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Better nutrition purchase zestoretic 17.5 mg overnight delivery blood pressure chart boy, iron supplementation or fortication zestoretic 17.5mg online arteria axillaris, child spacing and the prevention and treatment of malaria and hookworms can all prevent iron deciency buy 17.5mg zestoretic with visa prehypertension while pregnant. Correction of iron deciency anaemia is cheap generic 17.5mg zestoretic pulse pressure 30 mmhg, but a functioning health service is needed to promote the measures among the most vulnerable groups. There is, however, some evidence to suggest that iron supplementation at levels recommended for otherwise healthy chil- dren carries the risk of increased severity of infectious disease in the presence of malaria and/or undernutrition. It is therefore advised that iron and folic acid supplementation be targeted to those who are anaemic and at risk of iron deciency. They should receive concurrent protection from malaria and other infectious diseases through prevention and effective case management (25). In addition, zinc supplementa- tion of young children in low income countries improves their neurophysiological performance (26), also in combination with iron supplements (27). Selenium deciency Selenium deciency has been linked to adverse mood states (29). Selenium supplementation together with other vitamins has been found benecial in the treatment of mood lability (30). Generally, the scientic information about selenium and neurological disorders remains scarce. There are, however, still a number of obscure neurological disorders occurring in localized epidemics or endemic foci in tropical countries. Most of these syndromes consist of various combinations of peripheral polyneuropathy and signs of spinal cord involvement. Syndromes of ataxic polyneuropathy Reports on a form of ataxic polyneuropathy described by Strachan and later by Scott led to the recognition of a tropical neurological syndrome characterized by painful polyneuropathy, orogenital dermatitis and amblyopia, known as Strachan s syndrome. During the Second World War, prisoners of war in tropical and subtropical regions suffered from similar syndromes with burning feet, numbness and loss of vision with pallor of the temporal border of the optic disks. Since the Second World War, ataxic polyneuropathies have been reported from many tropical and subtropical areas (31). Their cassava-based diet was suggested to be the cause, as the students improved during holidays. The cyanide-yielding capac- ity of bitter cassava and its toxic effects were described at that time. This syndrome of painful polyneuropathy, ataxia and blurred vision was extensively studied in Nigeria by Osuntokun (33). The diagnostic criteria used for this tropical ataxic neuropathy were the presence of two of the following: myelopathy, bilateral optic atrophy, bilateral sensorineural deafness, and symmetrical peripheral polyneuropathy. Men and women were equally affected, with a peak incidence in the fth and sixth decades of life. When discussing the neurological syndromes resembling Nigerian ataxic neuropathy described from different parts of the world, Osuntokun pointed out that it is unlikely that the same specic etiological factor is involved in all places. In Nigeria, tropical ataxic neuropathy has been shown to persist also into this millennium (34). Syndromes of spastic paraparesis The second clinical group of tropical myeloneuropathies proposed by Romn (31) is comprised of syndromes with spastic paraparesis as the main feature. Besides paraparesis as a sequel of extrinsic cord compression resulting from trauma or tuberculosis, several syndromes with spastic paraparesis have been reported in epidemics or endemic foci throughout the world. A third form of spastic paraparesis with abrupt onset has been reported in epidemic outbreaks in Africa. Clinically and epidemiologically it is similar to lathyrism but without any association with consumption of L. Konzo has been reported only from poor rural communities in Africa; it is characterized by the abrupt onset of an isolated and symmetric spastic paraparesis which is permanent but non-progressive. The name derives from the local designation used by the Congolese population affected by the rst reported outbreak in 1936. Outbreaks of konzo are described from Cameroon, the Central African Republic, the Democratic Republic of the Congo, northern Mozambique and the United Republic of Tanzania. Konzo has been associated with exclusive consumption of insufciently processed bitter cassava in epidemiological studies (42). It may be precipitated by poor nutrition and toxins (especially smoking and alcohol) but genetic predisposal is also an important factor. Most cases of nutritional amblyopia are encountered in disadvantaged countries (9). Typically, toxic and nutritional optic neuropathy is progressive, with bilateral sym- metrical painless visual loss causing central or cecocentral scotoma. Nevertheless, early detection and prompt management may ameliorate and even prevent severe visual decit. Alcohol-related neurological disorders Alcohol and other drugs play a signicant role in the onset and course of neurological disorders. As toxic agents, these substances directly affect nerve cells and muscles, and therefore have an impact on the structure and functioning of both the central and peripheral nervous systems. For example, long-term use of ethanol is associated with damage to brain structures which are responsible for cognitive abilities (e. In people with a history of chronic alcohol consumption the following abnormalities have been ob- served: cerebral atrophy or a reduction in the size of the cerebral cortex, reduced supply of blood to this section of the brain which is responsible for higher functions, and disruptions in the func- tioning of neurotransmitters or chemical messengers.

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Second Generation Cephalosporin s Ceftazidime and Ceforperazone are two of the 3rd The second generation cephalosporins are another class of generation cephalosporins which are also known as Anti- cephalosporins which have advantage over first generation Pseudomonal Cephalosporins zestoretic 17.5mg line blood pressure medication and exercise. They are effective against cephalosporins in terms of the activity spectrum they have Pseudomonas aeruginosa safe 17.5mg zestoretic hypertension zyrtec. Second generation cephalosporins have greater spectrum of activity against the Gram negative Fourth-Generation Cephalosporin s bacteria s with exception to anaerobes order zestoretic 17.5 mg free shipping blood pressure of 1200. They are also more Fourth generation cephalosporins have the broadest resistant to beta-lactamase zestoretic 17.5 mg online arrhythmia dizziness. Second-generation spectrum of activity, with similar activity against gram- cephalosporins are effective against Hemophilus influenza, positive organisms as first generation cephalosporins. Coli, Klebsiella, also have a greater resistance to beta-lactamases than the Neisseria gonorrheae. Cefepime and cefpirome second generation cephalosporins have a 7-alpha-methoxy are highly active against many resistant organisms that group that gives resistance to beta-lactamases and makes traditionally have been difficult to treat. They are effective them different from other cephalosporins against Gram-positive cocci, Streptococcus pneumoniae. It is also active toxic but are not effective against the Central nervous against Enterococcus. Another drug of choice among the 5th system infections as they cannot cross the blood-brain generation cephalosporins, is the Ceftobiprole which is a barrier. Cyphamycin is the drug of choice among the 2nd very broad-spectrum cephalosporin with activity against generation class of Cephalosporins. Drugs used in the generation cephalosporins shall be used with great treatment of infections and cancer and antibacterial drugs. Antibiotic is a chemical substance produced by a microorganism that inhibits the growth of or kills other microorganisms. Antimicrobial agent is a chemical substance derived from a biological source or produced by chemical synthesis that kills or inhibits the growth of microorganisms. The two terms are usually used synonymously and that practice will continue throughout this presentation. The word antibiotic will be used to describe: a chemical substance derivable from a microorganism or produced by chemical synthesis that kills or inhibits microorganisms and cures infections. These can be referred to as natural antibiotics Organismsdevelopresistance faster to the natural antimicrobials because they have been pre-exposed to these compounds in nature. In order to understand and use the software effectively, it is important to have a solid working knowledge of antibiotic classification. Understanding why antibiotics fail begins with the classification of antibiotics and their modes of action. Inhibitors of nucleic acid synthesis Antibiotics are usually classified based on their structure and/or function. Inhibitors of Cell Wall Synthesis Beta-lactams Penicillins Cephalosporins Monobactams Carbapenems Glycopeptides Fosfomycins Inhibitors of Cell Wall Synthesis Beta-lactams x There are about 50 different Beta ()-lactams currently on the market x They are all bactericidal x They are non-toxic (i. Inhibitors of Cell Wall Synthesis Beta-lactams (Penicillins) International Common Name Penicillins Penicillin G (pen G)* Penicillinase-stable penicillins Oxacillin (pen M) Methicillin Aminopenicillins* Ampicillin (pen A) Amoxicillin Carboxypenicillins* Ticarcillin (pen C) Ureidopenicillins* Piperacillin (pen U) E-lactam E-lactamase inhibitor Amoxicillin + clavulanic acid combinations Ampicillin + sulbactam Ticarcillin + clavulanic acid Piperacillin + tazobactam Amidinopenicillin Mecillinam * Penicillinase labile: hydrolyzed by staphylococcal penicillinase Inhibitors of Cell Wall Synthesis Beta-lactams - Penicillins Spectrum of Action 1. Natural penicillins Penicillin G: Active against Gram-positive organisms that do not produce beta-lactamases, Neisseria and some anaerobes 2. Penicillinase-resistant penicillins Penicillin M: Active against penicillinase-producing Staphylococci 3. It is possible to see the following: Pseudo monas Ticarcillin = S Ticarcillin/Clavulanic = R Enterobacteriaceae Piperacillin = S Piperacillin/Tazobactam = R bioMrieux,Inc. Inhibitors of Cell Wall Synthesis Beta-lactams (Cephems) International Common Name st 1 Generation Cephalosporins Cephalothin C1G Cefazolin nd 2 Generation Cephalosporins Cefuroxime C2G Cefamandole Cephamycin (new C2G) Cefoxitin Cefotetan removed rd 3 Generation Cephalosporins Cefotaxime C3G Ceftazidime Ceftriaxone th 4 Generation Cephalosporins Cefepime C4G Oral C3G Cefixime Cefpodoxime Next Generation Ceftobiprole Cephalosporins Ceftaroline Inhibitors of Cell Wall Synthesis Beta-lactams - Cephems Spectrum of Action 1st generation cephalosporins (C1G): Narrow spectrum; good Gram-positive activity and relatively modest Gram-negative activity. Less active than narrow spectrum agents against Gram-positive cocci, but much more active against the Enterobacteriaceae and Pseudomonas aeruginosa (better beta- lactamase stability). Inhibitors of Cell Wall Synthesis Beta-lactams - Cephems - Ceftobiprole Spectrum of Action Next generation cephalosporin: Broad spectrum; active against the common Gram-negative bacteria. Inhibitors of Cell Wall Synthesis Beta-lactams International Common Name Monobactams Aztreonam Penems Carbapenems Imipenem Meropenem Ertapenem Doripenem Penems Faropenem Inhibitors of Cell Wall Synthesis Beta-lactams: Monobactams Spectrum of Action Aztreonam: Gram-negatives (Enterobacteriaceae and Pseudomonas). Not hydrolyzed by most commonly occurring plasmid and chromosomally mediated -lactamases, and does not induce the production of these enzymes. Beta-lactams: Penems Slightly different structure than the other -lactams, make the Penems much more resistant to beta-lactamase hydrolysis. Regulates pH, osmotic pressure and availability of essential nutrients Bacterial Cell Wall or Peptidoglycan a. Cross-linked mesh that gives a cell its shape, strength and osmotic stability, a protective suit of armour b. Petide bond between amino acids In Gram-positive bacteria, peptidoglycan accounts for as much as 90% of the cell wall (approximately 40 layers), with the rest consisting of the teichoic acids.

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Pathophysiology Fluid accumulating within the closed pericardium may reduce ventricular lling and hence cause compromise Pathophysiology of the cardiac output (cardiac tamponade) cheap 17.5mg zestoretic amex hypertension abbreviation. Once the space between the pericardium and the heart becomes full of uid the ventricles are prevented Clinical features from lling properly during diastole thus reducing the Heart sounds are soft and apex beat is difcult to pal- cardiac output cheap zestoretic 17.5 mg without a prescription heart attack chest pain. If the effusion accumulates quickly buy zestoretic 17.5 mg visa pulmonary hypertension zebra, features of low cardiac output failure usually appear order zestoretic 17.5 mg overnight delivery blood pressure control chart. Slow accumula- tion of uid is often well tolerated until very large due to Clinical features distension of the pericardial sac. The pulse is of low volume and reduced on inspi- r Chest X-ray often shows an enlarged globular heart, ration (pulsus paradoxus). Oliguria or anuria develops which may have very clear borders (because cardiac rapidly and eventually there is hypotension and shock. If the tamponade is haemodynamically compromising the Management diagnosis may have to be clinical, but ideally an echocar- This is determined by the size and haemodynamic ef- diogram is done immediately on suspicion. The relief following pericardiocentesis is often Management temporary, so a ne catheter should be inserted for con- Bed rest and eradication of the acute infection, i. Prognosis Disorders of the myocardium Depending on the aetiology the prognosis is usually good,althoughachroniccardiomyopathymayoccasion- Myocarditis ally result. Denition An acute or chronic inammatory disorder of the my- Cardiomyopathies ocardium. These are diseases of the heart muscle, which may be primary (intrinsic to myocardium) or secondary (due Aetiology to an external or systemic cause). Myocarditis is often a feature of a systemic infection but r Primary cardiomyopathies include dilated cardiomy- occasionally septicaemia may lead to focal suppurative opathy, hypertrophic cardiomyopathy and restrictive lesions. Protozoa: Trypanosoma cruzi (Chagas disease), Toxo- r Secondary cardiomyopathies occur when ventricular plasma gondii. Dilated cardiomyopathy Clinical features Myocarditis is an acute illness characterised by fever and Denition cardiac failure. Patients often experience chest pain due Progressive ventricular dilatation with normal coronary to an associated pericarditis. Most cases are idiopathic but are often assumed to fol- low an undiagnosed viral myocarditis. Other factors: The myocardium shows an acute inammatory reaction r Genetic: Single gene mutations and skeletal muscular with interstitial oedema and cellular inltration. Investigations Many systemic diseases may cause the clinical features r Chest X-ray shows cardiac enlargement with signs of of dilated cardiomyopathy, e. Left ventricu- lar failure causes an elevated end-diastolic pressure with coronary artery disease, as this may present similarly resultant increase in pressure within the pulmonary cir- without any history of angina or myocardial infarct. Clinical features r Management Symptoms are dependent upon the degree of cardiac r General measures include bed rest, uid restriction failure. Tachycardia boembolicdiseaseorapresenceofintracardiacthrom- is common and low perfusion results in peripheral bous should be anti-coagulated. Severe cases may vascular shutdown (small thready pulse, cold extrem- benet from anti-coagulation without other risk fac- itiesandperipheralcyanosis). Ankle Prognosis and/or sacral oedema, mild hepatomegaly and jaun- Theprognosisisverypoor. Youngpatientsmaybetreated dice, due to hepatic congestion or tricuspid regurgita- with cardiac transplantation. Hypertrophic cardiomyopathy Macroscopy/microscopy The ventricles are dilated (left more than right), the Denition chamber walls are thin and the muscle poorly contrac- Hypertrophicorhypertrophicobstructivecardiomyopa- tile. Complications Aetiology Atrial brillation is common, particularly in alcoholic r Half the cases are due to an autosomal dominant in- cardiomyopathy, and bouts of ventricular tachycardia herited point mutation of the myosin heavy chain, may occur. Mural thrombosis may occur in either ven- which codes for a component of the cardiac muscle tricle with the associated risk of systemic embolisation. This may raphy cannot obtain adequate views particularly in result in obstruction to the outow of the left ventricle, apical hypertrophy. Clinical features Hypertrophic cardiomyopathy often presents similarly Management r -blockade is the mainstay of treatment as this lowers to aortic stenosis with dyspnoea, angina, syncope, or sudden death. Initially the pulse is jerky with a rapid outow due to hypertrophy, in the late stages ob- prevent ventricular arrhythmias and there is increas- struction results in a slow rising pulse. This may pertrophied septal wall (myotomy/myectomy) is in- be varied by dynamic maneouvres or drugs that can al- dicated with, where necessary, a mitral valve replace- ter the degree of functional obstruction. Surgical intervention is usually reserved for sound is often heard caused by ventricular lling due to severely symptomatic patients. ItisassociatedwithWolff diuretics should only be used with care as these in- Parkinson White Syndrome. Prognosis Macroscopy/microscopy Factors suggesting a worse prognosis include young age Hypertrophy is asymmetrically distributed. Disorganised branching of abnormal, short, thick muscle bres, in which there are large nuclei. Pathophysiology Inltrativediseasecausingadecreaseinventricularcom- Incidence pliance (increase in stiffness) affecting the myocardium. The result is a failure of relaxation during diastole, im- pairment of ventricular lling and compromise of car- Aetiology diacoutput.

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In speaking of multidisciplinary care order 17.5mg zestoretic amex prehypertension meaning in urdu, we can forget that such care involves more than a multidisciplinary group comprised Introduction of physicians buy 17.5mg zestoretic visa heart attack grill. True collegiality involves collaboration with Like college and colleagues zestoretic 17.5 mg online blood pressure physiology, the word collegiality derives from other health care disciplines zestoretic 17.5 mg overnight delivery arteria carotida interna, and there is much that each can the Latin collegere: to read together. Having said that, collegiality between collaborators in common pursuits, or having common duties and interests, is not automatic. It needs to be fostered and nurtured with re- and sometimes, by charter, peculiar rights and privileges. When a collegial atmosphere exists in an academic centre it can create a safe and productive setting for both teachers and Collegiality offers the beneft of a safe and protective com- learners. Collegiality can create a culture in which uncertainty, munity that can help us to cope in the face of stressful work lack of knowledge and feelings of incompetence are both tol- environments. It maximizes open communication and or advantaged club: it implies certain duties and responsibilities. In such a setting, Society does not appreciate a self-protective collegiality that a collegial faculty would be one that values a commitment to circles the wagons around questionable professional behav- the sharing of knowledge. And so it is important to remember that, like everyone else, physicians get sick and grow old, and that in the process their competence can be compromised. As is discussed elsewhere in this handbook, certain aspects of the culture of medicine, together with typi- cal attributes that otherwise hold physicians in good stead, can make physicians reluctant to admit when they fnd themselves in diffculty. However, the physician s responsibility to maintain his or her own health in order to practise safely also extends to a collegial duty to be aware of the health and ftness of others. Case resolution In the past, ill physicians, worried that their medical licence It is important for any organization or group to cultivate might be put in jeopardy, remained silent until a complaint was collegiality and mentorship. In this case, rumours are reported to a regulatory body or an adverse event occurred. Nor is it a colleague s role wait until problems are of such severity that regulatory bodies to try to diagnose or to treat the resident. Workplaces should have mechanisms in however, for a trusted colleague or colleagues to respect- place to ensure that potentially impaired practitioners promptly fully ask to meet with the resident privately and to present cease practice until their ftness to practise can be assessed. It would be appropriate to offer assistance Too often, however, a misguided sense of collegiality makes in connecting the resident with a personal physician if the physicians hesitate to respond to a colleague in diffculty or resident doesn t have one. In this case it would be appropriate for the colleague or colleagues to research contact information for the local An organized and responsible method for dealing with mat- physician health program and assist the resident in orga- ters of potential physician impairment would involve early nizing an appointment with medical staff there. It might identifcation of physicians who might require assistance and even be ftting for a colleague to accompany the resident to the provision of timely and caring intervention when it is such an appointment, but not to be part of that meeting. Academic departments or group It is to be hoped that incapacitated colleagues will respond practices should cultivate a resource list of primary care appropriately to support and advice, but at the end of the day physicians who are community based and not necessarily we cannot ignore our legal and ethical obligations to report associated with academic departments. These providers to the appropriate bodies impaired physicians who insist on should have experience in caring for physician colleagues practising despite reasonable offers of assistance. A supportive collegial group works proactively as a team to ensure the optimal function of all members. It is not focused Key references only on the individual practitioner s health, but also on the Brown G, Rohin M, Manogue M. Effective Learning & Teaching in Medical, Dental & Veterinary contribute to the stress of health care staff, but also encour- Education. Given that interpersonal confict is discuss collaborative attitudes and communication skills potentially all around us, it is important to learn strategies that that support the creative resolution of confict. Case Most instances of confict appear to have had an immediate, Two enthusiastic and ambitious residents seem to have observable trigger, a hot-button issue of some kind. In reality, butted heads regularly on several issues during their three the problem is usually more complex. Conficts occur repeatedly, other variables, of which the parties involved might not be whether it surrounds organizing the on-call rota, holiday fully aware. Such variables include the power relationships, true schedules, or topics for grand rounds. The confict seems needs as opposed to apparent wants, and styles in dealing with to be escalating, and each sees the other s behaviour confict. As is typical of unresolved it is important to be aware of our own typical responses to confict, the situation is becoming personalized, and both confict our confict styles. It is normal The situation is becoming diffcult for the department as to make presumptions and assumptions on the basis of experi- a whole, as both residents each seek to recruit colleagues ence. In this module we focus on interpersonal con- When we are in confict we can demonstrate behaviour that fict, which occurs when human need or interest is frustrated. A defensive style is usually more has been defned as a situation in which one or both persons adversarial, and refects the extent to which we are attempting in a relationship are experiencing diffculty in working or living to satisfy our own needs. This usually occurs due to different or in- ness, and refects the extent to which we are willing to satisfy compatible needs, goals or styles (Fisher 1977). Kilmann described fve personal relationships do not have confict-free relationships.