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Ap- Flexiblefibreopticbronchoscopyismostcommonlyused propriate staining and culture is needed purchase viagra sublingual 100 mg mastercard stress and erectile dysfunction causes. Therapies Topical local anaesthetic is applied to the nose and r Aspiration of mucus plugs. Following sedation the flexible bronchoscope is r Laser therapy for obstructing bronchial carcinoma. Once in the r Transbronchialstentingforobstructingbronchialcar- trachea further topical anaesthesia is administered. Radiographic screening can be used for peripheral cardiac arrhythmias (usually transient), pneumothorax, lesions which cannot be directly visualised. Chapter 3: Respiratory infections 97 Thoracic surgery Aetiology The primary cause is usually a respiratory virus, e. The potential space created by the removal is The virus enters via the airway by droplet inhalation filled with remaining lung, elevation of the diaphragm and causes local inflammation, inducing secretions and and mediastinal shift. The hilar vessels are ligated and the bronchus is divided and Clinical features closed close to the carina. The the operation not occupied by shift of other struc- patient may feel short of breath, wheezy and complain tures fills with blood and serum which organises and of chest tightness and retrosternal discomfort. Thecoughthenbecomeswet Thoracoscopy is used for diagnosis of pleural disease, and productive of yellow or green sputum. Discoloured mediastinoscopy to sample upper mediastinal lymph sputum signifies infection, which may be of bacterial or nodes and mediastinotomy to sample lower mediasti- viralorigin. Single lung ventilation is used to allow the collapse of the lung being operated on, e. The airway mucosa becomes red and oedematous, there Specific complications following thoracic surgery in- is often an overlying mucopurulent exudate. Respiratory infections Investigations Acute bronchitis These are usually not required, there may be a mild neu- trophil leucocytosis even in viral infections. Patients presenting with acute bronchitis during an influenza epidemic may ben- Incidence efit from treatment with a neuraminidase inhibitor if Very common. Only if secondary bacterial infection is suspected should a course of antibiotics be Age prescribed. Any Prognosis Sex The illness usually lasts up to a week in healthy adults, M = F prolonged symptoms may occur. Changes in the course 98 Chapter 3: Respiratory system of the illness or presence of bronchopneumonia suggest Table3. Conditions impairing Defence mechanism defence mechanism Pneumonia Cough Coma/anaesthesia Respiratory depression Definition Neuromuscular weakness Pneumonia is an infective, inflammatory disease of the Ciliary function Smoking, influenza, colds lung parenchyma. Bronchiectasis (including cystic fibrosis and Kartagener’s syndrome) Aetiology Ciliary function can also be It is useful to classify pneumonia according to the impaired mechanically by causative organism or the clinical setting, e. This helps to determine the choice of carcinoma Phagocytosis Smoking antibiotics for treatment. Alcohol Pneumonia most often occurs in children and the el- Hypoxia derly, but may also affect young, fit adults. Viralpneumonia is less common, but bacterial pneumo- r Atypical pneumonias cause predominantly interstitial nia may be a secondary complication. Causes include the atypi- Pathophysiology cal bacteria Chlamydia, Coxiella, Mycoplasma and Le- The infection may be as a result of impairment of one or gionella. Pathologically pneumonia Symptoms may include fever, dyspnoea, pleuritic pain can be divided into broncho-, lobar or atypical pneumo- and cough often productive of green sputum; however, nia depending on the pattern of inflammation. It is predisposed to by immobility and dation (such as dullness to percussion, increased vocal viral infections which lead to retention of secretions resonance, bronchial breathing) but even if frank con- especially in the lower lobes. The infection is centred solidation is not present, most patients have tachypnoea on the bronchi and bronchioles and spreads to involve (>20 breaths/minute) and crackles. In atypical pneu- adjacent alveoli, which become consolidated with an monia the signs of consolidation in the lung are often acute inflammatory exudate.

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Key: d Ref: Clinical Exam of Respiratory System (Page 649) Davidson’s Principles and Practice of Medicine 100 mg viagra sublingual with amex impotence 28 years old. A forty year old woman gives history of fever for last three weeks accompanied by dry cough, night sweats and weight loss. Key: a Ref: Tuberculosis (Page 696) Davidson’s Principles and Practice of Medicine. A young girl complains of nocturnal cough and shortness of breath which disturbs her sleep. Key: c Ref: Bronchial Asthma (Page 673) Davidson’s Principles and Practice of Medicine. A fifteen year old girl presents with history of fever, bleeding from gums and pallor for last fifteen days. Key: a Ref: Acute Leukemia (Page 1040) Davidson’s Principles and Practice of Medicine. Which of the following drugs is used in the treatment of hyperkalemia in acute renal failure: a) Amiloride. Key: d Ref: Treatment of Hyperkalemia, Acute Renal Failure Davidson’s Principles and Practice of Medicine. For the patient with history of fever, headache and neck stiffness, the most important investigation is: a) Cerebrospinal fluid examination. Key: a Ref: Meningitis (Page 1224) Davidson’s Principles and Practice of Medicine. The most common risk factor for chronic obstructive pulmonary disease is: a) Air pollution. Key: e Ref: Chronic Obstructive, Pulmonary Disease (Page 678) Davidson’s Principles and Practice of Medicine. Key: a Ref: Cushing’s Syndrome (Page 779) Davidson’s Principles and Practice of Medicine. In a young boy with hypertension, examination of cardiovascular system reveals radio-femoral delay. The most likely cause of hypertension in this patient is: a) Coarctation of aorta. Key: a Ref: Coarctation of the Aorta (Page 637) Davidson’s Principles and Practice of Medicine. The gait of a patient with cog-wheel rigidity and pill rolling tremors is likely to be: a) Drunken. Key: e Ref: Parkinsonism (Page 1218) Davidson’s Principles and Practice of Medicine. An old patient presented in emergency ward with history of weakness of right side of body of rapid onset. The most helpful first line investigation for management of this patient is: a) Cerebral angiography. Key: c Ref: Cerebrovascular Disease (Page 1200) Davidson’s Principles and Practice of Medicine. In a patient of thalessemia peripheral blood film for red cell morphology shows: a) Hypochromic microcytic cells. Key: a Ref: Thalessemia (Page 1038) Davidson’s Principles and Practice of Medicine. Key: b Ref: Pyogenic Liver Abcess (Page 986) Davidson’s Principles and Practice of Medicine. Key: d Ref: Cerebrovascular Disease (Fig: 26:34, Page 1209) Davidson’s Principles and Practice of Medicine. A forty year old man gives history of high grade fever for last one week associated with cough productive of rusty sputum. The anti diabetic agent of choice for a fifty year old obese lady with mild hyperglycemia is: a) Chlorpropamide. Key: d Ref: Oral Anti-Diabetic Drugs (Page 831) Davidson’s Principles and Practice of Medicine. Which of the following characteristic suggests a benign structure of esophagus: a) Anaemia. Key: c Ref: Benign Esophageal Structure (Page 880), Carcinoma of Esophagus (Page 882) Davidson’s Principles and Practice of Medicine. A thirty five year old man presents with history of low grade fever and cough for last three months.

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Schroedel generic viagra sublingual 100mg without a prescription impotence at 52, Braunschweig, 2004 Presentations at a media conference: The Roche Group – one of the world’s leaders in bio- tech, Basel, November 2004 http://www. Nevertheless, new discoveries about the molecular causes of diseases and the influence exerted by our genes on the effectiveness of medicines are already leading to the development of specific diagnostic techniques and better targeted treatment for individual patients. Any findings and medical science methods discovered by universities and institutes working in the life sciences usually find their way immediately into the industry’s development laboratories. Just a few ex- amples: T During the 1990s biology was defined by the fields of human genetics and genomics. By deciphering the human genome re- searchers obtained profound new insights into the hered- itary basis of the human body. From the mass of genetic in- formation now available researchers can filter out potential target molecules for new Terms biopharmaceuticals. T Since the late 1990s pro- Chimeric made up of components from two different species or individuals. The technique led to the produc- tion of the first humanised chimeric antibodies, in which variable seg- development. Because pro- ments obtained from mouse antibodies are combined with a constant teins can act either as target segment from a human antibody. Copegus (ribavirin) a Roche product used in combination with molecules or as drug mole- Pegasys for the treatment of hepatitis C. Therapeutic antibodies antibodies used as agents for the treat- and proteins have recently ment of diseases. It Therapeutic proteins proteins used as active substances in has been recognised that drugs. In addition, modifi- cations of therapeutic proteins strongly influence their effi- cacy and stability. T In recent years researchers have succeeded in shedding more light on the key functions of the immune system. These findings have led to various new diagnostic approaches and more refined methods for developing therapeutic antibodies. Research-orientated: development of therapeutic proteins Identification of The number of good molecular targets for new molecular therapeutic proteins is limited targets Assessment Pick the winners; assessment in cellular and animal of available models and new targets Design of therapeutic proteins, e. Most important Modern medical biotechnology uses a wide range drug group: therapeutic of methods to diagnose and treat diseases – from proteins the biotechnological production of simple natu- ral products to gene therapy. The most important group of biotechnological drugs by far, however, are the thera- peutic proteins. Most therapeutic proteins are chemical mes- sengers, enzymes or, especially in recent times, monoclonal an- tibodies. Now these molecules can be produced in genetical- ly modified cells that carry the hereditary information for pro- ducing the human protein. Main avenues of research 41 In addition, new findings from basic research now allow thera- peutic proteins to be coupled with non-protein components to improve their efficacy and duration of action. Since the substance is produced mainly in the kidneys, patients with renal damage are prone to develop anemia. Those affected – often dialysis patients – generally feel weak and tired, because their red blood cells no longer carry sufficient supplies of oxygen to the body. Since the early 1990s recombinant erythropoietin has replaced time-consuming, costly and risky blood transfusions, previous- ly the standard treatment for anemic patients. Because the hor- mone is a glycoprotein (see illustration), it cannot be produced in bacterial or yeast-cell cultures: the erythropoietin molecule has several carbohydrate side chains that slow its breakdown in the body but also modify its intrinsic bioactivity. These side chains can be attached to proteins only by the synthe- Erythropoietin: the molecule sising apparatus found in carbohydrate chain mammalian cells. For this reason, only mammalian cells can be used to produce complex therapeutic pro- teins. In renal clinical trials untreated anemic patients can ex- perience a correction of their anemia with one injection twice a month. Patients who are in maintenance can be managed with a single monthly injection whether they have reached end stage renal disease (chronic kidney disease stage 5) or not (typically chronic kidney disease stages 3 and 4). Less frequent adminis- trations reduce the oscillation in hemoglobin levels outside the optimal range of hemoglobin as defined by best practice guide- lines, which is often seen with existing short-acting compounds (epoetin, darbepoetin). Such excursions are associated with ad- verse events and considered to contribute to further deterio- ration of cardiac and renal functions. 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, diabetes, chronic heart failure and obesity.

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This is a property of dicarboxylic amino acids order viagra sublingual 100 mg online erectile dysfunction causes heart, since glutamic acid dosing in this animal model results in similar necrotic effects (Stegink, 1976; Stegink et al. There is still some uncertainty over the relevance to humans of the new- born rodent model for assessing the neuronal necrosis potential of aspartic acid. Neuronal necrosis in the hypothalamus was not found in newborn nonhuman primates with levels of plasma dicarboxylic amino acids 10 times those found in newborn mice with neuronal necrosis (Stegink, 1976; Stegink et al. In addition, human studies where high doses of aspartic acid or aspartame were given failed to find a significant increase in the plasma level of aspartic acid. In view of the ongoing scientific debate regarding the sensitivity of newborn animals to the consumption of supplemental dicarboxylic amino acids, it is concluded that aspartic acid dietary supplements are not advis- able for infants and pregnant women. The latter is a multienzyme system located in mitochondrial membranes (Danner et al. Men 51 through 70 years of age had the highest intakes at the 99th per- centile for leucine at 14. It should be noted, however, that in most of the animal studies reported below, it is not entirely clear that these various enzyme activities are critical determinants of the effects seen. Thus, while the animal data must be interpreted with caution, there is no well-established basis for disregarding them entirely. Leucine may affect muscle protein turnover (Elia and Livesey, 1983) and stimulate insulin release and tissue sensitivity (Frexes-Steed et al. They have also been used in parenteral nutrition of patients with sepsis and other abnormalities. Although no adverse effects have been reported in these studies, it is not clear that such effects have been care- fully monitored (Skeie et al. Additionally, the data from these studies, because they involved patients with significant and sometimes unusual disease states, are not directly relevant to the problem of assessing risks to normal, healthy humans. There have been several reports of clinical trials in which groups of healthy humans, in most cases trained athletes, were given high doses of leucine by intravenous infusion (Abumrad et al. These trials measured physical and mental performance, the impact on blood levels of other amino acids, and in one case, of insulin and glucose output. In fact, in one study glutamine output from forearm muscle was significantly increased (Abumrad et al. It should be noted, however, that possible side effects in all studies were those that might have been recognized subjectively. Thus, although this collection of studies provides no evidence of adverse effects of high doses of leucine, they are of highly limited value in assessing health risks. How- ever, these imbalances, which lead to catabolism of muscle, occur only in rats on marginally adequate protein diets (Block, 1989). Kawabe and coworkers (1996) reported on a subchronic feeding study in which L-isoleucine was administered to groups of 10 rats at dietary con- centrations of 0, 1. The amino acid caused no changes in body weights, food consumption, or hematological parameters. At the highest dietary level, increased urine volumes and rela- tive kidney weights and urine pH, together with some alterations in serum electrolytes, were clearly related to treatment. There is evidence that isoleucine acts as a promoter of urinary bladder carcinogenesis in rats (Kakizoe et al. In a follow-up study of similar design, Nishio and coworkers (1986) extended the experimental period to 60 weeks and included diets supplemented with 2 or 4 percent isoleucine or leucine. It thus appears that both leucine and isoleucine are potent promoters of bladder neoplasms in rats at dietary levels of 2 percent and above; a no-effect level was not identified in either of the above studies. There is no evidence that either amino acid is carcinogenic in the absence of an initiating agent. Persaud (1969) reported that leucine is a teratogen when it is administered by intraperitoneal injection in pregnant female rats at doses as low as 15 mg/kg of body weight. No papillomas or preneoplastic lesions were observed in the control groups or in the amino acid groups. Pregnant rats were fed a low protein (6 percent casein) diet supplemented with 5 percent leucine, isoleucine, or valine.

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