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By K. Ivan. Langston University. 2019.

Transition from residency with the university and its affliated hospitals to create training to academia cheap 5 mg warfarin arteria frontal. Junior doctors opinions about the tran- biannual individual career planning sessions sition from medical school to clinical practice: a change of between leaders and mentees (e buy warfarin 5 mg online blood pressure medication sweating. Sarcasm warfarin 5 mg free shipping hypertension table in icd 9, gossip cheap warfarin 5mg without a prescription blood pressure young female, cynicism, protectionism and with- Case drawal can all become an ingrained part of the health work A resident is in the second year of residency. Morale suffers, while a genuine desire for col- the resident engages in clinical practice, the more they fnd laborative and innovative practice begins to wane. Frustration themselves concerned about the environments in which rises, and professionals begin to feel that they have little input health care is delivered. Many of the resident s colleagues, into or control over their practice and practice setting. A culture other health professionals, and administrative staff seem of blame and shame begins to form, making the work environ- frustrated and in various phases of burnout. Tragically, such struggles are not uncommon in the resident fnds time spent with patients and supervi- Canada. The resident Thankfully, we all have a role to play in contributing to a more wonders if they made the right career decision and, in positive health care work environment. The resident mentions this to are all dedicated to the goal of stabilizing and strengthening the chief resident, who listens thoughtfully and suggests Canada s health care system. Introduction Choosing wisely One of the great joys, and one of the great challenges, of the On the level of the individual career, what is a physician to practice of medicine is its incredibly rapid pace of change. Although the current situation may seem dire, physicians Advances in biomedical knowledge are being made at an un- should recognize the many choices that lie before them. Technological innovations are transforming include the selection of specialty, the nature and location of the manner in which patient investigations are conducted and their practice, and even the hours of work. Ongoing debates surrounding health care have already been made, it is still possible to use positive strate- reform, together with shifting patient expectations, make for a gies to optimize one s work environment. Health care costs, paid Giving careful thought to the questions listed in the textbox for largely from the public purse, continue to rise exponen- may be of help. New models of management are under constant revision across Canada, and a consensus is growing that our health care system cannot continue to be sustained without signifcant Choosing a career path: Some factors to reform. Hundreds of thousands of Canadians do not have a consider primary care provider, hospitals struggle to maintain nurses Do you require signifcant leisure time to maintain and physicians, emergency rooms are overcrowded, and wait a sense of well-being? For example, although certain specialties can be The health care work environment is never static, and regard- practised only in a hospital setting, that hospital might be a less of where one practises there will always be challenges to community hospital situated in a small town or a large urban face. Because change is a stressor, particularly when it is paired tertiary care centre. It might be an academic health sciences with uncertainty, we must anticipate that it can affect the work centre with a dedicated focus on teaching and research, or it environment in a negative way. When this occurs, we need ef- might have no university affliation and hence no mandate as fective coping strategies. If a hospital setting is not necessary or is unappealing, there are ample opportunities to establish a solo Approaches that physicians can use to improve their current or a group practice focused on ambulatory care. A group work environment include identifying problems clearly and practice could be made up solely of physicians, or could in- objectively, discussing these problems with others in a way that clude multiple health care disciplines in a team-based model expresses feelings but refrains from simply complaining and of care. There are also opportunities for physicians to develop blaming, and proposing potential solutions. Offering to be part a career outside the clinical realm, at any stage in their career. They can be instrumental to creating and sustaining business management or public administration. It is essential to join an organization whose goals and vision are consistent with one s own values Case resolution and aspirations. Does the organization s culture refect what The resident meets with their program director of student you think and believe? Is it compatible with your approach to affairs, who presents information regarding the many life and patient care? This very important aspect of choosing choices and opportunities that are available to specialty a practice setting can be forgotten in the heat of negotiating physicians. Together they consider career choices with re- dollars, space and operating room time. They consider how to approach the work environment that the resident is cur- Finally, do existing staff members appear to be happy? The resident selects a mentor to they a collegial group who appear to collaborate and to be re- help them learn how to manage system issues and begins spectful of each other? Notice how they interact with and ad- to feel more hopeful about their future practice. An important element of sustaining pleasure in one s work is working with people who inspire trust and are Key references committed to the work. Psychosocial criteria for good work or- environments with a positive atmosphere and are supportive ganization. The Resilient Physician: Effective Because selecting a permanent place for one s practice requires Emotional Management for Doctors and Their Medical Organizations. This can be done by choosing to do locums for a period of time after completion of training. This provides an opportunity to try a practice setting and its location on for size. Immersing oneself in a few different practice settings can lead to a dis- covery of what combination of features will best satisfy one s individual needs. One is paid on a fee-for-service basis and is respon- medical lifecycle, and sible for all expenses associated with running one s own offce. Many physicians report that they are ill-prepared for this aspect when they frst start practice. Depending on the medical school, a stipend may resident is feeling anxious about the pending sub-specialty be associated with these affliations. It is certainly nizes that a more narrow focus may be in order to plan the possible to combine hospital and community-based practices, next phase of their career. The resident just doesn t quite especially in non-academic settings and smaller communi- know what to do. Continuity of care and the variety of one s practice Introduction is typically greater in such situations. However, such arrange- For many residents, focusing on completing medical school ments also mean having to balance one s work day to meet and then residency can leave little room to consider how their multiple demands. However, career planning should start early Some physicians provide care in only one setting, often be- during residency, since decisions made at this stage will have cause of a focus on primary or secondary care. At the community-based pediatricians, family physicians and psychia- same time, it is important to keep one s options and mind trists who do not admit patients to hospital work exclusively open. Many residents change their plans as they move through in a primary care setting, while those who provide tertiary care residency and experience different areas of practice. The type of patients cared for, the job might not be available when one is ready for it, and so it is needs of specifc communities, and professional and personal important to be prepared to work toward one s career objec- desires all infuence career decisions in this regard. Within family medicine Early career planning questions and the Royal College specialties there are varying degrees of Academic versus private practice. A general surgeon may sub-specialize in irritable tions residents often consider in planning their career path is bowel disease, while a family physician may focus on care of whether they would prefer to work in an academic or a private the elderly. The focus of one s The term academic practice usually refers to a practice affli- practice may well dictate other characteristics of that practice. It carries with may desire a sub-specialized practice, it can take some time it an expectation to contribute to the education of medical for such a practice to be developed. It is always prudent to students and residents and to make a contribution to medical be prepared for all aspects of practice; one never knows what scholarship.

Ajami selects and annotates more than 500 references on psychopharmacology for an interdisciplinary course on the U buy cheap warfarin 1 mg line heart attack sam tsui chrissy costanza of atc. National Clearing House for Mental Health order warfarin 2mg without prescription arteria jugularis externa, Bibliography of Drug Dependence and Abuse 1928-1966 (Chevy Chase 1mg warfarin with visa pulse pressure definition, Md order 2mg warfarin otc pulse pressure 37. Brunn, How to Find Out in Pharmacy: A Guide to Sources of Pharmaceutical Information (Oxford: Pergamon Press, 1969). Vaillant, "The Natural History of Narcotic Drug Addiction," in Seminars in Psychiatry 2 (November 1970): 486-98. Drugs depend both for their desirability and their effect on the milieu in which they are taken. The choice of the drug is a function of the culture, but the abuse of the drug is a function of the man. The ritualization of drug-taking creates its subculture: thus the history of drug addiction as that of society must be rewritten every few years. The extent to which addicts are forced into a ghetto of their own depends upon the community that rejects them. For instance, Puerto Ricans in New York do not reject their addicts in the way middle-class Americans do: J. Most societies cannot distinguish clearly between their pharmacopeia and their diet. This survey of cookbooks shows that many were written by physicians, with a frequent insistence that the best medicine comes from the kitchen and not from the pharmacy. They show that, though much abuse goes unobserved, even if observed it is not communicated to colleagues, and even if communicated it is treated by "talking to the offender" and remains uncontrolled. Self-regulation principally protects the profession by eliminating the incompetent butcher and the brazen moral leper. Goode, "The Protection of the Inept," American Sociological Review 32 (February 1967): 5-19. Modernization consists in the more efficient utilization of the inept in the self-interest of the group. Eliot Freidson and Buford Rhea, "Knowledge and Judgment in Professional Evaluations," Administrative Science Quarterly 10 (June 1965): 107-24. A search in the national registry of prescriptions in England and Wales shows that 8 out of 10 women who had borne a defective child after taking thalidomide on prescription denied that they had taken the drug, and that their physicians denied having ordered it. On publication day 57 drug firms started separate legal actions to have the book withdrawn and sued for reimbursement for probable damages. Young, Medical Messiahs: A Social History of Health Quackery in Twentieth-Century America (Princeton, N. Young, The Toadstool Millionaires: A Social History of Patent Medicines in America Before Federal Regulation (Princeton, N. This report to a study group initiated by Ralph Nader concludes that there is a total lack of internal quality control within the medical profession. Originally published as The Therapeutic Nightmare (Boston: Houghton Mifflin, 1965), this masterpiece of investigative journalism by a staff reporter of the Washington Post has done more than any other book to change the focus of the U. For ten years a benevolent minority had worried about the damage done by capitalist medicine to the poor. The medical variety has epidemic consequences and might be called "white-coat crime. Hellegers, "Chloramphenicol in Japan: Let It Bleed," Bulletin of Concerned Asia Scholars 5 (July 1973): 37-45. The expansion of federal controls over the export of drugs would only partially remedy this form of imperialism. Federal authority, which now does cover the $6 billion pharmaceutical drug industry, does not yet extenc over the $3 billion medical device industry. Robins company from supplying foreign companies with a model of a contraceptive shield which has been withdrawn from the U. This article is based on a paper presented at the International Health Seminar at Harvard University, February 1974. For an eyewitness report, see Ursula Bernauer and Elisabeth Freitag, Poder popular in Chile am Beispiel Gesundtieit: Dokumente ata Elendsvierteln (Stein/Nuremberg: Laetere/Imba, 1974). Describes the particular violence with which physicians were persecuted by the junta. The moderate rise in the cost of each prescription during the last years is due mainly to an increase in the size of the average prescription. Dunlop, "The Use and Abuse of Psychotropic Drugs," in Proceedings of the Royal Society of Medicine 63 (1970): 1279. Klerman, "Social Values and the Consumption of Psychotropic Medicine," in Proceedings of the First World Congress on Environmental Medicine and Biology (Haarlem: North-Holland, 1974). For a particularly pernicious form of medically prescribed drug addiction see Dorothy Nelkin, Methadone Maintenance: A Technological Fix (New York: Braziller, 1973). Within the category "nervous system drugs" alone, sales aggregate more than $1 billion per year. This compares with three other categories each aggregating about $500 million, and the rest, each less than $350 million. Hallan, "The Number and Cost of Prescribed Medicines: Selected Diseases," Inquiry 7 (1970): 38-50. National Commission for the Study of Nursing and Nursing Education, An Abstract for Action (New York: McGraw-Hill, 1970). Balint points out that in two-thirds of cases in which drugs were repeatedly prescribed without any technical justification, the physician himself took the initiative to offer the drug. Out of fear of "doing nothing" the practitioner is led to prescribe more than is indicated by instructions on the package. The traditional, usually religious setting and goal for drug consumption are contrasted with present- day laicized use of mind-altering substances. The French Vidal contains descriptions which suppress the warnings that are obligatory in the leaflet that comes with the drug. These compendia are not written for the guidance of physicians, but to provide drug manufacturers with technical standards that preparations must meet to be marketed legally in interstate commerce in the U. See also Science 180 (1973): 1038, for a report of a study conducted by the Federal Drug Administration on the ethics of physicians who conduct field research with new drugs. One-fifth of those investigated had invented the data they sent to the drug companies, and pocketed the fees. Oktober, 1971, Uberreicht von der Medizinisch-Pharmazeu- tischen Studiengesellschaft E. Short, valuable statement on the lack of useful measurements, which makes such a broad statement the best that can be responsibly offered. The author is a director of the Drug Efficacy and Safety Division of the World Health Organization. It compares 22 countries, noting significant differences in drug-consumption patterns but enormous difficulties in establishing precise comparisons. Therapeutic categories, cost evaluations, and measurements for pharmacological units differ. From the information it is legitimate to deduce that total consumption of medicine is largely independent of cost or of the kind of practice that is prevalent, i. The consumption in a given country of those drugs that require a prescription is positively related to the density of prescribing physicians. Freedman, "Drugs and Society: An Ecological Approach," Comprehensive Psychiatry 13 (September-October 1972): 411-20. The ability of the placebo to provoke symptoms of a specific kind, even when given in a double-blind situation, is discussed by Kienle in chap. Studies new drugs which became available in England and were widely discussed in the literature to which U. Wardell finds that the American specialist is not aware of the existence of these drugs unless they are marketed in the U.

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Ninety to Early or operable breast cancer (Up to T2 purchase 2 mg warfarin with visa blood pressure table, N1 generic warfarin 1mg otc blood pressure juicing, M0 breast ninety-ve per cent of the breast drains to the axillary cancer with or without mobile lymph nodes on the same Table10 cheap warfarin 1 mg without a prescription blood pressure medication weight loss. Postmenopausal women receive either tamoxifen or Local treatment: an aromatase inhibitor 2 mg warfarin for sale hypertension facts, which reduces the peripheral r Breast conservation surgery involves a wide local ex- conversion of androgens to oestrogen. Conservative breast surgery with hibitors appear to be as effective as tamoxifen with radiotherapy has been shown to be as effective as mas- fewer side effects. Anewclass Lymph node treatment: ofchemotherapeuticagentscalledtaxaneshasresulted r Assessment of the presence of spread to the lymph from yew tree-derived products, e. Trastuzumab nodes may be identied by intraoperative injection of (Herceptin) has been shown to prolong survival in atraceraround the tumour site. Locally advanced disease: Patients are treated with pre- N: Nodal involvement reduces 5-year survival from 80 operativesystemictherapyandtheniftheybecomeoper- to 60%. In more than 65% of women, M: Haematogenous spread has a much poorer progno- the tumour shrinks by more than 50%, which makes it sis (5-year survival is only 10%). Average survival is more likely that the whole tumour is excised at surgery 14 18 months with chemotherapy. Treatments include radiotherapy, systemic treatment Females aged 50 69 years are invited every 3 years for and surgery to debulk the primary tumour, which may screening by a craniocaudal and a mediolateral oblique be ulcerating through the skin and alleviate symptoms mammogram (see also page 412). If identied, a stereotactic needle core biopsy can used depends on whether patients are pre- or post- be performed to obtain tissue for histology. The lump can then be iden- effect of screening on mortality, but as the range of mor- tied and either undergo excision biopsy or wide local talityratesexceedthereductionofmortalitybyscreening excision with the removal of a margin of surrounding it is difcult to demonstrate a statistical benet. If the histology demonstrates malignancy it appears that one woman in every 1000 who under- further treatments for breast cancer may be required (see goes breast screening may be prevented from dying from page 417). This must be balanced against false pos- The evidence of the breast cancer screening pro- itive screening results and unnecessary biopsies, which gramme is difcult to assess. The endocrine system is the mechanism by which in- Endocrine dysfunction generally results in over or un- formation is communicated around the body using der functioning of a gland. For example, hypothy- secreted by glands and may be transported through the roidismmayresultfromafailureoftheanteriorpituitary bloodstream to a distant target organ (endocrine ac- gland or a failure of the thyroid gland. Endocrine test- tivity) or may act directly on local tissue (paracrine ing is used to both identify the lack of hormone and to activity). For example, tides, glycoproteins, steroids or amines such as cate- r measurement of thyroid hormones is used to detect cholamines. Steroid hormones and thyroid hormones circulate Clinical features of apparent hormone deciency may freely and bound to plasma proteins. The bound hormone acts as a buffer against rapid In these cases a single random hormone sample will not changes in hormone levels. In such ins- intracellular receptors, which travel to the cell nucleus tances either testing at specic times of day (e. Dynamic endocrine testing uses techniques to The sensitivity of target organs to a hormone is depen- stimulate or suppress hormone secretion. The hypothalamus and pituitary form the basis of the Introduction to the hypothalamus central control of various endocrine axes, which are vital and pituitary to everyday function (see Fig. Disorders of the The pituitary gland lies in the sella turcica, which is a hypothalamus itself are very rare; however, disorders of tightly enclosed bony space at the base of the cranium, the pituitary are common. The optic chiasm lies just above the pituitary fossa and the cavernous sinuses Pituitary adenomas run lateral to it. It consists of two lobes: Denition r The posterior lobe is a physical and functional exten- Pituitary adenomas are benign slow growing tumours sion of the ventral hypothalamus. Gene though the anterior lobe is of separate origin to the hy- mutationshavebeencharacterisedinsomepituitaryade- pothalamus,itisunderitsclosecontrol. The hy- Pathophysiology pothalamussecretespolypeptidehormonesthatregulate Seventy per cent of pituitary adenomas are functioning, anterior pituitary hormone secretion, mostly by stim- i. Increasingly asymptomatic hormone (10%) pituitary adenomas are found at incidental imag- ing. Continuing growth disrupts other hormone secretion and can result in hypopituitarism. Denition Macroscopy Hypopituitarism is a clinical term referring to under- r Tumours less than 1 cm in diameter without enlarge- function of the pituitary gland. This may imply a de- ment of, or extension outside the pituitary fossa are ciency of single or multiple hormones. The commonest causes are pituitary or hypothalamic r Tumours 1 2 cm may extend outside the fossa to- tumours, or secondary to pituitary surgery or cranial wards the hypothalamus and optic chiasm, laterally radiotherapy (see Table 11. Pathophysiology Hypopituitarism may be primary due to destruction of Investigations the anterior pituitary gland or secondary to a deciency r A mass within the sella turcica (pituitary fossa) may of hypothalamic stimulation (or excess of inhibition). Microadenomas take up less Symptoms and signs are related to the deciency of hor- contrast and macroadenomas take up more contrast. General symptoms of panhy- Ifapituitarymassisidentied,hormoneassaysshould popituitarism include dry, pale skin with sparse body beundertakentoidentifyfunctioningadenomas. On examination postural hypotension and brady- ing also helps identify any associated hypopituitarism, cardia may be found with decreased muscle power and with stimulation or suppression testing where appro- delayed deep tendonreexes. Management Investigations r Forprolactinomas medical treatment with a All functions of the pituitary should be assessed using dopaminergic drug is the treatment of choice (see sec- basal levels, stimulation tests and suppression testing tion on Hyperprolactinaemia, page 424). Progestagen is used to induce bleeding and Type Causes prevent endometrial hyperplasia. In ado- Pituitary apoplexy (haemorrhagic infarction of lescent males testosterone induces epiphyseal closure, pituitary tumour) so replacement therapy should be delayed as long as Inltration Sarcoidosis, haemochromatosis, histiocytosis X possible. Treatment of associated infertility requires Injury Head trauma complex hormone replacement to stimulate ovula- Immunologic Organ-specic autoimmune disease Iatrogenic Surgery, irradiation tion/spermatogenesis. Pituitary haemorrhage causing death of the r Gonadotrophin deciency in women may be treated lactotrophs results in failure of lactation (Sheehan s with cyclical oestrogen replacement to maintain syndrome). The zona deciency glomerulosa and aldosterone secretion usually remains relatively intact, so Addisonian crisis is rare. Clinical features Hyperprolactinaemia In women hyperprolactinaemia causes primary or sec- ondary amenorrhoea, oligomenorrhoea with anovula- Denition tion or infertility. Hyperprolactinaemia is a raised serum prolactin level Oestrogen deciency can cause vaginal dryness and causing galactorrhoea and gondadal dysfunction. In men galactor- Incidence rhoea occurs occasionally, but the most common early Most common endocrine abnormality of the hypothala- features are decreased libido and sexual dysfunction, mic pituitary axis. Complications Acromegaly Headache, visual impairment and hypopituitarism due to local effects of the adenoma. Sex Management M = F Prolactinomasaretreatedwithdopaminergicdrugssuch as cabergoline. The minority of tumours that do not Aetiology respond to medical treatment and hyperprolactinaemia r 95% of cases result from growth-hormone-secreting due to stalk compression are treated surgically. Sleep, exercise, stress Hypoglycaemia Postprandial hyperglycaemia/ free fatty acids Clinical features Glucocorticoids (hence short The course of the disease is slowly progressive. Soft tissue stature in children on overgrowth is the characteristic early feature, causing long-term oral steroids) enlargement of hands and feet, coarse facial features. Acne, sebaceous r Accompanying hypopituitarism is treated as appro- cysts and skin tags are common. Acanthosis nigricans priate with corticosteroids, thyroxine and gonadal of the axillae and neck may occur. Acromegaly causes increased morbidity and r Organomegaly: Thyroid and salivary gland enlarge- mortality mainly due to diabetes and cardiovascular dis- ment, hepatomegaly. Thyroid axis Macroscopy/microscopy The tumour is solid and trabecular, often 1 cm in diame- terbythe time of diagnosis. Oestrogens conversely increase the sensitivity suppress growth hormone production. Large tumours re-absorption of colloid by the cells and the production may be resected by transfrontal craniotomy. The majority of T is converted from the less active 3 r Octreotide or lanreotide, a long-acting somatostatin T4 by peripheral tissues.

In this technique generic 2mg warfarin amex prehypertension 134, the patient is given 100% oxygen to breath in order to wash out the air (mostly made up of nitrogen) from the lungs buy 2mg warfarin blood pressure zanidip. The concentration of nitrogen is continuously monitored in the expired gas purchase warfarin 2mg visa blood pressure essential oils, and when the exhaled concentration of nitrogen is essentially zero generic warfarin 1mg on line blood pressure for teens, the test ends. Body Plethysmography Body plethysmography is another technique used to measure lung volumes. This method incorporates the physiologic principle of Boyle s law which states that the product of the pressure times the volume of a gas is constant if the temperature is unchanged, or P1V1=P2V2. This causes the chest volume to expand which in turn causes a decrease in the box volume and a corresponding increase in box pressure. The pressure change in the box is recorded and thereby allows for a calculation of the change in box volume, which is equal to the change in lung volume. Lung volumes measured by body plethysmography, may be higher than volumes measured by using gas dilution method. This is primarily due to the measurement of both communicating and non-communicating compartments of the lungs with plethysmography, as opposed to just measuring the communicating compartments alone using the gas dilution techniques. It is therefore a more accurate test in patients with severe airway obstruction (where there is trapped air from airways that collapse at low lung volumes) as well as those with bullous lung disease or emphysema. Diffusing Capacity Diffusing capacity is a measurement of the ability of gases like oxygen to transfer from the alveoli into the pulmonary capillary blood. A low diffusing capacity is rarely a cause for hypoxia (low oxygen levels) at rest but can be a cause during physical exertion. Diffusing capacity is a non-invasive test which involves the inhalation of a gas mixture containing a small amount of carbon monoxide because this gas is normally not present in the lungs or blood, and is very soluble in blood. This small amount will not be harmful to the patient and does not last long in the body so it will not be present later that day if a fire fighter has carbon monoxide level taken at a fire or in an emergency room. During the diffusing capacity test, a known amount of carbon monoxide is breathed in and then whatever is not subsequently breathed out should represent the amount that diffused through the lung and into the pulmonary capillary system. In this technique, the patient exhales completely, and then inhales a gas mixture deeply, that contains 0. The patient then holds their breath for 10 seconds, during which time the carbon monoxide leaves the air spaces and enters the blood. The amount of gas diffused from the lung into the pulmonary capillary system is related to the surface area of the lung, the capillary blood volume, and the thickness of the alveolar-capillary membrane. Any condition which alters any one of these factors can cause a reduction in diffusion. In emphysema, the walls between the alveoli break down, creating fewer alveoli, and this loss of surface area is associated with reduced diffusion. Pulmonary embolism (blood clots) or pulmonary hypertension results in the obliteration and/or obstruction of pulmonary arteries. In these patients, the measurement of gas transfer for carbon monoxide is usually reduced. Interstitial lung diseases affect the meshwork of lung tissue (alveolar septa) other than the air spaces (alveoli), and can result in thickening of the alveolar-capillary membrane making it harder for gas to diffuse. Pulmonary diseases that essentially just affect the airways, such as asthma or chronic bronchitis, do not demonstrate a reduced diffusion capacity. Increased diffusion capacity is rarely important but may occur if the patient is bleeding into their lung. Diffusion capacity is a valuable tool in the diagnosis and monitoring of pulmonary diseases. It should be noted however that there are some patients with interstitial lung disease who are found to have diffusion abnormalities before lung volume abnormalities are present. It is low in some patients with obesity due to compression of the lung and its circulation. Low hemoglobin concentration (as in anemia) also leads to a reduced diffusion capacity as there is less blood to diffuse onto; a correction for anemic patients is sometimes used. Likewise, diffusing capacity can be elevated in a condition called polycythemia (increased number of red blood cells). It can also be low in patients with carbon monoxide intoxication (acute or chronic exposures even from tobacco smoke). People with asthma will respond to bronchoprovocation with a greater degree of airway obstruction than will normal subjects. Methacholine is a commonly used provocative agent that is a nonspecific stimulus of bronchoconstriction, though cold air and exercise testing are also sometimes used. Following testing, a bronchodilator is administered and lung function returns to normal and symptoms resolve. The lower the dose that is required, the more hyperreactive the individual s airways are. Cough variant asthma, in which the patient has asthma though only coughs as the main presentation, can also be diagnosed by this method. It also has been used to follow subjects with exertional asthma, occupational asthma, document the severity of asthma and to assess the response to treatment. Presence of increased airway responsiveness is a significant predictor of subsequent accelerated decline in pulmonary function. It is important to understand that provocative testing is only of use in patients with normal lung function when the diagnosis of asthma is in question. Medications may influence this test and therefore should be carefully discussed with the physician before provocative challenge testing is ordered. Corticosteroids, leukotriene antagonists (such as Singulair) and antihistamines may interfere with the accuracy of provocative testing. However, if you have a history of using these medications you should bring them with you, tell the person administering the test about them and be prepared to use them on your way home if necessary. Exercise testing allows for the correlation of exercise-induced symptoms with objective data. Exercise tests can quantitate the degree of functional impairment and help determine whether the limiting factor is pulmonary, cardiac, pulmonary vascular, or due to decreased conditioning. This would include any individual who has severe physical or emotional impairments where testing is deemed unsafe. Examples include patients with severe arthritis or neuromuscular disorders who may not be able to perform the required maneuvers. Patients with severe cardiac disease such as unstable angina or aortic stenosis should not be tested. In addition, patients with uncontrolled asthma should not be tested until their asthma is under better control. A mask that allows for expired air to be monitored and a nose clip are placed on the patient. After exercise testing, the subject recovers for about two to three minutes by pedaling at a low work rate to prevent hypotension caused by pooling of blood in dilated vessels. A number of physiological indices are measured and calculated during cardiopulmonary exercise testing, and are beyond the scope of this chapter. An integrative approach using clinical data and patterns of physiologic responses based on measured indices is used to determine the cause; no one single index is considered diagnostic of a cause for exercise limitation. The primary advantage is that the test is simple and practical; no exercise equipment is necessary. The disadvantage is that the test does not provide specific information on the role of the different organ systems that can contribute to exercise limitation.

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When the precautionary principle disrupts 3 years of antibiotic stewardship: Nitrofurantoin in the treatment of urinary tract infections buy warfarin 5mg free shipping blood pressure medication and q10. Various factors affect the treatment outcomes of infectious diseases including host defense mechanisms buy generic warfarin 1mg on-line blood pressure chart jnc, the site of infection 2 mg warfarin otc pulse blood pressure chart, the viru- lence of the pathogen cheap warfarin 1mg overnight delivery pulse pressure young adults, and the pharmacologic properties of the antimicrobial agent used to treat the infection. The factor under the greatest control of the clinician, how- ever, is related to the choice and dosing of antimicrobial agents. Various pharmaco- logic factors govern the design of an optimal antimicrobial regimen. These factors are conventionally divided into two distinct components: (1) pharmacokinetics and (2) pharmacodynamics. Examination of pharmacokinetic and pharmacodynamic rela- tionships have been undertaken for most antibacterial drug classes and more recently for a number of antifungal and antiviral drug classes. These analyses are being recog- nized as increasingly important in the design of optimal antimicrobial therapies. It is these factors that determine the time course of drug concentrations in serum and tissues for a given dosing regimen. With antimi- crobial agents one is particularly concerned about concentrations at the site of infection. Kinetics at Site of Infection Many studies have attempted to correlate antibiotic concentrations in serum with those in various tissues or sites of infection. However, several problems arise in both the measurement and the interpretation of drug concentrations in tissues. In theory, tissue concentrations consist of vascular, interstitial, and intracellular compartments. Different antimicrobial agents can vary in their ability to accumulate within these three compartments. Because most infections occur in tissues and the common pathogens are extracellular, interstitial fluid concentrations at the site of infection should be the prime determinants of efficacy. Free-drug concentrations in serum are a much better surrogate of interstitial fluid concentrations than are tissue homogenate concentrations. The majority of studies, however, have used tissue homogenates to determine antibi- otic concentrations in tissue. Tissue homogenates mix interstitial, intracellular, and vascular components together. Measurement of antibiotic concentra- tions in tissue homogenate tends to underestimate or overestimate interstitial fluid concentrations depending upon the ability of the antimicrobial to accumulate 2 I Antimicrobial Pharmacokinetics and Pharmacodynamics intracellularly. However, tissue homogenate methods suggest this centrations serve as an adequate surrogate of concentrations class of drugs penetrates poorly into the interstitial space at the site of infection, there is growing controversy in because of the dilution of samples with intracellular con- regard to certain classes of compounds in the treatment of tents. Techniques that directly extract interstitial fluid, lower respiratory tract infections. However, at this time there have not One may then anticipate superior quinolone potency in been either animal model or clinical trial data supporting or the treatment of these infections. Furthermore, it is clear that not ing can have a detrimental effect, whereas in others it all drugs that accumulate intracellularly do so in similar may enhance dosing efficacy. For example, fluoro- of a drug is inversely related to the extent of protein bind- quinolones reside in the cytosol, whereas macrolides con- ing. A common inaccurate assumption is that a given 80 00 degree of protein binding will exert a similar pharmaco- logic effect on all antimicrobials. Excretion of drugs into the urine occurs either by 20 9h glomerular filtration or tubular secretion. Protein binding O reduces the rate of elimination only of drugs cleared by 0 Oft) a7 glomerular filtration. Thus, if peak level was the important effect of protein binding would tend to slow elimination. On the other hand, if the duration of time protein binding would affect elimination very little. One might predict that binding of greater than 80% time course of antibiotic concentration in serum and at would be necessary to reduce unbound free drug levels in sites of infection include several measures of exposure the body enough to adversely affect antimicrobial activity. Administration of large mice was directly related to the degree of protein binding. Relationship of the area under the con- centration curve of total and free drug in serum and 10 free drug in blister fluid with the percentage of pro- 0- Total drug in serum tein bound drug for 16 R-lactams. Another dosing generalization has been that an increase in concentrations will invariably enhance antimicrobial efficacy. These parameters do not provide informa- mechanisms of action vary in respect to the effect of tion regarding the time course activity of drugs, however. Understanding these relationships for various antimicrobial effects that can persist after drug exposure. The persistent suppression of organism growth or the development of in vitro susceptibility breakpoints, regrowth after short antimicrobial exposures has been and (3) the understanding how antimicrobial dosing called the postantibiotic effect. The first is the rate of 25 -0 - Control growth organism killing and whether increasing drug concen- - - Cefazolin 12. Simultaneous drug activity and in fact have been demonstrated to be serum cefazolin concentrations are also shown. Baltimore, Williams & Wilkins,1996, pp it is important to maximize the duration of time for which 296-329. The pharmacologic goal of dosing regimens with these Antifungal compounds have also been shown to have agents would be to maximize concentrations by adminis- prolonged persistent effects. Nearly all antibacterials appear to be capable of producing per- On the basis of these two time-course characteristics sistent effects with staphylococci. This pattern of killing and per- did not appreciably increase the rate of killing. Thus high The dosing frequency is usually not a major factor in concentrations will not kill the organisms faster or more determining the efficacy of these drugs. Effect of increasing the dose or U 1 changing the dosing interval of a hypothetical E drug on the C.. These however, vary dosing frequency comparing the efficacy relationships have been examined primarily in in vitro and of continuous vs. Investigation in human clinical tri- otics, including cefamandole, in febrile neutropenic als to support or refute the observations from in vitro and patients. Two other studies have impact of higher doses of drug on efficacy with usually all compared continuous and intermittent infusions of cef- tazidime in the treatment of gram-negative infections. However, much of the Although it can be difficult to vary dosing regimens interdependence among pharmacodynamic parameters can in clinical trials enough to reduce the inherent parameter be eliminated with dosing regimens that use different dosing interrelationships, studies in animal infection models do intervals. I nterrelationship among dosing interval number and the pharmacokinetic and pharmacodynamic parameters. The 02 value represents the percentage of variation in bacterial numbers that could be attributed to differences in each of 0 20 40 60 80 3 30 300 3000 3 30 300 3000 the individual pharmacodynamic parameters. Pairs of neutropenic mice were treated with drugs 12,13 For example, Blaser et al demonstrated superior multiple dosage regimens of meropenem that varied both efficacy with single compared with multiple aminoglyco- in the total dose and dosing interval. The dotted line reflects the 5 00 00 number of bacteria at the initiation of therapy. Various studies, however, concentrations are used, and for different sites of infec- have demonstrated the impact of dose and dosing interval tion. Most recently this type of 100 analysis has been used in the development of antimicro- 50 bial treatment guidelines for otitis media, sinusitis, and community-acquired pneumonia.

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The goal in treating acute asthma is to minimize maternal hypoxemia generic warfarin 1mg free shipping heart attack 30 year old female, hypocarbia purchase warfarin 1mg with amex heart attack 6 minutes, or respiratory acidosis and to maintain adequate oxygenation for the fetus discount warfarin 1mg free shipping blood pressure medication ringing in ears. Alternatively buy cheap warfarin 5mg on-line arrhythmia guideline, subcutaneous terbutaline or intramuscular epinephrine can be administered and repeated in 30 minutes (32). Some gravidas who do not respond to albuterol will respond to epinephrine given intramuscularly. When epinephrine is administered by the intramuscular route, its effects are primarily b-adrenergic stimulation. There is a fear that epinephrine will cause fetal loss by decreasing uterine blood flow. The use of intramuscular epinephrine (for acute asthma or anaphylaxis) increases cardiac output, which can maintain uterine perfusion. The adverse effects of acute asthma can be a serious threat to the gravida and fetus; therefore, effective control of acute asthma is necessary. P>Inhaled b2-adrenergic therapy with metaproterenol has not been associated with adverse effects and is considered acceptable therapy by some investigators ( 2). When the gravida presents with moderate or severe acute wheezing dyspnea, oral corticosteroids should be administered with initial b 2-adrenergic agonists. Corticosteroids have a number of beneficial effects in acute asthma, although an effect in the first 6 hours may not be detectable. When the gravida has not improved substantially after albuterol (or intramuscular epinephrine), status asthmaticus is present and hospitalization is indicated. Theophylline intravenously has not been found to be superior to intravenous methylprednisone and albuterol therapy in hospitalized gravidas ( 19). When assessing a gravida in the emergency room, if hospitalization is required for status asthmaticus, an arterial blood gas measurement is indicated, as is supplemental oxygen administration. The physician managing the pregnancy should assess the gravida from the obstetric perspective. Excessive fluid replacement is not indicated, but volume depletion should be corrected. The gravida can develop acute pulmonary edema (noncardiac) from excessive crystalloid administration as she is volume expanded during gestation. If the gravida can be discharged from the emergency room, a short course of oral corticosteroids should be given to prevent continued asthma symptoms and signs (47). In the rare setting of acute respiratory failure during status asthmaticus, an emergency cesarean delivery may be necessary ( 14). If mechanical ventilation (48) is indicated, the physician managing asthma and the obstetrician must plan for when a cesarean delivery might be indicated. Avoidance measures are indicated to reduce bronchial hyperresponsiveness and the need for antiasthma medications. Dyspnea can be sensed during gestation in the absence of asthma during the first two trimesters ( 49). A respiratory rate of more than 18 breaths/min has been considered a warning sign for pulmonary pathology complicating dyspnea during pregnancy ( 49). For severe persistent asthma, beclomethasone dipropionate (840 g) or budesonide (800 g) can be inhaled. Should asthma be managed ineffectively with avoidance measures and this combination of medications, cromolyn or theophylline can be considered. If the gravida has wheezing on examination or nocturnal asthma, however, a short course of prednisone may be indicated to relieve symptoms (25). In some gravidas with severe persistent asthma, bronchiectasis from allergic bronchopulmonary aspergillosis, or inhaled corticosteroid phobia, theophylline can be used. For non corticosteroid-requiring asthma, inhaled beclomethasone dipropionate or budesonide, cromolyn, or possibly theophylline are appropriate during gestation. If these drugs are ineffective because of worsening asthma such as from an upper respiratory infection, a short course of prednisone such as 40 mg daily for 5 to 7 days may be administered. There are no data supporting teratogenicity of penicillins or cephalosporins ( 50). These medications have been used throughout gestation without an increased risk of reported teratogenicity. Appropriate therapy during gestation in the ambulatory patient Essentially all patients can be managed successfully during gestation. Some patients with potentially fatal asthma are unmanageable because of noncompliance with physician advice, medications, or in keeping ambulatory clinical appointments. Long-acting methylprednisolone (80 120 mg intramuscularly) is of value to prevent repeated episodes of status asthmaticus or respiratory failure ( 51). This approach should be instituted to try to prevent fetal loss or maternal death in the nearly impossible to manage gravida. Gravidas with malignant potentially fatal asthma, however, may refuse evaluation or necessary therapy. The serum glucose should be determined regularly because of hyperglycemia produced by long-acting methylprednisolone. Other antiasthma medications should be minimized to simplify the medication regimen. Minute ventilation increases to as great as 20 L/min during labor and delivery ( 30). Should cesarean delivery be necessary, complications from anesthesia should not create difficulty if asthma is well controlled. When the gravida has used inhaled corticosteroids or oral corticosteroids during gestation, predelivery corticosteroid coverage should include 100 mg hydrocortisone intravenously every 8 hours until postpartum, and other medications can be used. Parenteral corticosteroids suppress any asthma that might complicate anesthesia required for cesarean delivery. The prior use of inhaled corticosteroids or alternate-day prednisone should not suppress the surge of adrenal corticosteroids associated with labor or during anesthesia. When the gravida who requires regular moderate- to high-dose inhaled corticosteroids or daily or alternate-day prednisone plans to have a cesarean delivery, preoperative prednisone should be administered for 3 days before anesthesia. The gravida should be examined ideally 1 to 2 weeks before delivery to confirm stable respiratory status and satisfactory pulmonary function. In gravidas with persistent mild asthma whose antiasthma medications consisted of theophylline, cromolyn, or inhaled b2-adrenergic agonists, additional preanesthetic therapy can consist of 5 days of inhaled corticosteroid. When the gravida presents in labor in respiratory distress, emergency measures such as inhaled albuterol, intramuscular epinephrine, or subcutaneous terbutaline should be administered promptly. It has been estimated that 30% to 72% of gravidas experience symptoms of rhinitis during gestation ( 52). Nasal biopsy results from symptom-free gravidas showed glandular hyperactivity manifested by swollen mitochondria and increased number of secretory granules ( 54). Special stains demonstrated increased metabolic activity, increased phagocytosis, and increased acid mucopolysaccharides, thought to be attributed to high concentrations of estrogens. Additional findings included increased (a) goblet cell numbers in the nasal epithelium, (b) cholinergic nerve fibers around glands and vessels, and (c) vascularity and transfer of metabolites through cell membranes (54). Women using oral contraceptives but in whom no nasal symptoms had occurred have similar histopathologic and histochemical changes, as do symptom-free gravidas ( 55). Oral contraceptive use in women who developed nasal symptoms was associated with interepithelial cell edema, mucus gland hyperplasia, and proliferation of ground substance analogous to symptomatic gravidas ( 55). Serum concentrations of estradiol, progesterone, and vasoactive intestinal polypeptide did not differentiate symptomatic from asymptomatic gravidas ( 56). It has been estimated that in nonpregnant adults, 700 to 900 mL of nasal secretions are generated per day for proper conditioning of inspired air. Nasal congestion that causes symptoms is likely to occur in the second and third trimesters ( 52).

The dose of these antibiotics in tablets or syrup preparations depends on the age or weight of the child 1mg warfarin overnight delivery blood pressure medication name brands, as given in Table 35 buy cheap warfarin 2mg online hypertension age 70. These dosages also apply to the treatment of pneumonia purchase 2mg warfarin visa heart attack what everyone else calls fun, which will be discussed in Section 35 buy cheap warfarin 5mg on line pulse pressure normal rate. Age (weight) Co-trimoxazole (give twice per day for ve days) Amoxicillin (give three times per day for ve days) Adult tablet Paediatric tablet Syrup Syrup(125mg/5ml) (80 mg trimethoprim + (20mgtrimethoprim+ (80mgtrimethoprim+ 400 mg 100 mg 400 mg sulphamethoxazole) sulphamethoxazole) sulphamethoxazole /5 ml) 2 12 months tablet 2 tablets 5 ml (1 teaspoon) 5 ml (1 teaspoon) (4 10 kg) 12 months to 5 1 tablet 3 tablets 7. If the pus continues to discharge from the ear after ve days, refer the child to a health centre for further assessment and treatment. In most cases, the tonsils are affected and become inamed and ulcerated (tonsillitis). In this section, we will describe the clinical manifestations, complications and treatment of pharyngitis. A better understanding of these points will help you to identify a child with pharyngitis and know that you should refer them to a higher level health facility. Pharyngitis can be caused by viruses or bacteria, but the most important causes are bacteria of the type known as Group A Streptococci. Library for the Health Sciences, The immune system recognises Group A Streptococci as foreign and University of Iowa, accessed produces antibodies that attack the bacteria. However, in rare cases, the antibodies produced to ght 36 Study Session 35 Acute Respiratory Tract Infections Group A Streptococci can attack the heart muscle of the infected child. Early diagnosis and If you identify children with correct treatment greatly improve the outcomes and reduce the risk of pharyngitis, you should refer complications. Pharyngitis due to Group A Streptococci should be treated by them to the nearest health doctors using a drug called Benzathine penicillin. This drug is given in the centre or hospital for specialised form of an injection, which is not authorised for use at Health Post level. The lungs are made up of small sacs called alveoli, which are lled with air when a healthy person breathes in. When an individual has pneumonia, the alveoli are lled with pus and uid, which makes breathing painful and limits the amount of oxygen they can take into the body. Pneumonia is caused by a number of infectious agents, mainly by certain bacteria and viruses (Box 35. Haemophilus inuenzae type b (Hib) the second most common cause of bacterial pneumonia. Pneumonia is the number one cause of death among children in Ethiopia and worldwide: globally, it causes an estimated 1. Airborne droplets spread when the sick person coughs or sneezes, and inhaled into the lungs (breathed in) by a susceptible person;. During or shortly after birth, babies are also at higher risk of developing pneumonia from coming into contact with infectious agents in the birth canal, or from contaminated articles used during the delivery. These modes of transmission help to explain why certain risk factors increase the probability that children or adults will develop pneumonia. Under-nutrition/malnutrition, which weakens the immune system and reduces resistance to infection. Inadequate breastfeeding or formula feeding of infants under six months old, which predisposes them to malnutrition and infection. Lack of immunization against vaccine-preventable diseases that affect the respiratory system. Exposure to indoor air pollution, especially smoke from cooking res burning vegetable and animal waste (e. Children who have bacterial pneumonia usually become severely ill and show the following symptoms:. This classication is very important because it determines what treatment is given to the patient (as you will see in Section 35. Presence of general danger signs (unable to drink or eat, lethargic or A child with fast breathing, chest unconscious) in-drawing or stridor should be immediately referred to hospital. You should refer all patients with severe pneumonia immediately to the nearest health centre or hospital, where appropriate drugs Infants less than two months old can be prescribed by doctors or health ofcers. Here we remind you of the oral antibiotics you can give children with non-severe pneumonia without any other danger signs. The course of treatment is for ve days with either co-trimoxazole (the preferred antibiotic drug), or if co-trimoxazole is not available, give amoxicillin. The doses of co-trimoxazole or amoxicillin depend on the age or weight of the child, and were summarised earlier in Table 35. What dose of co-trimoxazole syrup would you give this child, and for how many days? If any of your non-severe patients She is between 12 months and ve years, so you should give her 7. You need to know about them so you can teach members of your community how they can protect their children and vulnerable adults from acute otitis media, pharyngitis and pneumonia. Control measures, such as the treatment or isolation of cases, are applied after the occurrence of the disease, with the aim of reducing the transmission of the infectious agents to new susceptible people. Feeding children with adequate amounts of varied and nutritious food to keep their immune system strong. Avoiding irritation of the respiratory tract by indoor air pollution, such as smoke from cooking res; avoid the use of dried cow dung as fuel for indoor res. Haemophilus inuenzae type b (Hib) vaccine at 6, 10 and 14 weeks; The dosages, schedules and Hib is one of the ve vaccines in the pentavalent vaccine used in vaccination routes for Hib, Ethiopia. Immunization also increases control, by reducing the reservoir of infection in the community and increasing the level of herd immunity (described in Study Session 1 in Part 1 of this Module). Children with symptoms of acute otitis media should be identied as soon as possible and treated by wicking the pus from the ear, and giving antibiotics to prevent complications such as deafness, meningitis and pneumonia. Children with symptoms of pharyngitis should be referred to a higher level health facility for assessment and treatment. Children with severe pneumonia are at high risk of death, and should immediately be referred to a higher level health facility to save their lives. C Rheumatic heart disease is the result of the heart becoming infected with bacteria. Early diagnosis and treatment Adequate nutrition Immunization against respiratory tract infections Reduction of indoor smoke pollution Coughing or sneezing into a cloth, or turning away from other people 43 Study Session 36 Louse-Borne Diseases: Relapsing Fever and Typhus Study Session 36 Louse-Borne iseases: Relapsing Fever and Typhus Introduction You already learned about the most widespread vector-borne disease in Ethiopia malaria, transmitted by mosquitoes (Study Sessions 5 12 in Part 1 of this Module). Two other vector-borne diseases of public health importance in Ethiopia are the subject of this study session. They are caused by different bacteria, but are transmitted by the same vector the human body louse (plural, lice). The diseases are louse-borne relapsing fever and louse- borne typhus, which are classied as febrile illnesses because the symptoms always include high fever. In this study session, you will learn about the causes, modes of transmission, symptoms and methods of prevention of these diseases. This will help you to identify patients and quickly refer them to the nearest health centre or hospital for specialist treatment. You are also expected to report any cases of these louse-borne diseases to the District Health Ofce, so that coordinated action can be taken to prevent an epidemic from spreading in your community. Learning Outcomes for Study Session 36 When you have studied this session, you should be able to: 36. The human body louse (species name, Pediculus humanus humanus) is commonly found in the clothes, bedding and on the bodies of people living in overcrowded and insanitary conditions, where there is poor personal hygiene. When body lice are found, for example in clothes, the articles are said to be louse-infested. The bites cause an allergic reaction in the person s skin, which becomes inamed and itches, causing the person to scratch the area.

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