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By: M. Luca, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.
Deputy Director, Kansas City University of Medicine and Biosciences College of Osteopathic Medicine
Complications In the most severe cases there is systemic organ failure: Management r Cardiovascularsystem:Shock(hypotension blood pressure medication one kidney generic metoprolol 12.5 mg online,tachycar- The early management depends on the severity of the dia arteria thoracica inferior cheap metoprolol master card, arrhythmias) blood pressure chart gov generic metoprolol 12.5mg online. Patients require careful uid balance zymes walled off by compressed tissue), pancreatic using central venous pressure monitoring and uri- abscesses (which may contain gas indicating infection nary catheterisation to allow accurate urine output withgas-formingbacteria)andduodenalobstruction. Prophylactic Investigations broad-spectrumantibioticsaregiventoreducetherisk When supportive clinical features are present the diag- of infective complications. Ascites and persistent obstructive jaundice with conservative management require laparoscopic may occur. Prognosis Investigations Pancreatitis is a serious condition: overall mortality is Serum amylase uctuates, but may be moderately raised 10%. Endoscopic retrograde cholangiopancreatography mayshowscarringoftheductalsystemandevenstonesin the pancreatic duct. Magnetic resonance cholangiopan- Chronic pancreatitis creatography is increasingly being used. Denition Chronic pancreatitis is an inammatory condition that Management results in irreversible morphological change and impair- Precipitating factors especially alcohol need to be re- ment of exocrine and endocrine function. Adequate analgesia is required, thoracoscopic splanchnicectomymayberequiredinrefractorypainnot Age associated with main pancreatic duct dilatation. Surgical M > F techniques include sphincteromy or sphincteroplasty, partial pancreatectomy or opening the pancreatic duct Aetiology/pathophysiology along its length and anastomosing it with the duodenum Two patterns of chronic pancreatitis are seen, a chronic or jejunum. Total pancreatectomy can be carried out, relapsing course with recurring acute pancreatitis and with replacement oral pancreatic enzymes and insulin. Risk factors includealcoholabuse,hereditarypancreatitis,ductalob- Tumours of the pancreas struction (e. Hy- percalcaemia, hyperlipidaemia and congenital pancre- Denition atic malformations are recognised associations. Clinical features Incidence Patients may present with an acute episode of pancre- 10 per 100,000 per annum and rising. Late com- plications include impaired glucose tolerance, diabetes Age mellitus and malabsorption (steatorrhoea) associated Mainly >60 years. Aetiology There appears to be some familial clustering and hence Investigations it is suggested that genetic susceptibility may play an There are no useful tumour markers or pancreatic func- important role. Specic inherited risks include famil- tion tests for diagnosis, which must be histological. Mosttumoursdevelop intheheadofthepancreasandthesetendtopresentearly ducts and may also be used for intervention. Clinical features Pancreatic cancer is associated with several clinical syn- Management dromes: Surgical resection offers the only chance of cure, but only r One third of patients present with painless obstructive about 10 15% of patients are suitable for radical surgery jaundice, i. Chronic epigastric pain radiating to the back similar to chronic pancre- denectomy with block resection of the head of pan- atitis develops in most patients at some stage. There is signicant orrhoea is common and failure to absorb the fat- perioperative morbidity and mortality. Stents of the bile duct and/or duodenum tend to become blocked and Macroscopy/microscopy have to be replaced. Most tumours are moderately differentiated The prognosis is extremely poor with an overall 5-year adenocarcinoma with a prominent brous stroma. Radiolabelled octreotide (a somato- statin analogue) can be used for localisation of the primary tumour and detection of any metastases. Insulinoma: Ausually benign islet-cell tumour that may r Several options are available for the treatment of occur in the pancreas or at ectopic sites causing the metastatic neuroendocrine tumors including oc- hypersecretion of insulin.
Single Code It s okay to buy the same antibiotics hypertension kidney stones purchase metoprolol 50mg on-line, or request these from a doctor blood pressure medication questions metoprolol 25 mg otc, if you re sick and they helped you get better when you had the same symptoms before 1 arrhythmia leads to heart failure generic 50mg metoprolol with mastercard. Don t know 47 #AntibioticResistance 8) Do you think these conditions can be treated with antibiotics? Can t remember 11) Please indicate whether you think the following statements are true or false Single Code per statement Rotate order asked 1. Antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work as well 2. Many infections are becoming increasingly resistant to treatment by antibiotics 3. If bacteria are resistant to antibiotics, it can be very difficult or impossible to treat the infections they cause 4. Antibiotic resistance is only a problem for people who take antibiotics regularly 7. Bacteria which are resistant to antibiotics can be spread from person to person 8. Antibiotic-resistant infections could make medical procedures like surgery, organ transplants and cancer treatment much more dangerous 49 #AntibioticResistance 12) On the scale shown, how much do you agree the following actions would help address the problem of antibiotic resistance? The mention of specic companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. The latter used to consider the brain as a black box where only the input and output were known but not at all the neuronal com- ponents and the way they interact with each other. At the beginning of the third millennium, due to pro- longed ageing, neurodevelopmental disorders are growing and a much deeper knowledge of the brain is necessary. Scientic and technological research, from molecular to behavioural levels, have been carried out in many different places but they have not been developed in a really interdisciplinary way. Research should be based on the convergence of different interconnected scientic sectors, not in isolation, as was the case in the past. As this report demonstrates, the burden of neurological disorders is reach- ing a signicant proportion in countries with a growing percentage of the population over 65 years old. With this report go my best wishes that it be disseminated worldwide and that it receive the deserved attention of the Global Health Community in all the countries of the world. The world health report 2001 Mental health: new understanding, new hope is an advocacy instrument to shed light on the public health as- pects of mental disorders, and the report Neuroscience of psychoactive substance use and dependence produced by the department in 2004 tackles the area of substance abuse and alcohol. A clear message emerges that unless immediate action is taken globally, the neurological burden is expected to become an even more serious and unmanageable problem in all countries. There are several gaps in understanding the many issues related to neurological disorders, but we already know enough about their nature and treatment to be able to shape effective policy responses to some of the most prevalent among them. To ll the vast gap in the knowledge concerning the public health aspects of neurologi- cal disorders, this document Neurological disorders: public health challenges fulls two roles. On one hand, it provides comprehensive information to the policy-makers and on the other hand, it can also be used as an awareness-raising tool. It is the result of a huge effort bringing together the most signicant international nongovernmental organizations working in the areas of various neurological disorders, both in a professional capacity and in caring for people affected by the conditions. This exercise thus demonstrates that such collaboration is not only possible but can also be very productive.
Close monitoring of fluid balance in cases of Jerish-Herxhemier reaction that may occur following antibiotics treatment blood pressure medication benicar side effects cheap 25 mg metoprolol visa. Food handlers arteria umbilical unica 2012 cheap 25 mg metoprolol amex, especially if they are intermittent carriers are particularly dangerous and have been responsible for many epidemics blood pressure cuff size purchase metoprolol paypal. Transmission: infection is acquired through ingestion of contaminated water and food by feces 118 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia and urine of patients and carriers. Flies may infect foods in which the organism multiplies to achieve an infective dose. Confirmed case: A suspected case with widal test, O titer of 1/160 and more is very suggestive. General management Report the suspected case to the next higher level of the health system. Specific management Treat the suspected cases with antibiotics based on recent susceptibility results, if available. Pediculus humanus corporis (body and head louse), which is peculiar to humans, is the only important vector of epidemic typhus. Cases of epidemic typhus now occur in significant numbers in Ethiopia and probably in highland areas of impoverished countries. Transmission: Human beings generally are infected when rickettsia laden louse feces are rubbed into the broken skin, scratching the louse bite facilities this process. Pathogenic rickettsias reside for a long period of time in patients with epidemic typhus. Case definition Suspected case: Any person with an abrupt onset of headache, chills and rapidly mounting fever, malaise, prostration and rash. Visceral leishmaniasis is 125 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia distributed throughout the low lands of Ethiopia with varying degree of endemicity. The most important foci are the Metema and Humera low lands in the north-west, the Segen valley and its surroundings in Konso (South-west) and the lower Omo plains (South-west). The north eastern part of the country along the Awash valley to the Ethio-Djiboutic border is as well potentially enedemic. The leshimaniases are parasitic diseases with a wide range of clinical symptoms: of mainly cutaneous, mucocutaneous and visceral. The leishmaniases are caused by different species of protozoan parasites belonging to the genus leishmania. Visceral leshimaniasis is characterized by irregular bouts of fever, substantial weight loss, swelling of the spleen and liver, and anemia (occasionally serious). In epidemic visceral leishmaniasis, people of all ages are susceptible except those who acquired 126 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia immunity during a previous epidemic. Transmission: the disease is transmitted to humans by the bite of a tiny 2 to 3 millimeter-long insect vector, the phlebotomine sandfly. Risk factors: Movement of non-immune people into potential visceral leishmaniasis endemic; areas Malnutrition; Ecological change in favour of the sand fly vector. Case definition Suspected case: Any person with irregular bouts of fever, substantial weight loss, swelling of the spleen and liver, and anemia. Investigation Investigate the case to determine risk factors contributing to transmission. Specific management Treat the confirmed cases with sodium stibogluconate or other available effective alternative drugs. Transmission: transmitted human-to-human via the bite of aedes mosquitoes (urban epidemic) or via forest mosquito species and forest primate reservoir (jungle cycle).
Syndromes
Both of these agents were associated with serious interactions with drugs that were also metabolized by the liver cytochrome P-450 enzyme 3A4 blood pressure nicotine order cheap metoprolol line, such as erythromycin and ketoconazole blood pressure high in the morning quality 50mg metoprolol. This led to accumulation of the parent compound hypertension ranges buy metoprolol paypal, which caused cardiac side effects such as torsades de pointes. Although this was a rare occurrence and dose dependent, the advent of newer antihistamine drug metabolites that were not dependent on cytochrome oxidase metabolism made them expendable. Pharmacokinetics The pharmacokinetic data available for second-generation agents are summarized in comparison to first-generation agents in Table 5. Data in humans on volumes of distribution for these agents is not available ( 3,17). The major active meta bolite of astemizole is N-desmethylastemizole, which has a half-life of 9. Astemizole is unique because it has a slower elimination half-life of 18 to 20 days, compared with terfenadine, which has a half-life of 4. Even though the half-life of terfenadine in children is only 2 hours, it is equally effective pharmacodynamically as in adults ( 41). Cetirizine and fexofenadine are not extensively metabolized in the cytochrome P-450 system and are therefore less likely to compete for elimination with other medications metabolized by the same cytochrome P-450 enzyme systems. Its elimination can be also impaired in patients with renal insufficiency ( 3,32,40). Food and Drug Administration became aware of numerous reports associating terfenadine with malignant cardiac arrhythmias such as torsades de pointes ( 42). By July 1992, 44 reports of adverse cardiovascular events had been reported, 9 resulting in death, 3 of which occurred after an overdose of terfenadine ( 42). Retrospective analysis of case reports citing terfenadine-induced cardiovascular events has been helpful in defining risk factors in patients prone to these cardiac side effects ( 42). It should be emphasized that terfenadine and astemizole were very safe and effective drugs that were able to be used in most clinical circumstances. Pharmacodynamics In contrast to first-generation agents, second-generation agents do not operate by simple competitive inhibition. Instead, these agents bind to and dissociate from H 1 receptors slowly in a noncompetitive fashion. They are not displaced from H 1 receptors in the presence of high histamine concentrations ( 29,42). However, the second-generation antagonists are potent suppressors of the wheal-and-flare responses, and this feature has been established as a useful method for comparing the clinical potencies of the different agents available ( 38,44). Their lipophobic properties prevent them from crossing the blood brain barrier; thus, their activity on H 1 receptors is restricted to the peripheral nervous system ( 30,45). Pharmacy Second-generation antihistamines are available only as oral formulations. Studies have reported that a single dose of terfenadine (120 mg) or fexofenadine (180 mg) is equally effective as 60 mg given twice a day in improving allergic rhinitis symptom scores and suppressing histamine-induced wheal-and-flare responses ( 46,47). Astemizole and loratadine should be injected on an empty stomach to avoid problems with absorption. All three agents have comparable antihistaminic potency to each another and to first-generation antihistamines. Azelastine has been demonstrated to inhibit superoxide generation by eosinophils and neutrophils, which may represent one of its important antiinflammatory mechanisms (52). These drugs can bind to H1 receptors in a competitive and noncompetitive fashion ( 3,53,54). Because doxepin has a very high H1 receptor affinity, it has become an acceptable alternative agent for the treatment of chronic idiopathic urticaria ( 64). Numerous studies have compared the antihistaminic efficacy of second-generation antagonists with that of first-generation antagonists in the treatment of allergic rhinitis.
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