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By: Jennifer Lynn Garst, MD

  • Professor of Medicine
  • Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/jennifer-lynn-garst-md

Sasipim Sallapant Chulalongkorn University heart attack vegas buy moduretic 50mg without a prescription, Bangkok blood pressure age chart effective 50mg moduretic, Thailand Division of Gastroenterology heart attack man generic 50mg moduretic mastercard, Department of Medicine heart attack remix dj samuel order moduretic 50 mg free shipping, Chulalongkorn Unibersity, Bangkok, Thailand 9. Satimai Aniwan Chulalongkorn University, Bangkok, Thailand Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand Contributors 19. Tanassanee Soontornmanokul Chulalongkorn University, Bangkok, Thailand Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand 20. Vichai Viriyautsahakul Division of Gastroenterology, Department of Medicine, Department of Medicine, King Chulalongkorn Chulalongkorn University, Bangkok, Thailand Memorial Hospital, Thai Red Cross Society 21. Progressive scarring disease may lead to blistering diseases that predominately affects the 4 esophageal stenosis requiring dilatation procedures. The oral mucosa is involved in 89-100% of cases pemphigoid (cicatricial pemphigoid). Clin and the rate of conjunctival involvement is 61-71% with Dermatol 2012;30:34-7. The first contour, commonly in the upper esophagus, and international consensus on mucous membrane 3 representing the advanced stage of the disease. Her symptoms were partially improved increased number esophageal capillary loops (Figure 1 with proton pump inhibitors. A 24-hr esophageal pH monitoring was compatible revealed minimal change of distal esophageal mucosa. World J disease that the novel technology such as magnifying or Gastrointest Endosc 2010;2:121-9. A 64-year-old woman was scheduled for a Sodium sulfate, Sodium hydrogen carbonate, Sodium colonoscopy as a part of her colon cancer screening chloride and Potassium chloride). He underwent smooth narrowing segment of mid esophagus with surgery, radiation and chemotherapy 6 months ago. Microscopic Esophagoscopy showed narrowing esophageal lumen examination showed organizing inflammation with with smooth surface at 33 cm from the incisor (Figure 1 granulation tissue (Figure 5). The median duration between the end of radiation therapy and the time for diagnosis of References esophageal stricture was 8 months (1-132 months). Figure 1-2: Pin-point esophageal lumen (at 15 cm from incisor) Figure 3-4: After dilatation, esophageal tear Diagnosis: Corrosive esophageal stricture Benign esophageal stricture Discussion: Alkali ingestions typically damage the Dilation (Savary-Gilliard or balloon) up to esophagus more than the stomach or duodenum 16–18 mm 1 whereas acids cause more severe gastric injury. Ingestion of alkali (such as ammonia or sodium hydroxide) acutely results in a penetrating injury called liquefactive necrosis. Up to one-third of patients who suffer caustic esophageal injury develop esophageal strictures. Dilation usually relieves symptoms of dysphagia; however, recurrent strictures occur in selective cases. A 25-year-old male was admitted to the erythematous mucosa were observed in the mouth emergency department with a sore throat, dysphagia, and on the tongue. These may result in perforation, Esophageal corrosive injury from paraquat mediastinitis and/or pneumomediastinum. The ingestion contribution of this direct caustic effect to mortality 2 is probably underestimated. The very endoscopies at Chang Gung Memorial Hospital between high case fatality of paraquat is due to inherent toxicity 1980 and 2007. Their findings showed a potential relationship failure, pulmonary hemorrhage, and late pulmonary between the degree of hypoxia, mortality, and degree of 3 fibrosis. Mucosal lesions in the corrosive esophageal injury after intentional pharynx, esophagus and stomach are also very common paraquat ingestion. Self covered stent placement expandable metal stenting of refractory upper gut corrosive strictures: a new role for endoscopy A 61-year-old man underwent esophageal a well-defined erythematous flat mucosa, 1. Figure 4: Microscopic examination showed disorganization and disorientation of esophageal mucosa with scatter pleomorphism of nuclei. Histological Vienna consensus for diagnosis of early esophageal precursors of oesophageal squamous cell neoplasia. The relative risk of high grade esophageal carcinoma: results from a 13 year prospective dysplasia patient to develop esophageal squamous cell follow up study in a high risk population. A 61-year-old man with a history of squamous dysplasia, at 32 cm from the incisor (Figure 1-2). Feasibility of 1 endoscopic resection in superficial esophageal develop esophageal squamous cell carcinoma. Gastrointest Endosc 2011; node metastasis, thus forming the basis for endoscopic 73:881-9. A 41-year-old man presented with dyspepsia demonstrated papillary projection of the esophageal and gastroesophageal reflux symptoms for 3 months. Esophageal squamous papilloma Morphologically, it is a benign lesion, but there is much debate as to whether it is a premalignant lesion. Discussion: At present, there is no evidence for this, and malignant Esophageal papilloma is rare benign epithelial 2, 3 changes have not been reported in humans. The etiology of esophageal squamous papilloma of the esophagus: long-term follow up. Most etiology in humans is chronic cell papillomas of the esophagus: report of 20 irritation from reflux esophagitis; two-thirds of reported cases and literature review. Am J Gastroenterol cases of esophageal papillomas are found in the distal 1994;89:434-7. The Esophageal Inlet patch inlet patch found in 10% of the population with careful searching at endoscopy but it is often overlooked by Discussion: endoscopists and radiologists and studies frequently Inlet patch is a congenital anomaly of cervical 1 report prevalence between 0. It occurs most Most inlet patches are largely asymptomatic, frequently in the postcricoid portion of the esophagus at but in problematic cases complications related to acid secretion such as esophagitis, ulcer, web, and stricture References may produce symptoms such as chest and throat pain, 1. Adenocarcinoma endoscopic prevalence, histopathological, may arise in the ectopic gastric mucosa but this is demographical and clinical characteristics. Frequency, 1-3 histopathological findings, and clinical significance associated with inlet patches as they are not metaplastic. Heterotopic gastric mucosa in only part of the circumference, but some are annular the upper esophagus: a prospective study of 33 and multiple lesions are not uncommon. Visible columns of red tortuous ectatic about 4% of all non-variceal upper gastrointestinal vessels along the longitudinal folds of the antrum are 1 6 bleeding. This is supported by findings that there is no significant Endoscopy 2004;36:68-72. Gastric (mean mucosal capillary cross-sectional area) with the antral vascular ectasia in cirrhotic patients: absence degree of portal hypertension and lack of response to of relation with portal hypertension. There are from severe portal hypertensive gastropathy in distinct entities that require different treatments. Liver disease in hereditary hemorrhagic this disease is diagnosed by the Curacao criteria which is telangiectasia. Hepatic vascular clinical features: nose bleeding history, mucocutaneous malformations in hereditary hemorrhagic telangiectasia, visceral involvement (pulmonary, cerebral, telangiectasia. Figure 7 Endoscopically, adenomatous polyps are typically velvety, lobulated solitary (82%), located in the antrum, typically with size less than 2 centimeters (cm) in diameter. Histology reveals dysplastic another area of the stomach has been found in up to epithelium without detectable invasion of the lamina 30% of patients with an adenomatous polyp, and up propia. Both conditions the risk of association between adenomatous 1, 2 are often found in patients with chronic, atrophic, polyps and cancer increases with age. In addition, they share a common of the American Society of Gastrointestinal endoscopy epidemiological pattern. Surveillance endoscopy 1 year after removing adenomatous gastric polyps is reasonable References to assess recurrence at the prior excision site, new or 1. Nat Rev Gastroenterol after resection of polyps with high-grade dysplasia or Hepatol 2009;6:331-41. A 61-year-old man, diagnosed as cirrhosis with without recent bleeding stigmata (Figure 1-2). Type 1; isolated gastric varices References involve only gastric fundus; have a high incidence of 1.

Achilles tendon wounds are not permanently and properly repaired by using split-skin grafts because of durability blood pressure of 90 60 buy 50mg moduretic overnight delivery, vascularity and mobility problems – a flap repair is better heart attack kid buy moduretic 50mg line. Wounds of the ankle and lower third of the leg can be repaired using fasciocutaneous or free flaps heart attack signs buy 50 mg moduretic mastercard. Doppler apparatus is an easy and good way to arteria elastica buy moduretic 50 mg amex identify perforating vessels on the skin surface. B, D, E Nerve and tendons can be used as free grafts – the sural nerve and, when available, the palmaris longus tendons are useful sources of donor tissue. The fibula is a useful source of free flap for bone to reconstruct the jaw the radial forearm flap is a good example of an axial pattern flap as it is designed around well-known vessels. Latissimus dorsi or transverse rectus abdominis flaps can be used as free flaps or pedicled muscle or musculocutaneous flaps in breast reconstruction. A, C For major tissue reconstructions, meticulous planning and teamwork is essential for success. If this is to be done using a microvascular procedure, the use of loupes is not satisfactory and the best results are obtained using proper staff and apparatus. Good vessels in both donor flap and recipient area, the lack of tissue induration, lack of tension and lack of infection in the area of reconstruction are also important for successful repair. The ischaemic time is dependent on the presence or absence of muscle tissue in the free flap – it is less in the case of the former. A 1–2 h period is safe for muscle-containing free flaps – longer times of up to 6 h are permissible only in skin or/and fascia flaps. Which of the following are appropriately coloured label attached to characteristics of a natural disaster B the armed services will be needed to Transport of patients restore order and reconstruct. Which of the following statements C Shelter for large numbers will be one of regarding transport of patients is true A It should be delayed until the patient is D They occur over a short period of the stabilised. B It should be carried out using the fastest E Most countries have organisations form of transport. Which of the following statements D Patients should not be sent out with drip regarding action priorities in a natural sets and fluids if these are needed at the disaster are true A Assessment of the extent of damage is undertaken once rescue operations are Emergency care in the field underway. Which of the following statements back from the disaster area to carry out regarding emergency care in the field planning. C Local volunteers should not be involved, A Major surgery should only be considered only trained staff. D Replantation of limbs should be A Triage means treating the most seriously attempted. E Open fractures should be cleaned in the B Triage is carried out where the casualties field. F Repair of damaged major vessels should C Triage is carried out at the same time be attempted, if this is needed to save a as simple emergency life-saving limb. G Repair of damaged nerves should be D Triage does not mean that a patient’s attempted. E It frequently involves leaving the wound E the gas produced is oxygen from open. A Casualties hidden behind walls or other obstructions are protected from blast D the spores are found in soil. E Heavily contaminated wounds require B Blasts mainly affect fluid-filled cavities in anti-tetanus globulin as well as tetanus the body. C Penetrating wounds from fragments are F Penicillin V is ineffective against the deep and their borders difficult to define. D Contamination of a wound is not G Patients developing tetanus can be an issue as the heat sterilises any managed using sedation and do not fragments. Which of the following statements Case study – crush regarding necrotising fasciitis are true When he is finally B It can also be caused by infection with freed, he is confused, his pulse is faint several different organisms. F Surgery should not be undertaken while (a) Which two of the following are likely causes of his confusion F Atrial fibrillation (c) What organ is most at risk as the G Hypoxia limbs start to reperfuse H Uraemia A Brain – due to hypoxic shunting to the I Liver failure crushed limbs J Alcohol. B Liver – due to blood breakdown products (b) Which three of the following C Lung – due to multiple microemboli techniques are most appropriate for D Kidney – due to release of muscle his rewarming A, B, C the specific characteristics of a natural disaster are that the very services needed to maintain civil order and bring help to those in need are equally affected by the disaster and so will be crippled. The armed forces will be needed to maintain law and order and to provide the skilled manpower for transport of food, water, shelter and medicines. Natural disasters such as flooding can develop over an extended period and are not always a single event. Disasters attract attention and support in the short term but there is a natural fatigue within the media and the public, which frequently results in interest being lost long before the consequences of the disaster have been repaired. The countries most susceptible to natural disasters are often those least prepared for them in terms of planning and infrastructure. Even those countries who should, and can, plan for disaster usually find that the size and complexity of major disasters overwhelm the best-laid plans. B, D Assessment of the extent of damage must take place before and during the initial rescue efforts, not afterwards. Experienced staff will need to go into the field as only they can tell what is needed. However, other senior staff will need to stay back to organise the strategy and logistics of the rescue effort. It is tempting only to allow trained specialist staff to deal with a disaster but in the early hours and days they may not have arrived and local knowledge and initiative are going to be key to sustainable recovery in the long term. B, C, D, E Triage does not necessarily mean treating the most seriously injured first. They may have to be left to die, because devoting all your resources to a small number of them might result in a far greater loss of life amongst the many for whom quick and simple interventions could be life-saving. Triage is carried out simultaneously with simple life-saving procedures which should not be allowed to delay the process of triage. There is nothing to prevent a patient having their triage category changed when they are reassessed at a later time. Some patients may deteriorate and others improve during the minutes and hours after the disaster. The triage category of a patient is best 214 recorded on a coloured label attached to their wrist or hung around their neck, so that any other medical worker can see at once that they have been triaged and what it is felt needs to be done. A, B, C, D Patients should be stabilised before they are transferred, as assessment and treatment of a patient during transfer (whether in a helicopter or in an ambulance) is very difficult indeed. Journeys always take longer than expected so the patient should be prepared for the worst possible scenario, and adequate supplies provided to cover the journey, however delayed; otherwise there is little point in starting the journey. If the patient is being monitored and lines are being used, then the patient will need to be accompanied by a trained member of staff, despite the fact that this will remove skills from the disaster zone. Each patient should go with enough fluids and medication to enable their evacuation to be completed safely. A, B, C, E, F Major surgery should not be undertaken in the field, unless there is a threat to life of limb which can be averted by surgery (damage limitation). This might be to control catastrophic haemorrhage or amputation of a devitalised and potentially gangrenous limb. Open fractures also need cleaning in the field as otherwise contamination will rapidly turn to rampant infection. If a rapid repair of a major vessel can be undertaken and this will save a limb, this too should be attempted. Replantation and other long and complex operations should not be undertaken as they tie up resources, which cannot then be used for maximum gain, nor should nerve repairs be attempted. C, D, E, F the ‘old’ meaning of this word was to release pus, but it has now come to be used to describe the process of cleaning and tidying of a wound, removing foreign material, contaminated and non-viable tissue. It requires a long incision to be sure that all of the affected tissue can be clearly seen and adequately dealt with.

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In patients with altered mental status hypertension question and answers purchase moduretic 50mg fast delivery, the sodium and glucose levels must be measured Respiratory assessment and initial management and corrected blood pressure chart guidelines cheap moduretic 50 mg fast delivery. Hypoglycemia can be a result of decreased A patient who presents with tachypnoea and/or hypoxia (or intake over many days arteria femoralis communis cheap moduretic 50 mg with amex, especially in paediatric patients who low oxygen saturation documented with pulse oximetry) must are at baseline malnourished and then get sepsis prehypertension blood pressure treatment purchase moduretic 50 mg online. Oxygen surgery lasts longer than 1 hour, recheck the blood sugar again delivery to the cells may be inadequate in conditions of poor as undetected hypoglycaemia under anaesthesia can have perfusion for instance due to septic shock, which results in serious neurological implications. Hyponatremia (low sodium) is common in the surgical Subtle changes in the respiratory system may precede frank paediatric patient and could be caused by diarrhoea, vomiting, respiratory failure if the child becomes exhausted and low salt oral fuids, and use of incorrect fuids such as 4% compensation is overwhelmed. As with the cardiovascular system, the 5% dextrose (without added sodium) due to concerns about respiratory reserve is immense but can suddenly fail, resulting blood glucose levels can present with an altered mental status in respiratory arrest. Any sudden slowing of the respiratory and even seizure activity due to iatrogenic hyponatremia. The treatment of this metabolic process seizure medications such as diazepam, and even phenobarbital, if the sodium level is below 120mmol. Tese patients is not bicarbonate but resuscitation fuids (normal saline), titrated as described. Note that anaesthesia care provider should not delay emergency surgery fever will also elevate the respiratory rate and could confuse the until the plasma sodium level is normal if the intravascular clinical picture. An alternative cause of tachypnoea in this patient may be when can you start the surgery Bowel ischaemia, common in the child less than 1 year and when a child has a necrosis then perforation (with ensuing sepsis) increases distended abdomen, refux of gastric contents occurs readily. If the Gentle insertion of a nasogastric tube should be considered patient continues to demonstrate metabolic acidosis after to drain some gastric fuid, although this procedure can resuscitation with isotonic fuids, removal of a necrotic section prompt emesis and aspiration in the child with a decreased of intestine may be the only intervention that improves the mental status. The heart rate, respiratory rate of chest sounds will help to diferentiate between metabolic and peripheral perfusion should begin to normalize prior to acidosis (non-pulmonary) and aspiration pneumonia. Establishing some urine output chest sounds are clear the chance of aspiration pneumonia is is a useful sign and indicates improved renal preload following lowered but if you hear crackles or wheezing particularly on the resuscitation eforts. Pneumonia in this setting should not delay surgery in a child The following laboratory measurements need to be obtained if with compromised gut perfusion, but will indicate that the possible, but do not delay surgery for the results to normalize: child is at greater risk postoperatively. Cricoid pressure needs to be applied so that it does not distort the airway, as this • Glucose will make the intubation more difcult. Ask the assistant to If you are working in a hospital that cannot measure direct the trachea backwards, upwards and gently to the right. However, preoxygenation may be difcult Prepare the theatre with a warmer if the environment is cool, if the child is crying, but you can achieve some form of as the child will have extensive exposure and opportunity for preoxygenation if you waft high fow oxygen through a mask heat loss. Prepare all the equipment required to anaesthetise a directed towards the child’s face. Do not attempt to give the anaesthetic alone but fnd less responsive, a good mask ft may be achieved, which will an assistant. Explain about airway management, the aspiration allow preoxygenation with 100% oxygen, thus reducing the risk, and the need for cricoid pressure. As you can see from fgure 3, if the abdomen is very distended it has the potential Consider the plans for postoperative care well in advance: to restrict diaphragmatic movement and lung volumes, • Stafng level on the ward particularly in the supine position. Both of these factors will cause a rapid drop in the oxygen saturation once the patient • Oxygen stops breathing spontaneously. Some suggest it should be removed immediately prior to induction to ensure a good seal with the facemask if you need to ventilate the patient with cricoid pressure, should more than one attempt at intubation be required. Check the position of the endotracheal tube by auscultation prior to removal of cricoid pressure. Early removal of the cricoid pressure can result in aspiration if the endotracheal tube is placed in the oesophagus. Uncufed tubes are still prompting a rapid drop in oxygen saturation during intubation routinely used in many institutions. Monitor urine output as an indirect measurements to assess An even lower dose of induction agent should be used if adequate organ perfusion and keep the patient warm in the the patient is in shock not responding to fuid. If the child perioperative period with the means which you have available has been sick for some time, the blood pressure may drop to you in your hospital setting. Never perform an inhalation induction in these The use of inhalation agents, ketamine, opioids or any patients. You will need to control the ventilation, the intraoperative and postoperative course. If the patient is acidotic (determined Maintenance concerns clinically or by measurement of the venous or arterial blood After induction of anaesthesia and intubation with gas), they will not tolerate spontaneous ventilation with low succinylcholine, monitor the haemodynamic status closely. If this happens, give a fuid bolus of normal depolarising muscle relaxant to assist the surgeon and expedite saline or blood in 10ml. Place a three-way stop-cock in line so that due to hypovolaemia, myocardial depression, or associated blood or normal saline can be pushed with a 20-60ml syringe. Blood should be given based upon blood loss, with the goal of At the end of surgery, consider the options for extubation improving oxygen delivery dictated by cardiac output, oxygen carefully. Studies have shown that in decompress the bowel and the abdominal compartment may “stable sepsis” in the paediatric population that a haemoglobin not be too tight. In severe this fgure may need to be higher due to the weak medical cases of obstruction and sepsis, primary anastomosis would infrastructure and support systems. In either case, the child needs to be fully awake, breathing well Inotropes will need to be started if blood pressure remains low and adequately reversed, indicated clinically by fexion of the despite fuid administration. In addition, movement of The two most important factors for safe postoperative care are bacteria from the obstructed, and possibly necrotic intestines the location in the hospital and the nurse: patient ratio. The to the blood stream may release mediators and hydrogen ideal location should have oxygen, suction, good lighting, be ions (producing acidosis), resulting in more cardiovascular close to the nursing station; the room should be warm, the instability during surgical manipulation and repair of the head of the bed elevated, and there should be, one paediatric damaged intestines. In many hospitals the nurse: may be useful whilst an infusion of adrenaline is prepared patient ratio is 1:15, with very ill children, and this will not (dilute 1 mg adrenaline in 1000ml saline to give a solution of be safe for this child for the 72 hour period when the risk 1mcg. Many of these patients will have an oxygen requirement reFerenceS for a few days while the sepsis and any pneumonia resolves. Profle of pediatric The respiratory status, respiratory rate, should be monitored abdominal surgical emergencies in a developing carefully, particularly if opioids are given to a child receiving countries. A fall in saturation is a late fnding and narcotics should only be used in the setting of a 1:2 nurse:patient ratio. Mayo Clin Proc 2003; 29: 605-606, Emergency surgery for bowel obstruction in children presents vii. Children have a great reserve and ability to heal but may also hide the seriousness of their illness, 5. Red blood cell transfusion thresholds in and have the potential for sudden decompensation. PediatrCrit Care Med 2011; outcomes rely on meticulous perioperative planning, proper 12, No. The open fontanelles varies with age and children with serious head and sutures also predispose infants to a higher trauma often have multiple injuries. The presentation of head injury from road trafc collisions and sports related causes of death and disability varies with the severity of the insult ranging from injuries. Children with serious head trauma often an altered level of consciousness to deep coma. Early Early identifcation and proper management identifcation and proper cerebral blood fow of these patients greatly afects the outcome. Children have a disproportionately larger brain injury; in this situation, cerebral blood and heavier head and relatively weak neck fow follows cerebral perfusion pressure passively. Sudden acute changes in intracranial pressure Cerebral perfusion pressure less than 50mmHg has been are not well tolerated at any age. If compensatory mechanisms demonstrated to be a predictor of poor outcome in severe are overwhelmed, intracranial pressure will increase rapidly traumatic brain injury in children and adults. Extreme and the brain will herniate through the structures within the hypertension should also be avoided, as it will result in skull or the foramen magnum (coning) to cause coma and increased cerebral blood fow and cerebral oedema. Treatment is usually surgical drainage to detect associate injuries (consider non-accidental injury). Establish a patent airway with jaw thrust, making sure to It can be self limiting but if large can raise the intracranial keep the cervical spine immobilised. Foreign objects in the mouth and pharynx the blood vessels within the brain tissue.

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Diseases

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  • Fiber type disproportion, congenital
  • Subaortic stenosis short stature syndrome
  • Pulmonary cystic lymphangiectasis
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References:

  • https://www.aapm.org/pubs/reports/rpt_104.pdf
  • http://s2.bitdl.ir/Ebook/Biology/Salkind%20-%20Encyclopedia%20of%20Human%20Development%20(Sage,%202006).pdf
  • https://stacks.cdc.gov/view/cdc/6536/cdc_6536_DS1.pdf?