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By K. Anktos. Goldey-Beacom College.

Asbestos fibers that are swallowed up by macrophages may become coated with an iron-containing material cheap escitalopram 20mg without prescription, forming an asbestos body or ferruginous body discount escitalopram 10mg on line. Only a small proportion (about one percent) of fibers becomes coated, so this cannot be considered an effective protective mechanism. There is evidence that amphiboles cause the formation of asbestos bodies more readily than chrysotile. The finding of abnormally high asbestos body concentrations in sputum, bronchoalveolar lavage fluid or lung tissue indicates a history of exposure to asbestos in excess of background and can support the diagnosis of asbestos-related disease. The absence of asbestos bodies does not rule out that asbestos fibers in the lung may have caused disease. High concentrations of asbestos fibers have been found in the lungs of exposed individuals who have developed scarring or fibrosis, but do not have unusual numbers of asbestos bodies in their lung tissue. Some asbestos fibers that penetrate into the interstitial lung tissue migrate to the pleural membrane that lines the lung and the chest wall, most likely by lymphatic channels. Some are distributed to other tissues in the body via the lymphatic circulation and via the bloodstream. The fibrosis results in a lung disease that generally becomes evident clinically after 15 to 20 years or more have elapsed from the onset of exposure. While there are biological differences among individuals in susceptibility to the scarring caused by exposure to asbestos, the likelihood of developing asbestosis is related to the cumulative amount of fiber inhaled over time. Such scarring is most commonly seen among workers exposed recurrently on the job and family members exposed repeatedly to take-home dust. There is no evidence that single or rare exposures to asbestos dust are associated with the development of scarring lung disease. The most prominent symptom of asbestosis is the gradual onset of shortness of breath on exertion, with progression over time. Chest pain, either sharp or aching in character, occurs in a small proportion of patients with asbestosis. Clubbing, a rounding of the end of the fingers and a spooning of the fingernails may be present when scarring is advanced. Interestingly, this has also been found among non-smoking workers exposed to asbestos but without chest x-rays evidence of asbestosis, suggesting that asbestos dust may have some mild irritant properties in addition to its ability to cause scarring. In individual cases, there is often a poor correlation among the appearance of scarring on the chest x-ray, the degree of shortness of breath and the pulmonary function results. Some patients with marked abnormalities on the chest x-ray may have few symptoms and normal pulmonary function. The converse may also be true, with the severity of symptoms and/or pulmonary function test results seemingly out of proportion to the degree of x-ray abnormality. Studies of groups of exposed workers, however, demonstrate relationships among these effects of the scarring process. In severe cases of asbestosis, respiratory impairment can lead to death, often when the affected individual develops a chest infection (e. When scarring becomes dense and extensive, increased resistance to blood flow through the small arteries in the lung may develop, from obliteration of the network of small arteries and capillaries and from pulmonary capillary constriction caused by low oxygen levels in the alveolar air sacs. This results in pulmonary hypertension and may ultimately cause the muscle of the right ventricle of the heart (which pumps blood through the lungs) to enlarge to overcome the increased resistance to blood flow. If the pulmonary hypertension is severe enough for a sufficient period of time, the right ventricle can fail, a condition known as cor pulmonale, a well-recognized potentially fatal complication of advanced asbestosis. Most important of the diseases listed are idiopathic pulmonary fibrosis (for details see the chapter on pulmonary fibrosis) and congestive heart failure. Most Common Conditions Mimicking Pulmonary Asbestosis Idiopathic pulmonary fbrosis Congestive heart failure (radiographic appearance) Hypersensitivity pneumonitis Scleroderma Sarcoidosis Rheumatoid lung Other collagen vascular diseases Lipoid pneumonia Desquamative interstitial pneumonia Other pneumoconioses (dust-related lung scarring) Table 2-10. The scarring can occur in localized areas in separate and discrete plaques (circumscribed pleural thickening) or can occur as a more extensive and diffuse scarring process over the surface of the pleura and involve the costophrenic angle (the angle or gutter made by the chest wall and the diaphragm where they come together) defined as diffuse pleural thickening. Evidence of pleural scarring usually appears after 20 or more years have elapsed since the onset of exposure to asbestos dust (the latency period), and a latency of 30 to 40 years after exposure begins is not uncommon. Under the microscope, the plaques appear as deposits of collagen, the protein that is deposited in early scar formation. Circumscribed pleural scarring more commonly involves the parietal pleura (the lining of the chest wall) and often can be found on the surfaces of the diaphragm. Pleural plaques can be found on the visceral pleura (the lining of the lung itself) as well. The pericardium (the lining around the heart) and the pleural surfaces in the center of the chest (the mediastinal pleura) may also be involved. Although non-calcified thickening is more common, calcium deposits in areas of pleural scarring, whether localized or diffused, is frequently evident on the chest x-ray and become more common with increasing time since onset of exposure.

Al- leadingtocentralnervoussystemeffects buy discount escitalopram 20mg,decreasedmus- ternatively failure to excrete acid or increased loss of cle power and reduced gut mobility buy 10mg escitalopram otc. Hyperkalaemia may occur as an im- rate;itcan cause acute or chronic renal failure; it can also portant complication (see page 7) particularly if there causenephrogenicdiabetesinsipidus(seepage445),uri- is also acute renal failure. This may result from any cause of hyperven- ening of the Q T interval but this is not associated with tilation including stroke, subarachnoid haemorrhage, an increased risk of cardiac arrhythmias. Early symptoms be caused by loss of acid from the gastrointestinal are often insidious, including loss of appetite, fatigue, tract (e. Hypokalaemia may occur toms of hypercalcaemia can be summarised as bones, (see page 8). Deposition of calcium in heart valves, coronary Aetiology arteries and other blood vessels may occur. Hyper- Important causes of hypercalcaemia are given in tension is relatively common, possibly due to renal im- Table 1. More than 80% of cases are due to malignancy pairment and also related to calcium-induced vasocon- or primary hyperparathyroidism (see page 446). The serum calcium should be checked and r Bisphosphonates can be used, which inhibit bone corrected for serum albumin because only the ionised turnoverandthereforereduceserumcalcium. Serum phos- Aetiology phate may be helpful, as it tends to be low in ma- Hypocalcaemia may be caused by r vitamin D deciency, lignancy or primary hyperparathyroidism but high in r hypoparathyroidism (after parathyroidectomy, thy- other causes. Pathophysiology r Patients should be assessed for uid status and any Hypocalcaemia causes increased membrane potentials, dehydration corrected. Rehydration reduces calcium which means that cells are more easily depolarised levels by a dilutional effect and by increasing renal and therefore causes prolongation of the Q T interval, clearance. Intravenous saline is often needed because which predisposes to cardiac arrhythmias. It may also many patients feel too nauseous to tolerate sufcient cause refractory hypotension and neuromuscular prob- oral uids and polyuria is common due to nephro- lems include tetany, seizures and emotional lability or genic diabetes insipidus. The preoperative assessment Neuromuscular manifestations Underlying any decision to perform surgery is a recog- Early symptoms include circumoral numbness, paraes- nition of the balance between the risk of the procedure thesiae of the extremities and muscle cramps. All patients un- but less specic symptoms include fatigue, irritability, dergo a preoperative assessment (history, examination confusion and depression. Myopathy with muscle weak- and appropriate investigations) both to review the diag- ness and wasting may be present. Carpopedal spasm nosis and need for surgery, and to identify any coexisting and seizures are signs of severe hypocalcaemia. Elici- disease that may increase the likelihood of perioperative tation of Trousseau s sign and Chvostek s signs should complications. In general any concerns regarding coex- be attempted, although it can be negative even in severe isting disease or tness for surgery should be discussed hypocalcaemia: with the anaesthetist who makes the nal decision re- r Trousseau s sign: Carpal spasm induced by ination of garding tness for anaesthesia. Cardiac disease by history, examination and, where appropriate, failure may occur. Elective surgery should be deferred by at caemia to guide management and to look for the under- least 6 months wherever possible. The serum calcium should be checked and r Hypertension should be controlled prior to any elec- corrected for serum albumin (see above). Blood should tive surgery to reduce the risk of myocardial infarction also be sent for magnesium, phosphate, U&Es and for or stroke. Chronic or complex arrhythmias should be Management discussedwithacardiologistpriortosurgerywherever This depends on the severity, whether acute or chronic possible. Mild hypocalcaemia is treated r Patients with signs and symptoms of cardiac failure with oral supplements of calcium and magnesium should have their therapy optimised prior to surgery where appropriate. Severe hypocalcaemia may be life- and require special attention to perioperative uid threatening and the rst priority is resuscitation as balance. Calcium gluconate contains only a third of the with a history of bacterial endocarditis should have amount of calcium as calcium chloride but is less irritat- prophylactic oral or intravenous antibiotic cover for ing to the peripheral veins. Patients must be asked pulmonary embolism, is a signicant postoperative about smoking and where possible should be encour- risk. Risk factors include previous history of throm- aged to stop smoking at least 6 weeks prior to surgery. Wherever possi- cated unless there are acute respiratory signs or severe ble, risk factors should be identied and modied (in- chronic respiratory disease with no lm in the last cluding stopping the combined oral contraceptive pill 12 months. Preop- coagulant or antiplatelet medication and chronic liver eratively all therapy should be optimised; pre- and disease may cause perioperative bleeding. Postopera- with known coagulation factor or vitamin K decien- tive analgesia should allow pain free ventilation and cies may require perioperative replacement therapy.

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Sensitive immunoassays have documented presence of mouse urinary protein (Mus d 1) in indoor environment air samples generic escitalopram 10mg without prescription. It is not possible to reduce indoor concentrations of house dust mite ( Der p 1) to a mite-free level buy escitalopram 20mg lowest price. Clinical benefit to dust mite sensitive patients, however, occurs if some avoidance measures are instituted. It is advisable that the mattress, box spring, and pillow be covered with special zippered encasings. Window blinds should be cleaned regularly or not installed, and attention to other dust collection sites should be given. Rugs should be vacuumed each week, and dust mite trapping vacuum sweeper bags should be used. In that Der p 1 is heat labile (but Der p 2 is not), some benefit has been reported of steam-cleaning carpets and upholstery along with applying dry heat (>100 C) to mattresses and blinds ( 257). Concentrations of both Der p 1 and Der p 2 were reduced for 1 year with that intensive treatment (257). The presence of moist basements and crawl spaces may provoke acute or chronic symptoms in certain patients allergic to fungal spores. Smoking Cigarette smoking must be discouraged in all patients and their family members. Its deleterious effects probably result from bronchial irritation and impairment of antibacterial defense mechanisms. Cigarette smoke has been shown to impair mucociliary transport and to inhibit alveolar macrophage phagocytosis. Patients with asthma who continue to smoke often require progressive increments in medication. Keeping a patient with asthma controlled with medication while the patient continues to smoke is not good practice of medicine. When emphysema occurs, episodes of asthma may be tolerated poorly and may result in frequent hospitalizations or in respiratory failure. Passive smoking by nonasthmatic subjects has been associated with statistically significant reductions in expiratory flow rates. This finding raises the possibility that some patients with asthma may experience increased symptoms in smoke-filled office rooms or homes. Exercise The subjective and psychological value of physical conditioning can be a helpful adjunct in treatment. Many children or adults may be discouraged by their inability to participate in sports or to withstand other normal exertional activities. These feelings of inferiority or anger promote additional physical and psychological incapacitation. An exercise program, once asthma has been stabilized with appropriate therapy, will result in a noticeable increase in physical capacities and hopefully self-image and self-confidence. Inhaled b 2-adrenergic agonists, inhaled cromolyn, or inhaled nedocomil taken 15 to 30 minutes before exercise will decrease postexercise bronchospasm. Some patients find that use of an inhaled corticosteroid or leukotriene antagonist on a regular basis allows full exercise or sports activities without need for other medications. Drugs to Use Cautiously or to Avoid Antidepressants of the monoamine oxidase inhibitor class are not recommended because these substances may induce a hypertensive crisis when taken with sympathomimetic drugs that are commonly used in the medical treatment of asthma. The tricyclic antidepressants are much less likely to produce this complication and can be used with asthma medications. Narcotics, such as morphine and meperidine, and other sedating medications are contraindicated during exacerbations of asthma. Asthma should not be considered primarily as an expression of an underlying psychological disturbance, and its diagnosis alone is not an indication for the use of antidepressant or anxiolytic medications. Nocturnal reductions in P O2 occur regularly in normal subjects and in patients with asthma. In this situation, even small doses of these drugs may cause respiratory depression. This results from their parasympathomimetic-enhancing effect due to the inhibition of acetylcholine catabolism. These drugs represent the primary drug treatment of myasthenia gravis; if asthma coexists, a therapeutic problem arises. When anticholinesterases are necessary, maximal doses of b 2-adrenergic agonists and inhaled corticosteroids may be necessary. The addition of oral corticosteroids may be indicated for more adequate control of asthma, but it must be remembered that, in some patients, myasthenic symptoms may initially worsen with addition of oral corticosteroids ( 258). As a result of the effect on the latter, b blockers may enhance or trigger wheezing in overt and latent asthmatic patients. The adrenergic receptors of the lung are predominantly b 2 in type, and they subserve bronchodilation. Should selective or nonselective b 2-adrenergic antagonists be required in a patient with asthma, cautious increase in dose with close supervision is recommended.

The contamination of soil buy cheap escitalopram 10 mg, water and vegetables with intestinal parasites was studied buy 10mg escitalopram overnight delivery. Screening for anti-helminthic and anti-gastric activity was done on some reputed traditional medicinal plants - including taw-kyet-thun and pineapple. Their pharmacognosy, pharmacology and efficacy as antihelminthics were investigated. Nutritional status in children with intestinal helminthic infection as related to school enrolment and to rice carbohydrate absorption was also investigated. The interactions between intestinal helminthic infection, nutritional status and rice carbohydrate absorption were further studied from various aspects. Studies of acute diarrhoea and its determinants were extended to include persistent diarrhoea in children. Risk factors and prognostic factors in acute diarrhoea and persistent diarrhoea including socio-economic characteristics, personal hygiene, and health related behaviour continued to be investigated. Neonatal diarrhoea received more attention and was studied in detail at a maternity hospital. Rice carbohydrate absorption and various aspects of its measurement including hydrogen and methane production in the gut and other interrelated factors such as small bowel bacteria overgrowth were further investigated. The socio-economic aspect of acute diarrhoea was studied: - cost analysis was done of patient hospitalized for acute diarrhoea and compared to hospitalization for acute respiratory infection; role of general practitioners in diarrhoea management was described; characteristics and health related behavour of diarrhoea patients seeking hospital admission through different services was compared; maternal knowledge, attitude and practice in relation to severity of diarrhoea was documented. Biochemical studies were done on the effect of cholera toxin on intestinal lysosomes and of diarrhoea on aldosterone levels. Infection with Helicobacter pylori as the etiology agent responsible for peptic ulcer has emerged as a refreshing new concept in recent years and was the subject of many studies in Myanmar during this period leading to better understanding, diagnosis and treatment of gastric and duodenal ulcers and non-specific gastritis. Other aspects of peptic ulcer and other medical conditions also continued to be studied such as use of anti-secretory agents like omeprazole; Various G. Various etiological concepts regarding this disease were forwarded in this century; but ingestion of gastric irritants I swidely accepted predisposing factor. As such, public should be informed of dangers of taking these drugs and alcohol unscrupulously. Legal control of analgesics and steroid should be promulgated and action should be taken against those who sell these drugs without prescription. In order to reduce morbidity and mortality of these cases, the prime aim is to identify the source of haemorrhage as early as possible. It is universally accepted that early endoscopy is the most efficient and effective method of diagnosis in upper gastrointestinal haemorrhage. So early endoscopy serves more advantages for treatment in considering which patients must continue the conservative treatment and which patients required emergency surgery. Endoscopy is very helpful not only in diagnosis but also in predicting likelihood of recurrent bleeding. If endoscopy shows massive erosive bleeding where conservative measure fail emergency surgery is available as early as possible to control bleeding. It prevents prolonged and potentially dangerous conservative treatment especially in high risk patients and also obviates disasters from early and inopportune surgery. If endoscopic facilities are not available, the decision whether to operate or not was decided according to history (rate and amount of blood loss) physical examination (vital sign). So, in early phase of hospital treatment, it is difficult to identify those patients who may eventually require operation. By the time that decision has been made, the continued hypoxia which inevitable despite multiple transfusion will have brought about damage to myocardium and other vital tissues and this, especially in elderly patients with previous cardio vascular diseases will load the patient against recovery. The morbidity and mortality can be lowered significantly by getting early diagnosis and proper prompt management. Emergency gastrointestinal uint can be established, and all patients admmited to hospital with these complaints were admitted to the unit and management according to protocol and active policy of early endoscopy, intensive care management, sugery and regular audit will certainly reduce mortality. As more than 130 patients with haematemesis and melena are admitted yearly to North Okkalapa General Hospital, Surgical Unit, it is felt that by establishing new emergency gastrointestinal unit here, the morbidity and mortality of haematemesis and melena can be dramatically reduced. In stress gastritis, bleeding rates may be reduced in patients receiving prophylactic therapy. Since the treatment of bleeding stress ulceration is unsatisfactory, prophylaxis is given to all high risk patients by H2 receptor blocker, incidence of stress ulceration is become much less. But it is not clear that the mortality rate is improved with prophylactic therapy, as most patients die from their underlying diseases. In conclusion, further large scale should be studied to determine accurately which factors are essential for decision of emergency surgery and which procedure is more benefit for bleeding gastric erosions. The main aim of the study was to reveal the direct and indirect costs incurred by patients/families during the children s illness and the cost contributed by the government so that the finding might help in future policy implication. The mean cost of hospitalization of each child was 1705 Kyats and medium cost was 1350 Kyats. The cost borne by family amounted to 64% of the total cost of which only 13% were for medicine and investigations. It was noted that majority of cases could be effectively treated at the hospitals in their local area.

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