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By: I. Tragak, M.B.A., M.B.B.S., M.H.S.
Deputy Director, Universidad Central del Caribe School of Medicine
For example medicine x ed buy cheap liv 52 on-line, peni Because the very young and the very old tend to have cillin symptoms juvenile rheumatoid arthritis discount liv 52 60ml on line, cephalosporin treatment lymphoma buy 100ml liv 52 visa, and macrolide antibiotics (all Cate- increased sensitivity to drugs, the dosage per kilogram of gory B drugs) are preferred for treating many infections in body weight should be reduced when most drugs are used pregnant women, whereas tetracycline antibiotics (Category in the treatment of these populations. Acetaminophen (Category B) is usually the analgesic of choice in pregnancy, but ibuprofen Disease and related drugs are also in Category B and may be used Hepatic and renal disease may reduce the capacity of the when required. For the treatment of nausea and vomiting of liver and kidneys to biotransform and excrete drugs, thereby pregnancy, the combination of pyridoxine (Category A) in reducing drug clearance and necessitating a dosage reduction combination with doxylamine (Category B) is the only to avoid toxicity. Coumarin anticoagulants Fetal warfarin syndrome (characterized by chondrodysplasia punctata, malformation of ears and eyes, mental retardation, nasal hypoplasia, optic atrophy, skeletal deformities, and other anomalies). Ethanol Fetal alcohol syndrome (characterized by growth retardation, hyperactivity, mental retardation, microcephaly and facial abnormalities, poor coordination, and other anomalies). Phenytoin Fetal hydantoin syndrome (characterized by cardiac defects; malformation of ears, lips, palate, mouth, and nasal bridge; mental retardation; microcephaly; ptosis; strabismus; and other anomalies). Hydrocephaly; malformation of ears, face, heart, limbs, and liver; microcephaly; and other anomalies. Thalidomide Deafness, heart defects, limb abnormalities (amelia or phocomelia), renal abnormalities, and other anomalies. Valproate Cardiac defects, central nervous system defects, lumbosacral spina bifda, and microcephaly. Other drugs that should be avoided during the second and third trimester of pregnancy are angiotensin-converting enzyme inhibitors, chloramphenicol, indomethacin, prostaglandins, sulfonamides, and sulfonylureas. Other drugs that should be used with great caution during pregnancy include antithyroid drugs, aspirin, barbiturates, benzodiazepines, corticosteroids, heparin, opioids, and phenothiazines. Most established the prescription class of drugs, stricter antiepileptic drugs pose some risk to the fetus, and the selec- requirements for human drug testing, incentives tion of drugs for treating epilepsy in pregnant women for developing orphan drugs for rare diseases, and requires careful consideration of the risks and benefts of abbreviated procedures for marketing generic drug such medication. Some drugs can be taken by lactating women without • The Comprehensive Drug Abuse Prevention and posing a risk to their breast-fed infants. Other drugs place Control Act, also called the Controlled Substances Act the infant at risk for toxicity. Most inter- and pharmacologic characterization, experimental actions are caused by pharmacokinetic effects, particu- studies to test for toxicity in animals, and clinical larly inhibition or induction of drug biotransformation. The study would therefore be classifed are done to establish safety and pharmacokinetics in as a healthy subjects, often students in the health professions. The 4th to 10th (E) fetal jaundice week of gestation is the period when fetal organs are 4. Teratogenic drugs may cause fetal malforma- most likely to lead to sustained elevations of plasma drug tions if taken by a pregnant woman during this interval. Drug-induced labor or jaundice is (C) displacement of a drug from plasma albumin–binding primarily of concern during the last trimester of preg- sites nancy. Drug-induced cardiac arrest and hemorrhage are (D) inhibition of the P-glycoprotein carrier protein not specifcally associated with the 4th to 10th week of (E) acceleration of gastric emptying by a “prokinetic” gestation. Elderly persons may have altered drug disposition drug-metabolizing enzymes will increase the half-life and because of plasma concentrations of affected drugs, thereby posing (A) markedly reduced absorption of many drugs a risk of toxicity. Induction of these enzymes will reduce (B) higher volumes of distribution for water-soluble half-life and plasma levels. Displacement of a drug from drugs plasma proteins or inhibition of P-glycoprotein might (C) accelerated renal excretion of ionized drugs increase plasma levels temporarily until the rate of elimi- (D) increased permeability of the blood-brain barrier nation increases. Acceleration of gastric emptying might (E) reduced capacity to oxidize drugs increase the rate of drug absorption but would not per- manently increase plasma drug levels. Conjugative metabolism is relatively unchanged in the elderly, but oxidative drug metabolism is usually reduced. The elderly tend to have a higher percentage of body fat than younger adults and therefore have increased volumes of distribution of fat-soluble drugs.
Diseases
Nolst Trenité The optimal timing for nasal surgery and septorhinoplasty in approaches used are shown in ▶Table 65 treatment xanax withdrawal buy liv 52 on line amex. A variety of techniques were used to has been employed by most surgeons till an empirical age of 16 reconstruct the nose in 106 cases treatment concussion generic liv 52 60 ml otc. This was a reasonable approach symptoms you have worms purchase liv 52 200 ml on-line, supported by and homologous—and their exploitations are summed up in clinical observations1,2 and experimental studies,3–10 in view of ▶Table 65. Of a total of 106 patients, 76 patients did have the popularity of submucosal resection in previous decades. This population is divided into groups cartilaginous and bony septum were widely acknowledged and treated by (1) an open approach (broken columella incision or warned against. There has been a change in perception V-Y incision) and (2) a closed approach (hemitransfixion, deliv- recently,11–14 with some authors claiming a paucity of evidence ery, or other). Indications and demographic patient details are for untoward effects of conservative surgery,14,15 and sugges- also shown in ▶Table 65. The techniques used to reconstruct tions have been made that some such conservative techniques, the nose in 76 cases (open or closed approach) and the different which have gained support through animal research, may be grafts—autogenous and homologous—and their exploitations employed in pediatric and adolescent groups. Those advocating surgery on a growing nose have employed follow-up periods that do not adequately settle the issue. The expected bene- effects of surgery and trauma on the midfacial growth are fits of early intervention in a given indication have to be either subjective or based on analysis of two-dimensional weighed against the possible adverse outcomes owing to the measurements. Outcomes and effects on midfacial growth in these Closed approach (n) 53 patients, who underwent surgery before puberty, provide valua- Broken Columella incision (n) 44 ble evidence. This chapter presents our experience with septo- V-Y procedure (n) 11 rhinoplastyinchildrenoverthelasttwodecades. Thisisthe Delivery (n) 8 largest series of patients of this age group where the results and sequelae have been studied after septorhinoplasty, keeping in Follow-up period February 1994-August 2007 mind the importance of adequate follow up after the growth Follow-up period 53 (12–157) spurts. The patients in this series have been followed for variable (>12 months), months (range) periods after puberty and adolescence. The clinical circumstan- Follow up too short, 12 ces, indications for surgery, extent of surgical interference, and Operation recently done (<12 outcomes in 106 patients are discussed. Clinical guidelines for months) (n) surgery in this group of patients, based on our experience and Lost to follow up (<12 months) 16 the evidence from research so far, are presented. The upper age of our study population >16-<20 52 was extended to 19 years to ensure adequate follow up beyond Indications the midfacial growth spurt during puberty and adolescence. Indications, demographic patient details, and 514 Pediatric Rhinoplasty in an Academic Setting Table 65. Suptratip onlay 4 0 Columella onlay 4 0 Dorsal strut 2 0 Rim graft 1 0 515 Age Considerations in Rhinoplasty Fig. Repair was achieved by straight- forward reconstruction without disturbance of growth zones and with minimal purging of tissue. Unfortunately, at the age of 16 this patient traumatized his nose, resulting in a nose fracture. At this point, extensive recon- struction of only the septum was performed via an endonasal approach. The adage to postpone septorhinoplasty till after the pubertal Several series with limited follow up gave rise to misleading growth spurt, to prevent growth inhibition and redeviation, is statements in the literature that septorhinoplasty in children still valid. Severe functional and aesthetic concerns, however, does not have consequences for the outgrowth of the nose and may necessitate early surgical intervention. Experimental studies in young female New Zealand white Distinct indications for immediate intervention are acute rabbits showed comparable outcome with clinical observations nasal trauma, septal abscess, and malignancies; severe septal made in posttraumatic cases, both accidental and surgical.
Unlike other auta- oil consumption and a decreased incidence of throm coids medicine expiration dates buy liv 52 in india, no evidence exists of vesicular storage or calcium- botic events (strokes and heart attacks) in certain native mediated exocytosis for eicosanoid substances within the populations medicine pills effective liv 52 120ml. Eicosanoid drugs exist as either purifed prep- blood fow and glomerular fltration medicine bottle buy liv 52 american express. These actions are arations of the same naturally occurring substance or closely particularly important in persons with renal insuffciency related synthetic analogues. The renal actions of prostaglandin also effects on smooth muscle, platelet aggregation, neurotrans- appear to exert an antihypertensive effect, partly by increas- mission, glandular secretion, and other biologic activities by ing water and sodium excretion. Several prostaglandins also produce a by G proteins that increase or decrease cyclic adenosine cytoprotective effect on the gastrointestinal mucosa. The leukotrienes are produced primarily in infammatory Thromboxanes, which are substances derived from prosta- cells, including mast cells, basophils, eosinophils, macro- glandin synthesis (see Fig. The eicosanoid released from a kotrienes are secreted in the presence of asthma and ana- tissue or cell will depend on the particular set of synthetic phylaxis and play a major role in bronchospastic disease. Prostacyclin is released primarily from lined in Table 26-4 and summarized in the following vascular endothelial cells and serves to prevent platelet paragraphs. Chapter 26 y Autacoid Drugs 281 Leukotriene inhibitors act either by inhibiting uterine contractions of pregnant women. In pregnant women the vaginal insert or gel is used primarily to alleviate pain and infammation. The suppository is used to evacuate infammatory, antiallergic, and antineoplastic effects and the uterine contents in cases of intrauterine fetal death, are used in the treatment of a wide variety of adrenal diseases benign hydatidiform mole, or second-trimester termination and nonadrenal disorders. Carboprost is administered intramuscularly to control Prostaglandin Drugs postpartum bleeding when other measures have failed and Prostaglandin E1 and Prostaglandin to terminate pregnancy (abortifacient). Latanoprost was the frst prostaglandin drug indicated Alprostadil is given by continuous intravenous infusion to for the treatment of glaucoma. It is administered topically maintain the patency of the ductus arteriosus in neonates as eyedrops and is used to treat open-angle glaucoma that is who are awaiting surgery for some types of congenital heart resistant to other pharmacologic treatments. It can alter the color of the iris and cause a permanent (coarctation of the aorta and hypoplastic left ventricle). For this oped for the reduction of intraocular pressure in patients purpose, the drug is injected into the cavernosa of the with open-angle glaucoma or ocular hypertension are bima penis, or slow-release pellets or drops of cream are inserted toprost and travoprost. Given the rise in the use of oral drugs to (prostacyclin) that is used to treat pulmonary arterial treat erectile dysfunction, for example, sildenafl (Viagra), hypertension. Misoprostol acts locally on the gastrointestinal mucosa a continuous subcutaneous infusion via a self-inserted sub- to exert a cytoprotective effect by inhibiting gastric acid cutaneous catheter using a microinfusion pump designed secretion and by increasing bicarbonate secretion from specifcally for subcutaneous drug delivery. The two main and in women of childbearing age who are not using hor- groups of eicosanoids are prostaglandins and leukot- monal contraceptives. Alprostadil is used to maintain patency of the although the clinical impact of such high selectivity is not ductus arteriosus in neonates awaiting surgery for known. It is also used to treat erectile dysfunc- hepatic function and enzyme level monitoring. As sildenafl inhibits phosphodiester- ripening before induction of labor and for evacuation ase type 5, an increase of cyclic guanosine monophosphate of the uterine contents. Latanoprost and other prosta- glandin antiglaucoma drugs that increase the aqueous humor outfow are used to treat glaucoma. These substances usually act tan, endothelin-1 receptor antagonists, and a new on the same tissue in which they are produced. Cetirizine, desloratadine, and loratadine also (A) selectivity at H1 receptors lack cardiac effects.
For example medicine 6 year course 200 ml liv 52 with mastercard, the st u dent sh ou ld kn ow that ch ron ic h ypert en sion may affect vari- ous end organs symptoms 5 days after iui discount liv 52 120 ml with visa, such as the brain (encephalopathy or stroke) treatment yersinia pestis generic liv 52 120ml fast delivery, the eyes (vascular ch an ges), the kid n eys, an d the h ear t. Un d er st an din g the t ypes of con sequ en ces also helps the clinician to be aware of the dangers to a pat ient. The clinician is acutely aware of the need t o monit or for the end-organ involvement and undert akes the appropriate intervent ion when involvement is present. To answer this quest ion, the clinician needs t o reach the correct diagnosis, assess the severity of the condition, and weigh the situation to reach the appropriate intervent ion. For t he student, knowing exact dosages is not as import ant as under- st anding t he best medicat ion, rout e of delivery, mechanism of act ion, and possible complicat ion s. It is imp or t ant for the st u d ent t o be able t o ver balize the diagn osis and the rat ionale for t he therapy. A common error is for t he student to “jump to a treatment,” like a random guess, and therefore be given “right or wrong” feedback. In fact, the student’s guess may be correct, but for the wrong reason; conversely, the answer may be a very reasonable one, with only one small error in thinking. Instead, the student should verbalize the steps so that feedback may be given at every reasoning point. For example, if the qu est ion is, “W h at is the best t h erapy for a 25-year-old man wh o complains of a nont ender penile ulcer? T herefore, the best treatment for this man with probable syphilis is int ramuscular penicillin (but I would want to confirm the diagnosis). In the scenario above, the man with a nontender penile ulcer is likely to have syph- ilis. Knowing the limit ations of diagnostic tests and the manifest at ions of disease aids in t his area. There are four steps to the clinical approach to the patient: making the diag- nosis, assessing severity, treatment based on severity, and following response. Assessment of pretest probability and knowledge of test characteristics are essent ial in t he applicat ion of t est result s to t he clinical situat ion. There are seven questions that help to bridge the gap between the textbook and the clinical arena. Her fa m ily h ist o ry in clu d e s o n e m a t e rn a l co u sin wit h o va ria n ca n ce r. On e xa m in a t io n, she is found to have blood pressure 120/70 mm Hg, heart rate 70 bpm, and tem- perature 98°F. Pelvic examination shows a normal multiparous cervix, a normal-size uterus, and no adnexal masses. The patient states that she has regular Pa p a n ico la o u (Pa p ) sm e a rs, a n d t h a the la st o n e p e r fo rm e d 1 ye a r a g o wa s normal. Next step: Each of the following should be performed: stool for occult blood or colonoscopy or sigmoidoscopy, pneumococcal vaccine, influenza vaccine, tetanus vaccine (if not within 10 years), cholesterol screening, fasting blood glu cose. Understand which health maintenance studies should be performed for a patient older than 65 years. Understand that preventive maintenance consists of immunizations, cancer screening, and screening for common diseases. Co n s i d e r a t i o n s The approach to health maintenance consists of three parts: (1) screening for cancer, cardiovascular disease or other conditions, (2) immunizations, and (3) behavioral counseling regarding healthy behaviors such as regular exercise and tobacco cessation.
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