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Half of the strictures are confined to the intrapancreatic portion of the bile duct buy extra super avana pills in toronto erectile dysfunction lotion. Shaffer 581 To aid the diagnosis discount 260mg extra super avana with amex impotence after 50, IgG4 immunostaining tissue can be obtained from the ducts buy extra super avana 260 mg mastercard erectile dysfunction drugs generic names, ampulla or pancreas (e purchase kamagra oral jelly 100mg free shipping. Associated autoimmune pancreatitis with inflammatory masses cheap clomiphene uk, and associated weight loss, can sometimes make this difficult to differentiate from malignancy. Neoplasia Benign tumors (adenomas, papillomas, cystadenomas) are rare causes of mechanical biliary obstruction. Ampullary adenocarcinomas should be considered for a Whipples pancreaticoduodenectomy. The most common malignant stricture of the bile duct is due to invasion from to pancreatic cancer. Cholangiocarcinoma, the most frequent primary biliary tract malignancy, is rather uncommon in the Western world. There may be a deep-seated, vague discomfort - a feeling of fullness localized in the right upper quadrant of the abdomen. A distended, non-tender gallbladder may rarely be palpated, feeling like a small rubber ball, if the common duct is obstructed below the insertion of the cystic duct (Courvoisiers sign). For hilar/intrahepatic tumors, surgical decisions are more complicated and depend on stage (like vascular and bilateral liver involvement). If non-invasive imaging reveals a resectable non-hilar lesion in a young surgical candidate, it may be reasonable to go straight to surgery avoiding stenting, but generally a tissue diagnosis is pursued preoperatively in most patients. Palliation of distal tumors using biliary stents placed across strictures helps improve quality of life via alleviating jaundice, pruritus. Plastic stents are removable/exchangable but occlude after an average of 3-4 months, whereas self-expandable metal stents (both removable and non-removable varieties now available) can last longer (6-12 mos), but are much more costly (5-10 times). Hilar tumors are managed differently (both surgically and endoscopically) and should be suspected when the characteristic painless jaundice of cholangiocarcinoma occurs in the presence of intrahepatic biliary dilatation, but without extrahepatic biliary dilatation. Shaffer 582 non-invasive and quite accurate at staging these tumors (Bismuth classification) and determining their resectability. Draining one lobe is often sufficient for palliation although occasionally both sides may require drainage, especially if both sides are contaminated with dye at a procedure, or if cholangitis develops after stenting one side. Aantomy The pancreas is located retroperitoneally in the upper abdomen overlying the spine and adjacent structures, including the inferior vena cava, aorta and portal vein and parts of their major tributaries. Its retroperitoneal location makes the pancreas relatively inaccessible to palpation. The head and unci- nate process lie within the curvature of the duodenum, while the body and tail extend to the hilus of the spleen. The arterial supply of the pancreas is from the major branches of the celiac artery, including the splenic and gastroduodenal arteries, and the superior mesenteric artery, as well as an arborization of smaller branches (i.


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Can be non-specific (not coping extra super avana 260mg without prescription smoking and erectile dysfunction statistics, immobile buy extra super avana uk erectile dysfunction 70 year olds, etc) Threshold effect: Change in functional status can occur in the absence of a clear precipitant due to build up of subclinical dysfunction and loss of physiologic reserve Disordered homeostasis and the cascade effect: Age related effects ability to maintain homeostasis in the presence of a threat (eg medication) purchase extra super avana american express erectile dysfunction treatment hypnosis. Eg osteoarthritis Impairment: Loss or abnormality of psychological discount vardenafil 20 mg visa, anatomical or physiological function purchase advair diskus on line. Eg reading a newspaper, shopping, etc However, some things dont fit well into this model (eg psychiatric illness). Social worker in involve family and ensure adequate finance Medication review Nutritional supplements: eg add milk powder to food, eat high-density foods, take supplements Falls In elderly, refers to a fall during an activity that is usually safe 25 35% of those over 65 fall each year. Occurrence with age < 5% of falls cause a fracture (40% of these to proximal femur). Treatment by extraction and implantation improves visual acuity in about 90% but a smaller proportion benefit in terms of activities of daily living Age related macular degeneration: Variety of causes. More serious ones include choroidal neo- vascularisation detachment and scarring Glaucoma Diabetic neuropathy Senile arcus: ring of lipid and calcium salts in a ring at the junction of the cornea and sclera. About 5% of elderly people subject to abuse, usually by a spouse, child or relative Risk factors for abuse: Dependence by the older person for all or part of their care Cognitive impairment, especially disruptive or aggressive behaviour Substance abuse or mental illness of the abuser Shared living arrangements External stress Social isolation History of violence Screening for elder abuse: Will not be volunteered: need to ask the right questions Watch for injuries or health or emotional problems with vague or inconsistent explanations Observe interactions, especially in own environment Question older person away from carer: Do you feel safe at home? Cognitive screening should be included due to the profound effect on driving, the insidious nature of cognitive impairment, good social facades by patients, and frequent lack of insight. Check for malnutrition, anaemia, fluid and electrolyte abnormalities Cognitive impairment: If they cant concentrate or remember, their involvement is compromised. Always screen for impairment Depression: Unwell and disabled people have a high prevalence of usually treatable depression. Diagnosis can be complicated due to overlapping symptoms (eg fatigue, apathy, psychomotor retardation and sleep disturbance) Communication problems: Screen for poor eyesight and hearing Low expectations and ageism: decline is not always as inevitable or severe as thought. Eg age, sex, or cause specific Age adjusted mortality rate: adjusts with reference to a standard population to allow comparisons between populations with different age distributions Premature mortality: death occurring before the average life expectancy within a given population Advantages: Death is easy to diagnose Is recorded, and doctors are legally bound to state the cause Disadvantages: Cause not always accurately described Reduces health status to being alive or not. Difference between age of death and the life expectancy at that age Changes over time have largely been due to social and economic changes (particularly public and personal hygiene). Contribution from health services is much less important Morbidity = Incidence or prevalence of a condition or disease in a population over a set period of time Measurement: Objective measures: Biochemical markers (eg blood glucose) Physiological markers (eg blood pressure) Pathological markers (eg tumour size) Functional measures: See also Disability, page 673 Impairment: reduction in physical or mental capacity usually due to an organ/system. If a random bias then association in results and odds ratio moves towards 1 Interviewer bias: systematic difference in soliciting, recording and interpreting of responses ( by training the interviewers always check this has been done) Recall bias: should be < 2 weeks for health events. If these cast the net widely, then will include people with unrelated disease odds ratio moves towards 1 (if random effect) Selection of controls: Representative of the population from which cases drawn but without the outcome Aim is to establish expected exposure in case group Want to compare exposures between the cases and the population at large. Matching does reduce the effect of confounding but there are other ways to deal with that when doing the number crunching Identical methods must be used to collect information from both Cant estimate relative risk in a case-control study: Outcome (eg Disease) Exposure Yes (Cases) No (Controls) Yes A B No C D Odds Ratio = (A/C)/(B/D) Relative Risk = [ A/(A+B) ] / [ C/(C+D)] = Risk of disease among exposed/risk of disease if not exposed) In a case-control study, the ratio between the cases and the controls is fixed by the study design, not the prevalence in the population. South America also at risk Urban Yellow Fever: Spread by Aedes Aegytpi mosquito Human mosquito human cycle.

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