Pierre Kory, MPA, MD
- Associate Professor of Medicine, Fellowship Program Director, Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Beth Israel Medical Center Icahn School of Medicine at Mount Sinai, New York, New York
https://www.medicine.wisc.edu/people-search/people/staff/5057/Kory_Pierre
The concept of palliative care should be adapted to reflect local traditions gastritis diet cheap pariet 20 mg with amex, beliefs gastritis diet 600 20 mg pariet amex, and cultures-all of which vary from community to community and from country to country gastritis rare symptoms order pariet 20 mg fast delivery. Palliative care is holistic and comprehensive gastritis ct discount pariet 20 mg with amex, and thus ideally it should be delivered by a multidisciplinary team of care givers, working closely together and defining treatment goals and care plans together with the patient and his or her family. In many resource-poor countries the multidisciplinary care team will include community workers and traditional healers as well as nurses, doctors, and other health care professionals. Nurses have a key role in the provision of palliative care due to their availability within resource-poor settings, and they are often the coordinators of the multidisciplinary team. The health care professional may be working alone with little support from others, particularly in rural settings. Community health workers and volunteers can provide support to the health workers and have been trained with good effect to support them with basic medical care. In many resource-limited settings, community workers and volunteers are indispensable for the provision of palliative care and in particular with regard to social support for patients. There are however, specific situations where professional support from peers or from a team is required. Ethical decision-making in complex situations, disagreeable patients or families, or family systems with complex conflicts may trigger a need for such support. For health care professionals working on their own it Principles of Palliative Care the national cancer unit was based in the capital city over 250 km away from her village, and once her pain was controlled and the radiotherapy was finished, she wanted to go back home. As well as being nearer to her children, she could not afford the expense of being in hospital, and she was worried that the children would not be being looked after properly by her elderly motherin-law. She was worried about the future of her two children aged 12 and 14 years, and concerned whether her mother-in-law would be able to support them if she died. These problems were addressed with repeated talks with Grace about issues surrounding the health of her children, both of whom seemed to be in good health. Grace was referred to a local home-based care team in her village and was advised as to how she could continue to access oral morphine for pain control, and she was discharged 10 days after having been admitted. It is about management of pain and other symptoms, but it is also about psychological, social and spiritual problems. It is about the coordination and continuity of care in different settings and across the disease trajectory. It is about interdisciplinary and cross-sectional team work involving staff from different health care professions as well as volunteer services, including caregivers in their role as partners in the team as well as in their role as family members who require care and support. It is also important to try to assess the cause of any pain or symptoms that the individual might be experiencing, and if the cause is treatable. The baseline assessment should include a minimum set of information elicited by the health professional to help provide information about the context of care. The description of the care setting should include where the patient lives, who provides care, how many people there are at home, and an overview of financial and emotional resources and the needs of the patient and family. A sociogram can offer a rapid overview of family relations, and important events in the family history including any history of illness. A thorough baseline assessment before the initiation of palliative care interventions as well as regular follow-up evaluations are paramount to ensuring adequate relief of symptoms and distress, and to adapting treatment to the individual patient. The initial assessment will describe the needs of the patient and form the basis not Along with information about the context of care, the baseline assessment should not be restricted to physical symptoms, but should include several dimensions: physical, psychological, social, and spiritual deficits and resources. Many symptoms such as pain, dyspnea (difficulty breathing), nausea, or fatigue depend on subjective feelings rather than on objective measurable parameters, and so self-assessment by the patient is preferable. An African version has been developed that has been used with good effect in resource-poor settings. However, many patients with advanced diseases and with declining cognitive and physical function will not be able to complete even short self-assessment instruments. Assessment of psychological, spiritual, and social issues can be more complex, with limited tools being available to aid the health care professional. Performance status is also well suited for evaluation and monitoring of services, as it describes the patient population cared for.
The parasites are transformed inside the fly and delivered to a new host gastritis symptoms in child buy pariet 20mg fast delivery, and the life-cycle continues Fig 3 diet gastritis adalah buy pariet 20mg low price. It is characterized by chronic irregular fever gastritis diet to heal purchase 20mg pariet with visa, profound wasting gastritis symptoms remedy buy pariet 20mg with amex, debility and hepatosplenomegally. Epidemiology Visceral leishmaniasis affects many countries in Africa, mainly Ethiopia and the Sudan the Middle East, Southern soviet union, India and S. It is endemic in low land Ethiopia mainly North Western Ethiopia (Metema, Humera), Gikawo (Gambella), lower Omo river basin and in the south Woito and Segan river basin, Moyale and lower Genale river. Transmission the commonest way of transmission is by inoculation of promastigotes into humans by the bite of sand flies which breed in termite hills and forests. The source of the aflagellate forms may be either humans or extra human vertebrate reservoirs, and the disease may have life cycles that involve humans and sand flies only, or humans, sand flies and extra human vertebrate reservoirs together. Pathogenesis the common site of entrance is the skin where primary cutaneous lesion appears at the sites of sand fly bite. Here a cellular reaction by lymphocytes and plasma cells develop around the amasitigote-filled histiocytes in the dermis. As immune response develops epitheloid and giant cells appear, to be followed in some by healing. In others usually 4-6 months later amastigotes escape to the blood in macrophages, hematogeneous spread occurs and colonize the cells of reticuloendothelial system, where they multiply further and released after rupture of the cells and transported to new cells. The cells affected include that of spleen, liver, bone marrow and lymphatic glands, where the parasite multiplies and cause overcrowding of cells and as a result these organs are enlarged. The liver with its Kuppfer cells packed with amastigotes is enlarged & progress to cirrhosis. Clinical Features · · · Incubation period usually varies from weeks to months but can be as long as years. Visceral infections remain sub clinical or become symptomatic with acute, sub acute or chronic course. The onset is often gradual but can also be sudden with high grade fever (intermittent or remittent) lasting for 2-6 weeks and occasionally longer. The patient will be markedly emaciated, with hepatosplenomegally, generalized peripheral lymphadenopathy and marked pallor in the late stage of the disease. Edema of the legs, brittle dry hair, hemorrhages from any site (gum, skin etc) with purpura and petechiae of the skin may occur. Diagnosis · Definitive diagnosis is based on demonstration of the Parasite Giemsa stained smear of peripheral blood (in Indian form) and tissue touch preparation of organ aspirates and examined by light microscopy. Following the bite of sand flies, leishmania multiply in the macrophages of the skin. Single or multiple painless nodules occur on exposed areas (mainly the face) within one week to 3 months of the bite. The nodules may enlarge and ulcerate with erythematous raised border and overlying crust which may spontaneously heal over months to years. Different clinical patterns are described depending on the etiologic agents as follows:60 Internal Medicine Table I- 3. Investigation for Diagnosis · · Giemsa staining of smear from a split skin: this demonstrates leishmania in 80% of cases Culture followed by smear 61 Internal Medicine · Leishmanin skin test is positive in over 90% of cases although it is negative in diffuse cutaneous leishmaniasis. However large lesions or those on cosmetically important sites require treatment either · · Locally - by surgery, curettage, cryotherapy or hyperthermia (40-420c) or Systemic therapy: with drugs like Pentostam. Treatment is less successful than visceral leishmaniasis as antimonials are poorly concentrated in the skin L. Bolivia, Uruguay and Northern Argentina) In the early stage it affects the skin, but in secondary stage of the disease it involves the upper respiratory mucosa. Initially painful, itchy nodules appear on the lower limbs and then ulcerate with lymphangitis. In about 40% of patients, secondary lesions appear several years later at the mucocutaneous junctions of nesopharynx. This leads to nasal obstruction, ulceration, septal perforations and destruction of the nasal cartilage called Espundia. Death usually occurs from secondary bacterial infection 62 Internal Medicine References: 1. Tuberculosis Learning Objective: At the end of this unit the student will be able to 1.
Congestive heart failure: Treats by conventional therapy such as digoxin and diuretics gastritis diet dairy purchase pariet 20mg without prescription. But in symptomatic patients benzodiazepines (diazepam) or phenothiazines (haloperidol) may be helpful in controlling symptoms gastritis diet generic pariet 20 mg mastercard. Administer secondary prophylaxis: is indicated for all patients with rheumatic fever no xplode gastritis pariet 20mg amex. Taking benzathin penicillin is the first choice for better compliance and longer prevention gastritis gel diet buy pariet 20 mg on-line. Congestive Heart Failure Learning objectives: at the end of this lesson the student will be able to: 1. Etiology: the most common cause of heart failure is left ventricular systolic dysfunction (about 60% to 70% of patients). Reduced preload 4) Reduced compliance states: Constrictive pericarditis, Restrictive cardiomyopathy Precipitating factors for heart failure: · · these are relatively acute disturbances that place an additional load on a myocardium that is chronically and excessively burdened. In compensated state patients are asymptomatic; however as patients have little additional reserve, they become symptomatic in the presence of these precipitating factors. Initially, as a direct result of inadequate cardiac output and systemic perfusion, the body activates several neurohormonal pathways in order to increase circulating blood volume. However, left ventricular chamber dilatation causes increased wall tension, worsens subendocardial myocardial perfusion, and may provoke ischemia in patients with coronary atherosclerosis. Furthermore, left ventricular chamber dilatation may cause separation of the mitral leaflets and mitral regurgitation with worsening of pulmonary congestion. Enhanced neurohormonal stimulation of the myocardium also causes apoptosis, or programmed cell death, leading to worsening of ventricular contractility. Clinical Manifestations · Progressive dyspnea which initially occurs with exertion and later occurs at rest. Dyspnea on exertion has been found to be the most sensitive complaint, yet the specificity for dyspnea is less than 60%. Apical impulse frequently is displaced laterally Cardiac auscultation may reveal aortic or mitral valvular abnormalities, S3 or S4. Echocardiography: may help identify valvular abnormalities, ventricular dysfunction, cardiac temponade, pericardial constriction, and pulmonary embolus. Identify and treat the precipitating factors Control the congestive state Improve myocardial performance 213 Internal Medicine 4. Activity and life style modification: o o o Meals should be small in quantity but more frequent. Control of the Congestive state Diuretics: are useful in relieving congestion and reduce or prevent edema. Most patients with heart failure have some degree of symptomatic congestion and benefit from diuretic therapy. Usually a loop diuretic is required, with the addition of a Thiazide diuretic in patients refractory to the loop diuretic alone. Loop and thiazide diuretics are useful for symptomatic relief; however they have not been shown to improve survival. Spirinolactone: is an aldosterone inhibitor, reduces mortality in patients with advanced heart failure. Neurohormonal modulation of centrally mediated parasympathomimetic and sympatholytic activity. Digoxin use is recommended for patients with left ventricular systolic dysfunction, particularly if they have atrial fibrillation. Through vasodilatation they reduce the peripheral resistance and after load and improve cardiac performance. Prevention of deterioration of Myocardial function: · the following drugs prevent deterioration in myocardial function by inhibiting the neurohumeral mechanism which causes cardiac remodelling and progression of heart failure. Captopril, Enalapril, etc) have been shown to improve mortality, symptoms, and hospitalizations. Lasortan: Dose: - 25-50 mg once 0r twice daily 3) Beta Adrenorecepter blockers Administration of these drugs with gradually increasing dose has been reported to improve symptoms of heart failure, the need for hospitalization and reduce mortality. Introduction · · · · Valvular heart disease from chronic rheumatic fever is still the commonest cardiac disease in the developing world, occurring at the younger age.
Although bupropion is classified as a norepinephrine and dopamine reuptake inhibitor gastritis diet mayo clinic pariet 20mg, the latter effect is relatively weak gastritis symptoms and causes purchase 20 mg pariet visa, and its mechanism of action remains unclear (106) gastritis symptoms in toddlers discount pariet 20mg otc. There are three formulations of bupropion: immediate release gastritis dogs cheap 20mg pariet amex, sustained release, and extended release. Bupropion is distinct from most antidepressants in not having an indication for the treatment of any primary anxiety disorder, and it may be less well tolerated than other antidepressants among patients with significant anxiety. Bupropion may be a good choice for patients who have a goal of quitting smoking as it has U. Patients typically experience minimal weight gain or even weight loss on bupropion (111), and for this reason it may be an appropriate antidepressant for patients who are overweight or obese. Mirtazapine is thought to work through noradrenergic and serotonergic mechanisms, although this tetracyclic compound is not a reuptake inhibitor (112). Although trazodone is an effective antidepressant, relative to placebo (105, 114, 115), in contemporary practice it is much more likely to be used in lower doses as a sedative-hypnotic than as an antidepressant. Despite widespread use of trazodone as a hypnotic, few data support its use for this indication. Nefazodone has an analogous structure to trazodone but somewhat different pharmacological properties. There are no comparative studies of the newer transdermal (skin patch) formulation of selegiline; its efficacy has only been established relative to placebo (123125), and clinical experience is limited. Side effects of antidepressant medications the severity of side effects from antidepressant medications in clinical trials has been assessed both through the frequency of reported side effects and through the frequency of treatment dropout. The likelihood of different side effects varies among classes of antidepressant medications, among subclasses, and among individual agents. When side effects occur during treatment with an antidepressant, an initial strategy is to lower the dose of the antidepressant or to change to an antidepressant that is not associated with that side effect. When lowering the dose or discontinuing the medication is not effective, additional strategies may be considered. These additional strategies are described in Table 7, which also lists prominent and clinically relevant side effects associated with particular medication classes. Serotonin syndrome, as the name implies, is presumed to result from high levels of serotonin in the brain. Because knowledge of potential drug-drug interactions is frequently changing, it is useful to consult a frequently updated drug information database before selecting an antidepressant in a patient taking other medications. These adverse events are generally dose dependent and tend to dissipate over the first few weeks of treatment. If akathisia does occur, a beta-blocker or benzodiazepine can be tried to reduce symptoms. The psychiatrist should ascertain whether the reported sexual dysfunction is a result of the antidepressant medication, the underlying major depressive disorder, a co-occurring medical disorder, a disturbance in a relationship, or a need for education about sexual functioning. If sexual dysfunction is determined to be a side effect of the antidepressant medication, a number of strategies are available, including Copyright 2010, American Psychiatric Association. Obtain dental consultation, if clinically indicated Add an 1-adrenergic antagonist. If clinically indicated, obtain bone density monitoring and add specific treatment to reduce bone loss. Specific pharmacological treatments that can be added for arousal difficulties, erectile dysfunction, or orgasm dysfunction include buspirone (131), bupropion (132), sildenafil (133), and tadalafil (134). Other phosphodiesterase inhibitors may be also useful in treating sexual side effects, and a variety of other medications have been used with anecdotal success (135, 136). Neurological effects Selective serotonin reuptake inhibitors can initially exacerbate both migraine headaches and tension headaches. These effects tend to be transient and improve within the first few weeks of treatment. Selective serotonin reuptake inhibitors have also been associated with extrapyramidal side effects, including akathisia, dystonia, parkinsonism, and tardive dyskinesia (139, 140). Falls Selective serotonin reuptake inhibitors, like other antidepressive agents, have been associated with an increased risk of falls.
Generic pariet 20mg free shipping. Darren Heals Gastritis Helicobacter Pylori through Plant-based diet - Part 1.
References
- Nappi RE, Ferdeghini F, Abbiati I, et al: Electrical stimulation (ES) in the management of sexual pain disorders, J Sex Marital Ther 29(Suppl 1):103n110, 2003.
- Stedmanis medical dictionary, ed 27, Philadelphia, PA, 2000, Lippincott Williams & Wilkins, p 257. Strasser H, Tiefenthaler M, Steinlechner M, et al: Urinary incontinence in the elderly and age-dependent apoptosis of rhabdosphincter cells, Lancet 354(9182):918n919, 1999.
- Boll B, Gorgen H, Fuchs M, et al. ABVD in older patients with early-stage Hodgkin lymphoma treated within the German Hodgkin Study Group HD10 and HD11 trials. J Clin Oncol 2013;31(12):1522-1529.
- Parkin DM. The evolution of the population-based cancer registry. Nat Rev Cancer 2006;6(8):603-612.
- UKHCDO. Guidelines on the selection and use of therapeutic products to treat haemophilia and other hereditary bleeding disorders. Haemophilia 2003;9:1-23.
