<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Hypodontia and explain in detail? [/INST] Hypodontia is defined as the developmental absence of one or more teeth excluding the third molars.  It is one of the most common dental anomalies, and can have a negative impact on function, and also appearance. It rarely occurs in primary teeth (also known as deciduous, milk, first and baby teeth) and the most commonly affected are the adult second premolars and the upper lateral incisors. It usually occurs as part of a syndrome that involves other abnormalities and requires multidisciplinary treatment.
The phenomenon can be subdivided into the following according to the number of teeth concerned:

Hypodontia: one to six missing teeth excluding the third molars
Oligodontia: six or more missing permanent teeth excluding the third molars
Anodontia: complete absence of teeth

Signs and symptoms
Typically, all baby teeth will be present by the age of three. As for all adult teeth, they erupt between the ages 6 to 14, with the exception of the third molar, also known as the wisdom teeth which normally erupt between 17 and 25 years of age. If the tooth has yet to erupt by an appropriate age, panoramic x-rays are taken.

Dental features
Microdontia may be present in one or more of the other teeth. This means that the teeth appear smaller than normal, may be observed in both the primary and permanent dentition. This condition can be genetically-linked and in severe cases, may present themselves in the form of ectodermal dysplasia, cleft lip or palate or Down Syndrome. A delay in tooth development may also serve as an indication, whereby the absence of an adult successor slows down the normal resorption of the roots of the baby teeth, which is the progressive loss of parts of the tooth.
Misplaced (ectopic) positioning of the adult teeth may be discovered upon examination or a radiograph. One of the consequences may be an adult tooth intercepting with a baby tooth, causing premature loss or wrong positioning. This can be due to either the absence of neighboring teeth acting as a guide during eruption or the lack of space in the jaw for them to erupt into because of malocclusion.

Skeletal features
Several studies have discovered that anteriorly missing teeth can accompany retrognathic maxilla, also known as an underbite, prognathic mandible, where the lower jaw protrudes out more than normal, and smaller posterior cranial base length. Occurrence of hypodontia can be associated with reduced anterior lower facial height and lip protrusion. This can be linked to lower maxillary to mandibular plane angles.
A more acute mandibular angle and flatter chin may develop as a result. These characteristics become more prominent as the condition becomes progressively severe, particularly when more than one tooth is missing.

Other dental and radiographic features
Data derived from principal component analysis of radiographic images show that children with mild hypodontia may display significant increase of the interincisal angle and decrease in the maxillary and mandibular incisor angles.
Cephalometric tracing is commonly used to study a patients dentofacial proportions in the craniofacial complex. This can aid in predicting growth changes, allowing dentists, especially orthodontists, to develop a suitable treatment plan. Coupled with that, findings consistent among individuals include:

Anterior hypodontia associated with hyper divergent craniofacial pattern;
A tendency toward a class III malocclusion identified in maxillary hypodontia, and;
Reduced lower posterior facial height in children with posterior and mandibular hypodontia.

Associated anomalies
Reduction in coronal or radical dimensions
Retained primary teeth
Ectopic canine eruption
Abnormal morphology such as peg-shaped maxillary lateral incisors and taurodontism, characterized by an enlarged tooth body and roots that are reduced in size
Extracted teeth

Cause
Several theories regarding the aetiology of hypodontia have been proposed in existing literature. There have been various theories mostly looking into genetic and environmental aspects and how they may both be involved. However, the exact cause remains unclear. The extent of individual influences of genetic and environmental factors is still widely debated.Theories regarding the mechanism through which hypodontia occurs can be categorised into evolutional or anatomical.Preliminary studies focused on an evolutionary approach which suggested shortening of the intermaxillary complex and thus shorter arches may contribute to a decrease in number of teeth. This was also suggested in 1945 by Dahlberg using Butlers Field Theory that focused on evolution and development of mammalian teeth into human dentition in an attempt to analyse different of agenesis. In each jaw, four morphological sites were identified (incisors, canines, premolars and molars). The tooth at the end of each region was less genetically stable and hence more prone to absence. In contrast, the tooth most mesial in each region seemed to be more genetically stable. A subsequent theory hypothesised the teeth at the end of each region were possibly "vestigial bodies" that became obsolete during the evolutionary process. At present, it has been theorised that evolutionary change is working to decrease the human dentition by the loss of an incisor, premolar and molar in each quadrant. According to Vastardis (2000), the size of jaws and number of teeth seem to decrease along with human evolution.Theories focusing on anatomical principle, hypothesised that specific areas of the dental lamina are especially prone to environmental effects during tooth maturation. Svinhufvud et al. (1988) suggested that teeth that were more prone to absence developed in areas of initial fusion of the jaw. For instance, maxillary lateral incisors originate where the lateral maxillae and medial nasal bone processes fuse. In contrast, Kjaer et al. (1994) suggested regions where innervation developed were more sensitive than areas of fusion. Commonly affected regions were found to undergo innervation last, this might imply the developmental relationship between nerve and hard tissue. It is thought to be local nerve development that affects tooth agenesis rather than global development, as brainstem anomalies have not been seen to affect tooth development.Presently, the role of polygenic and environmental factors on hypodontia is recognised in most theories.

Environmental factors
Environmental factors can be classified into two main groups, invasive and non-invasive. These factors act additively or independently, ultimately affecting positioning and physical development of the tooth.Invasive environmental factors potentially affect tooth development and positioning leading to hypodontia and impaction. Examples include jaw fractures, surgical procedures and extraction of the preceding deciduous tooth. Treatment such as irradiation has been shown to have severe effects on developing teeth. In a smaller capacity, chemotherapy was also found to have a similar effect. Thalidomide (N-phthaloylglutamine) was also discovered to have a causative effect on mothers who took the drug during pregnancy, resulting in congenitally missing teeth in their children. A link was found between systemic diseases, endocrine disruption (i.e. idiopathic hypoparathyroidism and pseudohypoparathyroidism) and ectodermal dysplasia. However, a definite etiological relationship has yet to be established. Examples of infections include rubella and candida. Exposure to PCBs (such as dioxin), allergies, and toxic epidermal necrolysis folloeing a drug reaction may also be contributing factors.
In a recent study assessing environmental risk factors for hypodontia, it was established that maternal smoking does play a causative role in hypodontia. Passive smoking and caffeine were also assessed but showed no statistical significance.The Journal of the American Dental Association published preliminary data suggesting a statistical association between hypodontia of the permanent teeth and epithelial ovarian cancer (EOC). The study shows that women with EOC are 8.1 times more likely to have hypodontia than are women without EOC. The suggestion therefore is that hypodontia can serve as a "marker" for potential risk of EOC in women.

Genetics
Genetic causes also involve the genes MSX1 and PAX9.Genetic associations for selective tooth agenesis ("STHAG") include:

Failure of tooth formation due to disturbances during the early stages of development could be the cause of congenital missing teeth; this is also known as tooth agenesis. A variety of studies show that missing teeth are commonly associated with genetic and environmental factors. Some literature also shows that a combination of both factors may contribute to the occurrence of hypodontia.Most craniofacial characteristics are influenced by both genetic and environmental factors through complex interactions. The variable expressivity of traits can be either completely genetically determined, environmentally determined, or both. That genetics plays an important role in hypodontia is shown in many different cases. There are hundreds of genes expressed and involved in regulating tooth morphogenesis. Although a single gene defect may contribute to hypodontia, more studies propose that hypodontia is the result of one or more points of closely linked genetic mutations, or polygenic defects.The pattern of congenitally missing teeth seen in monozygotic twins is different, suggesting an underlying epigenetic factor, which may be due to the simultaneous occurrence of two anomalies. This multifactorial aetiology involves environmental factors which trigger the genetic anomalies, resulting in the occurrence of dental agenesis. Common environmental factors include infection, trauma and drugs which predispose to the condition. In hereditary cases, evidence of dental germ developing after surrounding tissues have closed the space required for development may be a large contributing factor, as well as such genetic disorders as Down syndrome, ectodermal dysplasia, cleidocranial dysplasia, and cleft lip and cleft palate.

MSX1
MSX1 (muscle segment homeobox 1) is involved in condensation of ectomesenchyme in the tooth germ. Among the members of homeobox genes, MSX1 and MSX2 are crucial in mediating direct epithelial-mesenchymal interactions during tooth development by expressing in regions of condensing ectomesenchyme in the tooth germ. MSX1 mutations have been identified as a contributing factor in missing second premolars, third molars, and a small percentage of first molars. MSX1 is less likely to cause anterior agenesis.Heterozygous mutations in PAX9 (paired box gene 9) could arrest tooth morphogenesis as it plays a role of transcription the gene expressed in tooth mesenchyme at the bud stage during tooth development. A study showed that single nucleotide polymorphisms in PAX9 were highly associated with missing upper lateral incisors.

AXIN2
The AXIN2 (AXIS inhibition protein 2) gene is a negative regulator of the Wnt signalling pathway, which is important in regulating cell fate, proliferation, differentiation and apoptosis. Its polymorphic variant may be associated with hypodontia such as missing lower incisors or in a more severe form of agenesis like oligontia (lack of six or more permanent teeth).

EDA
EDA provides instructions for making a protein called ectodysplasin A. It encodes transmembrane protein that is part of TNF (tumour necrosis factor) family of ligands. EDA gene defects cause ectodermal dysplasia, which is also known as X-linked hypohidrotic ectodermal dysplasia. Common dental features of ectodermal dysplasia are multiple missing teeth and microdontia.PAX9 and TGFA are involved in regulating between MSX1 and PAX9, causing hypodontia of the molars.Hypodontia can be found in isolated cases too. The familiar or sporadic type of isolations are more frequently reported than the syndromic type. Isolated cases of autosomal dominant, autosomal recessive, or X-linked inheritance patterns may have an impact on the isolation conditions in expressing variation of both penetration and expressivity of traits. Mutations in MSX, PAX9 and TGFA genes are known to cause congenitally missing teeth in some racial groups.

Research
In the 1960s and 1970s, several studies were conducted sponsored by the U.S. Atomic Energy Commission, with the aim of finding a link between genetics and hypodontia.

Impact
There are numerous studies and research reports on the prevalence, aetiology, and treatment of hypodontia and the dentoskeletal effect of hypodontia. A few studies have investigated Oral Health-related Quality of Life (OHRQoL) in individuals with hypodontia and provided some evidence that hypodotia may have an impact on quality of life.

Psychosocial
Cosmetic dentistry has become more notable and prevalent in modern society. Interpersonal relationships and perceived qualities, such as intelligence, friendliness, social class, and popularity can be affected by dentofacial appearance. Some studies have shown that the extent of complaints made by patients was associated with the severity of the condition and the number of missing permanent teeth.Meta-analyses and theoretical reviews have demonstrated that attractive children are seen by others as more intelligent and exhibit more positive social behaviour and traits, other than receiving much more positive treatment than their less attractive counterparts. Therefore, a divergence from perceived ideal dentofacial aesthetic, particularly in children, might adversely affect self-esteem and self-confidence besides attracting mockery from peers.It is therefore reasonable to theorize that deviations from "normal" or "ideal" dentofacial aesthetic could be destructive to an individuals psychosocial and emotional well-being, which brings upon some psychosocial distress in that individual as a result of their condition.

Functional
Individuals with hypodontia tend to have deeper bites and spaces. Further deepening of the bite can also be seen on individuals with missing posterior teeth. Apart from that, hypodontia may lead to non-working interferences, poor gingival contours and over-eruptions of the opposing teeth.It has been found that individuals with hypodontia experience more difficulty during mastication or functioning movements due to smaller occlusal table available. A recent cross-sectional study showed that hypodontia patients have more difficulties in chewing, especially if the deciduous teeth associated with the missing permanent teeth had been exfoliated. Despite currently limited evidence to support this statement, it is plausible that hypodontia may pose functional limitations, which eventually affect that individuals general well-being and quality of life.Hypodontia can indeed pose limitations on the chewing ability of a patient. The condition can be associated with split in the upper lips – a condition known as oral cleft. Hypodontia can have impacts on speech, aesthetics and function of muscles in the mouth. As a result, hypodontia can have negative impacts on the quality of life, although the condition can be well managed and treated by dentists and orthodontists. To manage the condition, the patient will need to have long-term orthodontic treatment.

Financial
Patient with hypodontia requires careful treatment plan due to complex case in order to ensure the best treatment outcomes. Such treatment plans require multi-disciplinary approach, which usually come at a financial cost to both patient and possibly their family. Due to this reason, a team consists of different dental specialties is involved in the patient care.

Management
Hypodontia is a condition that can present in various ways with differing severities. This results in a wide range of treatment methods available. Those affected should be allowed to consider and select the most suitable option for themselves. Early diagnosis of hypodontia is critical for treatment success. The treatment of hypodontia involves specialists in departments such as oral and maxillofacial surgery, operative dentistry, pediatric dentistry, orthodontics and prosthodontics.Before determining a treatment plan, the following should be determined:

Evaluate the number of teeth missing
The size and number of remaining teeth in both arches
Malocclusion
Facial profile
Bone volume
Age: Definitive treatment for hypodontia only commences once all permanent teeth erupt, or upon the completion of orthodontic treatment
Primary teeth condition
Patients motivation towards treatmentTraditionally, the management of hypodontia has involved replacing missing teeth. By replacing the missing teeth, it can prevent neighbouring teeth tilting or drifting and also prevents the overeruption of opposing teeth which could then impact on occlusion and temporo-mandibular joint dysfunction and impact the patients susceptibility to gum disease, tooth wear and tooth fractures. However, studies have suggested that a stable occlusion can be achieved even with a shortened arch of 10 occluding pairs of teeth. The findings support the concept that a healthy and stable occlusion can exist despite missing teeth as long as an acceptable number of teeth are in occlusion. However, this management technique may not be suitable for those with gum disease, parafunctioning activity (tooth grinding or clenching) or malocclusion.It should also be noted that spaces within the dental arch should be monitored, especially in younger patients, as teeth are more likely to drift, tilt or over-erupt. To do this, study models and clinical photographs could be taken in order to record baseline records. If tooth movement was to occur, another form of management may be required depending on the severity and nature.The following below are the methods used to manage hypodontia:

Accept spacing
This is a method suitable to individuals if the space from a missing tooth is not deemed to be an aesthetic concern. Appearance may not be a problem in some cases, for example, when spacing present behind the canines may not be particularly visible, depending on the individual.

Management of retained primary teeth
When there is a case of hypodontia of the permanent premolar teeth, the primary molar teeth would often remain in the mouth beyond the time they are meant to be lost. Therefore, with a presence of healthy primary teeth in the absence of a permanent successor, retaining the primary teeth can be a feasible management of hypodontia.
The primary molars present also functions as a space maintainer, prevent alveolar bone resorption and delays future prosthodontic space replacement by acting as a semi permanent solution going into adulthood Previous studies also shown a good prognosis of retained primary molars going into adulthood. However, leaving the primary teeth in place may run the risk of tooth infraocclusion where the occlusal surface is below that of adjacent teeth.Despite this, the retention of primary teeth, particularly molars, are more susceptible to occlusal wear, over-eruption of opposing teeth and the loss of inter-occlusal space.

Orthodontic space closure
Orthodontic space closure is a way of using orthodontics in order to close spaces in the mouth where the teeth are missing. The ideal age for definitive orthodontic treatment is early adolescence but it is important to consider the patients age, severity of hypodontia, patient expectations and their commitment to treatment. It can be an option for hypodontia management in the case of missing maxillary lateral incisors through the reshaping, and mesial re-positioning of the adjacent canine. This management is indicated in hypodontia cases of Class I molar relationship with severe crowding in the mandibular anterior region where the extraction of lower premolar leads to a predictable outcome, and Class II molar relationship in the absence of crowding and protrusion of the mandibular anterior dentition.When moving the canine into the space of the lateral incisor, the dimensions of the canine, root position and gingival position differ from a lateral incisor and therefore preparation of the canine is necessary in order for it to mimic the incisor. This may involve:

Reduction of the incisal tip and addition of composite on the incisal edge to create a straight contour and a rounded disto-incisal corner
Reduction of the mesial and distal surfaces to reduce the width of the tooth
Flattening of the labial surface to reduce bulbosity. However, removal of enamel by expose the darker coloured dentine and therefore further restoration may be required.
Preparation of the palatal surface of the canine to reduce its bulk.The use of veneers can also be used instead of composite however, these are more expensive and more time-consuming.
There have been several studies which showed the advantages of orthodontic space closure without prosthodontic space replacements. The main advantage mentioned is the early completion of the treatment during early adolescence and the long lasting result of the treatment outcome. In individuals with a high smile line, the mesial re-positioning of canine maintains the normal soft tissue architecture is important in maintaining the aesthetic appearance. This option also negates the risks and costs that comes with prosthodontic treatment and the impression that there is no missing tooth.Some factors need to be considered when making a decision whether to undergo space closure. These include facial profile, size and dimension of canine, the shade of colour of the teeth and the gingival contour and height. Group function occlusion is usually present as a result of the mesial movement of the canine. In order to maintain the stability of the closed space, direct-bonded lingual retainers are usually required.

Orthodontic space opening prior to prosthodontic treatment
The need for orthodontic space opening prior to prosthodontic management depends on the amount of edentulous space available in relation to adjacent teeth, occlusion and aesthetic concerns. To determine the amount of space needed, three methods in the literature can be used which are the golden proportion, the Bolton Analysis and comparing the edentulous space with the contralateral tooth size if present.Space opening and prosthodontic treatment is indicated where there is a Class I molar relationships in the absence of malocclusion Class III molar relationships presenting with a concave facial profile. However, the alteration in appearance during orthodontic treatment (e.g. creating diastema for placement of prostheses) before the filling up the space, although temporary, can negatively impact the oral health-related quality of life in adolescents.

Removable partial dentures
Removable partial dentures are known to be an effective interim method for maintaining functional and aesthetic demands in a growing patient, where definitive fixed restorations are not suitable yet. Removable dentures act as a space maintainer and also prevent the migration of adjacent or opposing teeth, thereby preserving the face height. They are also easy to adjust or add on to in the event of further tooth eruption. However, it may be difficult for young individuals to adhere with wearing removable dentures, due to their bulk. Some patients also find the idea of dentures functionally and socially unacceptable, making them unwilling to comply. Removable prosthetic devices are also known to cause damage to the remaining teeth if worn over a long period of time.

Conventional crown and bridgework
Fixed restorative options are generally preferred over removable ones.
Resin-bonded bridges: Due to its minimal preparation required, this method of replacing teeth is more suited to young adults. It is a definitive restoration with the ability to fill up one or two tooth spaces. Research has reflected a survival rate of 80% over a period of 6 years or longer, and that cantilever resin-bonded bridges are at least as good as conventional fixed-fixed bridges. Restoring teeth with this method can only be done after orthodontic treatment and will need an element of retention to ensure that tooth contacts are not misplaced.
Conventional bridges: Teeth tend to be prepared for conventional bridgework if there are large restorations present, thus being more commonly done on adult patients with hypodontia. Treatment with conventional bridgework will require significant reduction of tooth structure, which will put the tooth at risk of biological damage i.e. loss of vitality. This risk is especially high in young patients with large pulp chambers.

Tooth autotransplantation
Autotransplantation involves the removal of a tooth from one socket and relocating to another socket in the same individual. If done successfully, it is able to ensure stable alveolar bone volume as there is continuous stimulation of the periodontal ligament.

Implant supported tooth replacement
Placing dental implants has proven to be a predictable and reliable method of treating hypodontia, along with bringing excellent aesthetic results. Implant placement should be delayed until jaw growth in an individual is complete. One limitation of implant placement would be the need for a sufficient amount of bone volume, which if not met, may affect the positioning of the implant. However, bone grafting can be carried out to overcome this.

Epidemiology
Hypodontia is less common in the primary dentition, with reported prevalence rates ranging from 0.5% in the Icelandic population to 2.4% in the Japanese population </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Vaginal vault and explain in detail? [/INST]  </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Krukenberg tumor and explain in detail? [/INST] A Krukenberg tumor refers to a malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract, although it can arise in other tissues such as the breast. Gastric adenocarcinoma, especially at the pylorus, is the most common source. Krukenberg tumors are often (over 80%) found in both ovaries, consistent with its metastatic nature.

Signs and symptoms
Krukenberg tumors often come to the attention when they cause abdominal or pelvic pain, bloating, ascites, or pain during sexual intercourse. Krukenberg tumors can occasionally provoke a reaction of the ovarian stroma which leads to hormone production, that results in vaginal bleeding, a change in menstrual habits, or hirsutism, or occasionally virilization as a main symptom. In rare cases the disease can manifest with hydronephrosis and hydroureter.All these symptoms are non-specific and can also arise with a range of problems other than cancer, and a diagnosis can only be made following confirmatory investigations such as computed tomography (CT) scans, laparotomy and/or a biopsy of the ovary.

Cause and incidence
Krukenberg tumors can be seen in all age groups, with an average age of 45 years. In most countries, cancer that has metastasized to the ovary accounts for only about 1 to 2% of ovarian cancer; in the remainder, the ovary itself is the primary cancer site. However, in Japan they represent a much higher percentage of malignancies in the ovary (almost 20%) due to the increased prevalence of gastric cancer.Krukenberg tumors account for about 15% of metastatic cancers that initially appear to have arisen in the ovary, and as such is less common than metastasis arising from ovarian epithelial and germ-cell tumors.In people who have had nongynecologic malignancy, approximately 20% of adnexal masses are malignant, and 60% of these are Krukenberg tumors.

Pathogenesis
There has been debate over the exact mechanism of metastasis of the tumor cells from the stomach, appendix or colon to the ovaries </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Constriction ring syndrome and explain in detail? [/INST] Constriction ring syndrome (CRS) is a congenital disorder with unknown cause. Because of the unknown cause there are many different, and sometimes incorrect names. It is a malformation due to intrauterine bands or rings that give deep grooves in, most commonly, distal extremities like fingers and toes. In rare cases the constriction ring can form around other parts of the fetus and cause amputation or even intrauterine death. The anatomy proximal to the site of constriction (or amputation) is developmentally normal.
CRS can be associated with other malformations with club foot being most common.
The precise configuration of the bands, lymphedema, and character of the amputations are not predictable and vary with each individual patient. Also more than one extremity is usually affected, and it is rare for only one ring to present as an isolated malformation with no other manifestation of this syndrome.

Signs and symptoms
The constriction of appendages by amniotic bands may result in:
Constriction rings around the digits, arms, and legs
Swelling of the extremities distal to the point of constriction (congenital lymphedema)
Amputation of digits, arms, and legs (congenital amputation)

Cause
There are three different theories to the cause of the constriction ring syndrome.
The first is the intrinsic theory, which was proposed by Streeter in 1930, implicates an anomaly in germ plasm resulting in the defects. This theory is reinforced by the clinical presentation of the constriction rings with other internal visceral and systematic anomalies. Because of these other anomalies the names "Constriction Ring Syndrome", "Constriction Band Syndrome", and "Streeter Bands" are given to this defect/disease. This is sometimes attributed to vascular disruption shared between cleft palate and other forms of cleft defects occurring together with ABS; this co-occurrence suggests an "intrinsic" defect of the blood circulation.The second theory postulates the involvement of an intrauterine disruption during pregnancy followed by a cascade of events involving amniotic rupture. When spontaneous rupture of the amnion occurs early in the second trimester, the separation of amnion from chorion produces many small, thin strands that can become entangled within digits and toes. Later, as the fetus grows but the bands do not, the bands become constricting. This constriction reduces blood circulation, hence causes congenital abnormalities. In some cases a complete "natural" amputation of a digit(s) or limb may occur before birth or the digit(s) or limbs may be necrotic (dead) and require surgical amputation following birth. The names "Amniotic Band Syndrome" (ABS), "Amniotic Disruption Complex", and "Amniochorionic Mesoblastic Fibrous Strings" are based on this theory.
The third theory postulates the involvement of intrauterine trauma. Intrauterine trauma could be something like amniocentesis, or something like a fetal surgery. An intrauterine trauma could result in hemorrhage leading to acrosyndactyly. One study also showed the presence of bands as confirmed by sonography after fetal surgery.Because of these different theories, there are many names for this syndrome. For a long time people believed the second theory about the amniotic rupture and strands. In the research cases not every child had a real (amniotic) strand. It could be that there has to be another explanation for the development of these anomalies.

Diagnosis
The diagnosis of constriction ring syndrome can be confirmed with an ultrasonography. The clinical manifestations can be extremely variable. It could be a single or multiple manifestation. This can be confirmed at the end of the first trimester or at the beginning of the second trimester. But not every patient will be diagnosed at that moment, most will get this diagnosis at birth.Individual strands are small and hard to see on ultrasound, so bands are detected indirectly because of the constrictions and swelling upon limbs or digits. Misdiagnosis is also common, so if there are any signs of amniotic bands, further detailed ultrasound tests should be done to assess the severity. 3D ultrasound and MRI can be used for more detailed and accurate diagnosis of bands and the resulting damage/danger to the fetus.
Decreased fetal movement could be a sign of a serious problem which may include ABS. It is rare but possible for the membrane to become wrapped around the placenta or the neck of the baby in the womb causing strangulation and death.
There is a strong relationship between ABS and clubfoot (also called "talipes"). 31.5% of clubfoot cases can be correlated with ABS, with 20% occurring bilaterally. Other abnormalities found with ABS include: clubhands, cleft lip, and/or cleft palate, and hemangioma.

Differential diagnosis
The differential diagnosis includes:
Symbrachydactyly
Congenital amputations
Hypoplasias of hand, digit, thumb
Adams–Oliver syndrome
ADAM complexADAM Complex; CRS is sometimes mislabeled as ADAM complex. ADAM is an abbreviation for Amniotic Deformity, Adhesions Mutilations. CRS is the malformation due to a constriction ring around mostly a limb. ADAM-complex is the association of limb defects (caused by constriction rings) and certain craniofacial clefts"Adams–Oliver syndrome is often mislabeled as CRS and consists of cutis aplasia of the scalp in which a longitudinal defect can vary in size and can often be associated with full-thickness skullcap loss. The distal digital or toe hypoplasia-aplasia is often confused with CRS. Constriction rings with or without edema are not present. The digital or toe hypoplasia-aplasia usually contains diminutive nails or nail folds".

Classification
The constriction ring syndrome is a complex collection of asymmetric congenital anomalies, in which no two cases are exactly alike. This is why a classification is difficult to make.
The most widely used classification system was proposed by Patterson. This classification system is based on the severity of the syndrome and is useful because, the different types require different treatments. Other clinicians have amended this scheme by separating the depth of the ring into mild, moderate, severe, and amputation and by further defining the presence or absence of lymphedema or soft tissue loss distal to the ring. Expanding over subdivision in depth of the clefts for every classification is not necessary because the principles of treatment and technique for correction are the same.There are four categories:

simple constriction rings
constriction rings associated with deformity of the distal part with or without lymphedema
constriction rings associated with acrosyndactyly
uterine amputationPatterson divided the constriction ring associated with acrosyndactyly into three types:

Type I: conjoined fingertips with well-formed webs of the proper depth
Type II: the tips of the digits are joined, but web formation is not complete
Type III: joined tips, sinus tracts between digits and absent websPatterson IThere are simple constriction rings which are strands most commonly around the distal extremities as fingers and toes. In general, the thumb is not likely to be affected by a constriction ring because the fetus typically holds the thumb in tight adduction flexion, making entanglement with strands less likely. These malformations need to be surgically removed which must be executed in different stages and can done by different techniques (see also treatment).

Patterson IIThe CRS involves strands which obstruct the lymphatic vessels and thus causing fluid retention, distal of the affected extremity. This utters itself with swollen parts distal of the constriction.

Patterson IIIIn this form there is a complex form of syndactyly named acrosyndactyly, the fingers (or toes) were initially separated but due to the constriction they are formed back together. Sometimes multiple fingers can be involved. The distal fusion between digits or toes never initially involves a skeletal coalition. The digits are usually hypoplastic if multiple digits are involved. When the constriction cuts off the blood supply to the fingers, the fingers can form a peak with the most palmar digit being the index finger. Normal neurovascular bundles are not present in the distal parts. Hands with fused fingers need to be released in phases to preserve the distal blood supply.

Paterson IVOne of the most severe consequence of constriction strains is probably intrauterine amputations, this is where the constriction goes as deep as the bone and cuts off the blood supply of the proximal extremity. The result will be that the developing toe or finger will become ischemic and fall off. Because the result is a transverse amputation that cuts off the vascular supply to the developing extremity, the actual constriction ring is not seen.
This can result in different outcomes:

complete resorption; this is the most common form of amputation. In this form the amputated digit is completely resorbed during intrauterine development and therefore the amputated digit cant be found.
recovery of the digit; the digit is recovered with the placenta during delivery.
engraftment elsewhere; the amputated digit can be, in rare cases, engrafted somewhere on the fetus.Intrauterine deathIn extremely rare cases a strain can form around the umbilical cord and cut off the blood supply to the fetus which will result in intrauterine death.

Malformation associated with constriction ring syndromeThe percentage of associated anomalies varies from 40% to as high as 80%
Constriction ring deformities are as common on the lower extremity as on the upper, almost all of these involve the musculoskeletal system, with clubbed feet being the most common in up to 30% of reported cases.
Large reported series reveal an incidence between 5% and 15% of craniofacial malformations with clefting of the lip or palate.

Prevention
Amniotic band syndrome is considered an accidental event and it does not appear to be genetic or hereditary, so the likelihood of it occurring in another pregnancy is remote. The cause of amnion tearing is unknown and as such there are no known preventative measures.

Treatment
Surgical correction is recommended when a constriction ring results in a limb contour deformity, with or without lymphedema.

Surgical technique
At the beginning of the surgery a tourniquet will be applied to the limb. A tourniquet compresses and controls local arterial and venous circulation for about 2 hours. The constriction band must be dissected very carefully to avoid damaging the underlying neurovasculature. When the constriction band is excised, there will be a direct closure. This allows the fatty tissue to naturally reposition itself under the skin."With complete circumferential constriction bands, it is recommended that a two-stage correction approach be used. At the first operation, one-half of the circumference is excised and the other one-half can be excised after three to six months. This will avoid any problems to the distal circulation in the limb, which may already be compromised. Lymphedema, when present, will significantly improve within a few weeks of the first surgery."For the direct closure of the defect after dissecting a constriction band there are two techniques:

Triangular flaps; For this technique the circumference between the two borders must be measured. Depending on the difference the number of triangular flaps can be decided. With a triangular flap you can create more skin.
Z-plasty or W-plasty; "Z-plasty is a plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It can elongate a contracted scar or rotate the scar tension line. The middle line of the Z-shaped incision (the central element) is made along the line of greatest tension or contraction, and triangular flaps are raised on opposite sides of the two ends and then transposed."In rare cases, if diagnosed in utero, fetal surgery may be considered to save a limb that is in danger of amputation or other deformity. This operation has been successfully performed on fetuses as young as 22 weeks. The Melbournes Monash Medical Centre in Australia, as well as multiple facilities in the United States of America, have performed successful amniotic band release surgery.

Reconstructions and prosthetics
Treatment usually occurs after birth and where plastic and reconstructive surgery is considered to treat the resulting deformity. Plastic surgery ranges from simple to complex depending on the extent of the deformity. Physical and occupational therapy may be needed long term.Prosthetics may help some people with ABS to live more functional lives. The price and complexity of these prosthetics vary dramatically, but advances in 3-D printing have helped to increase the availability of artificial fingers while reducing their cost of production.

Prognosis
The prognosis depends on the location and severity of the constricting bands. Every case is different and multiple bands may be entangled around the fetus.
Bands which wrap around fingers and toes can result in syndactyly or amputations of the digits. In other instances, bands can wrap around limbs causing restriction of movement resulting in clubbed feet. In more severe cases, the bands can constrict the limb causing decreased blood supply and amputation. Amniotic bands can also sometimes attach to the face or neck causing deformities such as cleft lip and palate. If the bands become wrapped around the head or umbilical cord it can be life-threatening for the fetus.
The number of cases of miscarriage that can be attributed to ABS is unknown, although it has been reported that it may be the cause of 178 in 10,000 miscarriages. Up to 50% of cases have other congenital anomalies including cleft lip, cleft palate, and clubfoot deformity. Hand and finger anomalies occur in up to 80%.

Epidemiology
The reported incidence of constriction ring syndrome varies from 1/1200 and 1/15000 live births. The prevalence is equally in male and female.Fetomaternal factors like prematurity, maternal illness, low birth weight, and maternal drug exposure are predisposing factors for the constriction ring syndrome.No positive relationship between CRS and genetic inheritance has been reported.

Society
Notable people living with ABS include:

Sophie Wells, British member Paralympics dressage team
Gina Casillas, US volleyball player
Ian T. Jamison, US artist
Anna Johannes, US Paralympic swimmer
Jean-Jacques Machado, 7th degree red-and-black belt in Brazilian Jiu-Jitsu
Monica Price, a case study of a young woman born with amniotic band syndrome
Kingsley McGowan, U.S. Mens Rugby Player
Troy Fumagalli, University of Wisconsin Football Player (2017 Cotton Bowl Offensive MVP)
Lyric Mariah Heard U.S. model
Shaquem Griffin, Miami Dolphins Football Player (2016 AAC Defensive Player of the Year)
Jennifer Bricker, acrobat and aerialist
Sarah Herron, The Bachelor Season 17 contestant, Bachelor in Paradise Seasons 1 and 3 contestant, founder of "She Lift" for girls with disabilities.
Victoria Canal, Cuban-American singer and songwriter

See also
List of skin conditions
Ainhum, auto-amputation of the fifth toe in adults

References
Further reading
Walter JH, Goss LR, Lazzara AT (1998). "Amniotic band syndrome" </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Pneumatosis and explain in detail? [/INST] Pneumatosis is the abnormal presence of air or other gas within tissues.In the lungs, emphysema involves enlargement of the distal airspaces, and is a major feature of chronic obstructive pulmonary disease (COPD). Other pneumatoses in the lungs are focal (localized) blebs and bullae, pulmonary cysts and cavities.
Pneumoperitoneum (or peritoneal emphysema) is air or gas in the abdominal cavity, and is most commonly caused by gastrointestinal perforation, often the result of surgery.
Pneumarthrosis, the presence of air in a joint, is rarely a serious sign.

Lung cysts
A lung cyst, or pulmonary cyst, encloses a small volume of air,  and has a wall thickness of up to 4 mm. A minimum wall thickness of 1 mm has been suggested, but thin-walled pockets may be included in the definition as well </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Mixed receptive-expressive language disorder and explain in detail? [/INST] Mixed receptive-expressive language disorder (DSM-IV 315.32) is a communication disorder in which both the receptive and expressive areas of communication may be affected in any degree, from mild to severe. Children with this disorder have difficulty understanding words and sentences. This impairment is classified by deficiencies in expressive and receptive language development that is not attributed to sensory deficits, nonverbal intellectual deficits, a neurological condition, environmental deprivation or psychiatric impairments. Research illustrates that 2% to 4% of five year olds have mixed receptive-expressive language disorder. This distinction is made when children have issues in expressive language skills, the production of language, and when children also have issues in receptive language skills, the understanding of language. Those with mixed receptive-language disorder have a normal left-right anatomical asymmetry of the planum temporale and parietale. This is attributed to a reduced left hemisphere functional specialization for language. Taken from a measure of cerebral blood flow (SPECT) in phonemic discrimination tasks, children with mixed receptive-expressive language disorder do not exhibit the expected predominant left hemisphere activation. Mixed receptive-expressive language disorder is also known as receptive-expressive language impairment (RELI) or receptive language disorder.

Classification
If assessed on the Wechsler Adult Intelligence Scale, for instance, symptoms of mixed receptive-expressive language disorder may show as relatively low scores for Information, Vocabulary and Comprehension (perhaps below the 25th percentile). If a person has difficulty with specific types of concepts, for example spatial terms, such as over, under, here and there, they may also have difficulties with arithmetic, understanding word problems and instructions, or difficulties using words at all.
They may also have a more general problem with words or sentences, both comprehension and orally. Some children will have issues with pragmatics – the use of language in social contexts as well; and therefore, will have difficulty with inferring meaning. Furthermore, they have severe impairment of spontaneous language production and for this reason, they have difficulty in formulating questions. Generally, children will have trouble with morphosyntax, which is word inflections. These children have difficulty understanding and applying grammatical rules, such as endings that mark verb tenses (e.g. -ed), third-person singular verbs (e.g. I think, he thinks), plurals (e.g. -s), auxiliary verbs that denote tenses (e.g. was running, is running), and with determiners (the, a). Moreover, children with mixed receptive-expressive language disorders have deficits in completing two cognitive operations at the same time and learning new words or morphemes under time pressure or when processing demands are high. These children also have auditory processing deficits in which they process auditory information at a slower rate and as a result, require more time for processing.

Presentation
Related disorders
Studies show that low receptive and expressive language at young ages was correlated to increased autism symptom severity in children in their early school years. Below is a chart depicting language deficits of children on the autistic spectrum. This table indicates the lower levels of language processing, receptive/expressive disorders, which is more severe in children with autism </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Dicheirus and explain in detail? [/INST]  </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Communication disorder and explain in detail? [/INST] A communication disorder is any disorder that affects an individuals ability to comprehend, detect, or apply language and speech to engage in dialogue effectively with others.  The delays and disorders can range from simple sound substitution to the inability to understand or use ones native language.

Diagnosis
Disorders and tendencies included and excluded under the category of communication disorders may vary by source.  For example, the definitions offered by the American Speech–Language–Hearing Association differ from those of the Diagnostic Statistical Manual 4th edition (DSM-IV).Gleanson (2001) defines a communication disorder as a speech and language disorder which refers to problems in communication and in related areas such as oral motor function. The delays and disorders can range from simple sound substitution to the inability to understand or use ones native language. In general, communication disorders commonly refer to problems in speech (comprehension and/or expression) that significantly interfere with an individuals achievement and/or quality of life.  Knowing the operational definition of the agency performing an assessment or giving a diagnosis may help.Persons who speak more than one language or are considered to have an accent in their location of residence do not have a speech disorder if they are speaking in a manner consistent with their home environment or that is a blending of their home and foreign environment.

DSM-IV
According to the DSM-IV-TR, communication disorders are usually first diagnosed in childhood or adolescence, though they are not limited as childhood disorders and may persist into adulthood.  They may also occur with other disorders.
Diagnosis involves testing and evaluation during which it is determined if the scores/performance are "substantially below" developmental expectations and if they "significantly" interfere with academic achievement, social interactions, and daily living.  This assessment may also determine if the characteristic is deviant or delayed.  Therefore, it may be possible for an individual to have communication challenges but not meet the criteria of being "substantially below" criteria of the DSM IV-TR.
The DSM diagnoses do not comprise a complete list of all communication disorders, for example, auditory processing disorder is not classified under the DSM or ICD-10.
The following diagnoses are included as communication disorders:

Expressive language disorder – characterized by difficulty expressing oneself beyond simple sentences and a limited vocabulary. Individuals can better understand than use language; they may have a lot to say, but have more difficulty organizing and retrieving the words than expected for their developmental stage.
Mixed receptive-expressive language disorder – problems comprehending the commands of others.
Stuttering – a speech disorder characterized by a break in fluency, where sounds, syllables, or words may be repeated or prolonged.
Phonological disorder – a speech sound disorder characterized by problems in making patterns of sound errors (e.g., "dat" for "that").
Communication disorder NOS (not otherwise specified) – the DSM-IV diagnosis in which disorders that do not meet the specific criteria for the disorder listed above may be classified.

DSM-5
The DSM-5 diagnoses for communication disorders completely rework the ones stated above. The diagnoses are made more general in order to capture the various aspects of communications disorders in a way that emphasizes their childhood onset and differentiate these communications disorders from those associated with other disorders (e.g. autism spectrum disorders).
Language disorder – the important characteristics of a language disorder are difficulties in learning and using language, which is caused by problems with vocabulary, with grammar, and with putting sentences together in a proper manner. Problems can both be receptive (understanding language) and expressive (producing language).
Speech sound disorder – previously called phonological disorder, for those with problems with pronunciation and articulation of their native language.
Childhood-Onset Fluency Disorder (Stuttering) - standard fluency and rhythm of speech is interrupted, often causing the repetition of whole words and syllables. May also include the prolongation of words and syllables; pauses within a word; and/or the avoidance of pronouncing difficult words and replacing them with easier words that the individual is better able to pronounce. This disorder causes many communication problems for the individual and may interfere with social communication and performance in work and/or school settings where communication is essential.
Social (pragmatic) communication disorder – this diagnosis described difficulties in the social uses of verbal and nonverbal communication in naturalistic contexts, which affects the development of social relationships and dialogue comprehension. The difference between this diagnosis and autism spectrum disorder is that in the latter there is also a restricted or repetitive pattern of behavior.
Unspecified communication disorder – for those who have symptoms of a communication disorder but who do not meet all criteria, and whose symptoms cause distress or impairment.

Examples
Examples of disorders that may include or create challenges in language and communication and/or may co-occur with the above disorders:

autism spectrum disorders - autistic disorder, pervasive developmental disorder not otherwise specified (PDDNOS), and Asperger disorder – developmental disorders that affect the brains normal development of social and communication skills.
expressive language disorder – affects speaking and understanding where there is no delay in non-verbal intelligence.
mixed receptive-expressive language disorder – affects speaking, understanding, reading and writing where there is no delay in non-verbal intelligence.
specific language impairment – a language disorder that delays the mastery of language skills in children who have no hearing loss or other developmental delays. SLI is also called developmental language disorder, language delay, or developmental dysphasia.

Sensory impairments
Blindness – A link between communication skills and visual impairment with children who are blind is currently being investigated.
Deafness/frequent ear infections – Trouble with hearing during language acquisition may lead to spoken language problems.  Children with frequent ear infections may temporarily develop problems pronouncing words correctly. Some of the above communication disorders can occur with people who use sign language.  The inability to hear is not in itself a communication disorder.

Aphasia
Aphasia is loss of the ability to produce or comprehend language. There are acute aphasias which result from stroke or brain injury, and primary progressive aphasias caused by progressive illnesses such as dementia.

Acute aphasias
Expressive aphasia also known as Brocas aphasia, expressive aphasia is a non-fluent aphasia that is characterized by damage to the frontal lobe region of the brain. A person with expressive aphasia usually speaks in short sentences that make sense but take great effort to produce. Also, a person with expressive aphasia understands another persons speech but has trouble responding quickly.
Receptive aphasia also known as Wernickes aphasia, receptive aphasia is a fluent aphasia that is categorized by damage to the temporal lobe region of the brain. A person with receptive aphasia usually speaks in long sentences that have no meaning or content. People with this type of aphasia often have trouble understanding others speech and generally do not realize that they are not making any sense.
Conduction aphasia
Anomic aphasia
Global aphasia
Primary progressive aphasias
Progressive nonfluent aphasia
Semantic dementia
Logopenic progressive aphasia

Learning disability
Dyscalculia – an impairment in the systems used in communicating numbers
Dyslexia – an impairment in systems used in reading
Dysgraphia – an impairment in the systems used in writing

Speech disorders
cluttering - a syndrome characterized by a speech delivery rate which is either abnormally fast, irregular, or both.
dysarthria - a condition that occurs when problems with the muscles that helps a person to talk make it difficult to pronounce words.
esophageal voice - involves the patient injecting or swallowing air into the esophagus. Usually learnt and used by patients who cannot use their larynges to speak. Once the patient has forced the air into their esophagus, the air vibrates a muscle and creates esophageal voice. Esophageal voice tends to be difficult to learn and patients are often only able to talk in short phrases with a quiet voice.
lisp - a speech impairment that is also known as sigmatism.
speech sound disorder - Speech-sound disorders (SSD) involve impairments in speech-sound production and range from mild articulation issues involving a limited number of speech sounds to more severe phonologic disorders involving multiple errors in speech-sound production and reduced intelligibility.
stuttering - a speech disorder in which sounds, syllables, or words are repeated or last longer than normal. These problems cause a break in the flow of speech (called disfluency).

See also
References
Further reading
Cherney LR, Gardner P, Logemann JA,  et al. (2010). "The role of speech-language pathology and audiology in the optimal management of the service member returning from Iraq or Afghanistan with a blast-related head injury: position of the Communication Sciences and Disorders Clinical Trials Research Group". J Head Trauma Rehabil </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Vascular access steal syndrome and explain in detail? [/INST]  </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Dhat syndrome and explain in detail? [/INST] Dhat syndrome (Sanskrit: धातु दोष, IAST: Dhātu doṣa) is a condition found in the cultures of South Asia (including Pakistan, India, Bangladesh, Nepal, and Sri Lanka) in which male patients report that they suffer from premature ejaculation or impotence, and believe that they are passing semen in their urine. The condition has no known organic cause.In traditional Hindu spirituality, semen is described as a "vital fluid". The discharge of this "vital fluid", either through sex or masturbation, is associated with marked feelings of anxiety and dysphoria. Often the patient describes the loss of a whitish fluid while passing urine. At other times, marked feelings of guilt associated with what the patient assumes is "excessive" masturbation are noted.
Many doctors view dhat as a folk diagnostic term used in South Asia to refer to anxiety and hypochondriacal concerns associated with the discharge of semen, with discoloration of the urine, and feelings of weakness and exhaustion.
Dhat is thought to be a culture-bound syndrome similar to jiryan (South-East Asia), prameha (Sri Lanka), and
shenkui (China). Dhat syndrome might be related to other post-orgasmic diseases, such as post-coital tristesse (PCT), postorgasmic illness syndrome (POIS), and sexual headache.

Signs and symptoms
Young males are most often affected, though similar symptoms have been reported in females with excessive vaginal discharge or leucorrhea, which is also considered a "vital fluid". In addition, there are symptoms of fatigue and weakness. Patients with Dhat condition most normally ascribe their semen misfortune (secretion of semen in urine) to reasons like inordinate masturbation, sensual dreams, and unreasonable sexual longing. Nocturnal emission and secretion of semen in urine are considered to be the most widely recognized symptoms of semen misfortune. Patients with Dhat condition frequently dread the result of semen misfortune and regularly have the conviction that it will lead to decrease in sexual performance. The most widely recognized side effects in patients with Dhat condition are shortcoming of the body, sluggishness, low energy, and low temperament. Premature ejaculation and impotence are commonly seen. Other somatic symptoms like weakness, easy fatiguability, palpitations, insomnia, low mood, guilt and anxiety are often present. Males sometimes report a subjective feeling that their penises have shortened. These symptoms are usually associated with an anxious and dysphoric mood state. Another sign of this syndrome is white discharge. According to Ayurvedic, an Indian medical system, men who have experienced this have shown signs of anxiety issues. This disease is a culture bound syndrome. Semen loss is generally viewed as taboo and harmful. It is also associated with a lower socioeconomic class. Being able to produce semen is viewed as longevity of ones health and certain powers. In Indian culture, it is important for a man to produce semen.

Treatment
Cognitive behavioral therapy is the mainstay of treatment </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Follicular cyst of ovary and explain in detail? [/INST]  </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Polioencephalitis and explain in detail? [/INST] Polioencephalitis is a viral infection of the brain, causing inflammation within the grey matter of the brain stem.  The virus has an affinity for neuronal cell bodies and has been found to affect mostly the midbrain, pons, medulla and cerebellum of most infected patients.  The infection can reach up through the thalamus and hypothalamus and possibly reach the cerebral hemispheres.  The infection is caused by the poliomyelitis virus which is a single-stranded, positive sense RNA virus surrounded by a non-enveloped capsid.  Humans are the only known natural hosts of this virus.  The disease has been eliminated from the U.S. since the mid-twentieth century, but is still found in certain areas of the world such as Africa.

Signs and symptoms
Signs and symptoms may vary and some individuals may not experience any symptoms at all.  The most common reported symptom of polioencephalitis is fatigue. Fatigue is associated with difficulty in attention, cognition, and maintaining wakefulness Some individuals experience psychiatric symptoms that include anxious mood, pain, insomnia, and depressed mood.  Confusion and disorientation of time and space have also been reported.  Motor symptoms vary more from patient to patient, but can include incoordination and tremors, nystagmus, loss of conjugate eye movements, rigidity and hemiparesis.

Mechanism
The poliomyelitis virus is an enterovirus that enters through the mouth and multiplies in the throat and epithelial cells of the gastrointestinal tract.  It will then move to the bloodstream and is carried to the central nervous system.  Once in the CNS, the virus will attach to a host cell by binding with a cell surface receptor.  The host cell surface receptor is a glycoprotein that has been recently identified as CD155.  Once the virus has bound to the host cell, it will penetrate the host cell membrane and begin the replication of its genome.  Many cells contain the surface receptor CD155; however, manifestation of this disease does not occur in all cells.  The reason for incidence of the disease in only certain areas of the brain such as the brainstem is unknown.  Once areas of the brain have been invaded by the virus, inflammation will occur.  During inflammation, the brain’s tissues become swollen due to the body’s immune system response to the infection.  Fluid, white blood cells, dead cellular debris and inactivated viruses resulting from the actions of the immune response can significantly alter the fluid surrounding healthy neurons.  The function of these healthy neurons can decline due to disruptions in the cell membrane affecting electrical properties of the neuron or by interfering with the blood supply causing anoxic cellular damage.  Depending on which neurons are damaged will result in a variety of different symptoms.

Diagnosis
If someone is suspected of having polioencephalitis a sample of throat secretions, stool or cerebrospinal fluid is checked for the virus.  Blood tests can be done to detect antibodies against viral antigens and foreign proteins.  Virus isolation is the most sensitive method and it is most likely to be isolated from stool samples.  Once isolated, RT-PCR is used to differentiate naturally occurring strains from vaccine-like strains.

Prevention
The virus is most often spread by person to person contact with the stool or saliva of the infected person.  Two types of vaccines have been developed to prevent the occurrence and spread of the poliomyelitis virus.  The first is an inactivated, or killed, form of the virus and the second is an attenuated, or weakened, form of the virus.  The development of vaccines has successfully eliminated the disease from the United States.  There are continued vaccination efforts in the U.S. to maintain this success rate as this disease still occurs in some areas of the world.

Treatment
There is no cure for polioencephalitis so prevention is essential.  Many people that become infected will not develop symptoms and their prognosis is excellent. However, the prognosis is dependent on the amount of cellular damage done by the virus and the area of the brain affected.  Many people that develop more severe symptoms can have lifelong disabilities or it can lead to death </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Pathological jealousy and explain in detail? [/INST] Pathological jealousy, also known as morbid jealousy, Othello syndrome or delusional jealousy, is a psychological disorder in which a person is preoccupied with the thought that their spouse or sexual partner is being unfaithful without having any real proof, along with socially unacceptable or abnormal behaviour related to these thoughts. The most common cited forms of psychopathology in morbid jealousy are delusions and obsessions. It is considered a subtype of delusional disorder.Overvaluing an idea, which is defined as “an acceptable, comprehensible idea pursued by the patient beyond the bounds of reason. The idea is not resisted and, although it is not a delusion, the patient characteristically attaches utmost importance to investigating and maintaining the partner’s fidelity at great personal disadvantage and to the distress of the partner”. Overvalued ideas are characterized by being existent in the individuals own thoughts, being egosyntonic; meaning that the ideas project the behaviors, values, and feelings that are aligned with the desires and aims of the individuals ego, or consistent with the individuals ideal self-image, the ideas are also amenable to reason but are not resisted.

Definition
This disorder occurs when a person typically makes repeated accusations that their spouse or sexual partner is being unfaithful, based on insignificant, minimal, or no evidence, often citing seemingly normal or everyday events or material to back up their claims.
Unlike other delusional disorders, people who suffer from this disorder have a strong association with stalking, cyberstalking, sabotage, or even violence. It can be found in the context of schizophrenia and delusional disorder, such as bipolar disorder, but is also associated with alcoholism and sexual dysfunction and has been reported after neurological illness (i.e. Parkinsons).
The name "Othello Syndrome" comes from the character in Shakespeares play Othello, who murders his wife as a result of a false belief that she has been unfaithful. Recently, some psychologists and psychiatrists have asserted that Othello was deceived rather than deluded about Desdemonas alleged infidelity and thus did not have ‘the Othello Syndrome’.

Psychiatric history
Presenting difficulties: neurotic or psychotic jealousy
Past psychiatric history: neurotic or psychotic disorders, deliberate self-harm and attempted suicide
Family history: mental illness including pathological jealousy
Relationship history: incorporating both the current and previous relationship and taking account of the quality of the relationships and the difficulties experienced
Forensic history: previous and pending charges and convictions as well as deviant behavior which was not reported or did not result in a charge or conviction (including aggressive behavior and stalking)
Medical history: organic causes which may be responsible for the morbid jealousy (i.e. Parkinsons)

Forms
Obsessions: the individuals own thoughts are egodystonic; they are acknowledged to be senseless, and usually resisted. Jealous thoughts are experienced as intrusive and excessive, and compulsive behavior such as checking up on their partner may follow.  Egodystonicity (the distress caused by thoughts that are unwanted and viewed as contrary to conscious wishes) generally varies a large amount between patients and “a continuum from obsessional to delusional, which morbid jealousy has been suggested” (Insel & Akiskal 1986).
Extreme obsessions: much time is taken up by jealous concerns, and there is a great difficulty in putting the concerns out of the mind. Impairment of the relationship, limitation of the partners freedom and checking on the partners behavior may occur. Although a distinction was occasionally difficult to make, the categories of ‘psychotic’ (delusional) and ‘neurotic’ jealousy contained similar proportions (each between one-third and one-half).
Delusions: the individuals own thoughts are egosyntonic; they are regarded as true, and not resisted. Some authors compare morbid jealousy to a delusional state (e.g. Enoch & Trethowan, 1979). Beliefs may include the morbidly jealous subjects suspicion that: 1. he or she is being poisoned or given some substance(s) to decrease sexual potency by the partner, 2. that the partner has contracted a sexually transmitted disease from a third party 3. is engaging in sexual intercourse with a third party while the subject sleeps.

Causes
Psychological
There are many psychological causes that go along with morbid jealousy. Some people equate morbid jealousy with a delusional state. “Delusions of infidelity exist without any other psychopathology and may be considered to be morbid jealousy in its ‘purest’ form” (Kingham and Gordon). For morbid jealousy to occur ones memories are subconsciously changed and their partners actions are misinterpreted as well to the extent that the person is absolutely convinced of betrayal from the partner. It is thought that even some brain disorders might eventually lead to delusions of betrayal. It has also been recorded by Cobb (1979) “that morbid jealousy may be present with all types of cerebral insult or injury.” "It has been suggested that morbid jealousy may potentially arise in response to reduced sexual function”. Cobb (1979) drew attention to the elderly man whose waning sexual powers were insufficient to satisfy a younger wife.
Mullen (1990) considered morbid jealousy to be associated with four features:
An underlying mental disorder emerges before or with the jealousy
The features of the underlying disorder coexist with the jealousy
The course of morbid jealousy closely relates to that of the underlying disorder
The jealousy has no basis in reality

Personality
People who are very insecure, or even fearful, are more likely to become anxious, or question their partners commitment to them. “Insecure attachment style correlates strongly with borderline personality disorder” (Kingham and Gordon).

Environmental
Some people even believe that someone who is morbidly jealous might suspect that he or she is being drugged or given some kind of substance that might decrease their sexual potency, or they might even be under the impression that their significant other has somehow received a sexually transmitted disease from another person while the subject is unaware.

Epidemiology
There is no known prevalence of morbid jealousy; currently there is no community survey tracking its existence in individuals. As of late, it is considered to be a rare occurrence. Still, many counselors encounter cases of morbid jealousy. Some clinicians may never be able to treat this condition due to other dominating psychopathologies present within the jealous person that call for more attention.
Men and women differ dramatically when it comes to morbid jealousy. Men who suffer from morbid jealousy are more likely than women to use violence and also are more likely to harm or kill with their hands rather than a blunt object. Women on the other hand, when using violence, tend to use a blunt object or knife. Men focus on the rivals status and resources when it comes to the threat of jealousy they fear. Women tend to become more jealous of a potential threat on their rivals youth and physical attractiveness.

Triggers
For men the strongest trigger is sexual infidelity and with women the strongest trigger is emotional infidelity. If partner-related violence does not stop infidelity from happening, the male mate will sometimes resort to suicide instead. The final resort to stopping infidelity inside of morbid jealousy is to commit partner murder. Women are much less likely to kill their partner, unless it is in self-defense. Morbid jealousy can occur in a number of conditions such as chronic alcoholism, addiction to substances other than alcohol (i.e. cocaine, amphetamines, marijuana.), organic brain disorders (i.e. Parkinsons, Huntingtons), schizophrenia, neurosis, affective disturbances or personality disorders.

Associated drug and alcohol use
Alcohol and drug misuse has a well-recognized association with morbid jealousy. “In two studies, morbid jealousy was present in 27% and 34% respectively of men recruited from alcohol treatment services” (Shrestha et al., 1985; Michael et al., 1995). Amphetamine and cocaine increase the possibility of a delusion of infidelity that can continue after intoxication stops. (Shepherd, 1961).

Assessment
In an attempt to counsel or treat the morbid jealousy of an individual, proper and thorough assessment must be employed. This approach is broad in nature, but necessary so as to provide adequate information that will aid in the possible reparation of a dynamic containing a morbidly jealous person. To begin, a careful history should be taken of both partners if possible; separate and together. It is imperative that a full and detailed psychiatric history and mental state examination be recorded for the jealous partner; doing so may enable one to distinguish whether the jealousy is obsessional or delusional in nature. It is also possible that the jealousy may be the result of a thought that has been given too much importance. Considering that jealousy is a very delicate issue, any reference made to it should be approached carefully and with tact. It must be kept in mind that the jealous individual may be displacing blame for their issues onto their partner and their alleged infidelity as opposed to their own behavior. If there is any history of relevant or related mental illness and substance misuse it should be noted as it may possibly be a contributing or aiding factor. In order to get the best grasp on the issues and begin positive progression, multiple interviews should be held to assess the marital relationship.After completing the assessment, it is best to deliver information about risk with both individuals in the relationship. Due to confidentiality, the patient should give consent for this information to be shared unless there is a risk to another individual and it is serious and immediate. This is the only case in which confidentiality is invalid. The professional should ensure that all necessary steps are taken to guarantee the safety of a potential victim, keeping in mind that it is possible that authorities may have to be alerted regarding the matter. If the professional has reason to believe that there is a high risk of harm to themselves or another person, the individual who is morbidly jealous should be admitted to hospital as soon as possible to prevent any negative outcomes for any parties involved.

Management
Morbid jealousy encompasses various psychiatric states and the best way to approach treatment depends on the symptoms that are observed in the individual. Therefore, prognosis and outcomes vary from person to person and depends on the situation and the complexities of the interpersonal relationships being observed. Also, other issues that may exacerbate the negative aspects of the environment created by jealous behavior need to be addressed in order to begin reparations. For example, if alcoholism plays a role in the behavior of the morbidly jealous individual, treatment of their addiction can positively affect their progress in trying to change their jealous nature. While psychotherapy can be an effective method of treating morbidly jealous persons, it is not sufficient when the nature of their illness is more serious. It is not possible to say that there is one form of treatment that is superior over all those that are currently available.  Even though this may be true, cognitive behavioral therapy is the treatment that has proven to be most effective.Medical

Treatment of the primary psychiatric condition
Antipsychotic medication
Antidepressant medicationPsychological

Psycho education for the affected person and the partner
Behavioral therapy
Cognitive therapy
Individual psychotherapy
Insight oriented psychotherapies
Family therapy
Couple therapySocial

Geographical separation of the partners
Social work involvement for child protection issues
Alcohol and substance misuse treatment

Risks associated
Confirmatory behaviors
When suspicions of the partners fidelity arise, they quickly become all that is thought about. Certain behaviors, such as interrogation of the partner, repeated telephone calls to work and surprise visits, stalking behavior, setting up recording devices in the home or work, or hiring a private detective to follow the partner, are all common in trying to determine if there is truly infidelity or if it is just perceived. Individuals that are jealous may take drastic measures, such as searching the partners clothing and belongings, look through diaries and other communication methods (email, text messaging), or examining bed sheets, undergarments and even genitalia for evidence of sexual activity.

Harm to self
Suicidal thoughts are common in morbid jealousy, especially because of its association with depression and substance abuse.

Risk to others
Violence can occur in any relationship tainted with jealousy, either normal or morbid jealousy. In a recent study of jealousy by Mullen & Martin in 1994, 15% of both men and women reported that at some time they had been “subjected to physical violence at the hands of a jealous partner.” Culturally, jealousy may be even used to “justify violence towards partners.” Victims in a homicide case are most likely to be current or ex-partners in both female and male perpetrators.
When a partner repeatedly denies infidelity, this may provoke anger and extreme violence. On the other hand, the partner that is suffering may give up and give a false confession, which in turn most likely will provoke rage in the jealous individual. In the U.S. a sample was taken of 20 participants with delusional jealousy. 19 were male and Silva (1998) found that 13 had threatened to kill their spouse because of their perceived infidelity. Of the 13 males, nine actually attacked their spouse. Out of the 20, a weapon was used by three of them, and 12 had harmed their spouse.
A presence of paranoid delusions and hallucinations of injury to the spouse were most often associated with violence. This suggests that individuals that suffer from delusional jealousy that partake in violence may be solely driven by psychotic phenomena. A higher risk of assault was associated with alcohol consumption.

Risk to children
Children that live in a household with a parent that suffers from morbid jealousy may suffer emotional and/or physical abuse as a direct result of the actions made by the parent. Children may also accidentally overhear arguments or witness physical violence between their parents. They could even be potentially accidentally injured during assaults. The morbidly jealous parent may employ a child or more than one to spy on the other parent. It is not out of the question for a child to witness a homicide or suicide where their parent is the victim.

See also
References
Sources
Enoch, D. & Ball, H. (2001) The Othello Syndrome. In Enoch, D. & Ball, H. Uncommon psychiatric syndromes (fourth edition) pp50–73.  London: Arnold. ISBN 0-340-76388-4

Further reading
Easton, J.A.; Shackelford, T.K.; Schipper, L.D. (2008). "Delusional Disorder--Jealous Type: How Inclusive are the DSM-IV Diagnostic Criteria?" (PDF). Journal of Clinical Psychology. 64 (3): 264–275. doi:10.1002/jclp.20442 </s>


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