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It is caused when excessive amounts of thyroid hormones are released during the operation medicine to stop diarrhea cheap 2mg kytril. This can affect people with hyperthyroidism who are not well treated with appropriate medication before their operation symptoms concussion buy kytril 2mg overnight delivery. The symptoms are fever symptoms 7 days past ovulation purchase kytril 2 mg on-line, weakness treatment innovations generic kytril 2 mg on line, palpitations, changes in mental status and, in some cases, coma (loss of consciousness). Death from thyroid storm is in the range of 20-30% (20-30 in 100) in people who experience thyroid storm. Risks of general anaesthesia: Modern anaesthesia is very safe and serious problems are uncommon. The risk to you as an individual will depend on: whether you have any other illness, personal factors (such as smoking or being overweight) or if you are having surgery which is complicated, long or done in an emergency. Please talk to your anaesthetist about any pre-existing medical conditions you have, including any allergies. Pre-operative assessment Before your operation you will need to come for an appointment at the Pre-operative Assessment clinic. At this clinic we will ask you for details of your medical history and carry out any necessary clinical examinations and investigations to make sure you are ft to have the operation and anaesthetic. We will ask you about any medicines or tablets that you are taking either prescribed by a doctor, bought over the counter or herbal remedies. It helps us if you bring details of your medicines with you for example, bring the packaging with you. If you have any further questions, please ask a member of the surgical team on the day of your operation before signing the consent form. What happens on the day of your operation We have a separate leafet which explains how you should prepare for your operation, fasting instructions, the admission process, and going to the operating theatre. When you come into hospital please bring all your medicines with you in the special green pharmacy bag, which we will give you at your Pre-operative Assessment appointment. Recovery after the operation You will wake up in the recovery area with an oxygen mask on your face. The recovery nurse will look after you until you are awake and ready to go to the ward. Once you are able to drink without feeling sick, you will be able to have a warm drink and something light to eat. When you get out of bed for the frst time a member of staff should be with you in case you feel light-headed or dizzy. After your operation Thyroid function the day after your total thyroidectomy we will test your blood to check the level of active hormone and you may be started on thyroid medication. If all of your thyroid gland was removed you will require lifelong replacement of the hormone it would have produced, thyroxine. This is a straightforward once-a-day tablet with little need for adjusting the dosage over time. It is very important that you continue to take it every morning, as you need more energy in the early part of the day. If only half of your thyroid was removed (thyroid lobectomy) you will not need any thyroxine tablets. We will carry out a blood test to check the function of your remaining thyroid at your follow up appointment. If you are having a thyroid lobectomy you may be discharged on the same day as your operation. Wound care Your wound should be kept dry for 48 hours and it can be left without a dressing. You are likely to have dissolvable stitches which do not need to be removed; your nurse will let you know the type of stitches you have before you are discharged. The Steristrips should stay on for one week, after which time you can remove them. You can shower 48 hours after your surgery, but shouldn?t have a bath, as this will make the Steristrips peel off too early. Follow-up We will give you an appointment to be seen in the Outpatient department about six weeks after your operation. At this appointment the surgeon will talk to you about the results and any further treatment and follow-up you may need. This is to check whether your parathyroid glands have been affected by the operation. You will normally be well enough to return to work in 1-2 weeks, but this will vary depending on the type of work you do. You can drive as soon as you are able to perform an emergency stop without pain, but also check with your insurance company, as policies vary. You should not drive, return to work, drink alcohol, operate machinery, sign any important documents or be responsible for small children in the frst 48 hours after your operation. General anaesthetic can still affect your judgement during this time, even if you think you feel fne. If there is any information in this booklet that you do not understand, or if you are unclear about any other details of your operation, please speak to one of the surgical team. Please do not sign the consent form until you are happy that you understand the information and that any questions have been answered. Your risk for Graves? disease is higher if you: A: Graves? disease can lead to an eye problem called. Have a history of infection with the virus that causes will depend on how serious your eye problems are. Smoking is also a leading risk factor for the eye problem seen in Graves? disease called A: Left untreated, Graves? disease can cause: Graves? ophthalmopathy. Too much thyroid hormone can cause irregular menstrual periods Q: What are the symptoms of Graves? disease? Bulging, irritated eyes (called Graves? ophthalmopathy) can make it harder for women with Graves? disease to get pregnant. Thickening and reddening of the skin, especially disease have problems getting pregnant. These blood tests look for antibodies of pregnancy, but it may get worse after delivery. This suddenly increases your heart rate, blood pressure, A: There are three main treatments for Graves? disease: and temperature to dangerously high levels. Heart problems, such as irregular heartbeat thyroid gland from making too much thyroid hormone. This cures the A: To diagnose Graves? disease, your doctor will do overactive thyroid gland, but it can lead to underactive a physical exam and may do some tests including: thyroid gland. M ostA m ericans get enough iodine from iodiz ed table saltand certainfoods (eggs, dairy,m eat,seafood) H ow com m on is th yroid issues? A lien snatch ing ourth yroid glands W h atis th e m ostcom m on cause of h ypoth yroidism (? slow th yroid?)in th e U S A? A lien snatch ing ourth yroid glands S ym ptom s ofH ypoth yroidism (? S low T h yroid?)? Y oung people and ch ildren are ath igh er risk (over40 years old usually don?tneed it) Picture:citiz ented. Lassmann and the administration and patient preparation techniques to Department of Nuclear Medicine, University of Wurzburg, be used. Lassmann therapy and alternate or additional treatments to this e-mail: lassmann@nuklearmedizin. Consecutive autopsy studies have shown that papillary microcarcinoma Definition and goals is frequent in the general population. It seeks to eliminate thyroid remnants to relatively high, reaching 10?30% [7?10] in some series. This state of affairs has driven the [15] and serves to treat any microscopic tumour deposits. Indeed, outcome has been shown to be superior in patients with radioiodine-avid metastases compared to those with radioiodine-negative extra-thyroidal lesions [4]. In impact of radioiodine ablation on disease-specific mortality multivariate analysis, this study found that greater numbers and relapse rate is hard to substantiate. However, a recent meta-analysis documented significantly with overall mortality [27].

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Developmental delays have been shown in children that were not adequately treated during the first years of life [28] medications 1 gram generic 2mg kytril overnight delivery. Only occasionally have some children shown developmental delays in later childhood medications vs grapefruit purchase 2 mg kytril, and a small percentage have shown persisting impairments in the language symptoms dengue fever discount kytril 1 mg visa, neuromotor [27 medications xanax buy cheap kytril 1 mg on-line, 29, 30], and perceptomotor areas [31]. Such difficulties appear to be more evident in children with thyroid aplasia or severe hypothyroidism at the time of diagnosis [27]. For example, the prevalence among Japanese is approximately 1:7600, while in Israel it is about three times higher (Table 6). Recent research has shown that much of this discrepancy may be attributed to differences in thyroid ectopy and are gender related. However, reports limited to iodine deficient areas indicate incidences as high as 1:600. Proteins in serum effectively bind circulating T4 such that only about 1% exists in the ?free? form. These protocols are only shown as examples and the actual testing values should be adjusted to fit the local programme on the basis of testing experiences. In any case, a similar testing protocol should be outlined so that the methods used are clear to all persons who are involved in conducting the screening. For this reason, initial T4 screening is often considered as an alternative procedure in screening populations where blood specimens must, of necessity, be collected early (less than 24 hours of age) in a high number of newborns. The first step in developing the infrastructure is to understand what is necessary to make newborn screening work and then to define the responsibilities for each component. Throughout the planning process it is important to consider the availability and cost of technology that will be used as part of the testing and follow-up process. Quality indicators should also be considered for each operation and should be developed into a quality assurance plan that covers the entire system. One mechanism for understanding and developing the system is to diagram the flow of the screening process. In this diagram, the first steps shown are demographic data entry and specimen collection. However, before these steps can effectively be taken, it is necessary to provide an education programme to help the specimen collector, the parents, and the health care providers understand the purpose for and expectations behind newborn screening. In this sense, this simplistic diagram showing the mechanics of a system for the screening of newborns provides a basis for more detailed development. They are: education, screening, early follow-up (and outreach), diagnosis, management and evaluation (and assurance). Component 1 Education Education on Education is perhaps the most essential component in the initial newborn screening stages of the development of a newborn screening programme. Not only must be provided to: must health professionals be educated in the benefits and operation of. Professionals, newborn screening as a preventive public health programme, they must. Parents and the public at large must also understand the preventive health measures which are encompassed in the newborn screening activities. Professional education From the outset, for a screening system to succeed, professional health practitioners must be involved in its development. Even though the successful implementation of the newborn screening programme will most likely depend on the efforts of a few individuals interested in infant health, family and societal benefits, health professionals will be responsible for the implementation of the programme and ultimately for successful outcomes as a result of early diagnosis and treatment. Efforts must be made to gather pertinent educational materials (professional literature, video and/or audio tapes, newspaper articles) to share with physicians, nurses, midwives, and other health professionals so that they will understand the programme and lend their support. Many articles have been published about the benefits of newborn screening since the 1960s. Articles that can be most persuasive in the local environment should be collected in the form of an information sourcebook for sharing, as needs arise. Sometimes sourcebook information can be useful in the form of newspaper articles, at other times it may be important to have professional articles available. Participation in seminars and local, regional, and national Information manuals professional society activities also provides excellent venues for can provide professional education. Use of outside experts can often provide the physicians with pertinent information additional information and interest needed to gather the local about their screening professional support needed to sustain programme activities. As the programme progresses, consideration should be given to developing a manual in support of newborn screening activities that is directed at health care professionals. This manual should provide a clear picture of the role of the professional in the system, with flow diagrams about system functions and individual responsibilities, and answers to questions about the programme. In order to ensure adequate and appropriate blood specimens for A national standard laboratory testing, educational materials must be distributed on for blood collection collection techniques and the responsibilities of the person who submits with the aid of filter paper exists in the specimens. Creation of an instruction sheet for specimen collection should be a consideration of any newly starting programme. Training workshops to discuss responsibilities and demonstrate proper specimen collection techniques will likely be needed before the programme begins, and periodic continuing education will be needed to meet the needs in relation to personnel turnover at the various collection centres and hospitals. One of the items often overlooked in calculating programme costs is the need for ongoing professional education to ensure proper specimen collection. Many programmes have used these posters for distribution to collection facilities who in turn have posted them in critical locations within the facility. Parent education Parent information In order to assist parents must be brief, in understanding the informative and in importance and need for simple language. Sharing information on the screening which explain the newborn of newborns with mothers as part of screening programme, its post-natal care education. Such pamphlets are best distributed to expectant mothers through gynecologists, midwives, in public health maternity clinics and through pre-natal training classes, if available. They should also be available at hospitals as part of any general information on newborns given to the mother. In most cases, information pamphlets are best developed in cooperation with specialists and are distributed to parents through their physician during the diagnosis process. It is not necessary to reinvent these pamphlets since many programmes have already prepared them and are willing to share them. Information provided should seek to dispel the concept of ?fault? that might exist when inherited conditions are the topic under consideration. Education of policy makers One of the biggest challenges facing newborn screening Policy makers are programmes is adequate and appropriate education of policy makers. It important to sustain will usually fall to the programme manager to make a special effort to programmes and must be educated involve and educate any policy makers who might be important to self about prevention and sustainability of the programme. Outside experts can provide assistance benefits to family and in this area by personal visits and letter writing. Since most policy makers are totally unfamiliar with the consequences of the untreated or delayed treatment of disorders in newborn screening programmes, it is often helpful to provide graphic illustrations of the catastrophic consequences of undetected and untreated disorders. Often the tendency is to provide pictures of healthy newborns as evidence of the worthwhile nature of the programme, but it is sometimes more effective to show pictures of the tragic results of not having an effective newborn screening programme in place. Parents can also provide important programme advocacy when educating policy makers. It is important to document programme successes and to cultivate parent advocates for convincing policy makers of the importance of the screening programme. It is also essential that the concept of a newborn screening system be conveyed, since there is sometimes misunderstanding among policy makers who tend to perceive newborn screening as simply a laboratory test. Sometimes this results in inadequate attention to the need for a comprehensive newborn screening system that serves the screening population with effective education and follow-up, and appropriate medical service delivery. Cost and financing will invariably be a concern of policy makers and it will be important to have considered programme costs and developed comparisons with other programmes that may already be in place. These costs should include costs to the family for items such as days away from work for patient care. Policy makers should be aware of the organizational development of the programme and the steps to institutionalizing it including: developing pilot data, creating a centralized infrastructure, beginning local and/or regional projects, expanding local projects into a national network, and institutionalizing the programme at the national level, including adequate quality assurance measures. Collection activities Screening includes: the process of screening begins well before specimens reach the. It is important to allow parents the opportunity to consent to the testing and to supply them with sufficient information about the programme to allow them to make an informed decision about screening. The person who is responsible for obtaining consent must be knowledgeable about the programme.

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The opinions and assertions contained herein are the private views of the authors and are not to treatment eczema generic 1 mg kytril with visa be construed as offcial or as refecting the views 14 symptoms vaginitis order 2 mg kytril amex. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism [published correction appears in the Authors Endocr Pract medications gabapentin discount kytril 1 mg overnight delivery. Treatment of hypothyroidism with College of Physicians of London medicine 5e generic kytril 1mg without a prescription, the Endocrinology and Diabetes Com once weekly thyroxine. Timing and magnitude of increases in levothyroxine requirements controlled trials. In dogs with low or low normal T4 results and with consistent Catalyst Total T4 Results clinical signs, consider one or more of the following to aid in confirming hypothyroidism: Low <1. Total T Testing Guide: 4 Feline Hyperthyroidism Dynamic Range Feline Screening Cats with consistent clinical signs and total T4 (T4) values 0. In these cases, consider the following to aid in confirming the diagnosis: Catalyst Total T4 Results. Physicians do consider and rule out thyroid methodologies have progressively improved the specificity and dysfunction more frequently than they establish a diagnosis sensitivity of the methods. Considering this scenario, many patients the present scenario with thyroid disorders will remain undiagnosed if laboratory Currently, thyroid testing is performed on serum specimens evaluation of only those patients with clearly suggestive signs using either manual or automated methods employing specifc and symptoms of thyroid dysfunction is performed. Methodology is still evolving as performance becomes imperative to implement routine laboratory screening standards are established by the professional organizations to identify such patients, so that appropriate treatment for and new technology and instruments are developed by thyroid disorders can be instituted or conservative monitoring manufacturers. A multitude of tests are currently available for carried out to anticipate potential future consequences. The advantage of this test is usually confrms the diagnosis but should not be undertaken that its negative predictive value is very high and a vast majority until the appropriate biochemical confrmation has been made. Such cases may occur due to assay artefacts or abnormal (Table 2) laboratory errors and this should be considered frst. These include the presence of binding determination and occasionally imaging studies need to be protein abnormalities (such as familial dysalbuminaemic carried out. In both cases, the great majority of patients do not and the hypothyroid status (80-90%) of patients. The responsibility of providing pertinent clinical information to help guide the lab Total T3 in selecting the most appropriate thyroid function test lies with Currently routine measurement of serum T3 is not carried out the requesting physician. About 25% of patients with hypothyroidism have low unaltered T3 and T4 values, are not available, then laboratories normal T3 values. This is should be performed in the following setings: a more prudent strategy than just measuring frst-line serum 1. In patients taking drugs that inhibit the peripheral conversion of T4 to T3 (such as dexamethasone, propranolol, propylthiouracil, amiodarone, and iodine-containing Considerations which contrast media). Optimising thyroxine therapy in newly diagnosed patients is appropriate because total-T and free-T tests have 3 3 with hypothyroidism. Currently, automated tests are replacing Thyroid Autoimmunity Thyroid the older manual agglutination tests. Over ?healthy? euthyroid subjects and even higher percentages the last fve decades, antibody measurement techniques have of patients with various non-thyroid autoimmune disorders. TgAb is detected 10 in approximately 20% of patients with diferentiated thyroid carcinoma compared with 10% of normal subjects by the % immunoassay methods. False positives may occur due to assay artifacts or illegitimate transcription while false negatives results 3. Current tests are manual and expensive and vary in Thyroglobulin autoantibodies (TgAb) precision, sensitivity, specifcity and reference ranges. The incidence is particularly high in patients who undergo Thyroid Function Tests in Special surgery and receive high doses of radiation because the efect Patient Populations is dose-dependent. The onset of overt hypothyroidism due to surgery or irradiation is gradual and may precede subclinical Patients with atrial fibrillation, hyperlipidaemia, hypothyroidism for many years. In such patients, thyroid osteoporosis, infertility function assessment should be carried out annually. Assessment of thyroid function in these can be corrected by treating the underlying cause. Women with type 1 diabetes Treatment of thyrotoxicosis with anti-thyroid drugs Type 1 diabetes in women raises their likelihood of developing Antithyroid drugs used in the management of thyrotoxicosis, post-partum thyroid dysfunction by three times. Women with carbimazole and propylthiouracil, decrease thyroid hormone type 1 diabetes should have their thyroid function (including secretion. Women with a past history of post-partum thyroiditis Patients on thyroxine therapy In women with post-partum thyroiditis, there is an increased In patients undergoing thyroxine therapy regardless of the long-term risk of developing hypothyroidism and its recurrence cause, long-term follow-up with annual measurements of serum in subsequent pregnancies. This helps to check compliance, verify of post-partum thyroiditis should be recommended to have a the dosage and take account of variations in dosage requirements yearly thyroid function test, and also prior to and at 6 to 8 weeks due to concomitant medications. In patients with type 2 diabetes, thyroid function should be assessed at diagnosis, Thyroid Test Methodologies however, annual thyroid function assessment may not be There are four categories of interferences in competitive recommended. Endogenous analyte antibodies recommended to undergo thyroid function assessment annually, keeping in mind the high incidence of hypothyroidism seen in 3. Endogenous analyte antibodies is associated with mild to overt hypothyroidism in up to 34% Robbins et al were the frst to report an unusual thyroxine to 16% of patients respectively, which can occur abruptly even binding globulin in the serum in 1956. However, the currently used methods the presence of fuorophor-related therapeutic or diagnostic rarely have this interference problem. Characteristics of agents in the specimen may alter the results of thyroid tests interference due to endogenous autoantibodies may lead that employ fuorescent signals. Moreover, the result may not be be instituted or conservative monitoring carried out to abnormal; it may be inappropriately normal. Use of Fab fragments and heterospecies inadequate sensitivity and specifcity in this seting. Interpretation of Laboratory Thyroid Function Tests: Selection and Interpretation. Lippincot Williams & concentration of an interfering therapeutic or diagnostic Wilkins. An example is that of hypothyroidism in children on continuous ambulatory peritoneal furosemide which competitively inhibits thyroid hormone dialysis. Hypothyroidism is a condition characterized by abnormally low thyroid hormone production. Because thyroid hormone affects growth, development, and many cellular processes, inadequate thyroid hormone has widespread consequences for the body. The gland wraps around the windpipe (trachea) and has a shape that is similar to a butterfly formed by two wings (lobes) and attached by a middle part (isthmus). The thyroid gland uses iodine (mostly available from the diet in foods such as seafood, bread, and salt) to produce thyroid hormones. The two most important thyroid hormones are thyroxine (T4) and triiodothyronine (T3), which account for 99% and 1% of thyroid hormones present in the blood respectively. Once released from the thyroid gland into the blood, a large amount of T4 is converted into T3 the active hormone that affects the metabolism of cells. Thyroid Hormone Regulation-the Chain of Command the thyroid itself is regulated by another gland located in the brain, called the pituitary. In turn, the pituitary is regulated in part by thyroid hormone that is circulating in the blood (a "feedback" effect of thyroid hormone on the pituitary Hypothyroidism Information Sheet (continued) gland) and in part by another gland called the hypothalamus, also a part of the brain. If a disruption occurs at any of these levels, a defect in thyroid hormone production may result in a deficiency of thyroid hormone (hypothyroidism). In persons with hypothyroidism, there is a persistent low level of circulating thyroid hormones. The condition is more common in women than in men, and its incidence increases with age. Below is a list of some of the common causes of hypothyroidism in adults followed by a discussion of these conditions. In this condition, the thyroid gland is usually enlarged (goiter) and has a decreased ability to make thyroid hormones. When the inflammation is caused by a particular type of white blood cell known as a lymphocyte, the condition is referred to as lymphocytic thyroiditis. This condition is particularly common after pregnancy and can actually affect up to 8% of women after they deliver.

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It is not the aim of this chapter to treatment xeroderma pigmentosum safe kytril 1mg recommend any one instrument in particular symptoms vertigo purchase kytril 1 mg amex, but to medicine 029 purchase 2mg kytril fast delivery strongly urge thalassaemia clinics to medicine 10 day 2 times a day chart kytril 1 mg without a prescription adopt and use an instrument of their choice and apply it over time to their patients. These instruments can be used to monitor and evaluate individuals, as well as groups of patients, thus allowing them to evaluate clinic performance, and identifying any weaknesses that need to be addressed. Health related quality of life as estimated by these various tools cannot be used to make comparisons between the state of care between different geographical regions. Variables include the disease severity of patient groups (Musallam 2011), past management of patients, the onset of complications, whether on oral versus parenteral chelation (Porter 2012), the age of patients, and whether parents or children are responding (Coacci 2012). Monitoring patient groups over time using the same instrument can, however, provide invaluable data on measures of outcome and clinic performance. Ergometry and cardiovascular assessment may be necessary according to the activity proposed. Supplementation for all patients may be considered, since the risk of thrombosis may be reduced and toxicity low. Adequate blood transfusions from an early age will prevent maxillary deformities and reduce the need for orthodontic interventions. Treatment of vitamin thalassaemic patients and effect of L-carnitine D deficiency in transfusion-dependent thalassemia. Zinc hepatitis C virus entry into hepatocytes by hindering supplementation improves bone density in patients with clathrin-dependent trafficking. Nutritional deficiencies in patients with of life in Middle East children with beta-thalasaemia. Quality of of life of people with thalassaemia major between 2001 Life in hematology: European Hematology Association and 2009. Health-related life measure (the TranQol) in adults and children with quality of life and financial impact of caring for a child thalassaemia major. Disclosure and properties of the Specific Thalassemia Quality of sickle cell disorder: A mixed methods study of the Life Instrument for adults. El-Beshlawy A, El Accaoui R, Abd El-Sattar M, et Bone-related complications of transfusion-dependent al. Effect of L-carnitine on the physical fitness of beta thalassemia among children and adolescents. Health hypertension in beta-thalassemia major and the role of related quality of life in adults with transfusion L-carnitine therapy. Effect of nutrition support on immunity in and antiviral functions of silymarin components in paediatric patients with beta-thalassaemia major. Exercise capacity quality of life, treatment satisfaction, adherence and and cardiovascular changes in patients with beta persistence in? Clin Physiol Funct Imaging syndrome patients with iron overload receiving 2006;26:31922. It is not uncommon to have adult patients being transfused alongside children in many centres. This may be justified when patient numbers are small, but in areas of high prevalence, separate units were created many years ago in recognition of the need for patient privacy and safety, and to facilitate multidisciplinary care (Angastiniotis 1988). An ideal thalassaemia centre may share space and services with other red cell disorders such as sickle cell disease and the more rare congenital and chronic anaemias, since they share common complications and needs. This chapter shall examine how healthcare systems can be best organised to deliver optimal care to patients with thalassemia. The Multidisciplinary Team the multi-organ involvement seen in thalassaemia and other transfusion dependent anaemias has been made clear in these guidelines, and to a great degree it is these complications that dictate the composition of the multidisciplinary team. It is expected that a haematologist, or an experienced paediatrician or internist will supervise the provision of basic care to these patients (see Table 1), including the monitoring of iron overload and assessment of organ damage that inevitably result. Specialised nurses the important and wide-ranging responsibilities and competences of haemoglobinopathy nurses include the supervision of blood transfusions, practical aspects of iron chelation therapy, patient support and communication, provision of information, encouragement of self management, and symptom control, amongst others (Anionwo 2012, Aimiuwu 2012, Tangayi 2011). To develop the kind of expertise required there is need for continuity of care and not the frequent rotation of staff that is often witnessed in hospital services. The specialist nurse is an asset to the haemoglobinopathy service, representing the closest contact to the patient, and usually acting as liaison between the patient and medical team. In many centres, the patient is often referred to a cardiologist only once symptoms manifest. It is strongly recommended that a cardiologist with specialist knowledge of thalassaemia care becomes a regular member of the team. It is therefore important that cardiology colleagues involved in the care understand the broader issues of concern, and are able to discuss these not only with colleagues on the same team but also with patients. For these reasons, the cardiologist should be kept well informed on issues such as patient compliance and psychosocial states, to permit them to contribute to the complete care of the patient. Cardiologists with special interest in thalassaemia should therefore be identified and invited to supervise monitoring and treatment of patients in close collaboration with the team. Management of liver disease is also complicated by the presence of iron overload, with or without the contribution of chronic viral hepatitis (Di Marco 2010). Matters such as the role of intensifying iron chelation, controlling haemoglobin levels when anti-viral agents are used, and dealing with the complications of anti-viral treatments make it imperative that the team work in close collaboration with the hepatologist. They affect quality of life as well as having serious consequences to physical wellbeing (see Chapter 8). It is therefore important from an early age that all transfusion dependent patients be reviewed by an endocrinologist to supervise all treatment that may be necessary. An international group of experts in the endocrinological aspects of thalassaemia has been set up in recent years, which encourages and trains endocrinologists in thalassaemia care (De Sanctis 2013). The importance of the endocrinologist in the multidisciplinary team is wide-reaching, as illustrated by the psychological impact of endocrine disorders such as delayed puberty and the need for frequent liaison of the team. The need for presence of a psychologist on the team should not require further emphasis. The role of the psychologist is also to support and advise the care team, including the patients? families. All relevant staff need training in dealing with chronic diseases, especially as they are frequently asked for advice well in advance of being seen by a professional psychologist. Psychiatric interventions are not frequently needed but teams should be alert to this possibility and make prompt referrals when necessary. There are however specific problems that arise in the family, financial and social settings which fall clearly in the realm of the social worker, depending on the role of the social and welfare system in each country. It is the role of the care team to decide whether there is a need for input from social workers according to the individual circumstances of the case, and to ensure their presence when appropriate. Summary of roles, desired characteristics and responsibilities of members making up the thalassaemia care team. Ensures continuity of care Cardiologist Preferably with special interest in haemoglobin disorders. Monitors all patients from childhood and takes charge of treatment when complication arise. Liaison with other team members on iron chelation needs Endocrinologist Ideally with a special interest in haemoglobin disorders. Suggests individual treatment of complications and acts as liaison with the whole team, as well as with gynaecologist in case of infertility or pregnancy Liver specialist (hepatologist) the liver specialist is called in when the need arises, often when hepatic viral infections require treatment Obstetricians Liaise with the haematology team mainly during pregnancy, which requires multidisciplinary care Psychologist and social worker Essential supportive services for patients and families. Professional dietetic input may help in answering queries and giving advice when complications relating to diabetes and liver disease necessitate specialist advice It is crucial that teams are well coordinated, and this is the role of the primary haematologist or other physicians in charge of basic therapy and care. For the team to fulfil its role there should be frequent meetings and shared decision making, with each specialty contributing its expert view on the clinical and psychosocial issues raised by individual cases, but also concerning the group of patients under their care. Concordance between the team and the patient may improve patient adherence (Haynes 2002). This requires information, guidance and encouragement to the patient by various specialties. For example, when a heart complication is detected, a common interview with the haematologist and cardiologist involved will be informative and also reassure the patient that there is continuity of care and experts have discussed their management and come to agreements on decisions regarding their care. Programming of Treatment the general organisation of a thalassaemia unit is illustrated in Figure 1. Visits to treatment centres are frequent and related to preparing and conducting blood transfusions, reviews by doctors including various specialist consultations, conduction of specialised tests, as well as visiting other specialist units such as magnetic resonance imaging centres.

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