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By B. Pranck. Principia College. 2018.

Fatalities from asthma are unnecessary because asthma is not an inexorably fatal disease generic 10mg paroxetine free shipping. Uncontrolled asthma can lead to mucus plugging of airways and frank collapse of a lobe or whole lung segment 10mg paroxetine with amex. Cough syncope or cough associated cyanosis occurs in patients whose respiratory status has deteriorated and in whom status asthmaticus or need for emergency therapy has occurred. During severe airway obstruction from asthma, during inspiration, intrathoracic pressure is negative because the patient must generate very high negative pressures to apply radial traction on bronchi in an attempt to maintain their patency. During expiration, the patient must overcome severe airway resistance and premature airways collapse. Increases in intrathoracic pressure during expiration with severe coughing, as compared with intraabdominal pressure, causes a decline in venous return to the right atrium. There may also be increased blood flow to the lung during a short inspiration, but that is accompanied by pooling in the pulmonary vasculature from the markedly elevated negative inspiratory pressure. There will be reduced blood flow to the left ventricle with temporary decreases in cardiac output and cerebral blood flow. Pulsus paradoxus is present when there is greater than a 10-mm Hg decline in systolic blood pressure during inspiration. The most frequent electrocardiographic findings during acute asthma are sinus tachycardia followed by right axis deviation, clockwise rotation, prominent R in lead V1 and S in lead V5, and tall peaked P waves consistent with cor pulmonale (151). Administration of oral corticosteroids is indicated to prevent repeated hospitalizations and frequent episodes of wheezing dyspnea. Alternate-day prednisone and recommended doses of inhaled corticosteroids do not result in growth retardation, especially when the dose is 30 mg on alternate days or less. Even high alternate-day doses in children can be tolerated reasonably well as long as status asthmaticus is prevented. Similarly, depot corticosteroids given every 2 to 3 weeks in high doses may result in growth retardation. The use of depot corticosteroids should be considered only in the most recalcitrant children in terms of asthma management. Ineffective parental functioning or poor compliance usually accompanies such cases in which reliable administration of prednisone and inhaled corticosteroids is impossible. The term malignant, potentially fatal asthma has been suggested for such patients (153). Psychological Factors Asthma has evolved from a disorder considered to be psychological to one recognized as extremely complex ( 127) and of unknown etiology. Psychological stress can cause modest reductions in expiratory flow rates such as occur during watching a terrifying movie ( 154). Laughing and crying or frank emotional upheaval, such as an argument with a family member, can result in wheezing. Usually, if the patient has stable baseline respiratory status, severe asthma necessitating emergency hospital care does not result. Nevertheless, some fatal episodes of asthma have been reported as associated with a high level of emotional stress. In an absence of how to quantitate stress and determine whether there is a dose-response effect in asthma, such information must be considered speculative. The patient with asthma may develop strategies to function with the burden of asthma as a chronic, disruptive, and potentially fatal disease. Some patients display hateful behavior toward physicians and their office staff personnel ( 155,156). Psychiatric care can be of value in some cases, but often patients refuse appropriate psychiatric referrals. Indeed, a psychologist, psychiatrist, or social worker may help identify what the patient might lose should asthma symptoms be controlled better. Suicidal attempts are recognized from theophylline overdosage and unjustified cessation of prednisone. Repeated episodes of life-threatening status asthmaticus are difficult to avoid in the setting of untreated major psychiatric conditions. The presence of factitious asthma indicates significant psychiatric disturbance ( 158). Abrupt referral of the patient to a psychiatrist can result in an unanticipated suicidal gesture or attempt. Psychiatric care can be valuable if the patient is willing to participate in therapy. It is helpful to categorize the type of asthma because treatment programs vary depending on the type of asthma present. The National Institutes of Health Expert Panel Report 2 has suggested assessing signs and symptoms of asthma in association with spirometry or peak flow measurements (2). Asthma severity is classified as intermittent (implying mild asthma) or persistent (mild, moderate, or severe).

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For example trusted 20 mg paroxetine, social activ- ity and work capacity are reduced in almost all people with migraine and in 60% of those with tension-type headache discount paroxetine 40mg free shipping. Headache often results in the cancellation of social activities while, at work, people who suffer frequent attacks are likely to be seen as unreliable which they may be or unable to cope. This can reduce the likelihood of promotion and undermine career and nancial prospects. While people actually affected by headache disorders bear much of their burden, they do not carry it all: employers, fellow workers, family and friends may be required to take on work and duties abandoned by headache sufferers. Because headache disorders are most troublesome in the productive years (late teens to 60 years of age), estimates of their nancial cost to society are massive principally from lost working hours and reduced productivity because of impaired working effectiveness (22). In the United Kingdom, for example, some 25 million working or school days are lost every year because of migraine alone (6). Not surprisingly, headache is high among causes of consulting both general practitioners and neurologists (23, 24). One in six patients aged 16 65 years in a large general practice in the United Kingdom consulted at least once because of headache over an observed period of ve years, and almost 10% of them were referred to secondary care (25). A survey of neurologists found that up to a third of all their patients consulted because of headache more than for any other single complaint (26). Far less is known about the public health aspects of headache disorders in developing and resource-poor countries. Indirect nancial costs to society may not be so dominant where labour costs are lower but the consequences to individuals of being unable to work or to care for children may be severe. There is no reason to believe that the burden of headache in its personal elements weighs any less heavily where resources are limited, or where other diseases are also prevalent. For ex- ample, in representative samples of the general populations of the United States and the United Kingdom, only half the people identied with migraine had seen a doctor for headache-related reasons in the last 12 months and only two thirds had been correctly diagnosed (27). Most were solely reliant on over-the-counter medications, without access to prescription drugs. In a separate general-population questionnaire survey in the United Kingdom, two thirds of respondents with migraine were searching for better treatment than their current medication (28). In Japan, aware- ness of migraine and rates of consultation by those with migraine are noticeably lower (29). Over 76 Neurological disorders: public health challenges 80% of Danish tension-type headache sufferers had never consulted a doctor for headache (30). It is highly unlikely that people with headache fare any better in developing countries. The barriers responsible for this lack of care doubtless vary throughout the world, but they may be classied as clinical, social, or political and economic. Clinical barriers Lack of knowledge among health-care providers is the principal clinical barrier to effective head- ache management. This problem begins in medical schools where there is limited teaching on the subject, a consequence of the low priority accorded to it. It is likely to be even more pronounced in countries with fewer resources and, as a result, more limited access generally to doctors and effective treatments. Social barriers Poor awareness of headache extends similarly to the general public. Headache disorders are not perceived by the public as serious since they are mostly episodic, do not cause death and are not contagious. In fact, headaches are often trivialized as normal, a minor annoyance or an excuse to avoid responsibility. These important social barriers inhibit people who might otherwise seek help from doctors, despite what may be high levels of pain and disability. Surprisingly, poor awareness of headache disorders exists among people who are directly affected by them. A Japanese study found, for example, that many patients were unaware that their headaches were migraine, or that this was a specic illness requiring medical care (31). The low consultation rates in developed countries may indicate that many headache sufferers are unaware that effective treatments exist. Political and economic barriers Many governments, seeking to constrain health-care costs, do not acknowledge the substantial burden of headache on society. They fail to recognize that the direct costs of treating headache are small in comparison with the huge indirect cost savings that might be made (for example by reduc- ing lost working days) if resources were allocated to treat headache disorders appropriately. Therefore the key to successful health care for headache is education (31), which rst should create awareness that headache disorders are a medical problem requiring treatment. Education of health-care providers should encompass both the elements of good management (see Box 3.

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Oral hypertonic glucose test for provocative dumping induces dumping in 60 per cent patients after truncal vagotomy and 40 per cent after partial gastrectomy 10mg paroxetine sale. Eventhough dumping is very rarely reported clinically discount 30 mg paroxetine fast delivery, the liability to dumping still exist among patients after gastric surgery. Food and barium meal studies of gastric emptying provide evidence of rapid gastric emptying after both operations and more so after partial gastrectomy than truncal vagotomy. Small bowel transit time is abnormally fast after truncal vagotomy than partial gastrectomy. Because of the comparable results of almost equalfrequency, no final comprehensive verdict can be drawn on a more satisfactory operation between the two treatment methods. The place of each operation in the treatment of chronic duodenal ulcer is discussed. Most of patients are males in the age group of 30-40 years which is the age group where the Burmese population lead the most active earning life. They are also manual and agricultural workers or of low income group, and they usually have chronic ulcers. Most of the patients are treated by simple suture, and this type of operation would not be suitable for many of the patients, and reviewed the management and reevaluate. Also included the study of statistical survey on the incidence of perianal infections in general with special reference to Fistula-in-ano, and the evaluation of the result of surgery and the cause of infection of the Fistula tract. The drug of reference was oral Emetine Biomuth Iodide with injection Emetine hydrochloride 60mg given for 3 days initially. Common bacteriological agents isolated from patients with diarrhoeal diseases in Rangoon were Vibrio cholera biotype El Tor, Salmonella, and Shigella and enteropathogenic Escherchia coli. The highest is among old people above 65 years of age with hospital admission rates of 151. Persons at the two extremes of age, were found to be little affected from food poisoning. Usual clinical features observed in diarrhoeal diseases were diarrhoea and vomiting. These two symptoms occurred in association with abdominal pain, fever and dehydration. About 5% of all cases 30 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar were severely dehydrated. Ringer lactate solution is being used with success as a rehydrating fluid at Infectious Diseases Hospital. Tetracycline is also used as an adjunct in severely dehydrated patients, no antibiotic is given to mild or moderate cases. Specific drugs are given to diseases like enteric fever, helminthiasis, amoebic dysentery and etc. Surveillance of contacts, disinfection of environment and health education are principal parts of this programme. Summing up The study of intestinal helminthiasis increased in scope, depth and complexity. The epidemiology of Ascariasis as well as the biology of Ascaris lumbricoides was studied in depth. Cross-sectional and longitudinal surveys were carried out in villages to determine distribution of worm load, the basic reproductive rate and transmission dynamics. Epidemiological models of Ascaris infection and theoretical simulation of the effect of mass chemotherapy were done, followed by a pilot experiment to examine the possibility of reducing Ascaris transmission to insignificant level by mass chemotherapy. The impact of periodic age-targeted mass chemotherapy on prevalence, intensity and morbidity due to Ascariasis was studied in village children. The impact of regular de-worming on nutrition and growth of school children was studied in a large experiment covering 21 villages. Result of these studies helped to fill the gap in contemporary scientific knowledge about the interrelationship between Ascaris infection and nutrition and provided information helpful in choosing between various public health options for preventing and controlling Ascaris infection in the community in Myanmar. It was realized that diarrhoea as distinct from cholera was one of the foremost causes of mortality and morbidity in Myanmar especially in children, and it became the first priority disease in People s Health Plan (1982-86). Prior to 1981 little was known regarding the etiology of acute diarrhoea in Myanmar apart from the fact that V. Important etiological agents, hitherto not known to be present in Myanmar were identified including Enterotoxigenic E. Rotaviruses as etiological agent of diarrhoea in children was studied for the first time in Myanmar and found to be prevalent during the cold season. The relative frequency of these etiological agents for diarrhoea was studied in children including neonates. The biological properties of these pathogens were studied such as invasiveness and adherence. The application of microbial genetics to the study of pathogenesis of gastro- intestinal infections was started beginning with plasmid profile analysis of E. Personal hygienic practices that affect diarrhea incidence were studied in particularly home and hand contamination in relation to diarrhoea and demonstration that hand washing with soap and water 33 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar after defecation and before meals reduced diarrhoea incidence; The role of fomites such as paper currency notes in the person to person transmission of diarrhoes was investigated.

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Patients awake breath- Syncope is dened as a transient loss of conscious- less and anxious cheap 10 mg paroxetine with visa, they often describe having to sit up ness due to inadequate cerebral blood ow generic 40 mg paroxetine mastercard. There may be no warning, or patients may describe feel- The distance a patient can usually walk on the at be- ing faint, cold and clammy prior to the onset. Asthenarrowing tend to be ushed and sweaty but not confused (unless ofthearteriesbecomesmoresignicant,theclaudication prolonged hypoxia leads to a tonic-clonic seizure). Eventually rest pain may occur, this r Vasovagal syncope is very common and occurs in the often precedes ischaemia and gangrene of the affected absence of cardiac pathology. The heart contracts force- fully, which may lead to a reex bradycardia via vagal Oedema stimulation and hence a loss of consciousness. A number of mechanisms tion, hypovolaemia or due to certain drugs especially arethoughttobeinvolvedinthedevelopmentofoedema. Normally tissue uid is formed by a balance of hydro- r Cardiac arrhythmias may result in syncope if there is a static and osmotic pressure. This may oc- Hydrostatic pressure is the pressure within the blood cur in bradycardias or tachycardias (inadequate ven- vessel (high in arteries, low in veins). The loss of consciousness occurs produced by the large molecules within the blood (albu- irrespective of the patient s posture. A Stokes Adams min, haemoglobin) and draws water osmotically back attack is a loss of consciousness related to a sudden into the vessel. The hydrostatic pressure is high at the loss of ventricular contraction particularly seen dur- arterial end of a capillary bed hence uid is forced out of ing the progression from second to third degree heart the vasculature (see Fig. The colloid osmotic pressure then draws uid back in r Carotid sinus syncope is a rare condition mainly seen at the venous end of the capillary bed as the hydrostatic in the elderly. As a result of hypersensitivity of the carotid sinus, light pressure, such as that exerted by atight collar, causes a severe reex bradycardia and hence syncope. The syncope results from an inability of the heart to increase cardiac output in response to in- Hydrostatic Oncotic 0ncotic Hydrostatic creased demand. Intermittent claudication Artery Vein Claudication describes a cramp-like pain felt in one or both calves, thighs or buttocks on exertion. This may be a result of blood bypassing uid is then returned to the circulation via the lymphatic the lungs (right to left shunting) or due to severe lung system. Mechanismsofcardiovascularoedemaincludethefol- lowing: r The arterial pulse Raised venous pressure raising the hydrostatic pres- sure at the venous end of the capillary bed (right ven- The pulse should be palpated at the radial and carotid tricularfailure,pericardialconstriction,venacavalob- artery looking for the following features: struction). The normal pulse is dened as a rate be- which increases the circulating blood volume with tween 60 and 100 beats per minute. Outside this range pooling on the venous side again raising the hydro- it is described as either a bradycardia or a tachycardia. Albumin is the major factor respon- r The character and volume of the pulse are normally sible for the generation of the colloid osmotic pressure assessedatthebrachialorcarotidartery. A drop volume felt at the carotid may be described according in albumin therefore results in an accumulation of to the waveform palpated (see Fig. Radio-femoral delay is suggestive of coarcta- is left after pressing with a thumb for several seconds) tion of the aorta, the lesion being just distal to the or nonpitting. Cardiac oedema is pitting unless long origin of the subclavian artery (at the point where the standing when secondary changes in the lymphatics may ductus arteriosus joined the aorta). Distribution is dependent lay suggests arterial occlusion due to an aneurysm or on the patient. Pleural effusions and Jugular venous pressure ascites may develop in severe failure. The internal jugular vein is most easily seen with the pa- tient reclining (usually at 45), with the head supported Cyanosis and the neck muscles relaxed and in good lighting con- Cyanosis is a blue discolouration of the skin and mu- ditions. It is due to the presence of desaturated toid muscle in the upper third of the neck, behind it haemoglobin and becomes visible when levels rise above in the middle third and between the two heads of ster- 5 g/dL. Cyanosis is not present in very anaemic patients nocleidomastoid in the lower third. Cyanosis is divided from the carotid pulse by its double waveform, it is non- into two categories: palpable, it is occluded by pressure and pressure on the r Peripheral cyanosis, which is seen in the ngertips and liver causes a rise in the level of the pulsation (hepato- peripheries. The jugular waveform and pressure give it is due to poor perfusion, as the sluggish circulation information about the pressures within the right atrium leads to increased desaturation of haemoglobin. This as there are no valves separating the atrium and the in- may be as a result of normal vasoconstriction in the ternal jugular vein (see Fig. Slow rising The slow rising pulse is seen in aortic stenosis due to obstruction of outflow. Collapsing The collapsing pulse of aortic regurgitation is characterised by a large upstroke followed by a rapid fall in pressure. This is best appreciated with the arm held up above the head and the pulse felt with the flat of the fingers.