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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Michelle Leech MBBS(Hons), FRACP, PhD
Toxicity Because vitamin A is fat soluble and can be stored symptoms 3 days dpo buy aggrenox caps 25/200mg online, primarily in the liver treatment 7 february aggrenox caps 25/200 mg amex, routine consumption of large amounts of vitamin A over a period of time can result in toxic symptoms medicine x 2016 buy 25/200mg aggrenox caps amex, including liver damage treatment hiatal hernia generic aggrenox caps 25/200 mg with mastercard, bone abnormalities and joint pain medicine for nausea purchase aggrenox caps 25/200 mg mastercard, alopecia symptoms 4-5 weeks pregnant purchase 25/200mg aggrenox caps, headaches and vomiting, and skin desquamation. Hypervitaminosis A appears to be due to abnormal transport and distribution of vitamin A and retinoids caused by overloading of the plasma transport mechanisms (104). The smallest daily supplement associated with liver cirrhosis that has been reported is 7500 µg taken for 6 years (100,101). Very high single doses can also cause transient acute toxic symptoms that may include bulging fontanels in infants; headaches in older children and adults; and vomiting, diarrhoea, loss of appetite, and irritability in all age groups. When this occurs, it usually results from very frequent consumption of liver products. Toxicity from food sources of pro-vitamin A carotenoids is not reported except for the cosmetic yellowing of skin. However, daily prophylactic or therapeutic doses should not exceed 900 µg, that is well above the mean requirement of about 200 µg daily for infants. An excess of bulging fontanels occurred in infants under 6 months of age in one endemically deficient population given two or more doses of 7500 µg or 15 000 µg preformed vitamin A in oil (106,107), but other large-scale controlled clinical trials have not reported excess bulging after three doses of 7500 µg given with diptheria-pertussis-tetanus immunisations at about 6, 10, and 14 weeks of age (108). No effects were detected at 3 years of age that related to transient vitamin Ainduced bulging that had occurred before 6 months of age (105,109). Occasionally diarrhoea or vomiting is reported but is transient with no lasting sequelae. Women who are pregnant or might become pregnant should avoid taking excessive amounts of vitamin A. Future research Further research is needed: · · · · on the interaction of vitamin A and iron with infections, as they relate to serum levels and disease incidence and prevalence; on the relation among vitamin A, iron, and zinc and their role in the severity of infections; on the nutritional role of 9-cis retinoic acid and the mechanism which regulates its endogenous production; on the bio-availability of pro-vitamin A carotenoids from different classes of leafy and other green and orange vegetables, tubers, and fruits as typically provided in diets. Effect of dietary fat on absorption of -carotene from green leafy vegetables in children. Compartmental analysis of the dynamics of -carotene metabolism in an adult volunteer. The function of vitamin A in cellular growth and differentiation, and its roles during pregnancy and lactation. Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries. United Nations Administrative Committee on Coordination, Subcommittee on Nutrition. Vitamin A and breast-feeding: a comparison of data from developed and developing countries. Nutritional and household risk factors for xerophthalmia in Aceh, Indonesia: a case-control study. Seasonal variation in signs of vitamin A deficiency in rural West Bengal children. Vitamin A supplementation in northern Ghana: effects on clinic attendance, hospital admissions, and child mortality. Impact of massive dose of vitamin A given to preschool children with acute-diarrhoea on subsequent respiratory and diarrhoeal morbidity. Impact of weekly supplementation of women with vitamin A or betacarotene on foetal, infant and maternal mortality in Nepal. Potential interventions for the prevention of childhood pneumonia in developing countries: a meta-analysis of data from field trials to assess the impact of vitamin A supplementation on pneumonia morbidity and mortality. Vitamin A supplementation reduces measles morbidity in young African children: a randomised, placebo-controlled, double blind trial. Vitamin A deficiency and diarrhoea: a review of interrelationships and their implications for the control of xerophthalmia and diarrhoea. Corneal ulceration in Tanzanian children: relationship between measles and vitamin A deficiency. Serum and liver vitamin A and lipids in children with severe protein malnutrition. Teratology society position paper: Recommendations for vitamin A use during pregnancy. Vitamin A concentrations in liver determined by isotope dilution assay with tetradeuterated vitamin A and by biopsy in generally healthy adult Humans. Plasma kinetics of an oral dose of [2H4]retinyl acetate in Human subjects with estimated low or high total body stores of vitamin A. Effect of simultaneous, single oral doses of carotene with lutein or lycopene on the -carotene and retinyl ester responses in the triacylglycerol-rich lipoprotein fraction of men. Carotenoids and food preparation: the retention of provitamin A carotenoids in prepared, processed, and stored foods. In: Report, Ad Hoc Panel of the Advisory Committee on Technology Innovations, Board on Science and Technology for International Development, Commission on International Relations. An indigenous fruit of North Vietnam with an exceptionally high Я-carotene content. Guidelines for the development of a simplified dietary assessment to identify groups at risk for inadequate intake of vitamin A. Food and Nutrient Intakes by Individuals in the United States, by Sex and Age, 1994-96, pp. Green and yellow vegetables rich in pro-vitamin A carotenoids can sustain vitamin A status in children. Serum retinol concentrations in children are affected by food sources of carotene, fat intake, and anthelmintic drug treatment. Biochemical and histological methodologies for assessing vitamin A status in Human populations. Attempts to define the minimal serum level of vitamin A required for normal visual function in a patient with severe fat malabsorption. Assessment of marginal vitamin A deficiency in Brazilian children using the relative dose response procedure. Serum vitamin A distribution curve for children aged 26 y known to have adequate vitamin A status: a reference population. Hyporetinolemia, illness symptoms, and acute phase protein response in pregnant women with and without night blindness. Influence of morbidity on serum retinol of children in a communitybased study in northern Ghana. Reduced mortality among children in Southern India receiving a small weekly dose of vitamin A. Age-specific reference intervals for plasma vitamin A, E and betacarotene and for serum zinc, retinol-binding protein and prealbumin for Sydney children aged 9-62 months. Neonatal vitamin A supplementation: effect on development and growth at 3 y of age. Randomised trial to assess benefits and safety of vitamin A supplementation linked to immunisation in early infancy. This active form regulates the transcription of a number of vitamin Ddependent genes coding for calcium-transporting proteins and bone matrix proteins. Vitamin D also modulates the transcription of cell cycle proteins, that decrease cell proliferation and increase cell differentiation of a number of specialised cells of the body. This property may explain the actions of vitamin D in bone resorption, intestinal calcium transport, and skin. Vitamin D also possesses immuno-modulatory properties that may alter responses to infections in vivo. The cell differentiating and immuno-modulatory properties underlie the reason why vitamin D derivatives are now used successfully in the treatment of psoriasis and other skin disorders. V Overview of the role of vitamin D Vitamin D, a seco-steroid, can either be made in the skin from a cholesterol-like precursor (7dehydrocholesterol) by exposure to sunlight or can be provided pre-formed in the diet (1). The version made in the skin is referred to as vitamin D3 whereas the dietary form can be vitamin D3 or a closely related molecule of plant origin known as vitamin D2. Because vitamin D can be made in the skin, it should not strictly be called a vitamin, and some nutritional texts refer to the substance as a prohormone and to the two forms as cholecalciferol (D3) or ergocalciferol (D2). From a nutritional perspective, the two forms are metabolised similarly in humans, are equal in potency, and can be considered equivalent. This ligand-receptor complex binds to a specific vitamin Dresponsive element and, with associated transcription factors. These functions serve 110 Chapter 8: Vitamin D the common purpose of restoring blood levels of calcium and phosphate to normal when concentrations of the two ions are low. The physiologic loop (Figure 10) starts with calcium sensing by the calcium receptor of the parathyroid gland (14). All these events raise plasma calcium levels back to normal, that in turn is sensed by the calcium receptor of the parathyroid gland. Not shown but also important is the endpoint of the physiologic action of vitamin D, namely adequate plasma calcium and phosphate ions, that provide the raw materials for bone mineralisation. Populations at risk for vitamin D deficiency Infants Infants constitute a population at risk for vitamin D deficiency because of relatively large vitamin D needs brought about by their high rate of skeletal growth. At birth, infants have acquired in utero the vitamin D stores that must carry them through the first months of life. Breast-fed infants are particularly at risk because of the low concentrations of vitamin D in human milk (16). Infants born in the autumn months at extremes of latitude are particularly at risk because they spend the first 6 months of their life indoors and therefore have little opportunity to synthesise vitamin D in their skin during this period. Consequently, although vitamin D deficiency is rare in developed countries, sporadic cases of rickets are still being reported in many northern cities but almost always in infants fed human milk (17-20). Excess production of vitamin D in the summer and early fall months is stored mainly in the adipose tissue (22) and is available to sustain high growth rates in the winter months that follow. Insufficient vitamin D stores during these periods of increased growth can lead to vitamin D insufficiency (23). Elderly Over the past 20 years, clinical research studies of the basic biochemical machinery handling vitamin D have suggested an age-related decline in many key steps of vitamin D action (24) including rate of skin synthesis, rate of hydroxylation leading to activation to the hormonal form, and response of target tissues. There is evidence that this vitamin D deficiency contributes to declining bone mass and increases the incidence of hip fractures (27). Although some of these studies may exaggerate the extent of the problem by focusing on institutionalised individuals or in-patients with decreased sun exposures, in general they have forced health professionals to re-address the intakes of this segment of society and look at potential solutions to correct the problem. Several groups have found that modest increases in vitamin D intakes (between 10 and 20 µg/day) reduce the rate of bone loss and the fracture rate (25-29). These findings have led agencies and researchers to suggest an increase in recommended vitamin D intakes for the elderly from the suggested 2. This vitamin D intake results in lower rates of bone loss and is suggested for the middle-aged (5070 years) and old-aged (>70 years) populations (33). The increased requirements are justified mainly on the grounds of the reduction in skin synthesis of vitamin D, a linear reduction occurring in both men and women, that begins with the thinning of the skin at age 20 years (24). Pregnancy and lactation Elucidation of the changes in calciotropic hormones occurring during pregnancy and lactation has revealed a role for vitamin D in the former but probably not the latter. The concern that modest vitamin D supplementation might be deleterious to the foetus is not justified. Consequently, there is no great drain on maternal vitamin D reserves either to regulate calcium homeostasis or to supply the need of human milk. Because human milk is a poor source of vitamin D, rare cases of nutritional rickets are still found, but these are almost always in breast-fed babies deprived of sunlight exposure (17-20). Furthermore, there is little evidence that increasing calcium or vitamin D supplements to lactating mothers results in an increased transfer of calcium or vitamin D in milk (38). Thus, the current thinking, based on a clearer understanding of the role of vitamin D in lactation, is that there is little purpose in recommending additional vitamin D for lactating women. The goal for mothers who breast-feed their infants seems to be merely to ensure good nutrition and sunshine exposure in order to ensure normal vitamin D status during the perinatal period. Accurate food composition data are not available for vitamin D, accentuating the difficulty for estimating dietary intakes. Skin synthesis is equally difficult to estimate, being affected by such imponderables as age, season, latitude, time of day, skin exposure, sun screen use, etc. In vitamin D replete individuals, estimates of skin synthesis are put at around 10 µg /day (24, 41), with total intakes estimated at 15 µg/day (24). Previously, many studies had established 27 nmol/l as the lower limit of the normal range. However, a recent editorial in a prominent medical journal attacked the recommendations as being too conservative (45). This came on the heels of an article in the same journal (46) reporting the level of hypovitaminosis D to be as high as 57 percent in a population of ageing (mean 62 years) medical in-patients in the Boston area. Of course, such in-patients are by definition sick and should not be used to calculate normal intakes. Nevertheless, in lieu of additional studies of selected human populations, it would seem that the recommendations of the Food and Nutrition Board are reasonable guidelines for vitamin D intakes, at least for the near future. In most situations, approximately 30 minutes of skin exposure (without sunscreen) of the arms and face to sunlight can provide all the daily vitamin D needs of the body (24). Because not all of these problems can be solved in all geographic locations, particularly during winter at latitudes higher than 42o where synthesis is virtually zero, it is 116 Chapter 8: Vitamin D recommended that individuals not synthesising vitamin D should correct their vitamin D status by consuming the amounts of vitamin D appropriate for their age group (Table 21). Vitamin D toxicity the adverse effects of high vitamin D intakes hypercalciuria and hypercalcemia do not occur at these new recommended intake levels. In fact, it is worth noting that the recommended intakes for all age groups are still well below the lowest observed adverse effect level of 50 µg/day and have not yet even reached the no observed adverse effect level of 20 µg/day (33, 48). There are some suggestions in the literature that these outbreaks of idiopathic infantile hypercalcemia may have been multifactorial with genetic and dietary components and were not just due to technical problems with over-fortification as was assumed (49,50). This is all the more cause for concern because hypovitaminosis D is still a problem worldwide, particularly in developing countries at high latitudes and in countries where skin exposure to sunlight is discouraged (51). The vitamin D story: a collaborative effort of basic science and clinical medicine. Induction of monocytic differentiation and bone resorption by 1б,25- dihydroxyvitamin D3. Specific high affinity receptors for 1,25-dihydroxvitamin D3 in Human peripheral blood mononuclear cells: presence in monocytes and induction in T lymphocytes following activation J.
Syndromes
Long term complications Long term complications include: - Chromosomal aberrations in circulating lymphocytes; - Chronic myeloid leukaemia (a single case); - No cancers were found in any of the joints treated medications like xanax aggrenox caps 25/200mg visa. If pain increases during the first days after dose administration treatment strep throat generic 25/200 mg aggrenox caps free shipping, local application of ice can be very helpful symptoms genital herpes aggrenox caps 25/200mg low price. Requirements for a therapy ward Therapy is usually carried out on an outpatient basis medicine quest buy aggrenox caps 25/200mg lowest price. Special precautions Leakage through the needle tract and lymphatic clearance are the major mechanisms whereby radiolabelled colloids escape from joint spaces medicine 911 cheap aggrenox caps 25/200 mg with visa. This cancer is most common in South and South East Asia medications while breastfeeding aggrenox caps 25/200 mg otc, although there are other areas with a high incidence including Mongolia and Latin America. The most commonly identified cause is chronic infection with hepatitis B or hepatitis C. Other contributing factors include alcohol abuse or other causes of cirrhotic liver disease. Treatment options ideally include complete surgical resection and, if the tumour is large, liver transplantation. However, once the tumour is greater than 5 cm and if it is multifocal, the probability of a surgical cure is reduced. It is this combination of growing tumour and failure of the remaining liver that tends to kill the patient. Details of one of the easiest, that of Okuda, which dates back to the middle 1980s, are given in Tables 6. Those with grade 2 disease tend to survive only if their liver disease is stable and if they have a complete surgical resection. The outcome for those with grade 3 disease is poor, with many surviving only a few weeks or months. It is clear that patients in stage 1 may be resectable if they have no impairment of liver synthetic function, and those with grade 3 will not survive even with treatment. Therefore most effort in terms of treatment should be concentrated on patients with stage 1 and stage 2 disease. Radionuclide or other treatment should be offered if the patient is unresectable or if there is residual and/or recurrent disease after resection. Tamoxifen was once held to reduce the rate of recurrence after surgery but once it was tested in a placebo controlled trial there was little evidence to support this view. The cannulation does not need to be precise since the origin of the right hepatic artery will feed the right lobe and likewise the left will feed the left lobe. Nevertheless, there are significant side effects to the treatment that can last for about 10 days after treatment, namely pain, often requiring infusion of opioids, severe nausea and jaundice. Despite these problems, this remains the only form of treatment that can be offered to a wide range of patients. This approach has not reached clinical practice but may be a possibility in patients with disease outside the liver. The other treatments including 131I-Lipiodol require local delivery of the radiopharmaceutical into the cancer via an angiographic catheter. Clinical trials are under way; 200 patients have received treatment, which is under review. It is also essential to decide who (the first key team member) will deal with the patient after treatment and tackle any potential problems that may arise. These occur most commonly because of the condition of the liver around the tumour; in a patient with poor liver function a significant degree of liver failure, requiring expert supportive therapy, may occur during the treatment. The second key team member is a competent radiologist with experience in identifying and cannulating the right and left hepatic arteries. This should be performed with a catheter of a reasonably wide bore such as a 5 French catheter. The type of catheter used will depend on local requirements but should have a Luer lock to enable connection of the syringes carrying the Lipiodol. The present manual merely serves as a guide, and any physician performing these studies should receive specific training in this technique. The fourth key team member is the physicist responsible for the safe handling of the product, monitoring the patient on the ward and calculating the dosimetry. The physical requirements for the administration of 131I-Lipiodol include: (a) (b) (c) A radiopharmacy with a sterile cabinet or a laminar flow cabinet in which the 131I-Lipiodol is diluted; A screening X ray room with real time imaging; A radionuclide therapy room with its own toilet facilities where the patient will need to be isolated for three to six days after treatment; 480 6. Iodine-131 Lipiodol Development of 131I-Lipiodol started in the 1980s and was pioneered by members of a liver cancer team from Rennes, France. Although they were able to demonstrate the efficacy of the method both in open label trials and in a small trial comparing 131I-Lipiodol and Cisplatin-Lipiodol, the mechanism for its utility was not clearly understood. When the cells were bathed in Lipiodol there was a normal cell survival after 24 hours; when bathed in 131I there was again normal survival. However, when bathed in 131I-Lipiodol at three different activities of 131I-Lipiodol, all the cancer cell lines died while the normal hepatocytes had a 90% 24 hour survival. The reason that 131I-Lipiodol does not work in colorectal cancer liver metastases is probably related to the poor blood supply of these metastases in vivo. When comparing 131I-Lipiodol with chemolipiodol, the Rennes group noted that when 1. It was, however, clear that patients in Okuda grade 2 had a very poor prognosis despite treatment. This was confirmed by results from London in which 131I-Lipiodol was compared with Epirubicin-Lipiodol in a total of 70 patients. In the Okuda stage 2 patients, the survival of the London patients was worse in both treatment groups. There was, however, a significant difference in major side effects, these occurring in 15% of the 131I-Lipiodol group, with discharge after three days related to radiation protection issues. In the chemolipiodol group, 70% had major side effects and discharge was after seven days, related to the need for supportive therapy for the patient. The theory for this treatment is that, as the liver starts to regenerate after surgery, microscopic daughter tumours can be stimulated. If these were pre-ablated by 131I-Lipiodol, there would be a lower chance of recurrence. A Hong Kong group working on this question has shown that after 24 months there is a significant increase in both the disease-free interval and the overall survival in those receiving 131 I-Lipiodol compared with age matched controls. Unfortunately the numbers studied were small, and confirmation in a larger group of patients is required. Patient preparation Patients being considered for 131I-Lipiodol must have a full understanding of the risks and possible benefits of the procedure, including the angiographic as well as the Lipiodol therapy. If a biopsy is required, a laparoscopic rather than a transdermal approach is generally recommended. The patient should not have a blocked portal vein and should have a tumour that is deemed non-resectable by a specialist liver surgeon. The patient should be clinically staged using the Okuda staging (or the ChildPugh staging). In patients with a large right lobe tumour that is greater than 50% of the right lobe, evidence should be sought of a shunt, which would allow tracer to pass into the right lung. The patient should have normal clotting and a platelet count of more than 100 000 mm3. Platelet infusions can be given but should be discontinued two hours before the angiogram. Since the Lipiodol very rarely leaves the liver, and given the very high ratio of non-radioactive to radioactive Lipiodol, no blockage of the thyroid is required for this treatment. Pharmaceutical preparation Although it is possible to produce radioiodinated Lipiodol by passing 131I gas through Lipiodol, it is not without danger as the gas is not only radioactive but highly corrosive. This volume is too small for most liver tumours and it is advisable that the 131I-Lipiodol be diluted in non-radioactive Lipiodol, to give a total volume of 612 mL depending on tumour size. If stored in a syringe, a polypropylene variety is recommended since it is important that the syringe does not dissolve in Lipiodol. If in doubt, nonradioactive Lipiodol should be placed in a syringe and the time taken for the plastic to melt measured. Administration the patient should be prepared for angiography in the radiology department. The syringe containing the 131I-Lipiodol is taken to the angiography room in a lead container. The Lipiodol can then be given over a period of three to five minutes via a nondissolvable three way tap, attached between the syringe containing the 131 I-Lipiodol and the Luer lock of the indwelling catheter. The rate should be sufficient to ensure delivery of the dose in five minutes, but not fast enough to cause reflux of the 131I-Lipiodol into the gastroduodenal artery. As it is radiolucent, the distribution of the 131I-Lipiodol can be seen in fluoroscopic examinations. This infusion is performed with a plastic sheet between the syringe and the patient so that any spills will not result in contamination of the patient. The infusion should be completed within five minutes or there is a danger of the catheter dissolving in the Lipiodol. If this starts to happen at any point during the infusion, the catheter should be removed and the infusion of Lipiodol stopped. When the last Lipiodol has been given, the catheter should be flushed with 10 mL saline and gently removed. As is the case with all angiograms, haemostasis is achieved, although the radiologist should not stand close to the liver to do this. Once the patient is removed from the fluoroscopy room, the drapes used on the patient are collected and put in a sealed plastic bag. This is monitored for contamination; if clear the drapes can be laundered, if not they should be stored until the activity is low enough for them to be cleaned. Monitoring of the room for contamination is also performed and any spills cleaned up. Post-procedure care Patients should remain in a supine position for eight hours after an angiogram. Vital signs should be monitored hourly; automatic monitoring devices are ideal for this purpose. After this time, patients may move around, eat and drink normally, and do as they wish within the confines of local radiation protection legislation. There may be some pain and fever 4872 hours after a procedure, which can be treated with pain relievers and anti-pyrogens such as paracetamol. Discharge will depend on the radiation levels allowed for discharge of patients who have received 131I. If more than 15% of the activity has passed into the lungs, this means that there is a significant shunt and re-treatment is not advised. Unless previously irradiated, the chance of radiation pneumonitis is low even at 1. Where there is significant lung uptake, patients should not be re-treated with Lipiodol. If there is any concern about lung radiation pneumonitis, a short two week course of steroids may help. Dosimetry Dosimetric calculations are rendered difficult by the non-homogeneous nature of the tumour and its uptake of 131I-Lipiodol. I-131 iodine lipiodol radiotherapy in the treatment of unresectable hepatocellular carcinoma, Cancer 76 (1995) 22022210. Introduction Percutaneous coronary angioplasty is an established therapeutic modality in the management of atherosclerotic coronary artery disease, although the high restenosis rate of 3050% limits its usefulness. Recoil and remodelling involve the mechanical collapse and constriction of the treated artery. The principal mechanism of restenosis, intimal hyperplasia, is the proliferative response to injury of a vessel wall, which consists largely of smooth muscle cells. A large body of animal investigations and a more limited number of clinical studies have established the ability of ionizing radiation to reduce significantly neointimal proliferation and the restenosis rate. It has been reported in human studies that intravascular radiation after first restenosis inhibits a second restenosis. Various modalities for intravascular radiation based on radiation sources and delivery systems have been proposed. Beta emitters are safe, deposit a large fraction of their energy locally and are preferable to gamma emitters for both operator and patient. Catheter based radiotherapy with beta emitting, nuclide filled balloons provides a safe, technically simple and inexpensive means to deliver therapeutic radiation. The balloon conforms to the vessel geometry in an optimal fashion and naturally locates in the centre of the lumen during inflation. Possible indications include treatment of long lesions, small vessel lesions and any restenotic lesions. Medication Once the patient has been admitted to hospital, the informed consent of the patient must be obtained for administration of the following medications: 488 6. Intervention procedure the intervention procedure has the following steps: (1) (2) (3) Coronary angiography and angioplasty are carried out using standard methods. Preparation of brachytherapy devices A transparent Lucite box is used for shielding the radioactive source during the procedure. The box is wrapped with a transparent vinyl covering and the syringe containing the radioactive source is shielded by a transparent Lucite cylinder. All other unshielded devices containing the radioactive source are manipulated with forceps. The lumen between the radioactive source and the indeflator is filled with mineral oil. The duration of balloon inflation for irradiation is 300600 s depending on radioactive source activity and the size of the balloon. The session is divided between 12 min of inflation and 30 s of deflation for coronary perfusion, adjusted to the tolerance of the patient. The balloon and syringe containing radionuclide are discarded as radioactive waste.
Appropriate investigation and management of hypertension is expected to improve health outcomes symptoms 8 weeks pregnant generic 25/200mg aggrenox caps otc. Determine whether hypertension is refractory/severe medications ok to take while breastfeeding cheap aggrenox caps 25/200 mg visa, prior treatment and response treatment plan for anxiety purchase aggrenox caps 25/200mg without a prescription, sudden dyspnea treatment 02 25/200 mg aggrenox caps, known renal problems treatment xdr tb guidelines purchase aggrenox caps 25/200 mg visa, headaches treatment junctional rhythm discount 25/200mg aggrenox caps, palpitations, sweating, muscle weakness, polyuria. Identify and determine extent of end organ damage; assess cardiovascular risk status of the patient. Examine fundi, heart, peripheral pulses, femoral pulses, lungs, weight, look for bruits, edema. Select anti-hypertensive medication which will not adversely affect concomitant conditions such as diabetes mellitus, asthma, and will benefit congestive heart failure or myocardial ischemia. Communicate the importance of consultation with other health care professionals. Determine factors contributing to non-compliance and discuss possible management strategies. Discuss cost effectiveness of management; select patients in need of specialized care. Outline the effect of cardiac output and systemic vascular resistance on blood pressure. Discuss autoregulation and the eventual consequence of this process on blood pressure and systemic vascular resistance when cardiac output is increased. Objectives 2 Through efficient, focused, data gathering: Diagnose hypertension and pseudo-hypertension; discuss white coat hypertension. Causal Conditions (same as hypertension in younger patients, but if age > 50 years, secondary hypertension becomes more likely) 1. Secondary hypertension Key Objectives 2 Define hypertension in the elderly in a manner similar to younger patients; define pseudo-hypertension and white coat hypertension. Objectives 2 Through efficient, focused, data gathering: Diagnose hypertension and pseudo-hypertension. Recommend treatment for systolic pressure>160 mmHg or>140 mmHg with risk factors such as diabetes or smoking; initiate non-drug therapy. Define the goals of treatment in elderly hypertensive patients and contrast these with the goals for younger patients. These include structural changes (orientation of the laminar unit within the wall, elastin fibre fracture, composition of wall with increased collagen content) along with arterial pulse change, and explain the systolic and pulse pressure elevation in the elderly (elastic properties or diminished compliance of the walls of arteries). List factors contributing to the increased prevalence of hypertension in the elderly. Objectives 2 Through efficient, focused, data gathering: Differentiate non-localizing neurologic symptoms (headache, nausea, vomiting, restlessness, confusion, seizures, and coma) from focal ones due to cerebral hemorrhage or infarct. Once blood pressure control is in place, diagnose the cause of the blood pressure elevation. Discuss advantages and disadvantage of various blood pressure lowering drugs used in malignant hypertension and other hypertensive emergencies. Describe and explain the potential hazards of lowering blood pressure levels below 100 - 105 mm Hg diastolic or>25% of baseline. Explain hypertensive encephalopathy (refers to the occurrence of cerebral edema caused by hyperperfusion when a sudden, severe rise in blood pressure exceeds the capacity of the afferent arterioles to auto regulate). Outline the mechanism of vascular injury when pressure exceeds autoregulation and the increase in pressure is transmitted to arterioles and capillaries, including role of renin-angiotensin. Explain the potential ischemic consequences of an excessive hypotensive response to therapy when autoregulation capacity is exceeded at the lower pressure end of the auto regulatory curve. Chronic hypertension complicates<5%, preeclampsia occurs in slightly>6%, and gestational hypertension arises in 6% of pregnant women. Preeclampsia-eclampsia (new hypertension and proteinuria after 20 weeks gestation) a. Preeclampsia superimposed on chronic hypertension and proteinuria, both present before 20 weeks (severe exacerbation of blood pressure, systolic>180 mmHg, diastolic>110 mmHg, in last half of pregnancy) c. Masked chronic hypertension (persists beyond 12 weeks postpartum) Key Objectives 2 Describe normal changes in blood pressure during pregnancy and define hypertension in pregnancy with these changes in mind. Objectives 2 Through efficient, focused, data gathering: List some risk factors for development of preeclampsia; perform rollover test in at risk patients. Differentiate preeclampsia from pre-existing chronic hypertension and gestational hypertension; differentiate preeclampsia superimposed on pre-existing hypertension from primary preeclampsia. Discuss strategies for the prevention of pregnancy-induced hypertension in at risk patients. List drugs indicated and contraindicated and pressure levels in the management of preeclampsia (systolic? Outline the changes in utero-placental circulation (impaired trophoblast invasion and placental ischemia) that occur in preeclampsia. Outline later changes resulting from placental ischemia such as altered capillary permeability, intravascular inflammatory response, abnormal prostaglandin metabolism, and activation of endothelial cells and the coagulation system. Regardless of underlying cause, certain general measures are usually indicated (investigations and therapeutic interventions) that can be life saving. Myxedema, Addison, liver failure Key Objectives 2 Elicit clinical and laboratory information necessary to diagnose the correct type of hypotension/shock. Objectives 2 Through efficient, focused, data gathering: Obtain history from relatives/medical records including recent complaints/activities, allergies, change in medications, drug intoxication, pre-existing diseases. Conduct an effective plan of management for a patient with hypotension: 2 Outline and conduct the initial management of the acute circulatory disturbance in a patient with hypotension/shock. Determine and perform initial therapeutic interventions specific for the underlying cause of hypotension/shock. Select and evaluate the clinical and laboratory parameters for monitoring a patient with hypotension. Recommend admission to an intensive care unit for patients with shock in need of specialized care or consultation. Outline the effect of cardiac output and systemic vascular resistance on blood pressure and tissue perfusion. Describe the effect of prolonged, severe hypotension on systemic tissue perfusion (results in decreased oxygen delivery, deprivation, and eventual cellular hypoxia). List some derangement of critical biochemical processes (cell membrane ion pump dysfunction, intracellular edema, leakage of intracellular contents, inadequate regulation of intracellular pH) that result from cellular hypoxia. Latex Key Objectives 2 Differentiate anaphylaxis from conditions which are similar such as shock from other causes, other flush syndromes, restaurant syndrome, increased endogenous histamine production, acute respiratory failure syndromes, or non-organic syndromes such as panic attacks or Munchausen syndrome. Objectives 2 Through efficient, focused, data gathering: Perform examination for skin involvement (90% have pruritus, urticaria, angioedema, flushing), upper and lower respiratory tract involvement (50%), shock or conduction disturbances (30%), gastrointestinal or nervous system involvement. Outline rationale for use of epinephrine, antihistamines, steroids, and Я2 agonists in aerosols for respiratory symptoms. Outline the interaction of different immune mediators involved in allergic reactions including leukotrienes, cytokines and other mediators. Invasive (invasive ductal/lobular carcinoma, tubular, medullary, papillary, mucinous) 2. Objectives 2 Through efficient, focused, data gathering: Determine lump location, how discovered, duration, discharge, change in size (with menses/time), past/family history of breast cancer, age of menarche, first pregnancy, menopause, alcohol, hormone replacement (risk for cancer). Examine lump (number, hard/soft, movable/immovable, size, borders), axillae, supraclavicular area. Select women who are at high risk for breast cancer based on age or the presence of other pre-existing risk factors/signs for mammography, family history (genetic screening). List indications for ultrasonography, fine needle aspiration, fine needle aspiration biopsy, and core needle biopsy. Outline the medical and surgical management of patients with suspected breast carcinoma. An appropriate and prompt evaluation is important in order to relieve anxiety, even though breast cancer is not generally considered a medical emergency. It is the responsibility of the primary care physician to be an advocate for the patient throughout the entire process of evaluation of the breast lump. The physician should learn about the proficiency of local consultants in order to communicate these facts to the patient. The patient needs to be followed very carefully, maximizing exchange of ideas at every step of the process until suitable resolution is achieved. Abnormal breast discharge (usually Uni ductal, bloody or serosanguineous) - breast neoplasm, benign or malignant Key Objectives 2 Differentiate between galactorrhea and breast discharge. Objectives 2 Through efficient, focused, data gathering: Determine whether discharge is expressed or spontaneous, unilateral or bilateral, color of discharge, medication use, which patients have menstrual irregularities, infertility, headaches or visual changes, symptoms of hypothyroidism. Select and interpret laboratory and diagnostic imaging in a patient with galactorrhea. Primary gonadal failure (Klinefelter, enzymatic defects in testosterone synthesis, testicular infections, trauma, malnutrition/starvation, renal failure) ii. Inhibitors of testosterone synthesis/action (aldactone, cimetidine, flutamide) iii. Idiopathic Key Objectives 2 Differentiate between gynecomastia and breast carcinoma. Objectives 2 Through efficient, focused, data gathering: Differentiate patients with gynecomastia due to physiologic or pathologic causes; ask about drugs, symptoms of liver/renal failure, hyperthyroidism, impotence, and libido. Diagnose patients with drug-induced gynecomastia who would benefit from withdrawal of the drug. Contrast pathophysiological mechanisms for gynecomastia (absolute increase in free estrogens compared to decreased endogenous free androgens, versus relative increase in free estrogen/free androgen ratio, as opposed to androgen insensitivity). An understanding of the patho-physiology and treatment of burns and the metabolic and wound healing response will enable physicians to effectively assess and treat these injuries. Stabilize the burn patient requiring referral to burn treatment center including stopping further burn injury, covering of burn area, protecting airway, resuscitate (oxygen, intravenous fluids), and provide physiologic monitoring and pain control. Communicate with the burn patients or their legitimate delegates in order to obtain consent or refusal to investigate or treat. Explain the potential outcome of the burn and available options; determine whether the patient can provide the information back to you in a coherent manner. Consult hospital ethics committees about continuing care in patients with burns so extensive that mortality approaches 100%. In patients with severe burns, avoid marginally beneficial investigations or therapies. Describe the local (necrosis, inflammation) and systemic (fluids and electrolytes, hypermetabolism) manifestations of thermal injury. Discuss the unique features of electrical injury in relation to skeletal muscle injury and potential effect on cardiac and renal function. This differentiation by physicians is important for both diagnostic and management reasons. Miscellaneous Key Objectives 2 Although not common, hypercalcemia can cause severe anatomic injury to the kidneys, and if severe, patients may develop hypercalcemic crisis. Formulate a management plan for hypercalcemia consistent with its causal condition. Objectives 2 Through efficient, focused, data gathering, Differentiate hypercalcemia caused by increased intake from that of excess bone resorption. Outline the metabolism of calcium including absorption, various forms of calcium in the blood, deposition, resorption and excretion. Include the various hormones (parathyroid, calcitonin), vitamin D and calcium receptors affecting these processes. Contrast the action of furosemide and thiazide diuretics on renal calcium handling. Hypomagnesemia Key Objectives 2 Calculate a corrected calcium concentration in the presence of hypoalbuminemia before initiating any other investigation (0. List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, 2 differentiation, and diagnosis: Contrast laboratory findings in the various conditions causing hypocalcemia. Objectives 2 Through efficient, focused, data gathering: Diagnose the cause of hypophosphatemia. Conduct an effective plan of management for a hypophosphatemic patient: 2 State that most patients will not require therapy other than repair of the underlying cause. Objectives 2 Conduct an effective plan of management for a hyperphosphatemic patient: Recommend low phosphate diet and phosphate binders (sevelamer hydrochloride, calcium carbonate) if chronic. Serum phosphate concentration is primarily determined by the ability of the kidneys to excrete dietary phosphate. As a consequence, balance is maintained unless the load is acute and excessive (>130 mmol/day). In the community, cardiac arrest most commonly is caused by ventricular fibrillation. As a consequence, operational criteria for cardiac arrest do not rely on heart rhythm but focus on the presumed sudden pulse-less condition and the absence of evidence of a non-cardiac condition as the cause of the arrest. Acquired (associated with ischemic injury from coronary atherosclerosis, hypertension, diabetes mellitus) i. Chest wall trauma Key Objectives 2 this ultimate medical emergency requires immediate treatment. Objectives 2 Through efficient, focused, data gathering: Identify and interpret quickly the signs of impending and actual cardiac arrest. If the resuscitation attempt was not successful, communicate with sensitivity the news of death to family members and discuss the possibility of an autopsy if indicated; if resuscitation is successful, communicate with sensitivity the news to the family and answer all pertinent questions. Demonstrate the techniques of cardiopulmonary resuscitation according to the age of the patient. However, in other situations, most ethicists believe that autonomy takes precedence over beneficence. As a consequence, physicians generally request decisions about resuscitation from patients and their families. This does not mean that physicians should not provide patients and families with their expert opinion on the advisability of the procedure.
Second; After joining the Salafi and gain an understanding of religion there did he know that lie in the conduct of the transaction treatment urinary retention order aggrenox caps 25/200mg on line, is haraam medicine x ed buy discount aggrenox caps 25/200 mg on-line. Third; Once he understands that lie in business transactions it is haraam medications like zoloft discount 25/200 mg aggrenox caps visa, then since that time he was no longer doing the buying and selling process by lying medications prescribed for adhd aggrenox caps 25/200mg low cost. In the books of Hadith medicine 750 dollars purchase aggrenox caps 25/200mg on line, the Prophet Muhammad said: "Sign of the hypocrites that there are three 7 medications that cause incontinence buy 25/200 mg aggrenox caps otc, one of which is a lie". In social life everyday, anyone, did not want to hang out with people who like to lie. Because, when we associate with people who love to lie, then a moment later we are deceived by that person. Economic actors who like to lie to customers, after finding out about the markings that he likes to lie to customers, then customers will eventually leave him. They will not buy or bring their vehicle to be serviced in the garage of the economic actors. Having a sincere intention With sincere intentions, all forms of activity are permissible (mundane work, including trade) turns into worship. As an example: According to an informant named Arwin, An informant named Arwin (building consultant), said that in doing economic efforts we should accustom ourselves to do a dual thing, the first one is expecting the help of God and the second, sincere work. So I do not really target the profits to be thus and so, important work well with two conditions earlier. If the record, there are some important things need to be underlined from the informant the information mentioned above. Therefore, in working every economic agent, is required to fix his intention to actually she worked sincerely for Allah. If the intention of an economic agent is not sincere, then he hopes to get ridla God, love, and His help it become futile. Do not worship because they want to get the position, wealth as much as possible, and so forth. If someone in worship, because it wants to gain position or riches, and so it is, that means that there are strings attached worship in it. Have budi noble character Among the manners referred to in the business world, it is like honesty, an attitude of trust and legowa, fulfill the promise. As an example: An informant named Creator, when I came to the workshop to interview him, the same time there is a prospect that brought the bike come to be done being broken engine in the garage. However, because there are two motors are being repaired engine and unfinished, the informant told the owner of the bike, I just worked alone, so if the motor is already finished my work, new father to take his bike here. But the man replied that: "seng apaapa, beta taru saja motor ini di sini", kalau sudah selesai itu, baru kerja beta punya". Of cases, it can be drawn a few important things: First, the owners do not want to blame when motorcycle unencumbered feeling was long done earlier also. Second, apparently the owner of the shop has a principle of order and regularity in the work that first job to be completed first, then move on to the second job, and so on. Because, sometimes, when I saw the amount of work to be done, mechanic and then worked in a hurry. Fourth, when the quality of the work is good, then the customer will be happy, and the workshop will be sprayed advantage with many enthusiasts who come as customers in the workshop, otherwise if the quality of work is not maintained, then the customer will run one after the other to the garage. Among the good morals is to be consistent in paying debts and tolerance in collecting debts, giving leeway to those who are in debt, then find it difficult to pay for it. Modal the beginning he was just setting up the place, being sold herbal medicine was loaned by a company distributor of the Salafists in Bekasi in debts. When she filed the request a second time, and when he has to pay its debts, it was not enough money to pay off debts that first turns the money is insufficient payment of the total debt first. With his parents reason ill and he had to bring his parents hospitalization at the hospital, he was given the leeway to suspend the payment of some of its debts, with a note later settled upon her request the next item. Based on these cases, it can be seen that, first, between the two parties (distributors and businesses) there is a relationship transaction debts. The first party is the creditor, which in this case is a distributor, being the second party is the party that owes two, in this case are business people. Second, that between the two sides there is an agreement, especially the second time when he filed a subsequent request herbal products, he must repay previous debt. Third, that at the time of the second party to pay its debts, he was experiencing financial difficulties which did not allow him to pay off the entire debt. Difficulties were submitted to the donor accounts, and with the humanitarian and religious reasons, the provider of accounts receivable gives leeway he (the second party) to suspend the payment of some of its debts. The attitude of the first party in accordance with the hadith of the Prophet who said: "He who provide convenience to people who have trouble in this world, God will give him the ease in the hereafter". That, of course, in line with the example of the Prophet, as his saying as follows: "I was sent to perfect noble character". Businesses that kosher An informant named Ari, when I interviewed him about his education, he said he was one of the alumni of the College of Computer Science at Jogja. I asked him: "if he did not think to look for a job in accordance with the educational background. He replied, work was all good, which is important kosher, if managed properly can bring pretty good income. From the experience of the Ari, there are some points of the lessons learned, first, that the output of higher education is not a guarantee that a person get a job in accordance with the level of education. Secondly, there are still people who study in higher education, as they are orientated want to be a Civil Servant. Third, basically any business, if it is lawful and can be managed properly, it will provide benefits for both economic operators concerned. The bad thing is when economic actors want a big advantage and he justified the means in his business. Fourth, A Muslim businessman should not commit offenses only for the pursuit of high profits that make it run on which Allaah and pursuing forbidden by God. Commodity trading is forbidden such as liquor, carcasses, pork, trade usury and the like, will not appease Muslim businessmen honest feelings to his Lord let alone have to throw yourself into all these illicit commerce or make it as a source of business. Accomplishing the rights of people An informant Amir name, (the seller of goods mix), he said that before he joined the Salafists, when he sells, he always reduce the scales, for example, the sugar that was filled in a plastic bag, when weighed usually not enough of one kilogram, but because it was displayed with the form kilogram bags, then people buy with the price of a kilogram (1 kg per bag). Furthermore, he said: "according to Ustadz, if we sell it that way, we essentially take the profits from the venture as if we fill hell fire in the belly". Indeed, often times people do such a fraudulent practice, sometimes followed the method performed by a fellow of economic actors. They usually practice like that, because a lot of gain, regardless of the loss on the other hand that the buyers want big profits. Therefore, I give the scales Muslim businessmen will hasten to fulfill the rights of others, whether it be wages, as well as the debt to a particular party. Avoid all forms of usury and gross transaction An informant, named Komeng, I would advise him to increase their capital by using banking facilities, he said: "do not want to , because we take the credit in the bank flowering. Furthermore, according to him, all the Salafis do not want to loan money in the bank to increase its business ". In Islam, he said, Doing business through various forms of illicit transactions, although enacting looked as kosher and promises many advantages which are basically not allowed by Allah and His Messenger. Do not harm others A Muslim businessman should be a good and respectable competitor. In doing business competition, he still adheres to the rule of "not doing injustice to its competitors, nor avenge injustice competitors to do the same way". He will not play the price of goods, raise and lower prices to the detriment of other traders. Because people who have the opportunity to control the prices of goods, and then he deliberately make the use of certain he will accept the punishment of Allah on the Day of Judgement. A Muslim businessman will not sell items that are still in the process of buying and selling transactions with others. He was always controlled by fair and wise attitude of doing things, because it is the nature of nature. All that is built upon the foundation of true faith and solid In this case, according to Abu Farhan, one of the Salafi cleric in the neighborhood, he said: "I am also a distributor of herbal". In fact, she will be very grateful to get the advantage that it is having a delicious gift of God. To find out how to practice religious teachings understood by Salafists in the field of entrepreneurship, then it can be seen in the characteristics of entrepreneurs conducted by businesses Salafi. As worship, then they should do the job according to the instructions of Allah and His Messenger. Principles they hold dear in entrepreneurship are: First: Sincere solely because of God, not because of any motivation other than Allah; Second: In running the business, they always invoke the aid of God; Third: Entrepreneurship in any field, they always underlying purpose was to obtain the contentment, love and won the help of Allah (Ustadz Abu Farhan and Arwin); Fourth: In entrepreneurship, they avoid all that is forbidden by Allah and His Messenger, both associated with the object (substance) that was traded (substance haraam or not), as well as of procedures, both belonging to usury, nor gharar (deception) which resulted in a losses on the other. For example, the prohibition relating to items prohibited: selling "liquor" or purchase goods, which obviously has known the status of the goods that it was stolen. Clothes they sell only the revealing and worth Bestial the instructions of the Prophet Muhammad. Clothes that are allowed for women is Muslim clothing, which does not accentuate curves and large veiled Therefore, if the pants that cover the ankle, then they do not sell it, because different opinion of the command of the Prophet Muhammad. They also do not sell cigarettes, because for them smoke it in fact does not bring benefits to those who consume them. And because smoking is haraam, then sell cigarettes was haraam; They do not sell television because television for they did not bring a positive impact, even more impressions actually a negative impact for children. Therefore, the houses of their own, none of the members of the Salafi who have televisions. Jamal example, when interviewed about household appliances in the home, whether he has the air "television"? Answered by Jamal: "all members do not have a television dl Salafi his house, because of television flu no avail. Many television shows that can actually damage the mental, moral and religious children. Therefore, he said "none of the members of the Salafi have televisions in his house". And they never buy mobile phones for their children, because even with mobile phones are freely accessible to children, even more dangerous. Related to that principle, then as a seller of electronic goods, Munir (sellers of electronic goods), "only sell goods kitchen wares and home appliances, such as fans, ironing etc"; Based on the phenomenon that I observed, that transaction activity they do is limited at certain times only. When the time for Asr prayer dhuzur and, for example, with their spontaneous stop the activity, because they have to perform prayers in congregation; When I asked about it at Abu Husein Farhan, he said that "prayer approached for their congregation is" mandatory ". Therefore, when the time for obligatory prayer, they must cease all activities in any aspect " Characteristic of them, when it is time for prayer, then all trading activity is stopped, then they prepare leading to the mosque to pray. Therefore, when the midday or Asr prayer time, they usually shut down its trading businesses, they also do not open their businesses on Fridays. If possible, they are better off borrowing to fellow members of the Salafi want to borrow in the bank. But until now no one among those who borrow money, despite of fellow Salafi themselves to increase their capital. The reason is, to borrow money to raise capital, it is possible for one may be considered good, but for me, will increase the burden of debt. Let the little capital, if managed well, God willing, will evolve as well, said Usman. They prioritize the quality of work; Therefore, if there is a job offer that would burden them / interfere with another job, although there are still a lot of work that is in the process of settlement, then the offer should be rejected, even though the pay is more expensive than the work being carried out. As an example case, Kohar for example; she mechanic motors (special loading and motorcycle engines); when I intended to interview him, at the same time there are people coming bring the bike then consult with Kohar, it turns out that there are problems motorcycle on the machine to be repaired (unloaded). Hearing that, Kohar replied: "no, I do not want to receive; this finishes later (two motors) first then you bring it comes motto ". My suggestion was answered him by saying: "I do not want to be a burden, I want to focus on doing two motors this first". Hear answers like that, I also understand that this Kohar want to keep the quality of his work, he does not want to interfere with the motor load is concerned, because it might work carelessly. In improving their understanding of the various issues to Islam, then every night they follow the teachings (study groups) in the mosque after maghrib prayers. It is special for the father, were to mothers, usually study conducted in the assembly hall of the mother. Second, in addition, according to Farhan, Pillars of Islam was not only four (Shahada, prayer, fasting and alms) only, but there are five, namely Hajji for those who can afford. Thirdly, the exception of the nuclear family, we also have parents who require the cost of living and so on. We are aware that all around us, there are still many poor people who need our helping hand. The suggestion will increase to mandatory when a person sleeps in a state of satiety were neighbors in a state of very hungry. This means that we are obliged to issue rights of poor people were then given to those who deserve it. Seventh, In a hadith, the Prophet said that "the sustenance that Allah gave to the rich, in fact thanks to the prayers and the sincerity of the poor people". That the Salafi understand the system and economic activity is an integral part of religious teachings. The formation of the economic ethos in Islam is a religious moral values synergy with the rationality of the calculation of profit and loss (from the viewpoint of Islam), so there is a balance between this world and the hereafter. That was their motivation for entrepreneurship is in the context of worship to God, both in upholding the rights of children, wives, and parents, the dluafa (needy, poor). With the principle of the worship they want to win the love, mercy and help of God. Ensiklopedi Alquran: Tafsir Sosial Berdasarkan Konsep- Konsep Kunci, Jakarta: Paramadina. Mahmud Tang: Faculty of Social and Political Sciences, University of Hasanuddin, Makassar, Indonesia.
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