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Airways may be cylindrical effective accutane 20mg acne home remedies, fusiform or saccular Microscopic appearance: Acute inflammatory exudate with desquamation and ulceration of the epithelium order 10mg accutane visa skin care gift sets. Chronic peribronchial fibrosis th th 82 4 and 5 Year Notes Clinical course: foul buy accutane 10mg otc acne quotes, bloody sputum cheap tadapox uk, especially in the morning purchase extra super viagra 200 mg free shipping. Rarely cor pulmonale discount 800 mg viagra vigour visa, metastatic brain abscesses and amyloidosis Restrictive/Interstitial Pulmonary Disease = Reduced expansion of the lung parenchyma British and Americans give them different names Over 150 different disease processes primarily affecting alveoli epithelium, interstitium and capillary endothelium, not airways Restrictive Lung Diseases Affecting chest wall or Interstitial or infiltrative diseases pleural space bellows function. Heavy lungs due to fluid accumulation (interstitial and later alveolar) Microscopic appearance: Early change: interstitial oedema, few cell infiltrates Acute exudative stage: microvascular injury breakdown of basement membrane leakage of plasma proteins into alveoli. Fibroblasts lay down collagen in interstitium and alveolar spaces interstitial and intra-alveolar fibrosis Prognosis: 50% mortality. Filling of alveolar with alveolar macrophages (not desquamated as originally thought). See Types of Lung Cancer, page 88 Laryngeal and perhaps extrapulmonary neoplasms When asking about occupational exposure, need to go back a long time. Serpentine crysotile form (curly, flexible) is more common, less dangerous, cleared more easily from bronchi and more soluble so dont persist in the alveoli. Monocytes recruited granuloma formation Macroscopic appearance: Chest X-ray shows bilateral hilar lymphadenopathy and/or diffuse interstitial disease. Tightly clustered epithelioid histiocytes, multiple giant cells, and a few peripheral lymphocytes Clinical course: Treat with steroids. Contain lots of cholesterol Pharyngeal pouch: Mucosa herniates out through triangle between the cricopharyngeus and thyropharyngeal muscles under pressure from swallowing when upper oesophageal sphincter doesnt relax properly. Treatment: radiotherapy unless spread through cartilage Supraglottic: 30%, above chords, involves false chord. Quitline 0800 778 778 Epidemiology of Lung Cancer Commonest cancer in the world In New Zealand, leading cause of cancer death in men (23%, bowel 15%, prostate 14%) and third most common in women. Maori women have the highest death rate from lung cancer of any female population in the world Males predominate. Females catching up Respiratory 87 60% not resectable at the time of diagnosis 23% of all lung cancers are mixed Smoking: > 90% are caused by smoking and are therefore preventable 25% of lung cancer in non-smokers is due to passive smoking Types according to smoking status: % Smokers % Non-smokers Squamous Cell 98 2 Small Cell 99 1 Large Cell 93 7 Adenocarcinoma 82 18 Bronchioalveolar 70 30 Presentation and Survival: Smokers Non-smokers Distant disease at presentation > 50% 10% Endocrine disorders 10 25% 5% 5 year survival 5% 17% Relative incidence changing rapidly: Squamous cell Adenocarcinoma (now more common than squamous cell in most countries) Bronchioalveolar carcinoma Large cell constant Presentation Fatigue 84% Cough 71% Dyspnoea 59% Anorexia 57% Pain 48% Haemoptysis 25% Diagnosis Cytology necessary for management. Fragile crushed causing blue streaks Complications: metastatic disease to lymph nodes, brain, liver and adrenals Two year survival 25% Treatment: chemotherapy. Grows by expansion rather than infiltration Mesothelioma: Primary pleural tumours, including benign and malignant (also tumours of the peritoneum, tunica vaginalis and pericardium) Benign mesothelioma does not produce pleural effusion and has no relationship to asbestos Malignant mesotheliomas arise in either visceral or parietal pleura, produce pleural effusion (can be unilateral) and are related to asbestos. Aggressive, bulky, peripheral tumour Pancoast tumour/syndrome: lung cancer (usually squamous) in the apex extending to supraclavicular th st nd nodes and involving 8 cervical and 1 and 2 thoracic nerves shoulder pain radiating in ulnar distribution.
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Estimating future trends in the spread of antibiotic resistance: the case of third-generation cephalosporin- resistant E order accutane mastercard acne disease. Investing in antibiotics to alleviate future catastrophic outcomes: what is the real option value of having an effective antibiotic to mitigate pandemic influenza? Horses for courses: how should the value attributes of novel antibiotics be considered in reimbursement decision making? Quantifying Uncertainty about Future Antimicrobial Resistance: Comparing Structured Expert Judgment and Statistical Forecasting Methods Gerardo Alvarez-Uria buy accutane on line amex acne vulgaris, Sumanth Gandra buy generic accutane 20 mg on line acne that itches, Siddhartha Mandal purchase silvitra line, Ramanan Laxminarayan buy discount propranolol 80 mg online. Global forecast of antimicrobial resistance of Escherichia coli and Klebsiella pneumoniae in invasive isolates cheap malegra fxt plus generic. Risk assessment of future antibiotic resistance eliciting and modelling probabilistic dependence between multivariate uncertainties of bug-drug combinations John H. Simulating market-oriented policy interventions for stimulating antibiotics development. Society for Computer Simulation International Theuretzbacher Ursula, Savic Miloje, rdal Christine, Outterson Kevin. Linking sustainable use policies to novel economic incentives to stimulate antibiotic research and development. An assessment of the future impact of alternative technologies on antibiotics markets. Policy briefs and interim reports: Policy brief: The necessity for greater antibiotic innovation. Policy brief: The importance of multinational coordination and increased public financing for antibiotic innovation. Developed for the United Nations General Assembly meeting on antimicrobial resistance in September 2016. Also disseminated at the Global Health Security Agenda 3rd Annual Ministerial Meeting, October 2016. Insights into early stage antibacterial development in small and medium sized enterprises: a survey of targets, costs, and durations 3. Incentivizing appropriate use of novel antibiotics with the Diagnostic Confirmation Model Savic M, rdal C. Factors influencing the introduction of new antibiotics approved between 1999 and 2014 Cecilia Kllberg et al. Quantitative assessment of factors influencing the introduction of new antibiotics. A literature review was undertaken to identify both published and grey literature containing theoretical or practical economic incentives for stimulating any type of biopharmaceutical innovation.
If sensorineural generic 10 mg accutane with amex acne keloid treatment, air conduction best Weber Test: Tuning fork on top of the head order accutane on line skin care 70. Louder in affected ear if conductive loss buy accutane line skin care education, softer in affected ear if sensory loss Pure Tone Audiometry: Can establish severity of hearing impairment and whether sensorineural or conductive Measures thresholds across a range of frequencies purchase cheap proscar on line. Eustachian tube obstruction Otoacoustic emissions: Test for cochlear function buy antabuse cheap online, eg in neonatal screening Also for tinnitis: is it cochlear or non-cochlear Paediatric testing: 0 3 months: referred from neonatal high-risk register buy clomiphene on line. Need to correct (eg hearing aid implants) by 9 10 months otherwise speech impairment 6 12 months: distraction testing looking for head turning, etc 1 2 years: in a room with speakers th th 150 4 and 5 Year Notes Hearing Loss See Hearing, page 580 for developmental delay resulting form hearing loss Congenital Sensorineural Deafness Irreversible Pathology: problems with nerve or cochlear Profound hearing loss at birth: 2 per 1,000 Most often detected by parents (ie believe them! Can be: Secretory diarrhoea: large volume Osmotic diarrhoea: disappears with fasting Abnormal intestinal motility Exudative diarrhoea: with blood or mucus Malabsorption: steatorrhoea Constipation: Check what they mean. Umbilicus is shallow or everted in ascites or pregnancy Gastro-Intestinal 155 Veins. Bend knees up if necessary to relax muscles Gently all round: look at face check for tenderness/peritonism, obvious lumps. Check for shifting dullness More firmly: looking for organs, masses What to palpate for: Liver: Dont usually feel in normal adult, may in child. Start palpation inferior to the umbilicus Kidney: if palpable either tumour or obstructed Aorta: can nearly palpate in most people key issue is width Gallbladder: Murphys sign: lay fingers along costal margin, patient takes a deep breath and it hurts. Enlarged gallbladder is unlikely to be gallstones as chronic gallstones fibrosis that cant then expand. Can be voluntary or involuntary (latter suggests peritonitis) Rigidity: muscles tight Rebound tenderness: push down surreptitiously then remove hand quickly watch face for pain (peritonitis) Percuss for: Liver Spleen: unreliable Kidneys: but overlying bowel makes this problematic Bladder: supra-pubic dullness indicates upper border of an enlarged bladder or pelvic mass Shifting dullness in ascites Ausciltate: Bowel sounds: just below umbilicus. Only part of bowel with faeces If they have ulcerative colitis shouldnt be bigger than 5cm otherwise toxic megacolon Transverse diameter of caecum shouldnt be bigger than 9 cm otherwise risk of rupture Small bowel: circularis goes right round. Gas if obstructed, diarrhoea, ileus or swallowing gas due to pain Gas under diaphragm = pneumo-peritoneum Can have gas in bilary tree (esp. Needs to be warm on arrival in lab Barium Enema Make sure they got to the caecum (i. But also specialised stuff Teeth and Teeth forming tissue: Genetic defects Severe illness eg measles bands on teeth Tetracycline discolouration Vomiting, regurgitation (eg bulimia) erosion Cysts or tumours of teeth forming tissue (eg ameloblastoma) Gastro-Intestinal 157 Gums: loose more teeth through gum disease than caries. Immunosuppressive disease can lead to abnormal gums (eg leukaemia) Salivary glands: Calcification in duct of major gland blockage Tumours/cysts Recurrent infections: short/wide ducts retrograde flow infection with oral commensals Post-radiotherapy to head and neck. Salivary tissue very sensitive dry mouth Drug induced dry month: made worse by anxiety, smoking, dehydration Sjogerns Disease: autoimmune attack of salivary and lacrimal glands Dry mouth rapid tooth decay (no buffering from saliva) Oral Mucosa: Hyperkeratosis with hyperplasia or atrophy: looks white Upsets to normal flora. Gastro-Intestinal 159 Exclude bilary colic, pancreas and heart pain Functional/idiopathic/essential dyspepsia = all investigations normal but still pain = Up to 60% of dyspepsia. H Pylori gastritis Abdominal pain without significant pathology very common Ask about weight: if overweight think reflux, if loosing weight think cancer Oesophagitis doesnt cause anaemia until proved otherwise Types: Reflux like heartburn/regurgitation treat with empiric H2 antagonist Dysmotility like bloating, nausea, fullness (? Predisposes to cancer Ulceration, stricture (always biopsy strictures as some cancers present like this) Adenocarcinoma Hiatus Hernia Common. Usually affects body of the stomach Helicobacter pylori infection: Hypertrophic gastritis: enlargement of rugal folds due to hyperplasia.