FriEndszzz....

A friend is someone...

who we can hold on to...

who we can care for...

who we can cry for...

who we can hope for...

someone,

who we can turn to in the moment of tears

and laughter..

someone,

who will take our whole life to forget...

and someone who will never be replace...

WRITING

Students sometimes have problem in decided which university they want to apply to. Suggest 3 factors that students should consider when applying to university. You may include some of following expect, courses offered and facility.



Nowadays, universities would be the first one among the students to apply to. But sometimes, students are having problem in deciding which universities they want to join. These difficulties are based on the courses offered, facilities and also the fees. Courses offered by the choosen universities is one of the criteria when applying to enroll in that particular universities. Today, many factors happened to students when applying the universities.



Firstly, one of the factor is influence by their friends. This is because they feel not confident and confused with themselves. So, that is why they just follow their friend’s suggestion without thinking which is the course they loved the most. Furthermore, they also do not know what is the correct course that suitable for them. Sometimes, parents also inforce their child to study at universities that they already choose eventhough their child unwilling to study there.



Secondly, the other factors are the facilities of universities that they want to apply. For instance an environment of universities, an accommodation, transportation and others. For an environment, sometimes the location of universities is not suitable for them to study there. It is because, there is a lot of forests and far away from the cities. In addition, their accommodation is far from the campus and cause they have to find the others transport like bus,cab,car or motorcycle to go to the campus.



Thirdly of the factors are the fees for their course. They interested with some course but the problems are having financial problem. Then, they have to find the money with their way to pay for the fees. For example they have to do part time at KFC, MC’Donald, cashier at supermarket or others. So that, it is difficult for them to choose which is the best universities for them. Beside that, they also lack of knowledge when they are choosing the course because of no clear information from the people who are graduate and had experienced. Sometimes, they never ask people or get to know the universities because they assume what they choose is the best for themselves.



In summarize, there are many problem in deciding which university they want to apply such as courses offered, facilities, influence by friends and the fees. As a student, they must choose the best university for their future by asking people who are advanced or they also can search through internet for clear information regarding their courses and get the best choice for their future.

CANDIDIASIS

Candidiasis or thrush is a fungal infection (mycosis) of any of the Candida species (all yeasts), of which Candida albicans is the most common.[1][2] Also commonly referred to as a yeast infection, candidiasis is also technically known as candidosis, moniliasis, and oidiomycosis.[3]:308










Candidiasis encompasses infections that range from superficial, such as oral thrush and vaginitis, to systemic and potentially life-threatening diseases. Candida infections of the latter category are also referred to as candidemia and are usually confined to severely immunocompromised persons, such as cancer, transplant, and AIDS patients.







Superficial infections of skin and mucosal membranes by Candida causing local inflammation and discomfort are common in many human populations.[2][4][5] While clearly attributable to the presence of the opportunistic pathogens of the genus Candida, candidiasis describes a number of different disease syndromes that often differ in their causes and outcomes.[2][4]



Contents

Signs and symptoms









Most candidial infections are treatable and result in minimal complications such as redness, itching and discomfort, though complication may be severe or fatal if left untreated in certain populations. In immunocompetent persons, candidiasis is usually a very localized infection of the skin or mucosal membranes, including the oral cavity (thrush), the pharynx or esophagus, the gastrointestinal tract, the urinary bladder, or the genitalia (vagina, penis).[1]







Candidiasis is a very common cause of vaginal irritation, or vaginitis, and can also occur on the male genitals. In immunocompromised patients, Candida infections can affect the esophagus with the potential of becoming systemic, causing a much more serious condition, a fungemia called candidemia.[4][5]







Children, mostly between the ages of three and nine years of age, can be affected by chronic mouth yeast infections, normally seen around the mouth as white patches. However, this is not a common condition.[citation needed]







Symptoms of candidiasis may vary depending on the area affected. Infection of the vagina or vulva may cause severe itching, burning, soreness, irritation, and a whitish or whitish-gray cottage cheese-like discharge, often with a curd-like appearance. These symptoms are also present in the more common bacterial vaginosis.[citation needed] In a 2002 study published in the Journal of Obstetrics and Gynecology, only 33 percent of women who were self-treating for a yeast infection actually had a yeast infection, while most had either bacterial vaginosis or a mixed-type infection.[6] Symptoms of infection of the male genitalia include red patchy sores near the head of the penis or on the foreskin, severe itching, or a burning sensation. Candidiasis of the penis can also have a white discharge, although uncommon.[citation needed] However, having no symptoms at all is common, and a more severe form of the symptoms may emerge later.[citation needed]



[edit] Causes



See also: Candida albicans







Candida yeasts are commonly present in humans, and their growth is normally limited by the human immune system and by other microorganisms, such as bacteria occupying the same locations (niches) in the human body.[7]







In a study of 1009 women in New Zealand, C. albicans was isolated from the vaginas of 19% of apparently healthy women, i.e., those that experienced few or no symptoms of infection. External use of detergents or douches or internal disturbances (hormonal or physiological) can perturb the normal vaginal flora, consisting of lactic acid bacteria, such as lactobacilli, and result in an overgrowth of Candida cells causing symptoms of infection, such as local inflammation.[8] Pregnancy and the use of oral contraceptives have been reported as risk factors,[9] while the roles of engaging in vaginal sex immediately and without cleansing after anal sex and using lubricants containing glycerin remain controversial.[citation needed] Diabetes mellitus and the use of anti-bacterial antibiotics are also linked to an increased incidence of yeast infections.[9] Diet has been found to affect rates of symptomatic Candidiases in some animal infection models,[10] and hormone replacement therapy and infertility treatments may also be predisposing factors.[11] Wearing wet swimwear for long periods of time is also believed to be a risk factor.[12]







A weakened or undeveloped immune system or metabolic illnesses such as diabetes are significant predisposing factors of candidiasis.[13] Diseases or conditions linked to candidiasis include HIV/AIDS, mononucleosis, cancer treatments, steroids, stress, and nutrient deficiency. Almost 15% of people with weakened immune systems develop a systemic illness caused by Candida species.[citation needed] In extreme cases, these superficial infections of the skin or mucous membranes may enter into the bloodstream and cause systemic Candida infections.







In penile candidiasis, the causes include sexual intercourse with an infected individual, low immunity, antibiotics, and diabetes. Male genital yeast infection is less common, and incidence of infection is only a fraction of that in women; however, yeast infection on the penis from direct contact via sexual intercourse with an infected partner is not uncommon.[14]







Candida species are frequently part of the human body's normal oral and intestinal flora. Treatment with antibiotics can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition[citation needed].



[edit] Diagnosis



Micrograph of esophageal candidiasis. Biopsy specimen; PAS stain.







Diagnosis of a yeast infection is done either via microscopic examination or culturing.







For identification by light microscopy, a scraping or swab of the affected area is placed on a microscope slide. A single drop of 10% potassium hydroxide (KOH) solution is then added to the specimen. The KOH dissolves the skin cells but leaves the Candida cells intact, permitting visualization of pseudohyphae and budding yeast cells typical of many Candida species.







For the culturing method, a sterile swab is rubbed on the infected skin surface. The swab is then streaked on a culture medium. The culture is incubated at 37 °C for several days, to allow development of yeast or bacterial colonies. The characteristics (such as morphology and colour) of the colonies may allow initial diagnosis of the organism that is causing disease symptoms.



[edit] Treatment







In clinical settings, candidiasis is commonly treated with antimycotics—the antifungal drugs commonly used to treat candidiasis are topical clotrimazole, topical nystatin, fluconazole, and topical ketoconazole.







For example, a one-time dose of fluconazole (as Diflucan 150-mg tablet taken orally) has been reported as being 90% effective in treating a vaginal yeast infection.[15] (Care should be taken by people who have allergic reactions to azole group of medicines; this medicine has different levels of contradictory reactions with other medicines as well. ) This dose is only effective for vaginal yeast infections, and other types of yeast infections may require different treatments. In severe infections (generally in hospitalized patients), amphotericin B, caspofungin, or voriconazole may be used. Local treatment may include vaginal suppositories or medicated douches. Gentian violet can be used for breastfeeding thrush, but when used in large quantities it can cause mouth and throat ulcerations in nursing babies, and has been linked to mouth cancer in humans and to cancer in the digestive tract of other animals.[16]







C. albicans can develop resistance to antimycotic drugs,[17] such as fluconazole, one of the drugs that is often used to treat candidiasis. Recurring infections may be treatable with other anti-fungal drugs, but resistance to these alternative agents may also develop.

[hide]

CATARACT

Cataract is a clouding that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight to complete opacity and obstructing the passage of light. Early in the development of age-related cataract the power of the lens may be increased, causing near-sightedness (myopia), and the gradual yellowing and opacification of the lens may reduce the perception of blue colours. Cataracts typically progress slowly to cause vision loss and are potentially blinding if untreated. The condition usually affects both the eyes, but almost always one eye is affected earlier than the other.[1]



A senile cataract, occurring in the elderly, is characterized by an initial opacity in the lens, subsequent swelling of the lens and final shrinkage with complete loss of transparency.[2] Moreover, with time the cataract cortex liquefies to form a milky white fluid in a Morgagnian cataract, which can cause severe inflammation if the lens capsule ruptures and leaks. Untreated, the cataract can cause phacomorphic glaucoma. Very advanced cataracts with weak zonules are liable to dislocation anteriorly or posteriorly. Such spontaneous posterior dislocations (akin to the historical surgical procedure of couching) in ancient times were regarded as a blessing from the heavens, because some perception of light was restored in the cataractous patients.


Cataract derives from the Latin cataracta meaning "waterfall" and the Greek kataraktes and katarrhaktes, from katarassein meaning "to dash down" (kata-, "down"; arassein, "to strike, dash").[3] As rapidly running water turns white, the term may later have been used metaphorically to describe the similar appearance of mature ocular opacities. In Latin, cataracta had the alternate meaning "portcullis",[4] so it is also possible that the name came about through the sense of "obstruction". Early Persian physicians called the term nazul-i-ah, or "descent of the water"—vulgarised into waterfall disease or cataract—believing such blindness to be caused by an outpouring of corrupt humour into the eye.[5] In dialect English a cataract is called a pearl, as in "pearl eye" and "pearl-eyed".[6]



Classification


Bilateral cataracts in an infant due to Congenital rubella syndrome


The following is a classification of the various types of cataracts. This is not comprehensive and other unusual types may be noted.


* Classified by etiology


* Age-related cataract


* Cortical Senile Cataract


* Immature senile cataract (IMSC): partially opaque lens, disc view hazy



* Mature senile cataract (MSC): Completely opaque lens, no disc view



* Hypermature senile cataract (HMSC): Liquefied cortical matter: Morgagnian cataract


* Senile Nuclear Cataract


* Cataracta brunescens



* cataracta nigra



* cataracta rubra



* Congenital cataract



* Sutural cataract



* Lamellar cataract



* Zonular cataract



* Total cataract


* Secondary cataract


Slit lamp photo of anterior capsular opacification visible a few months after implantation of Intraocular lens in eye, magnified view


* Drug-induced cataract (e.g. corticosteroids)


* Traumatic cataract


* Blunt trauma (capsule usually intact)



* Penetrating trauma (capsular rupture & leakage of lens material—calls for an emergency surgery for extraction of lens and leaked material to minimize further damage)


* Classified by opacities, cataract can be classified by using Lens Opacities Classification System III (LOCS III: Nuclear NC1-5, Cortical C1-5 and Posterior P1-5. By application planning in procedures of phacoemulsification, LCOS III can be converted in newer cataract grading system. Gede Pardianto (2009) introduced Optical Biometry Based Cataract Grading System (OBBCGS) that so helpful in cataract grading due to phacoemulsification planning. LOCS III's NC0, C0 and P0 acan be converted as OBBCGS' No cataract (NC), LOCS III's NC1-3, C1-3, P1-4 can be converted to OBBCGS' Optical Biometry Examined Cataract (OBEC) and LOCS III's NC4-5, C4-5, P4-5 can be converted to OBBCGS's Optical Biometry Un-examined Cataract (OBUC); that need examination by Applanation Ultrasound Biometry.[19]



* Classified by location of opacity within lens structure (However, mixed morphology is quite commonly seen, e.g. PSC with nuclear changes & cortical spokes of cataract)


* Anterior cortical cataract



* Anterior polar cataract



* Anterior subcapsular cataract



Slit lamp photo of posterior capsular opacification visible a few months after implantation of Intraocular lens in eye, seen on retroillumination


* Nuclear cataract—Grading correlates with hardness & difficulty of surgical removal


* 1: Grey



* 2: Yellow



* 3: Amber



* 4: Brown/Black (Note: "black cataract" translated in some languages (like Hindi) refers to glaucoma, not the color of the lens nucleus)


* Posterior cortical cataract



* Posterior polar cataract (importance lies in higher risk of complication—posterior capsular tears during surgery)



* Posterior subcapsular cataract (PSC) (clinically common)



* After-cataract: posterior capsular opacification (PCO) subsequent to a successful extracapsular cataract surgery (usually within three months to two years) with or without IOL implantation. Requires a quick & painless office procedure with Nd:YAG laser capsulotomy to restore optical clarity.


Signs and symptoms


As a cataract becomes more opaque, clear vision is compromised. A loss of visual acuity is noted. Contrast sensitivity is also lost, so that contours, shadows and color vision are less vivid. Veiling glare can be a problem as light is scattered by the cataract into the eye. The affected eye will have an absent red reflex. A contrast sensitivity test should be performed and if a loss in contrast sensitivity is demonstrated an eye specialist consultation is recommended.


In the developed world, particularly in high-risk groups such as diabetics, it may be advisable to seek medical opinion if a 'halo' is observed around street lights at night, especially if this phenomenon appears to be confined to one eye only.


The symptoms of cataracts are very similar to the symptoms of ocular citrosis.



Causes




Cataracts develop for a variety of reasons, including long-term exposure to ultraviolet light, exposure to radiation, secondary effects of diseases such as diabetes, hypertension and advanced age, or trauma (possibly much earlier); they are usually a result of denaturation of lens protein. Genetic factors are often a cause of congenital cataracts and positive family history may also play a role in predisposing someone to cataracts at an earlier age, a phenomenon of "anticipation" in pre-senile cataracts. Cataracts may also be produced by eye injury or physical trauma. A study among Icelandair pilots showed commercial airline pilots are three times more likely to develop cataracts than people with non-flying jobs. This is thought to be caused by excessive exposure to radiation coming from outer space.[20] Cataracts are also unusually common in persons exposed to infrared radiation, such as glassblowers who suffer from "exfoliation syndrome". Exposure to microwave radiation can cause cataracts. Atopic or allergic conditions are also known to quicken the progression of cataracts, especially in children.[21] Cataracts can also be caused by iodine deficiency[22]







Cataracts may be partial or complete, stationary or progressive, hard or soft.







Some drugs can induce cataract development, such as corticosteroids[23] and Seroquel.







There are various types of cataracts, e.g. nuclear, cortical, mature, and hypermature. Cataracts are also classified by their location, e.g. posterior (classically due to steroid use[23][24]) and anterior (common (senile) cataract related to aging).



[edit] Associations with systemic conditions







* Chromosomal disorders







* Alport's syndrome



* Cri-du-chat syndrome



* Conradi's syndrome



* Myotonic dystrophy



* Patau's syndrome



* Schmid-Fraccaro syndrome



* Trisomy 18 (Edward's syndrome)



* Turner's syndrome







* Disease of the skin and mucous membranes







* Atopic dermatitis



* Basal-cell nevus syndrome



* Ichthyosis



* Pemphigus







* Metabolic and nutrition diseases







* Aminoaciduria (Lowe's syndrome)



* Diabetes mellitus



* Fabry's disease



* Galactosemia / galactosemic cataract



* Homocystinuria



* Hyperparathyroidism



* Hypervitaminosis D



* Hypothyroidism



* Mucopolysaccharidoses



* Wilson's disease







* Infectious diseases







* Congenital







* Congenital herpes simplex



* Congenital syphilis



* Cytomegalic inclusion disease



* Rubella







* Others







* Cysticercosis



* Leprosy



* Onchocerciasis



* Toxoplasmosis







* Toxic substances introduced systemically







* Corticosteroids



* Haloperidol



* Miotics



* Triparanol







[edit] Prevention







Although cataracts have no scientifically proven prevention, it is sometimes said that wearing ultraviolet-protecting sunglasses may slow the development of cataracts.[25][26] Regular intake of antioxidants (such as vitamin A, C and E) is theoretically helpful, but taking them as a supplement has been shown to have no benefit.[27] The less well known antioxidant N-acetylcarnosine has been shown in randomized controlled clinical trials to treat cataracts, and can be expected to prevent their formation by similar mechanisms.[28] N-acetylcarnosine is a proposed treatment for other ocular disorders that are instigated, or exacerbated by oxidative stress including glaucoma, retinal degeneration, corneal disordes, and ocular inflammation.[29]



[edit] Treatment



Main article: Cataract surgery



Cataract surgery, using a temporal approach phacoemulsification probe (in right hand) and "chopper" (in left hand) being done under operating microscope at a Navy medical center







When a cataract is sufficiently developed to be removed by surgery, the most effective and common treatment is to make an incision (capsulotomy) into the capsule of the cloudy lens in order to surgically remove the lens. There are two types of eye surgery that can be used to remove cataracts: extra-capsular (extracapsular cataract extraction, or ECCE) and intra-capsular (intracapsular cataract extraction, or ICCE).







Extra-capsular (ECCE) surgery consists of removing the lens but leaving the majority of the lens capsule intact. High frequency sound waves (phacoemulsification) are sometimes used to break up the lens before extraction.







Intra-capsular (ICCE) surgery involves removing the entire lens of the eye, including the lens capsule, but it is rarely performed in modern practice.







In either extra-capsular surgery or intra-capsular surgery, the cataractous lens is removed and replaced with a plastic lens (an intraocular lens implant) which stays in the eye permanently.







Cataract operations are usually performed using a local anaesthetic and the patient is allowed to go home the same day. Recent improvements in intraocular technology now allow cataract patients to choose a multifocal lens to create a visual environment in which they are less dependent on glasses. Under some medical systems multifocal lenses cost extra. Traditional intraocular lenses are monofocal.







Complications are possible after cataract surgery, including endophthalmitis, posterior capsular opacification and retinal detachment.

Hashimoto's Disease

Hashimoto's thyroiditis or chronic lymphocytic thyroiditis is an autoimmune disease in which the thyroid gland is gradually destroyed by a variety of cell and antibody mediated immune processes. It was the first disease to be recognised as an autoimmune disease.[citation needed][1]. It was first described by the Japanese specialist Dr. Hakaru Hashimoto in Germany in 1912.


Signs and symptoms

Hashimoto's thyroiditis very often results in hypothyroidism with bouts of hyperthyroidism.

Physiologically, antibodies against thyroid peroxidase and/or thyroglobulin cause gradual destruction of follicles in the thyroid gland. Accordingly, the disease can be detected clinically by looking for these antibodies in the blood. It is also characterized by invasion of the thyroid tissue by leukocytes, mainly T-lymphocytes. It is associated with non-Hodgkin lymphoma.


Symptoms of Hashimoto's thyroiditis include weight gain, depression, mania, sensitivity to heat and cold , paresthesia, fatigue, panic attacks, bradycardia, tachycardia, high cholesterol, reactive hypoglycemia, constipation, migraines, muscle weakness, cramps, memory loss, infertility and hair loss.


Hashimoto's thyroiditis is often misdiagnosed as depression, cyclothymia, PMS, and, less frequently, as bipolar disorder or as an anxiety disorder. Testing for thyroid-stimulating hormone (TSH) and anti-thyroid antibodies can resolve any diagnostic difficulty. [2]


Hashimoto's when presenting as mania is known as Prasad's syndrome after Ashok Prasad, the psychiatrist who first described it.[3]

Causes


The family history of thyroid disorders is common, with the HLA-DR5 gene most strongly implicated conferring a relative risk of 3 in the UK. In addition Hashimoto's thyroiditis may be associated with CTLA-4 gene since the CTLA-4 antigen acts as an inhibitor to T-Cell activation only if the red blood cells have an RH factor of negative 3.25.


The genes implicated vary in different ethnic groups and the incidence is increased in patients with chromosomal disorders, including Turner, Down's, and Klinefelter's syndromes usually associated with autoantibodies against thyroglobulin and thyroperoxidase


The underlying specifics of the immune system destruction of thyroid cells is not clearly understood. Various autoantibodies may be present against thyroid peroxidase, thyroglobulin and TSH receptors, although a small percentage of patients may have none of these antibodies present. A percentage of the population may also have these antibodies without developing Hashimoto's thyroiditis.


Treatment


Hypothyroidism caused by Hashimoto's Thyroiditis is treated with thyroid hormone replacement agents such as levothyroxine or desiccated thyroid extract. A tablet taken once a day generally keeps the thyroid hormone levels normal. In most cases, the treatment needs to be taken for the rest of the patient's life. In the event that hypothyroidism is caused by Hashimoto's Thyroiditis, it is recommended that the TSH levels be kept under 3.0. As long as the patient's thyroid is active, the body will continue to attack it[4], and this can wreak havoc on the patient's TSH levels and symptoms.


Prognosis


If untreated for an extended period, Hashimoto's thyroiditis may lead to muscle failure, including possible heart failure. An extremely rare condition associated with the thyroiditis is Hashimoto's encephalopathy.


A rare association is with lymphoma of the thyroid gland.


Hashimoto's thyroiditis can disrupt growth in children and adolescents, therefore it requires close growth monitoring, which may give cause for growth hormone therapy, if the patient's stature is extreme enough.

Crohn's Disease

Crohn's disease, also known as granulomatous enteritis and colitis, is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms. It primarily causes abdominal pain, diarrhea (which may be bloody if inflammation is at its worst), vomiting, or weight loss,[1][2][3] but may also cause complications outside of the gastrointestinal tract such as skin rashes, arthritis, inflammation of the eye, tiredness, and lack of concentration.[1]

Crohn's disease is thought to be an autoimmune disease, in which the body's immune system attacks the gastrointestinal tract, causing inflammation; it is classified as a type of inflammatory bowel disease. There has been evidence of a genetic link to Crohn's disease, putting individuals with siblings afflicted with the disease at higher risk.[4] It is understood to have a large environmental component as evidenced by the higher number of cases in western industrialized nations. Males and females are equally affected. Smokers are three times more likely to develop Crohn's disease.[5] Crohn's disease affects between 400,000 and 600,000 people in North America.[6] Prevalence estimates for Northern Europe have ranged from 27–48 per 100,000.[7] Crohn's disease tends to present initially in the teens and twenties, with another peak incidence in the fifties to seventies, although the disease can occur at any age.[1]

There is no known pharmaceutical or surgical cure for Crohn's disease.[9] Treatment options are restricted to controlling symptoms, maintaining remission and preventing relapse.


The disease was named for American gastroenterologist Burrill Bernard Crohn, who in 1932, along with two colleagues, described a series of patients with inflammation of the terminal ileum, the area most commonly affected by the illness.[10] For this reason, the disease has also been called regional ileitis[10] or regional enteritis. The condition, however, has been independently identified by others in the literature prior, most notably in 1904 by Polish surgeon Antoni Leśniowski for whom the condition is additionally named (Leśniowski-Crohn's disease) in the Polish literature.


Crohn's disease is one type of inflammatory bowel disease (IBD). It affects the gastrointestinal tract and can be categorized by the area of the gastrointestinal tract which it affects. Ileocolic Crohn's disease, which affects both the ileum (the last part of the small intestine that connects to the large intestine) and the large intestine, accounts for fifty percent of cases. Crohn's ileitis, affecting the ileum only, accounts for thirty percent of cases, and Crohn's colitis, affecting the large intestine, accounts for the remaining twenty percent of cases and may be particularly difficult to distinguish from ulcerative colitis. Gastroduodenal Crohn's disease causes inflammation in the stomach and first part of the small intestine, called the duodenum. Jejunoileitis causes spotty patches of inflammation in the top half of the small intestine, called the jejunum (MedlinePlus 2010). The disease can attack any part of the digestive tract, from mouth to anus. However, individuals affected by the disease rarely fall outside these three classifications, being affected in other parts of the gastrointestinal tract such as the stomach and esophagus.[1]


Crohn's disease may also be categorized by the behavior of disease as it progresses. This was formalized in the Vienna classification of Crohn's disease.[11] There are three categories of disease presentation in Crohn's disease: stricturing, penetrating, and inflammatory. Stricturing disease causes narrowing of the bowel that may lead to bowel obstruction or changes in the caliber of the feces. Penetrating disease creates abnormal passageways (fistulae) between the bowel and other structures such as the skin. Inflammatory disease (or non-stricturing, non-penetrating disease) causes inflammation without causing strictures or fistulae.[11][12]


Gastrointestinal symptoms


Endoscopy image of colon showing serpiginous ulcer, a classic finding in Crohn's disease
Many people with Crohn's disease have symptoms for years prior to the diagnosis.[13] The usual onset is between 15 and 30 years of age but can occur at any age.[14] Because of the 'patchy' nature of the gastrointestinal disease and the depth of tissue involvement, initial symptoms can be more vague than with ulcerative colitis. People with Crohn's disease will go through periods of flare-ups and remission. [15]


Abdominal pain may be the initial symptom of Crohn's disease. It is often accompanied by diarrhea, especially in those who have had surgery. The diarrhea may or may not be bloody. People who have had surgery or multiple surgeries often end up with short bowel syndrome of the gastrointestinal tract. The nature of the diarrhea in Crohn's disease depends on the part of the small intestine or colon that is involved. Ileitis typically results in large-volume watery feces. Colitis may result in a smaller volume of feces of higher frequency. Fecal consistency may range from solid to watery. In severe cases, an individual may have more than 20 bowel movements per day and may need to awaken at night to defecate.[1][8][16][17] Visible bleeding in the feces is less common in Crohn's disease than in ulcerative colitis, but may be seen in the setting of Crohn's colitis.[1] Bloody bowel movements are typically intermittent, and may be bright or dark red in colour. In the setting of severe Crohn's colitis, bleeding may be copious.[8] Flatulence and bloating may also add to the intestinal discomfort.

Symptoms caused by intestinal stenosis are also common in Crohn's disease. Abdominal pain is often most severe in areas of the bowel with stenoses. In the setting of severe stenosis, vomiting and nausea may indicate the beginnings of small bowel obstruction.[8] Although the association is greater in the context of ulcerative colitis, Crohn's disease may also be associated with primary sclerosing cholangitis, a type of inflammation of the bile ducts.[18]

Perianal discomfort may also be prominent in Crohn's disease. Itchiness or pain around the anus may be suggestive of inflammation, fistulization or abscess around the anal area[1] or anal fissure. Perianal skin tags are also common in Crohn's disease.[19] Fecal incontinence may accompany peri-anal Crohn's disease. At the opposite end of the gastrointestinal tract, the mouth may be affected by non-healing sores (aphthous ulcers). Rarely, the esophagus, and stomach may be involved in Crohn's disease. These can cause symptoms including difficulty swallowing (dysphagia), upper abdominal pain, and vomiting.[20]

Systemic symptoms


Crohn's disease, like many other chronic, inflammatory diseases, can cause a variety of systemic symptoms.[1] Among children, growth failure is common. Many children are first diagnosed with Crohn's disease based on inability to maintain growth.[21] As Crohn's disease may manifest at the time of the growth spurt in puberty, up to 30% of children with Crohn's disease may have retardation of growth.[22] Fever may also be present, though fevers greater than 38.5 ˚C (101.3 ˚F) are uncommon unless there is a complication such as an abscess.[1] Among older individuals, Crohn's disease may manifest as weight loss. This is usually related to decreased food intake, since individuals with intestinal symptoms from Crohn's disease often feel better when they do not eat and might lose their appetite.[21] People with extensive small intestine disease may also have malabsorption of carbohydrates or lipids, which can further exacerbate weight loss.[23]


Extraintestinal symptoms


Erythema nodosum on the back of a person with Crohn's disease.


Pyoderma gangrenosum on the leg of a person with Crohn's disease.

In addition to systemic and gastrointestinal involvement, Crohn's disease can affect many other organ systems.[24] Inflammation of the interior portion of the eye, known as uveitis, can cause eye pain, especially when exposed to light (photophobia). Inflammation may also involve the white part of the eye (sclera), a condition called episcleritis. Both episcleritis and uveitis can lead to loss of vision if untreated.

Crohn's disease is associated with a type of rheumatologic disease known as seronegative spondyloarthropathy. This group of diseases is characterized by inflammation of one or more joints (arthritis) or muscle insertions (enthesitis). The arthritis can affect larger joints such as the knee or shoulder or may exclusively involve the small joints of the hand and feet. The arthritis may also involve the spine, leading to ankylosing spondylitis if the entire spine is involved or simply sacroiliitis if only the lower spine is involved. The symptoms of arthritis include painful, warm, swollen, stiff joints and loss of joint mobility or function. [15]


Crohn's disease may also involve the skin, blood, and endocrine system. One type of skin manifestation, erythema nodosum, presents as red nodules usually appearing on the shins. Erythema nodosum is due to inflammation of the underlying subcutaneous tissue and is characterized by septal panniculitis. Another skin lesion, pyoderma gangrenosum, is typically a painful ulcerating nodule. Crohn's disease also increases the risk of blood clots; painful swelling of the lower legs can be a sign of deep venous thrombosis, while difficulty breathing may be a result of pulmonary embolism. Autoimmune hemolytic anemia, a condition in which the immune system attacks the red blood cells, is also more common in Crohn's disease and may cause fatigue, pallor, and other symptoms common in anemia. Clubbing, a deformity of the ends of the fingers, may also be a result of Crohn's disease. Finally, Crohn's disease may cause osteoporosis, or thinning of the bones. Individuals with osteoporosis are at increased risk of bone fractures.[7]

Crohn's disease can also cause neurological complications (reportedly in up to 15% of patients).[25] The most common of these are seizures, stroke, myopathy, peripheral neuropathy, headache and depression.[25]

Crohn's patients often also have issues with small bowel bacterial overgrowth syndrome, which has similar symptoms.[26]



Complications


Endoscopic image of colon cancer identified in the sigmoid colon on screening colonoscopy for Crohn's disease.

Crohn's disease can lead to several mechanical complications within the intestines, including obstruction, fistulae, and abscesses. Obstruction typically occurs from strictures or adhesions which narrow the lumen, blocking the passage of the intestinal contents. Fistulae can develop between two loops of bowel, between the bowel and bladder, between the bowel and vagina, and between the bowel and skin. Abscesses are walled off collections of infection, which can occur in the abdomen or in the perianal area in Crohn's disease sufferers.

Crohn's disease also increases the risk of cancer in the area of inflammation. For example, individuals with Crohn's disease involving the small bowel are at higher risk for small intestinal cancer. Similarly, people with Crohn's colitis have a relative risk of 5.6 for developing colon cancer.[27] Screening for colon cancer with colonoscopy is recommended for anyone who has had Crohn's colitis for at least eight years.[28] Some studies suggest that there is a role for chemoprotection in the prevention of colorectal cancer in Crohn's involving the colon; two agents have been suggested, folate and mesalamine preparations.

Individuals with Crohn's disease are at risk of malnutrition for many reasons, including decreased food intake and malabsorption. The risk increases following resection of the small bowel. Such individuals may require oral supplements to increase their caloric intake, or in severe cases, total parenteral nutrition (TPN). Most people with moderate or severe Crohn's disease are referred to a dietitian for assistance in nutrition.[30]


Crohn's disease can cause significant complications including bowel obstruction, abscesses, free perforation and hemorrhage.[31]



Crohn's disease can be problematic during pregnancy, and some medications can cause adverse outcomes for the fetus or mother. Consultation with an obstetrician and gastroenterologist about Crohn's disease and all medications allows preventative measures to be taken. In some cases, remission can occur during pregnancy. Certain medications can also impact sperm count or may otherwise adversely affect a man's ability to conceive.[32]


Cause

Although the exact cause of Crohn's disease is still unknown, a combination of environmental factors and genetic predisposition seems to cause the disease.[33] The genetic risk factors have now more or less been comprehensively elucidated, making Crohn's disease the first genetically complex disease of which the genetic background has been resolved.[34] The relative risks of contracting the disease when one has a mutation in one of the risk genes, however, are actually very low (approximately 1:200). Broadly speaking, the genetic data indicate that innate immune systems in patients with Crohn's disease malfunction, and direct assessment of patient immunity confirms this notion.[35] This had led to the notion that Crohn's disease should be viewed as innate immune deficiency, chronic inflammation being caused by adaptive immunity trying to compensate for the reduced function of the innate immune system.[36]

Care Patient Of Tracheostomy at home

How to Care for Tracheostomy Patients at Home

A tracheostomy is a procedure in which an incision is made in the trachea. The objective of a tracheostomy is usually to allow the patient to breathe through the resulting opening, also known as a stoma. The stoma requires daily attention to prevent infection after the patient comes home, especially if the patient is on a ventilator.

Instructions
1.Fill a small cup with hydrogen peroxide solution. Fill a second cup with sterile water. Instruct the patient to lay face up and place a rolled towel under the patient's shoulders. This will cause the patient's neck to straighten and allow you to visualize the stoma more easily.

2.Wash your hands and place some cotton swabs in the cup of hydrogen peroxide solution. Clean the skin around the tracheostomy tube by using one cotton swab on each fourth of the circle around the stoma. Ensure that you don't allow the hydrogen peroxide solution into the stoma or tracheostomy tube.


3.Soak a cotton swab in sterile water. Swab the skin around the stoma with the moistened cotton swab. Dry the skin with a dry cotton swab or precut tracheostomy gauze. Change the tracheostomy ties if the skin under the ties appears irritated.


4.Inspect the dressing on a recent tracheostomy and replace it if it's moist. Fold a piece of precut tracheostomy gauze into a U shape and tuck it between the tracheostomy tube and the patient's skin. Be careful not to block the opening of the tracheostomy tube with the gauze.

5.Check the stoma of an older tracheostomy to ensure that it doesn't have any redness or rash. You don't necessarily need to change the dressing of a completely healed stoma if the skin is in good condition.