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On the other hand calan 80 mg lowest price blood pressure chart american heart association, Alters and co-workers concluded that intravenous magnesium sulfate statistically improves spirometry (168) order calan 80 mg with mastercard arteria thoracica inferior. Rowe and others suggested that although the current evidence does not support the routine use of intravenous magnesium sulfate in all patients with acute asthma buy 400 mg indinavir amex, magnesium may benefit patients who present with severe disease (169). In one study, 135 asthmatics were randomized to 2 g magnesium sulfate intravenously or placebo after 30 minutes and followed for 4 hours ( 170). Additional evidence supporting benefit in severe disease comes from a study of five mechanically ventilated asthmatics given magnesium ( 171). In this study, patients were given high doses of magnesium sulfate (10 20 g) over 1 hour, after which there was a significant decrease in peak airway pressure (43 32 cm H 2O) and in inspiratory flow resistance. Of interest, magnesium sulfate also may be of greater benefit in premenopausal women because estrogen augments the bronchodilating effect of magnesium ( 172). Nannini and colleagues recently evaluated the efficacy of inhaled magnesium sulfate (225 mg) versus normal saline as a vehicle for nebulized albuterol in a randomized, double-blind, controlled trial of 35 patients who presented to the emergency room ( 173). For now, routine use is not justified, with the possible exception of patients with severe disease and premenopausal women. Heliox Heliox is a gas consisting of 20% oxygen and 80% helium (30%:70% and 40%:60% mixtures are also available). As the percentage of helium decreases, so does the benefit of breathing this gas blend. Concentrations of helium of less than 60% are not effective, precluding its use in patients requiring significant supplemental oxygen. Heliox is slightly more viscous than air, but significantly less dense, resulting in a more than threefold increase in kinematic viscosity (the ratio of gas viscosity to gas density) compared with air. Theoretically, this property decreases the driving pressure required for gas flow by two mechanisms. First, for any level of turbulent flow, breathing low-density gas decreases the pressure gradient required for flow. Second, heliox decreases the Reynold number favoring conversion of turbulent flow to laminar flow (174). Heliox promptly improves dyspnea, work of breathing, and arterial blood gas abnormalities in patients with upper airway obstruction ( 175). If heliox is effective, it may buy time for concurrent therapies to work, and thereby avert the need for intubation in some cases. Of theoretical concern is the potential for heliox to mask worsening airflow obstruction, so that there may be less time (and no margin for error) to control the airway. Whether heliox augments the bronchodilator effect of inhaled b agonists compared with delivery in air is unclear.

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Management Pathophysiology Following resuscitation buy calan 240 mg with amex blood pressure medication diarrhea, prompt diagnosis and opera- r The bowel may obstruct from an intraluminal mass purchase cheap calan online artery dorsalis pedis, tion are essential to avoid strangulation purchase speman 60pills on-line. Theremaybecompressionofblood r Hernias are reduced and repaired, adhesions and vessels and a consequent ischaemia. As the ex- r Gallstones or food bolus causing intraluminal ob- tracellular pressure rises arteries become obstructed struction are milked into the colon. Clinical features Right colonic obstruction: Patients present with pain, vomiting and a failure to pass r Obstructive lesions of the right colon are managed by faeces or atus. The site of pain is dependent on the righthemicolectomy and end-to-end ileocolic anas- embryological gut: tomosis. Left colonic obstruction:Surgery is often a two-stage r Hind gut (down to the dentate line of the rectum). Auscultation reveals exaggerated with closure of the distal stump, which is returned to bowel sounds and high pitched tinkling sounds when the abdominal cavity). Sim- Denition ilarly in proximal colonic obstruction the ileocaecal Acessation of the peristaltic movement of the gastroin- valve forms a second point of obstruction. Aetiology/pathophysiology Causesofparalyticileusincludeabdominalsurgery,peri- Investigations tonitis, pancreatitis, metabolic disturbance (including Abdominal X-ray reveals the distension and allows as- hypokalaemia) or retroperitoneal bleeding. Fluid ac- Aetiology cumulation within the lumen of the bowel may result in r The most common cause is peptic ulcer disease (35 uid and electrolyte imbalances. This may further exac- 50%) often exacerbated by the use of nonsteroidal erbate the paralytic ileus. If patients are not nil by mouth they r Mallory Weiss tears of the oesophagus resulting from develop copious vomiting. Investigations r Rarer causes include upper gastrointestinal malig- Abdominal X-ray shows gaseous distension with multi- nancy and vascular malformations. Fluid and electrolyte imbalances digested blood; however, if there is very fast gut transit should be corrected. Any underlying cause should be time or rapid bleeding, bright red blood may be passed identied and treated. It is essential to identify any coexistent medical conditions especially renal or liver disease and those with Pseudo-obstruction widespread malignancy, as these patients (along with the Denition elderly) are at greatest risk of mortality. Arareconditioninwhichsymptomssuggestobstruction but where no obstruction is present. The haemoglobin level may not be low despite severe Clinical features blood loss until uid redistribution or resuscitation has Symptoms are similar to those of intestinal obstruction, occurred. Investigations and management Management Abdominal X-ray reveals gas extending to the rec- The initial management is to correct uid loss and hy- tum, which may be useful to differentiate from true potension. If the patient is in a state of shock they should be catheterised for accurate hourly uid balance. Incidence r Patients with more severe bleeding, particularly older 50 150 per 100,000 population per year. Advantages of contrast studies over endo- r In non-variceal bleeding failure of endoscopic therapy scopic procedures: or further bleeding after a second endoscopic treat- r No requirement for sedation, relatively well-tolerated.

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Serum sodium and chloride tend to increase in the patients and increase was more pronounced in the group suffering from both malnutrition and diarrhoea safe calan 240 mg hypertension lifestyle changes. On the other hand order 80mg calan blood pressure low, serum potassium tend to decrease and the decreases were significant in groups having malnutrition discount isoniazid 300mg otc. Serum protein level was found to be most depleted in the malnutrition associated diarrhoea group. Serum aldosterone levels were raised in all the three groups of patients namely malnutrition, diarrhoea and malnutrition associated diarrhoea when compared with the control whether aldosterone levels were expressed as ng/100ml or ng/g protein. The increase was still observed even after exclusion of the subjects whose ages lied within first one and half year of life for whom the serum aldosterone levels were found to have a sharp rise. Among the electrolytes only serum K+ appeared to correlate with serum aldosterone. However, serum Na/K ratio also seemed to correlate with serum aldosterone but in an inverse manner. The results suggested that aldosterone, a mineralocorticoid secreted by adrenal cortex might be involved in the regulation of electrolyte levels in blood possibly through the so called electrolyte pump, Na-K exhange system. They were taken by endoscopic examination at Thingangyun General Hospital and Yangon General Hospital during July and August 2000. Processing for isolation of Helicobactor pylori was done within 3 to 6 hours of having biopsy from the patients. Among 35 cases of endoscopically and/or surgically confirmed gastric masses, thirty cases (85%) were primary gastric carcinoma which was the commonest type, one was lymphoma and other four cases were benign lesions Twenty seven out of thirty cases of histologically confirmed primary gastric carcinoma were adenocarcinoma which was the commonest histological pattern. Four out of 31 cases of advanced malignant gastric lesions presented with mild symptoms. So middle age patients presenting with loss of appetite, slight nausea and discomfort after meal should always require careful investigation to get early diagnosis. Primary gastric carcinoma were commonly found in 51 to 70 year age group (23 cases) and males were more affected than females (3:2). Three cases (10%) were found in 149 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar gastric cardia. Even small frequency occurred in gastric cardia, it can be missed occasionally on barium meal, so careful examination is needed. Eighteen out of 36 cases of radiologically diagnosed gastric masses were fungating/polypoid lesion which was the commonest morphological appearance. In these lesions, the surface pattern is important to differentiate between benign and malignant masses.

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There are scabies/) thought to be about 300 million cases of scabies in the world each year buy calan overnight delivery arteriovenous graft. The characteristic raised red pimples on the skin that develop later are due to an allergic response to the mites buy 120mg calan with amex blood pressure ziac. You may also be able to see the threadlike burrows in the skin made by egg-laying female mites cheap 100mg trandate amex. Use a cotton swab to squeeze the lotion under the ends of the ngernails and toenails, where mites can hide. Repeat the treatment the following day and advise the patient not to wash for another 24 hours. The main control measures are early diagnosis and treatment of patients and contacts. However, onchocerciasis has additional symptoms such as loss of skin colour and nodule formation, whereas scabies rashes are raised red pimples and aky skin. Scabies occurs mainly in conditions of poverty and overcrowding where the mites can easily breed; whereas onchocerciasis is common in south-west Ethiopia in communities living near the fast-owing water required by the insect vector (blackies). There is a great deal of misunderstanding about the disease in affected communities. Some people think it is caused by treading on a snake or frog, others that it is a curse or form of punishment. The swelling begins in the feet and progresses up the legs, and both feet are usually affected. It cannot be transmitted between people, so close contact with someone who has podoconiosis is totally safe. You may wonder why you are learning about it in a Module on Communicable Diseases; there are two reasons. First, severe podoconiosis looks a lot like lymphatic lariasis, which you learned about in Study Session 37. It is important to know the difference between these diseases because there are differences in their treatment. Second, how you teach patients to reduce the disability due to podoconiosis is exactly the same as the methods you have already learned about for lymphatic lariasis. But there are some questions you can ask the patient that can help you to decide which diagnosis is most likely to be correct. If the patient lives more than about 1,200 metres above sea level, then the leg swelling is likely to be due to podoconiosis. This is because the mosquitoes that transmit lymphatic lariasis cannot survive above this altitude it is too cold at night. If the patient has always lived in dega or woina dega areas, or does not live in zones where lymphatic lariasis is known to be prevalent, then you should diagnose the leg swelling as podoconiosis. If it started in the feet and both feet/legs are affected, then the diagnosis is likely to be podoconiosis. See there is no vector so their houses don t need to be sprayed to kill StudySession5inPart1ofthis mosquitoes (unless, of course, malaria is endemic in the area).