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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Glenn M. Chertow, MD, MPH
Small amounts of vanadium are used in making rubber hypertension jnc 8 summary dipyridamole 100 mg with amex, plastics blood pressure medication micardis order 25mg dipyridamole overnight delivery, ceramics blood pressure average calculator cheap dipyridamole 100mg with visa, and other chemicals blood pressure x large cuff dipyridamole 100mg visa. Cooper Environmental Services 32 Exposure: Vanadium exposure can occur through eating foods containing vanadium arrhythmia research technology stock discount dipyridamole 100 mg with visa, higher levels are found in seafood; breathing air near an industry that burns fuel oil or coal; these industries release vanadium oxide into the air; working in industries that process it or make products containing it; breathing contaminated air or drinking contaminated water near waste sites or landfills containing vanadium blood pressure levels in adults generic dipyridamole 100 mg visa. Vanadium is not readily absorbed by the body from the stomach, gut, or contact with the skin. Small amounts of vanadium compounds are found in air where there is no known anthropogenic source; such concentrations are found to be in the range from 0. Urban sites may have vanadium levels as high as 164 ng/m3, while industrialized urban centers with a high consumption of residual fuel oil may have maximum levels up to 1,300 ng/m3 (range of 4501,300 ng/m 3). Short-term Health Effects: Breathing high levels of vanadium may cause lung irritation, chest pain, coughing, and other effects. Vanadium is considered a metal of concern, particularly due to its ability to produce reactive oxygen species (Chen and Lippmann 2009). Since vanadium is poorly absorbed from the gastrointestinal tract, inhalation exposures potentially pose the greatest risk. Concentrations of V2O5 exceeding 56 mg V/m 3 have resulted in local respiratory effects; other workers exposed intermittently to 56 mg V/m 3 showed no evidence of intoxication. Long-term Health Effects: Workers exposed to a range of vanadium pentoxide dust levels for as little as 1 day or as long as 6 years show mild respiratory distress, such as cough, wheezing, chest pain, runny nose, or sore throat. One study of chronically-exposed workers showed increased neutrophils in the nasal mucosa. Zinc has many commercial uses, such as coatings to prevent rust, in dry cell batteries, and mixed with other metals to make alloys like brass, and bronze. Common zinc compounds found at hazardous waste sites include zinc chloride, zinc oxide, zinc sulfate, and zinc sulfide. Zinc compounds are widely used in industry to make paint, rubber, dyes, wood preservatives, and ointments. Zinc is the fourth most common metal in use, trailing only iron, aluminum, and copper with an annual production of about 10 megatons. The Cooper Environmental Services 33 production for sulfidic zinc ores produces large amounts of sulfur dioxide and cadmium vapor. Smelter slag and other residues of process also contain significant amounts of metals. Exposure: Zinc is an essential trace element, necessary for plants, animals, and microorganisms. It is typically the second most abundant transition metal in organisms after iron and it is the only metal which appears in all enzyme classes. Some zinc is released into the environment by natural processes, but most comes from human activities like mining, steel production, coal burning, and burning of waste. Depending on the type of soil, some zinc compounds can move into the groundwater and into lakes, streams, and rivers. Most of the zinc in soil stays bound to soil particles and does not dissolve in water. Humans are exposed to zinc through drinking contaminated water or a beverage that has been stored in metal containers or flows through pipes that have been coated with zinc to resist rust; eating too many dietary supplements that contain zinc; and working in any of the following jobs: construction, painting, automobile mechanics, mining, smelting, and welding; manufacture of brass, bronze, or other zinc-containing alloys; manufacture of galvanized metals; and manufacture of machine parts, rubber, paint, linoleum, oilcloths, batteries, some kind of glass, ceramics, and dyes. Ambient Air Concentrations: the average vanadium concentration measured in 13 cities across the U. Harmful effects generally begin at levels 10-15 times higher than the amount needed for good health. Large doses taken by mouth even for a short time can cause stomach cramps, nausea, and vomiting. Inhaling large amounts of zinc (as dusts or fumes) can cause a specific short-term disease called metal fume fever. Acute exposure to zinc oxide can result in coughing, substernal pain, upper respiratory tract irritation, rales, chills, fever, nausea, and vomiting. Zinc chloride fume is an irritant of the eyes, skin, mucous membranes, and lungs in humans. The signs and symptoms of acute exposure to zinc chloride fume include conjunctivitis, irritation of the nose and throat, hoarseness, cough, dyspnea, wheezing, rales, rhonchi, chest tightness and/or pain, nausea, vomiting, epigastric pain, listlessness, lightheadedness, and a metallic taste in the mouth. Long-term Health Effects: Excessive concentrations of zinc taken on a long-term basis can cause anemia and decrease the levels of good cholesterol. Chronic exposure to zinc oxide by skin contact may result in papular-pustular skin eruptions in the axilla, inner thigh, inner arm, scrotum and pubic areas. Cancer Risk: Epidemiologic studies of zinc refinery workers found no correlation between industrial zinc exposures and lung or other types of cancer. Research was clearly beginning to show that particulate pollution was associated with respiratory system episodes, whereas no connection was apparent for other air components such as ozone and sulfur dioxide (Braun-Fahrlander 1992). Clearly, epidemiological data demonstrates a significant increase in pneumonia, chronic obstructive pulmonary disease, and other respiratory-inflammation-induced deaths associated with high air pollution days (Schwartz and Dockery 1992). Exposure to metals in the air is capable of causing a myriad of human health effects, ranging from cardiovascular and pulmonary inflammation to cancer and damage of vital organs (Utsunomiya 2004). The toxicity of particulate matter, in particular the fine and ultrafine particles (those particles smaller than 2. Furthermore, a significant segment of this population also lives in the vicinity of metals sources, such as waste incinerators, metal processors, metal fabrication, welding, etc. Levels such as these would prompt wearing respiratory personal protective equipment in Cooper Environmental Services 35 an industrial setting, yet these levels were found near not only unprotected members of the general public, but children, who are more sensitive to elevated airborne metals. Natural emissions are mainly from volcanism, wind erosion, as well as from forests fires and the oceans (Nordberg 2007). Specifically, the combustion of fossil fuels constitutes the principal anthropogenic source for beryllium, cobalt, mercury, molybdenum, nickel, antimony, selenium, tin and vanadium. Fossil fuel combustion also contributes to anthropogenic release of arsenic, chromium, copper, manganese and zinc. In addition, a large percentage of arsenic, cadmium, copper, nickel and zinc are emitted from industrial metallurgical processes. Exhaust emissions from gasoline formerly contained variable quantities of Lead, Copper, Zinc, Nickel and Cadmium. Several independent groups of investigators have shown that the sizes of the airborne particles determine the potential to elicit inflammatory injury, oxidative damage, and other biological effects (Costa and Dreher, 1997; Lippmann, 2006; Ghio et al. The particle size distribution of an aerosol will also determine the deposited fraction of inhaled particles in the various regions of the respiratory tract (Oller 2010). Once inhaled, these particles can affect the heart and lungs, travel throughout the body, deposit in organs, penetrate cell membranes, and cause serious health effects (Adachi and Buseck 2010). These particles can be directly emitted from sources such as forest fires, or they can form when gases emitted from power plants, industries and automobiles react in the air. These particles can be further defined with reference to relevant health effects for various regions, as described by Nieboer et al. According to current human health research, we now know that free radicals similar to those in cigarettes are also found in airborne fine particles and potentially can cause many of the same life-threatening conditions (Dollemore 2008). A metallic particle in contact with lung tissue/cells involves the release of metal ions into the biological system (Midander 2007). Fine and ultrafine particulate matter have the longest residence time in the atmosphere (~100 days), which allows for a large geographic distribution (Utsunomiya 2004). Ultrafine particles are known to have increased solubility, as compared to larger size particles of the same composition because of the increased surface-to-volume ratio for smaller particle sizes (Navrotsky 2001). These consequences demand to give priority to the chemical characterization of the fine and ultrafine fraction of airborne particles to understand their possible implication to health effects (K. Ionic forms of metals will be most bioavailable and therefore most likely to affect cells and organs beyond their deposition sites in the lung airways (Lippmann 2010). A study in the Utah Valley looked at the effect of metal, in particular transition metal, removal on the toxicity of airborne particulate matter (Molinelli et al. This study was prompted by human health data discovered following the closure of an open-hearth steel mill over a year in1987 (Pope 1989); respiratory disease and related hospital admissions were reduced significantly and increased upon reopening (Dye et al. Generally speaking, the extracts that were stripped of their transition metal content lost their potency to elicit inflammatory responses in the lung. A similar effect was found in Redcar, England when a steel plant was closed temporarily. Of metals analyzed, iron was most abundant in the total and acid extract, while zinc was the most prevalent metal in the water-soluble fraction. After exposure, significant increases in heart rate and heart rate variability were found on 14 of the 103 days. A back trajectory analysis of the weather patterns on all 14 of these days demonstrated a wind from the northwest. It was then discovered that the air mass passed by the largest nickel refinery plant in North America, located in Sudbury, Ontario, thus suggesting a source for the observed changes in heart rate and heart rate variability. Metals in the water-soluble fraction of air pollution particles decrease whole-blood coagulation time. These metals can potentially contribute to procoagulative effects observed following human exposures to air pollution particles (Sangani et al. Additional data not only extrapolates animal toxicity testing to humans, but also provides evidence linking transition metals directly to human health effects. Groups of particular interest include the elderly, pregnant women, those with heart and lung disorders, and young children. Researchers found that children exposed to nickel and vanadium in the air were more likely to wheeze. Michelle Bell, a Yale University environmental health scientist, looked at respiratory and cardiovascular hospital admissions of patients 65 years or older and found that counties with higher nickel, vanadium, and elemental carbon were found to have higher risk of hospitalizations associated with short-term particulate exposure (Konkel 2009). Table C-5 presents a chronological summary of studies that implicate metals as significant contributors to human health effects. Research shows that special attention must be taken with Ni and other transition metal concentrations, because of their high potential bioavailability. Nickel is important, in particular, mainly due to the high solubility of the chemical forms of Ni in the finest particles (Fernandez-Espinosa 2004). The olfactory system forms a direct interface between the nervous system and the external environment (Aschner et al. The olfactory (nasal) neuron can provide a pathway by which foreign materials can reach the brain (Bondier et al. The metals with potential to Cooper Environmental Services 42 travel through the olfactory nerve are aluminum, cadmium, cobalt, mercury, manganese, nickel, and zinc. Two metals that have recently been shown to be particularly toxic through the olfactory nerve transportation pathway are cadmium and manganese. As in inhalation studies, results of investigations into particle size uptake of manganese (Fechter et al. Manganese species and solubility also have an influence on the brain distribution of Mn in rats (Normandin et al. Although both metals are considered dangerous via the olfactory route, manganese is also capable of traveling along secondary and tertiary neurons, whereas cadmium is not (Aschner et al. Most of the epidemiological evidence for this has been gathered from high occupational exposures in the past (Knaapen et al. When comparing the levels considered to adversely affect human health at a community level versus levels permissible in an occupational setting, it is clear that a large discrepancy exists. In addition, extreme caution must be exercised with such metals as lead and beryllium as the U. Even more recent data, such as research being performed by Morton Lippmann and Chi Chen, suggests that nickel at even the lowest ambient levels has the potential to cause adverse health effects (2009). The concentration, composition, and size of suspended particulate matter at any given site are determined by such factors as: meteorological properties of the atmosphere, topographical influences, emission sources, and particulate parameters such as density, shape, and hygroscopicity (Fang et al. Countries without the regulatory infrastructure to properly monitor and reduce air toxics are particularly susceptible to elevated levels of airborne metals in ambient air. Some of these countries do not have high enough amounts of industrial activity to incite human health risks, such as in some African countries; however, other countries, such as Mexico and China, have levels of air toxics introduced by industrial activity far above what would be considered "safe" in more regulated systems. Significant health impacts from metal-containing air pollution have been reported in several developing countries. Bushfires in Singapore created significant increases in the concentration of Zn, Fe, and Cu. As a result, people seeking treatment for respiratory-tract infections went up 25% and asthma cases went up 29% (Karthikeyan et al. In Africa, an important source of direct human exposure to high levels of mercury is artisanal gold mining and processing. Exposure to vaporized mercury occurs during burning to separate gold from the gold-mercury amalgam. The release of mercury occurs within the breathing zone of workers who are typically not equipped with personal protective equipment (Nweke and Sanders 2009). Physical speciation of lead showed Cooper Environmental Services 44 that the major risk for health was from fine particles less than 2.
Lifelong follow-up is required and nephronsparing surgery employed in view of the recurrent nature of the disease blood pressure chart org generic dipyridamole 25mg visa. The classic presenting triad of loin pain blood pressure medication what does it do cheap dipyridamole 100 mg fast delivery, a mass and haematuria only occurs in about 10 per cent of patients blood pressure recommendations generic dipyridamole 25 mg visa. She has had an intermittent urinary stream for the last 24 h and complains of pain in the suprapubic region on voiding arterial duplex effective dipyridamole 100mg. Examination On examination of the abdomen there is some minor suprapubic tenderness blood pressure medication vitamins discount dipyridamole 100 mg overnight delivery, and a palpable bladder hypertension 32 years old cheap dipyridamole 100mg on-line. The patient should be resuscitated with intravenous fluids and a blood crossmatch taken. Blood clots can cause urethral obstruction so a three-way catheter should be inserted and the bladder initially washed. Urine cytology should also be sent to detect the presence of abnormal cells in the urine 142 Urology (once the haematuria has settled and the irrigation has stopped). The patient will require a urinary tract ultrasound to image the upper tracts and a flexible cystoscopy when the urine is clear. If these two last tests are negative, an intravenous urogram should be organized to exclude ureteric pathology. On questioning, he reports a worsening urinary stream over the last 6 months, together with increased nocturia. Examination On examination of the abdomen, there is a palpable suprapubic mass, which is nontender and dull to percussion. Acute and chronic retention are usually differentiated by the presence or absence of pain. Acute retention is painful, unlike chronic retention, when the bladder accommodates the increase in volume over time. A recent history of bedwetting is associated with a picture of chronic retention with overflow incontinence which usually occurs at night. A urethral catheter should be inserted and the colour of the urine and residual volume noted and recorded in the notes. If the urine output is greater than 250 mL/h, intravenous fluid replacement in the form of 0. His renal function needs to be monitored to assess a response to treatment, and if not improving early consultation with the renal physicians is recommended. Constipation or urinary tract infection can compound the problem and they need to be treated accordingly. Often the patient has a history of lower urinary tract symptoms, which in this case are both obstructive and irritative in nature. Features that suggest carcinoma of the prostate include hard gland, loss of normal contour (craggy prostate), loss of the midline sulcus, palpable nodule and a fixed gland. In cases of benign prostatic hyperplasia, the prostate feels enlarged and smooth as in this case. He tells you it is uncomfortable while walking, and describes a dragging sensation. Examination On examination a 3 cm palpable lump is felt on the inferior aspect of the right testicle. The rest of the testis and epididymis can be felt separately, and the mass does not transilluminate. A complete physical examination of the patient should be performed as there is potential for secondary deposits in the chest and brain. Lymphatic spread is to para-aortic lymph nodes in the abdomen rather than inguinal nodes in the groin, which only occur if the tumour erodes and involves the scrotal skin. All these markers are useful in monitoring disease progression and recurrence following various treatments. A computerized tomography scan of the chest and abdomen is required for staging purposes. When examining a lump in the scrotum it is important to determine whether you can get above the swelling. She also has a history of essential hypertension and she had a hysterectomy for menorrhagia when she was 40 years old. She is the sole carer for her husband who suffered a stoke 2 years ago and is bed-bound. The correct definition of this injury comes from Abraham Colles in 1814, who originally described a low-energy extra-articular fracture of the distal radius occurring in elderly individuals. The typical mechanism of injury has been given in this scenario, which is a fall on the outstretched hand resulting in forced extension at the wrist. In this injury it is not uncommon to develop symptoms associated with compression of the median nerve. Adequate analgesia can be provided locally with lidocaine injected into the fracture site, a so-called haematoma block, or regional anaesthesia is used. The latter is thought to provide better pain control as well as allowing more accurate fracture reduction and a better functional outcome. To achieve fracture reduction the distal fragment is further dorsally angulated in order to disengage it from the fracture site. Longitudinal traction is then applied while trying to manipulate that fragment in a distal and volar direction, thereby restoring the normal position and length to the radius. X-rays should be performed to check that there has been an adequate fracture reduction. The patient should be brought back to the fracture clinic in a few days in order to complete the cast and check that the fracture has not slipped out of position. This case also illustrates the secondary consequences of significantly injuring a limb. It is unlikely that this woman will be able to cope at home, looking after her incapacitated husband. Over the last 3 months she has required increasing amounts of painkillers to control the pain. The pain gets worse throughout the day particularly if she has been very active, and it often keeps her awake at night. There is no history of significant trauma and she denies any other joint symptoms. She is otherwise fit and does not take any regular medication other than analgesics. Examination Examination of her left knee demonstrates a moderate swelling with a palpable effusion. The hip and ankle joints both have a full pain-free range of movement, and examination of her back is normal. In this X-ray there is loss of the joint space on the medial side and periarticular sclerosis (arrow in. Primary osteoarthritis is a common degenerative condition predominantly affecting the elderly population. Radiological evidence of osteoarthritis is common, with 80 per cent of individuals over 80 years demonstrating some evidence of the condition. The symptoms of the disease do not, however, directly correlate with the radiological findings. A significant number of individuals remain symptom free despite radiographs showing extensive joint destruction. The commonest symptoms are pain, a reduction in mobility, and deformity of the affected joint. It is important when assessing the patient to examine the joints above and below as referred pain must be considered. He was playing squash when he suddenly felt as though he had been hit on the back of the ankle. This picture demonstrates normal plantar flexion with calf compression on the right leg. Failure of plantar flexion indicates that the patient has ruptured their Achilles tendon. The history of sudden pain affecting the calf during sporting activity is typical. Other examination findings may include a palpable gap in the Achilles tendon and an inability to actively plantar flex the ankle. The latter feature may be misleading, as the deep flexors of the foot can compensate for this movement. An ultrasound scan can confirm a gap in the Achilles tendon when the diagnosis is in doubt. Non-surgical management involves immobilizing the leg in a plaster of Paris cast, with the foot initially in full plantar flexion. While this avoids the risks of surgery, it delays functional rehabilitation and results in a greater risk of the tendon re-rupturing. The tendon can be repaired surgically, which is thought to result in a stronger tendon repair. This may be more appropriate for patients who require a greater level of sporting activity. Her friend says that they had been out drinking and that she had fallen off a 4-foot wall landing directly on her left knee. Her knee swelled up immediately and she has not attempted to walk since the injury. The hip and ankle joints are unremarkable, and the pedal pulses and foot sensation are normal. It is possible, however, to sustain a similar injury by an indirect mechanism, such as by vigorous jumping which leads to rapid flexion of the knee against a fully contracted quadriceps muscle. An indirect injury tends to result in less displacement and comminution of the fracture. The upper border is connected to the quadriceps tendon and the lower pole is connected to the patella tendon, which inserts into the tibial tuberosity. It is, therefore, very important when examining knee injuries to ensure the extensor mechanism is intact by feeling for any palpable gap and by getting the patient to actively extend the knee. If the extensor mechanism is disrupted and/or there is a greater than 3 mm gap in the fracture site, surgical fixation is necessary. If the extensor mechanism is intact and there is a small gap in the fracture site, more common with the indirect injuries, then a cylinder plaster of Paris cast is more appropriate. It is worth noting that a bipartite patella occurs in 1 per cent of the population, and it is not uncommon for patients to be misdiagnosed with a patella fracture. The diagnosis of a patella fracture is supported if there is a plausible mechanism of injury and the appropriate examination findings are present. She has previously had an appendicectomy and is known to have had mild attacks of asthma. She takes salbutamol and beclometasone regularly, and she is allergic to penicillin. Shoulder dislocations are the commonest joint dislocation, accounting for nearly half of all dislocations. Posterior dislocation is much less common and is typically secondary to either an epileptic fit or electric shock. The commonly used views are the anterior-posterior view in combination with either an axillary or scapular view. The axillary view has the advantage of showing the glenoid cavity, which may pick up any associated fracture. An assessment of both the distal vascular and neurological function must be made in any patient with a severe limb injury. The close relationship of the shoulder joint to the brachial plexus makes a nerve injury more likely. The incidence of axillary nerve neuropraxias following anterior shoulder dislocation is quoted at up to 10 per cent. The majority of anterior shoulder dislocations can be replaced by closed reduction. This will relax the shoulder musculature that is typically in spasm resisting any joint movement. After successful reduction, the patient should be able to touch the contralateral shoulder tip.
Patients in whom a diverticular perforation is suspected may require a laparotomy blood pressure medication for kidney transplant patients purchase dipyridamole 25 mg mastercard. Barium enema will confirm the diagnosis of diverticular disease blood pressure guidelines by age cheap 25 mg dipyridamole otc, but this should not be performed in the acute setting blood pressure medication effects libido cheap 100 mg dipyridamole amex. Once an acute episode has resolved exo heart attack order dipyridamole 25mg line, the patient should be commenced on a high-roughage diet to reduce the incidence of further attacks pulse pressure over 70 buy cheap dipyridamole 25 mg on-line. Haemorrhoids are congested vascular cushions containing dilated veins and small arteries understanding prehypertension buy dipyridamole 100mg online. A low-fibre diet results in straining with defecation, causing engorgement of the tissue. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause haemorrhoidal problems. If there is any doubt as to the cause of bleeding, especially in the older patient, a flexible sigmoidoscopy or full colonoscopy should be carried out. Patients should be advised to take plenty of fluid, fruit, fibre and laxatives to keep the stool soft and to avoid straining. Treatments include phenol injections into the submucosa above the haemorrhoid and/or rubber-band ligation. Past history includes a fractured femur 8 years ago and an appendicectomy at the age of 20 years. Digital rectal examination is unremarkable and rigid sigmoidoscopy to 20 cm does not show any abnormality. A colonoscopy would help to delineate the pathology within the colon and would allow biopsy to provide a tissue diagnosis. Right-sided lesions can present with iron-deficiency anaemia, weight loss or a right iliac fossa mass. Left-sided lesions present with alteration in bowel habit, rectal bleeding, or as an emergency with obstruction or perforation. Adjuvant radiotherapy is given for rectal cancer either pre- or postoperatively to prevent local recurrence. He also describes an intermittent colicky lower abdominal pain that occurs most days and is relieved by opening his bowels. A biopsy is taken and is reported as showing non-caseating granulomata with transmural inflammation of the bowel mucosa and frequent lymphoid aggregates in the subserosa. If the disease only affects the distal colon, topical (suppository/enema), steroids can be used. She had an appendicectomy at the age of 16 years with no other past history of note. Digital rectal examination shows soft stool with a small amount of bright red blood and mucus mixed in. Rigid sigmoidoscopy to 20 cm from the anal verge reveals bright red, friable rectal mucosa. Microbiology can analyse the sample for an infective cause or test for Clostridium difficile toxin in cases of pseudomembranous colitis. Ulcerative colitis occurs most commonly between the ages of 15 and 40 years, and usually involves the rectum then progresses more proximally. In cases of severe colitis, nutritional support and correction of electrolyte disturbances may also be required. If diarrhoea is particularly problematic, agents such as codeine phosphate and loperamide may be considered. The potential for malignant change is relatively high with long-standing ulcerative colitis and the risk in patients with pancolitis is approximately 3 per cent after 10 years. The risk of developing mucosal dysplasia increases with time, and surveillance should commence after 7 years. If dysplasia is detected, the patient should undergo total colectomy with end ileostomy. She has diabetes and is concerned about her blood sugars as she has not been able to eat a normal diet since the pain started. On examination of the abdomen, she is found to have tenderness in the right upper quadrant, which is worsened by placing two fingers beneath the tip of the ninth costal cartilage during inspiration. A palpable mass, caused by inflammation and adherent omentum, is present in up to 40 per cent of patients with cholecystitis. An abdominal ultrasound should be requested, which should confirm a thickened gallbladder wall with surrounding free fluid, supporting the diagnosis. The majority of episodes of acute cholecystitis settle with analgesia and antibiotics. For patients with recurrent episodes, or if the symptoms fail to settle despite conservative treatment, many centres now perform surgery during the same hospital admission. If this is not appropriate, then elective cholecystectomy can be carried out at an interval of approximately 6 weeks, after the inflammation has settled. Acute cholecystitis can lead to a build up of infected bile within the gallbladder lumen, resulting in an empyema. Patients are at increased risk if they are diabetic, immunosuppressed, obese or have a haemoglobinopathy. Initial decompression may be accomplished under radiographic guidance or via intra-operative laparoscope-guided needle drainage. Elderly patients with significant comorbidities must be treated aggressively with antibiotics and early decompression, as the resulting sepsis can be life-threatening. He is not on any regular medication, but admits to drinking in excess of eight cans of lager a day. The history and macrocytosis would suggest this is of alcoholic aetiology, but it is important to ultrasound the abdomen to exclude gallstones as the cause. The pain is typically severe and radiates through to the back, due to the retroperitoneal position of the pancreas. Vomiting is also a common feature, as a result of gastric stasis caused by the local inflammation. Twenty per cent of cases of pancreatitis have a normal serum amylase, particularly when there is an alcoholic aetiology. This should be done with an erect chest X-ray, which would show free subphrenic air in 90 per cent of cases. The serum amylase can be elevated in a patient with gastric perforation due to the systemic absorption of pancreatic enzymes from the abdominal cavity. They require prompt fluid resuscitation, a urinary catheter and central venous pressure monitoring. If there is evidence of sepsis, the patient should receive broad-spectrum antibiotics. An ultrasound may demonstrate the presence of gallstones, biliary obstruction or a pseudocyst. Computerized tomography is used to confirm the diagnosis a few days after the onset of the symptoms, and can be used to assess for pancreatic necrosis. He had been spiking temperatures during the afternoon and had increasing right-sided abdominal pain. You notice he has a yellow discolouration of the skin and sclera, and abdominal examination reveals that the maximal tenderness is in the right upper quadrant. The most common causative organisms are Escherichia coli, Klebsiella, Enterobacter, enterococci, and Group D streptococci. Blood cultures should be taken on at least two separate occasions from two different sites, and broad-spectrum antibiotics should be commenced. Imaging studies are essential to confirm the presence and cause of the biliary obstruction and also help to rule out other conditions. Greater than 7 mm indicates obstruction, although the bile duct diameter increases in the elderly and after cholecystectomy. The obstruction can then be relieved by removing the stone or inserting a biliary stent. Ulcers situated on the anterior duodenal wall perforate into the abdominal cavity resulting in free intraperitoneal gas. Posteriorly, ulcers erode into the gastroduodenal artery, which is more likely to result in bleeding. However, 10 per cent of perforations will still not demonstrate free gas on an erect chest X-ray. The patient requires prompt fluid resuscitation, with central venous pressure monitoring and hourly urine output measurements. Nasogastric intubation, broad-spectrum antibiotics and analgesia should also be given. Postoperatively, patients should receive Helicobacter pylori eradication therapy and should continue on a proton pump inhibitor. The recommended weekly intake of alcohol is 28 units per week for males and 21 units for females. He will require follow-up with his general practitioner to help modify his lifestyle to prevent relapse. During her descent the horse kicked her, and she is now complaining of generalized abdominal pain and left shoulder-tip pain. On examination of the abdomen, there is an abrasion on the left side beneath the costal margin with tenderness in the left upper quadrant. The patient is given 2 L of intravenous fluids and the blood pressure improves to 130/90 mmHg. On returning to the emergency department the patient becomes increasingly agitated. The nurse informs you that her blood pressure is now 80/60 mmHg and the pulse rate is 130/min. Unstable patients suspected of splenic injury and intra-abdominal haemorrhage should undergo exploratory laparotomy and splenic repair or removal. Blunt trauma, with evidence of haemodynamic instability which is unresponsive to fluid challenge, should be considered to be a life-threatening solid organ (splenic) injury. Those patients who respond to an initial fluid bolus, only to deteriorate again with a drop in blood pressure and increasing tachycardia, are also likely to have a solid organ injury with ongoing haemorrhage. Diagnostic peritoneal lavage may be a valuable adjunct if time permits and multiple other injuries are present. Those patients who undergo splenectomy have a lifetime risk of septicaemia and should receive immunizations against pneumococcus, haemophilus and meningococcus. The patient has had a 6-week history of constant right-sided abdominal pain which radiates up under the ribs and into her right shoulder. She did not receive any chemoradiotherapy postoperatively and there was no evidence of metastatic disease at the time of her operation. Examination There is no evidence of pallor, jaundice, clubbing or lymphadenopathy. Examination of the abdomen reveals a palpable irregular liver border about 3 cm below the costal margin. There are no other palpable masses in the abdomen and digital rectal examination is normal. It is important to send a full blood count as she has been feeling tired recently and may be anaemic. The patient should be brought back to the clinic, with her relatives, to discuss the options for further management. The number of metastases in the liver and their distribution would make local resection unfeasible. He has been suffering from heartburn for 5 years and is now complaining of difficulty in swallowing. He says he has to chew his food more than he used to and finds it difficult to eat meats. Symptoms of heartburn and regurgitation may improve as a stricture develops and provides a barrier to further episodes of reflux. Treatment should be initially by dilatation, followed by medical or surgical treatment of the underlying reflux disease. Even small degrees of luminal dilatation can produce significant improvements in symptoms. If frequent dilatations are required despite acid suppression, then surgery should be considered. The intestinal metaplasia of the distal oesophageal mucosa can progress to dysplasia and adenocarcinoma. The patient should then have endoscopic surveillance to detect dysplasia before progression to carcinoma. Causes of dysphagia Outside the wall Lymph nodes Goitre Enlarged left atrium Lung cancer Thoracic aneurysms Pharyngeal pouch In the wall Oesophagitis Stricture Motility disorders. He initially presented to his general practitioner with increasing difficulty in swallowing. Over the preceding months he has required a soft diet and is now only able to tolerate thin fluids.
This movement continues up the back coenzyme q10 high blood pressure medication cheap dipyridamole 100 mg online, the shoulders blood pressure by age dipyridamole 100 mg amex, the neck blood pressure chart kaiser safe dipyridamole 25 mg, and finally up on the head until you reach the level just above the ears heart attack 20s dipyridamole 100 mg line. Standing at the head of the table heart attack one direction lyrics discount 100mg dipyridamole, place both hands on either side of the spine at the waistline as close together as you can blood pressure rates chart discount 25mg dipyridamole with visa. Drag your palms with light pressure up the spine, allowing your fingers to trail behind like the train of a wedding dress. Continue this motion through the neck and head, allowing your hands to gently continue the motion lightly to the crown of the head. Place your hands at the waistline again, but separate them about two inches (this is Zone 2). However, once your hands reach the shoulders, turn the fingertips in, drag your palms out along the shoulder blade, rotate the fingers out, and slide them under the front of the shoulders as 3 0 Ess entiallife. Repeat for Zones 3, 4, and 5 as you did for zone 2, starting with your hands on the zone just outside the previous one. Perform the Auricular Stress Reduction on both ears at the same time while the client is laying face down. Place your hands on the back at the waistline with your thumbs on the muscles running directly on either side of the spine. In a circular motion with your thumbs, massage the muscle on either side as you walk up the spine in an alternating fashion until you reach the back of the head. Apply the oils (wild orange and peppermint) together, and spread on the bottom of the foot. Grip the foot with your hands and, using a circular motion with your thumbs similar to the thumb tissue pull, wipe the oil into the skin. Start at the side of the heel and move across it horizontally, then move down one half inch and work your way across the other direction almost like you are tilling a garden. The strip running from the heal to the big toe is Zone 1, the strip including the second toe is Zone 2, and so forth. To trigger the reflexes in the foot, place one thumb near the other thumb, starting at the heel on the inside (Zone 1), walk down the foot, pushing into the bottom of the foot with the thumbs using medium pressure. Gripping the foot, swipe down each zone with your thumb as you slightly compress the foot with your hand. Similar to lightly milking a cow, alternating your hands, swipe Zone 1 three times and then continue through all five zones. The Lymphatic Pump: If your recipient falls asleep let them sleep, or perform the Lymphatic Pump. Do this by taking both feet in the hands, saddling your thumbs just in front of the heel at the arch. Oils have undeniably potent chemistry and are capable of impacting the body in significant and meaningful ways, yet an oil chosen may still not work due to a number of circumstances. Consider the following ideas as important information to assist you in identifying ways to enhance results from your essential oil use. Application Method - There are three basic ways to use essential oils: aromatic, topical, and internal. For example, to eliminate a respiratory infection, both topical and internal use may be needed to address the multiple facets of that temporary issue. Take a moment to consider the variety of aspects of any situation and how you can address them by using more than one oil in more than one way. For further and detailed knowledge on how to use essential oils, refer to Application Methods on page 23. Also consider learning a special method, the Oil Touch Technique, taught on page 28. Therefore, repeated usage such as every 15-30 minutes for an acute condition and 2-4 times daily for a more chronic or long-lasting condition, is far more likely to drive the results you are looking for. Perhaps a stomach issue was suspected so a favorite digestion blend was used yet no effect. Really the gall bladder was the issue and grapefruit and geranium oils would have been the better selection. See the section in this book titled How to Know Which Oils to Use on page 21, to familiarize yourself with methods of selection. You will discover there are many ways to approach oil choices throughout the book. Quality - the quality of essential oils offered in the marketplace radically differ. Though the dealer may have found momentary profit, their choice drastically reduces the effects for the end user. If the body is void of necessary nutrition, then the oils have no way for their powerful instructions to be carried out. One of the most crucial habits for successful results from essential use is to make a healthy diet and use of high-quality dietary supplements vital daily wellness habits. Lifestyle - Assessing lifestyle and self-care patterns may be necessary to find the culprits of compromise. Lack of sleep or proper consumption of water, poor quality drinking water, lack of regular exercise or movement, consumption of acid-producing beverages. Oils can cover up for a myriad of sins, but lifestyle has a significant impact on the results you experience. After applying essential oils, avoid eye contact or the touching of sensitive areas. If essential oils enter the eyes, place a drop of carrier oil, such as fractionated coconut oil or olive oil, in the eye and blink until the oils clear. Some oils are "warm," creating a heat-like sensation on the skin, and should be diluted with a carrier oil when used topically. These oils can include birch, cassia, cinnamon, clove, eucalyptus, ginger, lemongrass, oregano, peppermint, thyme, and wintergreen. With babies, children, and those with sensitive skin or compromised health, it is particularly important to exercise caution or avoidance with these same oils, as they can be a temporary irritant or overly potent to delicate skin. When using these oils internally, it is best to consume in a gelatin or vegetable capsule. Some oils contain furocoumarins, a constituent that can cause skin to be photosensitive. Oils with concentrated amounts of furanoids include any cold pressed citrus oil such as bergamot, grapefruit, lemon, and lime, with lesser amounts in wild orange. Most essential oils applied topically and used reasonably are safe to be used during pregnancy and nursing. Some individuals prefer to avoid internal use during pregnancy and some use essential oils only aromatically during the first trimester. Internal use of peppermint essential oil should be avoided while nursing as it may reduce milk supply. Persons with critical health conditions should consult a healthcare professional or qualified aromatherapist before using essential oils and may want to research individual oils prior to using them. In general, those with low seizure thresholds should be cautious in using or avoid altogether fennel, basil, rosemary, birch, and any digestive blend that contains fennel. Those with high blood pressure should be cautious with or avoid thyme and rosemary essential oils. On occasion a person may experience a cleansing reaction, which takes place when the body is trying to rid itself of toxins faster than it is able. When this happens, increase water intake and decrease application of essential oils, or change the area of application. The compounds in essential oils are best preserved when stored and kept from light, heat, air, and moisture. Long exposure to oxygen begins to break down and change the chemical makeup of an essential oil. This process is called oxidation, and the oil is said to have "oxidative breakdown. For optimum storage of these types of oils for longer than a year, refrigeration is best. The oxidative process for oils that are opened and kept for a long period of time can be slowed by transferring the oils to smaller bottles. Some oils with bigger compounds, such as sesquiterpene compounds (myrrh and sandalwood) actually get better with age. Essential oils can be flammable and should be kept clear of open flame, spark, or fire hazards. Start by searching for the ailment in question, then note the recommended essential oils for each ailment. As you become versed in the powerful qualities of each oil, blend, and supplement, you will find confidence in turning to nature as your first resource for wellness. This section provides a detailed reference for the origins, qualities, purposes, and safety of individual essential oils. The top uses of each oil are intended to be a succinct guide, as more detailed uses are highlighted in Body Systems. While all oils are meant to be used aromatically and most topically, only verified pure therapeutic essential oils are intended for internal use. Stimulant - Apply T under nose and back of neck to stimulate body systems and awareness. Bacterial Support - Apply T to bottoms of feet or spine with fractionated coconut oil. Sunscreen - Apply T with helichrysum or lavender to protect against sun exposure. Emotional Balance - Use A aromatically & T topically to get from Overzealous - Composed. Earache - Apply T behind and down beneath ear area: swab ear canal to relieve pain and infection. Loss Of Sense Of Smell - Apply T under nose and to toes to regain or increase sense of smell. Migraines & Dizziness - Apply with wintergreen or peppermint T to temples and back of neck. Nausea & Cramping - Take I in a capsule or apply T to abdomen to ease discomfort. Gout & Rheumatism - Apply T to spine, bottoms of feet, ears, ankles, or area over heart. Self-Worth Issues - Apply T to belly button and over heart to enhance feelings of worth. Emotional Balance - Use A aromatically & T topically to get from Inadequate - Worthy. Bone Spurs, Gallstones, Kidney Stones & Cataracts - Apply T to bottoms of feet or areas of concern. Top Properties - Neurotonic, Antiinflammatory, Antidepressant, Antibacterial, Antifungal, Digestive (for more, see pg 252). Safety - Top Properties - Analgesic, Neurotonic, Anti-rheumatic, Stimulant, Steroidal, Warming (for more, see pg 252). Respiratory & Lymphatic Drainage & Cleansing - Use I a drop under tongue or A inhale / diffuse. Poor Circulation & Cold Extremities - Apply T with a warm compress to increase circulation and blood flow to muscles and nerves. Cold, Flu, Aches & Chills - Use I in a capsule or apply T to bottoms of feet or along spine. Congested Airways - Diffuse A or apply T to chest with white fir to clear airways. Food Flavor - Enhance your favorite foods by adding a drop as seasoning to add flavor and support digestion. Emotional Balance - Use A aromatically & T topically to get from Repressed - Honest. Acne, Eczema, Psoriasis & Sunburn - Apply T to affected area(s) with helichrysum. Asthma & Respiratory Issues, Hiccups - Combine with eucalyptus or peppermint and apply T to chest and / or under nose. Tension & Sinus Headaches, Migraines, Toothache - Massage T into temples, sides of nose, or gums. Cold, Flu, Mumps, Chicken Pox, & Muscle Aches - Apply T to affected area(s) or bottoms of feet. Emotional Balance - Use A aromatically & T topically to get from Inundated - Relieved. Safety - Top Properties - Antioxidant, Antispasmodic, Digestive, Expectorant, Neurotonic, Stimulant, Rubefacient (for more, see pg 252). Menstrual & Muscular Pain - Apply T to area of concern to relieve pain and inflammation. Sore Throat & Fevers - Gargle I a drop in water or apply T to throat and back of neck. Mental Fatigue & Confusion - Apply T under nose and to back of neck to clear your mind and ease fatigue. Pancreatitis - Apply T to area over pancreas and bottoms of feet to cleanse and restore pancreatic function.
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