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By: X. Miguel, M.B.A., M.B.B.S., M.H.S.
Professor, East Tennessee State University James H. Quillen College of Medicine
In vitro copper stimulation of plasma peptidylglycine -amidating monooxygenase in Menkes disease variant with occipital horns spasms right side under rib cage purchase 250 mg mefenamic with amex. Indices of copper status in humans consuming a typical American diet containing either fructose or starch muscle relaxant esophageal spasm buy 500 mg mefenamic visa. Cu nutrition in infants during prolonged exclusive breast-feeding: Low intake but rising serum concentrations of Cu and ceruloplasmin xiphoid spasms cheap mefenamic 250 mg amex. Consequences of severe copper deficiency are independent of dietary carbohydrate in young pigs spasms of pain from stones in the kidney mefenamic 500 mg line. Increased 8-hydroxydeoxyguanosine in kidney and liver of rats continuously exposed to copper. Copper absorption and retention in pregnant women fed diets based on animal and plant proteins. Copper absorption and retention in young men at three levels of dietary copper by use of the stable isotope 65Cu. Copper status and urinary and salivary copper in young men at three levels of dietary copper. Copper absorption, excretion, and retention by young men consuming low dietary copper determined by using the stable isotope 65Cu. Hephaestin, a ceruloplasmin homologue implicated in intestinal iron transport, is defective in the sla mouse. The effects of the dietary intakes of copper, iron, manganese, and zinc on the trace element content of human milk. Magnesium deficiency in alcoholism: Possible contribution to osteoporosis and cardiovascular disease in alcoholics. Constitutive expression of a vitamin D 1-hydroxylase in a myelomonocytic cell line: A model for studying 1,25-dihydroxyvitamin D production in vitro. Extracellular and intracellular magnesium depletion in pregnancy and gestational diabetes. Relative molar potency of 25-hydroxyvitamin D indicates a major role in calcium absorption. Effects of long-term oral magnesium chloride replacement in congestive heart failure secondary to coronary artery disease. Erythrocyte and plasma magnesium during teenage pregnancy: Relationship with blood pressure and pregnancy-induced hypertension. Effect of level and form of phosphorus and level of calcium intake on zinc, iron and copper bioavailability in man. An incidence of skeletal fluorosis associated with groundwaters of the maritime carboniferous basin, Gaspe Region, Quebec, Canada. Raised parathyroid hormone levels in the milk-alkali syndrome: An appropriate response Calcium intake and bone density of lactating women in their late childbearing years. Elevated secretion and action of serum parathyroid hormone in young adults consuming high phosphorus, low calcium diets assembled from common foods. Persistently elevated parathyroid hormone secretion and action in young women after four weeks of ingesting high phosphorus, low calcium diets. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, 3rd edition. Selective gastric hypersensitivity and reflex hyporeactivity in functional dyspepsia. Calcium intake and fracture risk: Results from the study of osteoporotic fractures. A controlled trial of the effect of calcium supplementation on bone density in postmenopausal women. Dobnig H, Kainer F, Stepan V, Winter R, Lipp R, Schaffer M, Kahr A, Nocnik S, Patterer G, Leb G. Elevated parathyroid hormone-related peptide levels after human gestation: Relationship to changes in bone and mineral metabolism. Refining the estimate of the critical period for susceptibility to enamel fluorosis in human maxillary central incisors.
In young children muscle relaxants yellow discount mefenamic 500 mg without a prescription, whose skeletons and teeth are still growing muscle relaxant liquid purchase mefenamic pills in toronto, as much as 80 percent of absorbed fluoride may be retained and only 20 percent excreted spasms 5 month old baby best order mefenamic. In healthy young and middle-aged adults gastrointestinal spasms buy 250 mg mefenamic mastercard, approximately 50 percent of absorbed fluoride is retained in the skeleton and 50 percent is excreted in the urine. In older adults, it is likely that the fraction of fluoride excreted is greater than the fraction retained. When fluoride intake is chronically insufficient to maintain plasma concentrations, fluoride excretion in both infants and adults can exceed the amounts ingested due to mobilization from calcified tissues. Although the prevalence of enamel fluorosis in both fluoridated and nonfluoridated communities in the United States and Canada is substantially higher than it was when the original epidemiological studies were done some 60 years ago, the severity remains largely limited to the very mild and mild categories. Any additional intake by children who are at risk of enamel fluorosis is almost certainly derived from the use of fluoride-containing dental products, especially if they are inadvertently swallowed. Decaffeinated teas have roughly twice the fluoride concentration of caffeinated teas. Dietary Supplements Fluoride supplements are intended for use by children living in areas with low water fluoride concentrations so that their intake is similar to that of children with access to water fluoride concentrations of approximately 1. Dental Products Fluoride intake from dental products (such as toothpaste and mouth rinse) can add considerable fluoride content to the diet, often approaching or exceeding intake from foods and water. This is a particular concern in young children who may inadvertently swallow toothpaste or mouth rinses. Bioavailability the bioavailability of fluoride is generally high, but it can be affected by the method in which it is ingested. When a soluble compound such as sodium fluoride is ingested from fluoridated water, absorption is nearly complete. The absorption of fluoride from ingested toothpaste, whether added as sodium fluoride or monofluorophosphate, is nearly 100 percent. Dietary Interactions There is evidence that fluoride may interact with certain nutrients and dietary substances (see Table 2). The rate and extent of fluoride absorption from the gastrointestinal tract are somewhat reduced by ingestion with solid foods and some liquids, particularly those rich in calcium, such as milk or infant formulas. The exclusion of children with reported exposure to fluoride supplements increased the difference to 25 percent. The following are stages of skeletal fluorosis: Stage 1 skeletal fluorosis: Characterized by occasional stiffness or pain in the joints and some osteosclerosis of the pelvis and vertebrae. The development and severity of skeletal fluorosis directly relate to the level and duration of fluoride exposure. Special Considerations Tropical climates: Reports of relatively marked osteofluorotic signs and symptoms have been associated with concentrations of fluoride in drinking water of approximately 3 mg/L in tropical climates. These adverse effects have been attributed to poor nutrition and hard manual labor leading to excessive sweat loss and compensatory high levels of water intake. Therefore, an increased risk for skeletal fluorosis from excess fluoride intake may exist for malnourished individuals who live in hot climates or tropical environments. Thus, fluoride supplements have been recommended based on life stage and level of water fluoridation. The primary adverse effects associated with chronic excess fluoride intake are enamel fluorosis and skeletal fluorosis. Dental products such as toothpaste and mouth rinses can significantly increase fluoride intake, a particular concern in young children if they inadvertently swallow these products. The requirements for iodine are based on thyroid iodine accumulation and turnover.
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Medications Aspirin muscle relaxant 750 buy 500 mg mefenamic visa, nonsteroidal anti-inflammatory drugs Antimalarial agents Nitrofurantoin spasms back pain and sitting buy 250mg mefenamic otc, sulfonamides Quinidine Infections Naphthalene Fava beans with class I disease may require inpatient treatment of acute exacerbations with transfusion spasms feel like baby kicking buy mefenamic overnight delivery, intravenous fluid support muscle relaxant causing jaundice purchase mefenamic 250mg free shipping, and monitoring of renal function. Although vitamin E and splenectomy have been advocated as possible treatments in more severe cases, neither has provided consistent benefit. Symptoms and Signs the most common clinical manifestations are jaundice, dark urine, pallor, abdominal pain, and back pain. These symptoms usually occur hours to days after an oxidative insult, which can be caused by a number of different agents (Table 31-3). Chemicals that can cause such an insult include primaquine, sulfa drugs, dapsone, nitrofurantoin, and naphthalene (found in mothballs). Aspirin and acetaminophen can precipitate hemolysis in certain individuals as well. Attacks can also be associated with infections (such as pneumonia, viral hepatitis, and Salmonella) and diabetic ketoacidosis. Again a spectrum of disease exists, from mild transient jaundice to severe jaundice, kernicterus, and death. Patients with one sickle cell gene and one -thalassemia gene, for example, can have significant clinical manifestations of hemoglobinopathy. During acute attacks in highly susceptible individuals, Hb levels can be as low as 34 g/dL. Many asymptomatic individuals, however, have only mildly depressed levels at 11-12 g/dL. The resulting HbS, which consists of two normal Hb chains and two abnormal Hb chains, is poorly soluble when deoxygenated. Treatment Individuals with mild disease require no treatment except for avoidance, whenever possible, of oxidative triggers. Howell-Jolly bodies and target cells are also present on the smear, indicating hyposplenism. The white blood cell count can be elevated at 12,000-15,000/mm3, even in the absence of infection. First, adequate hydration and oxygenation reduce the risk of Hb polymerization and subsequent vasoocclusive crises. Infectious complications can be reduced by immunization against Streptococcus pneumoniae, Haemophilus influenzae type B, hepatitis B, and influenza. During acute exacerbations, patients often require hydration and oxygenation, analgesia with nonnarcotic or narcotic medications, antibiotics if appropriate, and blood transfusions. American Academy of Pediatrics; Section on Hematology/ Oncology: Health supervision for children with sickle cell disease. About 30% of patients are discovered by 1 year of age and over 90% by 6 years of age. Acute pain episodes are the most common presentations; they can occur in the extremities, abdomen, back, or chest. Although generally no inciting factor is found, stresses such as cold, infection, and dehydration can precipitate attacks. Most patients experience autoinfarction of the spleen by early childhood due to occlusion of splenic capillary beds. Pneumonia, meningitis, osteomyelitis, and bacteremia are causes of significant morbidity and mortality in these patients. Depression, low self-esteem, and social withdrawal are common, especially when adequate coping mechanisms are not in place. Idiopathic Transfusion reaction Drugs (methyldopa, penicillin, quinidine) Connective tissue disorders Hematologic malignancies (chronic lymphocytic leukemia, non-Hodgkin lymphoma) Infections (Mycoplasma, syphilis) B. Classically the patient has a reticulocyte count increased to 3%-15%, Hb mildly or moderately decreased to 7-11 g/dL, elevated direct bilirubin and lactate dehydrogenase, and a depressed haptoglobin level. Treatment Although further hemolysis can result, blood transfusion should be given when the Hb level is significantly low (5-7 g/dL). Corticosteroids are often considered the treatment of choice, especially when autoantibodies are warm. Those who need long-term treatment and cannot take steroids can use other immunomodulating agents such as azathioprine, cyclosporine, and rituximab.
Although blood pressure is inversely associated with potassium intake and directly associated with sodium intake and the sodium:potassium ratio muscle relaxant options order mefenamic 500mg visa, the ratio typically is more influential spasms below left breast purchase mefenamic with visa. Given the interrelatedness of sodium and potassium gastrointestinal spasms order mefenamic 250mg with amex, the requirement for potassium may depend on dietary sodium intake spasms just below sternum buy 500 mg mefenamic. Dietary Interactions There is evidence that potassium may interact with certain other nutrients and dietary substances (see Table 2). Severe potassium deficiency is characterized by hypokalemia, a condition marked by a serum potassium concentration of less than 3. The adverse consequences of hypokalemia include cardiac arrhythmias, muscle weakness, and glucose intolerance. Moderate potassium deficiency, which typically occurs without hypokalemia, is characterized by increased blood pressure, increased salt sensitivity, an increased risk of kidney stones, increased bone turnover, and a possible increased risk of cardiovascular disease, particularly stroke. In unprocessed foods, the conjugate anions of potassium are mainly organic anions, such as citrate, which are converted in the body to bicarbonate. Consequently, an inadequate intake of potassium is also associated with a reduced intake of bicarbonate precursors. Bicarbonate acts as a buffer, neutralizing diet-derived noncarbonic acids such as sulfuric acid generated from sulfur-containing amino acids found in meats and other high-protein foods. If the intake of bicarbonate precursors is inadequate, buffers in the bone matrix neutralize the excess diet-derived acids. Excess diet-derived acid titrates bone, leading to increased urinary calcium and reduced urinary citrate excretion. The possible adverse consequences are increased bone demineralization and an increased risk of calcium-containing kidney stones. Special Considerations Climate and physical activity: Heat exposure and exercise can increase potassium loss, primarily through sweat, thereby increasing potassium requirements. Diuretics: Often used to treat hypertension and congestive heart failure, thiazide-type diuretics increase urinary potassium excretion and can lead to hypokalemia. Potassium-sparing diuretics prevent diuretic-induced potassium loss and are often concurrently used with thiazide-type diuretics. Individuals who take diuretics should have their serum potassium levels regularly checked by their health care providers. Very low-carbohydrate, high-protein diets: Low-grade metabolic acidosis occurs with the consumption of very low-carbohydrate, high-protein diets to promote and maintain weight loss. These diets, which may be adequate in potassium due to their high protein content, are inadequate as a source of alkali because fruits are often excluded from them. Gastrointestinal discomfort has been reported with some forms of potassium supplements. The specific product or vehicle in which the potassium supplement is provided is the critical determinant of the risk of gastrointestinal side effects. Special Considerations Problem pregnancy: High levels of potassium should be consumed with care by pregnant women with preeclampsia. The hormone progesterone, which is elevated during pregnancy, may make women with undetected kidney problems or decreased glomerular filtration rate (a side effect of preeclampsia) more likely to develop hyperkalemia when potassium intake is high. The ratio of extracellular to intracellular potassium levels affects neural transmission, muscle contraction, and vascular tone. Because African Americans have lower intakes of potassium and a higher prevalence of elevated blood pressure and salt sensitivity, this population subgroup would especially benefit from an increased intake of potassium. Good food sources of potassium include fruits and vegetables, particularly leafy greens, vine fruit, and root vegetables. Although uncommon in the general population, the main effect of severe potassium deficiency is hypokalemia, which can cause cardiac arrhythmias, muscle weakness, and glucose intolerance. Selenoproteins regulate thyroid hormone actions and the redox status of vitamin C and other molecules. Most selenium found in animal tissue is in the form of selenomethionine (the major dietary form of selenium) or selenocysteine, both of which are well absorbed. The method used to estimate the requirements for selenium relates to the intake needed to maximize the activity of the plasma selenoprotein glutathione peroxidase, an oxidant defense enzyme. Food sources of selenium include meat, seafood, grains, dairy products, fruits, and vegetables, and the major dietary forms of selenium appear to be highly bioavailable. However, the selenium content of foods greatly varies depending on the selenium content of the soil where the animal was raised or where the plant was grown.
