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V. Delazar. Central Bible College.

Effectiveness of prophylactic inhaled steroids in childhood asthma: a systemic review of the literature effective 200mg celecoxib. The effect of inhaled fluticasone propionate in the treatment of young asthmatic children: a dose comparison study order 100mg celecoxib free shipping. Efficacy of budesonide inhalation suspension in infants and young children with persistent asthma. Prophylactic intermittent treatment with inhaled corticosteroids of asthma exacerbations due to airway infections in toddlers. The effect of inhaled steroids on the linear growth of children with asthma: a meta-analysis. Factors predisposing infants to lower respiratory infection with wheezing in the first two years of life. Follow-up of asthma from childhood to adulthood: influence of potential childhood risk factors on the outcome of pulmonary function and bronchial responsiveness in adulthood. Spontaneous improvement in bronchial responsiveness and its limit during preadolescence and early adolescence in children with controlled asthma. During sleep onset, stage 1 sleep is seen with its characteristic slow rolling eye movements and easy arousability. A representative sample of sleep from a healthy young adult without sleep complaints. The homeostatic drive quantifies the physiologic need to sleep, and the circadian pacemaker ensures proper timing of the sleep process. Circadian Rhythms The word circadian is derived from Latin roots circa (about) and diem (a day). The term circadian rhythm refers to any behavior or physiologic process that is known to vary in a predictable pattern over a 24-hour period. First, inputs such as light and activity help synchronize (entrain) to the environment. Examples of these output pathways include lung function ( 9), sympathetic tone (10), and urine production (11), all of which vary over a 24-hour period so that optimum performance occurs during the daytime. Recent investigations have illuminated much about the site of the circadian pacemaker. There are nine currently identified genes that participate in a feedback system to regulate circadian processes. In animal models, significant modifications of these genes alter rhythms of sleep and activity ( 15), and there is a human disorder advanced sleep phase syndrome characterized by sleep which itself is normal but is temporally displaced ( 16). Sleep as a Homeostatic Process Homeostasis is the process by which the body maintains stability. Thirst, hunger, and temperature are all processes that are carefully regulated to ensure optimal function. These types of studies highlighted the use of a daytime multiple sleep latency test to quantitate sleepiness by measuring several times over the course of a day how quickly a subject could willingly fall asleep ( 17). The goal of the sleep homeostatic process is not well defined or understood; however, current models hypothesize that maintenance and remodeling of synaptic connections may be involved (19). Two-Process Model The two-process model of sleep regulation has been used to explain the relationship between circadian rhythm regulation of sleep (process C) and the homeostatic drive to sleep (process S). Both processes S and C have an impact on sleep regulation, and to promote optimum sleep quality, maximum sleep debt should intersect with appropriate circadian time (20,21). Immune cells such as lymphocytes, monocytes, and natural killer cells all have a circadian rhythm of expression, but this rhythm is modified by the sleep process ( 24). The impact of sleep deprivation on human immune function has yet to be fully investigated, but from animal studies it appears that sleep deprivation limits the ability of the immune system to function and respond to an influenza vaccine challenge ( 25). Two thirds of those who are sleepy responded that they just keep going when sleepy. One great risk of sleepiness is the risk of car accidents, and 19% of adults admitted that they have fallen asleep at the wheel during the past year ( 26). Endocrine function is affected by sleep deprivation, including impaired glucose tolerance and elevations in cortisol levels and sympathetic tone ( 28). Sleep deprivation also can contribute to cardiac disease and sleep apnea ( 29,30). The most common, but by no means only, cause of daytime sleepiness in the face of sufficient sleep is poor-quality nocturnal sleep. However, unattended home sleep studies are now more common, and although reservations persist, these studies can be helpful if they are performed for diagnostic proposes by well-trained sleep professionals ( 32). Snoring Until recently, it was commonly assumed that snoring was a benign annoyance, not associated with negative health outcomes.

Cardiac disease by history cheap celecoxib 200 mg free shipping, examination and generic celecoxib 200mg visa, 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. Coagulation deciencies should be corrected tervention, but should have perioperative blood glu- prior to surgery and careful uid balance is essential. The patient s alcohol intake should be elicited; symp- r Patients on oral hypoglycaemic agents should omit toms of withdrawal from alcohol may occur during a their drugs on the morning of surgery (unless under- hospital admission. In more major surgery, or Pre-existing renal impairment predisposes to the devel- when patients are to remain nil by mouth for a pro- opment of acute tubular necrosis. Hypotension should longed period, intravenous dextrose and variable dose be avoided and urinary output should be monitored so intravenousshortactinginsulinshouldbeconsidered. Close In patients requiring emergency surgery there may not monitoring of blood sugar and urine for ketones is be enough time to identify and correct all coexistent essential. It is however essential to identify any cardiac, should convert back to regular subcutaneous insulin respiratory, metabolic or endocrine disease, which may therapy. Any anaemia, uid and nutrition may cause signicant injury if extravasation electrolyte imbalance or cardiac failure should be cor- occurs. Other complications of parenteral nutrition rected prior to surgery wherever possible. Specic guidelines regarding the use of perioperative an- tibiotic prophylaxis vary between hospitals but these are Postoperative complications generally used if there is a signicant risk of surgical site infection. Prophylaxis for immunod- sions, wound dehiscence) and complications secondary ecient patients requires expert microbiological advice. It requires aggressive management and may necessitate return Nutritional support in surgical patients to theatre. Reactive haemorrhage occurs from small Signicantnutritionaldeciencyimpairshealing,lowers vessels, which only begin to bleed as the blood pres- resistance to infection and prolongs the recovery period. Blood replacement may be Malnutrition may be present preoperatively particularly required and in severe cases the patient may need to in the elderly and patients with malignancy. Enteral nutrition is the treatment of choice in all pa- r Alow-grade pyrexia is normal in the immediate post- tients with a normal, functioning gastrointestinal tract. Liquid feeds either as a supplement or replacement pletion, renal failure, poor cardiac output or urinary may be taken orally, via a nasogastric tube or via a gas- obstruction. Liquid feeds may be whole protein, oligopep- isation (or ushing of the catheter if already in situ) tide or amino acid based. These also provide glucose, and a clinical assessment of cardiovascular status in- essential fats, electrolytes and minerals. Mixed Early postoperative complications occur in the subse- preparations of amino acid, glucose and lipid are used quent days. Parenteralnutritionishypertonic,irritantandthrom- High-risk patients should receive prophylaxis (see bogenic. Intestinal stulae may be managed con- including cannulae) and Streptococci or mixed organ- servatively with skin protection, replacement of uid isms. The organisms responsible for organ or space and electrolytes and parenteral nutrition. If such con- infections are dependent on the site and the nature servative therapy fails the stula may be closed surgi- of the surgical condition, e. The risk of surgical perioperative atelectasis unless a respiratory infection site infection is dependent on the procedure performed. Prophylaxis and treatment Contaminated wounds such as in emergency treatment involves adequate analgesia, physiotherapy and hu- for bowel perforation carry a very high risk of infection.

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Other important neurological syndromes to exclude are transient ischaemic attacks purchase celecoxib 200 mg fast delivery, migraine generic celecoxib 100mg amex, narcolepsy and hysterical convulsions. Transient ischaemic attacks are characterized by focal neurological signs and no loss of consciousness unless the verte- brobasilar territory is affected. In narcolepsy, episodes of uncontrollable sleep may occur but convulsive movements are absent and the patient can be wakened. In this man s case the episode was witnessed by his wife who gave a clear history of a grand mal (tonic clonic seizure). There may be warning symptoms such as fear, or an abnormal feeling referred to some part of the body often the epigastrium before consciousness is lost. Due to spasm of the respi- ratory muscles, breathing ceases and the subject becomes cyanosed. After this tonic phase, which can last up to a minute, the seizure passes into the clonic or convulsive phase. After the contractions end, the patient is stupurose which lightens through a stage of confusion to normal consciousness. Blood tests should be performed to exclude metabolic causes such as uraemia, hyponatraemia, hypoglycaemia and hypocalcaemia. Blood alcohol levels and gamma-glutamyltransferase levels should also be measured as markers of alcohol abuse. This is necessary as he will probably not be able to continue in his occupation as a taxi driver. He has recently lost his job in a high-street bank because of his increasingly poor performance at work. His wife and friends have noticed the decline in his memory for recent events over the past 6 months. The patient is sleeping poorly and has developed involuntary jerking movements of his limbs especially at night. He appears to his wife to be very short-tempered and careless of his personal appearance. Aged 15, he received 2 years treatment with growth hormone injec- tions because of growth failure. Examination In the nervous system, muscle bulk, power, tone and reflexes are normal but there are occa- sional myoclonic jerks in his legs. The examination of cardiovascular, respiratory and abdominal systems is entirely normal. Dementia is a progressive decline in mental ability affecting intellect, behaviour and per- sonality. The earliest symptoms of dementia are an impairment of higher intellectual func- tions manifested by an inability to grasp a complex situation. Memory becomes impaired for recent events and there is usually increased emotional lability. In the later stages of dementia the patient becomes careless of appearance and eventually incontinent. Causes of dementia Alzheimer s disease Multi-infarct dementia As part of progressive neurological diseases, e. However, she has become much worse over 1 week with episodes of bloody diarrhoea 10 times a day. She has had some crampy lower abdominal pain which lasts for 1 2 h and is partially relieved by defaeca- tion. Over the last 2 3 days she has become weak with the persistent diarrhoea and her abdomen has become more painful and bloated over the last 24 h. In her family history, she thinks one of her maternal aunts may have had bowel problems. She took 2 days of amoxicillin after the diarrhoea began with no improvement or worsening of her bowels. Her abdomen is rather distended and tender generally, particularly in the left iliac fossa. In the absence of any recent foreign travel it is most likely that this is an acute episode of ulcerative colitis on top of chronic involvement. The dilated colon suggests a diagnosis of toxic megacolon which can rupture with potentially fatal consequences. Investigations such as sigmoidoscopy and colonoscopy may be dangerous in this acute situation, and should be deferred until there has been reasonable improvement. The blood results show a microcytic anaemia suggesting chronic blood loss, low potassium from diarrhoea (explaining in part her weakness) and raised urea, but a normal creatinine, from loss of water and electrolytes. If the history was just the acute symptoms, then infective causes of diarrhoea would be higher in the differential diagnosis. Inflammatory bowel disorders have a familial incidence but the patient s aunt has an unknown condition and the relationship is not close enough to be helpful in diagnosis. Smoking is associated with Crohn s disease but ulcerative colitis is more com- mon in non-smokers. She should be treated immediately with corticosteroids and intravenous fluid replacement, including potassium.

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They commonly see themselves Case as superior to others in their clinical competence and insist The chief resident in internal medicine has arranged to that others submit to their way of doing things celecoxib 200 mg sale. The resident doesn t come to teaching sessions discount celecoxib 100mg otc, doesn t show up for clinics on time, is always late when Causes showing up for on-call responsibilities and therefore never There is no single cause of disruptive behaviour. The it is not generally associated with substance use disorders, other residents are complaining to the chief. The nurses other underlying physician health issues such as stress and on the ward and the emergency room staff have started burnout can be contributing factors. The been associated with certain personality characteristics such chief wants something to be done. It is often a result of an inability to deal The term disruptive doctor is often thought of in relation to with the confict inevitable in the face of stressful work envi- physicians who demonstrate a pattern of offensive or objec- ronments and rapid change. Indeed, disruptive behaviour can tionable behaviour, such as berating staff in front of patients be a sign of failure within a system, where confict has become or using intimidation tactics when supervising residents. The focus is often exclusively Many defnitions have been developed to describe disruptive on the individual s behaviour, to the exclusion of any examina- behaviour. But focusing solely on changing defnes it as follows: Disruptive behaviour is demonstrated the physician s behaviour is not productive. Disruptive behaviour has negative consequences both for the But is it clear that physicians themselves must show leadership delivery of patient care and for the smooth running of medical in addressing disruptive behaviour in their practice settings departments. The issue should be approached and other adverse events, and has the potential to stife the even-handedly, taking logical steps. First, what constitutes respectful collaboration and interdisciplinary collegiality that disruptive behaviour needs to be clearly defned and its impact are crucial to effective care delivery in today s complex health understood. The development of a professional code of conduct to address workplace interpersonal behaviour is also important. It states: When the chief resident becomes aware of a resident who To satisfy our mission, all members of the medical is not meeting their responsibilities, the chief confrms and health staff will treat patients, staff and fellow the facts and meets with the resident to notify them of physicians in a dignifed manner that conveys respect the concern and discuss the issue. The chief obtains a for the abilities of each other and a willingness to work commitment that the behaviour will not be repeated. Behaviour that is deemed to be disruptive to chief then follows up to monitor future behaviour know- promoting an atmosphere of collegiality, cooperation, ing that future trangressions will need to be brought to the and professionalism will not be tolerated. The program director must ensure there is a policy or guidelines on the expectations Although one might feel that formalizing such a code of about professional responsibility. Such a code has a preventative role duct boundaries for physicians returning to the workplace after as well; it can help create a culture of respect and collegiality a confict arising from disruptive behaviour, it is wise to involve by offering guiding principles for all who work in the institu- the physician concerned. The code should be consistent with the philosophy of the organization s code of conduct, policies and procedures, to the larger organization, or could be the same code used by all ensure that the physician returning is clear on the expectations providers in the organization. After a return to work, consistent monitoring and reinforcement of appropriate behaviours will be critical to Even with an agreed-upon code of conduct, it can often ap- ensuring that change is lasting. Therefore, a clearly defned set of policies and Summary procedures that everyone is familiar with should also be devel- The appropriate approach to this issue should be one of reha- oped. Like the code of conduct, these policies and procedures bilitation and support rather than punishment. They organizations need to clarify their defnition of disruptive pro- need to be developed through consultation and consensus; to fessional behaviour. Leaders must appreciate what contributes be credible, this should involve the grass roots. It is no longer acceptable to rely expectations, and monitoring conduct after assessment or on the professionalism lectures that were provided early treatment. Ensuring that orientation to the code of conduct and policies The medical staff organization will usually need the support and procedures occurs on receipt of hospital privileges or and collaboration of the medical administration to ensure that employment can prevent problems down the road. At the end of the day, an approach to disruptive behaviour that is fair, consistent, timely It should be stressed that if administrative physicians were to and understood by all within the organization should be the hurriedly write a unilateral code of conduct or policies and goal. Born between roughly 1960 and 1980, this This chapter will cohort is also known as the Me Generation and the Lost describe key differences between generation Y, generation Generation. They will A mid-career physician in a busy academic hospital enjoys work hard, but demand negotiation, respect and clarity in order working with residents and values the unique perspectives to protect the balance between their personal and professional and energies they bring to clinical and academic work. However, the physician is increasingly concerned by what feels like a slippage of professional duty, commitment and Baby boomers. Known to roll up their sleeves and who indicated he needed to leave by 5 o clock to pick his pitch in, they are more prone to sacrifce themselves to realize daughter up for a soccer game. Their rates of burnout are high made a complaint about this behaviour to the site director (up to 42 per cent in Canada), as are their rates of divorce or for education. Born generally before the mid-1940s, this The Canadian medical community embraces a diverse mix senior cohort of physicians has a wealth of experience and tal- of learners and practitioners. Many have now retired from active practice but have had including gender, race, cultural heritage, political alliance a profound and valuable infuence on traditional structures in and philosophical world view. One facet of diversity that is medicine, including practice standards, training methodology becoming increasingly relevant to educational programs is that and professionalism. Obviously, any framework that clusters diverse people into specifc categories is at risk of overgeneralizing; Sources of tension however, the following sketches of today s generations and The varying experiences and expectations of these generational their traits may be a useful way to conceptualize challenges cohorts can give rise to misunderstandings and tensions arising that arise in training and practice environments.