By X. Harek. Gwynedd-Mercy College.
He combined calm and compassion with medical expertise in a thorough form of healing that I grew to expect purchase 20 mg erectafil overnight delivery erectile dysfunction for young adults, but have infrequently witnessed in poor communities generic erectafil 20 mg free shipping erectile dysfunction treatment in the philippines. As I strive to bring better health care to underserved populations erectafil 20mg cheap impotence viriesiem, I hope to do so with the same personal care and attention that comforted me in my youth. Undaunted and striving to help my community, I inquired about our local nursing home. My grandmother refused to enter the brown building with me, unable to interact with residents who were ailing and terminally ill. The residents who were so debilitated that they would never leave the care of the nursing home really moved me. It was amazing how the support of the medical staff and family members created an environment that allowed residents to live an enjoyable life. I will never forget one resident in his early thirties who was paralyzed from the waist down, unable to live as most young adults. My encouraging words and energy as a young person often brightened his day, and in return made me feel very joyful to serve. It was quite extraordinary to know that such a small gesture could positively impact someones life. From reading stories to assisting the professional staff with exercise routines for the residents, the experiences I had there were life-changing. It was then that I realized that my life would be most fulfilled working directly to improve the lives of others as it relates to medicine. I embarked on several projects within the disciplines of immunology, cell biology, genetics, and vascular biology. These research projects gave me an indescribable experience as a participant in the discovery process and newfound appreciation for biomedical research. I was ready to work in the hospital and wondered how various scientific discoveries were being used in medicine. However, once I suited up and walked into the shock trauma room, I knew medicine was the profession I was meant to pursue. Through my work, I witnessed the 8 medical staff working tirelessly to stabilize and care for patients who had experienced car accidents, stabbings, and other forms of trauma. I will never forget walking into the shock trauma room to find a crying mother and grandmother as they saw their son and daughter severely injured from a car accident. As I looked into the next unit, there was a middle-aged woman who was recovering from a stab wound. Although I could not physically interact with her, I felt like a part of the medical team---working to ease suffering and serve those in pain. The most striking incident occurred one Saturday morning when I walked into the resuscitation unit and saw a pool of blood surrounding the rolling bed of one patient. I watched the reactions of the staff as they silently covered his body and rolled it away. It was then that I realized that one day I would be in a position to save someones life. Most importantly, I understood the important role that I must be prepared for in helping families deal with such a life tragedy. As I was walking back to the locker room, I started to reflect on the joy I got from volunteering in the hospital and mentoring community kids, combined with my passion for science. I knew at that moment that I would love working as a physician who could not only heal and alleviate pain, but who can educate and innovate. The opportunity to change even a fraction of the lives of those in a city or underserved country is quite amazing. With the untimely death of various community members due to the advanced stages of cancer and the higher incidence of human immunodeficiency virus infection in minority women, I am inspired to join the struggle against deadly diseases and sickness. As I continue to strive for more, I can remember a quote by author Anna Eleanor Roosevelt: When you cease to make a contribution, you begin to die. The tent that housed the trauma bay hummed intensely yet somberly as the medical staff began evaluating the casualties. My trauma shears ripped through the soldiers charred uniform while I performed an initial assessment of the casualty with the attending physician. Exposing the injuries, I found that the soldier was badly burned due to the blast. He was unconscious, suffering from a compromised airway and his skin was peppered with shrapnel. I attached monitoring equipment, started a peripheral line and began cleaning the burns that blanched the majority of the soldiers upper body. Through the synchronized chaos of surgeons directing treatment, anesthetists intubating and nurses administering initial medications, I understood the fluid relationship between the levels of medical hierarchy. I became part of an intricate network of communication, and the demanding process of saving a life. Nothing has been more rewarding than serving my fellow soldiers and the local Afghan community during a year long deployment overseas. Working in a combat support hospital under personalized mentorship of a cardiothoracic, orthopaedic and general surgeon gave me the opportunity to learn about long and short term care, processes of diagnosis and proactive medical treatment in trauma situations. After serving in a combat zone I realized that a life is the most magnificent and powerful force in existence. It compels us to bridge language and cultural barriers, and it is the common denominator amongst all human beings.
Ultrasound guidance is used discount erectafil 20mg otc erectile dysfunction and diabetes type 1, and usually two cores are obtained using a spring-loaded biopsy needle buy erectafil 20mg without prescription erectile dysfunction underwear. These are examined under light microscopy order 20mg erectafil overnight delivery erectile dysfunction doctor tampa, electron microscopy andimmunouoresenceorimmunoperoxidasestaining. In up to 3% renal failure (creatinine clearance becomes inaccurate), of individuals, blood transfusion is required for bleed- for kidney donors and patients receiving chemotherapy. Contraindications to percutaneous renal biopsy: Anion gap calculation is useful in metabolic acidosis, to r Clotting abnormality or low platelets (unless cor- differentiate causes. The r Small kidneys (<9 cm), as this indicates chronic irre- formula used to calculate the anion gap varies from versible kidney damage. In metabolic acidosis, a normal anion gap indicates that there is failure to excrete acid or loss of base: Dialysis r Failure to excrete acid occurs in renal tubular disease When the kidneys fail to a degree that causes symptoms and Addisons disease. Despite advances in technology, these are still Renal biopsy is indicated when glomerular disease is sus- unable to completely mimic renal function, and none pected,andinunexplainedacuterenalfailure. The dialyser consists of an array of semi-permeable plications include hypotension, line infections, dialysis membranes. The blood ows past the membrane on one amyloid and increased cardiovascular mortality. Smallsoluteswithalarge and solutes across a highly permeable membrane and concentration gradient diffuse rapidly, e. Before the blood is returned to the body, atinine,whereasdiffusionisslowerwithlargermolecules uid is replaced using a lactate or bicarbonate-based so- or if the concentration gradient is low. Proteins are too large to cross the mem- of uid and changes in electrolyte concentration take brane. Underdialysis (lack changedacrosstheperitonealmembranebyputtingdial- of adequate dialysis) is associated with an increase in ysis solution into the abdominal cavity. Dialysateisrunundergravityintotheperi- toneal cavity and the uid is left there for several hours. Blood from Blood to Small solutes diffuse down their concentration gradients patient patient between capillary blood vessels in the peritoneal lining and the dialysate. Patients often develop some consti- Dialysate out Dialysate in pation which can limit the ow of dialysate, they are treated with laxatives. There is a large degree of bacterial peritonitis are the most common serious com- redundancy in the kidney, so many nephrons may be lost plications. This can be treated by adding antibiotics to the It is useful when considering the causes of renal failure peritoneal dialysate. The kidneys have three important functions: 1 Fluid and electrolyte balance, including acidbase bal- ance. High phosphates cause pruritus (itching), chronic r In prerenal failure, the kidney is not damaged but renal failure leads to renal osteodystrophy. Recovery may be possible, though if the disease is severe and scarring results, full Acute renal failure functional recovery is unlikely. The rate at which these rise depends on a number of factors, including how Clinical features catabolic the patient is, i. Complete anuria is only seen with bladder out- Oliguria (urine output <15 mL/hour or <400 mL/ ow obstruction, bilateral (or unilateral in a single 24hour) is common, but does not occur with all causes functioning kidney) ureteric obstruction. Water retention can lead to r Hyperventilationmaybeduetohypoxiaorrespiratory hyponatraemia. Acute glomeru- Primary and secondary causes r Bloods lonephritis of glomerular disease Acute interstitial Pyelonephritis, drugs 1 Anaemia (normochromic, normocytic if underly- nephritis ing disease or in chronic renal failure). Management Acute renal failure is an emergency, with possible life- threatening complications. Complications Reversiblecausesshouldbetreatedassoonaspossible; Hyperkalaemia may cause cardiac arrhythmias and sud- withdraw any potentially nephrotoxic drugs, treat sepsis, den death. Fluid overload may cause cardiac failure, malignant hypertension, and relieve any obstruction. Central venous r Persistent hyperkalaemia >6 mmol/L despite medical pressure measurement may be helpful, but should therapy not be relied upon over clinical assessment espe- r Severe acidosis cially in the presence of cardiac or pulmonary disease. If blood pressure remains low Prognosis despite lling (such as due to cardiac insufciency, Depends on underlying cause and concomitant medical sepsis), then additional treatment, usually inotropic conditions. Denition r In uid overload, or in oliguric renal failure high doses Necrosis of renal tubular epithelium as caused by hypop- of furosemide may be effective in causing a diuresis. However, there is no good evidence that furosemide speeds the recovery from renal failure, and it should Aetiology be avoided in those thought to have pre-renal failure. In addi- tion, in shock renal blood ow is particularly likely to Hyperkalaemia suffer because of constriction of renal vessels due to r Treatseverehyperkalaemia(K>6. Toxin induced r Endogenous Haemoglobinuria, myoglobinuria, Review all medication for dosages in renal failure. Glomerulonephritis 12% Toxinsmayhaveavarietyofmechanismssuchascaus- Pyelonephritis/reux nephropathy 10% ing vasoconstriction, a direct toxic effect on tubular cells Renovascular disease 7% Hypertension 6% causing their dysfunction, and they may also cause the Adult polycystic kidney disease 6% death of tubular epithelial cells which block the tubules. Blockageoftherenaltubulescauses renal function requiring any form of chronic renal re- asecondary reduction in glomerular blood ow. The ep- Incidence ithelial cells take time to differentiate and develop their The exact number of people with chronic renal failure is concentrating function. This phase renal disease such as amyloid, myeloma, systemic lupus may last many weeks, depending on the initial severity erythematosus and gout. Initially there may be a phase of large Prognosis volumes of dilute urine production due to reduction In acute tubular necrosis the mortality is high but if in tubular reabsorption. The kidneys are usually small and shrivelled, with 3 The hormone functions of the kidney are also affected: scarring of glomeruli, interstitial brosis and tubular at- reduction of vitamin D activation causes hypocal- rophy. The onset of uraemia is insidious, but by the time vious historical urea and creatinine measurements are serum urea is >40 mmol/L, creatinine >1000 mol/L, very useful.
It is believed that less fre- quent administrations represent a significant gain in quality of life for patients but also allow overworked nephrologists and nurses to concentrate on the other serious medical conditions affecting many of these patients such as hypertension cheap erectafil 20mg on line erectile dysfunction treatment reviews, diabetes discount erectafil 20 mg with mastercard erectile dysfunction evaluation, chronic heart failure and obesity cheap erectafil 20mg line erectile dysfunction getting pregnant. The principle of Improved efficacy of proteins can be achieved pegylation: Pegasys with the help of specific modifications. It is essential to select the proper moiety that will confer Main avenues of research 43 to the active protein the de- A pegylated protein: Pegasys sired properties. The choice of linker is also very impor- tant as its rigidity (or lack thereof) will influence the ultimate properties of the new medicine. Roche has successfully applied this principle to develop a drug for the treatment of hepati- tis C and B. In this method the drug is enveloped in one or two highly branched molecules of polyethylene glycol. It has been used for de- cades for treating hepatitis C, a widespread infection which causes inflammation of the liver. To date no treatment exists that is able to eradicate the hepatitis C virus from the body. As a result, drug levels in the patients blood- stream undergo significant fluctuations in a two-day rhythm, giving rise to side effects and limit efficacy. It is also considered that fluctuation is instrumental promoting the appearance of resistant viruses. Thanks to a carefully selected pegylation with the appropriate bond with the protein,Pegasys is broken down much more slow- ly than simple interferon and therefore remains active in the body longer. This has several advantages for patients: Firstly, Pegasys only has to be given once weekly. Secondly, the dose does not have to be adjusted gradually at least not to the same degree according to the patients age, hepatic status and renal function, a time-consuming process. Thirdly, interferon levels in the bloodstream are subject to less fluctuation, making the side effects more tolerable and improving patient compliance. First approved in 2002, Pegasys quickly became the internation- al market leader in the hepatitis C sector. The drug was also the first pegylated therapeutic protein in the world to be approved for the treatment of chronic hepatitis B. A new drug class: Therapeutic antibodies form a relatively new therapeutic antibodies drug class that was only made possible by modern biotechnology. These Y-shaped proteins bear on their two short arms two identical regions that recognise a specific foreign structure. The long stem of the molecule interacts with other components of the immune sys- tem, which then initiate destruction of the intruders. In 1972 Csar Milstein and Georges Khler, who later received the Nobel Prize, found a way to produce copies of identical antibody molecules in unlimited amounts. Within a few years these so-called monoclonal antibodies had revolutionised bio- logical research, allowing any desired molecule to be reliably identified and marked. However, it took more than 20 years for monoclonal antibodies to find widespread use in therapy. Not until the late 1990s did researchers succeed in exploiting the specificity of monoclonal antibodies for therapeutic purposes. For example, monoclonal antibodies can be designed to bind to specific molecules and block their disease-causing effects. However, drug developers were unable to use antibodies ob- tained from standard mammalian (usually mouse) cells. Because the molecules differ in structure from one species to the next, mouse antibodies proved to be of very limited benefit in humans. Re- searchers therefore turned their attention to what are known as chimeric and humanised antibodies, where only the recognition regions are based on mouse genes. It is now possible to insert all the human genes required to produce antibodies into laboratory Main avenues of research 45 A new drug class: therapeutic antibodies Mouse Chimeric Humanised Human Each antibody bears on its two short arms identical regions render them harmless. Whereas early therapeutic anti- that recognise a specific foreign structure, to which they bodies were still partly derived from mouse genes (yellow bind. This principle is exploited in therapeutic antibodies in segments), therapeutic antibodies of the latest generation order to recognise pathogenic and other substances and are indistinguishable from their human counterparts. Immunisation Gene transfer Mouse with human Ig genes Human monoclonal antibodies Fully human therapeutic antibodies are obtained by infect- production of immunoglobulins (Ig) with the target for the ing a transgenic mouse that carries human genes for the antibodies that one wishes to produce. As a result, medical science now has at its disposal an arsenal of therapeutic antibodies that are structurally identical to their natural counterparts in the human body. Example MabThera: A good example of a highly effective chimeric an- hope for patients with tibody is the Roche product MabThera/Rituxan lymphoma (rituximab). The target protein of this therapeutic antibody is a receptor located on the surface of B lymphocytes (white blood cells), which in lymphomas grow uncontrollably. The antibodies bind to the cancer cells, marking them out for destruction by the bodys immune system. At the same time rituximab makes the cells more susceptible to certain forms of chemotherapy, thus improving the survival chances of patients who previously had no further therapeutic options fol- lowing unsuccessful chemotherapy. A turbocharger for the Therapeutic antibodies such as rituximab help immune system the patients immune system to home in on dis- eased target cells. Main avenues of research 47 Enhanced immune response: modified therapeutic antibodies 120 Engineering of antibody 100 80 60 40 Wildtype antibody 20 Engineered negative 0 control antibody 0 10 20 30 40 50 Antibody concentration (ng/ml) Specifically modified therapeutic antibodies can induce a five to eight times stronger immune response (e. The next drug The next step was to link therapeutic antibodies generation: small with small molecules to form what are known as molecule conjugates small molecule conjugates. Antibodies have a disadvantage that they share with other thera- peutic proteins: they are too bulky to penetrate into the interior of cells.
It is associated with widespread airway obstruction that is reversible (but not completely in some patients) order 20mg erectafil amex erectile dysfunction gnc, either spontaneously or with treatment Epidemiology: Asthma is a common disease The prevalence of asthma is rising in different parts of the world buy generic erectafil 20mg online drugs for erectile dysfunction ppt. About 50% of patients develop asthma before the age of 10 and another 35% before the age of 40 discount erectafil 20mg free shipping psychological erectile dysfunction wiki. Most cases of asthma are associated with personal or family history of allergic disease such as eczema, rhinitis and urticaria. Etiology Asthma is a heterogeneous disease and genetic ( atopic ) and environmental factors such as viruses, occupational exposure and allegens contribute to its initiation and continuance. In general asthma which has its onset early in life tends to have strong allergic component, where as asthma that develops late in life tends to be nonallergic or to have mixed etiology. The cells thought to play important part in the inflammatory response are mast cells, eosinophils, lymphocytes and airway epithelial cells. These cells release inflammatory mediators which may result Bronchoconstriction (spasm of airways smooth muscles ) Vascular congestion and edema of airways mucosa Increased mucus production Injury and desquamation of the airways epithelium and impaired muco-ciliary transport Symptom and Signs The symptoms of each asthmatic patient differ greatly in frequency and degree. Psychological factors particularly those associated with crying, screaming or hard laughing may precipitate symptoms. On physical examination Varying degrees of respiratory distress tachypnea, tachycardia, and audible wheezes are often present. However, low grade wheezing maybe heard at any time in some patients, even when they claim to be completely asymptomatic. Complications during an Acute Attack of Asthma Pneumothorax: It may present as sudden worsening of respiratory distress, accompanied by sharp chest pain and on examination, hyperresonant lung with a shift of mediastinum. A family history of allergy, rhinitis or asthma can be elicited in most asthmatics. Physical examination should search for heart failure and signs of chronic hypoxemia (clubbing). Treatment General principles Assessing the severity of the attack is paramount in deciding management Bronchodilators should be used in orderly progression Decide when to start corticosteroids Treatment of the Acute Attack Mild acute asthmatic attack: Most patients can be managed as an outpatient st Salbutamol aerosol (Ventolin) two puffs every 20 minutes for three doses is the 1 line of treatment. However, over hydration may cause pulmonary edema and one should be cautious in fluid administration. However this can be overcome when underlying hypoxia and feeling of asphyxiation is treated. Maintenance Therapy for Asthma (Chronic Treatment) Goal of Therapy: To achieve a stable, asymptomatic state with the best pulmonary function, using the list amount of medication. Step wise approach for managing Asthma in adults Severity Symptoms Medication Alternative day/night treatment in resource limited setting Mild 2 days/wk and 2 No daily medication intermittent nights /month needed Treat when there is acute exacerbation Mild > 2days /week but < Low dose inhaled steroids Theophedrine tablets Persistent 1 per day and > 2 or or Salbutamol tabs nights/month Cromolyn Moderate Daily symptoms and Low-medium does inhaled Theophylline Persistent more than 1 night /wk steroid and long acting B- sustained release agonist inhaler Salbutamol Tabs Prednisolone tablets (low dose Sever Continual daily High dose inhaled steroid Theophylline Persistent symptoms and and long acting inhaled B- sustained release 183 Internal Medicine frequent night agonists and Oral steroids Salbutamol Tabs symptoms (if needed ) Prednisolone tablets (high dose) or Celestamine tabs References: 1) Kasper L. Both these diseases occur together in the same individual in a variable proportion but the manifestations of one often predominates the clinical picture. Etiology Emphysema: Any factor leading to chronic alveolar inflammation would encourage development of an emphysematous lesion. Congenital enzyme defects such as 1- antitrypsin deficiency are also risk factors for the disease. In developing countries household smoke from fire wood is said to be a major contributing factor. Nowadays, the incidence of this disease in females is increasing because of the increasing smoking habit. Pathological changes and pathophysiology Chronic bronchitis is characterized by hypertrophy of mucus glands in both large and small airways with thickening of walls and accompanying excess production of mucus and narrowing of airway lumen. This leads to abnormal V/Q (arteriovenous shunt) and patients usually suffer from hypoxemia (manifested with cyanosis) and acidosis, which causes pulmonary hypertension and right heart failure in the long term. Moreover, emphysema causes mucus production and airway narrowing with accompanying reduction in ventilation. This leads to retention of carbon dioxide in the blood and severe dyspnea from reduced tissue perfusion. However, these patients dont suffer from hypoxia and acidosis, and have less chance of development of pulmonary hypertension and cor-pulmonale. However, patients usually have a mixed picture of emphysema and chronic bronchitis. In patients with chronic bronchitis, severe hypoxemia may be noted relatively early. The course can be repeated at the first sign of recurrence of bronchial infection. Oxygen should be given in such patients with hypoxia, and in severe cases a portable oxygen therapy ( 16 hrs /day) for home use is recommended. Antidepressants may be necessary but they should be used cautiously to avoid sedation. If sputum becomes purulent, a course of broad-spectrum antibiotics should be given. Phlebotomy 189 Internal Medicine should be done when the hematocrit level is very high (above 55%) and patients are symptomatic. Design appropriate methods of prevention of bronchiectasis Definition: It is a pathologic, irreversible destruction and dilatation of the wall of bronchi and bronchioles, usually resulting from suppurative infection in an obstructed bronchus. Etiology and pathogenesis: Small bronchi of children are susceptible to recurrent infections and obstruction by foreign body, lymph node, or impacted secretions, all of which lead to persistent infection and the development of bronchiectasis. Clinical features Chronic cough productive of copious and offensive purulent sputum is the cardinal feature of bronchiectasis.