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Cristiana A. Costa, DO

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/cristiana-costa-do

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Barium x-rays identify the affected region as a constricted segment because the excitatory effects of the neurotransmitter acetylcholine are unopposed as a result of the absence of inhibitory neurotransmitter medicine 9312 purchase seroquel 100 mg with amex. The autonomic nervous system comprises sensory nerves medications list template discount seroquel 200 mg buy on line, whose cell bodies are found in the dorsal root ganglia medications 6 rights seroquel 100 mg buy lowest price, and motor nerves, the sympathetic and parasympathetic nerves. Parasympathetic nerves innervating the right colon travel in the vagus nerve, and those innervating the left colon originate from the pelvic sacral nerves. Parasympathetic nerves are predominantly excitatory, and sympathetic nerves are inhibitory. Autonomic nerves modulate the enteric neural circuits within the colon and participate in neural reflexes at the level of the autonomic ganglia, spinal cord and brain. Braingut connections are important both for perception of visceral stimuli (sensory) and in modifying colonic function (motor) in response to central stimuli. An example of a central stimulus that can evoke significant changes in colonic activity through this connection is acute stress. This stimulus provokes release of central hormones, such as corticotropin releasing factor. These hormones activate parasympathetic pathways that stimulate motility patterns in the colon, and can result in diarrhea. The fundamental feature of colonic electrolyte transport that enables this efficient water absorption is the ability of the colonic mucosa to generate a large osmotic gradient between the lumen and the intercellular space. In contrast to the small intestine, where sodium in the intercellular space can diffuse back into the lumen and become iso-osmotic, hypertonic solutions are maintained in the intercellular space of the colon because the tight junctions are much less permeable to sodium diffusion. The net result is that the hypertonic fluid within the intercellular space draws water passively into the mucosa from the colonic lumen. In the colon there is also a highly efficient + + absorption of sodium (Na ): of the 150 mEq of Na that enters the colon each day, less than 5 + mEq is lost in the stool. In contrast to Na, the tight junctions of the colon are highly permeable + + + to potassium (K ), allowing K to move from the plasma to the lumen. K is normally secreted into the lumen unless intraluminal potassium rises above 15 mEq/L. This handling of potassium may account for hypokalemia seen with colonic diarrhea and may play a role in maintaining potassium balance in the late stages of renal failure. One important difference is the effect of the hormone aldosterone, which is absent in the small intestine. Aldosterone is secreted in response to total body Na+ depletion or K+ loading, and in the colon, aldosterone stimulates sodium absorption and potassium secretion. The movement of fecal material from cecum to rectum is a slow process, occurring normally over 3-4 days. Several contractile patterns exist within the circular and longitudinal muscle of the colon. Ring contractions are due to circular muscle contraction, and these are either tonic or rhythmic. Tonic contractions are sustained over hours, form the haustral markings evident on barium x-rays and play a role in mixing. Regular contractions are nonocclusive, occur over a few seconds, and migrate cephalad (right colon) and caudad (left colon). Intermittent ring contractions occur every few hours, occlude the lumen, and migrate caudad. They result in the mass movement of stool, particularly in the sigmoid colon and rectum. Contractions of the longitudinal muscle produce bulging of the colonic wall between the taeniae coli, but the physiological importance of this action remains poorly understood. The origin of the contractions of the longitudinal muscle is not completely understood, but it depends upon the slow wave frequency of smooth muscle. Action potentials occur on the peaks of these membrane oscillations and hence they control the frequency of contractions. The nature of the contractile patterns within the colon depends upon the fed state.

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A provincial survey however symptoms zoloft withdrawal discount seroquel 200 mg with amex, this may reect the severity of illness rather than a gly- of over 2 medicine 5e cheap seroquel 200 mg online,000 people with diabetes admitted to hospital found that cemic control advantage medicine online order seroquel 50 mg with mastercard. If the patient cannot demon- assessment of barriers and goal setting, have also been associated strate and/or describe the above-mentioned actions and desires to with improvements in glycemic control (97,111). Different pump manufac- programs evaluated with real-time metrics have been shown to turers will recommend discontinuing pumps for certain hospital- improve glycemic control and safety of insulin ordering (97,114). To date, metrics for monitoring glycemic control programs in To promote a collaborative relationship between the hospital staff hospitals have not been established (115). Documents that stipulate contraindications into the development and implementation of appropriate S120 J. Every 1 to 2 hours for people on continuous intravenous insulin or communication with primary providers at discharge (111), have been those who are critically ill [Grade D, Consensus]. Provided that their medical conditions, dietary intake and glycemic control ing people with diabetes and their family or caregivers with written are stable, people with diabetes should be maintained on their pre- and oral instructions regarding their diabetes management at the hospitalization noninsulin antihyperglycemic agents or insulin regimens time of hospital discharge will facilitate transition to community [Grade D, Consensus]. For the majority of noncritically ill hospitalized people with diabetes, lowering medications. For most medical/surgical critically ill hospitalized people with diabetes primary care providers is important. In hospitalized people with diabetes requiring insulin therapy, protocols Hypoglycemia remains a major barrier to achieving optimal using basal insulin with/without bolus insulin should be used for post- glycemic control in hospitalized people with diabetes. In hospitalized people with diabetes, hypoglycemia should be mini- care workers about factors that increase the risk of hypoglycemia, mized. Programs consisting of the following elements should be implemented for optimal inpatient diabetes care: Insulin administration errors a. Health-care professional development regarding in-hospital diabe- Insulin is considered a high-alert medication and can be tes management [Grade D, Level 4 (95)] c. Algorithms, order sets and decision support [Grade C, Level 3 associated with risk of harm and severe adverse events. All hospitalized people with a history of diabetes to identify indi- viduals that would benet from glycemic optimization [Grade D, Consensus] Other Relevant Guidelines b. All hospitalized people with newly diagnosed hyperglycemia or those with diabetes risk factors to identify individuals at risk for ongoing Glycemic Management in Adults With Type 1 Diabetes, p. S80 dysglycemia [Grade C, Level 3 (16)] Pharmacologic Glycemic Management of Type 2 Diabetes in c. Repeat screening should be performed 6 to 8 weeks post-hospital discharge for individuals with an A1C 6. Clinical decision support systems in the care of inpatients with diabetes in non-critical care setting: System- atic review. Miller reports based reporting and benchmarking center for inpatient glucometrics. Hyperglycaemia is associated with and grants and personal fees from Boehringer Ingelheim, Janssen, poor outcomes in patients admitted to hospital with acute exacerbations of Merck, outside the submitted work. The relation between hyperglyce- mia and outcomes in 2,471 patients admitted to the hospital with community- ance), and Merck Canada, outside the submitted work. Intensive insulin therapy and marker of in-hospital mortality in patients with undiagnosed diabetes. Windows of opportunity to improve diabetes care when cal Endocrinologists and American Diabetes Association consensus state- patients with diabetes are hospitalized for other conditions. Presentation blood glucose and death, hos- tive insulin infusion protocol in a medical intensive care unit. Diabetes Care pitalization, and future diabetes risk in patients with acute heart failure syn- 2004;27:4617. Glucose metabolism in patients with Indications, methods, and transition to subcutaneous insulin therapy. Endocr acute myocardial infarction and no previous diagnosis of diabetes mellitus: Pract 2004;10(Suppl. Utility of HbA(1c) levels for diabetes and the risk of infectious complications in a cohort of adults with diabetes.

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Prevalence and antimicrobial susceptibility pattern of extended-spectrum beta-lactamase-producing Enterobacteriaceae in the United Arab Emirates hair treatment discount seroquel 200 mg buy on line. Antibiotic resistance of coliform bacteria from community-acquired urinary tract infections in the Zenica-Doboj Canton medications during labor generic 200 mg seroquel otc, Bosnia and Herzegovina medications lisinopril seroquel 50 mg without a prescription. Epidemiology and susceptibility to antimicrobials in community, hospital and long-term care facility bacteremia in northern Israel: a 6 year surveillance. Epidemiology of bacteremia episodes in a single center: increase in Gram-negative isolates, antibiotics resistance, and patient age. Community-acquired complicated intra-abdominal infections in children hospitalized during 1995-2004 at a paediatric surgery department. Study of extended-spectrum (beta)-lactamase-producing bacteria from urinary tract infections in Bangladesh. Study of antimicrobial susceptibility of clinically signifcant microorganisms isolated from selected areas of Dhaka, Bangladesh. Antibiotic susceptibility patterns of uropathogens isolated from pediatric patients in a selected hospital of Bangladesh. A survey on antimicrobial sensitivity pattern of diferent antibiotics on clinical isolates of Escherichia coli collected from Dhaka city, Bangladesh. A ten year analysis of multi-drug resistant blood stream infections caused by Escherichia coli & Klebsiella pneumoniae in a tertiary care hospital. Symptomatic and asymptomatic urinary tract infection by Escherichia coli among pregnant women attending out patient clinic of obstetrics and gynecology. Extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae in diabetic foot infections. Prevalence of extended-spectrum beta-lactamases among Escherichia coli and Klebsiella pneumoniae isolates in a tertiary care hospital. Prevalence of extended spectrum beta lactamase and AmpC beta lactamase producers among Escherichia coli isolates in a tertiary care hospital in Jaipur. Antimicrobial susceptibility profles of aerobic and facultative Gram-negative bacilli isolated from patients with intra-abdominal infections in the Asia-Pacifc region according to currently established susceptibility interpretive criteria. Antibiotic susceptibility of intra-abdominal infection isolates from Indian hospitals during 2008. The eect of age on the bacteria isolated and the antibiotic-sensitivity pattern in infections among cancer patients. Antibiotic resistance pattern among common bacterial uropathogens with a special reference to ciprooxacin resistant Escherichia coli. Study of antimicrobial susceptibility pattern of Escherichia coli isolated from clinical specimens in a Teaching Hospital, Pondicherry. High prevalence of extended-spectrum (beta)-lactamase-producing pathogens: Results of a surveillance study in two hospitals in Ujjain, India. Increasing burden of hospital acquired infections: Resistance to cephalosporin antibiotics among klebsiella and Escherichia coli. Prevalence of bacteriuria in Jeyaseharan hospital of South India and their antibiogram. Changing trends of in vitro antimicrobial resistance patterns in blood isolates in a tertiary care hospital over a period of 4 years. Antibacterial resistance and trend of urinary tract pathogens to commonly used antibiotics in Kashmir Valley. Trends in antimicrobial susceptibility of gram-negative bacteria isolated from blood in Jakarta from 2002 to 2008. Surveillance and correlation of antibiotic prescription and resistance of Gram-negative bacteria in Singaporean hospitals. Aetiology of community-acquired urinary tract infection and antimicrobial susceptibility patterns of uropathogens isolated. A survey of bacterial isolates cultured from apparently healthy individuals in South Western Nigeria. Prevalence and susceptibility patterns of urine isolates of escherichia coli to various fuoroquinolones in South-South Nigeria. Bacteriuria and antimicrobial susceptibility of e coli isolated from urine of asymptomatic university students in Kef, Nigeria.

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Ethnography is a study of people in the context of their social and physical environment brazilian keratin treatment buy cheap seroquel 50 mg online, and includes observations treatment 5th metatarsal base fracture generic seroquel 300 mg otc, face to face interviews and documentary analysis symptoms 10 days before period generic seroquel 200 mg mastercard. Tribalism in medicine Ethnography has also been used to describe the infuence has been described and discussed in the literature. Further of culture and team dynamics on the antibiotic prescribing evidence of the confict between the behaviours of individuals, behaviours of surgical teams in a study conducted across 6 the medical hierarchy and guidelines and policy can be found surgical teams in a large teaching hospital in London. What was identifed was platform for an international research collaboration investigating the existence of tacit rules governing prescribing. Hierarchy antibiotic prescribing in the surgical pathway in low and middle and prescribing etiquette overruled policy and guidelines: income countries. Senior clinicians wielded signifcant infuence on the prescribing choices and decisions of junior doctors. The study called for a need to improve the Charani E, Castro-Sanchez E, Sevdalis N, et al. This may be because Norway, being a more egalitarian society with Audio fle eforts made to fatten visible hierarchies (eg. Though efective to and essential to bringing about behavior change there is less evidence of their use in antibiotic Quality improvement interventions take many forms. In its widest sense quality Audit and feedback, which has been tried in stewardship improvement is the combined and unceasing eforts of everyone interventions, is the monitoring and feedback provision on to make changes that will lead to better patient outcomes, better outcomes of behaviour to the people whose behaviour is system performance (care) and better professional development. A summary of all the behaviour change techniques that are applicable to antibiotic stewardship are in Change making should become an intrinsic part of everyones the references below: job, every day, in all parts of the system. Changing systems is only part of the improvement arsenal behaviours also need to be improved. Despite existing policies and guidelines, antibiotic use in hospitals continues to be suboptimal, in the face of rising resistance. Evidence from social sciences can help develop more sustanble and context driven stewardship interventions. A Cochrane review on audit and feedback and its efect on healthcare professional behaviours has been This technique is based on the premise that for any change in published. In it the authors identify the key steps to successful behavior, a person must: and efective audit and feedback as: Be physically and psychologically capable of performing the 1) utilising multimodal approach to delivery of the feedback necessary actions (e. Interventions to improve antibiotic prescribing practices for Professor Susan Michie, Director of the Centre for Behaviour hospital inpatients. Behavior change strategies to infuence antimicrobial prescribing in acute care: A systematic review. An antibioticstewardship program initiative: A qualitative study on prescribing practices among hospital doctors. Ethnographic study of knowledge of interventions where social science and behavior change management in primary care. Mapping the 2017;72(12):3223-31 decision pathways of acute infection management in secondary 2. Understanding antibiotic decision making As the evidence in this chapter has demonstrated social science in surgery a qualitative analysis. Face-to-face educational visits have been shown to have greater and longer lasting efects on changing prescribing behaviour than printed material or group interactions alone. Improving drug-therapy decisions through educational outreach: a randomised controlled trial of academically based detailing. Dif data Finally in 2013, the national action plan on antimicrobial analysis resistance specifed actions required to improve professional Distance learning through Future Learn (e. Australia antibiotic resistance awareness through education Develop resources to support the implementation and training. Once there is civil-society-organisations-in-health-on-antibiotic- a realistic assessment of knowledge, skills and competence, use-and-resistance learning needs and how these can be met can be determined. London: Institute of Personnel and consists of fve dimensions, each of which includes statements Development, 1999. Introduction: Educating the public and clinicians in the prudent use a framework for examining organisational of antimicrobials as part of an antimicrobial stewardship efectiveness. Organisational Efectiveness: Improving surveillance, and infection prevention and control The Role of Psychology. Association Pharmacy Infection Network and endorsed by the Royal Pharmaceutical Society as a tool to support 3.

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In many cases treatment for uti order seroquel 200 mg amex, this dose will be higher eters for the nonpharmacologic treatment of chronic insomnia treatment centers for alcoholism purchase seroquel 50 mg without prescription. Standards of or olanzapine may be specifcally useful in individuals with bi- Practice Committee of the American Academy of Sleep Medi- polar disorder or severe anxiety disorders medications errors pictures purchase seroquel overnight. In for the psychological and behavioral treatment of insomnia: an some cases, medications such as gabapentin or pregabalin may update. Practice parameters with a longer-acting analgesic medication near bedtime may for the use of actigraphy in the assessment of sleep and sleep also be useful, although narcotic analgesics may disrupt sleep disorders: an update for 2007. Rules of evidence and clinical recommendations for bid insomnia may beneft from behavioral and psychological the management of patients. The burden of chronic insomnia on society: awaken- Combined Therapy for Insomnia ing insomnia management. Characteristics of insomnia in the United Hypnotic medications are effcacious as short-term treatment States: results of the 1991 National Sleep Foundation Survey. Epidemiology of insomnia: what we know and what sleep in a model of transient insomnia related to a novel sleep we still need to learn. Beneft-risk assessment of zaleplon in the miology of insomnia: prevalence, self-help treatments, consul- treatment of insomnia. Philadelphia: Elsevier mary insomnia: results of a polysomnographic double-blind con- Saunders, 2005:714-25. A review of the evidence for the effcacy and safe- Psychophysiological insomnia: the behavioural model and a neu- ty of trazodone in insomnia. Quantitative criteria on sleep physiology measures with major depression and insom- for insomnia. Vale- diagnostic criteria for insomnia: Report of an American Academy rian-hops combination and diphenhydramine for treating in- of Sleep Medicine Work Group. National Institutes of Health State nightly use of zolpidem in chronic insomnia: results of a large- of the Science Conference statement on Manifestations and Man- scale, double-blind, randomized, outpatient study. Certifed behavioral sleep clone over 6 months of nightly treatment: results of a randomized, medicine specialists. Rebound insomnia: dura- zolpidem for chronic insomnia: A meta-analysis of treatment ef- tion of use and individual differences. Eszopiclone co-admin- mals and patients with insomnia after abrupt and tapered discon- istered with fuoxetine in patients with insomnia coexisitng with tinuation. Trazodone for antide- chological treatment for insomnia in the management of long- pressant-associated insomnia Am J Psychiatry 1994;151:1069-72. Am J Psychiatry pharmacological therapies for late-life insomnia: a randomized 2004;161:332-42. Sedative hypnotics in cotherapy combined with stimulus control treatment in chronic older people with insomnia: meta-analysis of risks and benefts. The cover photo shows a bioreactor at Roches Penzberg facility and conveys at least a rough of idea of the sophisticated technical know-how and years of experience required to manufacture biopharma- ceuticals. Modern biotechnology plays a crucial role both in the elucidation of the molecular causes of disease and in the development of new diagnostic methods and better target- ed drugs. These developments have led to the birth of a new economic sec- tor, the biotech industry, associated mostly with small start-up companies. For their part, the more established healthcare com- panies have also been employing these modern techniques, known collectively as biotechnology, successfully for many years. By studying the molecular foundations of diseases they have developed more specific ways of combating diseases than ever before. This new knowledge permits novel approaches to treatment, with new classes of drug biopharmaceuticals at- tacking previously unknown targets. Increasing attention is also being paid to differences between individual patients, with the result that in the case of many diseases the goal of knowing in advance whether and how a particular treatment will work in a given patient is now within reach. When a disease, rather than being diagnosed on the ba- sis of more or less vague signs and symptoms, can be detected on the basis of molecular information, the possibility of suc- cessful treatment depends largely on what diagnostic techniques are available. To the healthcare industry this represents a major development in that diagnosis and treatment are growing ever closer together, with clear benefits for companies that possess competence in both these areas. To patients, progress in medical biotechnology means one thing above all: more specific, safer and more successful treatment of their illnesses.

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A post-antibiotic erain which common infections and minor injuries can killfar from being an apocalyptic fantasy medicine lodge treaty purchase seroquel canada, is instead a very real possibility for the 21st century medications beta blockers purchase seroquel 200 mg. Of these medications definition purchase 200 mg seroquel visa, 114 provided data for There are signifcant gaps in surveillance, and a at least one of the nine combinations (22 countries lack of standards for methodology, data sharing provided data on all nine combinations). Non- or emergence in other regions, of artemisinin- representativeness of surveillance data is a limitation resistant strains could jeopardize important recent for the interpretation and comparison of results. Current status of resistance in selected Routine surveillance in most countries is often based bacteria on samples taken from patients with severe infections In the survey forming the basis for this part of the report, particularly infections associated with health care, information was requested on resistance to antibacterial and those in which frst-line treatment has failed. The chosen bacteria underrepresented among samples, leading to gaps are causing some of the most common infections in in coverage of important patient groups. The main fndings are summarized in the following tables: X Summary Bacteria commonly causing infections in hospitals and in the community No. The extent of the problem and its may not be available in resource-constrained impact on patients is not completely clear because of settings, and are also likely to further accelerate variation in how the reduced susceptibility or resistance development of resistance. Because invasive pneumococcal provided data, with proportions of resistance up to disease (e. The large gaps in knowledge of the and serious disease in children and elderly people, situation in many parts of the world further add to better monitoring of this resistance is urgently needed. Available data are insufcient to estimate currently circulating A(H1N1) and A(H3N2) viruses have the wider societal impact and economic implications left neuraminidase inhibitors as the antiviral agents when efective treatment for an infection is completely recommended for infuenza prevention and treatment. Surveillance is hampered by cured after completion of treatment (with 25% lost insufcient implementation of harmonized global to follow-up). Surveillance of antimalarial drug efcacy is critical Integrated surveillance systems would enable for the early detection of antimalarial drug resistance, comparison of data from food-producing animals, because resistance cannot be detected with routine food products and humans. Foci of either suspected or confrmed artemisinin resistance have been identifed in Cambodia, Myanmar, Thailand and Viet Nam. Further spread of artemisinin-resistant strains, or the independent emergence of artemisinin resistance in other regions, could jeopardize important recent gains in malaria control. Resistance to uconazole, Systemic candidiasis is a common fungal infection a common antifungal drug, varies widely by country and worldwide and associated with high rates of morbidity species. Resistance to the newest class of antifungal and mortality in certain groups of patients. Although it is agents, the echinocandins, is already emerging in known that antifungal resistance imposes a substantial some countries. The report and information assembled for the report (noting the also establishes a baseline against which progress main gaps in knowledge), and considers directions in strengthening global surveillance capacities and for future work in this feld. It will also be of interest to the other sectors that are directly involved, including veterinary drug and animal husbandry, agriculture and aquaculture. Already in his Nobel Prize speech in 1945, Alexander Fleming, who discovered penicillin, warned that bacteria could become resistant to these remarkable drugs. Indeed, the development of each new antibacterial drug has been followed by the detection of resistance to it. The development of resistance is a normal evolutionary process for microorganisms, but it is accelerated by the selective pressure exerted by widespread use of antibacterial drugs. Resistant strains are able to propagate and spread where there is non-compliance with infection prevention and control measures. It is essential to preserve ways that favour the selection and spread of resistant the ecacy of existing drugs through measures to bacteria. Consequently, antibacterial drugs have minimize the development and spread of resistance become less eective or even ineective, resulting in to them, while eorts to develop new treatment an accelerating global health security emergency options proceed. Countries with and access to clean water, and exploring a more appropriate surveillance systems have the ability to: widespread use of vaccines. Although preventive obtain national information on the magnitude and vaccines have become available for several bacterial trends in resistance; infections, their application is still limited. This means that progress in modern and monitoring of trends to inform global strategies. When data from national ofcial sources were Common infections in neonatal and intensive care not available or were available in sample sizes that are increasingly becoming extremely difcult, were too small (i.

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Passing forward medicine woman dr quinn generic seroquel 200 mg online, they form the cavernous nerves symptoms 6 days after conception buy 50 mg seroquel fast delivery, which branch into the body of the penis medicine 3605 100 mg seroquel order otc. These pass through the inferior mesenteric plexus, the superior hypogastric plexus, and the pelvic plexus and branch off to the organs involved in ejaculation. The sensory nerves of the penis and scrotum are all branches of the pudendal nerve, which can be traced back to branches of S2S4. With these systems in mind, it can be seen that an erection can be initiated by two independent mechanisms. The nerve impulses synapse in the spinal cord and form a reex arc with nerves of the parasympathetic system responsible for the erectile response. The other mechanism involves the higher centers of the brain that interpret sensory and fantasy stimuli triggering an erotic response resulting in an erection. The erection starts with the stimulation of one or both of these systems in a neuronally modulated hemodynamic response. The exact mechanism of neurotransmission in the erectile response is not yet fully understood. It has previously been noted that the erectile response can be very rapid and synchronized, and it has been found that individual smooth muscle cells are able to communicate directly with each other via gap junctions. Here again, the effect is to reduce the levels of intracellular calcium and produce smooth muscle relaxation. There are other pharmacological agents that employ this alternative mechanism to elicit an erection. In order for a sustained erection to occur, there must be: dilatation of the arteries to allow more blood to enter the penis; engorgement of the sinusoids to establish rigidity; narrowing of the venous system to prevent blood leaking back out. At the same time, the trabecular smooth muscle relaxes and blood is allowed to ll the enlarged sinusoids. As the pressure rises, the penis becomes more tumescent and the subtunical venules become compressed between the collagenated smooth muscle and the tunica albuginea, so that outow is diminished. Further reex contraction of the ischiocavernous muscles during sexual intercourse or masturbation produces a rigid erection with internal pressures of several hundred millimeters of mercury. These have an opposing action to that described earlier so that smooth muscle contracts once more. Blood ow into the penis diminishes and the subtunical veins are opened, allowing blood to escape again. There are several etiological factors that need to be assessed in the history and examination of the affected man. In the anxious individual, there can be overactivity of the sympathetic system leading to increased smooth muscle tone. Alternatively, signals from the brain of an individual with a psychogenic issue can override the erectogenic parasym- pathetic output from the sacral spinal cord. For instance, if he is able to mastur- bate with an erection while alone, but is unable to perform with a partner suggests a situational response. Gay and bisexual men in straight relationships may have difculty achieving an erection with a female partner due to feelings of guilt about their true sexual preference. A high level of cir- culating prolactin causes inhibition of gonadotrophin releasing hormone which lowers levels of testosterone. Determination of free testosterone is preferred as it represents the most accurate parameter to reect a real testosterone deciency in the respective target cells. However, because the methods used most widely for determination of these parameters (e. Since the erectile response is a hemo- dynamic event, it is hardly surprising that damage to the vessels will result in partial or complete loss of the ability to not only achieve but also maintain an erection long enough for it to be useful to its owner and his partner. A standard vascular examination can reveal important clues that may not only indicate a vascular reason for loss of the ability to have an erection, but may also point to major undetected pathology. Drugs, whether prescribed or taken recreationally, may be a source of the problem. Use open ques- tions to elicit the bulk of the information, and clarify issues by asking closed questions and by reecting ideas back to ensure that you have understood what the patient means. Employment related stress and relationship difculties are often involved in the etiology. Ask about the problem, its duration, frequency, and specics such as whether the erection can be elicited but not maintained (suggestive of a veno-occlusive disorder).

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Multicentral clinical dysfunction: a community-based study in rural New York State symptoms 5th week of pregnancy buy seroquel 300 mg free shipping. Significance of phentolamine redosing during prostaglandin E1 penile color Doppler Ayub W treatment borderline personality disorder order seroquel on line amex, Fletcher S symptoms 97 jeep 40 oxygen sensor failure buy seroquel 300 mg on line. End-stage renal disease and ultrasonography in diagnosis of vascular erectile dysfunction. Effects of incidence of androgen deficiency in middle-aged and older men: endogenous testosterone and estradiol on sexual Estimates from the Massachusetts male aging study. Journal of Clinical Endocrinology & Metabolism Araujo Andre B, Durante Richard, Feldman Henry A et al. Sexual & Marital Therapy 1996;11(2):123 Arnavaz A, Aurich A, Weissenborn K et al. The effects of a evaluation of erectile dysfunction: sildenafil plus Doppler new alpha-2 adrenoceptor antagonist on sleep and ultrasonography. J Am Coll Surg tamsulosin in the management of orgasm-associated 2004;199(3):446-461. A new atypical antipsychotic: population: data from the Prostate Cancer Awareness quetiapine-induced sexual dysfunctions. Sex Psychostimulants apparently reverse sexual dysfunction inventories: can questionnaires replace erectile secondary to selective serotonin re-uptake inhibitors. Erectile up of a randomized prospective study comparing transurethral dysfunction and priapism. Laboratory evaluations of erectile dysfunction: an evidence based Beasley C M, Mitchell M I, Dmitrienko A A et al. J Am Coll Cardiol 2005;46(4):678 the restoration of erection in spinal cord injured males: 687. Erectile dysfunction in Latin America and treatment with sildenafil citrate (Viagra ): Introduction. The clinical evaluation of the patient presenting the safety of sildenafil for male erectile dysfunction: with erectile dysfunction: what is reasonable?. A randomised minoxidil in the treatment of erectile dysfunctions in spinal cord comparison of the effects of nebivolol and atenolol injured men. Adverse events of apomorphine formulations for erectile dysfunction: associated with testosterone replacement in middle- Recommendations for use in the elderly. Drugs Aging aged and older men: A meta-analysis of randomized, 2006;23(4):309-319. Journals of Gerontology Series A-Biological Sciences & Medical Sciences Briganti A, Salonia A, Zanni G et al. Beneficial cardiovascular effects and safety of sildenafil reported in trio of studies. Clinical & Experimental Pharmacology & Physiology Relationship between patient self-assessment of 2007;34(4):327-331. Testosterone and erectile function, nocturnal penile tumescence and Brown J S, Wessells H, Chancellor M B et al. Urologic rigidity, and erectile response to visual erotic stimuli complications of diabetes. The effects of testosterone administration and visual erotic stimuli on Buddeberg C, Bucher T, Hornung R. Sexual function does trial of sustained-release fampridine in chronic spinal not change when serum testosterone levels are cord injury. Proc Annu Clin Spinal Cord Inj Conf pharmacologically varied within the normal male range. Safety and tolerability of apomorphine Sexual dysfunction: Male erectile disorder. Efficacy of tadalafil for the treatment of erectile Carosa E, Benvenga S, Trimarchi F et al. Testosterone replacement therapy in the nonresponders: A multicentre, double-blind, 12-week, ageing man. The Journal of Mens Health & Gender flexible-dose, placebo-controlled erectile dysfunction 2005;2(4):396-399. Clinical course of penile prostaglandin E1 and its main metabolites after intracavernous fibrosis in intracavernosal prostaglandin E1 injection injection and short-term infusion of prostaglandin E1 in patients therapy: a follow-up of 44 patients.

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Poor diet Contributory factor in many countries but rarely sole cause Clinical manifestation: Is insidious in onset and progressive in course Patients often present with nonspecific symptoms mentioned above with/without some specific symptoms symptoms narcolepsy seroquel 100 mg lowest price. Inadequate response may imply Continuing hemorrhage non compliance to therapy Wrong diagnosis Mixed deficiency associated folate or vit symptoms 2dp5dt seroquel 50 mg overnight delivery. Inability or unwillingness to take orally Iron-dextran complex or iron sorbitol citrate can be used Intra-muscularly or intra-venous route medicine for diarrhea order seroquel 50 mg. Correction of reversible contributors (iron, folate, cobalamine supplements if necessary) C) Sideroblastic anemia: Refractory anemia with hypochromia with marrow iron Many pathological ring sideroblasts are found in the bone marrow Is caused by defect in hem synthesis Classification: Hereditary (sex linked recessive trait) Acquired 399 Internal Medicine o Primary :Myelodysplasia o Secondary : - Malignant diseases of the marrow - Drugs e. Macrocytic Anemia Learning objectives: at the end of the student will be able to:- 1. Understand the management of Megaloblastic anemia and asses response to therapy properly Megaloblastic Anemia and other Macrocytic Anemia Pathogenesis: Its a descriptive morphologic term in which maturation of the nucleus is delayed relative to that of cytoplasm. Abnormalities of vitamin B12 or folate metabolism, transcobalamine deficiency, antifolate-drugs 4. B12 deficiency 1) Nutritional: especially in vegans 2) Malabsorption a) Gastric causes i) Adult (addisonian) pernicious anemia ii) Congenital lack or abnormality of intrinsic factor iii) Total or partial gastrectomy b) Intestinal causes i) Intestinal stagnant loop syndrome, jejunal diverticulosis, blind loop, stricture etc. Vit B12 Deficiency: is treated with Hydroxocobalamine which is given parentraly Dose: Initial dose: 6 x 1000 g over 2-3 weeks and Maintenance : 1000 g every 3 months Prophylactic therapy is indicated in patients with Total gastrectomy and Ileal resection 2. Folate deficiency: is treated with Folic acid preparation which is given orally Dose: 5 mg Po daily Prophylactic therapy is indicated in pregnancy, sever hemolytic anemia, in patients with dialysis, and premature newborns 3. Additional measures: Correct underlying cause Antibiotics for bacterial over growth and treatment of fish tapeworm Response to therapy Feeling of general well being is restored in 48 hrs Reticulocytosis begins in 3-4 days and peaks in 7-10 days. Leukemias Learning Objective: At the end of this unit the student will be able to 1) Define leukemia 2) Classify the different types of leukemias 3) Describe the possible etiologies and epidemiology of leukemia. Cell of origin : there are two types of leukemias Lymphoid leukemias Myeloid leukemias 2. But studies have demonstrated that both genetics and environmental factors are important in the causation of these diseases. Genetics There is a greatly increased incidence of leukemia in the identical twin of patients with leukemia. Environmental factors like Ionizing radiation: The relation between acute leukemia and ionizing radiation, has been established in those having occupational radiation exposure, patients receiving radiotherapy and Japanese survivors of atomic bomb explosions. Epidemiology Globally the incidence of all leukemias is 13/100,000/ year usually affecting men more than women. Acute Leukemias Acute leukemias are characterized by the presence of immature white blood cells in the marrow and peripheral blood. Pathophysiology Acute leukemias are characterized by clonal proliferation of immature hematopoietic cells. In the majority of cases the initial symptoms are present for less than 3 months and are the consequence of bone marrow failure, i. Laboratory Investigation The definitive diagnosis of acute leukemia is made on the basis of peripheral blood film and bone marrow aspirate examination. The following tests should be done to detect the disease & other associated abnormalities. Remission induction is characterized by intensive systemic chemotherapy with the goal of reducing leukemic cell below the level of clinical detection called complete remission. Consolidation/ early intensification phase After complete remission if there is no further treatment given, leukemia cells will expand and lead to relapse. Appropriate preventive measures should routinely be employed to prevent infections in such immunocompromised patients. These include Isolation of staff and visitors by the use of face masks Practice careful hand washing before coming in contact with the patient Advise the patient to eat only cooked foods When infections occur, gram negative sepsis is the commonest presentation, which requires prompt evaluation and empirical antibiotic treatment until definitive diagnosis is made by blood culture, after which the antibiotic(s) can be modified depending on the organism identified & its drug sensitivity. However, the majority will have signs and symptoms resulting from:- 1) tissue infiltration by leukemic cells 2) Bone marrow failure with peripheral blood cytopenias and immune suppression. If a patient has stage 0 disease without other poor prognostic factors, the median survival would be more than 10 yrs without treatment. It has a progressive clinical course with three phases starting with chronic phase and evolving to accelerated phase and then to blast transformation. Chronic Phase: The onset is insidious and some patients can be diagnosed while asymptomatic during health screening visits. Physical examination may show In the early stage 90% of or more of the cases may show o Moderately pale conjunctivae o Enlarged spleen and mild liver enlargement.

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These are also associated with autosomal inheritance and either normal or only mildly impaired carbohydrate metabolism (63 medications used for bipolar disorder cheap 200 mg seroquel mastercard,64) medicine q10 purchase seroquel 100 mg overnight delivery. The metabolic abnormalities associated with mutations of the insulin receptor may range from hyperinsulinaemia and modest hyperglycaemia to symptomatic diabetes (65 symptoms 10dpo order seroquel 300 mg free shipping,66). Leprechaunism and Rabson Mendenhall syndrome are two paediatric syndromes that have mutations in the insulin receptor gene with subsequent alterations in insulin receptor function and extreme insulin resistance (66). The former has characteristic facial features while the latter is associated with abnormalities of teeth and nails and pineal gland hyperplasia. With the exception of cancer, damage to the pancreas must be extensive for diabetes to occur. However, adenocarcinomas that involve only a small portion of the pancreas have been associated with diabetes. If extensive enough, cystic fibrosis and haemochromatosis will also damage beta cells and impair insulin secretion (70,71). Fibrocalculous pancreatopathy may be accompanied by abdominal pain radiating to the back and pancreatic calcification on Xray and ductal dilatation (72). Pancreatic fibrosis and calcified stones in the exocrine ducts are found at autopsy. Diseases associated with excess secretion of these hormones can cause diabetes (e. These forms of hyperglycaemia typically resolve when the hormone excess is removed. These drugs may not, by themselves, cause diabetes but they may precipitate diabetes in persons with insulin resistance (76,77). In such cases, the classification is ambiguous, as the primacy of beta cell dysfunction or insulin resistance is unknown. Certain toxins such as Vacor (a rat poison) and pentamidine can permanently destroy pancreatic beta cells (7880). The list shown in Table 4 is not allinclusive, but reflects the more commonly recognized drug, hormone, or toxin induced forms of diabetes and hyperglycaemia. Postprandial hyperglycaemia of a severity sufficient to fulfil the criteria for diabetes has been reported in rare individuals who spontaneously develop insulin autoantibodies (85,86). However, these individuals generally present with symptoms of hypoglycaemia rather than hyperglycaemia. The stiff man syndrome is an autoimmune disorder of the central nervous system, characterized by stiffness of the axial muscles with painful spasms (87). Patients receiving interferon alpha have been reported to develop diabetes associated with islet cell autoantibodies and, in certain instances, severe insulin deficiency (88). Antiinsulin receptor antibodies can cause diabetes by binding to the insulin receptor, thereby reducing the binding of insulin to target tissues (89). However, these antibodies also can act as an insulin agonist after binding to the receptor and can thereby cause hypoglycaemia (90). Antiinsulin receptor antibodies are occasionally found in patients with systemic lupus erythematosus and other autoimmune diseases (91). As in other states of extreme insulin resistance, patients with antiinsulin receptor antibodies often have acanthosis nigricans. These include the chromosomal abnormalities of Downs syndrome, Klinefelters syndrome and Turners syndrome. Wolframs syndrome is an autosomal recessive disorder characterized by insulindeficient diabetes and the absence of beta cells at autopsy (92). Additional manifestations include diabetes insipidus, hypogonadism, optic atrophy, and neural deafness. This clustering has been labelled variously as Syndrome X (22), the Insulin Resistance Syndrome (47), or the Metabolic Syndrome (47). Central obesity was not included in the original description so the term Metabolic Syndrome is now favoured. It is well documented that the features of the Metabolic Syndrome can be present for up to 10 years before detection of the glycaemic disorders (97). The Metabolic Syndrome with normal glucose tolerance identifies the subject as a member of a group at very high risk of future diabetes. Thus, vigorous early management of the syndrome may have a significant impact on the prevention of both diabetes and cardiovascular disease (98).

Ayitos, 49 years: Circulating immune complexes and autoantibodies cause tissue damage and organ dysfunction.

Rocko, 28 years: A positive diagnosis can be made, particularly in women, if the abdominal pain is present for at least three months in the last year, and if the pain is relieved by defecation.

Myxir, 41 years: Ann hyperglycaemia on microvascular outcomes in type 2 diabetes: An analysis of Intern Med 1995;122:5618.

Vigo, 62 years: Your feelings If you feel stressed, Shared stress and ask about ways to problems?

Rune, 60 years: Market exclusivity gives a company exclusive marketing rights for a particular medicine for a set period of time.

Kulak, 48 years: In the fall of 2000, Gilman embarked on transducer, or switch molecule, passes the a groundbreaking effort to begin to untangle What is a liposome?

Dargoth, 59 years: For most men, erectile dysfunction cannot be cured, for some there may be a reversible underlying cause.

Kan, 25 years: In all cases, the priority at initial assessment is to ensure hemodynamic stability and initiate appropriate volume resuscitation before conducting a detailed history and physical examination.

Ali, 43 years: I also learned that the term medical community signifies a constant discourse between the many facets of medicine.

Einar, 54 years: High prevalence of extended-spectrum (beta)-lactamase-producing pathogens: Results of a surveillance study in two hospitals in Ujjain, India.

Owen, 38 years: Other symptoms include odynophagia, chest pain (which may radiate to the mid-scapular region), hoarseness (due to recurrent laryngeal nerve involvement) and blood loss.

Faesul, 37 years: The non-profit antibiotic developer was transformed, based upon the feedback, into the pipeline coordinator, with more emphasis on collaboration with the private sector.

Denpok, 40 years: May express tumour marker alpha-fetoprotein Choriocarcinoma: Placental tissues (resembles hydatiform mole).

Varek, 32 years: Type 1 includes those cases attributable to an autoimmune process, as well as those with beta cell destruction and who are prone to ketoacidosis for which neither an aetiology nor a pathogenesis is known (idiopathic).

References

• Witztum JL, Steinbrecher UP, et al. Autoantibody to glycosylated protein in the plasma of patients with diabetes mellitus. Proc Natl Acad Sci USA 1984; 81:3204.
• Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol 2006;47(10):2130-2139.
• McDermott MT, Ridgway EC. Central hyperthyroidism. Endocrinol Metab Clin North Am 1998; 27(1):187-203.
• O'Brien SM, Lamanna N, Kipps TJ, et al. A phase 2 study of idelalisib plus rituximab in treatment-naive older patients with chronic lymphocytic leukemia. Blood. 2015;126(25):2686-2694.