1 Condition Polymyositis and dermatomyositis Polymyositis and dermatomyositis This booklet provides information and answers to your questions about these conditions.
2 What are polymyositis and dermatomyositis? Polymyositis and dermatomyositis are conditions that cause inflammation in the muscles. Polymyositis causes pain and weakness in many muscles, whereas dermatomyositis causes similar inflammation that occurs with a skin rash. In this booklet we ll explain about the symptoms, causes, tests and treatments. At the back of this booklet you ll find a brief glossary of medical words we ve underlined these when they re first used in the booklet.
3 Arthritis Research UK Polymyositis and dermatomyositis What s inside? 2 Polymyositis and dermatomyositis at a glance 4 What are polymyositis and dermatomyositis? What are the other types of myositis? 5 What are the symptoms of polymyositis and dermatomyositis? 6 What causes polymyositis and dermatomyositis? 6 What is the outlook? 6 What are the possible complications? 8 How are polymyositis and dermatomyositis diagnosed? Blood tests Other tests 10 What treatments are there for polymyositis and dermatomyositis? Drugs Exercises and physiotherapy 12 Research and new developments 13 Glossary 14 Where can I find out more? 16 We re here to help
4 At a glance Polymyositis and dermatomyositis What are polymyositis and dermatomyositis? Myositis means an inflammation of the muscles. Polymyositis is inflammation of many muscles and it especially affects larger ones such as those around the shoulders, hips and thighs. Dermatomyositis is a condition where a particular skin rash occurs with muscle inflammation that s similar to polymyositis. Both conditions are autoimmune diseases. This means the immune system attacks your body s own tissues. What are the symptoms? The severity of the symptoms of polymyositis and dermatomyositis is different from person to person. Most people will only have mild symptoms. These typically include: weak and tired muscles muscles that feel tender to the touch and painful feeling generally unwell, weight loss and night sweats. Polymyositis and dermatomyositis are rare diseases, affecting only 6 8 people out of 100,000. When myositis occurs with a red/pink rash, it s called dermatomyositis. The rash occurs on the upper eyelids, face and neck, and the backs of the hands and fingers. You may also notice swelling in the affected areas, which causes a characteristic puffiness and colouring around the eyes. Who gets them? Polymyositis and dermatomyositis are rare diseases, affecting only 6 8 people out of 100,000. It mostly affects adults, although children can be affected by a type of dermatomyositis called juvenile dermatomyositis. 2
5 Arthritis Research UK Polymyositis and dermatomyositis How are they diagnosed? The symptoms for polymyositis and dermatomyositis can be similar to many other conditions, so the doctor may base the diagnosis on: an examination blood tests an electromyography (EMG) test a muscle biopsy a magnetic resonance imaging (MRI) scan of the muscles with the most symptoms. What treatments are there? In most cases symptoms can be eased fairly quickly with treatment. A number of different treatments may be used to treat polymyositis and dermatomyositis, including: In many cases disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, azathioprine, ciclosporin or cyclophosphamide can control the condition. A small number of people have been treated with biological therapies such as infliximab and rituximab when other treatments haven t been effective. Infusions of immunoglobulin Antibodies collected from blood donations given by healthy people help stop your immune system from attacking your own tissues. Most people won t need this treatment. Exercise Exercises will be given to counter any muscle wasting after the condition is controlled. Drugs Steroids are normally the first choice of treatment for reducing the inflammation.
6 What are polymyositis and dermatomyositis? Myositis means inflammation of the muscles (myo = muscle, itis = inflammation). Polymyositis affects many areas (poly = many), mainly the larger muscles like those around the shoulders, hips and thighs. When polymyositis develops alongside a skin rash, the condition is called dermatomyositis (derm = skin). What are the other types of myositis? Post-infectious reactive myositis can occur after some viral infections. After killing the virus, the immune system may cause inflammation in some parts of the body for a few months. If the inflammation occurs in muscles, it causes myositis. The symptoms of post-infectious reactive myositis are similar to those of polymyositis (muscle pain/weakness), and you may get a positive result for some tests that diagnose polymyositis, but post-infectious reactive myositis is usually mild and will settle without treatment. Inclusion body myositis (IBM) causes muscle weakness like polymyositis and dermatomyositis, and tests to diagnose IBM show similar results as tests for the other two conditions. However, in IBM the weakness usually affects muscles near the ends of the limbs (hands, forearms and calves). The key difference in IBM is the presence of abnormal lumps of protein (inclusion bodies) in muscle cells, which aren t found in the muscle cells of people with polymyositis and dermatomyositis. These lumps are so tiny that they can only be seen with special microscopes. IBM doesn t respond well to steroids, so if you re diagnosed with polymyositis and steroids aren t working you may needfurther tests for IBM. IBM only rarely causes muscle pain and it generally affects people over 50. Myositis means inflammation of the muscles. 4
7 Arthritis Research UK Polymyositis and dermatomyositis What are the symptoms of polymyositis and dermatomyositis? The symptoms of polymyositis and dermatomyositis vary between individuals. Most people will only have mild and short-lived symptoms. These can include: weak and tired muscles making normally easy tasks like getting up from low chairs very tiring inflamed muscles causing pain (known as myalgia) and feeling tender to the touch generally feeling unwell (malaise) weight loss night sweats. If you have dermatomyositis (myositis with a rash), you may get some of the above symptoms as well as the ones below: a red/pink rash on the upper eyelids, face and neck, and on the backs of the hands and fingers (see Figure 1) swelling of the affected skin, causing a characteristic puffiness and colouring around the eyes. Myositis has similar symptoms to fibromyalgia, another condition that causes muscle pain and tiredness. Unlike myositis, fibromyalgia isn t an autoimmune disease, and the conditions aren t related. See Arthritis Research UK booklet Fibromyalgia. Upper eyelids Face Neck Figure 1 A red/pink rash occurs in people with dermatomyositis Photography used with kind permission of Elsevier. Elsevier Taken from Rheumatology, fifth edition. Edited by Marc C Hochberg, Alan J Silman, Josef S Smolen, Michael E Weinblatt and Michael H Weisman. 5
8 6 In most cases the pain and feelings of being unwell can be eased fairly quickly with drug treatment. Other conditions can mimic polymyositis. These include: the side-effects of some medications (for example steroids and statin cholesterol-lowering drugs) toxic effects of long-term excess alcohol intake hormonal conditions (for example under- or overactive thyroid) low vitamin D levels, or abnormal calcium or magnesium levels infections other, rarer nerve-muscle diseases (for example muscular dystrophies). What causes polymyositis and dermatomyositis? Polymyositis and dermatomyositis are autoimmune diseases. This means that the immune system, which normally protects the body against infections, attacks the body s own tissues. This causes inflammation in the muscles and skin. We don t yet know why this happens. What is the outlook? The outlook for people with polymyositis and dermatomyositis is good. Symptoms aren t often severe and in most cases the pain and feelings of being unwell can be eased fairly quickly with drug treatment. Even in severe cases myositis responds to treatment. The condition frequently becomes inactive. Muscle strength will take longer to recover, but you ll be given exercises to counter any muscle wasting and to improve the strength of the recovering muscle once the disease is controlled. What are the possible complications? In a few cases of polymyositis and dermatomyositis, drug treatment doesn t work and the muscles stay weak. We re still doing research into why this happens, but moderate exercise (so you start breathing faster but aren t straining yourself) still helps the recovery of your muscle strength and improves your ability to use your muscles. Occasionally polymyositis can also affect breathing and swallowing. This may occur at the start of severe cases when the muscles used become very weak. It may also cause weakening of the heart, and inflammation of the lungs may cause scarring. This affects how the lungs work. Lung and heart conditions can cause long-term breathlessness. Children with dermatomyositis may develop painful calcium deposits in damaged muscles. These deposits, combined with immobility, can occasionally result in permanently bent joints (flexion contracture).
9 Arthritis Research UK Polymyositis and dermatomyositis
10 Polymyositis occasionally occurs in patients who also have another autoimmune rheumatic disease such as rheumatoid arthritis, lupus and scleroderma. See Arthritis Research UK booklets Lupus; Rheumatoid arthritis; Scleroderma. On rare occasions, myositis can be associated with cancer. Most people with polymyositis and dermatomyositis don t develop cancer, but your doctor might arrange tests such as a chest x-ray or an ultrasound scan of your abdomen and pelvis to be on the safe side. How are polymyositis and dermatomyositis diagnosed? Your doctor will talk to you about your symptoms and examine you, but because the symptoms of polymyositis and dermatomyositis are similar to many other conditions you ll probably have blood tests and other examinations. Blood tests Creatine phosphokinase Creatine phosphokinase is an enzyme that leaks out of damaged muscle. It s likely that you ll have a high level of this in your blood if you have polymyositis or dermatomyositis, but the level should fall as the disease is treated and brought under control. You ll need to have repeat measurements taken throughout the course of the condition to tell the doctor how well it s responding to treatment. Erythrocyte sedimentation rate Erythrocyte sedimentation (ESR) detects and measures inflammation by assessing how quickly blood cells settle at the bottom of a test tube. Inflammation occurs in other conditions so a high ESR alone won t confirm polymyositis or dermatomyositis. Autoantibodies Antibodies are part of the immune system and usually help us to fight off infections by recognising and attacking viruses or bacteria. Some people s immune systems develop autoantibodies, antibodies that attack the body s own tissues. This can contribute to causing autoimmune diseases like polymyositis and dermatomyositis. No autoantibody test proves a person has polymyositis or dermatomyositis, but there are tests that are helpful in making the diagnosis. One of these is called the anti-nuclear antibody test (ANA). This tests whether a patient s blood contains antibodies to the nucleus (the central part) of cells. About 80 90% of people with polymyositis and dermatomyositis test positive for ANA, but healthy people can also test positive so it s only helpful alongside all the other information about the patient s symptoms. 8
11 Arthritis Research UK Polymyositis and dermatomyositis Other autoantibody tests include ENA (extractable nuclear antigens) and the anti-jo-1 test. These tests are sometimes positive in patients with polymyositis and dermatomyositis. Other tests These tests may not be able to diagnose polymyositis or dermatomyositis, but they can help to rule out other conditions. You may need other tests to confirm a diagnosis. Electromyography (EMG) A thin electrode probe is inserted into the muscle to record electrical discharges from nerve endings that cause your muscles to move. An unusual pattern of electrical activity in a number of different muscles suggests you have polymyositis or dermatomyositis. This test isn t painful but may be slightly uncomfortable. Muscle biopsy A small sample is taken out of one of your larger muscles (for example at the front of your thigh) and examined under a microscope. The site of the biopsy might be chosen using an MRI scan to assess the area with the most symptoms. The part of the muscle that looks most abnormal on the scan will be the site of the biopsy. You ll be given a local anaesthetic to numb the area while the sample is taken, but there may be some discomfort for a few days afterwards. The biopsy may show white blood cells sticking to the covering of the muscle and damaging the proteins that make your muscles contract, which causes the weakness and fatigue.
12 You may need to have a repeat biopsy if your condition doesn t improve with standard treatments. This is to check for the proteins found in people with inclusion body myositis (IBM). You may see different specialists depending on which symptoms are giving you the most trouble. You could be referred to one or more of the following people: a nerve specialist (neurologist) for muscle weakness a muscle specialist (rheumatologist) for muscle pain a skin specialist (dermatologist) for rashes. See Arthritis Research UK booklet Meet the rheumatology team. What treatments are there for polymyositis and dermatomyositis? Treatment for polymyositis and dermatomyositis includes a combination of drug treatment and exercise. Drugs The first choice for treatment is steroids, which are usually given in high doses to begin with. They can be given as tablets or injections. This should reduce the inflammation very quickly and settle muscle pain and the feeling of being unwell. High doses of steroids can have sideeffects so your doctor will reduce the dosage as quickly as possible. Other drugs may be prescribed alongside the steroids to reduce the risk of these, for example to decrease the chance of developing osteoporosis. See Arthritis Research UK booklet and drug leaflets Osteoporosis; Local steroid injections; Steroid tablets. The first choice for treatment is steroids. When taking steroid tablets you must carry a steroid card. Sometimes the inflammation can flare up when the steroid dosage is lowered. Your doctor may prescribe other drugs to help reduce the inflammation. 10
13 Arthritis Research UK Polymyositis and dermatomyositis The most common drugs are methotrexate, azathioprine and ciclosporin. Cyclophosphamide may also be prescribed. These are all types of disease-modifying anti-rheumatic drugs (DMARDs) and have side-effects, so you need regular blood tests to check for any problems. See Arthritis Research UK drug leaflets Azathioprine; Ciclosporin; Cyclophosphamide; Methotrexate. When taking steroid tablets you must carry a steroid card, which records your dose and how long you ve been taking it. If you become ill, or are involved in an accident in which you re injured or become unconscious, it s important for the steroids to be continued and also the dose might need to be increased. This is because the treatment may prevent your body from being able to produce enough natural steroids in response to stress, as normally happens in this situation. Your doctor, rheumatology nurse specialist or pharmacist can give you a steroid card. See Arthritis Research UK drug leaflets Infliximab; Rituximab. Infusions of immunoglobulin might also be given. Immunoglobulins are antibodies that stop your immune system attacking your body s own tissues. Infusions are given in hospital at monthly or 3-monthly intervals. Sometimes you might a feel a little unwell (as if you have flu) during this infusion. See Arthritis Research UK drug leaflet Intravenous immunoglobulin. Occasionally the drugs mentioned above aren t enough to control the disease. A small number of people with severe muscle disease and complications have been treated with biological therapies, which are a type of DMARD. They work by blocking the process of inflammation. Examples include infliximab and rituximab.
14 Once the polymyositis or dermatomyositis is under control, you ll need to start exercises to restore muscle strength and improve stamina. Even in severe cases myositis usually responds well to treatment, though some people do need to carry on taking drugs to keep the condition under control. Exercises and physiotherapy It s probably best to rest when your myositis is very active, but once it has calmed down you ll need to start exercises. Aerobic exercise (any exercise that makes you breath more heavily and your heart beat faster) is especially important to help restore muscle strength and improve stamina. At first this should be done under the supervision of a physiotherapist, who ll give you a tailored programme to suit your specific needs regarding pain relief and improvement in muscle function/rehabilitation. Very strenuous exercise should be avoided. Children with juvenile dermatomyositis will need more vigorous physiotherapy to prevent flexion contracture. This is a condition where the joints, especially the knees, become permanently bent. Some people with severe inflammation never fully recover but most people do, though it may take several months for muscle strength to improve. It may take weeks or months for your body to repair your muscles and you may get tired more quickly than normal, so don t worry if you re not back to full strength straight away. Research and new developments A lot of research is being done on polymyositis and dermatomyositis. Because the conditions are so rare, research centres are joining forces for their studies. One of these studies is looking at the effectiveness of steroids in various combinations with other drugs. It aims to find the best combination of drugs that are currently available for treating polymyositis and dermatomyositis. Another study is the UK Adult-Onset Myositis Genetic Collaboration, which is starting to find out what genetic factors might make some people more likely to get myositis. This may help us understand the processes that cause muscle damage, which will hopefully lead to the development of new and more effective treatments. New tests are also being developed to help tell myositis apart from other muscle diseases. 12
15 Arthritis Research UK Polymyositis and dermatomyositis Glossary Autoimmune disease a disorder of the body s defence mechanism (immune system), in which antibodies and other components of the immune system attack the body s own tissue rather than germs, viruses and other foreign substances. Antibodies blood proteins that form in response to germs, viruses or any other substances that the body sees as foreign or dangerous. The role of antibodies is to attack these foreign substances and make them harmless. Biopsy the removal of a small amount of living tissue from the body. The sample can help diagnose illness when examined under a microscope. Disease-modifying anti-rheumatic drugs (DMARDs) drugs used in rheumatoid arthritis and some other rheumatic diseases to suppress the disease and reduce inflammation. Unlike painkillers and non-steroidal antiinflammatory drugs (NSAIDs), DMARDs treat the disease itself rather than just reducing the pain and stiffness caused by the disease. Examples of DMARDs are methotrexate, sulfasalazine, gold, infliximab, etanercept and adalimumab. Erythrocyte sedimentation rate (ESR) a test that shows the level of inflammation in the body. Blood is separated in a machine with a rapidly rotating container (a centrifuge), then left to stand in a test tube. The ESR test measures the speed at which the red blood cells (erythrocytes) settle. Fibromyalgia a long-term (chronic) form of widespread pain in the muscles and soft tissues surrounding the joints throughout the body. Immune system the tissues that enable the body to resist infection. They include the thymus (a gland that lies behind the breastbone), the bone marrow and the lymph nodes. Immunoglobulins a class of blood proteins that are responsible for immunity to specific infections. Inflammation a normal reaction to injury or infection of living tissues. The flow of blood increases, resulting in heat and redness in the affected tissues, and fluid and cells leak into the tissue, causing swelling. Lupus (systemic lupus erythematosus or SLE) an autoimmune disease in which the immune system attacks the body s own tissues. It can affect the skin, the hair and joints and may also affect internal organs. It s often linked to a condition called antiphospholipid syndrome (APS). Magnetic resonance imaging (MRI) a type of scan that uses high-frequency radio waves in a strong magnetic field to build up pictures of the inside of the body. It works by detecting water molecules in the body s tissue that give out a characteristic signal in the magnetic field. An MRI scan can show up soft-tissue structures as well as bones. 13
16 Osteoporosis a condition where bones become less dense and more fragile, which means they break or fracture more easily. Physiotherapist a therapist who helps to keep your joints and muscles moving, helps ease pain and keeps you mobile. Rheumatoid arthritis an inflammatory disease affecting the joints, particularly the lining of the joint. It most commonly starts in the smaller joints in a symmetrical pattern that is, for example, in both hands or both wrists at once. Scleroderma a medical condition characterised by hardening and tightening of the skin. It often affects other parts of the body as well including the connective tissues that surround the joints, blood vessels and internal organs. Ultrasound scan a type of scan that uses high-frequency sound waves to examine and build up pictures of the inside of the body. Where can I find out more? If you ve found this information useful you might be interested in these other titles from our range: Conditions Fibromyalgia Lupus Osteoporosis Rheumatoid arthritis Scleroderma Therapies Meet the rheumatology team Occupational therapy and arthritis Physiotherapy and arthritis Self-help and daily living Fatigue and arthritis Keep moving Looking after your joints when you have arthritis Drug leaflets Azathioprine Ciclosporin Cyclophosphamide Infliximab Intravenous immunoglobulin Methotrexate Rituximab Local steroid injections Steroid tablets You can download all of our booklets and leaflets from our website or order them by contacting: Arthritis Research UK PO Box 177 Chesterfield Derbyshire S41 7TQ Phone:
17 Arthritis Research UK Polymyositis and dermatomyositis Related organisations The following organisations may be able to provide additional advice and information: Arthritis Care 18 Stephenson Way London NW1 2HD Phone: Helpline: Offers self-help support, a helpline service and a range of leaflets on arthritis. Myositis Support Group 146 Newtown Road Woolston Southampton Hampshire SO19 9HR Phone:
18 Arthritis Research UK Copeman House, St Mary s Court, St Mary s Gate, Chesterfield, Derbyshire S41 7TD Tel calls charged at standard rate Registered Charity No Arthritis Research UK 2011 Published April /PMDM/11-1
20 Το εργαστήριο µας αποτελεί ένα διαγνωστικό εργαστήριο αναφοράς, για την πραγµατοποίηση µικροβιολογικών, βιοχηµικών, αιµατολογικών, ανοσολογικών και ορµονολογικών εξετάσεων. Στο εργαστήριο µας επίσης εκτελού νται και πιο εξειδικευµένες εξετάσεις όπως µοριακός έλεγχος µε PCR (πχ( για την µέτρηση ιικού φορτίου, έλεγχο θροµβοφιλίας κλπ), ανοσολογικός έλεγχος δυσανεξίας σε διατροφικούς παράγοντες και µέτρηση Τ Τ λεµφοκυτταρικής ανοσολογικής απάντησης. Τέλος, εκτελούνται ερευνητικά πρωτόκολλα που περιλαµβάνουν ανά λυση βιολογικών δειγµάτων, στατιστική επεξεργασία α ποτελεσµάτων και ανάπτυξη ʺin ʺ houseʺ διαγνωστικών µεθόδων, όπως ELISA µε ʺcustom ʺ peptidesʺ κλπ Επιστηµονικός υπεύθυνος του εργαστηρίου είναι ο Δρ Ιωάννης Ρούτσιας. Είναι Χηµικός και Ιατρός Βιοπαθολό γος Μικροβιολόγος µε διδακτορικό δίπλωµα στην Ανο σολογία. Το ερευνητικό του έργο είναι σηµαντικό (συνολικό Impact Factor διεθνών δηµοσιεύσεων = 242) και διεθνώς αναγνωρισµένο (H index( = 18), έτυχε δε δέκατρι ων ελληνικών και διεθνών βραβείων και διακρίσεων. Αριστούχος υπότρο φος Χηµικός, εισήχθη και φοίτησε εν συνεχεία στην Ιατρική Σχολή του Πανεπιστηµίου Ιωαννίνων ( ) 1997) όπου και εκπόνησε και την διδακτορική του διατρι βή µε υποτροφία (ΕΜΥ). Έλαβε την ειδικότητα Μικροβιολογίας στην Αθήνα (Νοσ Παίδων Π&Α Κυριακού) και υπήρξε Λέκτορας ʺΙατρικής Ανοσοχηµείαςʺ στο Χ.Π.Α. ( ), 2004), ενώ από το 2004 έως το 2011 είναι Λέκτορας Ανοσολογίας/Μικροβιολογίας στην Ιατρι κή σχολή του Πανεπιστηµίου Αθηνών. Είναι συντάκτης κριτής σε 12 διεθνή περιοδικά, έχει δηµοσιεύσει 50 άρθρα σε διεθνή περιοδικά (µεσος IF/αρθρο=4.8) µε > 900 βιβλιο γραφικές αναφορές (cita ons).( Έχει επιβλέψει 12 διατριβές, έχει διδάξει 10 διαφορετικά αντικείµενα (µαθήµατα) σε 6 τµήµατα (Ιατρική, Οδοντιατρική, Φαρµακευτική, τµήµα Διαιτολογίας, Χηµικό, ΠΣΕ Βιοχηµείας) και έχει 146 ανα κοινώσεις σε συνέδρια (Ελληνικά: 53, Διεθνή: 93). Τέλος έχει γράψει κεφάλαια σε 6 διεθνή και 7 ελληνικά βιβλία και είναι µέλος σε 6 επιστηµονικές εταιρίες και συλλό γους. ΠΑΡΑΛΑΒΗ ΑΠΟΤΕΛΕΣΜΑΤΩΝ Αποτελέσµατα εξετάσεων: Οι ιατροί έχουν την δυνατό τητα να βλέπουν τα αποτελέσµατα των δικών τους ασθενών, ανά πάσα στιγµή, από την ιστοσελίδα του ιατρείου.
21 Μικροβιολογικό Διαγνωστικό Ιατρείο Υπεύθυνος: Ιωάννης Γ. Ρούτσιας, Λέκτορας Ιατρικής Σχολής Εθνικού και Καποδιστριακού Πανεπιστηµίου Αθηνών Διεύθυνση: Δ. Σούτσου 48 & Αλεξάνδρας Αµπελόκηποι, Αθήνα έναντι του σταθµού Μετρό (στάση Αµπελόκηποι) Τηλ: Fax: E mail: Web: lab.gr
Drug information Drugs and arthritis Drugs and arthritis This leaflet provides information on drugs and arthritis and will answer any questions you have about the treatment. Arthritis Research UK produce
Condition Polymyalgia rheumatica Polymyalgia rheumatica (PMR) This booklet provides information and answers to your questions about this condition. What is polymyalgia rheumatica? Polymyalgia rheumatica
Πώς μπορεί κανείς να έχει έναν διερμηνέα κατά την επίσκεψή του στον Οικογενειακό του Γιατρό στο Ίσλινγκτον Getting an interpreter when you visit your GP practice in Islington Σε όλα τα Ιατρεία Οικογενειακού
Διαβητική αμφιβληστροειδοπάθεια Diabetic retinopathy Η εικόνα αυτή δείχνει ένα παράδειγμα του πώς μπορεί η διαβητική αμφιβληστροειδοπάθεια να επηρεάσει την όραση. Τι είναι η διαβητική αμφιβληστροειδοπάθεια;
Condition This booklet provides information and answers to your questions about this condition. What is reactive arthritis? is a condition which can develop following an infection of the bowel or genital
Q1. (a) A fluorescent tube is filled with mercury vapour at low pressure. In order to emit electromagnetic radiation the mercury atoms must first be excited. (i) What is meant by an excited atom? (1) (ii)
Arkansas Tech University MATH 4033: Elementary Modern Algebra Dr. Marcel B. Finan Composition. Invertible Mappings In this section we discuss two procedures for creating new mappings from old ones, namely,
180 Section 9. Polar Equations and Graphs In this section, we will be graphing polar equations on a polar grid. In the first few examples, we will write the polar equation in rectangular form to help identify
«Ειδικό πρόγραμμα ελέγχου για τον ιό του Δυτικού Νείλου και την ελονοσία, ενίσχυση της επιτήρησης στην ελληνική επικράτεια» Παραδοτέο Π1.36 Έκδοση ενημερωτικών φυλλαδίων Υπεύθυνος φορέας: Κέντρο Ελέγχου
Condition This booklet provides information and answers to your questions about this condition. What is scleroderma? is a long-term condition that causes thickening and hardening of the skin, but it can
GREEK Newborn Upfront Payment & Newborn Supplement Female 1: Το μωρό μου θα ρθει σύντομα, θα πρέπει να κανονίσω τα οικονομικά μου. Άκουσα ότι η κυβέρνηση δεν δίνει πλέον το Baby Bonus. Ξέρεις τίποτα γι
EE512: Error Control Coding Solution for Assignment on Finite Fields February 16, 2007 1. (a) Addition and Multiplication tables for GF (5) and GF (7) are shown in Tables 1 and 2. + 0 1 2 3 4 0 0 1 2 3
ΤΕΧΝΟΛΟΓΙΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΚΥΠΡΟΥ ΣΧΟΛΗ ΕΠΙΣΤΗΜΩΝ ΥΓΕΙΑΣ Πτυχιακή Εργασία ΣΤΑΣΕΙΣ ΚΑΙ ΣΥΜΠΕΡΙΦΟΡΕΣ ΝΟΣΗΛΕΥΤΩΝ ΚΑΙ ΦΟΙΤΗΤΩΝ ΝΟΣΗΛΕΥΤΙΚΗΣ ΣΕ ΣΧΕΣΗ ΜΕ ΤΟ ΣΤΙΓΜΑΤΙΣΜΟ ΑΣΘΕΝΩΝ ΜΕ HIV Μιλτιάδους Γιώργος Λεμεσός
ΤΕΧΝΟΛΟΓΙΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΚΥΠΡΟΥ ΣΧΟΛΗ ΕΠΙΣΤΗΜΩΝ ΥΓΕΙΑΣ ΤΜΗΜΑ ΝΟΣΗΛΕΥΤΙΚΗΣ ΠΤΥΧΙΑΚΗ ΕΡΓΑΣΙΑ ΠΩΣ Η ΚΑΤΑΝΑΛΩΣΗ ΦΡΟΥΤΩΝ ΚΑΙ ΛΑΧΑΝΙΚΩΝ ΕΠΗΡΕΑΖΕΙ ΤΗΝ ΠΡΟΛΗΨΗ ΚΑΡΚΙΝΟΥ ΤΟΥ ΜΑΣΤΟΥ Όνομα φοιτήτριας ΚΑΛΑΠΟΔΑ ΜΑΡΚΕΛΛΑ
Problems, Concepts, and the Swisscom Test Data Organizer Do you have issues with your legal and compliance department because test environments contain sensitive data outsourcing partners must not see?
Topic 1: Describe yourself Write your name, your nationality, your hobby, your pet. Write where you live. Χρησιμοποίησε το and. WRITE your paragraph in 40-60 words... 1 Topic 2: Describe your room Χρησιμοποίησε
She selects the option. Jenny starts with the al listing. This has employees listed within She drills down through the employee. The inferred ER sttricture relates this to the redcords in the databasee
Section 1: Listening and responding Presenter: Niki Farfara MGTAV VCE Seminar 7 August 2016 Section 1: Listening and responding Section 1: Listening and Responding/ Aκουστική εξέταση Στο πρώτο μέρος της
Condition (temporal arteritis) This booklet provides information and answers to your questions about this condition. What is giant cell arteritis? (GCA) or temporal arteritis is an inflammatory condition
ΠΕΡΙΛΗΨΗ Εισαγωγή Η παιδική παχυσαρκία έχει φτάσει σε επίπεδα επιδημίας στις μέρες μας. Μαστίζει παιδιά από μικρές ηλικίες μέχρι και σε εφήβους. Συντείνουν αρκετοί παράγοντες που ένα παιδί γίνεται παχύσαρκο
ΤΕΧΝΟΛΟΓΙΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΚΥΠΡΟΥ ΣΧΟΛΗ ΕΠΙΣΤΗΜΩΝ ΥΓΕΙΑΣ Πτυχιακή διατριβή Διερεύνηση της αποτελεσματικότητας εναλλακτικών και συμπληρωματικών τεχνικών στη βελτίωση της ποιότητας της ζωής σε άτομα με καρκίνο
Chapter 2 * * * * * * * Introduction to Verbs * * * * * * * In the first chapter, we practiced the skill of reading Greek words. Now we want to try to understand some parts of what we read. There are a
Therapy Physiotherapy and arthritis Physiotherapy and arthritis This booklet provides information and answers to your questions about this therapy. In association with Arthritis Research UK produce and
60 61 62 63 64 65 Ο Δ Η Γ Ι Ε Σ Σ Υ Ν Τ Η Ρ Η Σ Η Σ Τ Ω Ν Κ Ο Υ Φ Ω Μ Α Τ Ω Ν Ι Ν S T R U C T I N O N S C O N C E R N I N G Τ Η Ε C A S E M E N T S M A I N T E N A N C E Ο τακτικός καθαρισμός των βαμμένων
Ελληνικά/Αγγλικά Greek/English Κατανοώντας τη Νόσο του Πάρκινσον Understanding Parkinson s disease Parkinson s What is Parkinson s disease? Tι είναι η νόσος του Πάρκινσον; Parkinson s disease is a condition
ΦΥΛΛΟ ΕΡΓΑΣΙΑΣ Α 2 ειδήσεις από ελληνικές εφημερίδες: 1. Τα Νέα, 13-4-2010, Σε ανθρώπινο λάθος αποδίδουν τη συντριβή του αεροσκάφους, http://www.tanea.gr/default.asp?pid=2&artid=4569526&ct=2 2. Τα Νέα,
1st Workshop on Evidence Based Medicine Athens, 6-7 December 2003 Ελληνικό Ίδρυµα Καρδιολογίας & Εργ. Βιοστατιστικής, Τµήµατος Νοσηλευτικής Πανεπιστηµίου Αθηνών Μέτρα Υπολογισµού του Κινδύνου εκδήλωσης
ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΙΓΑΙΟΥ ΣΧΟΛΗ ΑΝΘΡΩΠΙΣΤΙΚΩΝ ΕΠΙΣΤΗΜΩΝ ΤΜΗΜΑ ΕΠΙΣΤΗΜΩΝ ΤΗΣ ΠΡΟΣΧΟΛΙΚΗΣ ΑΓΩΓΗΣ ΚΑΙ ΤΟΥ ΕΚΠΑΙ ΕΥΤΙΚΟΥ ΣΧΕ ΙΑΣΜΟΥ «ΠΑΙ ΙΚΟ ΒΙΒΛΙΟ ΚΑΙ ΠΑΙ ΑΓΩΓΙΚΟ ΥΛΙΚΟ» ΙΠΛΩΜΑΤΙΚΗ ΕΡΓΑΣΙΑ που εκπονήθηκε για τη
Οδηγίες: Να απαντηθούν όλες οι ερωτήσεις. Ολοι οι αριθμοί που αναφέρονται σε όλα τα ερωτήματα είναι μικρότεροι το 1000 εκτός αν ορίζεται διαφορετικά στη διατύπωση του προβλήματος. Διάρκεια: 3,5 ώρες Καλή
Math 6 SL Probability Distributions Practice Test Mark Scheme. (a) Note: Award A for vertical line to right of mean, A for shading to right of their vertical line. AA N (b) evidence of recognizing symmetry
Condition Psoriatic arthritis Psoriatic arthritis This booklet provides information and answers to your questions about this condition. What is psoriatic arthritis? Psoriatic arthritis is a condition that
Ενότητα 7α: Impact of the Internet on Economic Education Τμήμα Εφαρμοσμένης Πληροφορικής Άδειες Χρήσης Το παρόν εκπαιδευτικό υλικό υπόκειται σε άδειες χρήσης Creative Commons. Για εκπαιδευτικό υλικό, όπως
Για να ελέγξετε το λογισμικό που έχει τώρα η συσκευή κάντε κλικ Menu > Options > Device > About Device Versions. Στο πιο κάτω παράδειγμα η συσκευή έχει έκδοση λογισμικού 220.127.116.116 με πλατφόρμα 18.104.22.168.
Centre No. Candidate No. Paper Reference(s) 1776/04 Edexcel GCSE Modern Greek Paper 4 Writing Thursday 21 May 2009 Afternoon Time: 1 hour 15 minutes Materials required for examination Nil Paper Reference
Capacitors - Capacitance, Charge and Potential Difference Capacitors store electric charge. This ability to store electric charge is known as capacitance. A simple capacitor consists of 2 parallel metal
B-Trees Index files can become quite large for large main files Indices on index files are possible 3 rd -level index 2 nd -level index 1 st -level index Main file 1 The 1 st -level index consists of pairs
BECAUSE WE REALLY WANT TO KNOW WHAT YOU THINK ABOUT SCHOOL AND YOUR GARDEN Name GRADE Science Teacher A. What do I think about School? bit I try hard to do well in school. I look forward to coming to school.
How to run a Herdbook: Basics and Basics According to the pedigree scheme, you need to write down the ancestors of your animals. Breeders should be able easily to write down the necessary data It is better
How to register an account with the Hellenic Community of Sheffield. (1) EN: Go to address GR: Πηγαίνετε στη διεύθυνση: http://www.helleniccommunityofsheffield.com (2) EN: At the bottom of the page, click
LESSON 6 (ΜΑΘΗΜΑ ΕΞΙ) REF : 201/045/26-ADV 10 December 2013 I get up/i stand up I wash myself I shave myself I comb myself I dress myself Once (one time) Twice (two times) Three times Salary/wage/pay Alone/only
ΤΕΧΝΟΛΟΓΙΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΚΥΠΡΟΥ ΣΧΟΛΗ ΕΠΙΣΤΗΜΩΝ ΥΓΕΙΑΣ ΤΜΗΜΑ ΝΟΣΗΛΕΥΤΙΚΗΣ Πτυχιακή Εργασία Καρκίνος του Μαστού: Οι παράγοντες που επηρεάζουν τη ψυχοσωματική υγεία των γυναικών που υποβλήθηκαν σε μαστεκτομή
Bring Your Own Device (BYOD) Legal Challenges of the new Business Trend MINA ZOULOVITS LAWYER, PARNTER FILOTHEIDIS & PARTNERS LAW FIRM firstname.lastname@example.org What is BYOD? Information Commissioner's Office
ΤΕΧΝΟΛΟΓΙΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΚΥΠΡΟΥ ΣΧΟΛΗ ΕΠΙΣΤΗΜΩΝ ΥΓΕΙΑΣ ΤΜΗΜΑ ΝΟΣΗΛΕΥΤΙΚΗΣ Πτυχιακή Εργασία ΣΥΜΠΛΗΡΩΜΑΤΙΚΕΣ ΚΑΙ ΕΝΑΛΛΑΚΤΙΚΕΣ ΘΕΡΑΠΕΙΕΣ ΩΣ ΠΡΟΣ ΤΗ ΔΙΑΧΕΙΡΙΣΗ ΤΟΥ ΠΟΝΟΥ ΣΕ ΑΣΘΕΝΕΙΣ ΜΕ ΚΑΡΚΙΝΟ. Ονοματεπώνυμο:
Your source for quality GNSS Networking Solutions and Design Services! Page 1 of 5 Calculating the propagation delay of coaxial cable The delay of a cable or velocity factor is determined by the dielectric
ΤΕΧΝΟΛΟΓΙΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΚΥΠΡΟΥ ΣΧΟΛΗ ΕΠΙΣΤΗΜΩΝ ΥΓΕΙΑΣ ΠΤΥΧΙΑΚΗ ΕΡΓΑΣΙΑ ΑΞΙΟΛΟΓΗΣΗ ΣΤΑΣΕΩΝ ΚΑΙ ΕΠΙΠΕΔΟΥ ΓΝΩΣΕΩΝ ΤΩΝ ΝΟΣΗΛΕΥΤΩΝ ΣΕ ΜΟΝΑΔΕΣ ΕΝΤΑΤΙΚΗΣ ΘΕΡΑΠΕΙΑΣ ΣΧΕΤΙΚΑ ΜΕ ΤΗ ΜΕΤΑΜΟΣΧΕΥΣΗ ΟΡΓΑΝΩΝ ΑΠΟ ΕΓΚΕΦΑΛΙΚΑ
TMA4115 Matematikk 3 Andrew Stacey Norges Teknisk-Naturvitenskapelige Universitet Trondheim Spring 2010 Lecture 12: Mathematics Marvellous Matrices Andrew Stacey Norges Teknisk-Naturvitenskapelige Universitet
,**1 The Japanese Society for AIDS Research The Journal of AIDS Research +,, +,, +,, + -. / 0 1 +, -. / 0 1 : :,**- +,**. 1..+ - : +** 22 HIV AIDS HIV HIV AIDS : HIV AIDS HIV :HIV AIDS 3 :.1 /-,**1 HIV
ΤΕΧΝΟΛΟΓΙΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΚΥΠΡΟΥ ΣΧΟΛΗ ΕΠΙΣΤΗΜΩΝ ΥΓΕΙΑΣ Πτυχιακή Εργασία ΓΝΩΣΕΙΣ KAI ΣΤΑΣΕΙΣ ΤΩΝ ΕΠΑΓΓΕΛΜΑΤΙΩΝ ΥΓΕΙΑΣ ΓΙΑ ΤΗΝ ΕΠΑΓΓΕΛΜΑΤΙΚΗ ΕΚΘΕΣΗ ΣΤΟΝ HIV Στυλιανού Στυλιανή Λευκωσία 2012 ΤΕΧΝΟΛΟΓΙΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ
Condition This booklet provides information and answers to your questions about this condition. What is fibromyalgia? is a condition that causes widespread muscular pain. It s not life-threatening or progressive
Living and Nonliving Created by: Maria Okraska http://enchantingclassroom.blogspot.com Living Living things grow, change, and reproduce. They need air, water, food, and a place to live in order to survive.
HISTOGRAMS AND PERCENTILES What is the 25 th percentile of a histogram? The point on the horizontal axis such that of the area under the histogram lies to the left of that point (and to the right) What
Τ.Ε.Ι. ΔΥΤΙΚΗΣ ΜΑΚΕΔΟΝΙΑΣ ΠΑΡΑΡΤΗΜΑ ΚΑΣΤΟΡΙΑΣ ΤΜΗΜΑ ΔΗΜΟΣΙΩΝ ΣΧΕΣΕΩΝ & ΕΠΙΚΟΙΝΩΝΙΑΣ ΠΤΥΧΙΑΚΗ ΕΡΓΑΣΙΑ Η προβολή επιστημονικών θεμάτων από τα ελληνικά ΜΜΕ : Η κάλυψή τους στον ελληνικό ημερήσιο τύπο Σαραλιώτου
www.xtremepapers.com UNIVERSITY OF CAMBRIDGE INTERNATIONAL EXAMINATIONS International General Certificate of Secondary Education *6301456813* GREEK 0543/03 Paper 3 Speaking Role Play Card One 1 March 30
ΑΤΕΙ ΙΟΝΙΩΝ ΝΗΣΩΝ ΤΜΗΜΑ ΔΗΜΟΣΙΩΝ ΣΧΕΣΕΩΝ ΚΑΙ ΕΠΙΚΟΙΝΩΝΙΑΣ ΑΡΓΟΣΤΟΛΙ ΚΕΦΑΛΗΝΙΑΣ 2014 Η ΜΕΤΑΒΑΣΗ ΑΠΟ ΤΗ ΣΤΑΘΕΡΗ ΣΤΗ ΚΙΝΗΤΗ ΤΗΛΕΦΩΝΙΑ ΚΑΙ ΟΙ ΕΠΙΔΡΑΣΕΙΣ ΤΗΣ ΣΤΗΝ ΕΠΙΚΟΙΝΩΝΙΑΚΗ ΣΥΜΠΕΡΙΦΟΡΑ ΕΠΙΒΛΕΠΩΝ ΚΑΘΗΓΗΤΗΣ:
ΠΑΝΕΠΙΣΤΗΜΙΟ ΠΑΤΡΩΝ ΠΟΛΥΤΕΧΝΙΚΗ ΣΧΟΛΗ ΤΜΗΜΑ ΜΗΧΑΝΙΚΩΝ Η/Υ & ΠΛΗΡΟΦΟΡΙΚΗΣ ΔΙΠΛΩΜΑΤΙΚΗ ΕΡΓΑΣΙΑ ΣΤΑ ΠΛΑΙΣΙΑ ΤΟΥ ΜΕΤΑΠΤΥΧΙΑΚΟΥ ΔΙΠΛΩΜΑΤΟΣ ΕΙΔΙΚΕΥΣΗΣ ΕΠΙΣΤΗΜΗ ΚΑΙ ΤΕΧΝΟΛΟΓΙΑ ΤΩΝ ΥΠΟΛΟΓΙΣΤΩΝ του Γεράσιμου Τουλιάτου
ΠΑΝΕΠΙΣΤΗΜΙΟ ΠΕΙΡΑΙΑ ΤΜΗΜΑ ΝΑΥΤΙΛΙΑΚΩΝ ΣΠΟΥΔΩΝ ΠΡΟΓΡΑΜΜΑ ΜΕΤΑΠΤΥΧΙΑΚΩΝ ΣΠΟΥΔΩΝ ΣΤΗΝ ΝΑΥΤΙΛΙΑ ΝΟΜΙΚΟ ΚΑΙ ΘΕΣΜΙΚΟ ΦΟΡΟΛΟΓΙΚΟ ΠΛΑΙΣΙΟ ΚΤΗΣΗΣ ΚΑΙ ΕΚΜΕΤΑΛΛΕΥΣΗΣ ΠΛΟΙΟΥ ΔΙΠΛΩΜΑΤΙΚΗ ΕΡΓΑΣΙΑ που υποβλήθηκε στο
ΑΡΙΣΤΟΤΕΛΕΙΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΘΕΣΣΑΛΟΝΙΚΗΣ Μελέτη των υλικών των προετοιμασιών σε υφασμάτινο υπόστρωμα, φορητών έργων τέχνης (17ος-20ος αιώνας). Διερεύνηση της χρήσης της τεχνικής της Ηλεκτρονικής Μικροσκοπίας