GoingPlatinum http://www.goingplatinum.com Own Your own piece of the Internet, when you join the WORLD'S 1st Co-Operative Online Community! 2 Streams of Income - Join the Going Platinum Community FREE and earn commissions on your referrals 4 levels deep for everything YOU & 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad they do online. Or pay a one time $25 and become a Going Platinum Affiliate and earn a potentially high monthly Income. Signup FREE Today and check us out..there is NO Program Online to match this incredible Opportunity. You will also earn sign up bonuses for people that you refer into the program that become paying members. You must visit the website for all of the pertinent details. Highly Recommended.
My Counter
Wednesday, April 15, 2009
MLMLeadGenie
MLMLeadGenie http://www.mlmleadgenie.com/resellers.php MLMLeadGenie.com's parent company, GenerationX-Solutions, Inc. is the nation's leading web advertising service provider. We reach over 300 million worldwide consumers each month and reach 75% of the entire U.S internet using population. To become a MLMLeadGenie.com reseller you must submit a non refundable setup fee of $25 and a weekly purchase commitment of $200. We offer resellers unmatched service and advantages : *GenerationX-Solutions ensures that your client campaigns go live within 10 seconds using our automated CAMPAIGNLIVE software. *GenerationX-Solutions, Inc. guarantees unmatched telephonic and email support. *GenerationX-Solutions, Inc. offers resellers the most competitive rates in the industry. To setup a reseller account contact reseller@mlmleadgenie.com.
eHealthInsurance
eHealthInsurance.com http://www.ehealthinsurance.com/ehealthinsurance/affiliates.html Link to eHealthInsurance and Earn Cash! Now you can bring eHealthInsurance's blue-chip service, brand, and content to your site and earn money at the same time. As an eHealthInsurance performance partner, you will: *Join the #1 health insurance partner program *Partner with the #1 place to purchase health insurance online *Earn money with no risk and no cost to you eHealthInsurance will: *Offer the broadest selection of leading heath plans *Deliver unparalleled customer service through licensed agents *Provide free instant quotes and side-by-side comparisons of plan benefits and prices *Help people discover that health insurance is affordable and attainable EHealthInsurance is a pioneer in online health insurance services. We continue to be a leader in providing "anytime, anywhere" access to health insurance information and transaction capabilities. Strategic Partnerships, email strategic@eHealthInsurance.com to learn more about our co-branded marketplace partnerships.
iGlobalMedia
iGlobalMedia http://www.marketing.iglobalmedia.com/index1.html iGlobalMedia is a leading e-gaming company that owns a number of online :Poker, Casino and Bingo brands. Our sites include PartyPoker.com, the world's largest online poker room; StarluckCasino.com, PlanetLuck most favored online casino's since 1997; and PartyBingo.com, launched in August 2003 is our new bingo platform. With several thousand marketing partners and several million dollars in payouts, iGlobalMedia is the most reputed Online Advertiser you can work with. Please send all business enquiries by email to : ppc@iGlobalMedia.com Call us at: +1 - 888 - 292 - 4728
TV Products
Sylmark http://www.sylmark.com/ars.htm Some Of The Hottest Selling As-Seen-On-TV Products Anywhere! Our Affiliate Program is an opportunity for you to earn money by simply placing links to our Products on your Web site, on emails you send out, in your e-newsletter or on banner ads. We are a leader in the Infomercial industry and have created some of the hottest As-Seen-On-TV products available. Most of these As-Seen-On-TV products are only available thru us.
Make Money Program
Sales referrals are tracked through our own customized affiliate tracking system. On average, our sales conversion for a referred visitor is between 0.7% and 1.0% (in other words, every 1000 visitors yields 7-10 sales), this calculates to an effective return of approx. $280- $400 per thousand clicks. For example, someone visits www.yoursite.com and clicks on one of the DentalPlans.com banners. Your custom tracking code (which is provided in your affiliate members panel) will generate a cookie to be dropped on the users machine that has a 10 year lifespan. They are tracked using our custom affiliate program, and your payout commission on any sale generated from your site goes into your account. To receive your commission balance at any time, please email berta@dentalplanscorp.com with your affiliate number and billing address. Please check your balance periodically. With our custom-built affiliate member panel , you can view real time stats on sales, account balances, clicks, and referral data to track campaigns. Our unique tracking system even allows you develop and track multiple independent campaigns all under a single affiliate ID. Many of our current affiliates have praised our affiliate members area and tracking as one of the best they have ever seen. Create your own subcampaigns and extract the creatives at any time online! Whether your web site receives 10 page views a day or 10 million, there are no limitations to our program. There is no fee or obligation for affiliates to signup, so what are you waiting for?!
Free marketing resources
*Free marketing resources, including search engine tips and tricks *Full customer support-all email inquiries are replied to within 24 hours *Huge 30% commission rates! ( And 10% for all 2nd tier affiliates!) Our products have proven to be extremely successful. Aimed at customers desiring a greater level of discretion, our products have found an enormous consumer base on the Internet. Whereas many products can easily be purchased at local drug stores and malls, our products demand slightly more discretion, and the Internet has shown to be the ideal place to distribute our high quality product line. Our products are all manufactured with the greatest amount of care and precision. No cheap or stale ingredients are employed in production, ensuring that customers receive the absolute highest quality product. This policy of high standards has established Cybermed Industries Inc. as a reputable and highly regarded online distributor. Whereas most affiliate programs are content with paying commission rates varying from 15% to 25%, Team Cybermed starts all affiliates with a full 30% commission on all sales generated! Plus you earn 10% of all 2nd-tier affiliate sales! This means that you receive a portion of any sales generated from affiliates that signup under you! .
Make Money
Some companies will pay you just to receive and or read e-mail advertisements. You will receive email pertaining to categories you select when you signup. You will have to click a link in the email to be paid for it. Although some don't mention it, you should stay on the site for 15 - 30 seconds to make sure you receive credit for the visit. The reason we list so many Paid to Read companies is we believe they will continue to thrive even in the current advertising recession. We suggest you sign up for all these programs. They're free and they don't require a lot of effort to use. Consequently you will receive more emails and more money!
DentalPlans
DentalPlans http://www.dentalplans.com/affiliate.htm Internet Affiliate Program Start promoting the #1 dental plan web site, and get paid for every sale! Internet Affiliate Program Highlights: No signup fee or obligation! Real time statistics and sales tracking! No limits on site participation or campaigns! Banner and ad creative provided online! Free technical and customer support! Free URL Friendly landing pages available! As of April 20, 2004 Over $1,000,000.00 in Internet Affiliate commissions paid! If you are a company interested in our affiliate program, please contact our Director of New Business Development, Evan Weber directly at mailto:marketing@DentalPlans.com/. DentalPlans.com offers set payout commission on all dental plan sales generated through sales referrals.
How to Get Paid to Click
I n order to succeed, you must know what you are doing, like what you are doing, and believe in what you are doing. - Will Rogers You can make it on the web EASILY and SUCCESSFULLY without web knowledge but you Have to do it right and That is What TimeToTakeControl.com is all about! The sooner you start .. the sooner your income grows. You have very little to lose and a successful life to gain! TimeToTakeControl.com can help you make your dreams come true with the absolutely best home business opportunities that you can believe in. You can change your life, health, finances, and REALLY take control of your future! And we will help you succeed because if you succeed we succeed. All this can be done in your home with an internet based business done the right way that grows daily. Follow the 5 steps and you will be in business 24/7 and the income and traffic will grow exponentially! We offer 100's of affiliate programs that are ABSOLUTELY free to join...but you do need to get your own website and host it and then link to these programs. EVERYTHING IS EASY! 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 4. GoZing Surveys http://www.gozing.com/ For every survey you complete, goZing will pay you $4 to $25 in cash via PayPal or Amazon.com Gift Certificates! Gozing has OVER $400,000 PAID OUT TO DATE! goZing currently offers surveys to residents of the U.S., Canada, U.K., and Ireland. This affiliate program pays per lead and the payout is not the same per person. If you want to complete surveys and get paid for it click here or the link above. Gozing is also now accepting telephone surveys, so if you want to get paid more money you can complete telephone surveys. Highly Recommended get paid to surf the web program 5. SuperPayLine http://www.superpayline.com SuperPayLine offers an upstream and downstream matrix with huge bonuses and spillover. You get 2 websites, company referrals, weekly pay, software, promotion, a host of products, and the potential of making $10,000's. The pay plan is doubled and is lucrative to the enroller. They just launched so get in early! It costs less than $40. 6. The Ultimate Matrix Solution! http://www.the-ultimate-matrix-solution.com The Ultimate Matrix Solution! Problems finding referrals for any of your programs? Always failed to find a downline to cover your monthly fee? We now offer you the PERFECT Solution! Pay $ 35 once and be on the road to $ 7,340.00 a month! Unlimited benefits for a one time payment of $ 35! -5 ways to profit! -5 bonus programs! -Unlimited positions! -Fast moving matrix -$ 48.00 a month in the 3x3 company matrix! -$ 1,018.00 a month in the 4x4 company matrix! -And an astonishing $ 7,340.00 a month in the 5X5 company matrix! 7. 1WorldLine http://www.1worldline.com 1WorldLine... "After many months of development, planning and consultation with the Top Builders on the Internet, 1WorldLine is NOW ready to become The Largest Downline Club of all time. I suggest you Join Now while it's still early." Join Free! Get yourself in front of the rest and you'll reap the rewards. JOIN NOW! 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 8. Atomania http://www.atomania.com Atomania..The Easiest Money You Will Ever Make! This program is a great money maker because once you JOIN, you simply let the professionals do all the recruiting work. The key points of this program: - It will take none of your time - No bothering friends, family or attending meetings - All work is done by the Partners and the professional marketing team - Join and forget about it.........except to collect your MONEY!!! Don't leave to tomorrow what you can do today Every Atomaniac will make money. It is only a matter of time! Save your time & JOIN NOW!!! You can make over $1,000,000 on a one time $45 investment !! 9. SendMoreInfo http://www.sendmoreinfo.com Start earning Cash Back right now, today! Join the 2,902,300 who have already signed up! Cash for Email. Affiliate Opportunity. Member Benefits. And More to Come! Don't wait. Join the best Cash Back email media company on the web. Tell your friends, and we will even give cash back for their participation, too! It's FREE, it's EASY, and it's FUN! Become a member today. That's right this company is paying you to read email. Advertisers will send you email according to your interests. Billions of emails are sent over the internet every Day! Now, get paid for every email you receive from SendMoreInfo! You can make an additional $20, $60, $100 or more when people send email. That's right, we pay our members for reading their email! (Choose several interest categories when signing up to receive more email.) 10. SurveySavvy http://www.surveysavvy.com Welcome to SurveySavvy.com, where we value your opinion - literally. When you complete our online surveys, you make a difference in the marketplace and get paid for it. When you refer friends and they complete surveys, and when their friends complete surveys, you'll get paid too! SurveySavvy.com* is the online division of Luth Research, a leader in market research for 25 years. SurveySavvy is an online survey company. They have already paid out millions to their members, which is what you will be. Their excellent pay plan is the following, 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad for every survey you complete you will be paid $3.00. PLUS you will be paid $2.00 for every survey your referrals complete (people you refer to SurveySavvy), and you will be paid $1.00 for all the surveys that your referral's referrals complete. Their pay plan is on 3 levels and you get paid for each one. This is an amazing pay plan, use their income calculator to see how much you can potentially make with this. 11. VMC Satellite http://www.vmcsatellite.com/channels/home.cfm Make $50 per sale with our Affiliate Program! We paid our best affiliate $169,300.00 in one month! 80,487 affiliates all over the world can't be wrong! Join our team of 80,487 affiliate marketers today! (We welcome affiliates from any country, but please remember that our services are only available to US residents.) Our SMART website pays you $50 whenever we give away a free Satellite Dish System Installation from Dish Network! (Plus overrides on sub affiliates two levels deep!) We've already paid out over $3 Million to affiliates just like you. How much will we pay you? 12. Interland http://www.interland.com/ Interland's Hosting Reseller Program allows Web designers, developers, consultants and others the opportunity to purchase hosting plans with Dedicated Reseller Discounts and Shared Reseller Discounts and resell them for a profit. You control your hosting costs and your profits based on your sales volume! After the purchase of your first hosting plan all subsequent plans will be eligible for a discount. Interland's Partner Advantage Centralized Tool (iPACT) provides Resellers with email marketing tools, product specifications, brandable collateral, training documentation, marketing programs, access to online technical support, site management and billing support. This powerful tool is available through 24 hours a day, 365 days a year. 13. TeamCybermed http://www.teamcybermed.com/ Now paying All New Affiliates 35% to Start! We work extra hard at providing assistance and technical support in an attempt to help you reach your goals of e-commerce success and financial independence. Our #1 priority is seeing our affiliates succeed and excel financially as a result of being a part of our team. A few of the ways we strive to achieve this are by offering: 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad *Free web page with your affiliate code embedded in the html (for affiliates that don't have their own website yet)
How to Get Paid to Read Email
Paid to click companies are good money earners. These companies will pay you to visit their advertisers’ sites and to sign up for FREE 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad offers from other advertisers. You can only visit so many advertisers in a certain period of time; usually about a dozen advertisers in a 24- hour period of time. This keeps people from visiting the same advertisers’ site over and over to rack up money. This is the main reason we list so many of these companies. You can go down the line and click all the advertisers from each site and make a substantial amount of money (Each company has a different time you must spend on each advertiser’s site to get credit for it. We recommend staying for 30 seconds to ensure you get proper credit). How to Get Paid to Signup Some companies also encourage you to sign up for free offers they and their advertisers are promoting. This is a great way to earn some extra money fast. How to Get Paid to Take Surveys Survey sites are paid by companies to conduct surveys. The survey company then contacts you by email informing you that a survey that matches your profile is available for you to fill out. Surveys can take anywhere from 5 to 30 minutes and can pay you from $1 to $25 or more. This all depends on the site, the length of the survey, and how fast the company paying for the survey wants the results back. You do not have to complete every survey that matches your profile. You can pick and choose which ones you fill out. You are under no obligation to fill out any particular survey or all surveys sent to you. How to Get Paid to Surf Paid to Surf companies will pay you to display a small advertisement banner on your screen while you are online and using your computer. The advertisers based on how many of their ads you viewed in turn pay them. The banner is downloaded from the company's web site and will display rotating advertisements based on your personal profile (filled out when you sign up). You have to be online so the ads can be sent to the banners and you will have to verify you are using your computer from time to time so the companies know you are viewing the ads. Please remember, Paid to Surf companies require you to download and install software from their site. Each of the companies you sign up for will add an icon to your desktop when you install their software. Whenever you go online, just double click the icon, the bar will appear and you will be making money. It's that simple. Some Important Tips : 1.You will receive all the paid-emails at the email address that you specify when you register with the paying websites; and since you will be getting lots of paid emails from many such sites in future, you should create a new email address which is different from the one that 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad you regularly use. This way your personal and paid emails will never mix up. We suggest that you create a new email id on Yahoo and sign up to these websites using that id. 2.Do not use any of these email services to join the programs: Email.com, Indiatimes.com, Rediffmail.com, Mail.com, MyRealBox.com, Netkhajana.com. You can use any other reliable email service like Yahoo.com or Hotmail.com for doing this work on Internet. 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 1.berich4life.com http://www.berich4life.com Take Control of Your Financial Future !!! CASHCulture is a Revolutionary System that gives you everything you need to achieve all your financial freedom. Discover the Revolutionary 2x15 Personally Forced Matrix Residual $77,360.27 per month X 12 month You WILL earn $928,323.24 Annually! And the best thing: SELF-FUNDED when you fill-up your 2nd level! It Is Impossible NOT To Earn! Getting in Early is Very Beneficial Getting in at the VERY BEGINNING is a chance of a LIFETIME !!! This is a 2x15 forced matrix driven by the BIG BOYS! This is just ONE Matrix - No Smoke, No Mirrors Compressed monthly to keep YOU in the BEST position! Welcome to CASHCulture! Whether you landed here by recommendation or by chance, by visiting this site, you've just taken your first step to financial freedom! 2. My Money Machine http://www.mymoneymachine.com 15 Minutes From Now You Can Have Six 100% Profit Websites! Even if you know nothing at all about building a website! Are you tired of searching the Internet for the perfect work-at-home business, one that would allow you to earn a significant income while allowing you time to do the things you really value? What if you could switch from living paycheck to paycheck to having an unlimited income potential in just a few minutes? Own Your Own Business Selling The Most In Demand Products On The Internet Now you can make as much money as you want, with virtually no overhead, all from the comfort of your own home. It's time to join the e-book and software revolution, and start making the kind of money you deserve! I nternet experts agree that e-books and software are the perfect product to sell on the Internet. You only have to buy them once, and you can resell them a million times and never run out. And, since these products exist only in cyberspace, you can do it all from your home. You don't need a store, and you don't need to store inventory in your garage. 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad 225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad Best of all, e-books and software are in demand. The need for them is only going to grow as more and more people realize the convenience and variety of available publications and software. When you join My Money Machine, you'll get master resell rights to 100s of the most in demand, best-selling software and e-books on the Internet. You'll get six websites, completely setup and ready to start making money today. Each one is packed with the software and e-books hundreds of thousands of people are scrambling to get their hands on. And guess what?... You get to keep 100% of the money you earn from each and every sale. You won't find a deal like this anywhere else! We Provide Everything You Need To Start Making Money Get your FREE money machine which includes a state of the art, e-commerce enhanced, web site capable of accepting credit cards and electronic checks! You earn $5 for each Kickit! Membership sold from your web site and $5 for each Turbo! Membership sold from your web site! Earn higher commissions by joining Kickit or Turbo. Turn your computer into a virtual cash machine! 3. TimeToTakeControl.com ... http://www.timetotakecontrol.com
Make Money At Home
This is the home based business era. More and more people find out that the best way to improve their lives is to create a business of their own that willoperate with the most comfortable way: from the comfort of their homes. A home based business that will have minimal expenses, and grate effectiveness! No matter how a person's income varies from one job to another, more and more people look forward to increasing their income and improving their working conditions. More and more people look forward to creating a home based business of their own. It is a real opportunity, a realoffer! You are not obliged to pay anything and this is what makes this homebase business offer a real opportunity.225 Ways To Make Money At Home Ósubkuchonline technologies, Ahmedabad225 Ways To Make Money At Home Ósubkuchonline technologies, AhmedabadThere are people all over the world, young and old, from all walks of life thatwork at their own home based business and make money. So can you!225 Ways To Make Money at Home (ebook) was created to assist peoplewho are interested in and searching for, work at home job opportunities and/orstarting a Home Based Business. Working at home is what this website is allabout! We have also focused our attention on helping job seekers locate apart time job which can be performed in the home. Our team of investigatorssearched through out the internet for the very best companies who providewhat you need to know about working out of your home. All of theopportunities listed have been thoroughly investigated and researched forlegitimacy.Most all of the information here is on starting and maintaining a homebusiness or locating an honest work at home job on the Internet.Work At Home Opportunities found here are all COMPATIBLE with andcomplement each other. This means there is no conflict with working morethan one of them at the same time. In fact, the most successful people do justthat. Most all of the Work At Home Job and Home Business Opportunities youwill find here, are FREE to signup so you can check and see if it is right foryou. However, to actually get seriously involved and make money; there maybe an investment required.This E-book contains a list of around 225 such programs on internetthat pay members to read emails, to signup free offers, to takesurveys, to clicks ads or to produce income in various ways, as pertheir terms and conditions. If you don't have time to sign up for all ofthem right away, start with few programs first to see how they work.Before joining these programs you should read the information givenin next post.
Wall Street gains as GMAC gets financing
NEW YORK – Wall Street staged a big advance in the next to last session of 2008 Tuesday after Washington's latest lifeline to the auto industry bolstered hopes that the government will do whatever is necessary to cut short the recession.Investors found solace in news that General Motors Corp.'s troubled financing arm received $5 billion of financing. The Treasury Department said late Monday it would provide the money to GMAC Financial Services LLC from the $700 billion bank rescue program.The injection is on top of the $17.4 billion in loans the Bush Administration agreed to provide to the auto industry on Dec. 19. GMAC said Tuesday it would immediately resume lending to certain customers it had previously said were too great a risk for auto loans because of tight credit markets."This is trying to slow down the economic train wreck," said Jack Ablin, chief investment officer at Harris Private Bank. "Investors are taking a step back, and realizing that this will enable auto buyers to finance their cars and add liquidity to the market."Ablin also said the move will have an effect on the entire economy, especially amid a backdrop of sluggish consumer spending, which drives more than two-thirds of the U.S. economy.Wall Street got another disappointing reading about the mood of Americans after the Conference Board reported its Consumer Confidence index dropped to a record low. The trade group reported the index's reading fell to a 38 in December from a revised 44.7 in November, well below the expectation of 45 economists surveyed by Thomson Reuters.Investors were well prepared for a downbeat report after consumers reluctant to spend left retailers with their worst holiday season in years. The International Council of Shopping Centers said Tuesday that weekly same-store sales, those from stores open a year or more, dropped 1.5 percent last week at the 40 retailers it polls.The Dow Jones industrial average rose 184.46, or 2.17 percent, to 8,668.39. But even with that advance, the blue chips are still down 36.04 percent for the year with one more trading day remaining.Broader indexes also moved higher. The Standard & Poor's 500 index rose 21.22, or 2.44 percent, to 890.64, leaving it down 40.79 percent for the year; while the Nasdaq composite index added 40.38, or 2.67 percent, to 1,550.70, leaving it down 43.06 percent for 2008.With many traders away for the holidays, volume was low, which can exaggerate price moves. Advancing issues led decliners by 4 to 1 on the New York Stock Exchange, with consolidated volume at a light 3.23 billion shares, up from 2.98 billion on Monday.Most investors are looking past 2008 for clues about how stocks will fare in the coming year.Subodh Kumar, global investment strategist at Subodh Kumar & Associates in Toronto, said the market's moves in the final days of the year are more noteworthy than some investors realize; stocks have been fairly steady despite low volume that could easily lead to sharp declines. But he predicts trading will remain volatile into mid-2009."It's still relatively encouraging that the markets have been able to hold up," he said.Investors might have been able to overlook the disappointing consumer data after a surprise uptick in the Chicago Purchasing Managers' index, which measures business conditions across Illinois, Michigan and Indiana. It advanced in December for the first time since August. Wall Street had expected a decline. The index, which rose 34.1 from 33.8 in November, is considered a precursor to the Institute for Supply Management's manufacturing survey on Friday.Bond prices were higher. The yield on the benchmark 10-year Treasury note, which moves opposite its price, fell to 2.06 percent from 2.10 percent late Monday. The yield on the three-month T-bill, in great demand because it is considered one of the safest investments, rose to 0.06 percent from 0.03 percent late Monday.Light, sweet crude fell 99 cents to $39.03 on the New York Mercantile Exchange. Oil prices rose Monday as investors worried fighting between Israel and Hamas in Gaza would disrupt oil shipments.The dollar was mixed against other major currencies, while gold prices fell.In corporate news, shares of GM rose 20 cents, or 5.6 percent, to $3.80 after GMAC was given government financing. GM owns 49 percent of GMAC, while private equity firm Cerberus Capital Management holds the remainder.The Federal Reserve last week approved GMAC's application to become a bank holding company, a move that cleared the way for the company to receive money from the financial rescue fund. In addition to the cash infusion for GMAC, the government also agreed to lend $1 billion to GM so it can contribute to the financing arm's reorganization as a bank holding company.Meanwhile, General Motors said it is offering financing as low as zero percent over the next week for several 2008 and 2009 models in a big year-end sales push.The Russell 2000 index of smaller companies rose 16.62, or 3.57 percent, to 482.77.Overseas, Japan's Nikkei stock average rose 1.28 percent in the final session of the year, ending 2008 with a loss of 42 percent. Markets in Japan are closed for a holiday Wednesday. Britain's FTSE 100 rose 1.70 percent, Germany's DAX index rose 2.24 percent, and France's CAC-40 rose 2.76 percent.
Stock Exchang News
Stock looks to '09 with relief after terrible '08 NEW YORK – The last trading day of 2008 on Wall Street provided a merciful end to an abysmal year — the worst since the Great Depression, wiping out $6.9 trillion in stock market wealth. Six years of stock gains disappeared as the economy crumbled and markets crashed around the globe, shaking the confidence of professional and individual investors alike.But the year's chaos went far beyond the stock market. Credit markets that drive lending became paralyzed, plunging the country further into recession and touching off an unprecedented rush for the safety of Treasury bills, notes and bonds. Commodities markets, usually ignored by most investors, soared on speculative buying and then collapsed when it became clear that the world economy was in trouble and that record high prices, including oil's peak above $147 a barrel, were unjustified."It was a feeling of flailing," said Jerry Webman, chief economist at Oppenheimer Funds Inc. "People couldn't get a grasp because there were not obvious historical precedents."By the year's end, many market analysts were predicting that 2009 would be better, but that recovery would be slow as investors, shaken by the devastation to their portfolios, U.S. companies and the overall economy, remain reluctant to buy."I think this may be much more of a show-me market than we're used to. The market is going to be looking for some stabilization, increases in earnings, a few more positives before it begins to recover," said Webman.Wall Street's stats for 2008 provide evidence of how stunningly terrible the year was:• The average price of a share listed on the New York Stock Exchange plunged 45 percent to $41.14 by the end of the year from $75.01 a year earlier.• The Dow Jones industrial average fell 33.8 percent for the year and 38 percent from its record close of 14,165.53 in October 2007, making it the Dow's worst year since 1931, when the country was in the midst of the Great Depression.• The Standard & Poor's 500 index, the indicator most watched by market pros, slumped 38.5 percent in 2008 and 42.3 percent from its 2007 high of 1,565.15.• Investors lost $6.9 trillion as relentless selling reduced the value of stocks across the market. That amount, measured by the Dow Jones Wilshire 5000 Composite Index, represented 38 percent of the total value of U.S. stocks at the start of 2008.Yet the last week of the year was almost serene.On Wednesday, the Dow rose 108.00, or 1.25 percent, to 8,776.39.Broader stock indicators also rose. The Standard & Poor's 500 index gained 12.61, or 1.42 percent, to 903.25. The Nasdaq composite index rose 26.33, or 1.70 percent, to 1,577.03 and ended the year down 40.5 percent. It's down 44.8 percent from its recent peak in October; the Nasdaq's record high close of 5,048.62 came in March 2000 just before the end of the dot-com boom.The Russell 2000 index of smaller companies rose 16.68, or 3.46 percent, to 499.45.The tranquility was a welcome change in a year that was rocky from the start as worries about the financial system were fed by reports that banks had suffered billions of dollars in losses on securities tied to defaulting mortgages. The forced-sale of Bear Stearns Cos. in March unnerved Wall Street, yet it still managed to right itself through the spring.The surging price of oil and other commodities dealt another blow to the market. As a barrel of crude leaped from $112 at the beginning of May to a once-unthinkable $147.27 on July 11. With retail gasoline prices soaring above $4 a gallon, stocks fell amid fears that consumers would have to cut back their spending because of higher energy prices.But the market again stabilized — until the September bankruptcy of one of the most venerable Wall Street investment firms, Lehman Brothers Holdings Inc., set off a panic on Wall Street and in the credit markets. Banks, fearing that other financial institutions would be unable to repay, stopped lending to each other. The market for short-term corporate debt known as commercial paper was frozen. Interest rates soared.The only thriving part of the credit markets was government debt. Investors desperate for safety poured money into Treasury issues, particularly short-term bills. The yield on the three month bill plunged to zero, and briefly to a negative return, as investors decided no return or a slight loss was better than the losses on Wall Street or in commodities.Wall Street's crash in 2008 didn't come in one day like the famous 22.6 percent plunge of Oct. 26, 1987. In many ways it was more nightmarish than Black Monday because there wasn't a quick end to the selling and record volatility.From Sept. 15 to Nov. 20, when the Dow fell to a close of 7,552.29, the depths it had reached in the bear market of 2002, the blue chips rose or fell by triple digits 41 trading days out of 49.Relative stability returned to the market during December. But Wall Street's horrific performance has cast a new mold for modern bear markets, often defined as a decline of more than 20 percent, and made expectations for 2009 so low that any reduction in the economic bloodletting would be considered a victory."Everyone is so down in the dumps about everything that I do think it gives you the opportunity to have a positive surprise if maybe the economy does turn quicker," said Bill Stone, chief investment strategist at PNC Wealth Management.Wall Street is hoping for signs of recovery by the second half of 2009, including evidence the housing market has hit bottom, increased lending by banks and a drop in unemployment accompanied by increased consumer spending.But for the near future economists and market experts predict more bad news."I have yet to see anyone who anticipates that the first half of next year is going to be rosy," said Dean Junkans, chief investment officer at Wells Fargo Private Bank.But even a modest improvement in the economy, which has been in recession since last December, could help stocks extend their recent run."If you're standing still, walking is a pickup of speed," said Alan Levenson, chief economist at T. Rowe Price Associates Inc.The government has helped calm markets with a $700 billion rescue of the financial sector and by agreeing to provide financing to the major U.S. automakers. The Federal Reserve slashed its benchmark interest rate to near zero to reduce borrowing costs.Cheaper oil prices — it settled at $44.60 a barrel on Wednesday — are expected to help bolster the economy, draining less money away from consumers and businesses. The declining prices of other commodities, which have come down in response to rapidly waning demand for raw materials around the world, should also help.In addition, some analysts believe the market will improve because so many investors have pulled out, leaving little room for more selling."Given the nasty carnage how much further risk is there?" said David Darst, chief investment strategist for Morgan Stanley's global wealth management group.Still, the credit markets remain nearly stagnant as banks continue to be anxious about lending.Corporate forecasts in January could help shape investor sentiment, even as expectations are modest.David Kelly, chief market strategist at JPMorgan Funds, said the prospects for the market are "exceptionally uncertain."For the market to hold its advance from November he contends the calmer trading of the past month must continue and president-elect Barack Obama's plan to boost the economy with spending on infrastructure must show it is working quickly."The great risk is we are in a wait-and-see economy," Kelly said. "What Obama needs to do is turn this into a do-it-now economy, give people a reason to buy."
Sunday, April 12, 2009
MEASUREMENT OF BP
od is, mean BP = DBP + 1/3 pulse pressure. For example, in the above mentioned subject, the mean BP is about 93 mm. Hg. Fig. 5.9.1. Recording of BP in man by the usual method (Riva-Rocci manometer). MEASUREMENT OF BP I. In human subjects in routine clinical practice, BP is determined by the sphygmomanometer, an instrument devised by Riva - Rocci, and subsequently improved by Von Recklinghausen. The sphygmomanometer is essentially a mercury manometer. However, instead of the classical U tube of the manometer, only one of its limbs is long the othar is very short, and acts as a raservoir of mercury (figure 5.9.1). The reservoir is, via a rubber tube, connected with an arm 'cuff the cuff, in turn is, via rubber tube, connected with a hand pump. Air can be introduced into the cuff by pumping the hand pump, a process called 'inflation'. Air from the cuff can be driven out by unscrewing the pump ('deflation'). The determination. The subject lies flat on his back, the cuff is wrapped round his arm (preferably the left arm, as the left subclavian artery unlike the right one, is a direct branch of the aorta). The heart sphygmomanometer and the arm should be at same horizontal plane. Then inflation is started by pressing the pump and the radial arterial pulse palpated concomitantly. A time comes when the radial pulse disappears. 'The height of mercury column at this stage is noted in the side scale. Then the cuff is deflated fully. The ball of the stethoscope is placed lightly on the brachial artery near the elbow. The cuff is again inflated and inflation continued for sometime even after the column of mercury has attained the previous height where the radial arterial pulse disappeared. Then deflation is started, at a rate of 2-3 mm/sec, neither more nor less. At first there is no sound heard by the stethoscope ('grave yard silence), after the deflation has reached a particular stage. a 'tap' sound is heard and this marks the SBP the reading at the side scale (of the height of the mercury column) is noted, deflation continued, till all sounds disappear. Between the 'tap' sound and the, reappearance of silence, a series of sounds, called Korotkov sounds, are heard as follows: For a long time, there was a raging controversy, viz, which phase corresponds, to the true diastolic pressure. Some said it was phase IV ('muffled' sound), some others said, disappearance of all sounds., (phase V). The true diastolic pressure is between the phase IV and phase V, but nearer the phase V of Korotkov sounds. Therefore it is now the official policy to regard phase V as the diastolic BP* According to an American heart association subcommittee report in 1967, it is desirable to mention the readings of both the IVth and Vth phases. Thus, if the SBP is 120 and the readings at phases IV and V be 80 and 70 mm Hg,the BP should be expressed as 120/80/70 mm Hg. Dependability of the clinical method. The precautions. In the same subject, the BP can be measured simultaneously in one arm by the above mentioned clinical method and in the other arm by the direct method. It has been found that, usually the SBP, as measured by the clinical (spliygmamanometric) method, is considerably lower (the difference is usually between 10-25 mm Hg) than the value obtained by the direct method. Further, if the IVth phase (of the sphygmomanometric method) is regarded as the DBP, the clinical method gives about 8 mm higher figure than that obtained by the direct method whereas if the Vth phase is regarded as the DBP, the differences of the values obtained by the two methods is almost nil "Dollery, CT: Arterial Hypertension, in Wyngarden. J 3 dc Smith, LH (Ed), Cecil Text Book of Medicine. Chap. 47 Saunders, 1985. The above method is called, 'auscultatory method' BP can also be determined by palpatory method: inflate the cuff and simultaneously also continue to palpale the pulse. A time comes when the pulse can no longer be felt, continue to inflate for still some time, keeping the fingers an the radial artery. Now begin to deflate the cuff. A time comes when the pulse can again be felt. Note, the value (on the side scale of the mercury column) where the pulse reappears. This is the SBP as recorded by the palpatory method. But the SBP recorded by this method is a trifle lower than that obtained by the auscultatory method. Moreover, by palpatory method, only the SBP (but not the DBP) can be recorded. Auscultatory gap. This is seen sometimes in patients suffering from high blood pressure. A subject has a BP of say, 200/100 mm Hg. The first sound of Korotkov, the 'tap' sound, appears at 200 mm height as expected, but as deflation proceeds all sounds disappear. The sound reappears again at a lower pressure. Thus, in this example, the sound disappears, say, at 190 mm of Hg and reappears, again at 170 mm Hg, the Vth phase (disappearance) remaining at 100 mm Hg. Thus, if the inflation is made only upto say, 180 mm Hg, and a simultaneous palpation of pulse is not done, the clinician will record the BP as 170/100 mm Hg and rhe patient and the clinician may develop a false sense of security. The silent zone, mentioned above, viz. 190 mm Hg to 170 mm Hg is the auseutatory gap. The pulse however can be felt throughout the zone. Of auseultatory gap'. The BP, as will be shown later, is affected by many factors like, excitement, anxiety, exercise, meal and exposure to cold. It is expected that the clinician remembers these factors while determining the BP, and ensures that while recording BP, his subject is at rest (mentally and physically), in a comfortable climate and has not taken a heavy meal
C sympathetic stimulation elevation of BP and tachycardia perfusion of the tissues is restored.
C sympathetic stimulation elevation of BP and tachycardia perfusion of the tissues is restored. (ii) Sympathetic stimulation also causes carotid chemo receptor stimulation by causing vasoconstriction of the artery feeding the carotid chemoreceptors. Further, hemorrhagic shock produces hypoxia which also causes chemoraceptor stimulation (particularly if the subject is restless). Chemoreceptor stimulation in turn, produces VMC stimulation. Fall of BP, if of sufficient degree, results in ischemia of the VMC and in turn produces stimulation of VMC (CNS ischemic response, chap. 8 sec. V, see also fig 5.8.1). Stimulation of VMC causes stimulation of sympathetic system elevation of BP restoration of perfusion. Also sympathetic stimulation causes redistribution of blood flow, the cutaneous, splanchnic and muscle blood flow are greatly cut down and the blood thus made available are flown to the brain and heart. Recall sympathetic stimulation, (i) has no effect on brain blood vessels, and (ii) causes coronary dilatation. The sympathetic stimulation produces some well known signs of shock, like pallor and sweating (pallor, because of the cutaneous vaso constriction. sweat glands are supplied by the sympathetic fibers, therefore sympathetic stimulation may lead to sweating and cold clammy skin). Endogenous substances like adrenalin are also liberated (as hemorrhage produces 'stress' and stress causes adrenalin secretion). Adrenalin reinforces the sympathetic activity. II. Tissue fluid shift As the BP falls the capillary blood pressure also falls. However, there is no fall of the colloidal osmotic tension. This causes stoppage of flow of fluid from the capillary to the tissue, or if the fall of BP is greater, the return of the tissue fluid to the capillary is enhanced (see Starling's hypothesis, fig. 1.1.9). This corrects the hypovolemia within the vascular compartment increase in cardiac inflow, and the real follows. III. Conservation of body water Fall of BP leads to lowering of perfusion pressure of the kidney production of renin production of angiotensin production of aldosterone [for details, see chapter on aldosterone, chap. 4 (control of sacretion) sec VI] sodium retention body water retention. It is now known, in stress, the hormone ADH is also secreted in greater amount. This reduces the volume of the urinary output body water conserved hypovolemia corrected. [Cardiovascular shock is a farm of stress. Recall, any deviation from homeostasis is a stress (chap 3 sec I). In massive hemorrhage, massive amounts of ADH is secreted. ADM in high concentration acts as vasopressin which is a powerful visoconstrictior. In addition, local autoregulatory mechanisms are also important. Even if the BP is falling for considerable period. the blood flow of the brain or heart does not fall, although blood flow in the other organs are falling. This is called autoregulation, whose mechanisms have been discussed earlier (chap. 6 sec V, see also fig. 5.10.2). However, if the fall of BP is severe, agtoregulation cannot manage. Compensatory mechanisms are often called 'negative feed back mechanisms', negative, because the results (effects) are in the opposite direction of the causes(chap. 3 sec I). For example, withdrawal of baroreceptor stimulation is caused by the fall of BP but effect of the withdrawal of baroreceptor stimulation is rise of BP A -ve feed back mechanism restores homeostasis, whereas a +ve feed back destabilizes the homeostasis irreversible shock if the shock continues and is not treated promptly, the stags of 'irreversible shock, develops, when the patient dies despite the (late) institution of the correct treatment. It will be seen afterwards, the term irreversible is rather misleading, a better term will be advanced stage of shock'. Causes of the irreversibility. At this stage some +ve feed back mechanisms appear in the scene with the result that there develops a vicious cycle [a cycle of 'vices' or sins; example, an individual begins, say, gambling loses money his financial situation deteriorates with a hope to improve his monetary position, he does more gambling further loss of money). These are: (a) Cardiac damage (i) Even normally, the subendocardial region of myocardium is susceptible to anoxia. When the BP is falling, this danger increases and ultimately subendocardial damages occur further fill of cardiac output (due to subendocardial damage) the vicious cycle operates (ii) A factor called, myocardial depressing factor, is suspected to appear in the circulation during advanced stages of shock. This reduces cardiac contractility vicious cycle, (iii) In advanced stages of shock, the acidosis (see below) develops and depresses the myocardial contractility still further further fall of BP vicious cycle. (b) Acidosis Tissue anoxia leads to accumulation of lactic acid acidosis. The fall of pH causes relaxation of the arteriolar and precapillary sphincter muscles vasodilatation operation of vicious cycle. (c)vToxemia Prolonged spasm or the splanchnic vessels (which develops as a result of compensatory mechanism) intestinal mucosal damage due to lack of 02 massive entry of the intestinal bacteria (through the damaged mucosa) which liberate toxin relaxation of the vascular smooth muscles due to the effect of the bacterial toxin. (Recall, during sympathetic simulation, powerful splanchnic vasospasm develops). (d) VMC ischemia Slight ischemia stimulates the VMC, but massive ischemia kills it. When VMC death sets in, there is sympathetic paralysis precipitate fall of BP. (e) Elderly people generally have artherosclerotic lesions in their coronary"
well as the likely information (s), which can be obtained from a particular test, should be clearly understood. Very often, in the early stages of som
well as the likely information (s), which can be obtained from a particular test, should be clearly understood. Very often, in the early stages of some renal diseases. it is not apparent from the signs and symptoms, that the kidneys have started to fail. Some test of kidney (e.g. blood analysis) may or may not reveal the incipient failure. However, more sophisticated tests (e.g. clearance tests) may reveal the incipient failure at this stage and the pnysician and the patient, both now being alive to the incoming danger, can take appropriate action. The tests of the kidney functions are Urine examination. Chemical examination of blood. Clearance tests. Concentrating power of the kidney, Radioiogicai and imaging investigations. Udrine examination Features of normal urine have already been deserbed (chap 2, sec VIII) The outstanding features which may be obtaned in a case of kidney dysfunction are mentioned below 1. Volume : Normally the volume, of urire per. day is f. 500 ml (range 800 lo 2,500 ml/day) if he volume is less than 500 ml/day (severe ollguria) waste product cannot be satisfactcrity excreted and they atcurnlate In blood. Conversety, in polyuria, so much water and Na may be lost that symploms may be produced Oliguna may be produced try severe lacK of drinking water, acute giornerlonephritis. cardavastilar shocK cardiac insufficiency and other conditions Diabetes mellitus, diabetes insipidus and chrome pyelonephritis are some of the well known causes of polyura}. 2 Specific gravity (Sp. gr) Very low and fixed sp.gr. (i.e where the kidineys have lost-the power to concentrate the urine) may be obtained r chrome nephrite Very high sp grof urine is found incases ofgtycosuna Proiemuna causes onfy a margnainge of ( HYPERLINKhttp//sp.gr) of urine. 3. Urinary reaction in some types of renal disorders. the ability secrete H* is reduced and as a result surfficiently acd urine cannot be formed, causing renal acidosis This may be esiabtehed by adminstratlon of NH4 Ci
. In certain areas of the world, drinking water is deficient in flurine
water. In certain areas of the world, drinking water is deficient in flurine. That is why fluoride ion is added to the water supply to the extent of 1 ppm (part per million) in some countries. FIBERS AND ROUGHAGE Leafy vegetables containing a cellulose or hemicellulose coating, are indigestible in hunan intestine. Hence if such substances are present, they tend to increase the bulk of the feces and mass peristalsis' (chap. 3.7. defecation) is favored, and constipation can be avoided. Great amounts of leafy vegetables however can produce diarrhea. Plant components (cellulose/nemicellulose/pectins/lignins etc) which cannot be digested by the enzymes of our digestive tract are collectively called fibers. Strong evidences indicate that, lack of fibers in the diet predispose colorectal cancer, breast cancer, diverticulosis and coronary heart disease. Grams, peas and dal contain good deal of indigestible vegetable fibers. FOOD HABITS, TABOOS, COST. Food habits must be considered. Thus a Bengalee likes fish and rice whereas a North Indian non-vegetarian likes wheat and meat. Religious taboos are too well known. Thus, a Hindu nonvegetarian wil not take beef whereas a Muslim will not touch pork. Many Hindus (including Jains and some Sikhs) are strict vegetarians, although most of them take milk. Such religious flats should be remembered and respected while formulating the diet and alternatives to the tabooed food should be priscribed. Cost also is to be consid-ered. Animal proteins in general are costly products. Many fruits are expensive although they have no special advantage over the cheaper fruits. LOSS Cooking, particularly in Indian way, causes much wastage. The classical Bengalee cooking deserves more condemnation. The habit of discarding the water after boiling rice (thus causing loss of water soluble vitamins, some quantities of aibumin and starch). extensive discarding or the skin of vegetables, hard frying in oils all cause variable loss of food vitamins. Digestibility is another important consideration. Some proteins, particularly dal and peas lose some of thaeir values because of lack of easy digestibility. In an average menu, loss due to cooking and indigestibility together may account for about 10% of the food value. THE BALANCED DIET CHART with the background mentioned above, a diet chart for a healthy young adult male may be set as an erample. The term balanced diet means a diet which is complete in all respects. (i e . it is not lacking in any respect) at the same time it contains no excess of any item that may cause harm to the body. The following should be noted :The calorie requirement varies from person to person and in the same person from time to time. To adjust the, carbohydrate (rice, wheat, potato, sugar, jaggery and so on) and fats and oils (butter, ghee, cooking oil) should primarily be adjusted whereas. ordinarily, protien should not be considered for adjustments of calories. SOME COMMON FOODS. Common articles of food may be divided as follows. I. Meat, fish, egg Sources of animal protein (meat about 20%, fish same as meat, egg about 14%). Proteins are of very high quantity. Disadvantage is high cost. However, because of the Government policy of encouraging poultry in most states of India, price of egg is not high. The associated fat (in ordinary butcher's cut of meat) is however saturated and its ingestion predisposes to atherosclerosis. II. Milk, milk products (excludrig ghee/butter). Milk is almost a complete food, very high quality protein (though not as high as in Gr. I), for details, see later. III. Grains (cereal) :Rice and wheat. Rich in starch and contain between 7 to 10% protein. Protein is of good quality. Deficient in fat, cheap. Table 7.16.1: Balanced diet (for non rich and moderately working man) Food vegetarian. Non vegetarian lacto vegetarian gms/day gms/day. Cereals rice/wheat 350 350 Pulses (dal), gram 90 60 Meat/fish . 60 Milk 300 100 vegetables (pulbul, ladies finger, cauliflowers, 100 100 carrot, brinjal etc. Potato 75 75 Green leafy vegetables 100 100 Egg one (about 60 gms) Fats and oils (crooking oil, butter/ghee, fat 50 40 associated with meat) Sugar and jaggery 40 40 Lemon one one Seasonal fruits some helps some helps N.B.: Values are approximate only. Important. See that, (othere is enough fibers in the diet (to prevent colorectal cancer, breast cancer, antherosclerosis), (ii) plenty of carotenoids are taken (to prevent cancer lung, breast cancer). (iii) fat, particularly saturated fat intake is low (iv) NaCl is restricted and finally (v) sugar intake is low. IV. Pulses (dal) and legumes. Dal. Rich in protein but poor in fat. Protein is somewhat less digestible and of lower qualify. It is the most important protein supplier throughout whole of lndia excepting marginal areas of North East india. Because of its impotance to the nation, the Government of India is trying very hard to improve the national yield of dal Protein content of the dry dal is between 20% to 25%, cheap. Byumes, usually the dried peas and beans are meant. Soyabean is also a kind of legume. They contain high amount of vegetable protein. The major protein supplier in Latin American counties is, kidney bean, which they consume in large quantity. Soyabean contains approximately 40% protein and 17% fat V. Nuts (peanuts, alrnonds, walnuts, ground nuts, etc) :very rich in fat (about 40%) and protein (about 25%) content is amost equal to dal. IV. Roots and tubers :Potato and sweet potato are examples oftubers.: They are rich in starch but poor in fat. Carrot and beet roots are examples of roots. Beet is a rich source of sugar like sucrose but not of starch. Protein content is very low. Carrot has protective effects against lung and breast cancers. VII. Green vegetables :Green leafy vegetables are primarily taken to increase the bulk of food and to avoid constipation. Other vegetables Iike brinjai, pulbul,lady's finger etc. are low in calories. MILK Milk is almost a complete food containing protein, carbohydrate and fat as well as the important vitamins and minerals. Milk however. is deficient in iron. Old people living in isolation and depending mostly on milk and bread (not fortified with iron) can thus develop anemia. which is sometimes called 'milk injury'. The protein of milk is of very high biological value(i.e., high quality protein). The composition of milk varies from species to species. Thus,
substances including coenzymes which must be present in many eniymatic reactions, in their absence the enzymatic reaction cannot proceed) Thus apo I I
substances including coenzymes which must be present in many eniymatic reactions, in their absence the enzymatic reaction cannot proceed) Thus apo I is a cotactor of lecilhm cholesterol acyl transtecase (LCAT) ativity, CM acts as a cofactor for lipoprotein lipase activity Genetic absence of CM in a family causes the disease familial hypercholesTeremia (b) bin from the pom! of view of medical students the most important fact is that because of the presence of these apoli pop roleins, the hpoproteins can combine with their specific race plots of the largal cells (and subsequently metabolized) Thin apo B binds with LDL and the LDL now can bind with its receptor it is hightly possible that abnormalities of these of such diseases like atherosclerosis and hyperchotesteremia. Structure of a lipoprolein [NB To keep the discussion simple, only 4 classes of lipoproteins have been mentioned above Most authors now include IOL {intermediate density lipoprol em) in addition lo the above 4 categories) Upoprotem lipase. After a meal very rich in fat. the plasma becomes milky. This milkiness is due ret the presence of exces s amount of chylomicron particles In the plasma In due time, or following a heparin injection, the plasma is cleared of its milkiness. This clearing is due to the activity of a clearing factof (.an enzyme] called plasma lipoproiem hpate As a result or the action of this enzyme, the Inglycenda portion of the lipoprotein is hydrulyzed to glycerol and free fatty acids (FFA) Most of the FFA rhus formed enter the ertrahepatic tissues (like the muscles, where they are catabolized) This causes clearing of the plasma. The anginal chylomrcron panicle therefore now becomes much smaller, and contains tha protein cholesterol and phospholipid portions but practically no Inglyceride. The small remnants of chylomicron* particles now go to liver where they will be further catabulued. The enzyme lipoprotir irpase (clearing factor lipast) is present in the walls of the capillaries of blood and therefore present in sufficient amount in large number of organs which 31 e rich in capillaries. This enzyme is different from (and therefore should not be confused with) the adipose tissue (also called, hormone sensitive") hpase Hepann injection causes release of the plasma hpoprorem lipase from the endothehal cells of capillary walls [Hepann also causes release of another hpase. from The liver, called, heparin releasable hepatic Ijpcprolem It-past, whose function is largely obscure] Applied biochemistry of plasma hpoproteins Disorders of lipid metabolism and lipoproieint Many disorders of lipid metabolism an aitociatid with changes of plasma lipoproteina. Thus atherosclerosis/ coronary heart diseases (CHD) are associated with changes of plasma lipid values as well as llpoprotem pattern, changes include increase of plasma cholesierol values (hypercholesteremia) and rise of p llpoprotem ((JLP) Further, in atheroscleiosis the ratio of pLP/ a LP increses. This 19 underslandable, inspection of Tsble 7 t2 will show that most of the cholesterol is present in the aLP (= LDL) fraction of The hpoproletns Kamholesma is also assoculpd with increase of pLP Idiopalhic
'hyperlipemia. diabetes mellitus. myixedema. nephrotic syndrome are also characterized by rise of plasma hpid values Importance of lipoproiem estimation in diseases in the late 1950s and 60s it began to be suspected strongly that for diagnostic (as well as prognostic) purposes in disorders of lipid metabolism (atheraselerosis. xantholesma. Thanhauser's disease etc J over and above the estimation of plasma cholesterol and triglycendes, estimation of plasma lipoproleins is also imptrative it was suggested N B (i) Sf = Svedberg's ftotation unit Higher the Sf value greater is tha tendency to float in the solution (a) Some authors recognize two furthtr vanties, (a) chylormcron remnants (s*« fool note previous page), (b) IDL, in between LDL and VLDL that value of plasma cnuTesierol may remain almost normal but the ratio of p LP/ a LP might increase. However, now it is usually conceded lhat for routine clinical purposes, estimation of serum (or plasma) cholesterol and Inglycende is reasonably enough, lipoproiem estimation does not give much additional informations. Rectnrly however, estimation of the different types of apohpoprotein, for predicting the possibility of CHD. is becoming popular Further, it is now agreed that persons who have a high cholesterol HDL ratio are specialty prone id atheraseter-asis. Therefore, like smoking, obesily. drabetes and hypertension, bad cholesterol HDL ratio is also a risk factor Free tally acids. The FFA accounts for about 5% of the lotal plasma lipids But because of the exlremely rapid lumover rate, this is a very important sechon of
.plasma lipids FFA in plasma remains bound with plasma albumin (and thus becomes soluble} Within the cells, There is a protein called Z protein (also called. fatty acid binding protein), which binda with the FFA Z protein is thus.tha caunltrpvt of albumin. Fatlora influencing plasma lipid valuta. A Hormones Insulin reduces plasma lipid values (Old standing diabetics nave sometimes abnomially high values of plasma Lipids which however may not always be controlled by insulin and diet control (sec chap 7. 9, diabetes and lipid merabolism)insulin promotes fatty acid synthesis by stimulating HMP which causes
generation of NAOPH. and the H atoms of NADPH can subsequently be utilzed for fitly acid synthesis. Insulin inhibits
inhibiting hormone sensitive Ijpoprolein hpase m adipose tissue and Thus Ihe FFA co
'hyperlipemia. diabetes mellitus. myixedema. nephrotic syndrome are also characterized by rise of plasma hpid values Importance of lipoproiem estimation in diseases in the late 1950s and 60s it began to be suspected strongly that for diagnostic (as well as prognostic) purposes in disorders of lipid metabolism (atheraselerosis. xantholesma. Thanhauser's disease etc J over and above the estimation of plasma cholesterol and triglycendes, estimation of plasma lipoproleins is also imptrative it was suggested N B (i) Sf = Svedberg's ftotation unit Higher the Sf value greater is tha tendency to float in the solution (a) Some authors recognize two furthtr vanties, (a) chylormcron remnants (s*« fool note previous page), (b) IDL, in between LDL and VLDL that value of plasma cnuTesierol may remain almost normal but the ratio of p LP/ a LP might increase. However, now it is usually conceded lhat for routine clinical purposes, estimation of serum (or plasma) cholesterol and Inglycende is reasonably enough, lipoproiem estimation does not give much additional informations. Rectnrly however, estimation of the different types of apohpoprotein, for predicting the possibility of CHD. is becoming popular Further, it is now agreed that persons who have a high cholesterol HDL ratio are specialty prone id atheraseter-asis. Therefore, like smoking, obesily. drabetes and hypertension, bad cholesterol HDL ratio is also a risk factor Free tally acids. The FFA accounts for about 5% of the lotal plasma lipids But because of the exlremely rapid lumover rate, this is a very important sechon of
.plasma lipids FFA in plasma remains bound with plasma albumin (and thus becomes soluble} Within the cells, There is a protein called Z protein (also called. fatty acid binding protein), which binda with the FFA Z protein is thus.tha caunltrpvt of albumin. Fatlora influencing plasma lipid valuta. A Hormones Insulin reduces plasma lipid values (Old standing diabetics nave sometimes abnomially high values of plasma Lipids which however may not always be controlled by insulin and diet control (sec chap 7. 9, diabetes and lipid merabolism)insulin promotes fatty acid synthesis by stimulating HMP which causes
generation of NAOPH. and the H atoms of NADPH can subsequently be utilzed for fitly acid synthesis. Insulin inhibits
inhibiting hormone sensitive Ijpoprolein hpase m adipose tissue and Thus Ihe FFA co
According to some recent works. thyroxine causes increased Ca++ ATPase activity of myosin (which in turn may be due to increase in the bulk of myosin
owever have challenged this idea. According to some recent works. thyroxine causes increased Ca++ ATPase activity of myosin (which in turn may be due to increase in the bulk of myosin in heart muscle due to thyroxine) increased contractility of myocardium. In short, excess thyroxine excess myosin in the myocardium increased contractility of the heart. (ii) Central nervous system In the neonatal slags, up to the age of approximately 1 year, normal amount of thyroxine is required for the satisfactory development of the neive fibers and their myelination. If sufficient thyronine is not available at this stage. the bram becomes small. The child grows in chronological age but his mental development does not occur. On the other hand, if thymune becomes deficient after the full development of the CNS, some mental signs like mental stowing still develops but can be completely cured by thyroid administration. This is not so in the case of hypolhyroidism in the neonatals If the hypolhyroidism is not corrected within about 1 year of birth, no matter how vigoros is the subsequent treatment, satisfactory brain development will not occur( iii) On skeletal system. ThyroHine is required for the growth and maturation of epiphyseal cartilage so that in the absence of this hormone, linear skeletal growth does not occur. Excess thrioxnine causes osleopoiosis because of calcium drainage from the bone (iv)On reproductive system Lack ofthyromne in adult woman of reproducing age usually causes menorrhagia (= excessive menstrual bleeding) but the explanation is not definitely known HypoIhyioidism may be associated with infertility also. (v)0n digestive system. Excess thyrocxine causes increased motitrty of the gastrc intestinal trad (and thus causing diarrhea) and/or, increased appelite. Lack of thyroxine causes reverse symptoms. (vi)0n blood In hypothyroidism a normoeytic normochromic anemia is seen MECHANISM OF ACTION As stated already (chap i, ssc VI, Mechanism of action. Thyroid hormones), thyroid hormones act somewhat like the steroid hormones. The free (not the TBG bound] T4 enters the target cell (almost all tissues are target cells of T4 , specially notable are the neurons, heart, liver, skeletal muscles, adipose tissues, mammary gland) converted into T3 HR (hormone receptor) complex is formed within The nucleus HR attachment with DMA occurs more mRNA production synthesis of more proteins biological action One single biochemical action of T4 (rather T3) at Ihe molecular level cannot explain all the actions of thyroid hormones (TH) Thus, (i) as stated already (see above), trie idea that TM causes 'uncoupling of oxidative phasphorylaiion' has bsen discarded, (ii)the idea, that. Na+K+ ATPase enzyme is vigorosly synthesized so that TH causes calori genesis, (although still very popular), does not explain all. (iii) TH causes mcreass in the synthesis of many proteins (including enzymes) which explains some of The effects of thyroxine (growth ol neuron/rise in myocaidial contractilily/lung development in tadpoles etc etc ) CONTROL OF THE THYROID SECRETION There are three major ways of controlling [he ihyroid secretion, viz. (i) Tha anterior pituitary, (ii) the hypolhalmus, and (lii) auloregulation Fig.6.2.4 gives a diagramatic representation of the mode of working of the first two factors Besides, some other factors like (iv) sympathetic stimulation (v) exposure to cold are also important. Fig. 6.2.4 Conlrol of Thyroid Secretion. TSH of the anterior pituitary Some details have been discussed previously (in this chapter) in connection with the biosynthesis of Ihe thyroid hormones. Additional details have been given in connection with the antenor pituitary hormones. In short, thyroid stimulating hormone, TSH. is secreted by Ihe specialized cells, tailed thyrotrophs' of the antenor pituitary, (i) TSH stimulates almost all the major steps of Thyromne biosynthesis as well as the release of thyroid hormones Hence, more TSH = more secretion of thyroid. (2) in addition, it causes increased vascuiarity and cellular growth of the thyroid gfarrd. These are the two major actions of the TSH. TSH is controlled by negative feed back mechanism eierted by T4 and T3. The circulating T4 is converted into T3 at the level of the anterior pituitary and thus both T4 and TB are active. Therefore, when Circulating T4 is in high concentration. the pituitary Ihyrolroph is inhibited so that TSH secretion is depressed, resulting in correction of excess T4 in blood Reverse occurs when T4 concentration of blood is low Hence, more T4 =less TSH TSH is the single most important regulator ef the thyroid secretion Hypothalamus From the hypolhalamus, thyrotropin releasing hormone. TRH is secreted (NB. Ihyrotropin = TSH). TRH acts on pituilary thyrc-trophs and stimulates them to secrele TSH Hence more TRH = more TSH Probably T4 and T3 do not operate at the level of the hypolhalamus level for the feed back mechanism Thyioxine and TRH both act at the level of thyrotrophs of ant pituitary where they antagonize each other. Another hormones called somatostatin inhibits the TSH secielion. Somatostatin, in this case, is released from the hypothalamus [somatoslatin is also secreted by the islets of Langerhans and slornach) Autoremulation of thyroid If there is deficiency of the food iodine, The iodine trapping mechanism of The follicular cells become super efficient. Therefore, unless there is frank (severe] food iodine deficiency, supply of iodine to the follicular cells, for synthesis of T4 and T3 continues satisfactorily Conversely, if there is evcess of the food rod
The actual exchange of CO2 therefore, occurs more, From this compound.
, however, be quickly formed or dissociated The actual exchange of CO2 therefore, occurs more, From this compound. Time required for oxygen uptake At real, an RBC stays for only about 1 sec in a pulmonary capillary but the Hb within it becomes saturated with in about 0.3 sec, that is this 1 sec is more than sufficient for full oiygenation of Hb During exercise, when the circulation speed is high, the transit time of the RBC may be as low as 0.3 sec. but even this Time as shown above, is sufficient SHUNTS Fig. 4. 4.2 shows that PO2 of oxigenated pulmonary capillary blood is practically same (100 mm Hg) as that of alveolar PO2, yet The PO2 of systemic arterial blood (PaO2) is little lower (95 mm Hg) How to explain this fall Answer is (i) various venous blood, that is. deoxygenated blood, gets mixed with the pulmonary venous Wood Such veins are bronchial veins and the bisian venous system, both carrying de oxygenated blood, (ii) Moreover in some areas of the lung, the alveoli are very poorly ventilated but perfusion of These alveoli (by the blood) is alright Pulmonary capllary blood, draining these poorly ventilated alveoli contains poor quantities of O2 and they too drain in the pulmonary veins All these factors lower the P02 of pulmonary venous blood slightly The total reduction of P02, due to these causes, in health, is only 5 mm Hg. All these factors, collectively, constitute the shunt APPLIED PHYSIOLOGY Pulmonary edema, bronchopneumonia and lobar pneumonia increase the resistance lo the alveolo capillary diffusion by bringing fluid into the alveolo capillary membrane Various industrial hazards like asbestosis. pneumoconiosis etc. also increase the thickness of the alveolocapillary membrane to produce alveolocapillary block. To overcome the block. O2 Therapy may be given For further details, see chapter 6 of section IV Gaseous enchange in the peripheral tissus. Some special problems. Diffusion of 02 and C02 at the level of peripheral capillaries are governed, as in the case of that at lung alveolar level, by Fick's law One important difference is that. the distance between, capillary blood and needy tissue (T in the Fick's law, see earlier this chapter] is usually much greater and therefore oxygenation of peripheral tissues, on theoretical grounds, should nol be easy Yet, the tissues normally show no anona. To explain this, it has been, proposed that there is a facilitated diffusion' of 02 (chap 1 sec I) at this level and myoglobin acts as the earner. Gunng euercise owever many capillaries open up( recruitment) and the vlaue of T therefore falls Perfiiaion inefficiency (reduction of puknonary blood flow) can also lead to hypoxemie. Thus pulmonary embolism is an important cause of this arveolocapillary block ultimately leads lo hyponemia (low P02 in the artenal blood) end hypercapnia (excess PC02 In the artenal blood) with their train of aitendent symptoms (see chapter 6 of sec. IV) SUMMARY The transfer of 02 or C02 across the alveolo capillary barrier is governed by the Fick's Law of diffusition of gases across a membrane. The transfer, normally, almost wholly, depends upon the diffusion, biological processes are not involved to any appreciable extent. All conditions ensling between the alveoli and pulmonary capillary favor a diffusion Provisions also exists so that total volume of transfer of gas (TL) can increase sufficiently during exercise in vanous diseases of the lung or heart, the abilrty lo exchange gas deienorales and symptoms develop. The TL value can now be determined in human sublets (halthy and diseased) fig 4.4.3. Illustrating the P02 ai different levels (see also Fig4.4.1) OXYGEN CARRIAGE AND UNLOADING 1 Introduction 2 Oxygen dissociation curve, biological advantages of the aigmoid curve 3. Unloading of 02 in the tissues, coefficient of utilization. 4. Myoglobm 5 A-V 02difference, VQ2 max Introduction In a healthy man, at sea level, the artenal blood contains aboul 19m1 of 02/1O0 ml, of which 0.3 ml is in physical solution and trie rest, i e 18.7 ml is in combination with Hb Therefore, 02 is earned in the blood in two forms; (1)in physical solution, and (ii) as oxyhemagtobin (Hb02) The lension of a gas in blood is produced by only mat portion of gas which is in physical solution it follows that the Hb02 is not directly responsible For the tension produced by 02 (i.e. Pa02) When anenal blood reaches the tissue level, rt is exposed to a Ptissue O2 level which is very low, say <>
FACTORS INFLUENCING VENOUS RETURNS
mm Hg. This equilibrium point is relatively viable For example, let at a given moment. I, the CVP is suddenly raised The first heart beat after the , because of the Frank-Starting mechanism, will have a greater stroke volume But because of this greater stroke volume, translocation of blood from the venous side to the arterial side will be greater and so the CVP will be somewhat lesser in the following beat Therefore, immediately after .the equilibrium point will shift no doubt, but it will try. to return to the original point gradually. Fig. 5.5.5. To show that when cardiac output rises, the rap' falls Fig. 5.5.6. See text FACTORS INFLUENCING VENOUS RETURNS 1. When the cardiac output rises, the velocity of circulation raised which results in greater cardiac inflow (= venous return to the. heart) per unit time Explanation (I) as the cardiac output rises, as explained above, the central venous pressure falls hence pressure in the peripheral veins also falls. (II) as the cardiac output rises, a little extra blood is pushed into the arterial system per beat As the arterial system resists distension even a slight increases in blood volume in it (the arterial system). causes a sharp rise of arterial BP When the above two factors, vast (I) and (ii) are considered together, it becomes obvious that the pressure gradients between the arterial and venous system (= the difference between arterial BP and venous BP) rises. This increase in the pressure radiance results in greater rate of flow of blood from the arterial to the venous side, stated simply this means greater venous return per unit time. 2. The respiratory pump During inspiration, the intrapleural pressure as well as (he intrathoracic pressure as a whole becomes more negative The intra abdominal pressure however rises due to the descent of the diaphragm Because of the increasing negativity, the diameters of the vane cave increase, and the BP within them falls So the pressure radiance (the difference of BP s between the intra abdominal part of the inferior vane cava and The right atrium) increases — flow of blood towards the right atrium increases. Conclusion, therefore, is, more vigorous is the respiration, speedier are the venous returning (cardiac inflow) This suction action of respiration is called the respiratory pump In violent muscular exercise, its effect may be spectacular. 3. The muscle pump When the skeletal muscles contact they exert a squeezing action on the veins Because of the presence of valves in them, when the veins are squeezed, blood moves only towards The heart. Conclusion is. when the skeletal muscles are working hard (e.g. muscular exercise) the venous rectum increases. 4. Gravity On assumption of erect posture. the venous drainage from head and neck is facilitated by gravity where as the same from the inferior extremity is opposed by gravity. 5. Vasomotor tone Veins are supplied by the sympathetic fibers When the sympathetic fibers are stimulated, the vein undergo constriction and The blood within it is driven towards the heart more speedily. Therefore sympathetic, stimulation leads to venison striation and greater cardiac inflow In some organs, veins normally hold great quantities of blood On sympathetic stimulation, the venous blood from these organs are evacuated and Thus the cardiac inflow increases Such organs are called reservoirs of blood ANATOMICAL CONSIDERATIONS AND THE STRUCTURE FUNCTION INTER RELATIONSHIP 1. The Major Division of the Vascular Tree. 2. General Structure of the Vascular Tree. 3. The Individual Segments of the Vascular Tree their functions and structural peculiarities The Vascular tree' begins at the beginning of the aorta. continues at branches of the aorta The branch repeatedly give rise to further branches, which are narrower and narrower and ultimately they become arterioles The areoles eventually open into the capelins. the capillaries into The venues (= very delicate veins) The venues unite with other venues To form veins. the veins unite with other veins and ultimately two great veins, via, the superior and inferior vane cave (singular, vena cava} are formed which open into the right atrium This portion of the vascular tree is called the systemic circuit, and its circulation called greater or systemic Circulation From the right ventricle, arises the main pulmonary artery, which divides into two branches. The right and the left pulmonary arteries, destined to supply the right and the left lung respectively Blood from the two lungs are eventually drained by the four pulmonary veins which open into the left atrium. This portion of The vascular tree is called the pulmonary circuit. and its circulation called, lesser or pulmonary circulation For descriptive purposes end viewed from functional point of view, the vascular tree is usually subdivided into following divisions (segments) or regions (fig. 5.10.4.). 1. Windless vessels', also called elastic arteries. 2. Precapillary resistance vessels' or the arterioles, also called, muscular arteries. 3. precapiltary sphincters .'4. 'Exchange vessels' or capillaries. 5. "Post capillary resistance vessels'chtefly the venues .6. Large veins or the 'capacitance vessels' A term 'microcirculation' is very popular amongst the physiologists and clinicians Micro circulation includes the precapillary sphincter region, capillaries and the smallest venues The name (i.e. 'microcirculation') owes its origin to the fact That they can be seen only under the microscope GENERAL STRUCTURE OF THE VASCULER TREE To start with. a big artery. e.g. the aorta, may be considered Such an artery has three coats, via (I)ton
. SCHIZOID PERSONALITY DISORDER & HSTRIONIC PERSONALITY DISORDER
responsible agents but genetic. constitutional. endocrinal and metabolic dastutbances also contribute to the development of these candhions. In an individual case, one or more of these factors may be of greater importancethen the others. It is the complex interactions of all these varied etiological factors which result in a psychosomatic condition. This view has a very important bearing in the treatment procedures of these diseases. Treatment Careful attention has to be given to the emotional and the psychological factors contributing to these illnesses or better therapeutic results, short term as well as long term In this respectT an internist with good orientation Inthe principles of psychological medicine will prove a better physician tothese sutteters. A psychiatrist would have to be included In the medical team managing these patients Paychiatric treatment of the underlying emotional and personality factors may necessitate the use of psychotropic drugs, psychotherapy, behaviour therapy, biofeadback. etc. Treatment of the organic dysfunction by appropriate mathods should be undertaken concurrently. 5 PERSONALITY DISORDERS Definition: The term personality refers to the unique characteristics of an indvidual which predispose to his typical or recurring patterns of behaviour. The presence of certain personality traits make some individuals more vulnerable to develop behavioural abnormalities when faced with stressful events With this degree of vulnerability, abnormal behaviour occurs only in response to environmental stress. In certain other personalities, unusual behaviour occurs even in the absence of stressful events. The latter group is referred to as personality disorders Central to this concept of personality disorders is the duration of abnormal or unusual behaviour. in question. if a person has behaved normally previously. and then show behavioural abnormalities. he is more likely to have an illness. On the other hand, if his behaviour has always been unusual or abnormal he is said to have a personality disorder. Types of personality disorders: 1 PARANOID PERSONALITY DISORDER - Characteristics are - (a) Pervasive and unwarranted suspicousness and mistrust of others. (b) being 'cold' and humourless. 2. SCHIZOID PERSONALITY DISORDER - The most striking feature is the lack of emotional warmth Indvidual with the disorder appears reserved, detached, introspective and aloof. They do not make intimate friendships and their hobbies and interest do not involve other people HSTRIONIC PERSONALITY DISORDER - A personality that is dramatic and attention-seeking. The interpersonal relationships of people with the disorder are charactaerised by their being vain, egocentric, manipulative, and dependent Such indviduals are viewed by others as being shallow and lacking genuineness. 4. ANTISOCIAL PERSONALITY DISORDER - (a) Presence of antisocial Traits before age of 15 years, e.g. truancy fromschool. delinquency. vagrancy. belligerencyr persistent lying, substance abuse. thefts. chronic violation of rules and repeated sexual intercourse In a casual relationship. (b) Disruption in multiple areas of life such as work, friendship, marriage, finance etc. 5. BORDERLINE PERSONALITY DISORDERS - The long-term functioning of such persons is characterised by preserve of self-damaging impulsivity. unstable interpersonal relationships, undue and inappropriate outbursts of anger, doubts about one's personal identity, variable moods or aftective instability, intoleranca of being left alona, and chronic feelings of emptiness or boredom. 6. SCHlZOTYPICAL PERSONALITY DISORDER - Characteristics include - (a) Magical thinking (superstioness. clairvoyance telepathy. etc.) (b) Social isolation. (c) Referantial thinking in sispiciousness (d)Oddspeech -vague, digressive. overelaborate or metamorphical (e) Recurrent illusions, (f) Undue social anxiety or hypersensitivity to real or imagined critism and (g) being emotionally 'cold' 7. NARCISSISTIC PERSONALITY DISORDER - Grandiose sense of salt importance and preoccupation with fantasies of unlimited success, power or intellectual brillance. They seek attention from others but show few warm Feelings in return These individuate tend to exploit othars for their own salfish needs and seek favours which they do not retum. 8 DEPENDENT PERSONALITY DISORDER - Such persons suffer from lack d self-confidence and passively allow others to assunme responsibillity for major areas of Iife because of their inabillty to functlon Independently Such people appear weak-willed and unduly compliant, falling in passively with the wishes of others. 9. AVOIDANT PERSONALITY DISORDER -Prominent features are - {a) Hypesensitivity to rejaction (b) Unwillingness to enter into Interpersonal relationships (c) Social withdrawal (d) Desire for affection and acceptance and (a) Low self -esteem. 10 COMPULSIVE PERSONALITY DISORDER -Rigid, perfectionstic, unduly conventional. formal. sitngy, undecisive "they show excessive devotion to work to the exclusion of pleasure and the value of interpersonal relationships. 11. PASSIVE-AGGRESSIVE PERSONALLY DISORDER - This term Is applied to those persons, who, when demands are made upon them for adequate performance respond with passive resistance.
The itching is alleviated with drying and anti-pruritic lotions, like calamine loticn with half percant menthol OF phenol.
Infiammation, lesions may contain small vesicles. Pruritus varies from case to case. The lesions disappear in 6-8 weeks.
Management; 1. The itching is alleviated with drying and anti-pruritic lotions, like calamine loticn with half percant menthol of phenol. 2 Antistaminics may ba raquired orally for pruritus 2. Psoriasis Definition; A chronic, recurrent, inflammatory diseaseof the skin of unknown origin, characterized by well-circumscribed erythematous, dry plaques of various sizes, covered with mica-Iike scales. Etiology -(a)Gencetics; (i) Many pts have a fust degree relative with psoriasis, (ii) Siblings, of psoriatic pts have an 8% risk of developing the disease, 16% risk if one parent has psoriasis and 50% if both parents have the disease (b) Environmentl factors - Attacks of psoriasis can be precipitated or aggravated by stress. infection (streplococcal. HIV), pregnancy, trauma. drugs (chloroquine/antimalarials, lithium), alcohol, tobacco smoking, sunlight. Clinical features; Erupiton - (a) Onset and character - The initial lesion e a papula covered with silvery scales. The papuls gradually enlarges penpherally and scales increase to a mass. The removal of the scales exposes pinpoint bieeding points (Auspllz sign). (b) Sites-The lesions occur predominately on the extensors of the extremtias especially the elbows, knees. sacrum and occput, but may occur anywhere on tha body. The lesions are prona to occur at sites of trauma (Koebner phenomenon). MORPHOLOGICAL VARIETIES 1. Chronic stable plaque psoriasis (Psoriasis vulgaris, nummular psoriasis) - is the most common form, Lesions are well defined, with sharply delineated edge, erythematous (salmon pink), coverad with silvery white scales. Discs of varying size on trunk. limbs and scalp. There may be single lesion or multiple lesions. The psoriatic plaque is encircled by a clear peripheral halo.2. Guttate psoriasis - Shower of small, round to oval, monomorphic lesions generally over the body particularly in children and young aduits and usually after acute streptococcal Infection. 3. Rupoid. elephantine psoriasis - Limpet like lesions with cone shaped hyperkeraiosis seen particularly on the feet. Elephanilne psoriasis dascribes the rare but very persistant, thick scaly and large plaques on back, limbs. hips and elsewhere Erythrodemic psoriasis - Types; (a) Chronic psoriasis may evolve gradually into exfoliative phase or occur as initial manifeslation. Almost all cutaneous surfaces are involved. Prognoses good (b) Part of spectrum of unatable psoriasis it can be precipicated by infection. antimalarials, tar. dithranol, corticosteroids and hypocalcemia. There is generalised erythema and profuse scaling. Pt is febrila and relapses are frequent. Pruritus is often severe. Sarlous metabrdlic complications can occur. 5 Pustular psoriasis - Localised (hands and feet) or ganaralised. Tha term is reserved for those forme in which macroscopic pustules appear. 6. Psoriatic arthritis - Association of psoriasis with a peripheral and/or spinal arthropathy involvement of distal interphalangeal joint is typical 7. Penis - The scaly patch on glans penis may lack scales but other characteristics are retained 8. Muosal involvement - is rare and seen more often in pustular and exfollative forms of the disease. Grey, yellow or white, well-demarcated plaques or annular lesions affect buccal mucosa, palate and tongue. Pattern of geographical tongue may also develop. REGIONAL VARIETIES - Certain varieties of psoriasis affect some parts of the body only. 1. Flaxural psoriasis - the interitnginous areas are affected like the axillae, groins, under the breasts, cubtial and popliteal regions. 2. Palmar and plantar psoriasis -involving the palms and soles with hyperkeratotic, scaly patches. 3. Scalp psoriasis -Discrete areas of scaling often thicker than elsewhere. Beneath this scaling, the- scalp has the typical psoriatic red hue. 4 Psoriasis of the nails - is associated with pitting and transverse ridging of the nail plate. There subungual hyperkeratoaes as well as red onycholyais Management Although there are many therapies for the control of psorasis, there is no way to predict or prevent recurrences. GENERAL -(a) Remove trigger factor if possible (b) A warm climate may help to control relapses TOPICAL TREATMENT 3. Lichen Planus Definition: It is an inflammatory disorder of the skin and mucous membranes, of unknown origin, characterzed by violaceous, scaling, angular papules on Ihe flexor surfaces of the skin, and in the mouth, usually resolving in 1 to 2 years; considered to be a cell-mediated autoimmune disorder. Clinical features: Typical striae lesions - Violaceous, flat topped, polyhedral papules wrth a firmly attached scale. Faint streaks on the surface of the lesions can ba seen with a lens (Wickfhams striage) Lesions are produced at sites of traurma (Koebner phenomenon) In the mouth. it appears as spots, streaks, or a lacy network. Sites - usually bilateral and symmetrical: front of the wrists, flexor surface of forearms. shins, lower back and genitalia ara the comnon sites Itching severe at times. Mucous membrane lesions -are present in 65% of patients. These are white reticulate areas seen most commonly on buccal mucosa. palate, or vulva VARIETIES 1 Annular lichen planus -Ringed lesions. 2. Hypertrophic: lichen planus - Thick plaques usually in lower extremities 3. Linear form - along nerve segments 4 Lichen planopilaris - Follicular
Management; 1. The itching is alleviated with drying and anti-pruritic lotions, like calamine loticn with half percant menthol of phenol. 2 Antistaminics may ba raquired orally for pruritus 2. Psoriasis Definition; A chronic, recurrent, inflammatory diseaseof the skin of unknown origin, characterized by well-circumscribed erythematous, dry plaques of various sizes, covered with mica-Iike scales. Etiology -(a)Gencetics; (i) Many pts have a fust degree relative with psoriasis, (ii) Siblings, of psoriatic pts have an 8% risk of developing the disease, 16% risk if one parent has psoriasis and 50% if both parents have the disease (b) Environmentl factors - Attacks of psoriasis can be precipitated or aggravated by stress. infection (streplococcal. HIV), pregnancy, trauma. drugs (chloroquine/antimalarials, lithium), alcohol, tobacco smoking, sunlight. Clinical features; Erupiton - (a) Onset and character - The initial lesion e a papula covered with silvery scales. The papuls gradually enlarges penpherally and scales increase to a mass. The removal of the scales exposes pinpoint bieeding points (Auspllz sign). (b) Sites-The lesions occur predominately on the extensors of the extremtias especially the elbows, knees. sacrum and occput, but may occur anywhere on tha body. The lesions are prona to occur at sites of trauma (Koebner phenomenon). MORPHOLOGICAL VARIETIES 1. Chronic stable plaque psoriasis (Psoriasis vulgaris, nummular psoriasis) - is the most common form, Lesions are well defined, with sharply delineated edge, erythematous (salmon pink), coverad with silvery white scales. Discs of varying size on trunk. limbs and scalp. There may be single lesion or multiple lesions. The psoriatic plaque is encircled by a clear peripheral halo.2. Guttate psoriasis - Shower of small, round to oval, monomorphic lesions generally over the body particularly in children and young aduits and usually after acute streptococcal Infection. 3. Rupoid. elephantine psoriasis - Limpet like lesions with cone shaped hyperkeraiosis seen particularly on the feet. Elephanilne psoriasis dascribes the rare but very persistant, thick scaly and large plaques on back, limbs. hips and elsewhere Erythrodemic psoriasis - Types; (a) Chronic psoriasis may evolve gradually into exfoliative phase or occur as initial manifeslation. Almost all cutaneous surfaces are involved. Prognoses good (b) Part of spectrum of unatable psoriasis it can be precipicated by infection. antimalarials, tar. dithranol, corticosteroids and hypocalcemia. There is generalised erythema and profuse scaling. Pt is febrila and relapses are frequent. Pruritus is often severe. Sarlous metabrdlic complications can occur. 5 Pustular psoriasis - Localised (hands and feet) or ganaralised. Tha term is reserved for those forme in which macroscopic pustules appear. 6. Psoriatic arthritis - Association of psoriasis with a peripheral and/or spinal arthropathy involvement of distal interphalangeal joint is typical 7. Penis - The scaly patch on glans penis may lack scales but other characteristics are retained 8. Muosal involvement - is rare and seen more often in pustular and exfollative forms of the disease. Grey, yellow or white, well-demarcated plaques or annular lesions affect buccal mucosa, palate and tongue. Pattern of geographical tongue may also develop. REGIONAL VARIETIES - Certain varieties of psoriasis affect some parts of the body only. 1. Flaxural psoriasis - the interitnginous areas are affected like the axillae, groins, under the breasts, cubtial and popliteal regions. 2. Palmar and plantar psoriasis -involving the palms and soles with hyperkeratotic, scaly patches. 3. Scalp psoriasis -Discrete areas of scaling often thicker than elsewhere. Beneath this scaling, the- scalp has the typical psoriatic red hue. 4 Psoriasis of the nails - is associated with pitting and transverse ridging of the nail plate. There subungual hyperkeratoaes as well as red onycholyais Management Although there are many therapies for the control of psorasis, there is no way to predict or prevent recurrences. GENERAL -(a) Remove trigger factor if possible (b) A warm climate may help to control relapses TOPICAL TREATMENT 3. Lichen Planus Definition: It is an inflammatory disorder of the skin and mucous membranes, of unknown origin, characterzed by violaceous, scaling, angular papules on Ihe flexor surfaces of the skin, and in the mouth, usually resolving in 1 to 2 years; considered to be a cell-mediated autoimmune disorder. Clinical features: Typical striae lesions - Violaceous, flat topped, polyhedral papules wrth a firmly attached scale. Faint streaks on the surface of the lesions can ba seen with a lens (Wickfhams striage) Lesions are produced at sites of traurma (Koebner phenomenon) In the mouth. it appears as spots, streaks, or a lacy network. Sites - usually bilateral and symmetrical: front of the wrists, flexor surface of forearms. shins, lower back and genitalia ara the comnon sites Itching severe at times. Mucous membrane lesions -are present in 65% of patients. These are white reticulate areas seen most commonly on buccal mucosa. palate, or vulva VARIETIES 1 Annular lichen planus -Ringed lesions. 2. Hypertrophic: lichen planus - Thick plaques usually in lower extremities 3. Linear form - along nerve segments 4 Lichen planopilaris - Follicular
DIFFERENCE BETWEEN ENDOGENOUS AND NEUROTIC DEPRESSION
Recurring episodes of depression only. (The term unipolar mania is not used because nearly all parents who have mania eventually experience a depressive disorder). These two disorders ware earlier referred to as manic depressive disorder. The depressive or manic symptoms should be of atleast 15 days duration. Types of depressive disorders 1. Endogenous depression - is characterised by the classical triad of depressive symptoms, sadness of mood. poverty of ideation and psychomotor retardation. The onset of this type of dapression can occur even in the absence of a significant stressor. 2. Reactive (or neurotic) depression - The onset of this disorder is usually precipitated by an environmental stressor. In addition to the depressive symptoms, concurrent symptoms of anxiety may be present 3. Dysthymic disorder -This type of depression is characterised by chronic depressive signs and symptoms which are not as severe as those in major depressive disorder. Depressive symptoms should be present for atleast two years during which time symptom-free periods, if any, should be less than two months at a time. DIFFERENCE BETWEEN ENDOGENOUS AND NEUROTIC DEPRESSION: Endogenous depression Neurotic depression 1. Significant stress situation preceeding the 1. Significant stress situation preceding 1. Hypomania - Milder form of manic disorder characterised by euphoria and over-estimation of personal abilities and importance. If the symptoms are not disruptive. the patient's work efflciency may be relatively unimpaired and he may be socially acceptable. 2. Dalirious mania -A severe from of mania with concurrent symptoms suggestive of delirium i.e. Clouding of consciousness, disorientation. Illusions, hallucinations. incoherence. This form of mania is usually precipitated by emotional or physical stress and frequently results in daterioration of physical health. 3. chronic mania - Continuous occurrence of manic symptoms in an attenuated form for a prolonged period of time. Prognosis of mood disorders. Suicidal tendencies and attempts are unpredictable, hence caution is always needed while determining the prognosis. 1 Duration of iliness - Shorter duration carries better prognosis. 2. Type of depression - Reactive depression has better long-term prognosis than endogenous depression. 3. Personality - Well adjusted personality carries better prognosis than maladjusted, neurotic (i.e obsessive, inadequate or anxious) personality. 4. Type of onset - Acute onset carries better prognosis than gradual onset. 5. Precipitating factors - Presence of precipitating factors carries better prognosis than absence of precipetating factors. 6. Number of attacks - Repeated episodes could result in chronicity. Management of depressive episodes - 1. Hospitalization - indicated in (a) severe attack of depression, (b) suicidal and homicidal tendencies, and (c) stuporose condition of the patient 2. ECT - About 6 to 8 convulsions spread out over a period of 2 to 3 weeks give excellent results in endogenous depression. (90 to 95% success rate). Indications: (a) Severe attack, (b) Suicidal and homididal tendencies, (c) Stupor and (d) Poor response to the other treatments (e) Patients non-compliant with drug treatment. 3. Drug therapy - (a) antidepressants: I. Anxiety disorder. II. Phobic disorder. III. Obsessive compulsive disorder. IV Hysteria: (a) Conversion disorder (b) Dissociation disorder. V. Somatisation Disorder VI. Psychogenic Pain Disorder VII. Hypochondriasis I. Anxiety disorder Defination: Anxiety disorder is characterised by an anxious and apprehensive overconcern often extending to panic and frequently associated with somatic symptoms EtiologyL: 1. Genetic factors -Roleol genetic factors in anxiety disorder is controversial and higher incidence in relatives of patients with the disorder could be the result of upbringing rather than inheritance 2. (Biochemical and endocrine factors) - In anxious patients there is increased secretion of adrenaline and noradrenaline. Also post-exercise serurn lactate levels are higher in patients with anxiety states than in normal subjects. But these disturbances have been shown to be accompaniments of anxiety rather than its cause. 3. Psycliological theories -regard anxiety to be the result of a failure of an individual to successfully repress unwanted thoughts, ideas, and feelings into the subconscious mind. Anxiety is also regarded as a fear response to another stimulus through the process of conditioning. 4. Age-Although the disorder can occur any age, it is most common in young adults. 5. Sex - Equal incidence in both sexes. 6. Personality - Persons with anxious, dependent and obsessive traits are more likely to suffer from anxiety states. Clinical manifestations: These are broadly grouped into: 1. PHYSICAL - They are referable to autonomic nervous system imbalance and commonly include palpitations, shortness of breath. fremulousness, unsteadiness, dryness of mouth, headache or heaviness of head, giddiness, blurring of vision, frequency of micturition, diarrhoea, and excessive sweating particularly in palms and soles, etc. On examination, one finds tachycardia, elevation of blood pressure, increase in depth and frequency or respiration, exaggerated deep reflexes. 2. PSYCHOLOGICAL - Worries, nervousness, apprehension, irrtability and a morbid fear as if
Subscribe to:
Posts (Atom)