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There are very few research studies on the reasons behind delayed medical attention for breast cancer in women in developing countries blood pressure lowering medications discount zestoretic 17.5mg fast delivery. Aim: To estimate the treatment delay hypertension emedicine discount zestoretic 17.5mg visa, and associated factors arterial blood pressure discount 17.5mg zestoretic otc, among women diagnosed with breast cancer treated on the National Cancer Institute in Rio de Janeiro hypertension table zestoretic 17.5 mg line, Brazil blood pressure medication ringing in ears discount 17.5 mg zestoretic visa. Times from diagnose to treatment initiation were analyzed according to the Brazilian law for cancer patient treatment (# 60 blood pressure line chart 17.5mg zestoretic otc. Association between sociodemographic, life style, clinical and treatment variables, and delays on treatment were estimated using X2-test and logistic regression model, with 95% confidential interval. Among those who arrived without diagnosis (n5666), prevalence of treatment delay was 34. Conclusion: Increased breast cancer treatment delay was observed among women who arrived with histopathological diagnosis. Time interval from diagnosis on the 1st visit at cancer center was the main factor associated to treatment delay, followed by old age; while high education level and late stage at diagnosis were negatively associated with treatment delays. Considering the whole cohort, old age, living outside Rio and chemotherapy were positively associated to delays on treatment, while college education level and late stage were negatively associated with treatment delay. While traditional academic and training programs designed to produce healthcare professionals in these countries fill a critical role, few programs exist that maintain, develop, and increase the knowledge, skills, and professional performance of current healthcare and oncology workforces. Mentoring partnerships and twinning programs can provide ongoing education and training that strengthen and build workforce capacity and capability for the full scope of cancer care. Aim: the goal is to achieve resource-appropriate multimodality cancer-care using guideline- and protocol-based education and training and also to develop the capability to conduct world quality research. The model utilizes in-person, in-country site visits lasting from several weeks to months and ongoing connectivity through weekly telemedicine video conferences. This information guides the programs and also provides metric-based investment in global health. Comorbidities influence the survival of patients with cancer; lead to presentation at advanced disease stages; and result in increased risk of treatment complications, higher rates of postoperative mortality, and a greater consumption of medical resources. Aim: To determine the magnitude and pattern of comorbidities in Nigerian cancer patients. Methods: this is a retrospective study, for which data were extracted from hospital records of patients presenting for oncology care between January 2015 and December 2016 in the Departments of Radiotherapy and Oncology of two tertiary health facilities in Lagos, Nigeria. Results: Eight hundred and forty-eight (848) cancer cases were identified, with breast (50. Conclusion: Comorbidities occur in at least one in four Nigerian cancer patients, and significantly influence the treatment outcome and prognosis of these patients. There is a need for a high index of suspicion and routine evaluation of cancer patients for comorbidities, with the aim of instituting appropriate and immediate multidisciplinary management measures where necessary. Tang3 College of Public Health, National Taiwan University, Taipei, Taiwan, Province of China; 2College of Public Health, National Taiwan University, Institute of Health Policy and Management, Taipei, Taiwan, Province of China; 3National Taiwan University Hospital, Division of Hematology, Department of Internal Medicine, Taipei, Taiwan, Province of China 1 Background: the incidence of hematologic malignancies has increased steadily in Taiwan. Along with the improvement of medical treatment, the survival of patients with hematologic malignancies has greatly improved. Cancer treatment may cause temporary or permanently infertility, which may lead to psychological distress and reduced quality of life. As patients live longer, the consequences of cancer treatments and fertility preservation are of increasing importance. Methods: In-depth interviews with 13 patients and 13 health care providers along with on-site observation were conducted. At the time of cancer diagnosis, most patients were preoccupied with cancer treatment and own survival, but once informed, most of them expressed an aspiration to preserve fertility. Conclusion: the fertility issues of patients with hematologic malignancies deserve attention, as their survival rate has been improved. Kaur University of the Witwatersrand, School of Molecular and Cell Biology (Biochemistry), Johannesburg, South Africa Background: Cancer cells have an increased need for cholesterol, which is required for cell membrane integrity. Cholesterol accumulation has been described in various malignancies including breast cancer. Cholesterol has also been known to be the precursor of estrogen and vitamin D, both of which play a key role in the histology of breast cancer. Thus, depleting the cholesterol levels in cancer cells is a proposed innovative strategy to treat cancer. Therefore, novel cholesterol-depleting compounds are currently being investigated. It solubilizes the cholesterol and is proven to be toxicologically benign in humans. Once we get our in vivo data, the compound would be patented for its mechanism of action in breast cancer. Aim: To determine whether continuous nursing care for lung cancer patients, compared with standard care, yields more improvements in terms of patient satisfaction and quality of life. Methods: this study was conducted at the Notre Dame University Hospital in Montreal. Methods: An online survey was performed in December 2017 as part of a larger mixed methods study to evaluate long term impact. Participants were asked questions on their fellowship experience and more in depth interviews will be performed to further investigate impact. The vast majority of fellows work in hospitals, treatment centers and research institutes; 67% are academic cancer professionals and 35% clinicians, with most working in the fields of cancer detection, diagnosis and cancer treatment. Over 57% of respondents rated the training received as "extremely effective", and 95% were still in contact with their host supervisors one year after their fellowship, with 28% copublishing with them. Over 80% estimated that their skills in cancer control had improved "a lot" or "a great deal" thanks to the fellowship training, with 12% saying "a moderate amount" and 1% "a little" or "none at all". Initiatives taken by fellows upon returning home include the launching of a new cervical cancer screening program, the founding of a national cancer society and the organization of a conference with the host supervisor as an invited speaker. Challenges included the perceived short duration of one month to achieve all the objectives and the language barrier. Over 43% were able to establish new collaborations in their country, 45% experienced professional growth and 27% increased their supervision of students "a great deal". Over 90% of respondents would apply for another fellowship and would recommend it to their colleagues. Conclusion: the majority of respondents were satisfied with their fellowship experience, and have been able to apply the knowledge gained and disseminated it to colleagues at their institutions. Fellowships have resulted in long term collaborations and have allowed fellows professional growth. Urquhart Dalhousie University, Halifax, Canada Background: Moving interventions. Conversely, organizations and providers sometimes adopt interventions in the absence of strong research evidence. Understanding decision-making around the adoption of new interventions is paramount to developing more effective strategies to facilitate the use of evidence-based interventions in practice. Aim: To illuminate the decision-making processes involved in the adoption of patientcentered interventions by cancer care teams, including how research evidence is considered, and identify additional factors influencing these decisions. Methods: Guided by the principles of grounded theory, we conducted semistructured interviews with clinicians, managers, and administrators of cancer care programs across Canada (n521). Data were collected and analyzed concurrently, using a constant comparative approach. Results: Participants emphasized that high-quality research evidence is often unnecessary when making adoption decisions around interventions that are intuitively "good ideas. Patients are for the most part abandoned to the care of inexperienced family members. Results: With a view to promoting access to palliative care patients, I intend to learn from the host organization the best practices that they apply to overcome communication difficulties with the patient and their relatives which can constitute delays to access to adequate care. This delay is more marked for patients suffering from cancer because the evolution of their pathology is unpredictable. Conclusion: In Congo, a cross-cutting approach is required to provide patients with palliative care and pain relief, as resources are limited, many people are in need of care, and there are few nurses and doctors empowered to provide care. An effective approach is to involve community or volunteer caregivers supervised by health professionals, and Palliafamilli is successful due in its multidisciplinary and multisectoral approach, with adaptation to cultural, social and economic specificities and its integration with existing health systems, focusing on primary health care and community and home care. However, complex changes have emerged, such as an explosive growth in knowledge about cancer in particular regarding other prognostic factors for outcome resulting in confusion regarding the uniform taxonomy of cancer stage around the globe. Aim: To evaluate the understanding and use of the cancer stage classification terminology. In addition, 81% agree that tumor markers have been shown to provide valid additional impact (in addition to extent of disease) on prognosis. Finally, there was no consensus on how anatomic extent of disease and other prognostic factors should be combined. However, there is no consensus on how anatomic extent of disease and other prognostic factors should be combined. A systematic, inductive approach was used to examine for clusters of concepts or topics, and codes were applied to characterize the research priorities into categories, phases, types, dimensions and aspects. The research topics in the treatment/ management phase were most frequently identified (30%). Five aspects characterized focal areas in cancer surveillance while two aspects revealed focal areas for research infrastructure. Details of the distribution of research by country and by dimensions will be discussed. The extent of research-related priorities demonstrates promise for transnational research collaborations. Next steps include improved understanding of key factors in achieving successful integration of research and control efforts through cancer control plan implementation. Data, such as the number of cervical cancer screening and syndromic treatment, was collected. Results: More than 14,000 people were reached and 14 service providers including midlevel providers were trained. The number of cervical cancer screenings was 2938 and 9862, before and after the project, respectively in the selected 6 branches. Evaluation of the Project Echo Tele-Mentoring Model for Knowledge Sharing and Technical Assistance in Cancer Control Planning and Implementation R. Results: Response rates for baseline surveys were: 32% in the Caribbean, 43% in Asia-Pacific, and 78% in sub-Saharan Africa. Low levels of knowledge were reported for: psychosocial support for cancer patients, family members, and caregivers in the Caribbean; survivorship care for cancer patients in Asia-Pacific; and alcohol consumption control in sub-Saharan Africa. Background: There is increasing demand for dissemination and implementation of evidence-based guidelines in cancer control. Medical records were reviewed to evaluate for molecular testing and target treatment. Both molecular testing and target therapy are restricted by the public healthcare system. We depend on clinical trials or the pharmaceutical industry support, in many cases, to test for and identify such patients with target therapies. However the challenge to offer better treatment of lung cancer patients in Brazil was not affected. Methods: We used a socio-ecological framework to identify and map key stakeholders and structures that create the ecosystem for comprehensive cervical cancer prevention. Data were collected through semistructured in-depth interviews and focus group discussions. Key stakeholders included women and men (30-45 years) residing in selected slums/villages, community influencers (village government, self-help group members), district and state-level government health and education officials, specialist doctors, frontline health workers, staff of cancer-related nongovernmental organizations, and journalists. Specialists, particularly those in leadership positions in the Federation of Obstetrics and Gynecology Societies of India and the Indian Academy of Pediatrics were strong advocates of vaccination. Community members lacked awareness about the vaccine and raised concerns on its safety, side effects and benefits as they would have for any new vaccine. All stakeholders highlighted cost as a major barrier to public provision of the vaccine. Government officials were concerned about how a vaccine program could be financed and sustained. Cultivating vaccine champions and identifying appropriate financing mechanisms to implement and sustain comprehensive cervical cancer prevention along with careful planning and implementation has the potential to save the lives of many women. For the quantitative part, N564 breast cancer patients were interviewed, with a structured questionnaire at the only pathology department in Mali, about breast symptom recognition and first health care visit. Information on begin of treatment and survival were collected at 18-months follow up. To discover additional barriers, three focus group discussions in the communities in Bamako were conducted (2). Knowledge of breast-self-examination, and correct symptom interpretation increased the chance to visit health care earlier. Shorter duration to first health care visit, working women compared with housewives, and living within Bamako prolonged time to diagnosis. Living outside Bamako, and smaller tumor size (T1/T2) prolonged time to treatment. Visit of a traditional healer, and larger tumor size (T3/ T4) shortened survival time, while time to first health visit, and subsequent time to diagnosis had no influence on survival.
Acne scarring has been best treated with lasers hypertension 130100 generic zestoretic 17.5mg with amex, including non-ablative infrared lasers heart attack 70 blockage discount zestoretic 17.5mg on-line, fractional non-ablative and ablative laser resurfacing blood pressure jumps around zestoretic 17.5mg online, and most recently needle-based radiofrequency devices blood pressure 8959 discount zestoretic 17.5mg fast delivery. Laser therapy is advantageous because it is an in-office treatment hypertension categories order zestoretic 17.5 mg with amex, which ensures patient adherence to therapy pulse pressure 2012 cheap zestoretic 17.5 mg with amex. In addition, it offers no systemic side effects that might complicate treatment when using oral acne medications. Non-ablative lasers have minimal downtime and produce gradual results, with the most significant improvement noted between 3 and 6 months following the final laser treatment [292]. While requiring more downtime, ablative lasers usually produce a higher degree of clinical improvement [297,298]. Raised scars and shallow boxcar scars improve the most with laser resurfacing, while icepick scars are more challenging to treat and may necessitate secondary resurfacing. Epilogue J Clin Pharm 2019 A better understanding of the pathophysiological mechanisms driving acne has allowed for the development of more effective topical and systemic therapies. These can be prescribed in logical combinations to target each relevant pathological factor and thus ensure optimal acne management. Each patient should receive education regarding acne and the available treatment options. A realistic explanation of the benefits, risks and expected outcomes of each therapy must be provided to promote autonomy. Patients also need to understand that, although most cases of acne can be cleared with available treatments, therapy requires time, and in the early weeks of treatment their acne may worsen. However, with frequent reassurance and follow-up, many patients will comply with treatment and achieve an acceptable outcome. Maintenance therapy is an important consideration as acne represents a chronic disease and frequently recurs without an ongoing treatment regimen. Among all pathogenetic factors of acne, inflammation seems to be rediscovered and anti-inflammatory concepts seem to become the new trend of systemic and topical acne treatment. Although a wide range of treatments are used, there is a lack of high-quality evidence on which are the most effective for acne scars. Despite the interest on the development of topical treatments for acne in the last decades, systemic treatment is still a milestone, especially in the treatment of moderate-to-severe scarring types of the 37 disease. The establishment of new systemic drugs for acne is based on the consideration of successes and pitfalls of the past and the emerging knowledge of the future. The issue of antibiotic resistance also impacts the prescribing patterns and treatment algorithms. The standard of care for the treatment of mild-to-moderate acne still lies with topical therapies. Poor adherence is one of the critical and negatively impacting factors affecting acne treatment outcomes. Moreover, limited patient education and awareness about acne treatment is also a roadblock to successful treatment. The acne therapy market is moving from mono therapy towards combination therapy options. The most likely reason is higher efficacy of combinations that consider the multifactorial pathogenesis of acne, reduced resistance levels, and the ease of single product use versus two separate mono therapies. Laser and light modalities, although not sufficiently studied for firstline use, show promise for the future. All pharmacists, officials, journalists, magazine analysts and associates that I met in this purpose, were very kind and helpful. The greatest help was from students and colleagues who continually supported me in collection and data extraction from books, journals, newsletters and precious time in discussion followed by providing information on different types of cosmetics in use. So, it is very much helpful for me to deliver better than before as many more things are studied. Kucharska A, Szmurlo A, Siska B (2016) Significance of diet in treated and untreated acne vulgaris. Romaska-Gocka K, Woniak M, Kaczmarek-Skamira E, Zegarska B (2016) the possible role of diet in the pathogenesis of adult female acne. Cappel M, Mauger D, Thiboutot D (2005) Correlation between serum levels of insulin-like growth factor 1, dehydroepiandrosterone sulfate, and dihydrotestosterone and acne lesion counts in adult women. Zari S, Alrahmani D (2017) the association between stress and acne among female medical students in Jeddah, Saudi Arabia. Geller L, Rosen J, Frankel A, Goldenberg G (2014) Perimenstrual flare of adult acne. Makrantonaki E, Ganceviciene R, Zouboulis C (2011) An update on the role of the sebaceous gland in the pathogenesis of acne. Taylor M, Gonzalez M, Porter R (2011) Pathways to inflammation: acne pathophysiology. The impact of acne vulgaris on quality of life and psychic health in young adolescents in Greece. Bondade S, Hosthota A, Basavaraju V (2019) Stressful life events and psychiatric comorbidity in acne-a case control study. Sparavigna A, Tenconi B, De Ponti I, La Penna L (2015) An innovative approach to the topical treatment of acne. Iftikhar U, Choudhry N (2019) Serum levels of androgens in acne & their role in acne severity. Purdy S, Langston J, Tait L (2003) Presentation and management of acne in primary care: a retrospective cohort study. Kartal D, Yildiz H, Ertas R, Borlu M, Utas S (2016) Association between isolated female acne and insulin resistance: a prospective study. Borodzicz S, Rudnicka L, Mirowska-Guzel D, Cudnoch-Jedrzejewska A (2016) the role of epidermal sphingolipids in dermatologic diseases. Coyner T (2018) Insights Into the Management of Acne Vulgaris: Clinical Considerations for Acne Treatment. John Harvey Kellogg (2006) Masturbation results in general debility, unnatural pale eyes and forehead acne. Li C, Chen J, Wang W, Ai M, Zhang Q, Kuang L (2019) Use of isotretinoin and risk of depression in patients with acne: a systematic review and meta-analysis. Czilli T, Tan J, Knezevic S, Peters C (2016) Cost of Medications Recommended by Canadian Acne Clinical Practice Guidelines. Du-Thanh A, Kluger N, Bensalleh H, Guillot B (2011) Drug-induced acneiform eruption. Fox L, Csongradi C, Aucamp M, du Plessis J, Gerber M (2016) Treatment Modalities for Acne. Bikowski J (2009) Facial seborrheic dermatitis: a report on current status and therapeutic horizons. Kravvas G, Al-Niaimi F (2017) A systematic review of treatments for acne scarring. Fife D (2011) Practical evaluation and management of atrophic acne scars: tips for the general dermatologist. Behnam B, Taheri R, Ghorbani R, Allameh P (2013) Psychological impairments in the patients with acne. Mahmood T, Akhtar N, Moldovan C (2013) A comparison of the effects of topical green tea and lotus on facial sebum control in healthy humans. Chatzikonstantinou F, Miskedaki A, Antoniou C, Chatzikonstantinou M, Chrousos G, et al. Kawashima M, Nagare T, Doi M (2017) Clinical efficacy and safety of benzoyl peroxide for acne vulgaris: Comparison between Japanese and Western patients. Hajheydari Z, Saeedi M, Morteza-Semnani K, Soltani A (2014) Effect of Aloe vera topical gel combined with tretinoin in treatment of mild and moderate acne vulgaris: a randomized, double-blind, prospective trial. Wohlrab J, Michael J (2018) Dapsone for topical use in extemporaneous preparations. Molinelli E, Paolinelli M, Campanati A, Brisigotti V, Offidani A (2019) Metabolic, pharmacokinetic, and toxicological issues surrounding dapsone. Subramaniam A, Corallo C, Nagappan R (2010) Dapsone-associated methaemoglobinaemia in patients with a haematologic malignancy. Rocha M, Sanudo A, Bagatin E (2017) the effect on acne quality of life of topical azelaic acid 15% gel versus a combined oral contraceptive in adult female acne: A randomized trial. Botsali A, Kocyigit P, Uran P (2019) the Effects of Isotretinoin on Affective and Cognitive Functions are Disparate in Adolescent Acne Vulgaris Patients. Farrah G, Tan E (2016) the use of oral antibiotics in treating acne vulgaris: a new approach. Lemay A, Poulin Y (2002) Oral contraceptives as anti-androgenic treatment of acne. Slopie R, Milewska E, Rynio P, Mczekalski B (2018) Use of oral contraceptives for management of acne vulgaris and hirsutism in women of reproductive and late reproductive age. Kang A, Lyons A, Herrmann J, Moy R (2019) Treatment of Moderateto-severe Facial Acne Vulgaris with Solid-state Fractional 589/1,319nm Laser. Jaisamrarn U, Santibenchakul S (2018) A comparison of combined oral contraceptives containing chlormadinone acetate versus drospirenone for the treatment of acne and dysmenorrhea: a randomized trial. Journal of Global Oncology is a registered trademark of American Society of Clinical Oncology, Inc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission by the Society. This publication contains abstracts selected and accepted by the 2018 World Cancer Congress Abstract Committee. When applicable, it is the responsibility of the treating physician or other health care professional, relying on independent experience and knowledge of the patient, to determine drug, disease, and the best treatment for the patient. All abstracts content has been published as it was submitted in its original form, and has not been edited for the purpose of this publication. This publication collects abstracts that were written by the disclosed authors in their personal capacity. By submitting an abstract for the 2018 World Cancer Congress, upon selection and acceptance by the Abstract Committee, authors agreed to have their abstract published in the following publication. Each disclosed conflict of interest has been included below the respective abstracts. The programme was built around five thematic tracks, which enabled the global cancer community to deliver a suite of innovative and interactive sessions, including abstracts, covering the full spectrum of cancer control. All information on the 2018 World Cancer Congress including its Committees and detailed programme may be found on Ezeani3 1 Federal Teaching Hospital Abakaliki, Abakaliki, Nigeria; 2Lifetouch Africa, Lagos, Nigeria; 3Ebonyi State University, Abakaliki, Nigeria Background: Cervical cancer is a highly preventable disease that affects women especially in developing countries. Over the years awareness and uptake of cervical cancer screening services have remained poor in developing countries. Lack of knowledge and poor attitude toward the disease and risk factors can affect screening practice and development of preventive behavior for cervical cancer. Aim: this study assessed the level of knowledge and barriers toward cervical cancer screening among female university students. Methods: We conducted a cross-sectional survey of 234 female students selected by stratified random sampling techniques at Ebonyi State University Abakaliki Nigeria. A pretested questionnaire was administered to assess knowledge, attitude and screening history. Common barriers include lack of centers where such services are obtainable (88%) and fear of cancer being discovered (9%). A significant association was found between institutional and personal barriers and having a Papanicolaou test. Conclusion: Comprehensive education on cervical cancer screening in universities is critical in reducing the morbidity and mortality associated with cervical cancer. Ngoma4 1 University of Dodoma, Public Health, Dodoma, United Republic of Tanzania; 2 University of Saskatchewan, Nursing, Canada; 3Nelson Mandela African Institution of Science and Technology, Health and Biomedical Sciences, Arusha, United Republic of Tanzania; 4Muhimbili University of Health and Allied Sciences, Oncology, Dar es Salaam, United Republic of Tanzania Background: Chronic noncommunicable diseases are increasingly captured as contributing to morbidity and mortality in low and middle income countries. Aim: this study aimed to investigate the epidemiology of colorectal cancer and the potential modifiable local risk factors in Tanzania. Methods: A cross sectional retrospective chart audit study was conducted to establish the pattern and distribution of colorectal cancer, the Food Frequency Questionnaire and the Step survey tool were used to collect data. Descriptive statistics, x2 tests, and regression analysis were used and augmented by data visualization to display risk variable differences. Two major dietary patterns, namely "healthy" and "western", existed among the study sample. Obesity was found in 25% of participants, whereas overweight was present in 28%; of note, the prevalence was higher in females (26. Both alcohol consumption and tobacco smoking were more common in men than women (22. The prevalence of vigorous, moderate, and low physical activity for both sexes was 18. Colon cancer is increasing at higher rate than rectal cancer seeming to align with change in lifestyle. We recommend a large longitudinal study with robust methodology which can establish cause and effect relationships between specific lifestyle behaviors and the incidence of colorectal cancer.
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Therapeutic options are limited and include pulmonary artery vasodilators and consideration of single lung transplant with repair of cardiac defect exo heart attack order 17.5 mg zestoretic fast delivery, or heart-lung transplantation arteria carotida interna 17.5mg zestoretic overnight delivery. Pulmonic Stenosis Moderate or severe stenosis (gradient > 50 mmHg) requires surgical (or balloon) valvuloplasty blood pressure chart normal blood pressure range zestoretic 17.5mg otc. May go undetected in early life or suspected by the presence of a systolic ejection click; often identified during echocardiography that was obtained for another reason pulse pressure 84 order zestoretic 17.5mg mastercard. Usually asymptomatic heart attack 42 year old cheap zestoretic 17.5 mg line, but it may cause headache arteria communicans anterior best 17.5 mg zestoretic, fatigue, or claudication of lower extremities. Physical Examination Hypertension in upper extremities; delayed femoral pulses with decreased pressure in lower extremities. Systolic (and sometimes also diastolic) murmur is best heard over the mid-upper back at left interscapular space. Echocardiography Can delineate site and length of coarctation, and Doppler determines the pressure gradient across it. Recoarctation after surgical repair may be amenable to percutaneous balloon dilatation. Repaired congenital heart disease with residual defects adjacent to site of a prosthetic patch or transcatheter device 3. A history of complete repair of congenital defects with prosthetic material or a transcatheter device within the previous 6 months. Doppler flow recordings provide estimation of transvalvular gradient, mitral valve area, and degree of pulmonary hypertension (Chap. Operation should be carried out before development of severe chronic heart failure. Pathology Redundant mitral valve tissue with myxedematous degeneration and elongated chordae tendineae. Physical Examination Mid or late systolic click(s) followed by late systolic murmur at the apex; exaggeration by Valsalva maneuver, reduced by squatting and isometric exercise (Chap. Echocardiogram Shows posterior displacement of one or both mitral leaflets late in systole. Prophylaxis for infective endocarditis is indicated only if prior history of endocarditis. Other causes are congenital (bicuspid valves) or rheumatic (almost always associated with rheumatic mitral valve disease). Symptoms Dyspnea, angina, and syncope are cardinal symptoms; they occur late, after years of obstruction. Murmur is typically loudest at 2nd right intercostal space, with radiation to carotids. Clinical Manifestations Hepatomegaly, ascites, edema, jaundice, jugular venous distention with slow y descent (Chap. Doppler echocardiography demonstrates thickened valve and impaired separation of leaflets and provides estimate of transvalvular gradient. Tricuspid Regurgitation Intensive diuretic therapy when right-sided heart failure signs are present. In severe cases (in absence of severe pulmonary hypertension), surgical treatment consists of tricuspid annuloplasty or valve replacement. Other causes include previous myocarditis, toxins [ethanol, certain antineoplastic agents (doxorubicin, truastuzumab, imatinib mesylate)], connective tissue disorders, muscular dystrophies, "peripartum. Chronic anticoagulation with warfarin, recommended for very low ejection fraction (<25%), if no contraindications. Restrictive Cardiomyopathy Salt restriction and diuretics ameliorate pulmonary and systemic congestion; digitalis is not indicated unless systolic function is impaired or atrial arrhythmias are present. Anticoagulation often indicated, particularly in pts with eosinophilic endomyocarditis. Typically results from mutations in sarcomeric proteins (autosomal dominant transmission). Physical Examination Brisk carotid upstroke with pulsus bisferiens; S 4, harsh systolic murmur along left sternal border, blowing murmur of mitral regurgitation at apex; murmur changes with Valsalva and other maneuvers (Chap. Periods of atrial fibrillation or ventricular tachycardia are often detected by Holter monitor. Chagas disease is a common cause of myocarditis in endemic areas, typically Central and South America. Physical Examination Rapid or irregular pulse, coarse pericardial friction rub, which may vary in intensity and is loudest with pt sitting forward. Echocardiogram Most readily available test for detection of pericardial effusion, which commonly accompanies acute pericarditis. Etiology Previous pericarditis (most commonly metastatic tumor, uremia, viral or idiopathic pericarditis), cardiac trauma, or myocardial perforation during catheter or pacemaker placement. History Hypotension may develop suddenly; subacute symptoms include dyspnea, weakness, confusion. Physical Examination Tachycardia, hypotension, pulsus paradoxus (inspiratory fall in systolic blood pressure >10 mmHg), jugular venous distention with preserved x descent, but loss of y descent; heart sounds distant. Viral, tuberculosis (mostly in developing nations), previous cardiac surgery, collagen vascular disorders, uremia, neoplastic and radiation-associated pericarditis are potential causes. Dramatic effects of respiration are typical: During inspiration the ventricular septum shifts to the left with prominent reduction of blood flow velocity across mitral valve; pattern reverses during expiration (Fig 123-2). Cardiac Catheterization Equalization of diastolic pressures in all chambers; ventricular pressure tracings show "dip and plateau" appearance. Always consider a secondary correctable form of hypertension, especially in pts under age 30 or those who become hypertensive after 55. Isolated systolic hypertension (systolic 140, diastolic < 90) most common in elderly pts, due to reduced vascular compliance. Presents with recent onset of hypertension, refractory to usual antihypertensive therapy. Abdominal bruit is present in 50% of cases; often audible; mild hypokalemia due to activation of the renin-angiotensin-aldosterone system may be present. Renal Parenchymal Disease Elevated serum creatinine and/or abnormal urinalysis, containing protein, cells, or casts. Coarctation of Aorta Presents in children or young adults; constriction is usually present in aorta at origin of left subclavian artery. Pheochromocytoma A catecholamine-secreting tumor, typically of the adrenal medulla or extraadrenal paraganglion tissue, that presents as paroxysmal or sustained hypertension in young to middle-aged pts. Associated findings include chronic weight loss, orthostatic hypotension, and impaired glucose tolerance. Pheochromocytomas may be localized to the bladder wall and may present with micturition-associated symptoms of catecholamine excess. Hyperaldosteronism Usually due to aldosterone-secreting adenoma or bilateral adrenal hyperplasia. In patients with systolic hypertension and wide pulse pressure, consider thyrotoxicosis, aortic regurgitation (Chap. Thiazides preferred over loop diuretics because of longer duration of action; however, the latter are more potent when serum creatinine > 2. May be used as monotherapy or in combination with a diuretic, calcium antagonist, or beta blocker. Side effects are uncommon and include angioedema, hyperkalemia and azotemia (particularly in pts with elevated baseline serum creatinine). A nonproductive cough may develop in the course of therapy in up to 15% of patients, requiring an alternative regimen. Subsequent doses and intervals of administration should be adjusted according to the blood pressure response and duration of action of the specific agent. Use sustainedrelease formulations, as short-acting dihydropyridine calcium channel blockers may increase incidence of coronary events. If bp proves refractory to drug therapy, workup for secondary forms of hypertension, especially renal artery stenosis and pheochromocytoma. Malignant Hypertension Defined as an abrupt increase in bp in patient with chronic hypertension or sudden onset of severe hypertension, and is a medical emergency. Overweight/obesity, sedentary lifestyle, increasing age, and lipodystrophy are all risk factors for the metabolic syndrome. Increased intracellular fatty acid metabolites contribute to insulin resistance by impairing insulin-signaling pathways and accumulating as triglycerides in skeletal and cardiac muscle, while stimulating hepatic glucose and triglyceride production. Associated conditions include cardiovascular disease, type 2 diabetes, nonalcoholic fatty liver disease, hyperuricemia, polycystic ovary syndrome, and obstructive sleep apnea. In general, recommendations for weight loss include a combination of caloric restriction, increased physical activity, and behavior modification. Weight loss drugs or bariatric surgery are adjuncts that may be considered for obesity management (Chap. Physical Examination Pallor, diaphoresis, tachycardia, S4, dyskinetic cardiac impulse may be present. Enoxaparin or heparin [60 U/kg (maximum 4000 U), then 12 (U/kg)/h (maximum 1000 U/h)] should be initiated with fibrinolytic agents. Later coronary angiography after fibrinolysis generally reserved for pts with recurrent angina or positive stress test. Patients who receive fibrinolytic therapy undergo noninvasive risk stratification (Noninv. Precipitating factors should be corrected [hypoxemia, acidosis, hypokalemia (maintain serum K+ ~4. Diuretic, vasodilator, and inotropic therapy (Table 126-1) may be guided by invasive hemodynamic monitoring (Swan-Ganz pulmonary artery catheter, arterial line), particularly in pts with accompanying hypotension (Table 126-2;. Pericarditis Characterized by pleuritic, positional pain and pericardial rub (Chap. Anticoagulants should be avoided when pericarditis is suspected to avoid development of tamponade. Consider addition of aldosterone antagonist (see "Congestive Heart Failure" section above). Physical Examination May be normal or include diaphoresis, pale cool skin, tachycardia, S4, basilar rales; if large region of ischemia, may demonstrate S 3, hypotension. If positive, the patient is admitted; if negative, the patient is discharged home with follow-up to his/her physician. Do not use nitrates in pts with recent use of phosphodiesterase-5 inhibitors for erectile dysfunction. Symptoms Angina is typically associated with exertion or emotional upset; relieved quickly by rest or nitroglycerin (Chap. Physical Examination Often normal; arterial bruits or retinal vascular abnormalities suggest generalized atherosclerosis; S 4 is common. Beta Blockers (See Table 128-1) All have antianginal properties; 1-selective agents are less likely to exacerbate airway or peripheral vascular disease. Calcium Antagonists (See Table 124-1) Useful for stable and unstable angina, as well coronary vasospasm. Use sustained-release, not short-acting, calcium antagonists; the latter increase coronary mortality. Performed on anatomically suitable stenoses of native vessels and bypass grafts; more effective than medical therapy for relief of angina. Placement of a bare metal intracoronary stent in suitable pts reduces the restenosis rate to ~30% at 6 months. Restenosis is nearly abolished when drug-eluting stents are used, but late stent thrombosis can rarely occur. The latter is prevented by prolonged antiplatelet therapy (aspirin indefinitely and clopidogrel for a minimum of 12 months). Prognosis is better in pts with anatomically normal coronary arteries than in those with fixed coronary stenoses. Symptoms are due to bradycardia (fatigue, weakness, lightheadedness, syncope) and/or episodes of associated tachycardia. Sinoatrial Node Dysfunction Remove or treat extrinsic causes such as contributing drugs or hypothyroidism. Tachyarrhythmias (Tables 130-1 and 130-3) Precipitating causes (listed above) should be corrected. Do not cardiovert sinus tachycardia; exercise caution if digitalis toxicity is suspected. Reduce dosage for pts with hepatic or renal dysfunction as indicated in Table 130-3. Anticoagulation should be continued for a minimum of 3 weeks after successful cardioversion.
London: British Medical Association and Royal Pharmaceutical Society of Great Britain blood pressure low symptoms cheap 17.5mg zestoretic amex, March 2008 blood pressure medication news generic zestoretic 17.5mg visa. Two months later she is readmitted with left loin pain arteria ethmoidalis anterior order zestoretic 17.5 mg fast delivery, hot hypertension journals ranking discount zestoretic 17.5mg with visa, cold and dizzy symptoms heart attack with pacemaker order 17.5mg zestoretic overnight delivery. Patient had radical operation: subtotal abdominal hysterectomy and bilateral salpingooophorectomy arterial bleeding purchase zestoretic 17.5 mg otc. What are the range of hormonal treatments available, their limitation and sideeffects? Royal College of Obstetricians and Gynaecologists (2006) the investigation and management of endometriosis. Questions 1 2 3a 3b 4a 4b 4c 5 Define the terms eclampsia/pre-eclampsia and severe pre-eclampsia. What signs and symptoms should be monitored if a woman is prescribed magnesium sulphate and what is prescribed if signs of magnesium toxicity are observed? Royal College of Obstetricians and Gynaecologists (2006) the management of severe pre-eclampsia/eclampsia. Dysmenorrhoea is cyclical, lower abdominal or pelvic pain which may also radiate to the back and thighs, occurring before or during menstruation or both. Primary dysmenorrhoea occurs in the absence of any obvious underlying disease that may be cause of pain. Risk factors include: I I I I I I nulliparity obesity cigarette smoking being sexually inactive late child-bearing positive family history. The mechanism of action is not completely understood but may be related to prostaglandin synthetase inhibition. Elevated prostaglandin levels are present in the endometrial fluid of dysmenorrhoeic women and correlate well with the degree of pain. Diarrhoea or rashes (withdraw treatment), vomiting, flatulence, constipation, ulcerative stomatitis. Some women find that it helps to start taking these painkillers a day or so before the period is expected to start. Alternatively, start to take them at the onset of pain or bleeding, whichever happens first. Mefenamic acid is a drug in the same group of drugs as ibuprofen; it is important that both mefenamic acid and ibuprofen are not taken together as this will increase side-effects in the stomach. The first part of the voided urine is discarded and without interrupting the flow approximately 10 mL is collected in a sterile container. Empirical treatment is then initiated with trimethoprim, nitrofurantoin or cefalexin. Once the sensitivity of the cultured organism is known treatment can be adjusted accordingly. A repeat urine culture should be done at approximately 7 days after the completion of treatment to confirm eradication of the bacteria has been achieved. Symptoms of pain and raised temperature due to infection may be treated with paracetamol. Urine cultures should be repeated monthly throughout the rest of the pregnancy to screen for asymptomatic infection. It is not associated with any increased risk to the fetus and is effective against most urinary pathogens. Trimethoprim can be used during pregnancy except in women with a known folate deficiency or those who are taking folate antagonists, because it may limit availability of folic acid to the fetus and impair normal development. There is equivocal evidence to suggest that folate supplementation reduces the risk of neural tube defects in offspring of pregnant women treated with trimethoprim. Therefore, folate supplementation is recommended in all women treated with trimethoprim during the first trimester as a precautionary measure. Trimethoprim should not be used if the woman has recently had a course (some clinicians recommend avoiding repeating treatment with trimethoprim within three months) or if the woman has a history of recurrent infections resistant to this drug. Co-amoxiclav can be separated into amoxicillin (see above 4a) and clavulanic acid; no adverse effects in newborn or fetus attributed to the combination of amoxicillin and clavulanic acid during pregnancy. Nitrofurantoin is thus contraindicated in pregnant women during the third trimester. The microcrystalline capsules and the twice-daily modified-release formulation may be better tolerated if nausea is troublesome and are offered as alternatives. Third-generation cephalosporins generally require parenteral administration and are reserved for use in secondary care for serious infections. Pivmecillinam is not known to be teratogenic but is not recommended in pregnancy because of insufficient safety data. Quinolones are contraindicated during all stages of pregnancy due to the risk of arthropathy. A healthy diet during pregnancy helps reduce the risk of having an infant of low birth weight who is at increased risk of poor health. A good diet contains a wide variety of foods including bread, cereals, pasta, rice and potatoes; fruit and vegetables; lean meat; fish and pulses; and reduced fat milk and dairy products. This is a general term for the infection of the upper genital tract including uterus, fallopian tubes and ovaries. Symptoms include: I I I I I I lower abdominal pain (usually most prominent symptom) dyspareunia abnormal vaginal bleeding abnormal vaginal discharge dysuria nausea and vomiting (rare in acute infection). A suggested alternative is ofloxacin 400 mg orally twice daily plus oral metronidazole 400 mg twice daily, both for 14 days. Broad-spectrum antibiotics all have the potential to cause gastrointestinal side-effects, such as nausea, vomiting and diarrhoea. Consider using a different antibiotic if the person has a true penicillin allergy, as cephalosporins show cross-reactivity to penicillins in about 8% of people. Precipitation of seizures is rare unless the person is already prone to epilepsy or related conditions. I 164 I P ha r ma c y Ca s e St ud ie s Metronidazole may cause gastrointestinal effects and react with alcohol. Common adverse effects include a metallic taste and gastrointestinal irritation (in particular nausea and vomiting). Some people taking oral metronidazole experience disulfiramlike reactions to alcohol (flushing, increased respiratory rate, increased pulse rate). Thus, people taking metronidazole should be advised of the possible consequences of drinking alcohol. I 4c Metronidazole is included to improve coverage for anaerobes as initial infection with Chlamydia or Neisseria gonorrhoea can cause epithelial damage, allowing other organisms to enter the cervix and cause ascending infection. Paracetamol is a safe and effective analgesic and antipyretic that is suitable for most patients. Codeine (alone or in combination with regular paracetamol) can be helpful when paracetamol alone is insufficient. Prescribing it separately offers greater flexibility in dosing and hence pain control. The need to avoid intercourse until both they and their partner(s) have completed treatment. The possible long term health implications for their health and the health of their partner(s). Endometriosis is a condition where endometrial tissue is found outside the uterus. A reflux of menstruation occurs in many women but in endometriosis refluxed cells implant in the pelvis, bleed in response to cyclic hormone stimulation and increase in size. It is often cyclic and responds to menstruation, but over time pain becomes a chronic pain syndrome which is acyclic and only disappears in pregnancy or menopause. Women can also have advanced lesions with tissue destruction and adhesions and may be asymptomatic. A study has confirmed prevalence among first-, second- and third-degree relatives, which suggests this disorder has a genetic basis. Women with severe chronic pain have a more advanced stage of disease at initial diagnosis. Surgical treatment by laparoscopic ablation of endometriotic lesions plus adhesiolysis may improve fertility. Hormonal treatments should not be used for endometriosis in women with fertility problems as they tend to lead to ovarian suppression. The hypothalamus causes pulsed releases of gonadotrophin-releasing hormone (GnRh). This results in the anterior pituitary producing follicle-stimulating hormone and luteinising hormone, which in the ovaries results in the production of oestrogens and progestogens. The different hormone treatments work by affecting different parts of this cascade. The end-result is to reduce the amount of oestrogen that is made or to block its actions in endometrial cells. Although oestrogen is present, the progestogen thins the endometrium and results in sparse bleeding at the regular withdrawals. This practice is off-licence but the regimen is safe, well tolerated and acceptable by women. Adverse effects include nausea, vomiting, headache, breast tenderness, changes in body weight, fluid retention and thrombosis. They induce endometrial atrophy and reduce oestrogen levels by inhibiting ovulation. It is licensed to be taken for 90 days although some clinicians advise continued use if adverse effects are minimal and symptoms are well controlled. Adverse effects include; irregular bleeding, bloating, skin changes, mood changes and weight gain. They have androgenic, anti-oestrogenic and anti-progestogenic activity and usually cause amenorrhoea and induce a postmenopausal state. I I Danazol is licensed to be taken continuously for up to six months but can only be used when other treatments have failed. It does not reduce bone mineral density as its anabolic effects counteract the effect of lowered oestrogen levels. It has similar actions to danazol but has a longer half-life, allowing twice weekly instead of daily dosing. Both are poorly tolerated because of androgenic adverse effects, which include weight gain, hirsutism, acne, mood changes and occasionally deepening of the voice, which may be irreversible. This is followed by anovulation, markedly reduced oestrogen levels and amenorrhoea, inducing a postmenopausal state and regression of endometrial deposits. As these need daily dosing they are not commonly prescribed, as psychologically the patient is constantly reminded of the disease. Goserelin, leuprorelin and triptorelin are monthly depot injection preparations which are more convenient. GnRh analogue treatment is only licensed for six months and only a single course of treatment is recommended by the manufacturers. This is a combination of one or more hormones with GnRh analogues to minimise or eliminate hypooestrogenic adverse effects such as bone loss and hot flushes. Other adverse effects of GnRh analogues include insomnia, reduced libido, vaginal dryness and headaches. With buserelin or naferelin, if a nasal decongestant is 168 P ha r ma c y Ca s e St ud ie s required, it should not be administered before or for at least 30 minutes after GnRh analogue use. With naferelin, sneezing during or immediately after dosing may impair absorption. Eclampsia is defined as the occurrence of one or more convulsions superimposed on pre-eclampsia. Pre-eclampsia is pregnancy-induced hypertension in association with proteinuria (>0. Severe pre-eclampsia is severe hypertension (diastolic blood pressure >110 mmHg on two occasions or systolic blood pressure >170 mmHg on two occasions) together with significant proteinuria (at least 1 g/L). List the clinical features of severe pre-eclampsia (in addition to hypertension and proteinuria). If creatinine is found to be elevated early in the disease process, underlying renal disease should be suspected. Falling platelet count is associated with worsening disease and is itself a risk to the mother. Antihypertensive treatment should be started if systolic blood pressure >160 mmHg or diastolic >110 mmHg.
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