Condet

Jerry Stein, MD

• Director, BMT Unit
• Department of Pediatric Hematology Oncology
• Schneider Children? Medical Center
• Petach Tikva, Israel

Accidental exposure by contaminated water supply medications 1 discount cytoxan 50 mg on-line, house freshly coated with lead paint medications ok for pregnancy generic cytoxan 50 mg overnight delivery, and sniffing of leadcontaining petrol (hence unleaded petrol introduced as fuel) medicine for runny nose 50mg cytoxan amex. The absorbed lead is distributed in two types of tissues: a) Bones asthma medications 7 letters buy generic cytoxan 50 mg line, teeth, nails and hair representing relatively harmless pool of lead. Lead toxicity occurs in the following organs predominantly: Nervous system the changes are as under: i) In children, lead encephalopathy; oedema of brain, flattening of gyri and compression of ventricles. Haematopoietic system these changes are: i) Microcytic hypochromic anaemia ii) Prominent basophilic stippling of erythrocytes. Kidneys Lead is toxic to proximal tubular cells of the kidney and produces lead nephropathy characterised by accumulation of intranuclear inclusion bodies consisting of leadprotein complex in the proximal tubular cells. General Pathology Section I Gastrointestinal tract Lead toxicity in the bowel manifests as acute abdomen presenting as lead colic. Hypothermia may cause focal injury as in frostbite, or systemic injury and death as occurs on immersion in cold water for varying time. Hyperthermia likewise, may be localised as in cutaneous burns, and systemic as occurs in fevers. Thermal burns depending upon severity are categorised into full thickness (third degree) and partial thickness (first and second degree). The most serious complications of burns are haemoconcentration, infections and contractures on healing. Electrical burns may cause damage firstly, by electrical dysfunction of the conduction system of the heart and death by ventricular fibrillation, and secondly by heat produced by electrical energy. Ionising radiation causes damage to the following major organs: Skin: radiation dermatitis, cancer. In the Western world, nutritional imbalance is more often a problem accounting for increased frequency of obesity, while in developing countries of Africa, Asia and South America, chronic malnutrition is a serious health problem, particularly in children. For good health, humans require energyproviding nutrients (proteins, fats and carbohydrates), vitamins, minerals, water and some nonessential nutrients. Primary deficiency this is due to either the lack or decreased amount of essential nutrients in diet. Secondary or conditioned deficiency Secondary or conditioned deficiency is malnutrition occurring as a result of the various factors. Obe ityisdefined s as an excess of adipose tissue that imparts health risk; a body weight of 20% excess over ideal weight for age, sex and height is considered a health risk. Insufficientpushingofoneselfoutofthechair leading to inactivity and sedentary life style. Recently, two obesity genes have been found: ob gene and its protein product leptin, and db gene and its protein product leptin receptor. Its causes may be the following: i) deliberate fasting-religious or political; ii) famine conditions in a country or community; or iii) secondary undernutrition such as due to chronic wasting diseases (infections, inflammatory conditions, liver disease), cancer etc. Hepatic gluconeogenesis from other sources such as breakdown of proteins takes place. Proteins Protein stores and the triglycerides of adipose tissue have enough energy for about 3 months in an individual. Proteins breakdown to release amino acids which are used as fuel for hepatic gluconeogenesis. Fats After about one week of starvation, protein breakdown is decreased while triglycerides of adipose tissue breakdown to form glycerol and fatty acids. Kwashiorkor which is related to protein deficiency though calorie intake may be sufficient. Besides 143 Chapter 8 Environmental and Nutritional Diseases 144 calcium and phosphorus required for vitamin D manufacture, others include: iron, copper, iodine, zinc, selenium, manganese, nickel, chromium, molybdenum,fluorine. However, out of these, the dietary deficiency of first five trace elements is associated with deficiency states as under: i) Iron: Microcytic hypochromic anaemia. Most of the vitamins are of plant or animal origin so that they normally enter the body as constituents of ingested plant food or animal food. They are required in minute amounts in contrast to the relatively large amounts of essential amino acids and fatty acids. In the developed countries, individualvitamindeficiencies are noted more often, particularly in children, adolescent, pregnant and lactating women, and in some due to poverty. While vitamin deficiency as well as its excess may occur from another disease, the states of excess and deficiency themselves also cause disease.

Metronidazole to provide anaerobic coverage should be added medications used for anxiety cytoxan 50mg cheap, but this would not elucidate or adequately treat the underlying condition treatment lupus buy cheap cytoxan 50mg online. Cholesterol stones are responsible for 80% of cases of cholelithiasis; pigment stones account for the remaining 20% medications mitral valve prolapse buy cytoxan 50 mg with amex. Obesity medicine 750 dollars buy cytoxan 50 mg fast delivery, cholesterol-rich diets, high-calorie diets, and certain medications affect the biliary secretion of cholesterol. Intrinsic genetic mutations in certain populations may affect the processing and secretion of cholesterol in the liver. Pregnancy results in both an increase in cholesterol saturation during the third trimester and changes in gallbladder contractility. Although rapid weight loss and low-calorie diets are associated with gallstones, there is no evidence that a high-protein diet confers an added risk of cholelithiasis. Painless jaundice always requires an extensive workup, as many of the underlying pathologies are ominous and early detection and intervention often offers the only hope for a good outcome. The cholestatic picture without significant elevation of the transaminases on the liver function tests makes acute hepatitis unlikely. The most judicious first step in evaluation is to test for gallstones and pursue more rare causes after the most common cause has been ruled out. The presence of three or more of these factors is associated with substantially increased risk for in-hospital mortality. Antibiotics are recommended for only patients who appear septic at presentation while awaiting the results of culture data. If cultures are negative, antibiotics should be discontinued to decrease the risk of the development of fungal superinfection. Similarly, several drugs have been evaluated in the treatment of acute pancreatitis and found to be of no benefit. These drugs include H2 blockers, glucagon, protease inhibitors such as aprotinin, glucocorticoids, calcitonin, nonsteroidal anti-inflammatory drugs, and lexipafant, a platelet-activating factor inhibitor. A recent meta-analysis of somatostatin, octreotide, and the antiprotease gabexate mesylate in the therapy of acute pancreatitis suggested a reduced mortality rate but no change in complications with octreotide, and no effect on mortality but reduced pancreatic damage with gabexate. Although there had been prior concern that feeding patients with pancreatitis may exacerbate pancreatic inflammation, this has not been borne out. Similarly, enteral feeding with a nasojejunal tube in patients with acute pancreatitis has been demonstrated to have fewer infectious complications than feeding with total parenteral nutrition. Because of this, nasogastric feeding is the preferred method of nutritional support in acute pancreatitis. Enteral feeding also helps to maintain the integrity of the intestinal tract in acute pancreatitis. During the initial phase, pancreatic injury leads to intrapancreatic activation of digestive enzymes with subsequent autodigestion and acinar cell injury. Acinar injury is primarily attributed to activation of zymogens (proenzymes), particularly trypsinogen, by lysosomal hydrolases. Once trypsinogen is converted to trypsin, the activated trypsin further perpetuates the process by activating other zymogens to further autodigestion. Experimental evidence suggests that neutrophilic inflammation can also cause further activation of trypsinogen, leading to a cascade of increasing acinar injury. The third phase of acute pancreatitis reflects the systemic processes that are caused by release of inflammatory cytokines and activated proenzymes into the systemic circulation. This process can lead to the systemic inflammatory response syndrome with acute respiratory distress syndrome, extensive third-spacing of fluids, and multiorgan failure. The disorder is notable for both endocrine and exocrine dysfunction of the pancreas. Often diabetes ensues as a result of loss of islet cell function; though insulin-dependent, it is generally not as prone to diabetic ketoacidosis or coma as are other forms of diabetes mellitus.

A 36-year-old woman has a history of hypertension and is planning on starting a family treatment deep vein thrombosis discount cytoxan 50mg otc. In which of the following categories should women undergo routine screening for gestational diabetes? Age greater than 25 years Body mass index greater than 25 kg/m2 Family history of diabetes mellitus in a first-degree relative African American All of the above I-39 medicine 906 cheap cytoxan 50mg. Which of the following surgeries would be considered at the greatest risk for postsurgical complications? Carotid endarterectomy Non-emergent repair of a thoracic aortic aneurysm Resection of a 5-cm lung cancer Total colectomy for colon cancer Total hip replacement 5 I-40 treatment quotes and sayings effective cytoxan 50 mg. A 64-year-old man is contemplating undergoing elective cholecystectomy for biliary colic and cholelithiasis medicine cabinets surface mount buy cytoxan 50mg free shipping. He has a history of coronary artery disease with coronary artery bypass surgery performed at the age of 51 after an anterior wall myocardial infarction. He also has a 45 pack-year history of tobacco, quitting after his surgery 13 years previously. Since his bypass surgery, he reports failure to return to full functional capacity. Which of the following would be considered poor exercise tolerance and increase his risk of perioperative complications? Schedule a follow-up meeting in 1 day to reassess whether there are additional informational and emotional needs. Delineation of specific interventions that would be acceptable to the patient under certain conditions Description of values that should guide discussions regarding terminal care Designation of a health care proxy General statements regarding whether the patient desires receipt of life-sustaining interventions such as mechanical ventilation I-41. A 74-year-old man is scheduled to undergo total colectomy for recurrent life-threatening diverticular bleeding. He denies any chest pain with exertion but is limited in his physical activity because of degenerative arthritis of his knees. He has no history of coronary artery disease or congestive heart failure but does have diabetes mellitus and hypertension. His current medications include aspirin 81 mg daily, atorvastatin 10 mg daily, enalapril 20 mg daily, and insulin glargine 25 units daily in combination with insulin lispro on a sliding scale. Based on this information, what is his expected his postoperative risk of a major cardiac event? She is developing increasing pain in her abdomen and is admitted to the hospital for pain control. Upon admission, she is initiated on morphine intravenously via patient-controlled analgesia. During the first 48 hours of her hospitalization, she received an average daily dose of morphine 90 mg and reports adequate pain control unless she is walking. What is the most appropriate opioid regimen for transitioning this patient to oral pain medication? Sustained-Release Morphine None 45 mg twice daily 45 mg twice daily 90 mg twice daily 90 mg three time daily Immediate-Release Morphine 15 mg every 4 hours as needed 5 mg every 4 hours as needed 15 mg every 4 hours as needed 15 mg every 4 hours as needed 15 mg every 4 hours as needed I-42. Age greater than 60 years Asthma with a peak expiratory flow rate of 220 L/min Chronic obstructive pulmonary disease Congestive heart failure Forced expiratory volume in 1 second of 1. You are caring for a 56-year-old woman who was admitted to the hospital with a change in mental status. Despite correcting her calcium and treating cerebral edema, the patient remains confused. You are asked to consult on 62-year-old man who was recently found to have newly metastatic disease. He was originally diagnosed with cancer of the prostate 5 years previously and presented to the hospital with back pain and weakness. He has been started on radiation and hormonal therapy, and his disease has shown some response. His family reports that he is sleeping for 18 or more hours daily and has stopped eating. He claims to have no interest in his usual activities and no longer interacts with his grandchildren. Do not initiate pharmacologic therapy because the patient is experiencing an appropriate reaction to his newly diagnosed metastatic disease.

A 77-year-old man undergoes coronary artery bypass grafting for refractory angina and three-vessel disease medications not to take before surgery purchase cytoxan 50mg with amex. His physical examination is normal except for poor performance on serial 7 subtraction and only recalling 1 or 3 objects at 15 minutes medications xyzal cytoxan 50 mg on-line. During his complicated 3-week course of respiratory failure medicine jewelry buy cytoxan 50 mg lowest price, he was placed on highfrequency ventilation and prone positioning necessitating paralysis and heavy sedation medicine reactions generic 50mg cytoxan with amex. While starting his physical therapy, it is noted that he has right footdrop and numbness on the lateral leg. Additional examination reveals a unilateral right motor defect in foot dorsiflexion with intact inversion. There is sensory loss of the lateral aspect of the leg below the knee extending to the dorsum of the foot. A 26-year-old woman presents to the emergency department complaining of shortness of breath and chest pain. These symptoms began abruptly and became progressively worse over 10 minutes, prompting her to call 911. Over this same period, the patient describes feeling her heart pounding and states that she felt like she was dying. It is currently about 20 minutes since the onset of symptoms and the severity has abated, although she continues to feel not back to her baseline. She denies any immediate precipitating cause, although she has been under increased stress as her mother has been hospitalized recently with advanced breast cancer. Her initial vital signs show a heart rate of 108 beats/min, blood pressure 122/68 mmHg, and respiratory rate 20 breaths/min. Reassure the patient and suggest medical and/ or psychological therapy if symptoms recur on a frequent basis. A 36-year-old man is being treated with venlafaxine 150 mg twice daily for major depression. After 2 months, his symptoms were inadequately controlled, necessitating an increase in the dose of venlafaxine from 75 mg twice daily. At that time, he was treated with fluoxetine 80 mg daily for 12 months, but found the sexual side effects difficult to tolerate. He should continue on the medication indefinitely as his depression is likely to recur. The medication can be discontinued safely if he establishes a relationship with a psychotherapist who will monitor his progress and symptoms. The medication can be discontinued safely now as his symptoms are well controlled. The medication should be switched to fluoxetine to complete 12 months of therapy, as this was previously effective for him. Which of the following will lead to a faster rate of absorption of alcohol from the gut into the blood? A 42-year-old woman seeks your advice regarding symptoms concerning for post-traumatic stress disorder. She was the victim of a home invasion 6 months previously where she was robbed and beaten by a man at gunpoint. She thought she was going to die and was hospitalized with multiple blunt force injuries including a broken nose and zygomatic arch. She now states that she is unable to be alone in her home and frequently awakens with dreams of the event. She has worsening insomnia and often stays awake most of the night watching out her window because she is afraid her assailant will return. She has begun drinking a bottle of wine nightly to help her fall asleep, although she notes that this has worsened her nightmares in the early morning hours. Which of the following best reflects the effect of alcohol on neurotransmitters in the brain?

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