Sunt frecvente situatiiile in care un pacient vrea sa faca o ecografie, ca sa se vada „toate modificarile si bolile” de care sufera.
Ecografia este o metoda de explorare utila, dar care are anumite limite, nefiind utila in toate situatiile.

Ce se vede la ecografia ficatului?

In principiu modificarile care se vad la ecografia ficatului pot fi descrise ca:

• Formatiuni hipoecogene (adica cu ecogenitate mai mica decat ficatul  normal)
  • metastazele hepatice
  • limfoamele hepatice,
  • abcesul hepatic,
  • hematomul hepatic
  • chistele hepatice complicate
  • adenomul hepatic
  • hiperplazia nodulara focala
  • hemangioamele hepatice atipice
  • focare de steatoza hepatica
  • vasele sau caile biliare,
  • cancerul de ficat
  • lipomul hepatic
• Zone hiperecogene (cu ecogenitate mai mare decat structura normala a ficatului)
  • metastaze hepatice
  • carcinom hepatocelular
  • colangiocarcinom
  • hemangion hepatic
  • tumori pseudoinflamatorii
  • focar de steatoza
• Imagini izoecogene (cu aceasi densitate ecografica cu ficatul)

Cand este indicata ecografia abdominala in general?
Explorarea ecografica  a abdomenului este utila in principiu pentru:

• depistarea modificarilor de structura aparute in organele solide:

• Ficat (marime, chiste, hemangioame, tumori, calcificari)
• Pancreas (marime, chiste, pseudochiste, tumori) – ecografia vede modificarile pancreasului mai putin bine decat pe cele ale ficatului-
• Rinichi (tumori, pietre, marimea si forma rinichilor)
• Prostata (marime, omogenitate)
• Uter si ovare
• Splina (marime, tumori, chiste)
• Ganglioni abdominali mariti
  

• depistarea unor modificari in organe tubulare:

• vezicula biliara si caile biliare (tumori, pietre, malformatii, dilatari, etc)
• vezica urinara (tumori, pietre, conturul prostatei, etc)
• uretere (dilatare)

• evaluarea prezentei lichidului (ascitei) in cavitatea abdominala

• evaluarea diametrului unor vase sanguine, care au semnificatie in diagnosticul unor boli (aorta, vena cava inferioara, vena porta, venele suprahepatice, vena splenica, arterele renale, etc)

Ce nu poate depista o ecografie abdominala?

In principiu ecografia abdominala nu poate da date certe referitoare la:

• Organe tubulare (stomac, duoden, intestin subtire si gros) – modificarile lor se pot evalua ecografic doar in situatii speciale.
• Hepatita (desi poate evalua ficatul, nu poate preciza diagnosticul de hepatita – in schimb pe cel de ciroza il poate pune)
• Pielonefrita
• Infectie urinara
• Ulcer, gastrita. colecistita (poate doar suspiciona acest diagnostic)
• Apendicita
• Colon iritabil

Ce poate depista o ecografie a ficatului sau cailor biliare?

• Modificarile scografice ale ficatului vazute la ecografie sunt
  • ficatul gras (reflectivitatea ficatului este crescuta) – vezi poza
    
  • tumori de ficat
  • chiste hepatice
  • hemangioame hepatice
  • modificari in ciroza (ascita, marirea venei porte, marirea splinei, modificari ale colecistului)
  • calcificari in ficat
  • marirea cailor biliare
• modificari ale colecistului (veziculei biliare)
  • colecist cudat
  • reziduu biliar
  • noroi biliar
  • colecist septat
  • pietre in colecist = litiaza veziculara
    
  • colecist marit
  • colecist cu perete ingrosat
  • polipi in colecist
  • lipsa colecistului prin scoatere chirurgicala
  • lipsa de vizualizare a colecistului (uneori colecistul nu se vede ecografic, desi exista, nu a fost extirpat)

Ce nu poate depista o ecografie hepatica?

O ecografie a ficatului poate fi perfect normala in urmatoarele situatii

• transaminazele crescute
• inflamatia ficatului
• fibroza ficatului
• virusurile hepatice
• hepatita cronica cu virus B sau C sau D

Cat de des se poate face ecografia?

Deoarece ecografia nu prezinta risc pentru sanatate, se poate face ori de cate ori este nevoie, fara nici un pericol.

Ce pregatire trebuie sa faci pentru ecografia abdominala?

De obicei ecografia se face cu bolnavul nemancat – dar acest lucru nu este absolut obligatoriu in urgenta- .

Daca se doreste si examinarea ureterului, prostatei sau vezicii urinare, este bine ca bolnavul sa nu fi urinat de cel putin 4-5 ore (sau de seara pana dimineata).

Ce trebuie sa faci atunci cand ai modificari gasite la ecografia hepatica sau biliara,sau alte analize hepatice modificate fara a se fi depistat cauza sau tratamentul?

Daca aveti probleme hepatice nelamurite este normal sa fiti ingrijorat, dar nu trebuie sa fiti fiti disperat, dar nici sa neglijati o situatie trenanta.

Va spun din experienta ca orice situatie medicala poate fi lamurita, iar  daca apelezi la medic in timp util ea poate fi si rezolvata, trebuie doar sa cauti specialistul potrivit situatiei respective. Situatiile simple pot fi lamurite practic de orice specailist, iar pentru cele mai … ciudate trebuie apelat la un specialist cu experienta, care a vazut multe in carierea lui,

Cel mai corect lucru este sa faci asa cum faci cand observi ca se scurge putin ulei la masina , nu o lasi sa crape motorul ci  mergi la mecanic. Este normal sa ai aceeasi grija de propriul organism, mai ales ca piesele de schimb  nu exista.

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Cum se pune diagnosticul de hepatita cu virus C?

FIBROZA HEPATICA poate fi mai mult sau mai putin evoluata, astfel

Alte metode de evaluare a starii ficatului in infectia cu virusul hepatitei  C

Biopsia hepatica se face de mai multe decenii, fiind o explorare relativ sigura; deoarece multe persoane se tem de aceasta explorare, mai ales datorita durerii (de altfel moderate, deoarece se face anestezie), s-a cautat gasirea unei formule de calcul prin care sa se estimeze indirect gradul de fibroza si inflamatie a ficatului.

Evaluarea bolii de ficat prin analize

Existe numeroase teste noninvazive (markeri serici) de evaluare a fibrozei si inflamatiei hepatice elaborate de-a lungul anilor prin luarea in calcul a diferite analize, cu prelucrarea matematica a rezultatelor, cele mai importante fiind enumerate mai jos, iar alaturat graficul corespondentei intre cele mai importante teste noninvazive hepatice:

Una din formulele de calcul folosite curent in Romania numita fibrotest  utilizeaza 6 analize de sange obisnuite, valoarea lor fiind supusa unei formule de calcul matematic, parametrii folositi in calcul fiind:

• Alfa2-Macroglobulina
• Haptoglobina
• Apolipoproteina A1
• Gama-glutamil transpeptidaza (GGT)
• Bilirubina totala
• TGP / ALAT

In afara de cele sase rezultate ale analizelor, mai sunt luate in calcul varsta si sexul pacientului.

Pentru elaborarea acestei formule, initial au fost studiati pacienti cu biopsie hepatica si analizele mentionate, si comparand cele doua tipuri de explorari, a fost elaborata o formula de calcul, care sa permita deducerea indirecta a gradului de afectare hepatica, fara a mai face biopsie hepatica.

Rezultatul explorariilor de laborator  este convertit intr-un scor de la 0 la 1, graficul fiind colorat in functie de  severitatea fibrozei sau activitatii inflamatorii , in paralel fiind prezentata si o estimare histologica conform scorului METAVIR (cu fibroza F0- F4, A0-3). Este evident ca modificarea unei analize se reflecta in modificarea scorului de inflamatie sau fibroza a testului, uneori acest rezultat fiind fals pozitiv (aratand o afectare hepatica mai mare decat cea reala estimata prin biopsia hepatica).

Exista dezavantaje in evaluarea fibrozei  si inflamatiei ficatului prin Fibrotest/ Actitest/Fibromax

Desi pare o metoda mai putin traumatizanta (se recolteaza doar sange), evaluarea fibrozei hepatice prin analize de sange are si destul de multe dezavantaje:

• Este o analiza relativ scumpa, si nu este decontata de Casa de Asigurari de Sanatate
• Pana la 5% din cazuri nu pot fi interpretate.
• In 25% din cazuri exista discordanta (mai mic sau mai mare) intre fibrotest si biopsia hepatica; se considera ca cu cat fragmentul de biopsie este mai mare, cu atat diagnosticul este mai corect; la un fragment de biopsie sub 25mm, fibrotestul si actitestul dau rezultate mai corecte, iar la un fragment de biopsie mai mare de 25mm, biopsia da diagnostic mai sigur; de obicei fragmentele de biopsie hepatica sunt de peste 30mm
• In afara indicatiilor de explorare (hepatitele virale B,C,D, hepatita alcoolica sau toxica, steatoza hepatica) metoda nu este operanta in alte situatii, neputand sa puna diagnosticul de tumora hepatica, sau modificari histologice ale unor noduli hepatici.
• Metodele serice permit diagnosticul de ciroza dar fac mai greu diferentierea dintre diferitele stadii vecine ale hepatitei cronice (adica pot confunda o fibroza 1 cu una 2 sau invers)
• Asa cum am mentionat deja, Fibrotest poate da rezultate neconcludente fals pozitive (supraestimeaza gravitatea bolii de ficat) in caz de:
  • Cresterea transaminazelor  sau GGT de alte cauze decat o boala hepatica cronica – hepatita acuta virala sau de alte cauze -medicamentoasa, alcoolica, toxica
  • Cresterea bilirubinei din alte cauze decat boli inflamatorii hepatice – hemoliză severa, icter mecanic, sindrom Gilbert, etc
  • Modificarile analizelor care apar intr-un sindrom inflamator acut

Evaluarea fibrozei hepatice cu ultrasunete – un fel de ecografie sau RMN

Evaluarea fibrozei hepatice fara biopsie se poate face – in afara de analize- si prin alte metode:

• Fibroscan
• Elastografie in timp real
• RMN cu dublu contrast cu gadolinium

Fiecare dintre metodele mentionate (biopsie, markeri serici, elastografie sau RMN) are avantaje si dezavantaje, iar in cazurile litigioase, in final tot biopsia hepatica lamureste lucrurile

Daca cele scrise mai sus v-au ajutat, este bine, inseamna ca nu am pierdut degeaba sute de ore ca sa scriu materialele medicale postate pe net si sa raspund la intrebarile pacientilor in loc sa odihnesc sau sa  ma plimb.

Ce trebuie facut cand aveti probleme cu fcatul?

Am vazut numerosi pacienti disperati din cauza unor probleme hepatice nelamurite in ciuda consultatiillor medicale facute in diferite locuri, uneori la specialisti fara nici o legatura cu hepatologia sau gastroenteroogia, disperarea lor fiind de obicei fara motiv.

Daca aveti probleme  de genul celor descrise in articolul pe care tocmai l-ati citit nu trebuie sa fiti disperat, dar nici sa neglijati problema, cel mai intelept este sa mergeti la un specialist gastroenterolog sau hepatolog competent pentru o evaluare corecta a situatiei, amanarea putand avea consecinte neplacute, uneori ireversibile. Nu mergi la mecanic cand a crapat motorul masinii, ci cand ai vazut o picatura de ulei scursa sub motor. Este normal sa avem aceeasi grija si de organismul nostru, mai ales ca ….  nu avem piese de schimb. Va spun din experienta mea ca pentru orice problema medicala exista o rezolvare corespunzatoare, trebuie doar sa gasiti un specialist cu experienta in prpblema respectiva.

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Intrebarile sunt luate de pe forumurile de pe site.

Mentionez ca raspunsurile sunt generale, teoretice, iar aplicare lor automata la o anumita persoana poate fi complet eronata, deci este nerecomandabila

Recent am descoperit ca am hepatita c as dori sa stiu daca voi ramane toata viata cu ea?va multumesc.

Aeasta intrebare trebuie adresata medicului hepatolog sau gastroenterolog care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele.

Teoretic o persoana cu virus C poate scapa de el sau poate ramane toata viata cu virusul, sau poate face hepatita cronica, ciroza hepatica sau cancer de ficat.

Buna ziua.As dori sa ma lamuriti,daca se poate,in privinta urmatoarelor rezultate: fibroscan in 2014- f2(9,1kPa),Fibroscan in 2014-f2(7,7kPa) si fibromax in 2015 cu f4,ciroza.Ce sa inteleg, ca analizele au fost gresite sau hepatita c a evoluat rapid?Sa refac analizele? Care? Multumesc.

Aeaste intrebari trebuiesc adresate medicului hepatolog sau gastroenterolog care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele.

Aveti pe site date teoretice despre concordanta fibromax-fibroscan si despre evolutia fibrozei in hepatita C

Vreau un sfat;am fost intimplator gasit cu hepatita c virala in 2013aprilie si in octombrie dupa aprobarea dosarului am inceput tratamentul cuCopegus si Pegintron un an pina in2014.dupa tratament analizele miau iesit bine.Nu sint consumator de alcol si cit am avut posibilitatea am tinut si regim alimentar dar a-r fi trebuit sa mai fac unele investigatii,ins am avut probleme familiale cit si financiare si nu am putut lua legatura cu medicul meu curant.Ce ma povatuiti sa fac?Multumesc anticipat.

Va sfatuiesc sa luati legatura cu un medic hepatolog sau gastroenterolog competent care sa decida in ce stadiu de boala sunteti  – sau poate sunteti vindecat-si ce este de facut in continuare

Am hepatita C, genotipul 1b.La fibroscan mi-a iesit fibroza de gradul 0/gradul 1. Mi sa spus ca unicul tratament de care pot beneficia in situatia respectiva fiind Interferonul. Din pacate acest genotip de hepatita C nu prea raspunde la tratament. Exista vreo sansa sa primesc unul din noile tratamente care au iesit acum pe piata ? multumesc anticipat.

Aeasta intrebare treubie adresata medicului hepatolog sau gastroenterolog care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele. Teoretic exista aceasta sansa

Mama mea in varsta de 62de ani a fost dg cu hepatita cronica virus C (transfuzie de sange in 1984)pe data de 10 iulie2015 datele sunt:TGP 80;viremie 150 000UI/ml si F2.spuneti-mi va rog daca are sanse de stagnare a virusului in eventualitatea unui tratament cu interferon?cu aceste valori credeti ca ne va fi acordat tratamentul? va multumesc!

Aeasta intrebare treubie adresata medicului hepatolog sau gastroenterolog care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele. Teoretic exista sanse de stagnarea a viruslui si de aprobare a tratamentului antiviral neceaar stadiului bolii

Buna ziua am hepatita c si anceput de ciroza nu am medic de familie pentru/ca lucrez in Italia acolo medici ma poarta pe drumuri de 2 /5anifara nici un medicament doar ma trimite sa fac analize din 3 an 3 luni dar nimic alcevace pot face an cazul mau pot sa/mi fac dosarul la C A S P VA MULTUMESC !

Daca aveti asigurare in Romania va puteti face dosarul aici- nu cnosc situatia din Italia si regulle de acolo

buna ziua  sotul meu are anticorpi la hepatita C pozitivi de 4-5 ani,viremia este nedetectabila tot timpul care este explicatia multumesc

Aeasta intrebare treubie adresata medicului hepatolog sau gastroenterolog care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele. Teoretic poate fi o vindecare a bolii sau o viremie foarte foarte mica

Buna ziua,prietenul meu in urma cu 3ani a luat acest virus de hepatita c de la dentist,a facut primul tratament cu interferon si nu i-a mers,acum am auzit ca anul acesta apare miraculosul tratament,si nu stie nimeni daca o sa apara,doar se spune,asa ca am vrea sa plecam in Spania pentru a il face acolo,si intrebarea mea este,daca platesc singura fara sa lucrez asigurarea de sanatate de acolo,beneficiez si de acest tratament?multunesc frumos,sanatate tuturor,si sa va vindecati

Nu stiu regulile di nSpania, probabil veti primi tratament si acolo

Sant diagnosticata cu hepatita c,nonresponder la interferon+ribavirin dupa 4 luni de tratament.Mi s-a intocmit dosar pt.tripla terapie ,dar casa de sanatate Buzau nu mi l-a primit pentru ca nu s-a aprobat pana acum includerea pe lista compensatelor si gratuitelor.Ce pot sa fac?Ma pot inscrie pe lista de asteptare?Unde anume?
Multumesc, Aurelia

Nu exista liste de asteptare pentru tripla terapie, deoarece nu sunt cunoscute oficial criteriile dupa care va fi acordat acest tratament.

Am 63 de ani. In 1998 mi-am facut operatie si cred ca atunci am fost infectata cu virusul C. Doctora de familie, desi a vazut ca mi-au crescut transaminazele de la an la an, abia in 2003 mi-a spus sa-mi fac analizele speciale pentru ca s-ar putea sa am hepatita C. Am fost la Fundeni iar apoi comisia mi-a spus ca in urma analizelor nu este cazul sa iau Interferon. In ultimul timp mi-am facut transaminazele, care in ianuarie 2014 erau TGP 53 si TGO 42. In august 2014 mi-am facut si transaminazele care au fost TGO 80.3 si TGP 55.7 si viremia care mi-a iesit: Numarul de copii/ml convertit in UI/ml = 3876214. Am fost foarte stresata in ultimul timp, mi-a murit fiica in accident si am fost distrusa. Va implor domnule doctor, pentru ca stiu de la multe persoane ca i-ati ajutat sa-mi spuneti si mie ce am de facut. Va multumesc anticipat

In mod normal medicul hepatolog sau gastroenterolog care va urmareste si care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele va poate sfatui mai corect. Daca doriti treceti pa la mine la un consult sa vedem care este situatia dvs medicala.

domnule doctor prin prezenta va rog datimi un sfat,am 65 ani am o hepatita cu virus c depistata din 2003,de atunci nu am mai pus in gura ,sare,alcool,tutun si cele interzise .am si o ciroza hepatica cu acumulare de lichid iar in luna noembrie 2014,mi sa extras lichidul cu acul rezultind aprox. 2 litri ,acum lichidul sa format din nou si nu mai inteleg deoarece sa strins mai mult,va rog spuneti-mi ce pot sa mai fac sau sa ma resemnez,va rog fiti franc.Multumesc de intelegere.

Aeasta intrebare trebuie adresata medicului hepatolog sau gastroenterolog care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele. Am avut mii de pacienti cu situatia dvs care cu tratamentul gastroenterologic corespunzator merg bine, dar nu cunosc situatia dvs medicala complet pentru a va da sfaturi compentente

Buna seara !Am 60 de ani si sufar de hepatita C ….MI-am refacut analizele recent iar printre altele birulibina are valoarea 3 iar trasaminazele 160 ,incarcatura virala 125 de mii .Simt o durere acuta in stomac care iradiaza in majoritatea abdomenului .Imi lipseste pofta de mancare ,urina este puternic colorata mai exact are culoarea coniacului .Dar aceasta problema de stomac a devenit aproape insuportabila .Tin sa mentionez ca am o stre foarte depresiva

La intrebarle de mai sus cel ma bine va poate sfatui medicul hepatolog sau gastroenterolog care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele. pe site aveti date teoretice despte toate problemele mentionate, dar ele sunt informative, iar eu, datorita riscului imens de eroare nu dau consutatii si sfaturi pe net  fara a cunoaste complet situatia medicala  repectiva

am fost diagnosticata cu hepatita cronica C iar fibroscan a aratat valoarea 28 ,am incercat sa obtin tratamentul de-a lungul a 3,4 ani dar de fiecare data dosarul a fost respins ca este incomplet sau ca valorile viremiei sunt prea mici . ce as putea face imi dau seama ca este destul de grava situatia iar starea mea de sanatate este din ce in ce mai proasta in ciuda regimului pe care il respect

Aeasta intrebare trebuie adresata medicului hepatolog sau gastroenterolog care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele. Fara tratament corespunzator este firesc ca o boala sa nu mearga bine, dar nu stu complet situatia dvs medicala pentru a va sfatui corespunzator

Buna ziua ! Am fost diagnosticata cu Hepatita C din Decembrie 2011.Am facut toate analizele am Fibromaxul F1 – F2, Steatoza S2,TGO = 167 ; TGP=207 .De atunci urmez tratament cu URSOFALC , Lagosa , iar acuma am gasit INTERFERONAT . Am dosarul depus pentru INTERFERON. Tin regim alimentar .Dar nu stiu de ce imi es TGO SI TGP valori asa mari.

Aeasta intrebare trebuie adresata medicului hepatolog sau gastroenterolog care are toate datele dvs medicale – anamneza, examinare medicala-consult- si toate analizele.Teoretic, daca virusul se inmulteste, el distruge celeuele ficatului din care ies transaminazele care cresc in sange – aveti pe site numeroase articole despre acesta problema

In urma cu 3 ani mama mea, acum in varsta de 64 ani, a fost diagnosticata cu hepatita C, viremie ff mare. Dupa biopsie si fibroscan rezulatl a fost fibroza de grad 4, ciroza hepatica. A facut un tratament cu interferon si ribavirina la Clinica Victor Babes, printr-un program elvetian.Dupa 6 luni viremia a disparut. Timp de doi ani a fost tinuta sub observatie, analize la 3, 6 si 12 luni, toate au iesit bune, se simtea bine. De vreo 2 luni a inceput sa slabeasca, nu prea mai poate manca. Are 40 kg si nu cred ca are ascita deoarece nu are deloc burta.Nu prea vrea sa mearga la doctor. Credeti ca ar mai fi posibil un transplant?. Mentionez ca eu sunt compatibila cu ea si doresc sa-i fiu donator. Cam la ce suma s-ar ridica costurile transplantului?. Casa de Asigurari ar suporta o parte din costuri?

In mod normal un bolnav de ficat trebuie ar fie ingrijit de un doctor specializat in bolile .. de ficat – gastroenterolog sau hepatolog, care se ocupa si de infectie si de consecintele sale potentiale – ciroza, cancer de ficat varice esofagiene, ascita , transpant de ficat,etc. Este o pierdere de timp ca un doctor sa te trateze de infectie, altul de varice esofagiene, altul de ascita, etc (de exemplu de apendicita, care este o boala infectioasa, nu te trateaza de infectie infectionistul ci chirurgul, de infectia urinara te trateaza doar nefrologul, daca ai abces dentar care este tot infectios nu mergi la infectionist ci stomatolog, etc),Transplantul de ficat este gratuit in Romania – asta nu inseamna ca nu costa nimic, dar costurile le acopera Casa de Asigurari-, iar indicatiile contraindicatiile, incidentele, etc sunt postate pe site

am fost operata de 3 saptamani de histerectomie totala cu salpingectomie. la cererea mea mi s-a facut si o biopsie hepatica, rezultatul acesteia si al biopsiei endometriale nefiind gata. sunt anemica de cel putin 20 ani, HLG fiind in jur de 9 g%0. in 2007 am fost depistata la INSTITUTUL Bals cu hepatita C. nu am urmat niciodata vreun tratament. la papanicolau a iesit hiperplazie endometriala.
m/ar interesa sa fac o programare la dvs. pentru o colono si analize specifice la ficat. cum ar trebui sa procedez?

In mod normal un bolnav de ficat trebuie as fie ingrijit de un doctor specializat in bolile .. de ficat – gastroenterolog sau hepatolog, care se ocupa si de infectie si de consecintele sale potentiale – ciroza, cancer de ficat varice esofagiene, ascita , transpant de ficat,etc. Este o pierdere de timp ca un doctor sa te trateze de infectie, altul de varice esofagiene, altul de ascita, etc.

Ar trebui sa va gasiti un medic gastroenterolog sau hepatolog competent care sa vada care este situatia dvs in acest moment a in urma consultului medical si analizelor corespunzatoare, si ce se poate face acum.

Ce trebuie sa faci atunci cand ai fost descoperit cu hepatita cronica?

Daca aveti hepatita cronica, nu trebuie sa fiti disperat, dar nici nu trebuie sa neglijati problema. Din experienta mea va pot spune ca situatia nu este atat de neagra pe cat si se poate parea, si poate fi lamurita si mentinuta sub control, trebuie doar sa  luati legatura cu un gastroenterolog sau hepatolog cu experienta, obisnuit cu astfel de sitiatii, pentru o evaluare a problemei.Cel mai corect lucru este sa faci asa cum faci cand observi ca se scurge putin ulei la masina , nu o lasi sa crape motorul ci  mergi la mecanic. Este normal sa ai aceeasi grija de propriul organism, mai ales ca piesele de schimb  nu exista.

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Orice om normal, atunci cand are ceva defect, apeleaza la un specialist.
De exemplu, atunci cand ai o problema la masina, frigider, aspirator sau .. acoperis, apelezi la un specialist.
Pentru repararea unei .. masini este nevoie sa mergi la service la un specialist, sa-i povestesti mecanicului ce ai observat anormal la masina, acesta o vede, o pune pe un tester, constata defectul si apoi o repara.

De sute de ani lucrurile stau la fel in orice situatie in care vrei sa vezi daca exista ceva anormal, si care este cauza acestei anormalitati.
Pentru a evalua cauza simptomelor unui pacient, trebuie sa mergi la consult la un specialist, iar procedura normala este la fel ca in cazul oricarui defect
0. Mergi la un specialist in problema rspectiva
1. Povestesti ce te supara, de cand te supara, cand apar simptomele, cand dispar simptomele ce problema ai mai avut pana atunci, ce analize ai facut, care au fost rezultatele, ce tratament si regim ai incercat, care au fost rezultatele lor ,etc – istoricul simptomelor si istoricului bolii
2, Specialistul te examineaza, insistand in jurul organelor acre tesuprar
3, Medicul prescrie explorarile pe care le considera necesare dupa examinarea si discutia cu pacientul
4, Medicul respectiv evalueaza rezultatul explorarilor si le coreleaza cu simptomele si elementele gasite la examinarea pacientului
5, Medicul prescrie masurile necesare- regim, tratament etc

Sigur ca poti incerca sa repari singur masina, dar daca chiar nu esti pregatit in problema respectiva, stim cu totii ca pierzi mult timp si bani si deseori tot la mecanic ajungi dupa o vreme
Fara respectarea acetui protocol pentru evaluarea simptomelor unui pacient, indicatiile date unui pacient sunt riscante.si deseori fara legatura cu realitatea.

De altfel Art.31. din codul deontologic medical nu permite explicit actul medical la distanta ( evaluarea medicala pe net), cu exceptia situatiilor de urgenta, sau cand bolnavul este asistat nemijlocit de medicul sau (deci cand medicul sau se sfatuieste la distanta cu alt medic) – citez mai jos actul respectiv
Actul medical de la distanță
Investigația ori intervenția medicală la distanță, în oricare dintre formele și modalitățile existente, este permisă numai în situația în care pacientul este asistat nemijlocit de către medicul său, iar scopul investigației și procedurilor la care este supus pacientul este acela de a ajuta medicul să determine diagnosticul, să stabilească tratamentul sau să întreprindă orice altă măsură medicală necesară finalizării actului medical sau a intervenției medicale în cazul operaților. Excepție fac situațiile de urgență.

Daca s-ar fi putut pune diagnosticul  unui defect, unor boli doar pe baza povestirilor, ar fi fost mii de siteuri care sa pune diagnosticul automat cu plata on line, dar NU exista asa ceva in nici o limba, in nici o tara.

Poti inceca sa-ti repari singur masina, ca daca nu merge, o duci la mecanic si pierzi eventual doar timp si bani, dar in cazulautodiagnosticului medical, timpul eventual pierdut, poate insemna mult mai mult , uneori pierderea de timp fiind irecuperabila.

Am vazut pacienti care din neglijenta, lipsa de timp, teama sau cautandu-si singur diagnosticul,au ajuns la medic in faze atat de avansate ale bolii, incat vindecarea a fost practic imposibila.

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In Romania a fost introdus tratamentul pentru infectia cu virusul hepatitei C fara interferon.

Deoarece prescrierea acestui medicament nu se va face in acest moment pentru orice bolnav cu infectie cu virus C, voi posta unele precizari lamuritoare,

De la inceput mentionez ca tratamentul NU este impotriva cirozei hepatice ci impotriva VIRUSULUI C, deci chiar daca virusul dispare, ciroza ramane, nu se vindeca,  dar prin disparitis virusului riscul de evolutie scade, mai ales cel de cancer de ficat

Medicamentul se numeste Viekirax-Exviera, iar costul tratamentului va fi acoperit de CNAS

Voi posta cele mai frecvente intrebari pe care le primesc de la pacientii mei

Ce bolnavi vor fi acceptati pentru acest nou  tratament  impotriva virusului C al hepatitei?

Pentru inceput vor fi acceptati pentru noul tratament bolnavii cu infectie cu virusul C si  fibroza 4, deci ciroza hepatica, dar fara ascita sau sangerare din varicele esofagiene si cei cu transplant de ficat pentru infectie cu virusul hepatitei C, Spun „se pare”deoarece nu au fost publicate in Monitorul oficial criteriile care sa arate ce bolnavi vor fi tratati cu noul tratament impotriva virusului hepatitei C

Unde se fac analizele ce vor trebui depuse la dosarul ce se depune la CNAS pentru noul tratament al infectiei cu virusul hepatitei C? Eu ma deja toate analizele facute dupa indicatia medicului curant din Ploiesti, le-am platit si am depus dosarul deja de un an ca sa prind un loc in fata..

Dosarele depuse inainte de aparitia reglementarilor mentionate in acest articol nu sunt luate in considerare, din pacate cei care au platit analizele, trebuie sa le repete dupa noile reglementari.

Analizele se fac doar la laboratoarele acreditate de CNAS – in Bucuresti Synevo si Bioclinica, pe baza unor vouchere , alte analize nu vor fi acceptate – vezi Precizari privind testarile fibromax_viremie_genotipare, Se vor face gratuit pe baza voucherelor ftibromaxul, genotiparea si viremia

Ce analize trebuiesc depuse la dosarul de la CNAS?

Analizele de la dosarul de tratament sunt urmatoarele

• Testările AgHBs, Ac anti -HIV sunt valabile 12 luni de la data efectuării

Unde se depun dosarele cu actele pentru noul tratament pentru hepatita C, la Casa judetena de Asigurari?

Dosarele NU se depun la Casa judeteana de asigurari de Sanatate ci numai in centrele Bucureşti, Cluj, Constanţa, Craiova, Iaşi, Sibiu,Târgu Mureş,Timişoara, Oradea, indiferent de locul de domiciliu al asiguratului si de medicul care l-a mai urmarit mai inainte. Pacientul se poate adresa unui medic gastroenterolog sau hepatolog din unul din aceste centre, unde doreste el, iar dosarul se va depune la Casa judeteana de unde este medicul care face dosarul si va urmari pacientul – adica Bucureşti, Cluj, Constanţa, Craiova, Iaşi, Sibiu,Târgu Mureş,Timişoara, Oradea, depune dosar. Aveti aici scrisoare către asigurat elaborata de CNAS. Cu ocazia depunerii dosarului pacientul va semna si un consimtamant vezi model consimţământ

Cat timp dureaza pana la aprobarea dosarului

CNAS promite ca aprobarea dosarelor se va face rapid, sub o luna

Ce medici vor putea sa faca aceste dosare, eu m-am tratat la un medic din Braila, pot sa merg tot la el?

Datorita faptului ca acest tratament este foarte scump pentru stat, pot prescrie acest nou tratament doar medicii gastroenterologi acreditati din Bucureşti, Cluj, Constanţa, Craiova, Iaşi, Sibiu,Târgu Mureş,Timişoara, Oradea

Alte lucruri despre noul tratament in hepatita C fara interferon

• Ce este acest medicament-   VIEKIRAX contine ombitasvir,paritaprevir si ritonavir , iar EXVIERA contine dasabuvir , deci 4 medicamente
• Ce face medicamentul  VIEKIRAX -EXVIERA. 

Virusul hepatitei C intra in celula hepatica pentru a se inmulti, fiind apoi eliminat din celula in sange.Aceasta asociere de medicamente ataca virusul in 3 etape ale desfasurarii inmultirii sale in celula ficatului, de aici si procentul mare de vindecare

• Cum se ia medicamentul – se iau trei tablete dimineata si o tableta seara – lucru mentionat pe cutie
• Cat timp dureaza tratamentul – in majoritatea cazurilor tratamentul dureaza 12 saptamani- in unele cazuri 24 saptamani
• Cati bonavi se vindeca cu acest tratament – vindecarea este posibila in cca 95% din cazuri dupa o cura de tratament
• Cine fabrica Viekirax-Exviera – firma se numeste AbbVie 
• Cine urmareste bolnavii cu acest tratament – in mod normal fiind vorba de  o boala de ficat avansata, care poate sa se complice in timp cu ascita, sangerare din varice sau cancer de ficat, este normal ca pacientii cu acest tratament sa fie supravegheati de un medic hepatolog sau gastroenterolog, Chiar daca CNAS va permite si altor specialisti sa prescrie acest tratament, ar fi ciudat ca acesti bolnavi sa fie supravegheati de alte specialitati medicale, iar atunci cand fac ascita, hemoragie din varice, cancer de ficat sau alte complicatii ale cirozei,sa fie trimisi la gastroenterolog sau hepatolog, medici care monitorizand tot timpul acest fel de boli, pot depista mult mai usor si precoce aparitia acestor complicatii, le pot preveni sau trata corespunzator.Cu frigiderul defect nu te duci mai intai la depanatorul de .. televizoare sa-i ceri o parere (in final si el repara electroice-electrice), iar apoi acesta se te indrume la depanatorul de frigidere, este evident o pierdere de timp si bani.
• Daca faci acest nou tratament, te vindeci de ciroza? Tratamentul mentionat nu este indreptat impotriva cirozei ci a virusului C. Daca faci acest tratament te vindeci de virusul C, iar ciroza hepatica nu mai evolueaza, dar ciroza  trebuie urmarita si tratata in continuare la gastroenterolog sau hepatolog, deoarece pot sa apara complicatii ca in orice ciroza de alta cauza. Este ca si cum un vierme ti-a gaurit un pom in curte. Daca dai  cu chimicale si omori viermele, gaura a ramas, si trebuie sa faci ceva ca sa nu se mareasca si sa se usuce pomul respectiv
• Cine fabrica Viekirax-Exviera? Firma care fabrica medicamentul se numeste AbbVie .
• Cat costa tratamentul nou pentru hepatita C? Costul tratamentului in Romania este suportat de CNAS, deci pacientul nu plateste nimic. Pe plan international costurile oscileaza de la tara la tara , in jurul sumelor 50.000 euro  – 73.000 euro. Se spune – neoficila- ca CNAS a obtinut cel mai mic pret din Europa pentru acest tratament, suma (repet neoficial) fiind in jur de 17.000 euro

• De ce va fi recomandat acest nou tratament bolnavilor cu ciroza care au sanse mai mici de supravietuire indelungata, si nu celor cu hepatita cronica care au sanse mai mari? Pacientii cu ciroza avand o durata de supravietuire mai mica, trebuie sa fie tratati preferential tocmai din aceasta cauza – cei cu hepatita pot astepta 20-30 de ani, iar cei cu ciroza numai 10-15 ani. Deci, dupa parerea mea indicarea acestui tratament mai intai la cei cu ciroza este justificata din punct de vedere medical.

• Daca am facut tratament cu interferon in Braila sau Calarasi, pot veni a dvs pentru dosarul de tratament fara interferon?

Puteti veni la mine sau la oricare dintre medicii gastroenterologi din cele 9 centre acreditate, poate veni orice bonav din tara, indiferent de judet pentru a face evaluare in vederea noului tratament. Asa sunt reglementarile Casei de Asigurari de Sanatate

• Daca am analize mai vechi pentru virusul C ele sunt valabile? 

Asa cum am mai precizat, CNAS a stabilit ca analizele mai vechi sunt valabile  daca au urmatoarea vechime:

• Hemograma, INR, ALT, AST, GGT, bilirubina totală, albumina serică, AFP- sunt valabile 3 luni de la data efectuării;

• Investigaţiile paraclinice – hemograma, INR, ALT, AST, GGT, bilirubina totală, albumina serică, AFP- sunt valabile 3 luni de la data efectuării;

• ARN-VHC cantitativ, fibroscan/fibromax sunt valabile 12 luni de la data efectuării;

• Puncţia biopsie hepatică este valabilă 3 ani în cazul pacienţilor cu F3/F4;

• Ecografia abdominală este valabilă 6 luni de la data efectuării;

• Testările AgHBs, Ac anti-HIV sunt valabile 12 luni de la data efectuării.
• Viremia, genotiparea si fibromax sunt valabila NUMAI daca sunt facute gratuit pe voucherele speciale care vor fi la dispozitia medicilor gastroenterologi din cele 9 centre medicale mai sus mentionate

FORUM – tratament fara interferon

Buna ziua,ma numesc elena am facut tratament ci interferon dar nu am raspuns .am terminat tratamentul in urma cu un an .aveam f2 iar viremia la incetarea tratamentului era undeva la 5000. As dori sa stiu daca are rost sa merg la consult pt dosar sau sa mai astept.Va multumesc.

Daca s-ar putea face medicina automat, ar exista siteuri in care se introduc datele medicale si iese recomandarea medicala, dar, din pacate acest lucru nu este posibil. Tinad cont de faptul ca sunteti in urmarirea unui medic hepatolog sau gastroenterolog care v-a prescris si urmarit pe periaoda tratamentului, si care stie situatia dve medicala, cred ca cel mai bine ar fi sa va sfatuiti cu el, sau cu alt medic care sa va si consulte inainte de a sti sa dea un sfat competent

Daca aveti infectie cu virusul hepatitei C, nu fiti disperat, situatia poate fi mentinuta sub control dar trebuie sa fiti urmarit si tratat de un gastroenterolog sau hepatolog cu experienta, nu trebuie sa neglijati problema.Cel mai corect lucru este sa faci asa cum faci cand observi ca se scurge putin ulei la masina , nu o lasi sa crape motorul ci  mergi la mecanic. Este normal sa ai aceeasi grija de propriul organism, mai ales ca piesele de schimb  nu exista.

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Medic gastroenterolog la Spitalul Fundeni

Secretar General al Asociatiei Romane pentru Studiul Ficatului

Steatoza hepatica reprezinta incarcarea ficatului cu grasimie, cauzele cele mai frecvente fiind consumul de alcool = steatoza alcoolica, dar si alte cauze- obezitatea, diabetul saharat, consumul unor medicamente -steatoza non – alcoolica. Desi pare un fleac, afectiunea poate sa evolueze catre steatohepatita, iar aceasta catre ciroza hepatica . Chiar si copiii pot avea steatoza hepatica – detalii in articol.

Care sunt cauzele steatozei hepatice? Ea am steatoza si n-am nici o cauza

Daca aveti steatoza hepatica, exista sigur o cauza chiar daca nu este evidenta in cazul dvs

Cauzele cele mai frecvente de steatoza (factori de risc) sunt:

• Alcoolul
• Obezitatea
• Diabetul zaharat
• Prediabetul (toleranta scazuta la glucoza)
• Sindromul metabolic (asociere dintre obezitate + grasimi crescute in sange + diabet zaharat tratat fara insulina + hipertensiune arteriala)
• Scaderea rapida in greutate
• Consumul unor medicamente ca anticonceptionalele – aveti pe site subiectul

Care sunt simptomele ficatului gras ?

De obicei afectiunea NU da simptome, sau da unele simptome necaracteristice :oboseala, lipsa chefului de viata, scadere in greutate (in fazele avansate catre ciroza). Nu trebuie saasteptati aparitia simpotmeor pentru a lua unele masuri impotriva steatozei hepatice, atunci poate fi cam tarziu

Cum se pune diagnosticul de steatoza hepatica ? Trebuie neaparat biopsie?

Sunt mai multe elemente care pot pune diagnosticul de steatoza hepatica :

1. Prezenta unuia dintre factorii de risc (mentionati anterior- obezitate.. etc)
2. Ficat marit si moale la palpare
3. Ecografia hepatica – care arata aspect caracteristic
4. Biopsia hepatica (este rareori necesara)
5. Steatotestul (NASH test) sau Fibromax
6. Analize de sange
   • AST
   • ALT; raportul AST/ALT<1
   • Fosfataza alcalina
   • GGT marit moderat
   • feritina serica crescuta
7. Uneori este necesar examenul CT sau RMN

PENTRU DIAGNOSTICUL DE STEATOZA HEPATICA NU ESTE SUFICIENTA DOAR UNA SAU DOUA DINTRE EXPLORARILE MENTIONATE, CI MAI MULTE.

Cat de frecvent apar complicatii in steatoza hepatica?

Desi poate sa para o problema simpla, steatoza hepatica poate creea mari probleme:

– 12% din cazuri evolueaza in 7 ani catre ciroza hepatica, aceasta la randul ei avand risc de aparitie a cancerului de ficat
– Creste riscul aparitiei complicatiilor in cazul operatiilor pe ficat
– Scade sansa de raspuns la tratament, daca la steatoza se asociaza si un virus
– Creste rapiditatea evolutiei catre ciroza daca se asociaza si un virus
– Evolutia catre ciroza este mai accelerata daca pacientul are steatoza si consuma alcool sau medicamente
– La cei cu ficat grad creste riscul de aparitie a unor boli de rinichi, plaman sau a diabetului

Care este tratamentul steatozei hepatice? Mie medicul meu nu mi-adat nimic…

Tratamentul steatozei hepatice nonalcoolice cuprinde sfaturi de viata, de alimentatie si medicamente:

• scaderea progresiva in greutate la obezi
• dieta alimentara echilibrata
• cresterea activitatii fizice
• inlaturarea consmului de alcool de orice fel
• renuntarea le medicamentele care nu sunt absolut necesare
• scaderea colesterolului
• echilibrarea glicemei la diabetici
• tratament medicamentos (are importanta mai mica decat celelalte metode enumerate anterior)

Sucul de fructe poate da steatoza hepatica?

Sucul de orice fel, inclusiv cel de fructe indulcit cu zahar sau indulcitori poate da steatoza hepatica. Cel natural, fara zahar adaugat, are si el zaharul lui, care ii da dulceata, deci poate contribui la aparitia steatozei, dar mai putin.

Pastele oceanic poate da steatoza?

Nu am auzit deasemenea posibilitate

Cu medicatie naturista se poate trata steatoza?

Nu ma pricep la acest tip de „medicatie”‘ in principiu medicatia „naturista” trateaza simptomele minore nu bolile grave (de aceea in perioada medicinii bazate pe mijloace „naturiste”, durata medie de viata a unui om era de cca 30-40 de ani). Steatoza hepatica este o boala serioasa care necesita un tratament standardizat.

La insulinemie 34 se pot consuma fructe?

Fiecare pacient trebuie sa aiba un medic care sa ii spuna ce sa faca i ncaz de probleme medicale. Problemele medicale nu se pot trata GLOBAL, „toti la gramada cu acelasi tratament in acceasi boala”, deorece fiecare organism are caracteristicile lui, omul nu este un produs „de serie” ca o masina, sa poata fi reparat standard. Medicul dvs care va monitorizeaza boala, poate sa vasfatuiasca, si trebuier sa va sfatuiti cu el.

In cat timp dispare steatoza cu regim?

Depinde, este diferit de la caz la caz, uneori nu dispare deloc (daca cauza steatozei este o exagerare a propriului metabolism, sau obezitate necorectata). In cateva luni – un an se vad efectele

Care este diferenta dintre ficat gras si ficat marit ?Ficatul poate fi numai marit fara a fi si gras in acelasi timp?Va multumesc pentru raspuns.

Ficatul marit poate fi cu steatoza sau nu, poate avea si alte cauze (cancet, icter, boli de inima, chiste, etc -le aveti pe site

Am vazut pe csid calculator de calorii, este valabil dupa parerea dvs?

Da, este o formula corecta pe cisd

How to Create a Question Speech

Secret limitations allow without letting others learn the messages they are transmitting, kids to communicate with friends. Parents may tuck a unique notice prepared in code within their lunchbox that is childs. Revealing communications that are secret can also be a good way for children that are young to rehearse their publishing and reading abilities. Key Letter Cipher In this way of key writing, the sender of the communication inserts a page at the end of each and every concept in the note and after that pauses the characters of the language up into various combinations. The receiver simply has to browse the key notification to unscramble the. For instance, ” Possess A day that is good, love you, mom”.Add a correspondence towards each word’s end. Words were widely used by use like „e” or „r” in place of words like „q” or „z”. For instance, ” havee daye lovee youe mome”.Rewrite most of the words of the information, including the key page into one concept that is long.

The writers while in the custom publishing organization should have numerous levels.

„haveeaegoodedayeloveeyouemome”.Next, break the message up into three-letter words.”hav eea vanity ode evening elo vee you emo me”.Let the individual understand, in another notice or telephone message exactly what the page that is crucial is really they can interpret the information. Write An Email Using Invisible Ink Miss composing messages in orange juice and rather stick on an item of paper that is damp onto window or a reflection to write the concept. Preserve a towel handy to wipe up the water that operates along the glass (and avoid doing this task near wood furniture).Dip a bit of plain white-paper right into a container of water.Smooth the report onto a mirror or window.Set a dry piece of paper over the moist paper.Write a note about the dried paper having a ballpoint pen. Holding a ballpoint pen only at that direction can prevent the printer from going. In the event the ink flows, it doesnt matter, the essential part is the stress the pen idea makes to the paper.Remove the dried document and place away it. Depart the soaked document in position on the glass. The communication will soon be visible but can vanish because the document dries. If the paper dries, it’ll falloff the window.Tell the notice person to drop the document in water to see the meaning.

Use phrases that are quick and immediate.

Key Code Crackers Produce the alphabet across the the top of page.Give each page several, but instead of starting the „A” as „1”, focus on another notification and after that continuing labeling the words in numerical termpaperswriter.org/research-paper-writing/ order. At „A”.Now, continue numbering after „Z”, create a note after which read it applying this signal. Thus, if the signal is set up so „M” is „1”, then „Have a good-day” becomes 22-15-10-19 15 21-3-3-18 18-15-13. Join the characters of individual terms with dashes.Let the page receiver know what notification to begin numbering the alphabet. To return and forth with words, a kid may, in the bottom of a notice, notify each other what letter to tag as „1” once they produce a response.Kids can have some fun writing records together with key rules or unseen messages. Terms could break up into habits that are puzzling, determine words a code, or write a key message on soaked report. They can deliver concealed messages to buddies or household while training their reading.

Here is a format that can simplify your activity of producing this kind of notice.

Whilst the www.abcpaperwriter.com College of Vermont at Chapel Hill highlights, instructors generally allocate assessment/contrast essays since such writing requires learners to research items or methods and reveal the similarities or variations between them. For example, an article might study how high school is much like – rather than like – faculty or the way the reasons for War I and two were similar and not same. The dissertation for an assessment essay explains the objective and corporation in one single brief sentence of the essay. Study the Project The dissertation confirms the key point of the composition. Does the job ask you to evaluate, distinction or equally? A dissertation asking distinction or to evaluate might examine, ” the game’s newest model varies from your older recreation in terms of cost, technological requirements and heroes.” Nonetheless, for a comparison and distinction, the thesis could be „While both use the same story-line and provide related hands per hour, the newest type of the game differs from the older sport with regards to figures, technological specifications and cost,” revealing the article will protect both parallels and variations. If the assignment demands you to claim a posture, reveal your position using a dissertation like „Although the latest model of the overall game differs in the older recreation with regards to heroes, technological requirements and cost, the older model is much popular with people.” Decide on a Topic After identifying the project specifications, come up with a subject that satisfies and produces an interesting composition it is possible to setup inside your thesis. In place of discussing evident similarities and variations, suggestions are explained by an assessment/contrast that is effective not easily apparent. For example, taking a look at the parallels between two models of sneakers may not be the most effective subject if such reviews are obvious. A topic selection that is more efficient could cause a dissertation including ” European football vary and National in score equipment and penalties.” While both activities are thought baseball, this report can address the contrasts.

The three-year-old has become in custody of the office of family and youngsters services.

Generate the Dissertation Set together to create a dissertation for your assessment/contrast article. The thesis’ principle part should clarify the significance of the similarities or distinctions in the document. This type of paper could fight this one political customer makes a better choice or that readers will see an authentic video more entertaining when compared to a remake. The thesis demonstrates the mindset that the major body of the essay may communicate, consequently produce a dissertation you are feeling you’re able to support with specifics within the article. Refine the Thesis Record the particular points you distinction or will evaluate inside the purchase they’ll come in the body. This structure gives a chart of one’s composition to the reader, either in point or a block format by level. While position by stage handles each similarity or distinction stop format covers each object in an individual part.

Take a look in the new age work at home plan for online financial liberty in easy 10 steps.

For instance, for your dissertation „The Morkie makes an improved puppy for children than the usual real Yorkshire due to its adoring perspective, playful personality and easy-care,” the body may have one-paragraph for your Morkie discussing every one of these principles followed by a passage about the purebred. The idea-by- business would have one for the attention then one-body sentence speaking about just how it contrasts together with the purebred followed by one in regards to the celebrities and the adoring attitude of the Morkie. The thesis sets the purchase of suggestions up.

5 Out-of-the-Carton Writing Motivate Companies6 Feed-back

Right away, we’re conversing with Stefanie Freele a poet and concise narrative contributor who dwells while in the North west. Stefanie can be described as Pushcart Reward Nominee and also publicized little stories in Glimmer Prepare, PANK, Sou’wester, Term Riot, R.KV.R.Y Quarterly Literary Record, Vestal Reviews, and many other. During the last 8 decades, she has submitted 99 quite short reviews. Isn’t that extraordinary?

Stefanie so i will be speaking of the appetite for newsletter, methods to know as soon as short experience is finished, as well as world’s need to have, or shortage thereof, for even more donut experiences. You can get Stefanie’s work on her web page, stefaniefreele.com, coupled with her two training books of original site simple tales, Providing Strays and In the midst of Waters.

Thanks a lot a great deal for becoming a member of us Stefanie!

For how long possessed you been writing previously your first quite short article was released?

I worked tirelessly on several small reports for two times ahead of I started sending them out. Upon loads of rejections, the initial experience recognised was „Cartwheeling” in South Dakota Report. Just what a celebratory occasion which has been!!!

According to your site, you published your first concise story in 2004, and afterward, you printed various each year. Was there a specific thing adjusted to cause you to so focused upon crafting fairly short accounts and becoming them revealed?

I went through a moment time period of simply being truthfully enthusiastic about sending reviews. That it was an especially prolific time frame also, well, i did actually have a lot of to send out out. At some time, I sent 365 submissions every year, the same in principle as a single each day covering the year. And, which was largely in-the-send submissions, just before the amazing creation of Submishmash (now Submittable).

Absolutely yes, I was being a minor crazzzzy: that initially acknowledgement obtained me hooked.

For an MFA student inside the Whidbey Authors Workshop (North west Institute of Literary Arts) I wrote a few new parts and because the Kathy Species of fish Fellow, Blogger In Property for SmokeLong Every quarter, I authored a bunch much more. And, then more and more. I don’t just think I’ve ever seriously has a writers’ inhibit in terms of imagination, a lot more of a writers’ prohibit in terms of existence stepping into inhibit the amount of time to publish.

You’ve been printed in a number of literary publications, equally make and virtual? Just how do you examine catalogs to get a match for ones reviews?

I generally use Duotrope to try the submitting explore as well as the contributor notices in the back of literary publications or at the back of Top American Shorter Reviews sequence. Once I seek for a tale I completely affection, I check out exactly where the article author is actually publicized and discover if that newspaper could be a wonderful match for my function.

Have you ever post a short storyline along with a selected mag in your mind?

You bet, a couple of times. Just a few samples – I created a item not long ago that we intentionally hoped Display Fiction Via the internet would agree to, and they also have And#8211; it will likely be being released very quickly, titled „How Have I Become The following Bruce”. Also, my account „Scantily Clad Submissive Wives” was unfinished, for the most part just remarks, but after reading a major issue of Pank, I ran across me personally inspired to complete it, and they recognised the tale: Scantily Clad Submissive Girls.

How can you determine a tale is finished?

Darn fantastic subject. The condition of simply being ended is a lot more instinctive than statistical. I have this sense a story has instructed its story, the articles are all there. I manage it because of a other copy writer or two for feed-back, and following that will it be completely low-scientific: it is focused on a gut experiencing, the experience of doneness.

What exactly several practices or methods you would probably advocate for freelance writers just getting started out creating and posting short testimonies?

Learn. Learn a lot of literary catalogues. Review the Ideal American citizen Little Reports sequence. When you get a storyline you love, separate it low, underline, make information, investigation the storyline.

What’s the worst tale you’ve at any time prepared?

There was clearly a story in regards to donut-eater i invested all the time editing and enhancing feverishly i with pride delivered it to my gentleman, Seth (who is often a initially viewer, marvelous editor, and champ of my effort). After looking at it, he folded away the document above and claimed incrementally using a somber look, „Does the entire world really want this donut narrative?” I proclaimed oh, and moved.

Cheers a whole lot of Stefanie! For extra frome Stefanie Freele, ensure you find out more about her web-site, stefaniefreele.com.

And if you would like to write and distribute concise reports, understand how by studying Let’s Create a brief Article! With well over 100 some-star assessments on The amazon website, it will likely be the start working the jeans you should get crafting.

Process

Now, look at a concise tale. And also, since we’ve just been speaking with Stefani Freele, article author of 99 of them, let’s look at among her reports.

Browse through on the list of right after or locate your own in her website:

• „Feisty Rojo,” released in Quarterly Western side
• „Cattails, Cakes, and Hugh’s Massive Toe,” circulated in The Pedastal Periodical
• „Zeal,” submitted in Night-time Train
• „Scantily Clad Submissive Most women,” posted in PANK

Benefit from!

I can’t produce my Dissertation perfectly although i know who is able to

It’s hard to accept but you can obtain a incredible Dissertation in a trio of numerous hours. Keep in mind that it will likely be appealing, with actual plan, fantastic format and useful subject material. Composed yourself it will eventually you should your lecturer and pass a plagiarism review with no labor.

Do you really continually keep in mind that it is designed in a couple of hours and hours? And completely from scratch?

How valedictorians send in Dissertations? (The bright way)

An individual who reached at this point (a final season of tests) realizes just a bit of simple fact about being productive academician.

Returns Matter much. The Way That YOUR Generate THEM Situations NOT

When considering this a valedictorian features an Dissertation crafting solutions. Following your graduation numerous secretly concede employing this aid some, very often. You give your subject matter, talk about criteria and delay until a posting specialist does your thing.

An critical invest in psychology dissertation topics in 3 or more countless hours. So no wonder a great deal of enrollees use experts’ support.

3 shorter positive factors that can make a longterm variance

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Vases animals and chocolates are just some of the items florists provide.

Writing An Ideal Personal Profile For A UK Online Dating Service The private account which you post onto a web based dating site is the key to achieving and luring the individual that is best. Specially when confronted with a bare computer screen nonetheless authoring oneself can be quite a daunting undertaking. You want to appear above all and assured but not pompous, separate but caring, ambitious but sensitive someone who on-paper symbolizes the real you. It can be very hard. An effective way to start out your account writing will be to take out a couple of minutes to write some feelings about yourself down on a little bit of paper. As an example solution the following issues about oneself: What am I prefer literally? Old am I, how large am I, what eyes and colour hair do I have? What’s my private circumstance that is existing? Where do I reside, what is my marital status, do I’ve children I performing? What do I like?

You may also look at the 3d images of what the pickup will appear like.

Do I am I a lover prefer being at residence or down the tavern or do I prefer other interests, what food do I like when was the final time that I’d a really good-night out? What am I looking for? I trying to find anyone to have youngsters with to wed or simply just to meet up with now and again for something and beverages to eat. What makes me particular? What can I offer another person, what do my relatives and buddies like about me, what’ve I realized in living? What’re my querks that is small? Do I like Brown gravy with everything, am I dependent on Eastenders, does politics produce my body boil, do I love red or white wine? What do I love in living?could it be hugs on the frosty evening, the Saturday Documents in Bed, football on Thursday with all the lads, jogging canine?

Don’t keep in touch with him, do not engage him, don’t pet him if he comes in your area.

These things all make-up pieces and the bits that make sure that you are a one-off, specific along with special. And these would be the tit bits of info that entice a like minded spirit for your account and ideally into your life. Once you’ve complied your record and given it some thought remain along yourself and publish your first draft recalling the following five gold principles: Be Straightforward! Imagine instead achieving a five foot one dog trainer and arriving to fulfill a six-foot two skilled polo person. The important thing to all associations is honesty of course if you’re unethical with you’re on a covering to nothing to start. Be yourself and become happy with who you’re, not who you could wish to be or feel that you’ve to be. A Photo Shows One Thousand Words! If you prefer more replies, add a good snapshot for your report.

After the clouds went fleeting, after a while the sky was lucidly sparkling.

Try to find one that effectively shows the way you look in lifestyle that is standard. About the method that you present your outfit as well as yourself think. Stuffing your rugby clothes down your Speedos and posing semi-nude showing off your once a fortnight gym muscles and tattoos indicating „I Enjoy My Momma” may at the time be considered a good idea nevertheless they are impossible to entice anybody who your mum could basically approve off. Likewise showing off your somewhat off-white and well washed Markings and Spencers Bra, gstring and Stocking Combination collection can entice a kind that is particular on interest in your report. Awareness which may not be welcome. Consider about dress accordingly and you intend to depict oneself. Read About www.termpaperwriter.org It!

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Think of a snappy topic. „Kid Seeks Girl” isnt planning to entice plenty of focus. Don’t wander too much from your truth although be innovative. „Brad look-a-like tries his Angelie – Jennifers will not need to utilize,” may capture people’s interest however, you might fall-down pertaining to your photograph! Get Actual! Disclose a bit of the you that are true. What’ve you been through in your lifetime, how has it formed you, what do you rely on?

You need to know what market you are targeting, before conducting a review in certain marketplace.

The particular the page the higher the answer. Simply do not uncover any particular contact details. Make Spell Check Your Friend First impressions count and you also do not wish your first effect to become damaging because of grammar or poor punctuation. Check if you will get someone else to test it and your account again and again again. One Closing Suggestion From Us When selecting your website username prevent phrases such as rabbit furnace, upset stalker, awful cow or nutcase. They will probably switch off any particular one individual whom you were destined to meet and quickly think of associations that are bad. Remember your online report is all about showing yourself within the lighting that is most great. Once you’ve posted it on the website, evaluate it again and now.

A kind „family” contains exclusively executed versions of the single typeface.

It could not be somewhat cringe unworthy to re-read take out the time to be sure that it is undoubtedly reflective of the individual although it you wish to be seen as. UK online dating service speed dating UK

I would like to give more types of phrases using these phrases to you.

Are you wanting to write a relationship book that may provide you with the name of a writer, or perhaps for enjoyment? it is enjoyable, although composing romance novels are not any matter http://researchpaperstar.com/ that is straightforward! Though there’s no correct „system”, there are some tips as possible follow. Advertising Steps Romance Novel Products Writing Your Own Romance Novel 1 Determine whether you’ll wish to provide your guide online, before beginning to create your love story or send it to a author to have of promoting it in stores, a more likely chance. Ad 2 They’ll toss the book in case you elect to send to some publisher, get a fictional representative. Get the representative you have in mind’s contact info. So you do not have to go search for this stuff again, preserve this in a protected place. If you’re currently planning to promote your book online, feel the movements of submitting a guide. Don’t publish something, however, only follow the principles firmly.

The fact of the response letter will be the etiquette followed in its vocabulary.

Consider up characters two principal characters, the main two different people while in the novel. They could be affected by think about perhaps, and past functions in their existence that. What’re their disadvantages and talents? Have they’d loves? Get to know your figure. People are a massive part of a romance book. For the contributes to appear „sensible” (if that is what you’re choosing), you should let them have weaknesses.

Tell a child about place perimeters between her as well as the crowd.

Nobody is perfect, so just why create your people perfect? (Nevertheless, producing them seem excellent to one another is completely great, so long as they’ve their imperfections underneath it all.) Do not have your main heroes enthusiastic about one-person or just one matter. The reader should be ready to make it to realize them beyond their passions that are passionate. 4 Choose their ages. Depending the group you’re writing this relationship for, pick the ages of the characters on. You will need your relationship novel to become relatable, therefore producing a grownup relationship story centered on fifteen-yearolds will not be a huge hit. Viceversa, if you should be publishing a romance that is young adult, try not to make them fortysomething, or even thirty-something, as these are the ages of the parents of the kids who will read your romance. Teens and tweens use more romance books, so it would not be worst if your people ranged from about 18 to 24.

By receiving more requests than they can provide, some firms prefer to earn money.

Strong your characters’ ages to the generation of people you want to study your romance. 5 Choose the location. Today if it’s later on, it probably won’t look like the world. Try making your own personal globe up if you are creating supernatural romance. Base it on what sub genre your love is on. Should you choosenot want to you don’t have to get super specific, but your visitors could have a less strenuous time should they may photograph the location, believing the tale. Additionally, the setting might help create your charactersif it certainly is sunlit, maybe one longs to live in a spot where it rains one day etc. Think of activities that really make your story a relationship. Include gatherings that have to do with romance, like dates breaks.

Atleast the versions that are wooden do.

Think of intriguing tips, not the same kinds that stories that are other purchased. Possibly one is hoping to get along with them, and of the characteris ex is envious of the partnership, or the parents might not accept and choose another associate for your character. Don’t forget to utilize different people in your guide too, like exes, parents, (whether or not it’s about teenagers), and friends. Do not usually create these activities a „picnic inside the playground with butterflies everywhere ” or just like a ” divorce, date, marriage, divorce, date, cheat, break up.” You would like your love story to standout from the relaxation. Provide the pair their share of difficulty on the way. The complete „son-meets-lady-and-they-drop-in-love-and-stay-fortunately-ever-after” matter is kind of a mainstream idea. Create it interesting, for instance, ” boy-satisfies-girl-and-they-hate-each-other-until-boy-considers-girl-getting-drunk-and insane-at-a-party-and-requires-her-on-a-pity-date-and-she-finds-out-about-the-disgrace-element” Yes, it’s really a prolonged circumstance, but it’s much more complex.

Louie lived to tell about it and experienced both odysseys.

Depending on what kind of romance you are creating, generate distinct dilemmas for the characters, including she’s a ghost, heis older than her and her household doesn’t agree 10 years, she’s impaired, he’s in the potential, Publish credible dialogue. „Um…I’m Charlotte. Do I am aware you?” seems credible. Feel free to provide them with cheesy dialogue like, „You have the absolute eyes that are most awesome.” Nevertheless, don’t fillup the whole story with goofy compliments. Romances must not be emotionless! Give sensations to them! Contain terms that are descriptive.

You will are part of a-team with additional researchers and medical doctors to conduct study.

„Good” or „Neat” sound unprofessional and are inclined to stop readers. 8 Start writing/typing your book. Think about a start that is hooked, like one-of your figures teasing with another individual they like, or if it’s paranormal, it might start in a magical place. That you don’t must stay with the outline, nevertheless, you should abide by it. Also think about an ending that is good. Many endings will be the two heroes living happily-ever after, but why don’t you attempt something different? The ending will soon be remembered, so that you should make it really good! Stop the story well. You’ll be able to create a relationship story that is amazing, if your ending is not sufficient, it will just be recalled as’ok’ or’I loved it, but the ending was poor’.

That features when he declares howmuch your activities injured him, silently hearing.

Because you’re fed up with plodding through chapter after section, don’t rush the closing. It’s best not worst to finish the story using lady and the dude getting. Since they desire the person and the gal to be together this will make the followers truly happy! Like you’ve to finish the book using the two primary people living happily after, nevertheless, do not feel. Have a look at Romeo. 10 Use punctuation, spelling and appropriate syntax. No one really wants to examine something which is really check as and as improperly worded, „and Dorothy, like, just went along to the toilet n never came back again actually and everybody was real unhappy. THE CONCLUSION, cheers for readin my guide, her’es my email, tell all ur buddies round it, BYE!!!” It’s probably no-one can acquire it.

Step 3: now begin writing your record that is personal.

They WILL preserve having your story changes until you end making problems/problems if you’re delivering it to some fictional agent. Don’t adjust the story if you have to revise anything! The broker could’ve rejected it if it was a really poor account, therefore if it has n’t been rejected by them up to now, do not modify something! (Besides faults the publisher wants one to correct.) 11 Have your novel is checked by your pals. Require critique, otherwise you will not get any benefit. Possess the tale released whenever they truthfully want it! Advertising We could genuinely use your support!

Do claim: add fats with some vitamins and minerals for the foods you presently eat.

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Composing the date is very vital in response words.

Remember detail is much better. Tips Present details. Please be comprehensive as you can in your explanation. We revise it for reliability and clarity will consider your detailed data, and incorporate it into an article that will help thousands of people. Do not say: Eat fats. Do state: Incorporate fats with some nutritional value towards the ingredients you presently eat. Attempt grape, butter, olive oil, and mayonnaise. Guidelines Don’t expect prompt success!

Add a rhyme to the organization title.

You may not get your book most likely and posted you’ll have to deliver it to multiple writer before it gets accepted. Just remember possibly massive brands, like Charles Dickens or J.K Rowling, had guides refused before. An outline will help you get organized and will give a standard review about your relationship to you and what things to include inside the book. If you want aid, Observe to Write an Outline. Avoid being pretty quickly to really get your books performed. A book requires a lot of responsibility and period thus take your time and try your best. Check spelling your language, syntax, and punctuation! Microsoft Term can be an excellent book-publishing word processor.

Existence clean will be kept by presenting goal to our lifestyles and encourage us.

While you have to pay, not always! Here is another trial offer if you prefer, first. But when you’ll be writing a guide that is very prolonged you can buy this system before your trial timer operates out! (Around 180 times to utilize the test). There is a great free option ” Open Office Author” that may enable you to conserve directly to the pdf-format employed by units. Alerts Avoid the several publishing firms that consult that you spend profit order in order for them to study your guide, change it, and promote it. It truly is likely they might be a scam!

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Furthermore, beware publishers that are online, they may be a fraud. If you intend to publish it by way of a history manager first do not release your books online. Selfpublishing has become increasingly more practical, and several Relationship novelists are selfpublishing their backlist (formerly revealed book fiction) as e-books. This method has gained enhanced revenue and a better audience to them. For many future Love authors (or creators of Enchanting tales that weren’t accepted by legacy marketers), self-publishing for e-readers has assisted them obtain a market and boost their revenue. In this age of digital books, bypassing the heritage publishing homes can not be unremunerative, nevertheless, you must be able to operate your personal enterprise and market yourself greatly. This means taking into account period that is howmuch will soon be used far from your Relationship novel writing.

Once the quality analyst ensures the item is ready, the program is released for creation.

If you think your guide is actually great but a specific critic-like pal says that it „stinks”, don’t think them! Then it’s really good, if everyone else whois only an average person truly wants your guide and you may obtain a large amount of sales. Things You May Need Computer/notebook Pad (if you are using a notebook) Tips

Sunt frecvente situatiiile in care un pacient vrea sa faca o ecografie, ca sa se vada „toate modificarile si bolile” de care sufera.
Ecografia este o metoda de explorare utila, dar care are anumite limite, nefiind utila in toate situatiile.

Ce se vede la ecografia ficatului?

In principiu modificarile care se vad la ecografia ficatului pot fi descrise ca:

• Formatiuni hipoecogene (adica cu ecogenitate mai mica decat ficatul  normal)
  • metastazele hepatice
  • limfoamele hepatice,
  • abcesul hepatic,
  • hematomul hepatic
  • chistele hepatice complicate
  • adenomul hepatic
  • hiperplazia nodulara focala
  • hemangioamele hepatice atipice
  • focare de steatoza hepatica
  • vasele sau caile biliare,
  • cancerul de ficat
  • lipomul hepatic
• Zone hiperecogene (cu ecogenitate mai mare decat structura normala a ficatului)
  • metastaze hepatice
  • carcinom hepatocelular
  • colangiocarcinom
  • hemangion hepatic
  • tumori pseudoinflamatorii
  • focar de steatoza
• Imagini izoecogene (cu aceasi densitate ecografica cu ficatul)

Cand este indicata ecografia abdominala in general?
Explorarea ecografica  a abdomenului este utila in principiu pentru:

• depistarea modificarilor de structura aparute in organele solide:

• Ficat (marime, chiste, hemangioame, tumori, calcificari)
• Pancreas (marime, chiste, pseudochiste, tumori) – ecografia vede modificarile pancreasului mai putin bine decat pe cele ale ficatului-
• Rinichi (tumori, pietre, marimea si forma rinichilor)
• Prostata (marime, omogenitate)
• Uter si ovare
• Splina (marime, tumori, chiste)
• Ganglioni abdominali mariti
  

• depistarea unor modificari in organe tubulare:

• vezicula biliara si caile biliare (tumori, pietre, malformatii, dilatari, etc)
• vezica urinara (tumori, pietre, conturul prostatei, etc)
• uretere (dilatare)

• evaluarea prezentei lichidului (ascitei) in cavitatea abdominala

• evaluarea diametrului unor vase sanguine, care au semnificatie in diagnosticul unor boli (aorta, vena cava inferioara, vena porta, venele suprahepatice, vena splenica, arterele renale, etc)

Ce nu poate depista o ecografie abdominala?

In principiu ecografia abdominala nu poate da date certe referitoare la:

• Organe tubulare (stomac, duoden, intestin subtire si gros) – modificarile lor se pot evalua ecografic doar in situatii speciale.
• Hepatita (desi poate evalua ficatul, nu poate preciza diagnosticul de hepatita – in schimb pe cel de ciroza il poate pune)
• Pielonefrita
• Infectie urinara
• Ulcer, gastrita. colecistita (poate doar suspiciona acest diagnostic)
• Apendicita
• Colon iritabil

Ce poate depista o ecografie a ficatului sau cailor biliare?

• Modificarile scografice ale ficatului vazute la ecografie sunt
  • ficatul gras (reflectivitatea ficatului este crescuta) – vezi poza
    
  • tumori de ficat
  • chiste hepatice
  • hemangioame hepatice
  • modificari in ciroza (ascita, marirea venei porte, marirea splinei, modificari ale colecistului)
  • calcificari in ficat
  • marirea cailor biliare
• modificari ale colecistului (veziculei biliare)
  • colecist cudat
  • reziduu biliar
  • noroi biliar
  • colecist septat
  • pietre in colecist = litiaza veziculara
    
  • colecist marit
  • colecist cu perete ingrosat
  • polipi in colecist
  • lipsa colecistului prin scoatere chirurgicala
  • lipsa de vizualizare a colecistului (uneori colecistul nu se vede ecografic, desi exista, nu a fost extirpat)

Ce nu poate depista o ecografie hepatica?

O ecografie a ficatului poate fi perfect normala in urmatoarele situatii

• transaminazele crescute
• inflamatia ficatului
• fibroza ficatului
• virusurile hepatice
• hepatita cronica cu virus B sau C sau D

Cat de des se poate face ecografia?

Deoarece ecografia nu prezinta risc pentru sanatate, se poate face ori de cate ori este nevoie, fara nici un pericol.

Ce pregatire trebuie sa faci pentru ecografia abdominala?

De obicei ecografia se face cu bolnavul nemancat – dar acest lucru nu este absolut obligatoriu in urgenta- .

Daca se doreste si examinarea ureterului, prostatei sau vezicii urinare, este bine ca bolnavul sa nu fi urinat de cel putin 4-5 ore (sau de seara pana dimineata).

Ce trebuie sa faci atunci cand ai modificari gasite la ecografia hepatica sau biliara,sau alte analize hepatice modificate fara a se fi depistat cauza sau tratamentul?

Daca aveti probleme hepatice nelamurite este normal sa fiti ingrijorat, dar nu trebuie sa fiti fiti disperat, dar nici sa neglijati o situatie trenanta.

Va spun din experienta ca orice situatie medicala poate fi lamurita, iar  daca apelezi la medic in timp util ea poate fi si rezolvata, trebuie doar sa cauti specialistul potrivit situatiei respective. Situatiile simple pot fi lamurite practic de orice specailist, iar pentru cele mai … ciudate trebuie apelat la un specialist cu experienta, care a vazut multe in carierea lui,

Cel mai corect lucru este sa faci asa cum faci cand observi ca se scurge putin ulei la masina , nu o lasi sa crape motorul ci  mergi la mecanic. Este normal sa ai aceeasi grija de propriul organism, mai ales ca piesele de schimb  nu exista.

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Cum se pune diagnosticul de hepatita cu virus C?

FIBROZA HEPATICA poate fi mai mult sau mai putin evoluata, astfel

Alte metode de evaluare a starii ficatului in infectia cu virusul hepatitei  C

Biopsia hepatica se face de mai multe decenii, fiind o explorare relativ sigura; deoarece multe persoane se tem de aceasta explorare, mai ales datorita durerii (de altfel moderate, deoarece se face anestezie), s-a cautat gasirea unei formule de calcul prin care sa se estimeze indirect gradul de fibroza si inflamatie a ficatului.

Evaluarea bolii de ficat prin analize

Existe numeroase teste noninvazive (markeri serici) de evaluare a fibrozei si inflamatiei hepatice elaborate de-a lungul anilor prin luarea in calcul a diferite analize, cu prelucrarea matematica a rezultatelor, cele mai importante fiind enumerate mai jos, iar alaturat graficul corespondentei intre cele mai importante teste noninvazive hepatice:

Una din formulele de calcul folosite curent in Romania numita fibrotest  utilizeaza 6 analize de sange obisnuite, valoarea lor fiind supusa unei formule de calcul matematic, parametrii folositi in calcul fiind:

• Alfa2-Macroglobulina
• Haptoglobina
• Apolipoproteina A1
• Gama-glutamil transpeptidaza (GGT)
• Bilirubina totala
• TGP / ALAT

In afara de cele sase rezultate ale analizelor, mai sunt luate in calcul varsta si sexul pacientului.

Pentru elaborarea acestei formule, initial au fost studiati pacienti cu biopsie hepatica si analizele mentionate, si comparand cele doua tipuri de explorari, a fost elaborata o formula de calcul, care sa permita deducerea indirecta a gradului de afectare hepatica, fara a mai face biopsie hepatica.

Rezultatul explorariilor de laborator  este convertit intr-un scor de la 0 la 1, graficul fiind colorat in functie de  severitatea fibrozei sau activitatii inflamatorii , in paralel fiind prezentata si o estimare histologica conform scorului METAVIR (cu fibroza F0- F4, A0-3). Este evident ca modificarea unei analize se reflecta in modificarea scorului de inflamatie sau fibroza a testului, uneori acest rezultat fiind fals pozitiv (aratand o afectare hepatica mai mare decat cea reala estimata prin biopsia hepatica).

Exista dezavantaje in evaluarea fibrozei  si inflamatiei ficatului prin Fibrotest/ Actitest/Fibromax

Desi pare o metoda mai putin traumatizanta (se recolteaza doar sange), evaluarea fibrozei hepatice prin analize de sange are si destul de multe dezavantaje:

• Este o analiza relativ scumpa, si nu este decontata de Casa de Asigurari de Sanatate
• Pana la 5% din cazuri nu pot fi interpretate.
• In 25% din cazuri exista discordanta (mai mic sau mai mare) intre fibrotest si biopsia hepatica; se considera ca cu cat fragmentul de biopsie este mai mare, cu atat diagnosticul este mai corect; la un fragment de biopsie sub 25mm, fibrotestul si actitestul dau rezultate mai corecte, iar la un fragment de biopsie mai mare de 25mm, biopsia da diagnostic mai sigur; de obicei fragmentele de biopsie hepatica sunt de peste 30mm
• In afara indicatiilor de explorare (hepatitele virale B,C,D, hepatita alcoolica sau toxica, steatoza hepatica) metoda nu este operanta in alte situatii, neputand sa puna diagnosticul de tumora hepatica, sau modificari histologice ale unor noduli hepatici.
• Metodele serice permit diagnosticul de ciroza dar fac mai greu diferentierea dintre diferitele stadii vecine ale hepatitei cronice (adica pot confunda o fibroza 1 cu una 2 sau invers)
• Asa cum am mentionat deja, Fibrotest poate da rezultate neconcludente fals pozitive (supraestimeaza gravitatea bolii de ficat) in caz de:
  • Cresterea transaminazelor  sau GGT de alte cauze decat o boala hepatica cronica – hepatita acuta virala sau de alte cauze -medicamentoasa, alcoolica, toxica
  • Cresterea bilirubinei din alte cauze decat boli inflamatorii hepatice – hemoliză severa, icter mecanic, sindrom Gilbert, etc
  • Modificarile analizelor care apar intr-un sindrom inflamator acut

Evaluarea fibrozei hepatice cu ultrasunete – un fel de ecografie sau RMN

Evaluarea fibrozei hepatice fara biopsie se poate face – in afara de analize- si prin alte metode:

• Fibroscan
• Elastografie in timp real
• RMN cu dublu contrast cu gadolinium

Fiecare dintre metodele mentionate (biopsie, markeri serici, elastografie sau RMN) are avantaje si dezavantaje, iar in cazurile litigioase, in final tot biopsia hepatica lamureste lucrurile

Daca cele scrise mai sus v-au ajutat, este bine, inseamna ca nu am pierdut degeaba sute de ore ca sa scriu materialele medicale postate pe net si sa raspund la intrebarile pacientilor in loc sa odihnesc sau sa  ma plimb.

Ce trebuie facut cand aveti probleme cu fcatul?

Am vazut numerosi pacienti disperati din cauza unor probleme hepatice nelamurite in ciuda consultatiillor medicale facute in diferite locuri, uneori la specialisti fara nici o legatura cu hepatologia sau gastroenteroogia, disperarea lor fiind de obicei fara motiv.

Daca aveti probleme  de genul celor descrise in articolul pe care tocmai l-ati citit nu trebuie sa fiti disperat, dar nici sa neglijati problema, cel mai intelept este sa mergeti la un specialist gastroenterolog sau hepatolog competent pentru o evaluare corecta a situatiei, amanarea putand avea consecinte neplacute, uneori ireversibile. Nu mergi la mecanic cand a crapat motorul masinii, ci cand ai vazut o picatura de ulei scursa sub motor. Este normal sa avem aceeasi grija si de organismul nostru, mai ales ca ….  nu avem piese de schimb. Va spun din experienta mea ca pentru orice problema medicala exista o rezolvare corespunzatoare, trebuie doar sa gasiti un specialist cu experienta in prpblema respectiva.

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With going cages piling around so many legalities and you to deal with, you’ve time for contemplating change of address postcards. The next free types supply possibilities for everyone, and certainly will produce a new handle a breeze’s educating individuals. Using Our Change of Address Postcards Clicking on any of the photos under will take you to a larger model of the graphic to help you have a greater search, whereas utilising the download link means you can easily save the change of target format to your drive, and print out for the personal use. All pictures are online in JPEG structure, meaning it is possible to transfer them into several software programs to either produce since they are, when you wish to make them all your personal or even to adjust. The conventional rating for postcards is 6″ x-4″, which is what the postcards’ proportions all calculate, before they start getting distorted however they all should scale up and down very easily to within two or an inch. We have Flown The Nest This design that is original has space for text straight underneath the henis nest’s image, or this area could be left bare efficiently too, writing a term paper how to speak properly utilizing it alternatively being an expanded framework. Whichever method you determine to utilize this change of address postcard, there’s lots of area while in target details’ goose-egg blue room at the end of the card, for the change.

Tips & alerts should you strikeout with one-source, try another..

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If she really wants to hug, she will not turn you down.

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Dissertation theme will include dilemma or a, which drives to think.

You’re liberated to use the layouts for use that is particular although not within an enterprise that is commercial. Image Credits: Home that is cartoon Chicken’s home – Clipart ETC Door – Gezim Mavric/ Flickr Paw Print – Clipart For-Free Buckingham Palace, Googleearth

Sometimes there may be a laugh the only weapon we have. Rabbit Though I wrote my book, The Courage to Laugh: Wit, Trust and Healing inside the Encounter of Demise and Dying, my father died. Year’s Eve 1996, he was taken fully to a medical facility. Eight days later, simply hours after my mum called to inform me he looked better, my dad was no further alive. I got on a jet that required me from my Florida household to my mommy’s property in Florida also to the burial following a rapid phone call to guide a journey and merely two hours of sleeping. I was able to hold-back my holes till I had been around the airplane. There, nevertheless, amidst business-men using the press of laptops as well as phones, I sat sobbing. Thus below I was, I imagined, while my dad died, authoring humor and death.

Do not be worried about style! we will look after it.

The world was evaluating me to view if I could find anything interesting inside the situationand I failed. I discovered nothing to laugh about because his demise washed over me’s jolt. Nothing hilarious that’s, before the flight attendant pushed a-cup of warm liquid under my nose and commanded, „Here. Drink this. I guarantee it’ll support.” „What is it?,” I requested. ” Coffee and Bailey Creme,” he explained. That’s when my tears mingled with fun. To start with, it was eight o’clock while in the morningnot just cocktail hour. Next, I chuckled because I never consume caffeine and, since I have am intolerant, I avoid milk productsespecially lotion.

This type of writing may be used for equally, fiction and non-fiction.

I declined the attendants suffering-comfort treatment but there was anything unique about it anyhow. Its amusing irony all built me laughnot fun big enough to totally end the tears but an inner chuckle that felt whispered and not uncomfortable that everything would not be all amiss. Then I had dissertation chapter outline how-to research an interest another cosmic chuckle. I recognized that I was merely given phrases for my guide to the opening. During the next few days, I cried alot. I had been experiencing alone and very prone. My tears were allowed by me to circulation although our mommy kept declaring never to cry. I pointed out that notwithstanding the disappointment of the specific situation, hilarious situations occurred anyhow. These attracted me away from my tears and created sets from a smile.

Reduce details to save declutter and space your site.

Among the funniest situations came once we were having a telephone conversation together with the rabbi. Inside the Jewish religion, it’s normal for the family that is immediate to sit Shivah for seven days following the memorial. Relatives pals and neighbors drop by to pay their condolences during this time. My mom had a of the tongue although showing the rabbi where he lives that my brother could be finishing his Shivah in Ct. In place of expressing ” Shivah „, she blurted out, „Shitting Sivah.” My brother and that I immediately convulsed with wit. The telephone was, recognizing what she had claimed, shoved by our mom in my palm. She was chuckling way too hard to speak.

Each idea gets a unique passage.

For the next couple of days, as I went right through this roller coaster ride of wit and tears, I discovered a number of things about humor and sadness. I realized that it could take a while to find fun following a loss. I discovered also that it may not always function as the fall-down-carry-your-tummy form of wit that we had experienced when my mum got tongue tied. Occasionally its merely an intrinsic giggle. But whichever type it’s, it’s there. It’s there to supply a brief respite. It is there to show us that indeed living goes on despite our loss.

The corporation has produced by 1000% in 13 years and it has strategies for further extension..

It is there to give us trust. In case you have lost somebody expensive for your requirements lately, I will not inform you to see this guide since, since I was told by the flight attendant, „I ensure it will enable.” An immediate suffering cure can not be guaranteed by any one; I don’t think there is one. What I – can declare from my own encounter, however, is the fact that laughter might help. Probably it will give you desire to proceed along with an essential respite from your own tears. When Shivah is sitting, it’s traditional for callers to bring food to the house so your surviving do not have to prepare or preparing meals. Remembrances of the deceased are frequently discussed, while there. Typically it features some lighthearted moments inside the deceased’s existence. Such as the food that the condolence callers bring to supply nutrition for the physique, I really believe the items they laugh provide diet for that soul.

3 Composing Tips You Are Able To Take From Animators31 Observations

As a bit of you might or might not know (for the way normally you browse the opinions at the Generate Training), I relocated to Denver at the outset of September from the Pittsburgh section. I’m helping to make my way close to and not using a family car, which is doing exercise alright for my situation since i have are located approximately some bus wrinkles, and it’s only one 20 or so or 25 minute travel to my clinic.

But also for the first few occasions, I leased an auto to work some rudimentary errands. When I went to the flight terminal to return the rentals, I witnessed this remarkably instructive authorize from the air port.

And this also gives you me to today’s grammar training: how and whenever to work with quote signifies.

Estimate represents have acquired new obligations in creating previously fifty years. Formerly, these were fairly specifically utilized to tag dialogue. But http://www.writemyessayfast.co.uk the creation of sarcasm and facetiousness into our everyday lives, they have got noticed a completely new motive.

Let’s explore today’s benefits of quote scars.

1. Estimate spots designate dialogue.

This might be the very first thing you learned about estimate marks in level institution. When minimal amount of Johnny and Sally have their very first interaction about monitoring Notice operated, their discussion was marked by quotation scars.

See Place managed, Johnny, expressed Sally.

Detect operates quickly! claimed Johnny.

Managed, Recognize, managed! claimed Sally.

Not a thing want with that. When a professional starts speaking, available the quotation represents. Once they put a stop to, in close proximity the quote markings. You should make sure your ending punctuation is into the prices.

2. Estimate represents specify titles of poems, content or shorter gets results of creating.

Robert Frost’s Stopping By Forests with a Snowy Nighttime is one of my earliest reminiscences of exposure to poetry. Hemingway’s Brush Cerebral vascular accidents is regarded as the favorite place around the Compose Process.

When you are making benchmark onto a scholastic piece of writing, local newspaper guide, or nearly anything the same, use estimate markings all around the title on the report/poem/blog post.

3. Estimate signifies demonstrate the utilization of sarcasm, irony, euphemisms, or slang.

It’s turn into a thing in United states lifestyle to operate atmosphere offers. I fully grasp now we have some overseas audience, so for all new, environment prices are once you get the first two fingers on your fretting hand and curl them like bunny ear.

The dude during this Wikipedia short article has it along.

Fresh air rates specify that what you’re declaring ought not to be applied at skin appeal. You are to be sarcastic or telling lies in full. Inside of your crafting, they’re widely used likewise. To give an example:

Alice sat for a recreation area counter and looked at the runners change their heads towards her, working to make eye contact.

The estimate scars in this particular case in point demonstrate the fact that joggers aren’t operating much as verifying her out, and are usually currently being fewer than subtle about this.

Going back to the illustration of the authorize via the flight terminal over, the prices around secrets would tell us how the hire capability doesn’t imply to keep your legitimate tips in a vehicle, but since they naturally do want you to exit your keys, the estimates the following are completely incorrect.

Grammarphiles all around you are outraged.

PRACTICE

Just about every individual has the right to are now living a grammatically suitable community.

For quarter-hour, post a message of protest chastising your car lease bureau. Ensure that you use numerous pricing quotes (in the right way) that you can. Be sarcastic. Cite made-up articles and reviews as solutions (having the titles in price quotes, surely). Then finally, use some conversation basically to display this bureau the best strategy to use insurance quotes.

Write-up your message of protest with the remarks. We’ll produce them out and give these phones the vehicle hire organization to obtain these people to improve their stinkin’ authorize.