L. Nafalem. Golden Gate University.

Educate residents spouses about the physician the confict between the demands training and home-life order tenormin 50 mg free shipping prehypertension causes and treatment, and health resources available to their families (e buy genuine tenormin online prehypertension range chart. These individuals are often the frst to in both parental and marital satisfaction. Adequate vacation time, fexible Case resolution work hours and equitable part-time work are conditions of The program director organizes a day-long retreat for the employment that are conducive not only to improved family residents and their signifcant others. The program director life and mental well-being but also to greater job satisfaction brings in a well-known speaker to discuss issues surround- and productivity. Physicians are most satisfed as parents when ing physician health, including work-lifebalance, ways to they have a supportive spouse and when the work home con- maintain healthy intimate relationships, and recognizing ficts of both partners are minimal. The resident body fnds the expe- medical practice can also affect physicians relationships with rience very useful and decide to make this an annual event their children. For instance, Armstrong s group, found that to help prevent family stress related to residency training physicians who worked for a salary were more fulflled in their and to help recognize the roles that each of their families parental role than physicians who worked on fee-for-service play in their own residency program. Finally, the employment status of one s spouse seems to play a role in parental satisfaction. It is also im- medical families, and portant to value the work and other pursuits of one s partner, explore challenges specifc to those relationships. Case As seductive as the practise of medicine can be, Michael Myers A resident requests a meeting with their supervisor over reminds us to say yes to the relationship and practise say- coffee. The resident becomes distraught while disclosing ing no to other offers (Myers 2001). Spend a minimum of that she miscarried her frst pregnancy three weeks ago twenty minutes alone with your spouse each day and plan a and that her partner, a more senior resident, is preoccu- date together every week. The resident acknowledges that her partner has tried Monica Hill and Nancy Love quote the novelist Henry James to be supportive, but feels that he just doesn t get it. For physicians as for anyone else, this means having population, domestic violence and abuse occurs in medical time together to develop the essential advantage of such rela- families too. Confict between work and familial roles is inevitable at times, whether one or both partners are physicians. Classically, role Work and family life strain has been more frequently noted among female physi- The issue of deferring intimacy in favour of medical work has cians, but in reality male physicians experience it as well. Half been described in the literature on medical marriages (Myers of married women physicians are married to other physicians 2001 and Gabbard 1989). Dual-physician relationships bring sional advancement over the nurturing of intimate relation- certain challenges, such as complicated schedules and career ships, working long hours at the expense of their home lives. Careers postpone their investment in the emotional bank account of can be shaped, reshaped and salvaged more easily than rela- their families or in some cases, avoid admitting that they in fact tionships and families. For example, while physicians of female physicians being the primary or sole income earner are accustomed to their role as experts and expect to be in in their households. In contrast to Protecting and nurturing our intimate relationships may require most physicians experience of medical education, marriage is a re-examination of our professional responsibilities and work non-competitive. John Gottman, a respected re- Does your group discuss shock-absorber systems for searcher in marriage and relationships, stresses the importance parental leaves and urgent family issues? She had speculated that a child would keep geographical triangle: home, school and workplace. Keeping her relationship together, given her partner s attraction to logistics as simple as possible will beneft your marriage and more medicine and achievement. He expresses fear of giving in Raising children together to his feelings lest they derail his career focus. With the For many women physicians, the question of when to plan counsellor s help, they review their priorities with regard childbearing is especially challenging when training demands to career plans and the timing of child-bearing. Supportive sessions lead to a better understanding of their mutual colleagues and training programs are nearly as important as a objectives, and of the supports available to them to help supportive partner. Furthermore, resi- dency training directors never accompany graduated residents impact on your family, whose sleep is being disturbed by the to the infertility clinic. The concept that it takes a village to raise a child applies to medical families, too. Women physicians are particularly aware Vacations are one of the non-urgent but important elements that the more they work, and the greater number of children of time management. Vacations in which play and fun and they choose to have, the greater the chance that they will need not perfection are modelled, where being rather than doing to rely on child care arrangements beyond the family. Many are valued and pleasure for its own sake is enjoyed, are healthy women physicians and dual-career couples fnd live-in help with for the whole family (Maier 2005) regard to child care invaluable. External assistance with regard to other household duties can also be a time-management tool Summary that benefts everyone. Managing the expectations of our partners and others can be problematic in medical relationships. Some of these expecta- Two points to remember when your medical relationship is tions may be fnancial, arising from assumptions about what blessed with children are these: the lifestyles of physicians will be. You do not have to be perfect, but you can be good pectation of concierge service within the health care system. All deserve Although little has been written about the children of physi- refection, good communication and attention to maintaining cians, we do know that children want and deserve their parents appropriate and ubiquitous boundaries. Depending on their stage of development, this may mean breastfeeding for the recommended time, taking Relationships go through cycles. Should your medical marriage the maximum possible parental leave, delaying a career move, run into challenges, remember you are not alone. Even if you cannot Myers, through his book Doctors Marriages, shares his wisdom always be there, it is important to work with your partner and that face-to-face couples therapy works best. Seek professional to communicate with your child so that you are emotionally help through your community resources or your physician involved and up-to-date with what is going on in your child s health program. In addition, more men than ever before are taking This chapter will advantage of parental leave policies. Thus, traditional gender describe some of the challenges commonly faced by phy- roles in Canadian culture are clearly undergoing a healthy evo- sician parents, lution. Medical students are watching this transition and may choose not to Case engage in specialty medicine if it is perceived to be adverse to A second-year resident has recently adopted an infant their family-related values and expectations. However, several residents in the year are In the meantime, academic medicine has not been particularly off on parental leave, and the frequency of call is higher kind to physician parents who have typically enjoyed less insti- than usual. In fact, the resident is perceive a slower progression of career goals, and have lower planning on taking leave, but is now dreading approaching levels of career satisfaction. Children add a dimen- sion to life that is unique and delightful, and the parental role Unique challenges of parenting provides opportunities to know ourselves better. That being Physician parents are in an unique position as they promote said, parenting can add to the complexity of managing busy and monitor their children s health and development. Where some may argue that knowledge about health is valuable and helpful, but as is the physician parents lack full professional commitment, others case with any parent their objectivity is limited. Issues that they ensure their children have a primary care provider confronting physician parents are many, and their complexities who is skilled and comfortable working with the dynamics concern both professional and personal roles.

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Of note tenormin 50 mg on-line prehypertension at 30, in none of these studies has smoking status been found to be a significant confounder order genuine tenormin on-line blood pressure medication list by class. Our experience has proven the multi-causality of respiratory symptoms in a disaster-exposed population, with contribution of any combination of upper and lower respiratory processes. Compared to most occupational exposures, disaster-related exposures are far more acute, are often to a wider range of contaminants and are more difficult to prepare for. Yet, the consequences are similar to many occupational and environmental respiratory diseases. For both occupational and disaster-related exposures the primary emphasis should be instituting preventive measures through the use of environmental controls and respiratory protection. Even after fit-tested respirators have been provided, there are far greater challenges to their effective use in a disaster than in a controlled occupational environment. A thorough understanding of user difficulties in wearing respirators should prompt a re-design of respirators for this environment and if this is not possible then work protocols, especially during the recovery phase should be adjusted to minimize unprotected exposures. Workers and volunteers, untrained for this environment should not be allowed on-site but instead should used off-site as support personnel. Exposures can be reduced but can never be prevented and therefore a robust health program for pre-screening, monitoring, disease surveillance and early treatment should be planned for in advance and then rapidly instituted beginning with on-site registration of all workers and volunteers. Chemical analysis of World Trade Center fine particulate matter for use in toxicologic assessment. Upper and Lower Respiratory Diseases after Occupational and Environmental Disasters. Cancer patterns of lung, oropharynx and oral cavity cancer in relation to gas exposure at Bhopal. Induced sputum assessment in New York City firefighters exposed to World Trade Center dust. Trends in Respiratory Symptoms of Firefighters Exposed to the World Trade Center Disaster: 2001-2005. Physical Health Status of World Trade Center Rescue & Recovery Workers & Volunteers New York City, July 2002 August 2004. Evolution of lower respiratory symptoms in New York police officers after 9/11: a prospective longitudinal study. Respiratory symptoms & physiologic assessment of ironworkers at the World Trade Center disaster site. Self-Reported Increase in Asthma Severity After the September 11 Attacks on the World Trade Center --- Manhattan, New York, 2001 Morb Mortal Wkly Rep. The World Trade Center residents respiratory health study: new onset respiratory symptoms and pulmonary function. Clinical guidelines for adults exposed to World Trade Center Disaster (Respiratory and Mental Health). Bronchial hyperreactivity & other inhalation lung injuries in rescue/recovery workers after the World Trade Center collapse. Longitudinal Assessment of Spirometry in the World Trade Center Medical Monitoring Program. World Trade Center fine particulate matter causes respiratory tract hyperresponsiveness in mice. Asthma diagnosed after September 11, 2001 among rescue and recovery workers: findings from the World Trade Center registry. Obstructive Airways Disease with Air- trapping among Firefighters Exposed to World Trade Center Dust. World Trade Center Sarcoid-Like Granulomatous Pulmonary Disease in New York City Fire Department Rescue Workers. Acute eosinophilic pneumonia in a New-York city firefighter exposed to World Trade center dust. World Trade Center dyspnea: bronchioloitis obliterans with functional improvement: case report. Biomonitoring of chemical exposure among New York City firefighters responding to the World Trade Center fire and collapse. American College of Gastroenterology: Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. They are usually performed in a lab or in a doctor s office and can be used to diagnose, assess severity and progression, and guide treatment of pulmonary diseases. Most pulmonary function measurements are routinely expressed as a percent predicted of normal so that the patient can see how they are doing compared to the population. Since pulmonary function measurements are known to be lower in shorter, older or female subjects, the percent predicted normal value automatically adjusts for age, height and gender. While obesity also has a direct effect in lowering pulmonary function measurements by placing a greater stress on the lungs, heart and skeletal muscles, the impact of obesity is not adjusted for automatically in the percent predicted equations. Therefore, if your values are low and you have central obesity (chest and/or abdomen) your values would likely be higher if you lost weight. As with the Olympics, the best effort counts and not the number of efforts required to produce that best effort. Simply, the patient blows as hard and fast as they can into a tube that measures the highest (or peak ) flow rate. The peak flow measurement occurs very early in expiration, when the flow rates are effort dependent. It is important to take a full breath in and blow out as hard as you can but after the first few seconds you don t have to blow out any further. Peak flow measurements are helpful in monitoring the status of chronic asthma, assessing the severity of acute exacerbations, evaluating therapy, and evaluating temporal (time-related or seasonal-related) relationships to triggers (ex. An asthma action plan can be written with instructions of what to do if the peak fow falls into these zones. Of note, falls in peak flow can occur even before symptoms worsen, making this a tool which potentially can lessen the severity of an exacerbation if the results are acted upon early on. Disadvantages of this test are that the results are not always reproducible and are effort dependent. A peak flow measure- ment does not obviate the need for spirometry to make the diagnosis of asthma. Spirometry Spirometry measures how much and how fast air moves in and out of the lungs. Spirometry, therefore, provides more data than a peak flow measurement and allows for a more accurate and reproducible measurement of asthma control. A typical study involves repeating the maneuver at least three times and the best of the three trials is accepted. Individual results are compared to normal values (predicted values) which are defined by a healthy population, adjusted for age, height and gender, and are expressed as a percentage of the predicted value. In healthy adults, spirometry results are normally distributed, meaning that 95% of test results in healthy adults will be between 80% - 120% of a predicted value. Perhaps more useful, however, is whether there is a rise or fall in these values in an individual patient over time. Because there are day-to-day variations in breathing capacity, a decline that is 15% or greater from your typical past recordings should be further evaluated by a physician. In obstructive lung diseases (such as asthma, emphysema and chronic bronchitis), the total amount of air that gets exhaled is normal or close to normal, but it takes more time for it to come out due to air flow limitation.

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Rice carbohydrate absorption and various aspects of its measurement including hydrogen and methane production in the gut and other interrelated factors such as small bowel bacteria overgrowth were further investigated generic tenormin 100mg line pulse pressure usmle. The socio-economic aspect of acute diarrhoea was studied: - cost analysis was done of patient hospitalized for acute diarrhoea and compared to hospitalization for acute respiratory infection; role of general practitioners in diarrhoea management was described; characteristics and health related behavour of diarrhoea patients seeking hospital admission through different services was compared; maternal knowledge cheap tenormin 50 mg otc blood pressure 5545, attitude and practice in relation to severity of diarrhoea was documented. Biochemical studies were done on the effect of cholera toxin on intestinal lysosomes and of diarrhoea on aldosterone levels. Infection with Helicobacter pylori as the etiology agent responsible for peptic ulcer has emerged as a refreshing new concept in recent years and was the subject of many studies in Myanmar during this period leading to better understanding, diagnosis and treatment of gastric and duodenal ulcers and non-specific gastritis. Other aspects of peptic ulcer and other medical conditions also continued to be studied such as use of anti-secretory agents like omeprazole; Various G. Various etiological concepts regarding this disease were forwarded in this century; but ingestion of gastric irritants I swidely accepted predisposing factor. As such, public should be informed of dangers of taking these drugs and alcohol unscrupulously. Legal control of analgesics and steroid should be promulgated and action should be taken against those who sell these drugs without prescription. In order to reduce morbidity and mortality of these cases, the prime aim is to identify the source of haemorrhage as early as possible. It is universally accepted that early endoscopy is the most efficient and effective method of diagnosis in upper gastrointestinal haemorrhage. So early endoscopy serves more advantages for treatment in considering which patients must continue the conservative treatment and which patients required emergency surgery. Endoscopy is very helpful not only in diagnosis but also in predicting likelihood of recurrent bleeding. If endoscopy shows massive erosive bleeding where conservative measure fail emergency surgery is available as early as possible to control bleeding. It prevents prolonged and potentially dangerous conservative treatment especially in high risk patients and also obviates disasters from early and inopportune surgery. If endoscopic facilities are not available, the decision whether to operate or not was decided according to history (rate and amount of blood loss) physical examination (vital sign). So, in early phase of hospital treatment, it is difficult to identify those patients who may eventually require operation. By the time that decision has been made, the continued hypoxia which inevitable despite multiple transfusion will have brought about damage to myocardium and other vital tissues and this, especially in elderly patients with previous cardio vascular diseases will load the patient against recovery. The morbidity and mortality can be lowered significantly by getting early diagnosis and proper prompt management. Emergency gastrointestinal uint can be established, and all patients admmited to hospital with these complaints were admitted to the unit and management according to protocol and active policy of early endoscopy, intensive care management, sugery and regular audit will certainly reduce mortality. As more than 130 patients with haematemesis and melena are admitted yearly to North Okkalapa General Hospital, Surgical Unit, it is felt that by establishing new emergency gastrointestinal unit here, the morbidity and mortality of haematemesis and melena can be dramatically reduced. In stress gastritis, bleeding rates may be reduced in patients receiving prophylactic therapy. Since the treatment of bleeding stress ulceration is unsatisfactory, prophylaxis is given to all high risk patients by H2 receptor blocker, incidence of stress ulceration is become much less. But it is not clear that the mortality rate is improved with prophylactic therapy, as most patients die from their underlying diseases. In conclusion, further large scale should be studied to determine accurately which factors are essential for decision of emergency surgery and which procedure is more benefit for bleeding gastric erosions. The main aim of the study was to reveal the direct and indirect costs incurred by patients/families during the children s illness and the cost contributed by the government so that the finding might help in future policy implication. The mean cost of hospitalization of each child was 1705 Kyats and medium cost was 1350 Kyats. The cost borne by family amounted to 64% of the total cost of which only 13% were for medicine and investigations. It was noted that majority of cases could be effectively treated at the hospitals in their local area. Despite having some extent of financial difficulty, more than 80% of families were willing to pay for hospital cost although 18% did not want to contribute anything at all. This study highlight that (a) public awareness regarding the availability of effective health care the two diseases at their respective local hospitals should be promoted. The antigen was found to be specific to anti-cholera and similar immunological reactions were obtained by the gel diffusion. The incidence of diarrhea in the Infectious Diseases Hospital and in the two community studies shows highly 80 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar significant seasonality during the rainy season. The peak diarrhea admissions or incidence occurred on the same months and peak rainfall and the former was found to be significantly correlated to the latter (r=0. Fortnightly data revealed that heavy rainfall preceded the peak diarrhea incidence. No such relationship holds for the environmental temperature or relative humidity. The findings in this article underlines once again on the importance of effective human excreta disposal in the prevention of diarrhoeal pathogen transmission. The children were divided into three groups, high, medium and low, according to the proportion of food and water samples found to be contaminated. The association between food and water contamination and the incidence of diarrhoea was assessed by comparing the cumulative incidences in the high and medium groups with that in the low group which served as reference. A total of 619 cases of adults with gastroenteritis admitted to Yangon General Hospital and No. Rates among cesarean infants were five times as high as those of infants born vaginally (51. One hundred eighty-four of the infants with diarrhea died (case fatality rate=12 percent). We conclude that neonatal diarrhea is endemic in this large maternity hospital in Burma, and that control efforts should be targeted especially to cesarean and low birthweight infants. It was found that the maximal specific activities of both the enzymes were decreased in the infected group when compared with the control suggesting a reduction in the ability of intracellular digestion by lysosome. On the other hand, the value of the ratio between maximal and basal activity (an expression of the degree of retention of enzyme by lysosome or lysosomal membrane stability) of acid phosphatase was significantly increased suggesting lesser extent of leakage of the enxyme into cytoplasm when compared with the control. However there was no difference in the lysosomal membrane stability when measured in terms of cathepsin D. The controls, consisted of 6 children from the same locality as patients, were apparently healthy and in the same age group. Serum chlorides tend to increase in the patients and the increase was more pronounced in the group suffering from both malnutrition and diarrhea. On the other hand, serum potassium tends to decrease and the decreases were significant in the groups having malnutrition. Serum aldosterone levels were raised in all the three groups of patients namely malnutrition, diarrhea and malnutrition associated diarrhea when compared with the control. The decrease was still observed even after exclusion of subjects whose ages lied within the first 1 year of life for whom the serum aldosterone levels were found to have a sharp rise. History of weight loss more than 20% was significant to predict postoperative complication.

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Hydrocortisone buy discount tenormin 100mg on line arteria spinalis, 100 mg intravenously order tenormin 100 mg on-line arteria apendicular, should be started before surgery and continued every 8 hours until the patient can tolerate oral or inhaled medications ( 296). The doses of prednisone and hydrocortisone needed to control asthma do not increase postoperative complications, such as wound infection or dehiscence ( 296). In patients with asthma, optimal respiratory status should be achieved before surgery occurs. Aerosol bronchodilators, deep-breathing exercises, adequate hydration, and gentle coughing should be instituted to avoid accumulation of secretions and atelectasis. Use of epidural or spinal anesthesia is not necessarily safer than general anesthesia ( 297). These complications are thought to result from the rupture of overdistended peripheral alveoli. The escaping air then follows and dissects through bronchovascular sheaths of the lung parenchyma. When severe tension symptoms occur, insertion of a chest tube under a water seal for pneumothorax may be needed. Tracheostomy may be required for severe tension complications of pneumomediastinum. A common feature of these conditions is chest pain; this is not expected with uncomplicated asthma, and when present should suggest the possibility of the extravasation of air. On auscultation of the heart, a crunching sound synchronous with the heartbeat may be present with pneumomediastinum (Hamman sign). It is often reversible with bronchodilators and prednisone, given immediately to avoid the risk of bronchoscopy, or at least to prepare for this examination. When the atelectasis does not respond to the above treatment within a few days, bronchoscopy is indicated for both therapeutic and diagnostic reasons. Occasionally, children may develop atelectasis of other lobes or of an entire lung. Rib fracture and costochondritis may occur as a result of coughing during attacks of asthma. These conditions occur with irreversible destruction of lung tissue, whereas asthma is at least a partially to completely reversible inflammatory condition. The identification of bronchiectasis in a patient with asthma should raise the possibility of allergic bronchopulmonary aspergillosis, undiagnosed cystic fibrosis, or hypogammaglobulinemia. Hypoxemia from uncontrolled asthma has been associated with adverse effects on other organs, such as myocardial ischemia or infarction. Although this effect typically produces no clinical ramifications, in the exceptional patient, irreversible asthma occurs ( 141). Most of these patients do not have steroid-resistant asthma because they have more than 15% bronchodilator response to 2 weeks of daily prednisone. The increase in mortality rate from asthma that occurred in the 1980s in the United States appeared to stabilize by 1996 but has not declined ( 298). The use of repeated doses of b2-adrenergic aerosols has been suspected to be a contributing factor in some of these deaths but is unlikely to be a satisfactory explanation. Fatality rates are lower in the United States and Canada than in many countries, including as New Zealand and Australia. A 1980s surge in deaths in New Zealand and the availability of albuterol inhalers without prescription in that country has been considered possibly analogous to the earlier epidemics of the 1960s. Undue reliance on inhaled b 2-adrenergic agonists by patients and physicians may contribute to fatalities in patients with severe exacerbations of asthma because essential corticosteroid therapy is not being administered. In addition, excessive deaths associated with the potent b 2-adrenergic agonist fenoterol have been reported. This has led to the recommendation that, in persistent asthma, inhaled corticosteroids should be used in conjunction with b2-adrenergic agonists. The latter phenomenon may be exemplified by the use of inhaled corticosteroids, which will not substitute for oral corticosteroids acutely. Patients with underlying restrictive lung disease, because of reduction in functional residual capacity, tolerate status asthmaticus poorly as well because baseline lung function favors more easy collapsibility of bronchi. Some fatalities occur in the setting of no medical care or are associated with substance abuse even without a history of a previous nearly fatal attack (101). Specific curative therapy can be realized only when basic pathologic mechanisms are understood. Then, therapeutic modalities can be devised rationally to reverse the underlying pathogenetic processes. Many patients with persistent asthma can be managed successfully with an inhaled corticosteroid and intermittent but not excessive use of b 2-adrenergic agonists. None of the medications can substitute for prednisone in patients with oral corticosteroid dependent asthma. Future therapies can be assessed for their ability to (a) decrease symptoms, (b) allow for withdrawal for prednisone or inhaled corticosteroids, (c) preserve lung function, and (d) permit improved quality of life without unacceptable adverse effects. Physicians managing patients with asthma should consider allergic triggers in all patients with persistent asthma because about 75% of patients have IgE antibodies by skin testing. Humanized monoclonal antibody therapy, such as anti-IgE, may be of value in the management of persistent asthma ( 299). Immediate and late bronchial responses to inhaled allergen challenge can be reduced by intravenous anti-IgE infusions ( 299). The requirement for b2-adrenergic agonists and asthma symptom scores were reduced. The true measure of an agonist in asthma is the effect when antagonists interact with the agonist and disease severity is reduced. Bronchial hyperresponsiveness to methacholine in patients with impaired left ventricular function. The interrelationship among bronchial hyperresponsiveness, the diagnosis of asthma, and asthma symptoms. Predictive value of respiratory syncytial virus-specific IgE responses for recurrent wheezing following bronchiolitis. The incidence of respiratory tract infection in adults requiring hospitalization for asthma. Rhinovirus and respiratory syncytial virus in wheezing children requiring emergency care. The pivotal role of 5-lipoxygenase products in the reaction of aspirin-sensitive asthmatic subjects to aspirin. The effect of aspirin desensitization on urinary leukotriene E 4 concentrations in aspirin-sensitive asthma. Environmental factors versus genetic determinants of childhood inhalant allergies.