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A chronic carrier state may be seen in wh ich the virus cont inues t o replicat e buy yasmin line birth control pills make you fat, but it does not cause irreversible h epat ic damage in the host generic 3.03mg yasmin mastercard birth control for women zombies. Hepatitis C is t ransmit t ed parenterally by blood transfusions or intravenous drug use 60mg cardizem, an d rar ely by sexual cont act. It is uncommonly diagnosed as a cause of acute hepatitis, often producing subclinical infection, but is frequently diagnosed later as a cause of ch r on ic h epat it is an d p ossibly liver cir r h osis. Patients afflicted with chronic hepatitis B virus who then become infected wit h hepat it is D may suffer clinical deteriorat ion; in 10% to 20% of t hese cases, individuals develop severe fat al hepat ic failure. For t un at ely, in most cases of acut e viral h epat it is, pat ient s recover complet ely, so the treatment is generally supportive. However, fulminant hepatic failure as a result of massive hepatic necrosis may progress over a period of weeks. T his usually may be caused by infection by the hepatitis B and D viruses, or can be drug induced. Toxin- or drug- induced liver injury is the cause of the majo rit y of cases of acute liver failure and may be due t o direct t oxic effect s of subst ances on the liver parenchyma (acetaminophen, Amanita phalloides), or due to idiosyncratic reactions of medi- cat ion s ( h alot h an e, ison iazid, ph en yt oin ). D ir ect t oxic effect s are pr edict able an d dose dependent, but idiosyncratic reactions are not. Acut e h epat ic failure is ch aract erized by rapid progression of enceph alopat hy from con fu sion or som n olen ce t o com a. Pat ien t s also h ave wor sen in g coagu lop at h y as measured by increasing prothrombin t imes, rising bilirubin levels, ascites and peripheral edema, hypoglycemia, hyperammonemia, and lactic acidosis. Fulminant hepatitis failure carries a poor prognosis (the mortality for comatose patients is 80%) and often is fatal without an emergent liver transplant. Diag no sis Clinical presentation does not reliably distinguish a specific viral etiology, so serologic studies are used to establish a diagnosis. Anti-hepatitis A immunoglobulin M (IgM) establishes an acute hepatitis A infection. Anti-hepatitis C antibody is present in acute hepatitis C, but the test result may be negative for several weeks. Acute hepatitis B infection is diagnosed by the presence of hepatitis B surface antigen (H BsAg) in the clinical context of elevat ed serum t ransaminase levels and jaundice. H BsAg lat er disappears when t he ant ibody (ant i-H Bs) is produced (Figure 26– 2). T here is often an interval of a few weeks bet ween the disappearance of H BsAg and the appearance of ant i-H BsAb. H epatitis B precore antigen (H BeAg) represents a high level of viral replication and high infectivity.

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A: As follows: First line treatment: Usually miltefosine should be given: • Adult: 50 mg twice daily for 12 weeks order 3.03mg yasmin mastercard birth control pills for hair growth. A: Because: • The mass is in the right hypochondrium and in the epigastrium (left lobe) purchase yasmin 3.03mg with amex birth control for women 8 pack. A: Yes buy generic calan 240mg on line, if it is pushed downward by any pathology in the right side of chest, such as emphysema, pleural effusion or pneumothorax. A: Investigations should be done according to the history and suspicion of cause: 1. A: 4 methods: • Percutaneous (by Vim–Silverman needle, Menghini needle or Tru-cut needle). If bilirubin is high, liver biopsy should not be done, as liver tissue does not take the stain. A: By percussion, upper border of liver dullness is in the sixth intercostal space or rib in right midcla- vicular line and the distance between this upper border and lower border is called liver span. It is character- ized by fever, pain in the right hypochondrium with radiation to right shoulder, tender hepatomegaly, hepatic rub and small right pleural effusion. Treatment: Tetracycline or doxycycline or erythromycin or azithromycin are used for Chlamydia infection. A: Because, the liver is hard, irregular, nodular, non-tender and there is hepatic bruit. Q:How to differentiate between primary carcinoma (hepatoma) and secondary carcinoma? Metabolic abnormalities are polycythaemia, hypercalcaemia, hypoglycaemia and porphyria cutanea tarda. A:Rarely, fbrolamellar hepatocellular carcinoma, common in young adults, affecting equally in male and female, in the absence of hepatitis B and cirrhosis. Other (rare) primary tumours are haemangioendothelial sarcoma, cholangiocarcinoma, hepatoblastoma, leiomyosarcoma, fbrosarcoma. Surgical resection, if pressure symptoms, also if pregnancy is desired (as size is increased in pregnancy). A: Because liver has dual blood supply causing relatively more blood fow (by portal vein and hepatic artery). A: It is a normal component of plasma protein, produced by the foetal liver older than 6 weeks and reaches maximum concentration at 12 to 16 weeks of foetal life. My diagnosis is tender hepatomegaly, which may be due to: • Acute viral hepatitis. Remember the following points: • Clinical features and pathological features are same by all viruses. But in cholestatic hepatitis or obstructive jaundice, alkaline phosphatase may be very high). A: As follows: • Acute fulminating hepatic failure (by B and sometimes E in pregnancy. It is seen in anxious patient who complains of malaise, anorexia, nausea, vomiting, right hypochondrial pain or discomfort in the absence of clinical or biochemical evidence of liver disease.

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Drugs for Disorders Involving Calcium and Bone Mineralization Calcium Salts Calcium salts are available in oral and parenteral formulations for treating hypocalcemic states cheap 3.03 mg yasmin otc birth control for women with migraine with aura. These salts differ in their percentages of elemental calcium 3.03mg yasmin otc birth control pills for menopause symptoms, which must be accounted for when determining dosage order line eurax. As discussed in Chapter 48, calcium supplements may have the added benefit of reducing symptoms of premenstrual syndrome. Also, data indicate that calcium supplements can produce a significant, albeit modest, reduction in recurrence of colorectal adenomas. Adverse Effects When calcium is taken chronically in high doses (3–4 g/day), hypercalcemia can result. Hypercalcemia is most likely in patients who are also receiving large doses of vitamin D. In addition, hypercalcemia may cause cardiac dysrhythmias and deposition of calcium in soft tissue. Hypercalcemia can be minimized with frequent monitoring of plasma calcium content. These drugs include tetracycline and quinolone antibiotics, thyroid hormone, the anticonvulsant phenytoin, and bisphosphonates. Thiazide diuretics decrease renal calcium excretion and may thereby cause hypercalcemia; however, loop diuretics increase calcium excretion and may cause hypocalcemia. Food Interactions Certain foods contain substances that can suppress calcium absorption. One such substance—oxalic acid—is found in spinach, rhubarb, Swiss chard, and beets. Phytic acid, another depressant of calcium absorption, and insoluble fiber, which also hampers absorption, are present in bran and whole-grain cereals. Preparations and Dosage The calcium salts available for oral administration are shown in Table 59. Note that the dosage required to provide a particular amount of elemental calcium differs among preparations. Chewable tablets are preferred to standard tablets because of more consistent bioavailability. Bioavailability of calcium citrate appears especially good, owing to high solubility. When calcium supplements are taken, total daily calcium intake (dietary plus supplemental) should equal the values in Table 59. To help ensure adequate absorption, no more than 600 mg should be consumed at one time.

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These data summarize the results of an experiment designed to study the effects of a natural transmitter (acetylcholine) and a series of drugs (nicotine cheap yasmin 3.03mg visa birth control pills during pregnancy, muscarine discount yasmin 3.03mg otc birth control options without hormones, d-tubocurarine buy generic duetact 17mg, and atropine) on two tissues: skeletal muscle and ciliary muscle. In the discussion that follows, we examine the selective responses of these tissues to drugs and see how those responses reveal the existence of receptor subtypes. Because both types of muscle respond to acetylcholine, it is safe to conclude that both muscles have receptors for this substance. Because acetylcholine is the natural transmitter for these receptors, we would classify these receptors as cholinergic. The effects of nicotine on these muscles suggest four possible conclusions: (1) Because skeletal muscle contracts in response to nicotine, we can conclude that skeletal muscle has receptors at which nicotine can act. The conclusions that can be drawn regarding responses to muscarine are exactly parallel to those drawn for nicotine. These conclusions are that (1) ciliary muscle has receptors that respond to muscarine, (2) skeletal muscle may not have receptors for muscarine, (3) muscarine may be acting at the same receptors on ciliary muscle where acetylcholine acts, and (4) the receptors for acetylcholine on ciliary muscle may be different from the receptors for acetylcholine on skeletal muscle. The responses of skeletal muscle and ciliary muscle to nicotine and muscarine suggest, but do not prove, that the cholinergic receptors on these two tissues are different. However, the responses of these two tissues to d-tubocurarine and atropine, both of which are receptor blocking agents, eliminate any doubts as to the presence of cholinergic receptor subtypes. When both types of muscle are pretreated with d-tubocurarine and then exposed to acetylcholine, the response to acetylcholine is blocked in skeletal muscle but not in ciliary muscle. Tubocurarine pretreatment does not reduce the ability of acetylcholine to stimulate ciliary muscle. Conversely, pretreatment with atropine selectively blocks the response to acetylcholine in ciliary muscle—but atropine does nothing to prevent acetylcholine from stimulating receptors on skeletal muscle. Because tubocurarine can selectively block cholinergic receptors in skeletal muscle, whereas atropine can selectively block cholinergic receptors in ciliary muscle, we can conclude with certainty that the receptors for acetylcholine in these two types of muscle must be different. The data just discussed illustrate the essential role of drugs in revealing the presence of receptor subtypes. If acetylcholine were the only probe that we had, all that we would have been able to observe is that both skeletal muscle and ciliary muscle can respond to this agent. This simple observation would provide no basis for suspecting that the receptors for acetylcholine in these two tissues were different. It is only through the use of selectively acting drugs that the presence of receptor subtypes was initially revealed. Today, the technology for identifying receptors and their subtypes is extremely sophisticated—not that studies like the one just discussed are no longer of value. As you can imagine, this allows us to understand receptors in ways that were unthinkable in the past. Drugs achieve their selectivity for receptor subtypes by having structures that are different from those of natural transmitters.