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The esophagus also clears any refluxed gastric contents back into the stomach and takes part in such reflex activities as vomiting and belching generic myambutol 800 mg without a prescription. Deglutition: Primary Peristalsis The act of deglutition is a complex reflex activity discount myambutol 800mg otc. Food is chewed discount 600 mg myambutol mastercard, mixed with saliva and formed into an appropriately sized bolus before being thrust to the posterior pharynx by the tongue. Once the bolus reaches the posterior pharynx, receptors are activated that initiate the involuntary phase of deglutition. This involves the carefully sequenced contraction of myriad head and neck muscles. The food bolus is rapidly engulfed and pushed toward the esophagus by the pharyngeal constrictor muscles. Simultaneously there is activation of muscles that lift the palate and close off and elevate the larynx in order to prevent misdirection of the bolus. These can be assessed manometrically using an intraluminal tube to measure pressures. Secondary peristalsis refers to a peristaltic sequence that occurs in response to distention of the esophagus. This is a localized peristaltic wave that usually begins just above First Principles of Gastroenterology and Hepatology A. Esophageal Body Peristalsis There is a fundamental difference in the control mechanisms of peristalsis between the upper (striated-muscle) esophagus and the lower (smooth-muscle) esophagus. In the striated-muscle segment, peristalsis is produced by sequential firing of vagal lower motor neurons so that upper segments contract first and more aboral segments subsequently. In the smooth-muscle segment, the vagal preganglionic efferent fibers have some role in the aboral sequencing of contraction, but intrinsic neurons are also capable of evoking peristalsis independently of the extrinsic nervous system. Transection of vagal motor fibers to the esophagus in experimental animals will abolish primary peristalsis throughout the esophagus; however, in this setting, distention-induced or secondary peristalsis will be maintained in the smooth-muscle but not in the striated-muscle segment. In the smooth-muscle esophagus, however, the response to vagal efferent nerve stimulation is quite different, in that the onset of contractions is delayed relative to the onset of the stimulus. The latency to onset of the contraction increases in the more distal segments of the esophagus (i. This experimental observation indicates that intrinsic neuromuscular mechanisms exist and can mediate peristalsis on their own. Further evidence for this mechanism is found in studies where strips of esophageal circular smooth muscle are stimulated electrically in vitro. The latency to contraction after stimulation is shortest in the strips taken from the proximal smooth-muscle segment and increases progressively in the more distal strips. This latency gradient of contraction is clearly important in the production of esophageal peristalsis. Although the exact mechanisms are unclear, initial or deglutitive inhibition is important. With primary or secondary peristalsis, a wave of neurally mediated inhibition initially spreads rapidly down the esophagus. This is caused by the release of the inhibitory neurotransmitter nitric oxide, which produces hyperpolarization (inhibition) of the circular smooth muscle. It is only after recovery from the initial hyperpolarization that esophageal muscle contraction (which is mediated primarily by cholinergic neurons) can occur. Thus, the duration of this initial inhibition is important with respect to the differential timing of the subsequent contraction. Derangements of the mechanisms behind this latency gradient lead to nonperistaltic contractions and dysphagia. Such derangements could result from problems with either the intrinsic neural mechanisms (enteric nervous system) or the central neuronal sequencing. Schematic representation of primary peristalsis as recorded by intraluminal manometry. Schematic representation of esophageal peristaltic contractions as evoked by swallowing and vagal efferent nerve stimulation. Swallowing evokes sequential esophageal contractions that pass smoothly from the striated- to the smooth-muscle segment. Electrical stimulation of the distal cut end of a vagus nerve, which simultaneously activates all vagal efferent fibers, evokes peristaltic contractions only in the smooth-muscle segment of the esophagus. In the striated-muscle esophagus, vagal stimulation causes simultaneous contractions that occur only during the period of stimulation. This demonstrates that the striated-muscle esophagus is dependent on central neuronal sequencing for its peristaltic contraction, whereas intrinsic neuronal mechanisms are capable of producing a persistaltic sequence in the smooth- muscle segment. This results in a pressure barrier that separates the esophagus from the stomach and serves to prevent reflux of gastric contents up into the esophagus. Extrinsic innervation as well as circulating hormones can modify the resting tone; however, the muscle fibers themselves have inherent properties that result in their being tonically contracted. The predominant inhibitory neurotransmitter released from these intrinsic neurons is nitric oxide. Dysphagia The sensation of food sticking during swallowing is a manifestation of impaired transit of food through the mouth, pharynx or esophagus. It is important to differentiate oropharyngeal (transfer) dysphagia from esophageal dysphagia. If the patient has problems getting the bolus out of the mouth, then one can be certain of an oropharyngeal cause; if the food sticks retrosternally, an esophageal cause is indicated.

They should get the help of a mental best when they are patient and appreciate any progress that is health professional if needed order 600mg myambutol with amex. There is a tendency to treatment (medication and psychotherapy) myambutol 800mg, providing support order myambutol 400mg amex, think of the causes of depression as moral or organic. Family members who believe the cause of depression is 5 antidepressant medication: what you should know Depression is regarded as a medical disorder (like diabetes). Contact your doctor immediately if you experience one or research has found that antidepressants are effective for more severe symptoms. It does not cover all possible uses, actions, pre- gers) are believed to regulate mood. This information does not constitute medical advice or treatment and antidepressant medications work to increase the following is not intended as medical advice for individual problems or for mak- neurotransmitters: serotonin, norepinephrine, and/or ing an evaluation as to the risks and benefits of taking a particular dopamine. The treating physician, relying on experience and knowl- edge of the patient, must determine dosages and the best treatment all antidepressants must be taken as prescribed for three to for the patient. This is because each persons brain chemistry is unique; what works well for one person may not do as well for another. Be open to trying another medication or combination of medications in order to find a good fit. Let your doctor know if your symptoms have not improved and do not give up searching for the right medication! Escitalopram (Lexapro) Vortioxetine (Brintellix) Fluoxetine (Prozac) Like all medications, antidepressants can have side effects. Com- gas; increased sweating; increased urination; lightheadedness mon side effects are also listed. They also increase norepinephrine in Desipramine (Norpramin or Pertofrane) the brain to improve mood. Mirtazapine (Remeron) Most people can adopt to a low tyramine diet without much Common side effects: constipation, dizziness, dry mouth, fa- difficulty. These medications are good alternatives if the newer medica- tions are ineffective. Have you lost interest or pleasure in your hobbies or being with friends and family? If you have felt this way for at least 2 weeks, you may have depression, a serious but treatable mood disorder. Everyone feels sad or low sometimes, but these feelings usually pass with a little time. To be diagnosed with depression, symptoms must be present most of the day, nearly every day for at least 2 weeks. An episode can occur only once in a persons lifetime, but more often, a person has several episodes. A person diagnosed with this form of depression may have episodes of major depression along with periods of less severe symptoms. Some forms of depression are slightly different, or they may develop under unique circumstances, such as: Perinatal Depression: Women with perinatal depression experience full-blown major depression during pregnancy or after delivery (postpartum depression). Other examples of depressive disorders include disruptive mood dysregulation disorder (diagnosed in children and adolescents) and premenstrual dysphoric disorder. Depression can also be one phase of bipolar disorder (formerly called manic-depression). But a person with bipolar disorder also experiences extreme higheuphoric or irritablemoods called mania or a less severe form called hypomania. Research suggests that a combination of genetic, biological, environmental, and psychological factors play a role in depression. Sometimes medications taken for these illnesses may cause side effects that contribute to depression symptoms. Sadness is only one small part of depression and some people with depression may not feel sadness at all. Biological, lifecycle, and hormonal factors that are unique to women may be linked to their higher depression rate. Women with depression typically have symptoms of sadness, worthlessness, and guilt. Men with depression are more likely to be very tired, irritable, and sometimes angry. They may lose interest in work or activities they once enjoyed, have sleep problems, and behave recklessly, including the misuse of drugs or alcohol. Older adults with depression may have less obvious symptoms, or they may be less likely to admit to feelings of sadness or grief. They are also more likely to have medical conditions, such as heart disease, which may cause or contribute to depression. Younger children with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Older children and teens with depression may get into trouble at school, sulk, and be irritable. Teens with depression may have symptoms of other disorders, such as anxiety, eating disorders, or substance abuse. The frst step in getting the right treatment is to visit a health care provider or mental health professional, such as a psychiatrist or psychologist. Your health care provider can do an exam, interview, and lab tests to rule out other health conditions that may have the same symptoms as depression.

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Edema: - Common sites for edema formation in the early stage include: dependent areas effective 800 mg myambutol, face order myambutol 600mg visa, peri-orbital areas and scrotum purchase 400mg myambutol. Hypoalbuminemia and primary water and salt retention by kidneys are the postulated mechanisms for edema formation. Hyperlipidemia: - is believed to be a consequence of increased hepatic lipoprotein synthesis & decreased clearance. Other complications: - Protein malnutrition Iron-resistant microcytic hypochromic anemia due to transferrin loss. Confirming significant proteinuria Quantify 24 hours urine protein Comparing with urinary creatinine level on a single void urine Measurement of urinary protein by a dipstick (+3 or +4 diagnostic if the first two are not available) 2. Renal biopsy ( if available ): to identify the underlying histopathologic abnormality 302 Internal Medicine Minimal change diseases: accounts for 80 % nephrotic syndrome in children < 10 yrs. Specific treatment of the underlying morphologic entity Minimal change disease : Steroids, and cytotoxic drugs Membranous nephropathy : Not steroid responsive 2. Dietary protein restriction: the potential value of dietary protein restriction for reducing proteinuria must be balanced against the risk of contributing to malnutrition. Thromboembolism : Anticoagulation is indicated for patients with deep venous thrombosis, arterial thrombosis, and pulmonary embolism. Acute Renal Failure Learning objectives: at the end of this lesson the student will be able to : 1. Refer patients with acute renal failure to hospitals with better facilities Definition: Acute renal failure is a syndrome characterized by: Rapid decline in glomerular filtration rate (hours to days ) Retention of nitrogenous wastes due to failure of excretion Disturbance in extracellular fluid volume and Disturbance electrolyte and acid base homeostasis. Oliguria (urine output < 400 ml/d) is a frequent but not invariable clinical feature (~50%). Acute renal failure may complicate a wide range of diseases, which for purposes of diagnosis and management are conveniently divided into three categories Etiologic classification of acute renal failure A. Pathophysiology: Hypovolemia leads to glomerular hypoperfusion, but filtration rate are preserved during mild hypoperfusion through several compensatory mechanisms. Urine and blood Chemistry: most of these tests help to differentiate prerenal azotemia, in which tubular reabsorption function is preserved from acute tubular necrosis where tubular reabsorption is severely disturbed. Thus, a high ratio is highly suggestive of prerenal disease as long as some other cause is not present. Radiography/imaging Ultrasonography: helps to see the presence of two kidneys, for evaluating kidney size and shape, and for detecting hydronephrosis or hydroureter. Preliminary measures Exclusion of reversible causes: Obstruction should be relived, infection should be treated Correction of prerenal factors: intravascular volume and cardiac performance should be optimized Maintenance of urine output: although the prognostic importance of oliguria is debated, management of nonoliguric patients is easier. High doses of loop diuretics such as Furosemide (up to 200 to 400 mg intravenously) may promote diuresis in patients who fail to respond to conventional doses. Initial rates of replacement are guided by estimates of bicarbonate deficit and adjusted thereafter according to serum levels. Absolute indications for dialysis include: Symptoms or signs of the uremic syndrome Refractory hypervolemia 313 Internal Medicine Sever hyperkalemia Metabolic acidosis. Chronic Renal Failure Learning objectives: at the end of this lesson the student will be able to : 1. Prerenal causes Sever long standing renal artery stenosis Bilateral renal artery embolism 2. Early additional clinical and laboratory manifestations of renal insufficiency may occur. These may include nocturia, mild anemia and loss of energy, decreasing appetite and early disturbances in nutritional status. Fluid, electrolyte and acid base disturbance a) Volume expansion and contraction (edema, dehydration) As long as water intake does not exceed the capacity for free water clearance, the extra cellular fluid volume expansion will be isotonic and the patient will remain normonatremic. On the other hand, hyponatremia will be the consequence of excessive water ingestion. With advancing renal failure, total urinary net daily acid excretion is usually reduced markedly. Renal osteodetrophy and Metabolic bone disease: Is due to disturbance in bone phosphate and calcium metabolism. Note that the low serum level of Ca is attributed to secondary hyperparathyroidism. The abnormal vitamin D metabolism may be related to the renal disease itself (since the active vitamin D metabolite is normally produced in the proximal tubule) and to the hyperphosphatemia, which has a suppressive effect on the renal 1-hydroxylase enzyme. Some of the resulting bony abnormalities are o Ostitis fibrosa cystica : is due to osteoclastic bone resorption of specially terminal phalanges, long bones and distal end of clavicle o Renal rickets ( Osteomalacia ) o Osteosclerosis : enhanced bone density in the upper and lower margins of vertebrae 3. Cardiovascular complications a) Congestive heart failure and/or pulmonary edema : it may be due to Volume over load Increase pulmonary capillary permeability b) Hypertension : Is the most common complication of end stage renal disease. Gastro intestinal abnormalities Early symptoms : anorexia, hiccup, nausea and vomiting Uremic fetor: the patients breathe smells like urine. Endocrine and Metabolic abnormalities Hypogonadism is common o In men : decreased plasma testosterone level, impotence m oligospermia o In women: amenorrhea, inability to carry pregnancy to term. Physical Examination: - Particular attention should be paid to: Blood pressure Funduscopy Precordial examination Examination of the abdomen for bruits and palpable renal masses Extremity examination for edema Neurologic examination for the presence of asterixis, muscle weakness, and neuropathy In addition, the evaluation of prostate size in men and potential pelvic masses in women should be undertaken by appropriate physical examination. Diagnostic work up These should also focus on a search for clues to an underlying disease process and its continued activity. The occurrence of normal kidney size suggests the possibility of an acute rather than chronic process.

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Inductive content order myambutol 600mg mastercard, which is recommended if there is not enough former knowledge about a subject or if the knowledge is fragmented (Elo & Kyngs 2008) cheap 800mg myambutol visa, is the content analysis process used in this thesis order myambutol 600 mg. Generally, there are three main phases in either the deductive or inductive content analysis process, namely: preparation phase, organisation phase and reporting of 36(55) results phase. The next phase is the organisation phase, where the data collected are read, un- derstood, interpreted and coded in a valid and reliable way. According to Polit & Beck (2004 as referred to by Elo & Kyngas 2008), in this stage, in order to become totally submerged into the data, it is important to read through the material several times and note the key question when reading the data and material. The reporting of results or found information is the last phase of content analysis (Elo & Kyngas 2008). Data re- lated to diabetes, diabetes type 2, drug therapy and diet therapy were searched and the articles or materials related to the topic were selected and read. The data was then organised by making notes and headings in the text while reading was going on. The chosen articles were read through several times focusing on points needed to provide information for the thesis writing. Questions stated by Polit & Beck (2004 as referred to by Elo & Kyngas 2008)) were noted and some an- swered. As many headings as necessary were written down in the margin to de- scribe all aspects of the content and sub-categories and generic categories were freely generated from these headings. Lifestyle modification General guidelines on the treatment and manage- Oral antidiabetic agents ment of type 2 diabetes. Similarities and differ- ences in the drug therapy between Finland and the Insulin therapy. The results also show the general guidelines necessary for nurses, patients and their caregivers (e. The quality of life is also essential to assess the need for chang- es in therapy and to ensure successful outcomes. Continuous nutrition self- management education and care needs to be available for individuals with diabe- tes. Asymptomatic individ- uals with a single abnormal test should have the test repeated to confirm the diag- nosis unless the result is unequivocally elevated. Lifestyle modifications and control of hyperglycaemia, blood pressure and cholesterol are important in the management of diabetes. Such education should start almost immediately after the diagnosis and throughout the care that will be given. People with diabetes should be advised that it is important to achieve and maintain an HbA1c below 7. For patients with co-morbidities and or history of hypoglycaemia due to an attempt to optimise control, a higher HbA1c target may be considered. For dia- betic patients HbA1c level should be regularly checked taking into account bene- fits, safety and tolerability. The on-going care or treatment should be reviewed and modified if HbA1c level is above or below the agreed target on two consecutive occasions. Medi- cation therapy is initiated when a desired hb1Ac value is not achieved with diet and exercise only. The treatment of type 2 diabetes is carried out mainly by the patient, thus the patients willingness to modify his or her life style, since life style modifications such as healthy eating habits and regular exercise are very im- portant in the treatment and management of type2 diabetes. The doctor decides the kind of medication to be administered alongside the life style modification treatment. If the patient is very obese, then bariatric surgery is advised or sug- gested to patient. Upon patient agreement, it is done to make the patient lose about 30 to 40 kilograms of their weight, which sometimes helps completely with their diabetes cure or restore their blood sugar level back to normal without any medication (Terveyskirjasto 2015). Type 2 diabetes affects about 90-95% of their population suffering from diabetes (Qaseem, Humphrey, Sweet, Starkey & Shekelle 2012). The treatment of diabetes is started with patient education and lifestyle modification. Pharmacotherapy is initiated as an add-on therapy to the lifestyle modification and can be adjusted based on patient response. The targeted HbA1c level for patients with low risk of hypoglycaemia and no coexisting serious illness is 6. In overweigh diabetic patients, obesity is first treated using lifestyle modifications (diet +exercise), medi- 41(55) cations and/or surgery. Generally, lifestyle modification is the first step in the treatment of type 2 diabetes. The most im- portant change in the diet of type 2 diabetes patients is to reduce their amount of energy (carbohydrate) intake, their level of salt intake should be monitored (should not be too high) to help treat diabetes related hypertension and cardiovas- cular diseases, their amount of saturated fat used is also monitored in order to control their blood cholesterol level. Grain, Beans and Starchy Vegetable- A person should eat six or more serving per day. Whole-wheat or any form of whole-grain flours in cooking and baking and low-fat breads, for ex- ample bagels, tortillas. A patient should eat ei- ther fresh or frozen vegetables without added sauces, fats, or salt. Yogurt has natural sugar in it, but it can also contain added sugar or artificial sweeteners. Yogurt with artificial sweeteners has fewer calories than yogurt with added sugar.

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