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A) Migraine Headache • Definition: migraine headache is a benign and episodic disease antibiotics for tooth infection buy tri azit with mastercard, characterized by headache antibiotics mixed with alcohol order tri azit discount, nausea antibiotics for urinary tract infection over the counter order tri azit from india, vomiting and/ or other symptoms of neurological dysfunction. Etiology: the cause of migraine is often unknown, but several common precipitants have been observed. Pathogenesis: different hypothesis are proposed including: 1) Vascular theory: in this theory it is said that migraine and neurological symptoms are results of extracranial vasodilatation and intracranial vasoconstriction. Clinical feature Migraine may be precipitated by some of the factors mentioned above. The syndrome of Classical migraine has five phases: • Prodromal phase: characterized by lassitude, irritability difficulty in concentrating • Aura phase: patients with aura often report visual complaints, vertigo, aphasia or other neurological deficit before the onset of the headache • Headache phase – characteristic migraine headache • Headache termination – usually occurs within 24 hours • Post headache phase – feeling of fatigue. Sleepiness and irritability Characteristic Migraine head ache is: Moderate to severe head pain, pulsating quality often unilateral ( affecting half part of the head ) It is exacerbation by physical activity and relived by sleeping It is often associated with Nausea and/or vomiting, photophobia, phonophobia/ sonophobia (dislike ad avoidance of laud sounds or noises). There are different variants of Migraine Common migraine • This is the commonest variation of migraine headache • No focal neurological disturbance precedes the recurrent headache 494 Internal Medicine Classic migraine • It is associated with characteristic premonitory sensory, motor or visual symptoms. Most common symptoms reported are visual which include scotomas and/or hallucinations. Complicated migraine • Migraine associated with dramatic transient neurological deficit, or a migraine attack that leaves a persisting residual neurological deficit. These drugs are effective for mild to moderate attacks and are most effective when taken early. Nonselective (Ergot preparations: Ergotamine and dihydro-ergotamine) o Widely used for relief of acute attacks o Has oral, sublingual, rectal, nasal and parentral preparation. Excess use may lead to rebound headache and dependency o Contraindication: patients with vascular diseases like coronary heart disease ii. Selective Triptans including (Naratriptan, Ritatriptan, Sumatriptan, and Zolmitriptan): are new drugs in management of migraine. Prophylactic Treatment: includes drug regimens and changes in patients behavior Medical therapy: • These are drugs that have capacity to stabilize migraine. Prophylactic treatment is indicated if the patient has three or more attacks per month. It lessens migraine attacks by helping patients deal more effectively with stress B) Cluster Headache • Cluster head ache is a vascular headache syndrome, characterized by severe, acute headache that occurs in clusters lasting several weeks followed by pain free intervals that averages a year. Male: Female ratio is 8:1 rd th • Usually begins 3 to 6 decades • Cluster headache is periorbital less commonly temporal. It is also severe and explosive in quality lasting 30 min to 2hrs, subsiding abruptly. Preventions/prophylactic therapy: clusters attacks can be prevented effectively by: 496 Internal Medicine • Prednisolone, Lithium, Methysergide, Ergotamine, Sodium valproate and verapamil C) Tension headache (Tension type headache ) • Most common cause of headache in adults • Common in women than men • Can occur at any age, but onset during adolescence or young adulthood is common. Etiology: various precipitating factors may cause tension headache in susceptible individual including. Clinical feature • Tension headache is characterized by mild or moderate, bilateral pain. Headache is a constant, tight, pressing or band like sensation in the frontal, temporal, occipital or parietal area. If treatment is unsatisfactory addition of caffeine or other analgesic is beneficial. Physical Therapy: different techniques can be used including Hot or cold application Positioning Stretching exercises Traction Massage 3. Psychological Therapy • Includes reassurance, Counseling, relaxation, stress management programs and biofeedback techniques reduce both the frequency and severity of chronic headache. D) Headache Associated with Brain Tumor • About 30% of patients with brain tumor present with headache.
For example antibiotics and sun order tri azit visa, coinfection with HxNy and HwNz could produce the hybrids HxNz and HwNy in addition to the parental types antibiotic resistance process generic 100 mg tri azit visa. The H3N2 subtype that caused the “Hong Kong” pandemic of 1968 arose by reassortment of the human H2N2 subtype with avian genes antibiotic resistance and infection control journal purchase 100mg tri azit otc. Other reassortments between the major human subtypes have been documented during the past twenty-?ve years (Cox and Bender 1995). Reassortment between subtypes may not occur frequently, but may be important in creating novel genotypes that have the potential to spread widely through a host population, causing pandemics. Widespread human epidemics have been limited to H1N1, H2N2, and H3N2, although occasional transfers of other subtypes occur from birds or mammals to humans. Other mammals and nonaquatic birds occasionally become infected, but do not appear to maintain stable lineages over time. The listing below shows the binding a?nities for sialic acid when particular amino acids are changed experimentally by site-directed mutagenesis (Martin et al. Redrawn from Skehel and Wiley (2000), with permission from the Annual Review of Biochemistry. The amino acids numbered within and around the binding site provide a reference for the location of important residues. The bottom of the ?gure shows the e?ect on binding a?nity to sialic acid caused by experimental change of particular amino acids. This space-?lling model has roughly the same orientation as the schematic diagram in ?gure 13. Antibody escape mutants map to the ridge of amino acids that ring the conserved amino acids in the binding pocket. Each upper arm forms an Fab fragment, with the binding region on the tip of the fragment. An antibody molecule can be cleaved to release two identical Fab fragments, each containing a binding region. Those sites are too far away to allow overlap of the direct antibodyepitope binding region with the sialic acid binding site. Clearly, neutralization depends on the structural environment of intact epitopes. Bulky side chains may cause steric hindrance that interferes with antibody-epitope contact. Glycosylation adds surface carbohydrates that can prevent antibody access to potential epitopes (Caton et al. Alternatively, amino acid changes sometimes cause physical displacement of various protein loops. When the antibody bound to the mutantepitope, the antibody-epitope complex reverted to the same structure as the antibody bound to the original type. However, the energy required to distort the conformation of the mutant epitope during binding reduced the binding a?nity of theantibody by 4,000-fold relative to the a?nity of the antibody for the original type. These various studies of antibody binding, structure, and kinetics provide necessary background for analyses of evolutionary change at the amino acid level. Sialic acid components of host cells form the primary site of in?uenza attachment. This function seems to aid in releasing progeny viral particles from infected host cells. It may be that viruses lacking neuraminidase activity enter host cells and replicate, but get stuck on the surface of the cell by attachment to sialic acid (Palese and Compans 1976). First, surface mapping determines which amino acids occur in sites accessible to antibodies. Statistical methods identi?ed which changed amino acids caused a reduction in antibody binding.
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Why diabetes mellitus patients are most susceptible for different kinds of skin infections? His condition slowly deteriorated in the period of time that he has been ill and he was drowsy antibiotics for sinus staph infection purchase tri azit without prescription. The health officer on duty examined him and the findings were an acutely sick looking boy who was conscious and in respiratory distress antimicrobial wound cream generic 250 mg tri azit otc. Blood pressure was 80/50 with the measurement taken in the supine position from the right arm n-922 antimicrobial buy 250mg tri azit visa. On further questioning it was found out that he lives in a one room thatched roofed house with his seven siblings and parents. There is no window in the house; the cattle are kept in the same room and firewood is burned in the same room. The house is very badly lit with the only source of light being the daylight coming through the door. He comes from a rural village 15Km far from the health center and had to be carried all the way to the health center by his relatives. Epidemiology the prevalence of diabetes mellitus has risen dramatically in the past two decades; it is also projected that the number of individuals with diabetes mellitus will continue to increase in the near future. The prevalence of diabetes mellitus is reaching epidemic proportions, in large part because of obesity and sedentary life style in both adults and children the incidence and prevalence of diabetes mellitus in the general Ethiopian population are unknown. A population based study done near Gondar on 2381 individuals using glycosuria screening with blood glucose confirmation showed glucose intolerance in 12 only 0. Patient education, dietary management and exercise play a central role in managing diabetic patients in addition to pharmacologic therapy. Patient Education • It should be viewed as a continuing process with regular visits for reinforcement and not just a one-time affair. The majority of these individuals are obese, and weight loss is strongly encouraged and should remain an important goal • Food intake must be spread evenly throughout the waking hours and taken at regular times in relation to the insulin dose. Despite its benefits, exercise presents several challenges for individuals with diabetes mellitus because they lack the normal glucoregulatory mechanisms. If the insulin level is too low, the rise in catecholamines may increase the plasma glucose excessively, promote ketone body formation, and possibly lead to ketoacidosis. To avoid exercise-related hyperor hypoglycemia, individuals with type 1 diabetes should • monitor blood glucose before, during, and after exercise • delay exercise if blood glucose is > 250 mg/dL, <100 mg/d), or if ketones are present • eat a meal 1 to 3 hours before exercise and take supplemental carbohydrate feedings at least every 30 min during vigorous or prolonged exercise • decrease insulin doses (based on previous experience) before exercise and inject insulin into a nonexercising area. Insulin formulations are available as U-100 (1ml of solution equivalent to 100 units) or U-40 (1ml of solution equivalent to 40units). It is very important that one designs and implements an insulin regimen that mimics physiologic insulin secretions. Twice daily administration of a short acting and intermediate acting insulin, given in combination before breakfast and the evening meal, is the simplest and most commonly used regimen. Two thirds of the dose is given in the morning and one third is given in the evening. Glycemic control is reassessed and if response is not achieved, pharmacologic agents may be tried. As type 2 diabetes is a progressive illness, monotherapy is seldom successful in the long term. Therapy is initiated with one class of agent, depending on patient characteristics and a second agent is added if adequate glycemic control is not achieved.
F etal:9 weeksto birth F irsteigh tweeksare furth er divided into 23 stages Stage one (day one) corresponds to fertiliz ation S ignificance • K nowledge ofdevelopmentofdifferentorgans virus protection free purchase tri azit 500 mg fast delivery,tissuesand systems virus removal tool cheap tri azit 500 mg on-line. G rowth antibiotic vs antibody trusted 100 mg tri azit,differentiationand metabolism alloccurside by side inth e developingembryo. C om m onterm sused inem bryology • O ocyte (O vum)amature secondary oocyte ready for fertiliz ation. C om m onterm sused inem bryology th • F etus-fetalperiod isfrom 9 week tillbirth wh ich is marked by differentiation,growth oftissuesand organsand subsequentweigh tgain. W ith more differentiationand growth,th e structure gradually ch angesto primary, secondary ordefinitive etc. G am etogenesis • Processofformationand developmentofspecializ ed generative cells– gamete • Preparessexcellsforfertiliz ation M eiosis • Producesh aploid gametes • A llowsrandom assortmentofmaternaland paternalch romosomesbetweenth e gametes • C rossingoverofch romosome segments-produces arecombinationofgeneticmaterial N ondisjunction-ch romosomally abnormalgametes • Inm ale th e sexorgansare th e testes wh ich produce sperm atoz oa(m ale gam etesorsperm s),44xy. S perm iogenesis • presence of prim ordialgerm cellsinth e sex cords(large pale cells). O ogenesisV sS perm atogenesis S im ilarities • P G C originate from th e sam e source and atth e sam e tim e. Secretory (progestational)-C h angesinfluenced by th e progesterone secretioninth e corpusluteum ofovary ( afterovulation). M enstruation Ifth ere isno fertiliz ation,progesterone secretionstopsafter14-15 days. Original and Review Articles – Original, and review articles are provided for residents who seek a more comprehensive understanding of a topic. We recognize that residency is a busy time, but we hope that you will take the time to read articles relevant to the management of your patients. In order to facilitate learning at many levels, several other educational opportunities are available. Tutorials – These are 20-30 minute sessions offered during the rotation that will provide the resident with hands on experience. The goal of morning rounds is to develop treatment plans that can be defended by the best available scientific evidence. In addition, morning rounds are an opportunity for residents to test their knowledge, gauge their progress in critical care education, and recognize the limits of the current medical practice. The faculty and fellows of Boston University Pulmonary and Critical Care section hope that you enjoy your rotation in the medical intensive care unit. Acute Respiratory Distress Syndrome and Ventilator-Associated Lung Injury / Literature D. Management and Optimal Timing of Tracheostomy / Literature Chapters on Cardiopulmonary Critical Care G. Treatment of Severe Sepsis & Shock: Part I (Fluids and Antibiotics) / Literature J. Pneumonia: Community-Acquired, Nosocomial and Ventilator-Associated Pneumonia / Literature P. Oxygen cascade: Describes the process of declining oxygen tension from atmosphere to mitochondria. During respiration air is humidified reducing atmospheric pressure by 47mmHg to 713mmHg so the maximal inspired partial pressure of oxygen is 149mmHg. Hemoglobin has 4 binding sites for oxygen, and if all are occupied then the oxygen capacity would be saturated. Assuming a hemoglobin concentration of 15g/dl O2 content is approximately 20ml/100ml. With a normal cardiac output of 5 l/min, the delivery of oxygen to the tissues at rest is approximately 1000 ml/min: a huge physiologic reserve.