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When she arrived in the morning totally fasted cheap 200mg topamax otc medicine 5113 v, a saliva sample was still Positive for malonic acid derivatives buy topamax cheap online treatment concussion. She had received three crowns (against directions) discount topamax line translational medicine, one bridge 100 mg topamax fast delivery medicine 2632, eight fillings, and two porcelain fillings (against directions). With a bacterial problem like hers, it was ill advised to invite them into a new hiding place under a crown. We explained it was not a moral issue, as she carefully brushed the tiny bit of plastic that was covering her tooth stub. The body would detoxify it to maleic anhydride and then not be able to detoxify it further in the lung. Her mouth looked beautiful again, her tumor was gone (last X-ray not shown), her lungs worked, and her departure date was just days away. And we had learned a mighty les- son: that malonic acid could come not only from tapeworm stages and food, but from a totally unrelated, inanimate sourceplastic. And it was a pre- cious discovery made by electronic testing of dental plastic directly. Would we now be able to clear up the mystery-source of malonates that had plagued us for so long? There were nine hemangioma-like cysts in the liver, which were the cause of her anxiety. She felt the brain tumor was not bothering her, although she had some facial paralysis. Our testing, though, showed there was malignancy (ortho-phospho- tyrosine) in the brain, not in the liver. If it rained and a main water pipe broke, water would be brought in by tankers; this always contained copper and all clinic patients did a hasty exodus to other quarters. Her metal glasses frames needed to be changed to plastic, too, to eliminate copper. Wendy was a forward looking person, though, ever practical; she scheduled it all for re- moval regardless of obstacles. She should eat high fat food, such as avoca- Aug 12 inner white spot with square is dos, butter, and cream. For the first eight days she continued to test Positive for copper and malonic acid. The tumor triglycerides 72 was about half its earlier size of a year cholesterol 232 ago. A liver scan was done, too (not shown), revealing the nine heman- giomasnot tumors. In her haste and anxiety over unfilled teeth, she accepted unsafe plastic dental ma- terial for restorations. Cancer Suzanne Codding was a beautiful twenty month-old girl, but there was quite a lump on the right side of her neck, It might have started with strep throat for which she had been given Augmentin and Amoxicillin (antibiotics). It was surgically removed and clinically tested for everything: malignancy, fungus, and bacteria. It was only six weeks since the surgery and the lump had already returned; in fact, it was 1 x 1 inches in size. Taking the tuberculosis hint, I searched for resonance with my three My- cobacterium slides. Ortho- phospho-tyrosine was Positive, indicating a malignancy, despite the earlier clinical tests. It can be found in the dental area, possibly under tooth fillings or in tooth infections, Of course, Suzanne had neither. Suzannes parents both tested Positive to Mycobacterium phlei, although there was no family dog. Perhaps she had been licked on the face: The parents were ad- vised not to let the child near a dog. They had done everything else, including daily zapping and once-a- week parasite herbs, scaled down to her age. But she was still Positive for copper and malonic acid although they had finished the plumbing job. They had been visiting relatives with her and her milk had been boiled, but no vitamin C had been added (this allows ma- lonic acid to persist). She had picked up some aflatoxin while visiting relatives, but the parents prom- ised to be more watchful. August 12 was their last visit, nothing could be seen or felt at the site of the former tumor. If the six- teen nodules were benign, then surgery to remove the prostate seemed wise to one of his doctors. But if the 16 nodules were malignant, then he was in a late stage of disease, with very little hope and prostate surgery useless. He started the parasite program at home, cor- rected his life style to shut out isopropyl alcohol and zapped a lot. He had successfully stopped his can- cer, but the task was now to shrink his tumors. He had a Staphylococcus infection spreading from his jaw although he wore full dentures. He was started by removing both dentures until they could be tested for malonate and the usual carcinogens. We reassured him that these liver tumors were small by comparison with the usual liver tumors we see. The nodules on the surface of liver and lungs certainly were perplexing; we would just wait and see what happened to them after getting rid of the internal liver tumors. Calcium was too low; implying a toxin in the parathyroids and alk phos was slightly high im- plying tumor activity in his lungs [dye toxicity]. He was given the usual supplements to detoxify malonic acid: B12 (4 mg), folic acid (25 mg twice daily), and vitamin C. He was still very Positive for copper at the parathyroid gland even without wearing his dentures. He simply threw Adam Lar- 8/12 8/19 away his supplements, except the sen list given which had been tested. Two radiologists could find no marbles, plaques, or tumors of any kind on the surface of his liver or rib cage. There were no small marbles inside his liver, either, although fibrous remnants were visible to me. He had tested Negative to copper, isopropyl alcohol, and staphylococcus bacteria in the prostate and had probably been free of them for ten full days in a row. He had two new dentures that tested free of ma- lonates and metals and he was eager to eat his food again, instead of drinking it. Or did luck play a role when no dental problems presented themselves that couldnt be corrected in one minutejust by removing his dentures?
These appears to be highly non-specific because it occurs in sera antibodies may act mimicking the physiologic hormo- from 60% of healthy fertile women and even occurs in nal action or blocking the hormone function depending 40% of male serum samples purchase topamax pills in toronto medicine 0636. Some investigators zona pellucida autoantibodies may be more in the order have described the presence of antibodies directed of 2 generic topamax 200mg amex symptoms endometriosis. However purchase 200mg topamax with amex medications at 8 weeks pregnant, such antibodies have also been detected in patients with iatrogenic ovarian failure (4) buy topamax 200 mg mastercard medicine 524. In experimental animal models, immune conditions varies somewhat between different these antibodies have been able to inhibit the follicular development (15). These patients with normal represent secondary effects of a more global endocrine number of ovarian follicles present gonadotrophin resis- autoimmune dysfunction. Autoimmune Ovarian Failure 279 and it has been suggested that estrogen may modulate the interfering with zona pellucida antigens, thereby disrup- T-cell activation arguing that T-cell activation observed in ting ovulation and/or fertilization (4). Furthermore, hormonal repla- include those methods that target zona pellucida; thus, cement therapy may decrease the number of activated immunization with heterologous zona pellucida antigens T cells (16). The T-killer cells are also diminished in number results in autoimmune oophoritis characterized by follicle and function as monocytes are (16). An inflammatory oophoritis such as that observed following immunization with ovarian homogenate, however, does not occur (18). The inflammation and other; they also determined different type of T cells subsides after 14 weeks, and the ovaries become atrophic. They also included two control This type of experimental oophoritis in mice is similar to groups. The authors concluded that subclinical ovarian failure is not an Conclusion autoimmune alteration. Serum ovarian present a greater incidence of type I diabetes and myasthe- antibodies appear after 28 days and may passively transfer nia gravis than general population. A novel autoantigen in patients with premature ovarian fail- J Clin Endocrinol Metab 1991; 73: 3607. Silva, Eduardo Ferreira Borba, Marcello Cocuzza, Jozelio Freire de Carvalho and Elosa Bonfa Abstract Testicular autoimmune disease may be primary or secondary. The former is characterized by an isolated infertility and autoantibodies directed to sperm, basement membrane, or seminiferous tubules without evidence of a systemic autoimmune disease. The pathogenesis of primary or secondary autoimmune orchitis is unknown and probably involves the access of the immune system to the testis due to inflammation, infection, or trauma in response to antigens or microorganism. Corticosteroids and immunosuppressive drugs are indicated in autoimmune orchitis associated active systemic autoimmune diseases. Keywords Autoimmune orchitis gonad sperm antisperm antibodies sexually transmitted diseases, for example, gonorrhea and Introduction Chlamydia trachomatis (2). Acute clinical orchitis was observed in to the causal agent such as infections (bacterial/viral) or 431% of Behc ets disease patients (8) and in 79% of traumatic events such as testicular torsion. Frequency of clinical orchitis in autoimmune sperm motility affecting acrosome reaction, cervical mucus diseases. Rheumatoid arthritis 1 case Systemic lupus erythematosus 1 case Dermatomyositis 1 case Diagnostic Criteria (Table 53. Documented orchitis cases due to autoim- Autoimmune orchitis is defined as autoimmune aggression mune diseases are illustrated in Table 53. The term infertility is used to describe the situa- downregulate occludin expression in Sertoli cells (12) with tion where a couple does not succeed in achieving a spon- a consequent disassembly of its tight junctions. They can be found in difficult to distinguish from those of other acute scrotal seminal fluid and plasma in men, in addition to cervical processes, mainly acute testicular torsion. We have ultrasound, color Doppler sonography, duplex sonogra- recently performed a global evaluation of gonadal func- phy, and magnetic resonance imaging. Surgical complications of testicular biopsies are rare as minimal hematomas or infections are detected in <2% of cases. At least 50% of the motile spermatozoa must be coated Symptomatic patients should receive analgesic treatment with immunobeads in order to validate the clinical sig- associated with local cooling, scrotal elevation, and bed nificance of test. Local anesthesia by a nerve block using 5 ml of 1% <10% bead attachment and positive control a score lidocaine around spermatic vessels may be necessary for >20% bead attachment (16). Corticosteroids and immunosup- pressive drugs are drugs of choice in secondary autoimmune The histopathology evolution of orchitis can be learned orchitis with testicular vasculitis (10). The impact of stages by peritubular and/or interstitial mixed cellular untreated testicular vasculitis on fertility is not well-known infiltrates. Studies fol- the critical pathway that targets the spermatogenic germ lowing different protocols report pregnancy rates of cells for autoimmune attack (17). How- On the contrary, in all autoimmune diseases, the under- lying pathological condition in testis is a severe vasculitis ever, a meta-analysis showed no significant improvement leading to inflammation and infarction of affected tissue. Diagnosis and treat- ment of immunologically infertile males with antisperm anti- 1. Gonad evaluation in male systemic lupus erythemato- Cambridge University Press; 2000: 186. Isolated polyarteritis nodosa of the Examination of Human Semen and Sperm-Cervical Mucus the male reproductive system. Renal involvement in SchonleinHenoch purpura: Comparison of prednisolone and placebo in subfertile men with A multivariate analysis of initial prognostic factors. A case of testicular injection for treating infertility associated with sperm auto- lupus. Keywords: Antinuclear antibodies smooth muscle antibodies interface hepatitis cirrhosis overlap syndromes immunosuppression. The disease has a progressive million of inhabitants in Caucasian population of devel- course to cirrhosis without treatment. It is considered to be oped countries, similar to the prevalence of other auto- an autoimmune disease because of its common association immune liver diseases, such as primary biliary cirrhosis. History Waldenstrom (1) gave the first description of autoimmune hepatitis in young women in 1950. Infectious hepatitis was introduced in 1993 by the International Auto- agents, such as viral agents, and other environmental trig- immune Hepatitis Group, which defined the diagnostic cri- gers and host factors (genetic susceptibility) play a role in teria (4). Serum alkaline phosphatase level is frequently increased, but usually below two-fold In more than one third of cases the disease has an acute normal. A value above three-fold normal is unusual and onset, mimicking an acute viral hepatitis, because of the suggests an overlap syndrome with primary biliary cir- presence of jaundice and a rise of serum transaminases rhosis (8). Differential diagnosis with the causes of acute hepatitis should be done in these cases (Table 54. A minority of cases with acute clinical presentation develop a fulminant hepatic failure, which may lead to Serological Features death if a liver transplantation is not urgently carried out. They are or by anorexia, pain in the right upper quadrant of the directed against structural components of the cell abdomen and easy fatigability. Peri- Male 0 portal hepatocytes may be organized forming rosettes Ratio of elevation of surrounded by lymphocytes and plasma cells. Such infiltrate patients should receive treatment for each one of their None of the above 3 diseases, steroids and ursodeoxycholic acid.
Not only that discount topamax 200 mg without prescription symptoms influenza, most are too small and not calcified 100mg topamax free shipping symptoms at 4 weeks pregnant, a prerequi- site for visibility on X-ray buy cheap topamax 100mg symptoms genital herpes. There are over half a dozen varieties of gallstones generic 100 mg topamax free shipping medications used for fibromyalgia, most of which have cholesterol crystals in them. Other stones are compos- itesmade of many smaller onesshowing that they regrouped in the bile ducts some time after the last cleanse. At the very center of each stone is found a clump of bacte- ria, according to scientists, suggesting that a dead bit of parasite might have started the stone forming. As the stones grow and become more numerous the back pressure on the liver causes it to make less bile. With gallstones, much less cholesterol leaves the body, and cholesterol levels may rise. In this way nests of infection are formed, forever supplying the body with fresh bacteria and parasite stages. No stomach infection such as ulcers or intestinal bloating can be cured permanently without removing these gallstones from the liver. For best results, ozonate the olive oil in this recipe to kill any parasite stages or viruses that may be released during the cleanse. Zap daily the week before, or complete the parasite killing program before attempting a liver cleanse. You want your kidneys, bladder and urinary tract in top working condition so they can efficiently remove any undesirable substances inci- dentally absorbed from the intestine as the bile is being excreted. Ingredients Epsom salts 4 tablespoons Olive oil half cup (light olive oil is easier to get down), and for best results, ozonate it for 20 minutes. Pint jar with lid Black Walnut Tincture, any 10 to 20 drops, to kill parasites strength. Choose a day like Saturday for the cleanse, since you will be able to rest the next day. Take no medicines, vitamins or pills that you can do with- out; they could prevent success. Eat a no-fat breakfast and lunch such as cooked cereal, fruit, fruit juice, bread and preserves or honey (no butter or milk). Wash grapefruit twice in hot water and dry; squeeze by hand into the measuring cup. Close the jar tightly with the lid and shake hard until watery (only fresh grapefruit juice does this). Take 4 orni- thine capsules with the first sips to make sure you will sleep through the night. You may use oil and vinegar salad dressing, or straight honey to chase it down between sips. Get it down within 5 minutes (fifteen min- utes for very elderly or weak persons). As soon as the drink is down walk to your bed and lie down flat on your back with your head up high on the pillow. If you have indigestion or nausea wait until it is gone before drinking the Epsom salts. Look for the green kind since this is proof that they are genuine gallstones, not food residue. You will need to total 2000 stones before the liver is clean enough to rid you of allergies or bursitis or up- per back pains permanently. The first cleanse may rid you of them for a few days, but as the stones from the rear travel for- ward, they give you the same symptoms again. Sometimes the bile ducts are full of cholesterol crystals that did not form into round stones. My opinion is based on over 500 cases, including many persons in their sev- enties and eighties. However it can make you feel quite ill for one or two days afterwards, although in every one of these cases the maintenance parasite program had been neglected. I like to think I have perfected this recipe, but I certainly can not take credit for its origin. It is easy to understand why this is thought: by the time you have acute pain attacks, some stones are in the gallbladder, are big enough and sufficiently calcified to see on X-ray, and have caused in- flammation there. When the gallbladder is removed the acute attacks are gone, but the bursitis and other pains and digestive problems remain. People who have had their gall- bladder surgically removed still get plenty of green, bile-coated stones, and anyone who cares to dissect their stones can see that the concentric circles and crystals of cholesterol match textbook pictures of gallstones exactly. Freon Removal Program Freon accumulates in the diaphragm and skin in healthy per- sons. Amino Acid Mixture Essential Amino Acids Non-essential Amino Acids 1 part isoleucine 1 part glycine 1 part leucine 1 part taurine 1 part lysine 1 part glutamic acid 1 part valine 1 part alanine 1 part methionine part aspartic acid part phenyl alanine part ornithine part threonine part proline part tyrosine part serine part cysteine 1 /3 part arginine 1 /3 part histidine Note that tryptophane is missing in the recipe. It is assumed that you will be taking much larger amounts of these, separately, and thus avoid crowding out the remainder in this combination recipe. Mix them all together (or as many as you can find) and take them in teaspoon amounts with meals or as described in the 21 Day Program. Their outside surface has receptor sites that must be able to see and feel enemies of your body. The drug Levamisole (available in Mexico) can do this (50 mg, take 3 a day), but here is an over the counter recipe that works also. For convenience, you can mix larger quantities of the dry ingredients ahead of time (this reduces the odor). But ferritin will re- turn to coat your white blood cells if you continue your expo- sure to asbestos. The powdered hydrangea is a source of organic germanium to replace that lost by oxidation. In advanced cancer use bromelain plus papain plus Levami- sole for two weeks, before reducing dosage. Such water is safer than the regular water for injection since water for injection often has antiseptic contamination. All quantities can be approximated, since the final concentration should be one part per million but need not be exact. For abdominal application, it should be thick when folded and measure about 10 inches wide by 14 inches long. You may clean your abdomen afterwards, by using one quart of water mixed with 4 tbs. Immediately tape over with masking tape or cellophane tape to make a tight seal to skin.
Characteristically discount 200 mg topamax otc medications 7, fbrinoid necrosis of the internal and external elastic lamina leads 2 100mg topamax mastercard medicine wheel. Takayasus arteritis (pulseless disease) represents an idiopathic granulomatous giant cell arteritis purchase topamax american express medicine in ancient egypt, primar- ily afecting the aorta and its major branches buy topamax 200mg lowest price treatment 7 february. Difuse dilations ies are afected (hence, the name), although occipital or and aneurysms are not uncommon (Kelley 2004). Temporal arteritis may be diagnosed by Doppler ultrasonography, which can depict both the vessel lu- 2. The vessel wall edema may be Wegeners Granulomatosis visualized by ultrasound as a characteristic and highly sensitive concentric hypoechogenic mural thickening This chronic systemic arteritis involves lungs, kidneys, (halo sign). In such cases, intracerebral and meningeal ne- particular, vessel wall changes, which are mural thicken- crotizing granulomas or vasculitis may occur. A 61-year-old woman presenting with hemiparesis of the right side and psy- chosis. The psychotic symptoms disappeared subsequent to the administration of high-dose steroids. A Multifocal patchy signal changes in the subcortical and deep 61-year-old woman presenting with hemiparesis of the right white matter of both hemispheres (a,b). The psychotic symptoms disappeared sub- zone infarction in the lef corona radiata (c). Contrast enhancement may be attributed to matosis is exceptional; however, involvement of the dura leakage in active lesions. Accord- deposition in the skin, blood vessels, and other organs ingly, water difusion may be either restricted in early leads to abnormal tissue fbrosis and microvascular im- stages of ischemia (cytotoxic edema) or increased in pairment. Multifocal patchy white matter hyperintensities in the 21-year-old woman with renal and cerebral afection. Petechial rhage (b, arrows) hemorrhages in the frontal and parietal cerebral cortex (a, ar- a b Fig. Note the enlarged ventricles as a result of white matter re- a Axial T1-weighted image. Microaneurysm of a leptomeningeal vessel 32-year-old woman with linear scleroderma en coup de sa- (b1b3) with hyperintensity of the inner layer of the vessel wall bre. Detail images of axial T1- structure on non-enhanced T1-weighted images (b2, arrow). Right frontal (a) and exhibit severe contrast enhancement (b3) lef temporopolar (b1) cortical and subcortical white matter 2. Since the age of 16 she has been sufering from sicca symptoms and hypothalamic dysfunction, the latter resulting in narcolepsy as well as postural and gait instability. Bilateral hyperintensities of the basal ganglia, predominantly of the lef thalamus (a). The basal ganglia hyperintensities were visible prior to contrast application as well (not shown). Firstly, purulent in- most commonly involved, ofen leading to hemorrhages fection at the base of the brain may lead to infamma- (Fig. Additionally, vessel wall damage may be aggravated by the activated im- mune response (such as cellular adhesion molecules, 2. Late complications might be septic thrombo- sis and thrombophlebitis (Younger 2004). Treponema pallidum-associated cerebral vasculitis is In tuberculosis, infammation of the adventitia of caused by spirochetal invasion of the endothelial cells small- and medium-sized arteries triggers prolifera- in the tertiary parenchymal syphilis syndrome. A 56-year-old woman with d Sagittal T1-weighted image afer contrast administration. Lef vasculitis involves preferably cortical arteries and veins, phetamines, cocaine, heroin etc. Borrelia burgdorferi-associated cerebral vasculitis is believed to result from focal mononuclear infamma- 2. The endothelial cell Differential Diagnoses of Cerebral swelling may lead to stroke-like lesions as well as suba- Vasculitides rachnoid hemorrhage (Fig. Atherosclerotic plaques preferen- cerebral vasculitis is infuenced by the duration and tially afect the branching points of large vessels (which degree of exposure, route of administration, immune is unusual for vasculitis). In particular, ally involve smaller branches, and are more likely asso- drugs with sympathomimetic amine-type activity (am- ciated with haemorrhage. Severe irregular cor- onstrated hydrocephalus (a) as well as cortical hyperdensities tical, subcortical, and even meningeal contrast enhancement and white matter hypodensities (b). Alternating areas of vessel constriction and dilation of the farctions and hemorrhages (cg). Focal area of restricted water anterior and middle cerebral artery, exhibiting sausage-string difusion in the subcortical white matter of the lef hemisphere appearance (h,i, arrows: microaneurysms) (c). Attacks of vasospasm occur most ofen few days afer subarachnoid haemorrhage, but may also be induced by sympathomimetic drugs (e. Most lesions are located in the periventricular normal lenticulostriate and thalamostriate collaterals white matter. Marked defect of the lef lentiform nucleus with aches, and recurring cramps in the right hand. Additionally, the pituitary gland is enlarged and demon- an with chronic cocaine abuse. Chronic damage due to vascul- afected regions are the superior frontal white matter opathy may be severe and include complete vessel oblit- and the external capsules leading to difuse white matter eration, leukomalacia, calcifying microangiopathy, and hyperintensities in the course of the disease (leukoen- brain atrophy. Cerebral autosomal-dominant arteriopathy cortical hyperintensities of the anterior temporal poles. Neurol Sci 26 studies in the diagnosis and follow-up of large-vessel vas- (Suppl 1):S9S14 culitis: an update. Rheumatology (Oxford) 47:403408 Ertl-Wagner B (2007) Pdiatrische Neuroradiologie. The spectrum of patho- Diagnostic Procedures 54 gens difers considerably depending on the route 3. References 70 Magnetic resonance imaging is the imaging pro- cedure of choice, not only in the primary diagno- sis, but also in planning surgical or stereotactic procedures, and in the follow-up of patients with pyogenic brain infections. The main diferential diagnoses of cerebritis include arterial or venous infarction, and non-pyogenic infammations. Abscesses have to be discriminated from autochthonous and metastatic brain tumors. Multiple infratentorial abscesses with ringlike enhance- ment (c) and perifocal edema (a,b). Huber- c Hartmann) Pyogenic Cerebritis and Brain Abscess 53 the frontal, parietal, and temporal lobes, and in the cer- 3. In the literal sense the terms cerebritis (from Latin: cerebrum) and encephalitis (from Greek: encephalon) mean exactly the same, that is, an infammation of the 3.
Comorbidities The presence of other diseases often increases risk for malnutrition buy generic topamax on-line symptoms 0f pregnancy. Some diseases have symptoms that may appear similar to those resulting from nutritional deficiencies discount topamax 100 mg free shipping symptoms bowel obstruction. Biotin and riboflavin deficiencies include scaly discount topamax denivit intensive treatment, red rashes on the face and around orifices generic topamax 100 mg without a prescription medicine guide, which should be not be confused with the facial rash often found on patients with systemic lupus erythematosus. But dietary assessment is difficult and must be done carefully to distinguish under- or malnutrition owing to diet alone (a primary deficiency) from that resulting from other causes (secondary deficiency) (20). Primary deficiency results from inadequate intake, which may be influenced by socioeconomic status and conditions such as alcohol abuse or eating disorders. Secondary nutrient deficiencies result from increased physiological needs, increased nutrient losses in feces and urine, and other causes. In planning interventions it may also be helpful to know about shopping and cooking habits and the frequency of meals consumed away from the home (5). Medications and dietary supplement intakes are important to consider when assessing dietary intake. Some medications provide nutrients, such as antacids containing relatively large amounts of calcium. There may be sources of amino acids, sugar, and vitamins and minerals in other medications as well. Dietary supplement intake of vitamins and minerals and other nutrients should also be included in assessing nutrient intakes. The use of other supplements, especially botanicals, may be helpful in assessing interactions with medications. The individual (or if a child is the patient, the parent or caretaker) is asked about intake over the last 24 hours. Probing is usually done to help the individual remember foods or beverages he or she may have forgotten. Memory aids and tools are used to promote an accurate estimation of portion sizes, including measuring cups and spoons, photographs of food in a known portion size, and food models. The individual should not be led to an assumed or socially acceptable answer; instead, open-ended questions should be asked. Computerized dietary assessment programs are now available for research purposes with a multiple-pass interview style that decreases underreporting (21). In the first pass, the individual recalls food and beverage intake for the designated time period. Finally, in the fourth and final pass, the interviewer questions the consumption of supplements and medications that contain nutrients. The disadvantages include the reliance on memory, thus making it inappropriate for individuals with a poor memory, and the fact that some foods may be forgotten or purposefully omitted (5,21). Because a computerized dietary assessment program is not used, it is also difficult to calculate nutrient intakes. Some simply present a list of common foods and ask the respondent to recall consumption of the food over the past year. This permits a rough estimate of nutrient intake, which may be useful in epidemiological studies in particular. Without adjustments for caloric intakes, intakes are usually grossly overestimated. There may also be biases with underreporting of socially unacceptable items or behaviors such as high-fat foods, alcohol, and so on. Food Records Food records are another method of collecting dietary intake for nutrient analysis. The individual records the brand names, cooking method, and ingredients of mixed dishes in household measurements (21). Forgetting to record intake and inaccurate estimation of volume and weights of foods and beverages are disadvantages to this method (5,21). Environmental assessment includes the identification of physical and social influences on intake. Influences in the Physical Environment on Intake Conditions within the household, access to food shopping and cooking facilities, and other factors may greatly influence intake. For those who have difficulties ambulating, the use of assistive devices should be queried because they can make the process of food preparation much easier. It may also be useful to identify the number of people in the home (5), the person responsible for purchasing and cooking food, and whether there are facilities to store and cook foods properly during periods of illness when the person may be shut in the house (5,22). Other factors to determine include whether a car is available and how far it is to the grocery or convenience store, avail- ability of foods at nearby stores, and the patients ability to commute to and transport food from the store to the home (5). An environment that promotes physical activity also contributes to nutritional status. If necessary, efforts should be made to assist a patient with applications for food assistance programs (e. Family support and frequency of communication and activity with family and friends also need to be assessed because they too can influence dietary intake (18). In scleroderma, the mouth may become small, making it difficult for patients to feed themselves and consume adequate nutrients. Generic Quality-of-Life Indicators Evaluation of quality of life includes assessing physical ability and functional activity as well as the health-related emotional and social implications. Quality-of-life questionnaires are also available specifically for pediatric or adolescent patients. The most common measures include the Childhood Health Questionnaire, Pediatric Quality of Life Inventory Scales, and Quality of My Life Questionnaire (29). Arthritis-Specic Quality of Life Disease-specific quality-of-life questionnaires have been designed for many rheumatoid diseases. Table 1 lists the disease-specific quality-of-life measures for arthritis and related diseases. They are particularly useful because they provide specific information that is directly related to the disease. Indicators of malnutrition also include rheumatoid cachexia, which involves muscle wasting that is often replaced with fat (30). Even with good disease control and adequate caloric intake, skeletal muscle catabolism persists (31,32). Assessment of caloric and protein intake is important because inadequate intakes will further accelerate muscle loss. Muscle wasting also affects functional status and mobility, which may impair food shopping, meal preparation, and cleanup. As a result of the chronic inflammation, anemia of chronic disease is often present (10,11,34). Medication-related effects on biochemical indices of folic acid and iron status are also common. Some medications such as methotrexate also affect calcium and vitamin D status (1719). Dietary and functional assessments should include attention to energy intake and problems related to obtaining, preparing, and eating food. Patients with social support may have a better quality of life, potentially moderating the impact of pain, depression, and physical disability (33).
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