L. Cruz. California State University, Monterey.
These are found along the area of superior vena cava cheap malegra dxt plus 160 mg with mastercard erectile dysfunction pump operation, common in neck purchase cheapest malegra dxt plus erectile dysfunction rates, face, chest and dorsum of hand, above the nipple lines, cause of which is unknown. Blanches on pressure with rapid flling on release of pressure, may pulsate if large. Physiological: • Rarely present in normal people (2%), 1 to 2 in number, common in children. Spider angioma in Spider angioma in Spider angioma in Spider angioma in shoulder hand nose face Mechanism of spider angioma: • Due to hyperdynamic circulation. Differential diagnoses of spider angioma: • Purpura (spontaneous bleeding into skin and mucous membrane, does not blanch on pressure, there is progressive colour change). It is caused by elevated venous pressure, does not blanch on pressure and blood fow is from periphery to the centre of lesion (opposite to spider angioma). Because circulating levels of oestrogen increase in both cirrhosis and pregnancy, oestrogen is thought to be the cause for the increased vascularity. Transverse white lines may also be seen in hypoalbuminaemia associated with liver cirrhosis. It is elicited by asking the patient to stretch out arms in front, separate the fngers, dorsifexion of wrist with fxed forearm by the examiner’s hand. Features of fapping tremor: • It is absent at rest, produced by intentional movement, maximum at sustained posture. It is due to methyl mercaptan, exhaled in breath, derived from amino acid methionine, which is not deaminated by the diseased liver. Methyl mercaptan is of intestinal origin (reduced by defaecation or use of antibiotics). Presence of foetor hepaticus indicates severe hepatocellular failure with collateral circulation. Actual cause is unknown, probably due to upregulation of opioid receptors and increased levels of endogenous opioids. Less or not helpful in parenchymal liver disease, as vitamin K is not used or less used by the diseased liver. It is reversible, does not cause marked pathological change in brain and may cause cerebral oedema in advanced stage. In diseased liver, these are not metabolized and enter into the brain through portosystemic shunt. Nitrogenous substances are: • Ammonia (due to breakdown of protein by intestinal bacteria). A: As follows: • Precipitating factors should be avoided (drugs, constipation, electrolyte imbalance, bleeding). Rifaximin 550 mg three times daily orally (not absorbed, acts by reducing bacterial content of bowel). A: Lactulose is a non-absorbable disaccharide, reaches the colon intact, metabolized by colonic bacte- ria to lactic acid. A: It is a clinical syndrome of encephalopathy characterized by confusion, stupor and coma, resulting from sudden severe impairment of hepatic function, occurring within 8 weeks of onset in the absence of pre-existing liver disease. A: As follows: • Two commonest causes are viral hepatitis (commonly B and E, rarely A) and paracetamol toxicity. Features of cerebral oedema due to raised intracranial pressure, such as: • Hyperventilation. A: Constructional apraxia means inability to perform a known act in the absence of any motor or sensory disturbance. A: It is tested in the following way (the patient is unable to do so): • Ask the patient to draw a star. Presentation of a Case: • The abdomen is distended, fanks are full and skin is hyperpigmented. It may be associated with other autoimmune diseases such as: • Sjogren’s syndrome. Urinary tract infections (caused by E coli or Lactobacillus delbrueckii), smoking and possibly hormone replacement therapy, hair dye are risk factors. A: When cirrhosis develops due to prolonged obstruction of the large biliary ducts. Other causes are Sjögren’s syndrome, systemic sclerosis, asymptomatic recurrent bacteriuria in women, pulmonary tuberculosis and leprosy. A: Actual cause is unknown but probably due to upregulation of opioid receptors and increased level of endogenous opioids. Other antibodies such as anti-smooth muscle antibody (35%) and anti-nuclear antibody (25%) may be present. Main dose (8 gm) is given before and after breakfast (as duodenal bile acid secretion is more). Rifampicin 300 mg/day or naltrexone (opioid antagonist) 25 mg/day up to 300 mg/day may be given. In intractable itching, plasmapheresis, liver-support device (molecular absorbent recirculating system) or liver transplantation may be considered. A: As follows: • Advanced liver disease (increasing jaundice with serum bilirubin. A: It is a chelating agent, acts by binding pruritogens in intestine and increases excretion in stool. A: As follows: • If asymptomatic or if the patient presents with pruritus: Survive for more than 20 years. Risk factors for malignancy are older age, male sex, prior blood transfusion, signs of cirrhosis and portal hypertension. Presentation of a Case: • The abdomen is distended, fanks are full with everted umbilicus. However, liver is enlarged if cirrhosis is due to haemochromato- sis and primary biliary cirrhosis. Secondary: Causes are— • Haemolytic anaemia such as:b-Thalassaemia major, chronic haemolytic anaemia due to other cause, pyruvate kinase defciency. A: In haemochromatosis, absorption of iron is more and inappropriate to the body needs. Ultimately progressive and excessive accumulation of iron causes elevation of plasma iron, increase saturation of transferrin and high level of ferritin, which is deposited in different organs of the body. In general population, serum iron and transferrin saturation are the best and cheapest tests available. A: As follows: • Avoid foods rich in iron (such as red meat), alcohol, vitamin C, raw shellfsh, also iron therapy. Then, venesection is continued as required to keep the serum ferritin normal (usually 3 to 4 venesections/year is needed). Following venesection, most of the symptoms improve or disappear, except testicular atrophy, diabetes mellitus and chondrocalcinosis.
Patients with this disease pattern have a significantly greater risk of developing cancers in comparison to individuals with shorter segments of colon ic involvement buy genuine malegra dxt plus line erectile dysfunction in cyclists. P r oph ylact ic pr oct ocolect omies are gen er ally r ecom men d ed for pat ient s wit h pan colit is of sign ificant durat ion s order malegra dxt plus 160mg mastercard erectile dysfunction pills don't work. T his pouch can then be att ached to the anus to form an ileal-j-pouch to anal anastomosis. The t erminal ileum is fashioned t o creat e a pouch wit h 500 to 1000 mL capacity and invagination of the ileum just below the fascia is con st r u ct ed t o pr ovid e cont in en ce. Because the drainage mechanisms are prone to failure in a high percentage of patients, this procedure is rarely done today. The procedure has t he advant age of being t echnically easier to reconst ruct ; however, t he major disadvan- tage is that cancer-prone mucosa is left behind and requires close surveillance. Patients may present with any number of sympt oms, including increased stool frequencies, fecal urgency, fecal incont inence, watery diarrhea, bleeding, abdominal cramps, fever, and malaise. T h er efor e, most pat ient s wit h pouchitis improve with a course of antibiotic treatment. Approximately 50% of patients following ileal-pouch reconstructions will have at least one episode of pou- ch it is, an d 10% t o 15% of pat ient s will d evelop ch r on ic p ou ch it is. Patients typically present with bloody diarrhea, abdominal pain, urgency, and tenesmus of varying severit y wit h episodes of remissions and flare-ups. Enteric infections by Sa lmon ella or Campylobacter species have been shown to correlate with disease development. Syst e m ic t o xicit y: Fe ve r, t a ch yca rd ia, a n e m ia, a n d e le va t e d in f a m m a t o ry m a rke rs. Tr e a t m e n t o U C Treatments generally follow a“step-up”approach that is similar to that described for Crohn disease treatment. Flare-ups or bout s of disease exacer- bations can be controlled with short courses of corticosteroids treatment (induc- tion therapy), with transition to nonsteroidal agents once the patient’s disease is under control. Immunosuppressive agents such as thiopurines and anti-T N F anti- body (infliximab) are also effective in inducing and maintaining remissions. Recent observations suggest that the combination of infliximab and azathioprine may be more effective than either agent alone. G en - erally t wo-t h ird of t he pat ient s will respond t o this t reat ment ; however, for t he one-third of patients who do not respond to intravenous steroids, rescue therapy wit h infliximab, int ravenous cyclosporine, or surgical resect ion will need to be expedit iously implement ed. O perat ive t reat ment s for pat ient s under these circumstances generally consist of total abdominal colectomy with end ileost omy format ion, and wit h t he removal of significant port ions of t he dis- eased burden. Preservation of the rec- tal segment during the initial operation gives patients the opportunity to undergo complet ion pr oct ect omy an d ileal– an al J-p ou ch r econ st r u ct ion wh en the pat ient ’s con dit ion s st abilizes. Early observat ions suggest t hat t his drug is associated wit h few adverse react ion s an d does n ot lead t o the in crease in in fect iou s risks. These cancers are different from the usual colorec- tal cancers in that these cancers generally do not develop from polyps. If a surveillance program is not instituted or not feasible, t h en a proph ylact ic proct ocolect omy sh ou ld be con sidered. The most commonly performed operat ion for the treatment of fulminant colitis is total abdominal colectomy with end ileostomy for- mation. This operation gives patients the opportunity to recover from their acute disease, with the possibility for a second operation where completion proctectomy wit h ileal– anal J-pouch reconst ruct ion can restore cont inence. If a pat ient does not have functional nalsphincters, permanent end ileostomy or continent-ileostomy (Koch Pouch) are the remaining long-term options. Following proctocolectomy and J-pouch reconst ruct ion, most pat ient s experience 4 to 6 bowel movement s a day and have occasional minor soilage. Preoperative patient counseling and patient educat ion, and proper pat ient select ion are crit ical fact ors for long-t erm pat ient sat isfact ion. C o lo r ect al can cer r isk of U C patient s is n o t in flu en ced b y fam ily h ist o r y of colorectal cancers C. T h e r isk of colo r ect al can cer in U C patient s h as b een m ar k ed ly u n d er - est imat ed C. Which of the following findings would be considered a contraindication for completion proctectomy and ileal pouch-anal anastomosis? The finding of high grade dysplasia in the rectal segment at 10 cm from the anal verge B. T h e fin d in g of h igh gr ad e d ysp lasia wit h car cin o m a in sit u in the p r evi- ously resected colon C. The finding of granulomatous changes and transmural inflammatory ch an ges in the pr eviou sly r esect ed colon D. D u r in g the colonoscopy, you notice that the disease involves the entire colon and ter- minal ileum, with sparing of the rectum. Screen in g an d sur veillan ce colon oscopy wit h biopsies is recommen ded in patients with at least left-sided disease (> one-third of colon involvement) or pancolitis. The associated finding of sclerosing cholangitis further increases the risk of colorectal cancers, and these patients are recommended to have year ly colon osco p y an d b iop sy. P at ien t s wit h proct it is or protosigmoidit is do not have significant ly increased risk of color ect al can cer s. A fam ily h ist or y of color ect al can cer in a fir st -d egr ee r ela- tive confers an additional 2-fold to 3-fold increase in cancer risk. Moderat e disease sever it y is defin ed by more t h an four but less t h an six st ools/ day, minimal signs of syst emic t oxicit y, normal or minimally increased inflammat ory markers. Proctocolectomy is associated with some improvements in extracolonic dis- ease manifestations, particularly erythema nodosum, arthritis, and some eye changes. T h e fin din gs of granu lomat ou s ch an ges an d t ran smural in flammat or y ch an ges su ggest the diagn osis of Cr oh n colit is, an d pr oct ocolect omy wit h ileal J-pouch to anal reconst ruct ion is not an appropriate operat ion for t reat - ment in a patient with Crohn disease. T h e colon oscopy fin din g of rect al spar ing disease wit h t er min al ileum involvement raises the quest ion t hat ulcerat ive colit is is not t he correct diag- nosis, and the patient may actually have Crohn disease. H igh -grade dysplasia foun d on colon ic sur veillan ce in a pat ient wit h U C needs to be treated with proctocolectomy because of the risk of cancers being present already and the risk for future cancer development. Pro ct o co le ct o m y is a sso cia t e d in im p ro ve m e n t s in so m e o the e xt ra - clonic processes. He co m p la in s o f in cre a se d p a in, m ild n a u se a, a n d subjective fever. The patient indicates a prior similar episode that was milder and la st in g se ve ra l d ays o n ce b e fo re. Th e p re vio u s e p iso d e re so lve d wit h o ra l a n t ib i- otics as an outpatient. The patient is otherwise healthy and without risk factors fo r ca rd ia c o r p u lm o n a r y d ise a se s. His abdo- men is soft and mildly distended, with localized tenderness to palpation in the left lo we r q u a d ra n t. Confirmation of diagnosis: A C T scan of the ab d om en an d p elvis will h elp wit h radiographic confirmation and identify complications; however, this patient will need endoscopy to rule out colon cancer after the acute inflammat ion resolves. Associated complications: Perforation, abscess formation, bowel obstruction, and fistula development are potent ial complicat ions.
However trusted malegra dxt plus 160 mg impotence legal definition, ongoing work with two agents is encouraging: • Anticocaine vaccine—Subjects receiving the vaccine develop antibodies that bind with cocaine and thereby render the cocaine inactive order malegra dxt plus 160mg online erectile dysfunction future treatment. Methamphetamine The basic pharmacology of the amphetamine family is discussed in Chapter 29. Description and Routes Methamphetamine is a white, crystalline powder that readily dissolves in water or alcohol. According to the 2014 National Survey on Drug Use and Health, use of methamphetamine by Americans 12 years and older continues to decline. Subjective and Behavioral Effects As discussed in Chapter 29 amphetamines act primarily by increasing the release of norepinephrine and dopamine, and partly by reducing the reuptake of both transmitters. Adverse Psychological Effects All amphetamines can produce a psychotic state characterized by delusions, paranoia, and auditory and visual hallucinations, making patients look like they have schizophrenia. Although psychosis can be triggered by a single dose, it occurs more commonly with long-term abuse. Methamphetamine-induced psychosis usually resolves spontaneously after drug withdrawal. Adverse Cardiovascular Effects Because of its sympathomimetic actions, methamphetamine can cause vasoconstriction and excessive stimulation of the heart, leading to hypertension, angina pectoris, and dysrhythmias. Other Adverse Effects By suppressing appetite, methamphetamine can cause significant weight loss. Use during pregnancy increases the risk for preterm birth, hypertension, placental abruption, intrauterine growth restriction, and neonatal death. Lastly, methamphetamine can cause direct injury to dopaminergic nerve terminals in the brain, leading to prolonged deficits in cognition and memory. Tolerance, Dependence, and Withdrawal Long-term use results in tolerance to mood elevation, appetite suppression, and cardiovascular effects. Although physical dependence is only moderate, psychological dependence can be intense. Other symptoms include fatigue, prolonged sleep, excessive eating, and depression. Treatment Methamphetamine addiction responds well to cognitive behavioral therapy. One such approach, known as the Matrix Model, combines group therapy, individual therapy, family education, drug testing, and encouragement to participate in non– drug-related activities. However, encouraging results have been achieved with two drugs: bupropion [Wellbutrin, Zyban], currently approved for major depression and smoking cessation, and modafinil [Provigil, Alertec ], a nonamphetamine stimulant currently approved for narcolepsy, shift-work sleep disorder, and obstructive sleep apnea−hypopnea syndrome. Preliminary results indicate that ibudilast may dampen cravings for methamphetamine and improve cognitive functioning. Marijuana and Related Preparations Marijuana is the most commonly used illicit drug in the United States. Cannabis sativa, the Source of Marijuana Marijuana is prepared from Cannabis sativa, the Indian hemp plant—an unusual plant in that it has separate male and female forms. However, the greatest concentration of psychoactive substances is found in the flowering tops of the female plants. Marijuana is a preparation consisting of leaves and flowers of male and female plants. The endogenous ligand for these receptors appears to be anandamide, a derivative of arachidonic acid unique to the brain. The concentration of cannabinoid receptors is highest in brain regions associated with pleasure, memory, thinking, concentration, appetite, sensory perception, time perception, and coordination of movement. There is evidence that marijuana may act in part through the same reward system as opioids and cocaine. Because of this extensive first-pass metabolism, oral doses must be 3 to 10 times greater than smoked doses to produce equivalent effects. With oral dosing, effects are delayed and prolonged: responses begin in 30 to 50 minutes and persist up to 12 hours. Behavioral and Subjective Effects Marijuana produces three principal subjective effects: euphoria, sedation, and hallucinations. This set of responses is unique to marijuana; no other psychoactive drug causes all three. The following effects are common: euphoria and relaxation; gaiety and a heightened sense of the humorous; increased sensitivity to visual and auditory stimuli; enhanced sense of touch, taste, and smell; increased appetite and ability to appreciate the flavor of food; and distortion of time perception such that short spans seem much longer than they really are. In addition to these effects, which might be considered pleasurable (or at least innocuous), moderate doses can produce undesirable responses. Among these are impairment of short-term memory; decreased capacity to perform multistep tasks; slowed reaction time and impairment of motor coordination (which can make driving dangerous); altered judgment and decision making (which can lead to high-risk sexual behavior); temporal disintegration (inability to distinguish between past, present, and future); depersonalization (a sense of strangeness about the self); decreased ability to perceive the emotions of others; and reduced interpersonal interaction. High-Dose Effects In high doses, marijuana can have serious adverse psychological effects. Euphoria may be displaced by intense anxiety, and a dissociative state may occur in which the user feels “outside of himself or herself. Because of the widespread use of marijuana, psychiatric emergencies caused by the drug are relatively common. Not all users are equally vulnerable to the adverse psychological effects of marijuana. Effects of Chronic Use Chronic, excessive use of marijuana is associated with a behavioral phenomenon known as an amotivational syndrome, characterized by apathy, dullness, poor grooming, reduced interest in achievement, and disinterest in the pursuit of conventional goals. The precise relationship between marijuana and development of the syndrome is not known, nor is it certain what other factors may contribute. Available data do not suggest that the amotivational syndrome is due to organic brain damage. Role in Schizophrenia Marijuana use is associated with an increased risk for schizophrenia. In young people with no history of psychotic symptoms, marijuana increases the risk for symptom occurrence. In the stabilized schizophrenic person, marijuana may precipitate an acute psychotic episode. Physiologic Effects Cardiovascular Effects Marijuana produces a dose-related increase in heart rate. Marijuana causes orthostatic hypotension and pronounced reddening of the conjunctivae. In addition, chronic use is closely associated with development of bronchitis, sinusitis, and asthma. Animal studies have shown that tar from marijuana smoke is a more potent carcinogen than tar from cigarettes. Effects on Reproduction Research in animals has shown multiple effects on reproduction. In females, the drug reduces levels of follicle-stimulating hormone, luteinizing hormone, and prolactin. Multiple effects may be seen in babies and children who were exposed to marijuana in utero. Some babies present with trembling, altered responses to visual stimuli, and a high-pitched cry. Preschoolers may have a decreased ability to perform tasks that involve memory and sustained attention.