Secondary generalised Partial seizures (simple or complex) can progress to secondary generalised seizures buy carvedilol 6.25mg with mastercard. Generalised seizures Nonconvulsive (absence) Impaired conciousness but without falling cheap carvedilol 12.5mg amex, although there may be involuntary movements cheap carvedilol 6.25 mg fast delivery. Atonic (drop attacks) Loss of muscle tone causing patient to fall to ground The main terms used to describe seizures are: gitis carvedilol 12.5 mg low cost, stroke etc which may need urgent treatment. It is Partial (focal, localised seizure) also important to decide if the patient is likely to have r A partial seizure may be simple (no loss of con- further seizures. Status epilepticus Management This is dened as a prolonged single attack or continuing With a rst seizure, it is important to exclude any under- attacks of epilepsy without intervals of consciousness. Sodium valproate Gabapentin r Lorazepam or diazepam are rst-line treatment Lamotrigine Topiramate r If no response, intravenous phenytoin loading dose Tiagabine Levetiracetam of 15 mg/kg is given. The management of epilepsy should include the discussion of social is- Acute confusional state (delirium) suessuchassupportathome,relationships,employment andpsychologicalissuessuchasdepression. Womenwho Denition wish to become pregnant need special advice, but there Rapid onset of global but uctuating confusion with an is no reason why they should not have children. There underlying toxic, vascular, ictal (seizure) or metabolic are support groups available. Consider saving r Disorientation and impaired conscious level urine for toxicology screen. Management r Motoractivity may be increased but is often purpose- r Detection of the underlying cause of the confusional less. Severe cases may require benzodiazepines, Toxic Alcohol intoxication, withdrawal haloperidol or one of the newer anti-psychotics such Drugs Prescribed/illicit drugs, including as risperidone or olanzapine. The prognosis is dependent Hepatic failure on the underlying cause and co-morbid features. Hypoxia Hypoxia and/or hypotension Vitamin deciency Vitamin B12 Thiamine (Wernicke Korsakoff) Coma Intracrania Denition Trauma Head injury Coma is a state of unrousable unconsciousness. Vascular Transient ischaemic attack, stroke, any intracranial bleed or space- occupying lesion Aetiology Epilepsy May be post-ictal (after a seizure) or The causes are mainly those of acute confusional state nonconvulsive status (see Table above), although there are other causes as well. No response 1 Best verbal response Management Orientated 5 Following resuscitation treatment of the underlying Disorientated 4 Inappropriate words 3 cause is the main priority. In at-risk patients such as alco- Best motor response holics and in pregnancy, intravenous thiamine should Obeys verbal commands 6 be given prior to any intravenous glucose as there Localizes painful stimuli 5 Withdrawal to pain 4 is a small risk of precipitating irreversible Wernicke Flexion to pain 3 Korsakoff s syndrome. No response 1 r Empirical use of naloxone (reverses opiates), umaze- nil (reverses benzodiazepines) should be considered. Head Injury Denition Head injury is one of the most common causes of death Clinical features and disability in young men, mainly due to road trafc It is important to establish the level of consciousness. Incidence 1 The rst priority is resuscitation stabilise airway, Common;basedonhospitalattendancesandadmissions breathing and circulation and check the glucose level the incidence is 250 per 100,000 population. Hypoxia, hypoglycaemia or hypotension are reversible causes of coma and will exacerbate any Age other cause. Pathophysiology The pathology of head injury can be divided into two groups: Complications r Primary brain damage: Short term: Vascular, e. Subarachnoid and intracerebral ticularly on the side of the trauma (coup lesion) and haemorrhage may also occur. Long term: ii Diffuse axonal injury due to shearing forces caus- r Posttraumatic epilepsy. Patients r Chronic traumatic encephalopathy (the punch drunk who survive such injury may have severe brain syndrome seen in professional boxers). Ifneckinjuryissuspected,thepatientshould cal treatment, whereas primary brain damage occurs be immobilised until a spinal cord injury or unstable at the time of injury and therefore can only be in- cervical spine has been excluded. Followingtrauma,thebrainismuch Coma Scale, and full neurological and general exami- more susceptible to hypoxia and hypotension due to nation. The decision to admit for observation is based disruption of autoregulation and impaired vascular on the history and assessment at presentation. Osmotic diuretics such as mannitol Clinical features may also be used to reduce brain oedema. In more severe injuries, there is persistent post- mission to intensive care for intracerebral pressure traumatic amnesia. Patients All patients require close monitoring to check for devel- may have other injuries depending on the nature of the opment of complications that require urgent treatment. Over a period of several hours there is oozing of r the patient is difcult to assess, e. Apathy and/or depression are common, there may be Prognosis disturbances of sleep, confusion of day & night, with Recovery may take weeks to months. Other neurological signs with a persisting disability or impairment is 100 such as hemiparesis, seizures tend to occur very late in per 100,000. Generally, in the early stages, the patient is aware of a loss of their memory and may become very frus- Dementia trated and anxious. Acollateral history from a relative or close carer who Incidence has known the patient for a long time is essential. The 1% of those aged 65 74 years, 10% of those over 75 and carer is often the one most emotionally affected by the 25% of those over 85 years.

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It is estimated that about 5% to 10% of isocyanate workers develop asthma from exposure to subtoxic levels after a variable period of latency ( 64) generic carvedilol 6.25 mg mastercard. The histology of bronchial biopsy specimens from workers with isocyanate asthma appears very similar to that from patients with immunologic asthma and thus is suggestive of an immunologic mechanism (65) buy generic carvedilol 25mg. Compared with those isocyanate workers with negative bronchial challenges purchase carvedilol 6.25mg free shipping, workers with positive challenges have a higher incidence and level of antibody against isocyanate protein conjugates ( 66) buy carvedilol 25 mg line. However, in most studies, isocyanate workers with positive challenges did not have detectable specific IgE in their serum. In a more recent study, an association between isocyanate asthma and specific IgE was again reported ( 67). Hypersensitivity pneumonitis (68) and hemorrhagic pneumonitis (69) due to isocyanates have been reported to be caused by immunologic mechanisms. Formaldehyde, a respiratory irritant at ambient concentrations of 1 ppm or more, is often cited as a cause of occupational asthma; however, documented instances of formaldehyde-induced IgE-mediated asthma are almost nonexistent (72). A bifunctional aldehyde, glutaraldehyde, has been reported to cause occupational asthma ( 73). Ethylenediamine, a chemical used in shellac and photographic developing industries, has been reported to cause occupational asthma ( 74). Chloramine T (75), reactive azo dyes (76), piperazine acrylates (77), and dimethyl ethanolamine are other chemicals that have also been reported to be causes of occupational asthma ( 78). No matter what the etiologic agent, the presentation follows one of three patterns. Any form can lead to severe pulmonary fibrosis with irreversible change; thus, it is important to recognize this disease early so that significant irreversible lung damage does not occur. A variety of organic dusts from fungal, bacterial, or serum protein sources in occupational settings have been identified as etiologic agents of hypersensitivity pneumonitis (79) (Table 25. Several chemicals, including anhydrides and isocyanates, as discussed previously, have been reported to cause hypersensitivity pneumonitis. It is being increasingly reported that rhinoconjunctivitis precedes occupational asthma in many cases (83,84). Immunologic evaluations may provide important information about the cause of the respiratory disease. Skin tests, with antigens determined to be present in the environment, may detect IgE antibodies and suggest a causal relationship ( 86). Haptens may be coupled to carrier proteins, such as human serum albumin, and used in skin tests (78) or radioimmunoassays. In cases of interstitial lung disease, double gel immunodiffusion techniques may be used to determine the presence of precipitating antibody, which would indicate antibody production against antigens known to cause disease ( 79). It may be necessary to attempt to reproduce the clinical features of asthma or interstitial lung disease by bronchial challenge, followed by careful observation of the worker. Challenge may be conducted by natural exposure of the patient to the work environment with preexposure and postexposure pulmonary functions, compared with similar studies on nonwork days. It is important that the intensity of exposure not exceed that ordinarily encountered on the job and that appropriate personnel and equipment be available to treat respiratory abnormalities that may occur. Some advocate the use of peak flow monitoring, whereas others find it unreliable ( 87,88). Evaluating induced sputum eosinophils has been reported to be a potentially useful technique to diagnose occupational asthma ( 89). All known information about the sources of exposure should be sought in the form of previously reported toxic or immunologic reactions. The obvious conclusion from these studies is that early diagnosis and removal from exposure are requisites for the goal of complete recovery. It must be appreciated that life-threatening attacks and even deaths have been reported when exposure continued after diagnosis (1). Sometimes, the worker can be moved to another station; efficient dust and vapor extraction can be instituted; or the ventilation can be improved in other ways, so that a total job change is not required (96). Consultation with an industrial hygienist familiar with exposure levels may be helpful in this regard. It is important to remember that levels of exposure below the legal limits that are based on toxicity may still cause immunologic reactions. Ideally, the working environment should be designed to limit concentration of potential sensitizers to safe levels. Unfortunately, this is impractical in many manufacturing processes, and even in a carefully monitored facility, recommended thresholds may be exceeded ( 97). Thus, avoidance may well entail retraining and reassigning an employee to another job. However, chronic administration of steroids for occupational hypersensitivity pneumonitis is not recommended.

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It may be due to stable blood pressure carvedilol 6.25mg low cost, effective analgesia (reflex suppression) and avoidance of narcotic drugs in study group discount carvedilol 6.25mg on line. In conclusion trusted 25 mg carvedilol, newer technique combined epidural and general anaesthesia may be efficient enough to fulfill the required condition during operation and gap between the optimal condition and present condition may be narrowed effective carvedilol 12.5mg. The sympathetic supply of the stomach was by the greater splanchnic nerves through the coeliac plexus. The roots of the greater splanchnic nerves arose from as high as 4th thoracic ganglion and as low as 10th thoracic ganglion: even variable origins in each side of the same specimen were observed. In the majority of cases, the segmental origin of the greater spanchnic nerve was found to come th th from the 6 to 9 thoracic ganglia (78% on the right side and 84% on the left side). In most of the cases, the parasympathetic nerves were seen to arise from a single anterior vagus and, a single posterior vagus (73. However, in 8 cases, two anterior vagal trunks and one posterior vagal trunk were seen (17. The histological examination of the distribution and the mode of termination of the gastric nerves were determined in the stomachs of 15 human adults, 3 human fetuses, 8 albino rat, and 4 specimens from operative biopsy tissue by using various neurohistological and histochemical techniques. Nerve plexuses and ganglia were observed in the submucosa, muscular, and serosa layers of the stomach. Free as well as encapsulated endings were observed in the wall of the stomach of human and albino-rats. The type of nerve endings were free and free but organized endings such as loop-like endings. Pharmacological experiments were done in the stomachs of 2 albino-rats to prove the sympathetic and parasympathetic activities. Sympatho- mimetic agents were seen to evoke inhibitory responses where parasym-pathomimetic agents were found to evoke excitatory responses. Neurohistological and histochemical studies were done on the specimens from fifteen human adults, three human fetuses, eight albino-rats, and four specimens from human operative biopsy tissue. All parts of the stomach were supplied by the gastric branches of the coeliac plexus formed by both th th vagi and greater splanchnic nerves mainly from 6 to 9 thoracic ganglia. Neurohisto- chemically nerve plexuses and ganglia were observed in the submucosa, muscular, and serosa layers of the stomach. Intraepithelial free nerve endings, free but organized nerve endings such as loop-like endings and encapsulated endings such as Meissner s corpuscle and small bulbous corpuscles were 190 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar seen. Histochemicaly, acetylcholinesterase - positive ganglia, varicose nerve fibres and formaldehyde fluorescent nerve plexus were observed. Pharmacological experiments with sympathomimetic agents, sympatholytic agents, parasympathomimetic agents, and parasym- patholytic agents were done in the stomachs of two albino-rats to prove the sympathetic and parasympathetic activities. The review also outlines the rational approach to promotion of growth of Myanmar children. Studies conducted in Myanmar have shown that rice malabsorption is common in children, and may occur in up to two thirds of the population. It is possible that Helicobacter pylori infection frequently acquired during childhhod in developing countries has an impact on small bowel function. The precise mechanism is unknown but it has been proposed that it relates to the impact of infection on acid secretion, resulting in hypochlorhydria which may open the gate to enteric infections, small bowel bacterial overgrowth, and associated carbohydrate malabsorption. Elucidation of these mechanisms would allow a rational approach to promotion of growth of Myanmar children. An increase in the number of siblings was also found to be a high risk factor for H. Density of living, drinking water source, and type of latrine were not significantly associated with H. The findings indicated that intrafamilial transmission could play an important role in the high prevalence of H. Before implementation of clinical use of such a serological test requires validations for local use. Again growing popularity of "test- and-treat" policy requires evaluation of usefulness of such serological test-performance among under and over forty-five years age groups. The objectives were: a) to compare the gastric acid secretion together with urine acid output between malnourished and well-nourished children, b) to determine the relationship between the gastric acid secretion and urine acid out put. The study was carried out during June to December 2000 at the Yangon Children Hospital. Gastric acid secretion and urine acid output level before and after coffee stimulation in 40 malnourished and 20 well-nourished children. It was found that there was significantly decreased volume of stimulated gastric acid secretion within first hour (17. However, there was no significant quantitative relationship between gastric acid secretion and urine acid output in both malnourished and well-nourished children. Malnourished children were unable to respond appropriate to a stimulus for gastric acid production, poor response was markedly observed in children with kwashiorkor and lesser extent in marasmic-kwashiorkor children. All these patients underwent semi-urgent haemorrhoidectomy (Standard Ligation and Excision).

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Examples include: Any restrictions on use of the archived message Messages are restricted to members and may not be shared without written permission of the author of the message quality carvedilol 25 mg. Sample Citation and Introduction to Citing Blogs The general format for a reference to a blog on the Internet discount carvedilol 25 mg on-line, including punctuation: 1472 Citing Medicine The general format for a reference to a contribution to a blog carvedilol 25mg on line, when the contribution is written by someone other than the blog owner order carvedilol 12.5mg with mastercard, including punctuation: Examples of Citations to Blogs Blog is a contraction of Web log. A blog is a publicly available Web site that serves as a personal journal or sounding board for an individual or as an information tool for an organization. Entries or messages are displayed in reverse chronological order and the site is usually updated daily. In citing a blog, note that: The word blog may or may not be a part of the title. If no beginning date is found, use the date of the earliest message posted (usually found under Archive) and place it in square brackets. Many blogs also post articles or other documents that were initially published elsewhere. Messages posted to discussion lists like a blog are considered a form of personal communication and are not often accepted by editors or others for inclusion in a reference list. Most authorities recommend placing references to such communications within the running text, not as formal end references. Such statements may include additional details, such as the reason for the posting. It is highly recommended that any message being considered for future citation be saved to disk or in print because blogs may not save or archive messages for retrieval or may withdraw individual messages. Continue to Citation Rules with Examples for Blogs Continue to Examples of Citations to Blogs Citation Rules with Examples for Blogs Components/elements are listed in the order they should appear in a reference. Author/Editor (R) | Author Affiliation (O) | Title (R) | Content Type (O) | Type of Medium (R) | Editor and other Secondary Authors (O) | Place of Publication (R) | Publisher (R) | Date of Publication (R) | Date of Citation (R) | Availability (R) | Language (R) | Notes (O) Author/Editor for Blogs (required) General Rules for Author/Editor List names in the order they appear on the opening screens Enter surname (family or last name) first for each author/editor Capitalize surnames and enter spaces within surnames as they appear on the assumption that the author approved the form used. Iakontov becomes Iakontov IuA Electronic Mail and Discussion Forums 1477 Georgios Th. Follow the same rules used for author names, but end the list of names with a comma and editor or editors. Box 108 Names for cities and countries not in English Use the English form for names of cities and countries when possible. Box 112 Titles in more than one language If a blog is written in several languages: Give the title in the first language found on the opening screens List all languages of publication after the availability statement Separate the languages by commas End the list of languages with a period If a blog has equal text in two or more languages, as may occur on Canadian sites: Give all titles in the order in which they are found on the opening screens Place an equals sign with a space on either side between each title List the languages, separated by commas, after the availability statement End the list of languages with a period Example: Kikanshi kunai choonpa dansoho = Endobronchial ultrasonography [blog on the Internet] Box 113 Titles ending in punctuation other than a period Most titles end in a period. Box 114 Titles containing a Greek letter or another special character Reproduce the title of a blog as closely as possible to the wording that appears on the screen, duplicating capitalization, spacing, and punctuation eHealth: a blog devoted to ehealth and healthcare information technology [Internet]. Blog in a language other than English Content Type for Blogs (optional) General Rules for Content Type Use a content type to alert the user that the reference is to a blog, not to a standard book or Web site Begin type information with a left square bracket Enter the words "blog on" End the content type with space Specific Rules for Content Type Titles ending in punctuation other than a period Titles not in English Box 115 Titles ending in punctuation other than a period Most titles end in a period. Box 116 Titles not in English If a translation of a title is provided, put the translation in square brackets 1486 Citing Medicine Place the content type and type of medium in square brackets after the translation Endotoksikoza [Endotoxicosis] [blog on the Internet]. Box 118 Titles ending in punctuation other than a period Most titles end in a period. Blog published with content type given Editor and other Secondary Authors for Blogs (optional) General Rules for Editor and other Secondary Authors A secondary author modifies the work of the author. Box 122 Non-English names for secondary authors Translate the word found for editor, translator, illustrator, or other secondary author into English if possible. For example, Chicago as the place of publication of a blog issued by the American Medical Association. Blog with unknown place of publication Publisher for Blogs (required) General Rules for Publisher Use for publisher the individual or organization issuing the blog Record the name of the publisher as it is found on the title page or opening screens, using whatever capitalization and punctuation appears When a division or another subsidiary part of a publisher appears in the publication, enter the publisher name first. Box 128 Abbreviated words in publisher names Abbreviate commonly used words in publisher names, if desired Examples: Acad. Blog with unknown publisher Date of Publication for Blogs (required) General Rules for Date of Publication Give the beginning date, i. Box 134 Non-English names for months Translate names of months into English Abbreviate them using the first three letters Capitalize them Examples: mayo = May luty = Feb brezen = Mar Box 135 Date of publication and date of copyright Some publications have both a date of publication and a date of copyright. Contribution to a blog on the Internet by someone other than the blog owner Language for Blogs (required) General Rules for Language Give the language of publication if not English Capitalize the language name Follow the language name with a period Specific Rules for Language Blogs appearing in more than one language Box 142 Blogs appearing in more than one language If the contents of a blog appear in several languages: Give the title in the first language found on the opening screens List all languages of publication after the Availability statement 1500 Citing Medicine Capitalize the language names Separate the language names by commas End the list of languages with a period If the first title is not English, follow with a translation when possible. Blog in a language other than English Notes for Blogs (optional) General Rules for Notes Notes is a collective term for any useful information given after the citation itself Complete sentences are not required Be brief Specific Rules for Notes Types of material to include in notes Box 143 Types of material to include in notes The notes element may be used to provide any further information. Blog with supplemental note included Electronic Mail and Discussion Forums 1501 Examples of Citations to Blogs 1. Diabetes Mine: a gold mine of straight talk and encouragement for people living with diabetes [blog on the Internet]. Contribution to a blog on the Internet by someone other than the blog owner Mantone J. Sample Citation and Introduction to Citing Wikis The general format for a reference to a wiki on the Internet, including punctuation: Electronic Mail and Discussion Forums 1507 Examples of Citations to Wikis A wiki is a multi-authored or collaborative Web site that permits users to create additional content for the site and to edit existing content. Users may also add comments to content, ask questions, and reply to questions posed by others.