlorhydria) occurs in gastric carcinoma. However, anacidity occurs only in a small proportion of cases with advanced gastric cancer. Also, not all patients with duodenal ulcer show increased acid output.
- To measure the amount of acid secreted in a patient with symptoms of peptic ulcer dyspepsia but normal X-ray findings: Excess acid secretion in such cases is indicative of duodenal ulcer. However, hypersecretion of acid does not always occur in duodenal ulcer.
- To decide the type of surgery to be performed in a patient with peptic ulcer: Raised basal as well as peak acid outputs indicate increased parietal cell mass and need for gastrectomy. Raised basal acid output with normal peak output is an indication for vagotomy.
- 05 Sep 2017
Box 855.1 Determination of basal acid output, maximum acid output, and peak acid output
- Volume: Normal total volume is 20-100 ml (usually < 50 ml). Causes of increased volume of gastric juice are—
• Delayed emptying of stomach: pyloric stenosis
• Increased gastric secretion: duodenal ulcer, Zollinger-Ellison syndrome.
- Color: Normal gastric secretion is colorless, with a faintly pungent odor. Fresh blood (due to trauma, or recent bleeding from ulcer or cancer) is red in color. Old hemorrhage produces a brown, coffee-ground like appearance (due to formation of acid hematin). Bile regurgitation produces a yellow or green color.
- pH: Normal pH is 1.5 to 3.5. In pernicious anemia, pH is greater than 7.0 due to absence of HCl.
- Basal acid output:
• Normal: Up to 5 mEq/hour.
• Duodenal ulcer: 5-15 mEq/hour.
• Zollinger-Ellison syndrome: >20 mEq/hour.
Normal BAO is seen in gastric ulcer and in some patients with duodenal ulcer.
- Peak acid output:
• Normal: 1-20 mEq/hour.
• Duodenal ulcer: 20-60 mEq/hour.
• Zollinger-Ellison syndrome: > 60 mEq/hour.
• Achlorhydria: 0 mEq/hour.
Normal PAO is seen in gastric ulcer and gastric carcinoma. Values up to 60 mEq/hour can occur in some normal individuals and in some patients with Zollinger-Ellison syndrome.
In pernicious anemia, there is no acid output due to gastric mucosal atrophy. Achlorhydria should be diagnosed only if there is no free HCl even after maximum stimulation.
- Ratio of basal acid output to peak acid output (BAO/PAO):
• Normal: < 0.20 (or < 20%).
• Gastric or duodenal ulcer: 0.20-0.40 (20-40%).
• Duodenal ulcer: 0.40-0.60 (40-60%).
• Zollinger-Ellison syndrome: > 0.60 (> 60%).
Normal values occur in gastric ulcer or gastric carcinoma.
|Increased gastric acid output||Decreased gastric acid output|
|• Duodenal ulcer||• Chronic atrophic gastritis|
|• Zollinger-Ellison syndrome||1. Pernicious anemia|
|• Hyperplasia of antral G cells||2. Rheumatoid arthritis|
|• Systemic mastocytosis||3. Thyrotoxicosis|
|• Basophilic leukemia||• Gastric ulcer|
|• Gastric carcinoma|
|• Chronic renal failure|
- 04 Sep 2017
- 04 Sep 2017
- 04 Sep 2017
- 04 Sep 2017
- 04 Sep 2017
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- 04 Sep 2017
- Life processes, interactions, and adaptations
- The movement of materials and energy through living communities
- The successional development of ecosystems
- The abundance and distribution of organisms and biodiversity in the context of the environment.
- 04 Sep 2017
- 30 Aug 2017
Microscopic examinations done on fecal sample are shown in Figure 846.1.
Collection of Specimen for Parasites
A random specimen of stool (at least 4 ml or 4 cm³) is collected in a clean, dry, container with a tightly fitting lid (a tin box, plastic box, glass jar, or waxed cardboard box) and transported immediately to the laboratory (this is because trophozoites of Entameba histolytica rapidly degenerate and alter in morphology). About 20-40 grams of formed stool or 5-6 tablespoons of watery stool should be collected. Stool should not be contaminated with urine, water, soil, or menstrual blood. Urine and water destroy trophozoites; soil will introduce extraneous organisms and also hinder proper examination. Parasites are best detected in warm, freshly passed stools and therefore stools should be examined as early as possible after receipt in the laboratory (preferably within 1 hour of collection). If delay in examination is anticipated, sample may be refrigerated. A fixative containing 10% formalin (for preservation of eggs, larvae, and cysts) or polyvinyl alcohol (for preservation of trophozoites and cysts, and for permanent staining) may be used if specimen is to be transported to a distant laboratory.
Patient should not be receiving oily laxatives, antidiarrheal medications, bismuth, antibiotics like tetracycline, or antacids for 7 days before stool examination. Patient should not have undergone a barium swallow examination.
In the laboratory, macroscopic examination is done for consistency (watery, loose, soft or formed) (Figure 846.2), color, odor, and presence of blood, mucus, adult worms or segments of tapeworms.
Trophozoites are most likely to be found in loose or watery stools or in stools containing blood and mucus, while cysts are likely to be found in formed stools. Trophozoites die soon after being passed and therefore such stools should be examined within 1 hour of passing. Examination of formed stools can be delayed but should be completed on the same day.
Color/Appearance of Fecal Specimens
- Brown: Normal
- Black: Bleeding in upper gastrointestinal tract (proximal to cecum), Drugs (iron salts, bismuth salts, charcoal)
- Red: Bleeeding in large intestine, undigested tomatoes or beets
- Clay-colored (gray-white): Biliary obstruction
- Silvery: Carcinoma of ampulla of Vater
- Watery: Certain strains of Escherichia coli, Rotavirus enteritis, cryptosporidiosis
- Rice water: Cholera
- Unformed with blood and mucus: Amebiasis, inflammatory bowel disease
- Unformed with blood, mucus, and pus: Bacillary dysentery
- Unformed, frothy, foul smelling, which float on water: Steatorrhea.
Preparation of Slides
After receipt in the laboratory, saline and iodine wet mounts of the sample are prepared (Figure 846.3).
A drop of normal saline is placed near one end of a glass slide and a drop of Lugol iodine solution is placed near the other end. A small amount of feces (about the size of a match-head) is mixed with a drop each of saline and iodine using a wire loop, and a cover slip is placed over each preparation separately. If the specimen contains blood or mucus, that portion should be included for examination (trophozoites are more readily found in mucus). If the stools are liquid, select the portion from the surface for examination.
Saline wet mount is used for demonstration of eggs and larvae of helminths, and trophozoites and cysts of protozoa. It can also detect red cells and white cells. Iodine stains glycogen and nuclei of the cysts. The iodine wet mount is useful for identification of protozoal cysts. Trophozoites become non-motile in iodine mounts. A liquid, diarrheal stool can be examined directly without adding saline.
Concentration of fecal specimen is useful if very small numbers of parasites are present. However, in concentrated specimens, amebic trophozoites can no longer be detected since they are destroyed. If wet mount examination is negative and there is clinical suspicion of parasitic infection, fecal concentration is indicated. It is used for detection of ova, cysts, and larvae of parasites.
Various concentration methods are available; the choice depends on the nature of parasites to be identified and the equipment/reagent available in a particular laboratory. Concentration techniques are of two main types:
- Sedimentation techniques: Ova and cysts settle at the bottom. However, excessive fecal debris may make the detection of parasites difficult. Example: Formolethyl acetate sedimentation procedure.
- Floatation techniques: Ova and cysts float on surface. However, some ova and cysts do not float at the top in this procedure. Examples: Saturated salt floatation technique and zinc sulphate concentration technique.
The most commonly used sedimentation method is formol-ethyl acetate concentration method since: (i) it can detect eggs and larvae of almost all helminths, and cysts of protozoa, (ii) it preserves their morphology well, (iii) it is rapid, and (iv) risk of infection to the laboratory worker is minimal because pathogens are killed by formalin.
In this method, fecal suspension is prepared in 10% formalin (10 ml formalin + 1 gram feces). This suspension is then passed through a gauze filter till 7 ml of filtered material is obtained. To this, ethyl acetate (3 ml) is added and the mixture is centrifuged for 1 minute. Eggs, larvae, and cysts sediment at the bottom of the centrifuge tube (Figure 846.4). Above this deposit, there are layers of formalin, fecal debris, and ether. Fecal debris is loosened with an applicator stick and the supernatant is poured off. One drop of sediment is placed on one end of a glass slide and one drop is placed at the other end. One of the drops is stained with iodine, cover slips are placed, and the preparation is examined under the microscope.
Classification of Intestinal Parasites of Humans
Intestinal parasites of humans are classified into two main kingdoms: protozoa and metazoa (helminths) (Figure 846.5).