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Differential diagnosis Course When fully expressed zigma herbals cheap geriforte 100mg on line, the clinical picture in adults is dis tinctive xena herbals cheap geriforte online american express. Diagnostic difficulties may arise in partial cases herbals vaginal dryness buy geriforte 100 mg online, Although there is some evidence that herbs native to outland buy 100 mg geriforte with mastercard, in males, intellectual and the correct diagnosis may be revealed only incidentally functioning may undergo a decline in late childhood or during a work-up for infertility or erectile dysfunction. Treatment Testosterone treatment improves libido and erectile function, and tends to help with energy and overall outlook (Nielsen Etiology et al. Developmental disabilities and the fragile X syndrome occurs secondary to mutations in the mental retardation are treated in the usual fashion. An expansion of this the fragile X syndrome is one of the most common causes sequence to include from 55 to 200 repeats is known as a pre of mental retardation in developed countries. Patients with pre-mutations do not develop the most common of the microdeletion syndromes, being the fragile X syndrome; however, those with full mutations found in up to 1 in 4000 live births. The fragile X syndrome the facial dysmorphism is characterized by hypertelorism, derives its name from the fact that when the cells of patients a large, bulbous nose with a squared-off nasal root, and are cultivated in a medium deficient in thymidine and folic micrognathia. Most patients have a degree of velopharyn acid, a fragile site will be found on the long arm of the X chro geal insufficiency, leading to a hypernasal voice. Autism has been noted mutation occurs readily during oogenesis but only rarely in a small minority (Fine et al. As these patients pass through adolescence into adult Magnetic resonance imaging studies have revealed years, up to one-third will develop a psychosis phenotypi hypertrophy of the hippocampus with atrophy of the supe cally similar to that seen in schizophrenia (Bassett et al. Mood disturbances may also have demonstrated that, although neuronal cell counts are occur and may be more frequent than psychosis: both normal in the cortex, dendritic spines are long and tortu manic or hypomanic episodes (Papolos et al. Obsessions and compulsions have also been noted in roughly one-third of teenagers (Gothelf et al. Differential diagnosis Other clinical features include cardiac defects, hypocal cemia secondary to hypoparathyroidism, and, in a small the full clinical syndrome of mental retardation, with or minority, seizures (Kao et al. As the course is chronic; although some die of cardiac com noted earlier, patients with pre-mutations do not develop the plications, most live a normal lifespan. First described in guished from schizophrenia, bipolar disorder, major 1978 by Shprintzen et al. Course Treatment Self-mutilation may decrease, or even remit, in early adoles cence (Mizuno 1986); most patients, however, die of infec There are no blinded treatment studies for this disorder; the tion or renal failure in their teenage or early adult years. The hyperuricemia, however, does not explain the ment disorder with both dystonic and choreoathetotic mental retardation, movement disorder or self-mutilation. Several studies have strongly suggested distur Clinical features bances in dopaminergic functioning. Post-mortem work has demonstrated reduced dopamine content in the caudate the overall clinical picture has been described in several (Saito et al. Despite being normally sensitive to pain, patients repeatedly bite at their lips, tongue, buccal mucosa, and fingers, to the Differential diagnosis point where the lips and fingers are literally bitten off in some cases. It must clearly be kept in mind that there is no anesthe Although patients with other forms of mental retardation sia here and that the biting is involuntary: Lesch and Nyhan may bite themselves, the degree of self-biting rarely ever (1964) commented that one of their patients ‘appeared terri approaches that seen in the Lesch–Nyhan syndrome. Treatment Hyperuricemia is a constant feature of this disease, and tophaceous gout and gouty nephropathy may appear in Allopurinol, by forestalling gouty nephropathy, may pro adolescence. A megaloblastic anemia may also occur in long life; it has, however, no effect on the central nervous some patients. In cases with finger biting, restraints may be help Both the Prader–Willi and Alstrom–Hallgren syndromes ful. Various medications have been reported in non-blind are characterized by obesity; however, neither of these dis case reports or studies to be helpful in reducing the biting, orders is associated with polydactyly or syndactyly. Further including risperidone (Allen and Rice 1996), levodopa differentiating features include a ravenous hunger in the (Jankovic et al. Although this syndrome is well terized by extreme hyperphagia, obesity, various dysmorphic characterized, there is some inconsistency in the literature features, and, in a majority, mild mental retardation; other regarding its name: in the past it was often referred to as neuropsychiatric features, as described below, may also be the Laurence–Moon–Biedl syndrome; however, the cur present. This is a not uncommon disorder, and is found rently preferred name is Bardet–Biedl syndrome. Clinical features Clinical features Clinical features have been discussed in a number of papers the overall clinical features have been described in several (Beales et al. Obesity is Dunn 1968; Greenswag 1987; Hall and Smith 1972; almost universal and tends to be of the central type. This disorder presents in infancy with Syndactyly or polydactyly is also almost universal; when somnolence, hypotonia, and decreased oral intake. By the polydactyly is present, it typically manifests with an extra age of 2 years, however, a remarkable transformation occurs, finger or toe, which may range from rudimentary to fully in that these patients become alert and begin to display a formed. Mental retardation ranges from mild to hunger: one patient literally ‘took off running’ and ‘as soon as severe, and is seen in the majority of cases. Other features she could walk, she was constantly near the refrigerator, beg include hypogenitalism in males, with a small penis and ging for food’ (Zellweger and Schneider 1968). Patients often testes, menstrual irregularities in females, renal dysplasia go to any lengths to satisfy this hunger and, if refrigerators (which may progress to renal failure in a minority), con and food cabinets are locked, may turn to other sources: one genital heart disease, hypertension, and diabetes mellitus. Characteristic dysmorphic features include a narrow Apart from retinal dystrophy and renal abnormalities, head, almond-shaped eyes, and a narrowed or tented upper both of which are progressive, the overall clinical course lip. Micromelia is also often present, with slender arms and remains static through adult life. Hypogonadism is present, manifesting in males with micropenis and cryptorchidism, and in females with hypoplastic labia, a lack of breast Etiology development, and varying degrees of amenorrhea. Mental retardation is present in the majority of patients, As noted, this disorder is inherited on an autosomal but is generally mild. Seizures may occur in a gested effectiveness of risperidone in this regard (Durst et minority. Obstructive sleep apnea and the Pickwickian syn Hypersomnolence is common and appears to be multi drome are treated as discussed in Sections 18. The congenital rubella syndrome occurs secondary to fetal infection during the first trimester. In the past, this was an important cause of mental retardation; however, in devel Etiology oped countries, vaccination of females has made this a very rare disorder. The Prader–Willi syndrome occurs secondary to a lack of a critical portion of the paternally-derived chromosome 15, and this deficit may occur via any one of three mechanisms. Clinical features the most common mechanism involves a microdeletion on the paternally derived chromosome 15; the next most com In its fully developed form (Forrest and Menser 1970; mon is uniparental disomy, with both chromosome 15s Forrest et al. The diag cataracts, deafness, and various cardiac abnormalities, such nosis, as indicated earlier, may be made via methylation as patent ductus arteriosus and ventricular septal defect. The methylation pattern on chromosome 15 differs minority of patients may also have autism (Chess et al. The remarkable hunger has suggested hypothala course is static, except in the small minority who go on to mic involvement, and one study found a reduction in the develop the dementia of progressive rubella panencephalitis, size and neuronal count of the hypothalamic paraventricu as discussed in Section 14. Etiology Differential diagnosis Maternal rubella infection leads to fetal infection via the Bardet–Biedl syndrome is distinguished by the pres transplacental spread and, if this occurs in the first trimester, ence of polydactyly or syndactyly. Growth hormone, given early in life, may improve both overall height and lean body mass (Myers et al. Early dietary management is essential and in some cases Differential diagnosis institutionalization may be required to forestall the develop ment of a lethal degree of obesity. In one double-blind Fetal infection with toxoplasma, cytomegalovirus or herpes study, fenfluramine was effective in reducing weight simplex virus can cause a similar syndrome. Prevention is critical, and females of child-bearing age Neuropathologic studies (Clarren et al. The fetal alcohol syndrome, caused by in utero exposure to alcohol, consists, classically, of a characteristic facial dys morphism, mental retardation, and behavioral problems, Differential diagnosis most notably hyperactivity (Clarren and Smith 1978; Jones and Smith 1973; Jones et al. This is a not uncom the characteristic facial dysmorphism, coupled with a his mon disorder, being present in roughly 1 in 1000 live tory of maternal alcohol use, strongly suggest the diagnosis. Partial syndromes possible to establish the degree of alcohol use during preg also occur, and such patients are often said to have ‘fetal nancy. A similar syndrome may occur in cases of in utero the characteristic dysmorphism includes microcephaly, exposure to various anti-epileptic drugs, most notably shortened palpebral fissures, epicanthal folds, maxillary phenytoin and valproic acid. Cardiac abnormalities informed that binge drinking may be as dangerous as daily may also occur, such as atrial or ventricular septal defects. Etiology Clinical features Although the syndrome is clearly related to maternal alcohol ingestion, multiple uncertainties remain as to the details. Stage I becomes apparent at around the age of 10 months Etiology and is characterized by a general stagnation of normal devel opment. There may be a failure of normal weight gain, and, Rett’s syndrome is an X-linked dominant disorder due to rather than beginning to crawl, patients may display a per any one of a large number of different mutations in the gene sistent ‘bottom shuffling’.
Syndromes
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The inves tigators proposed that many patients developed polymorphous light eruption and secondarily psoriasis as a Koebner phenomenon (42) herbs collision buy geriforte 100 mg with amex. Interestingly herbs collision generic geriforte 100 mg with visa, despite photosensitivity just herbals effective geriforte 100mg, in our experi ence and in that of others such patients can be successfully treated with photochemotherapy (43) rajasthan herbals international order geriforte 100mg with amex. Many patients probably have polymorphous light eruption, other light sensitivity (44,45), or fair skin to explain the subsequent development of psoriatic lesions as a Koebner phenomenon. The lesions occur on sun-exposed skin, usually the face, and have three clinical types: annular, dyschromic, and hyperpigmented (Fig. The dyschromic type presents as discrete and con uent whitish papules and the pigmented types consists of hyper melanotic patches. Lesions can occur on sun-protected skin and buccal mucosa (48,49), but not the nails (50). Sunlight is a major precipitating cause, with lesions occurring in the spring and summer, with residual hyperpigmentation in the winter. Treatment includes topical or intralesional steroids, antimalarials, and sunscreen (52). The lesions may have adherent, keratotic scale, with or without a carpet tack sign, follicular plugging, and telangiec tasias. Atrophic scarring as well as dyspigmentation may occur in older lesions, and involve ment of the scalp frequently results in permanent scarring alopecia. It can present as papulosquamous, psoriasiform plaques and annular-polycyclic plaques, with either form seen in about 50% of these patients, and some patients have features of both presentations. These patients have a lower incidence of renal or central nervous system disease, and the more typical systemic symptoms that can be seen in up to 50% include arthritis/arthralgias, fever/malaise, and myalgias. However, some patients do have immunoreactants to the epidermal side of 1 M NaCl split skin as well as other autoantibodies in their sera (71,72). Skin lesions found to be associated with a worse prognosis include photosensitivity, alope cia, oral ulcers, and Raynaud’s phenomenon (73). Skin lesions often occur in a photodistributed pattern and are more common in summer (65,80). Topical glucocorticoids and topical calcineurin inhibitors (pimecrolimus and tacrolimus) are helpful for limited disease or as adjunctive to systemic therapy. Antimalarials (Tables 2 and 3), immunosuppressives, thalidomide, dapsone, retinoids, and clofazamine can be helpful for more extensive or scarring disease (90). Glucocorticoids are occasionally used for short-term treatment if a patient has rapidly progressing scarring lesions or extensive involvement. Common skin changes include an erythematous, often violaceous eruption on the face, particu larly in the periorbital area (heliotrope pattern), sun-exposed areas of the face, anterior chest, upper back and shoulders, posterior neck, scalp, and over the joints on the hands, elbows, knees, and malleolus (Fig. Patients should obtain base line and regular screening for malignancy during that time (103). Frequently associated malignancies include lung, ovarian, pancreatic, stomach, colorectal, and non-Hodgkins lym phoma (104). Patients with muscle and skin disease must be treated with steroids and, for resistant disease, adjunctive immunosup pressive therapies. Photoaggravated Dermatoses 261 with azathioprine, mycophenolate mofetil, or methotrexate (111). There have been recent case reports and small case series reporting the ef cacy of Rituximab in some patients (112). It can be generalized or localized, and blister formation may preceed or be accompanied by an urticarial or eczematous eruption. Some reports suggest that mild disease can be treated with topical steroids, topical tacrolimus, tetracycline and niacinamide, dapsone, or sul fapyridine (118,119). One large study found topical steroids worked and minimized side effects in moderate to severe disease (118). Some patients require adjunctive therapy with immunosuppressives such as azathioprine, methotrexate, mycophenolate mofetil, or in very unresponsive disease cyclophosphamide. Very resistant patients may bene t from plasmapheresis in combination with glucocorticoids and immunosuppressives or from intravenous immunoglobulin (120). One epidemiologi cal study linked sunlight and air temperature to disease activity in pemphigus vulgaris (129). Severe unresponsive disease or patients who may not tolerate glucocorticoids sometimes require adjunctive therapy with intravenous immunoglobulin, plasmapheresis, or more potent immunosuppressives like cyclophosphamide or chlorambucil. For more mild disease or patients who are steroid-dependent, tetracycline or dapsone may provide additional bene t (136,137). There is a need for validated activity indices, standardized de nitions, and multicenter trials to systematically evaluate therapies in pemphigus. Induction of Darier’s disease by repeated irradiation by ultraviolet B; protection by sunscreen and topical ascorbic acid. Grover’s disease (transient acantholytic dermatosis): relationship of acantholysis to acrosynringia. Junctional proteins of keratinocytes in Grover’s disease, Hailey–Hailey’s disease, and Darier’s disease. Two cases of transient acantholytic dermatosis—with the analysis of 20 cases reported in Japan. Grover’s disease in patients with chronic renal failure receiving hemodialysis: clinicopathologic review of 4 cases. An outbreak of pellagra related to changes in dietary niacin among Mozambican refugees in Malawi. Ultraviolet-B radiation induces modulation of antigen presentation of herpes simplex virus by human epidermal cells. Recurrent post-herpetic erythema multiforme mimicking polymorphic light and juvenile spring eruption: report of two cases in young boys. Drug-induced, photosensitive, erythema multiforme-like eruption: possible role for cell adhesion molecules in a are induced by Rhus dermatitis. An unusual combination of phototoxicity and Stevens– Johnson syndrome due to antimalarial therapy. Photosensitive erythema multiforme and erythema multiforme-like polymorphous light eruption. The coexistence of psoriasis with lupus erythematosus and other photosensi tive disorders. Erythematosus actinic lich planus: a new clinical form associated with oral erosive lichen planus and chronic active hepatits B. A candidate gene analysis of three related photosensitivity disorders: cutaneous lupus erythematosus, polymorphic light eruption and actinic prurigo. Ultraviolet radiation-induced injury, chemokines, and leukocyte recruitment: an ampli cation cycle triggering cutaneous lupus erythematosus. The lexicon of cutaneous lupus erythematosus-A review and personal perspective on the nomenclature and classi cation of the cutaneous manifestations of lupus erythematosus. Subacute cutaneous lupus erythematosus: a cutaneous marker for a distinct lupus erythematosus subset. Subacute cutaneous lupus erythematosus associated with hydro chlorothiazide therapy. Lupus eyrthematosus induced by medications, ultraviolet radiation, and other exogenous agents: a review, with special focus on the development of subacute cutaneous lupus erythematosus in a genetically predisposed individual. Measuring the activity of the disease in patients with cutaneous lupus erythematosus. Seasonal variations in activity of systemic lupus erythematosus in a subarctic region. Seasonal variations in manifestations and activity of systemic lupus erythematosus. Clinical, histological and immunopathological features of 58 patients with subacute cutaneous lupus erythematosus. Photosensitivity in patients with lupus erythemato sus: a clinical and photobiological study of 100 patients using a prolonged phototest protocol. Evidence-based evaluation of immunomodulatory therapy for the cutaneous manifestations of lupus. Ultraviolet-B-induced apoptosis of keratinocytes: evidence for partial involvement of tumor necrosis factor-alpha in the formation of sunburn cells. The relative prevalence of dermatomyositis and polymyositis in Europe exhibits a latitudinal gradient. Global surface ultraviolet radiation intensity may modu late the clinical and immunologic expression of autoimmune muscle disease. Myositis-speci c autoantibodies: touchstones for understanding the in ammatory myopathies.
Surficial samples taken with a small core tube circum the collection of undisturbed samples from the vent many sampling problems and permit a highly consistent seafloor requires special coring techniques herbs during pregnancy discount 100 mg geriforte with amex. Plastic core tubes several centimeters in box cores have been used successfully to herbals and there uses geriforte 100 mg free shipping core the upper diameter with walls a millimeter or so thick are ideal and 3 herbals and liver damage buy discount geriforte 100mg on-line. Cut into short tubes several centimeters long rumi herbals chennai order genuine geriforte online, from which the bottoms have been removed are useful in they can be numbered and have rings drawn (or cut) on muddy sediments. The opening at the tubes are carried uncapped by the diver to the collection top of the container is sealed by a screw cap or stopper site. A tube is pushed into the sediment until the ring on after the can is emplaced in the sediment, and the sedi the side coincides with the sediment surface, and a cap is ment remains intact as the core is withdrawn. Its number is shaped or spade corer permits the taking of somewhat recorded, along with a description of the sample location. A trowel or rigid plate is slipped under the base of the tube, Cores can be taken in sandy sediment with a variety and the tube is then removed from the sediment and invert of devices, ranging in design from very simple to quite ed. This simple arrangement can be improved by by driving thin-walled tubing several centimeters in diame adding a removable one-way valve to the top end and a ter into the sediment. A simple apparatus consists of a Procedures for Scientific Dives 9-27 removable collar that can be attached firmly to a 3 inch seafloor site than by scientists working from a surface craft. A pounding Hydrocarbons in the sediment can be analyzed with sleeve consisting of a 3-inch (7. By forcefully sliding the sterilization, or opened under water, and then resealed pounding sleeve down onto the collar, a 3. Adding a removable piston attached In the context of this section, testing means determin to a stationary pole so that the piston remains at the sedi ing some variable of the sediment in situ that cannot be ment surface during coring can increase the penetration of identified accurately on the surface from a sample of the this apparatus to several meters. For example, Dill and Moore (1965) mod ed a coring apparatus that used a hydraulic jack hammer. The attaching device is a slip-fit made constantly increased until sediment failure occurred. From by press-fitting a collar to a standard jack hammer chisel this simple test, these authors were able to determine the shaft. During operation, the entire device is suspended in tinuing to twist the dial after initial shear occurred (see the water with an air bag or air-filled plastic garbage can. Use of this equipment generally is restricted Holding the core pipe in a vertical position, the diver releas to currentless locales because the diver has to remain es air from the air bag and descends slowly until the tube motionless during the test to operate the apparatus correct makes contact with the bottom. Experi the underwater environment is a superb natural labo ence has shown that loss due to compaction is less than ten ratory, and diving permits the geologist to study a number percent. Several excellent cated, depending on the nature of the phenomenon studied but costly commercial units are available; a less-expensive and the resources of the experimenters. Repeated observa unit can be constructed by attaching a simple concrete tions at a selected site can produce much information on vibrator to the top of a 3-inch (7. The unit can be cinephotography, or time-lapse photography produces a powered by a small motor located in the support boat; permanent record of an ongoing process that can later be cores 32. For example, unless great care Since many experimental studies in nature involve is taken, the sediment may be washed from the corer as it making serial observations of the same site, the experimen is removed from the water, or liquefied by excessive agita tal site may have to be reoccupied to continue the study or tion, or it will collapse during removal from the corer. Relocating the site can be difficult careful geologist avoids these frustrations by planning core and must be planned ahead of time. A buoy, stake, or retrieval and transport as an integral part of the coring sys prominent subaqueous landmark may suffice in clear, quiet tem. Divers have also been used to take read ings from diver-operated instruments in situ, such as light meters or fluorometers (Dunton and Schell 1986; Mazel 1997), to measure water motion using a variety of meth ods (Muus 1968; Foster et al. A description of how scuba is used in physical oceanography is provided in this section. It should be noted however, that because of the nature of this marine science discipline, diving has limited application for a number of reasons. Many physical oceanographers are interested in large-scale patterns and processes. Scientists researching micro-scale processes, such Taking a Vane Shear Measurement as flow dynamics and turbulent cells, often conduct their studies under carefully controlled laboratory conditions (in them, and landmarks are seldom close enough to the actu water tunnels or flumes). However, divers can and do play al site to be useful, especially when visibility is poor. Plac important roles in the data collection process in physical ing stakes at the actual site must be done carefully so as oceanography. Recovery of Instruments Some experiments involve the emplacement of unat the emplacement, inspection, maintenance, and tended sensors that monitor conditions at specific times or recovery of recording instruments and instrument arrays whenever certain events occur. The data from such sensors and the recovery of data in situ are jobs often performed by are either recorded in situ or transmitted by cable or radio divers in support of oceanographic studies. Relocation is necessary to maintain physical parameters measured by various types of oceano or recover the equipment used in such experiments. In description of oceanographic instrumentation is reviewed situ experimental studies, however, have become increas by Heine (1999). For example, scientists usually prefer to moor in oceanographic surveys are the deployment, inspec current meters on or over flat bottoms, well away from tion, maintenance and recovery of oceanographic instru underwater obstructions. Because most oceanographic instruments contain relatively fragile electronic components, divers are deployed to carefully attach and detach them from their moorings to prevent damage or loss that might occur if the instruments were deployed or recovered while coupled with their moorings (see Figure 9. Instruments and moorings often become fouled, and sometimes damaged, by marine growth, movement of sedi ment or bottom debris. Corrosion and electrolysis also can be problematic, especially in marine environments. Divers are indispensable for inspection and cleaning of instru ments and moorings in situ (see Figure 9. Inspections are not only important for assessing the condition of equip ment, but also to confirm that instruments are properly positioned on the bottom or at certain levels in the water column. Some state-of-the-art equipment can be down loaded in situ by divers who run a cable to the instrument from a shipboard computer. Of course, to inspect, clean, or recover instruments, scientists must first be able to find them. The most impor tant aspect of the relocation process occurs during the deployment phase when scientists should take the proper steps to pinpoint the location of instruments being deployed as precisely as possible. Circular search patterns have been found to be particularly effective in relocating moor ings. Alternately, divers can use portable underwater acoustic receivers to home-in on pinger transponders attached to the moorings or instruments. One of the first methods used to study currents on a small scale involved dye tracers (LaFond 1962; Zhukov et al. Water masses tagged with fluorescein dye can be tracked, timed and photographed or videographed to provide an accurate measurement of current speed and direction (see Figure 9. Dyes Dye-Tagged Water Moved by the Bottom Current are also ideal for investigating the turbulence occurring in various layers of the water column and can be used to study internal waves. This technique is particularly effec devices to obtain samples at the desired locations. The most important note of caution when obtained by swirling large plastic bags through the water conducting dye studies is the influence of diver motions on until filled, sealing their mouths, and carrying them to the water column disturbance, particularly the creation of arti surface. If the desired sample is taken of some type of water-soluble material such as plaster of below approximately 20 meters, the air-filled container will Paris (Muus 1968; Doty 1971), alabaster (Genovese and compress and deform, but when opened at the desired Witman 1997), or gypsum (Airoldi and Cinelli 1997). The depth the plastic can usually be manipulated by hand into dissolution of a given material, initially formed into its original shape. For deeper samples, the plastic contain spheres, slabs, or clods, is measured by weight loss or er should be filled with surface water, then pumped out of dimension reduction and then translated into water motion. At the desired depth, the diver inverts the unstopped rapid water flow (Denny 1983). The jar is described as rugged, simple to build, inexpensive and is then righted and, as the air bubbles out of the open hole requires no external power. Heine (1999) the air, the diver seals the jar by inserting the tip of the reviewed these and other mechanical methods for measur sampling tube into the open hole of the stopper or by ing currents and water motion under water by divers. Procedures for Scientific Dives 9-31 Diver-operated instruments that can quantify the spec tral reflectance and fluorescence excitation-emission spec trum of benthic organisms and substrates have recently been developed (Ackleson 1996; Mazel 1997). Using these state-of-the-art devices, divers can measure the fluorescence emitted by an object as discrete as a single coral polyp, view the data being recorded, store or discard the data, or change the instrument settings, all while under water.
After a period of bubbling the air herbs for weight loss buy geriforte 100mg cheap, backwash with water is herbs los gatos purchase 100 mg geriforte visa, of course herbals used for pain discount 100 mg geriforte overnight delivery, still required to everyuth herbals skin care products generic 100mg geriforte otc carry the fragments of the specific deposit out of the bed. If a plant has only water available for backwashing, a very high backwash rate has to be used to attain the shear forces required for effective media cleaning. This is an option commonly used in the United States in the past, where backwash rates were selected to get as high as 50% bed expansion upon backwash. If air scour is provided for, as is usually the case in South Africa, then much lower backwash rates can be used, as the water then only serves to flush the dirt from the bed. As the air starts to bubble through the bed, some of the interstitial water is driven from the bed, the bed compacts and the air starts to “channel” along fixed paths. This happens within a minute after starting the backwash and reduces the degree of rubbing amongst the media grains; an effect that is clearly not desired. For this reason, it serves little purpose to continue with air scour for more than two to three minutes. This led to the introduction of simultaneous air and water, which is also a common option found at South African treatment plants. The logic here is that a small but continuous supply 101 of water will prevent the bed from collapsing, thus maintaining the rubbing of the grains for as long as the backwash lasts. The following factors affecting backwash efficiency can now be recognised: the backwash rate inevitably decrease with time, due to impeller wear of the backwash pumps, valves that do not close completely when they should and the partial blocking of nozzles, leading to reduced hydraulic shear, bed expansion and backwash efficiency. How flow control works Various ingenious ways have been devised to ensure an evenly distributed flow amongst all the filters. This is not a trivial problem, as the filtration control system has to keep pace with fluctuations in the incoming flow rate, as well as the fact that all the filters have a different specific deposit at any given time and thus offer varying degrees of resistance to flow. A full explanation of the different flow control strategies is not appropriate here, except to say that practically all systems in South Africa are designed as constant-rate systems, meaning that all filters should equally share the flow at any given time. The flow control is either done with a weir inlet at the upstream end, or with a control valve downstream of the under-floor plenum. In either case, the efficiency of the filtration control system can be measured directly at the inlet weirs into the filter boxes or the outlet weirs in the outlet boxes. If all the weirs have exactly the same geometry (filters built under a single contract normally has identical dimensions) then it only remains to carefully measure the overflow depth at each weir at the same time. If one filter would overflow much more or less than the average, it means that that filter runs at a much higher or lower rate that it is supposed to. In extreme cases, mostly observed at plants with downstream filtration control, the automatic control system is patently broken of deliberately disabled, as evidenced by floats that are removed, control piping or wiring that is disconnected, etc. Such systems will never work satisfactorily and should be reported immediately and the affected filters taken off-line. It has become standard practice at some treatment plants to exploit the savings offered by cheaper off-peak electrical power during times of low water demand. Such plants are then operated for one or two shifts and shut down for the remainder of the day. However compelling the reasons for such an operational mode may be, it should be realised that optimal operation of a filtration plant is not possible under such 102 conditions. The specific deposit, after being left in the media with no flow for a few hours, simply cannot resist the detachment forces when the filters are brought on-line again and will break through. Modern computer technology makes it possible to incorporate two relatively new options into the filtration control system. Many studies indicated that the filter ripening period (the first hour or so of a filtration run) is the most likely period for the breakthrough of protozoan cysts and oocysts. Both options have been developed to ensure more robust performance of filtration systems during this critical period. The first is the filter-to-waste option, where the filtrate produced during the first hour or so is not supplied to the consumer, but returned to the raw water source. Should any unwanted organism break through during this period, the safety of the public is not compromised. The second is the slow-start option, which will reduce the load on a filter in the first hour or so after being backwashed. The slower filtration rate will lead to more efficient filtration, thereby reducing the chances of the breakthrough of harmful organisms. Care should be taken to slowly increase the flow rate from the slow start to the normal filtration rate after the ripening period. If the filtration control system is already computerised, then the adoption of the slow-start principle should simply be a matter of some programming. Should a switch to filter-to-waste be contemplated, it must be realised that some hardware changes may be necessary in addition to re-programming. Filter floor systems the hydraulics of filter floors and filter nozzles are beyond the scope of this chapter and something which cannot be altered by operation anyway. Keeping a filter floor system in good health, however, is very much the task and responsibility of the operating personnel. The following have been found to be common causes for malfunctioning filter floor systems: Filter nozzles break or are blown completely out of the filter bed. Once in the under-floor plenum, the media is washed back up into the nozzle stems of all the nozzles, partially blocking the nozzles from the inside. From the above, it is evident that the maintenance personnel should not be afraid to dig into a media bed to find and correct a problem. A number of precautions should be incorporated as standard procedure when this is attempted: Place plywood sheets around the area to be excavated and restrict human movement to these areas. Whereas a little gravel in the media layer will do no harm, a little media in the gravel layer could cause later problems. The filter nozzles are fairly delicate and will be damaged by heavy boots and careless walking. The following pointers are offered for when and how action could be taken to keep the filter floor in good condition: When a broken or blown-out nozzle is detected (usually easy to spot visually), get to it as quickly as possible to prevent the massive leakage of media into the under floor plenum. Avoid over-tightening, as this is often the cause of stripping the soft plastic thread. When small dead patches are spotted, for example, prod them with a steel bar during backwash first. The problem does not necessarily start at the filter floor, but could also be a local clumping or blockage within the media which is relatively easy to fix at an early stage. Measuring filtration performance Filtration has been explained as a dynamic process, with each filter potentially producing water of varying quality over time. Furthermore, different plant supervisors witness the filtration performance at different times. These factors establish two vital requirements of filtration monitoring, namely that of frequent measurement and systematic recording of measurements. Trends of short periods (comparable to the length of a filter run) may suggest problems of slow filter ripening or early breakthrough which will not show up with single infrequent snap samples. Likewise, a steady deterioration of performance of months or years will not be noticed unless it can be compared with a properly documented long-term history of plant performance. To ensure that the production guidelines are met, the samples have to be drawn from the combined filtrate coming from all the filters. Such a measurement, however, will not show the turbidity patterns of individual filters or even indicate when one filter is malfunctioning amongst a block with multiple filters. To get the detailed picture of how each filter is operating, it is necessary to monitor the individual outlets of all the filters. Ideally, it should be done with an on-line turbidimeter, with automatic data logging. As an alternative to on-line monitoring, the filters could be sampled and tested for turbidity every two hours. In both cases, the data should be captured in an electronic format which will allow subsequent recall and analysis. Manual sampling On-line turbidimeter Minimum requirement One on-line turbidimeter required One bench turbidimeter required (additional to bench turbidimeter) Combined filtrate Partial record of compliance Complete record of compliance No indication of problem filters No indication of problem filters One bench turbidimeter required Many on-line turbidimeters required Sampling requires huge effort for (additional to bench turbidimeter) Individual filters large number of filters Calibration requires huge effort Only perform intermittently Complete record of compliance Partial indication of problem filters Complete indication of problem filters Once a record of a specific treatment plant is available, it is prudent to develop more detailed site-specific criteria to alert the plant supervisor to more subtle changes in filtration efficiency. It will be necessary to step up to the sampling frequency during this stage to get a meaningful picture. Getting everything right at the same time Successful filtration depends on the combined success of three broad requirements. If any one of these requirements are not met, filtration will be less than optimal.
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