By J. Kalesch. MacMurray College. 2018.

Adequate munity cheap lasix 100 mg online hypertension remedies, and ensure that a culture of open and welcome com- leave also allows for the entire family to grow together as they munication is fostered lasix 100 mg with amex arteria yahoo. Children will not accept medicine as an move through the phases of expectation, arrival, integration excuse for parental distance or under-involvement, nor should and, fnally, resumption of professional roles. Besides, spending time with children is a healthy way to in physician families is a smart one and directly contributes to remove oneself from the stresses of medical training, return the long-term sustainability of the physician workforce. Career choices Specialty medicine in Canada is experiencing signifcant demo- graphic shifts, including with respect to the gender and age of practitioners. This creates a remarkably busy family environment that re- Case resolution quires careful planning, open communication, fexibility and The resident books a meeting with the program director creativity to manage well. Busy physician parents need to pay and formally requested the maximum parental leave open particularly good attention to their partner’s emotional and to them. The program director expressed his happiness physical needs in order to bring richness and closeness to for the resident and family while indicating that he will the relationship. However, there was one month in counselling should signifcant relationship diffculties arise: particular that posed a challenge in terms of call and early intervention is associated with high rates of success. This was readily managed with the resident’s Inadvertently, this can lead to physician parents having unreal- partner, and everyone was satisfed. Physician parents are well resident considers this year of leave one of their best life served by engaging in community activities with a diversity of experiences. Health Awareness Workshop Reference University programs are encouraged to openly and warmly Manual. Staying human in the medical family: the family members to program orientation sessions and retreats unique role of doctor-parents. Family-friendly programs often have an edge in recruiting and retaining ex- cellent residents who, in turn, contribute to the goals of the department in a spirit of collegiality, community and respect. Thus physical As a rule, they are energetic, hard-working, enthusiastic, intel- activity become a low priority, and a lack of healthy exercise ligent and self-disciplined. They have learned to delay gratifca- erodes one’s energy level and sense of well-being even more. They are idealistic, and most come to medicine because they are inspired to contribute Emotional and physical fatigue lead to behavioural changes. Decreased interest in activities that were once enjoyed during free time leads to social withdrawal and personal isolation. However, the profession of medicine is demanding, and it is Relationships with family and friends are compromised, and diffcult to put limits around its practice. Poor constant exposure to suffering, heavy workloads, long hours, coping strategies that are adopted might include the increased time pressures, physical and mental demands, and a lack of intake of caffeine and alcohol, or the use of illicit drugs. Physicians are acutely Faced with some or all of these effects, one might experience aware of the distress of others but are often less attentive to at the same time a reduced sense of accomplishment and the stress and fatigue that they experience themselves. It is easy to lose sight of one’s accomplishments caring for others often leads to neglect of oneself. This is the sign of We know that physicians, as a group, are well informed with signifcant stress. We also know that when physicians are overwhelmed by the demands Given that the demands of the profession are ever present, of their profession, they are vulnerable to neglecting those what is the solution? It requires, frst and foremost, awareness of the risks mises not only the physician’s health, but his or her ability to that will be present and deliberate attention to measures of continue to provide care for others. Physicians’ self-care presents a perfect opportunity to practise preventative care. When self-care is neglected When a physician becomes immersed in his or her work to the Solutions: Think “self-care” exclusion of self-care, a cascade of stress-induced symptoms In The 7 Habits of Highly Effective People, Steven R. A feeling of being chronically overwhelmed a compelling case for what he describes as the “Principles of leads to frustration and irritability. The physician may become Balanced Self-Renewal,” which he describes as “preserving and prone to emotional outbursts, or may be tearful at work in enhancing the greatest asset you have–you. He or she may take domains that require attention in self-care: physical, emotional, less pleasure in activities that were once much enjoyed. Effective self-care requires consideration meantime, a denial of the signifcance of these symptoms and of these four domains, and taking control of the things that the vulnerability they reveal can lead the physician to take on can be controlled.

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However 100 mg lasix free shipping blood pressure zanidip, while younger people gain more life years if they have a non-fatal event generic lasix 100 mg amex prehypertension 20 years old, older people are a lot more likely to die from an event. When discounting is taken into consideration, the quality adjusted life years gained by preventing events in young people are very similar to those gained in old people (Table 3) (50). Concern about the metabolic syndrome, characterized by central obesity, elevated blood pressure, dyslipidaemia, and insulin resistance (51, 52), has raised the question of whether identifying people with this syndrome should be a priority. There is, as yet, insufficient evidence to justify using metabolic syndrome as an additional risk prediction tool (63, 64). People with metabolic syndrome would, in any case, benefit from weight reduction, higher levels of activity (65–71), lowering of blood pressure, avoidance of drugs that tend to cause hyperglycaemia (72–75), lowering of choles- terol with a statin (76–80), and reduction of hyperglycaemia with metformin. There is insufficient evidence from randomized trials to support more specific management of dyslipidaemias (81). In summary, the great strength of the risk scoring approach is that it provides a rational means of making decisions about intervening in a targeted way, thereby making best use of resources available to reduce cardiovascular risk. Alternative approaches focused on single risk factors, or concepts such as pre-hypertension or pre-diabetes, have been popular in the past, often because they represented the interests of specific groups in the medical profession and professional societ- ies. Such an approach, however, leads to a very large segment of the population being labelled as high risk, most of them incorrectly. If health care resources were allocated to such false-positive individuals, a large number of truly high-risk individuals would remain without medical attention. Risk scoring moves the focus of treatment from the management of individual risk factors to the best means of reducing an individual’s overall risk of disease. It enables the intensity of interven- tions to be matched to the degree of total risk (Figure 2). Further research is required to validate existing subregional risk prediction charts for individual populations at national and local levels, and to confirm that the use of risk stratification methods in low- and middle-income countries results in benefits for both patients and the health care system. These charts are intended to allow the introduction of the total risk stratification approach for management of cardiovascular disease, particularly where cohort data and resources are not readily available for development of population-specific charts. The charts have been generated from the best available data, using a modelling approach (Annex 5), with age, sex, smoking, blood pressure, blood cholesterol, and presence of diabetes as clinical entry points for overall manage- ment of cardiovascular risk. Some studies have suggested that diabetic patients have a high cardiovascular risk, similar to that of patients with established cardiovascular disease, and so do not need to be risk-assessed. In addition, in people with diabetes, there is no gender difference in the risk of coronary heart disease and stroke (82). Therefore, separate charts have been developed for assessment of cardiovascular risk in patients with type 2 diabetes. In many low-resource settings, there are no facilities for cholesterol assay, although it is often feasible to check urine sugar as a surrogate measure for diabetes. Annex 4 therefore contains risk prediction charts that do not use cholesterol, but only age, sex, smoking, systolic blood pressure, and presence or absence of diabetes to predict cardiovascular risk. Obesity, abdominal obesity (high waist–hip ratio), physical inactivity, low socioeconomic position, and a family history of premature cardiovascular disease (cardiovascular disease in a first-degree relative before the age of 55 years for men and 65 years for women) can all modify cardiovascular risk. These risk factors are not included in the charts, which may therefore underestimate actual risk in people with these characteristics. While including these risk factors in risk stratification would improve risk prediction in most populations, the increased gain would not usually be large, and does not warrant waiting to develop and validate further risk stratifica- tion tools. Nevertheless, these (and other) risk factors may be important for risk prediction, and some of them may be causal factors that should be managed. Clinicians should, as in any situa- tion, use their clinical acumen to examine the individual’s lifestyle, preferences and expectations, and use this information to tailor a management programme. The risk prediction charts and the accompanying recommendations can be used by health care professionals to match the intensity of risk factor management with the likelihood of cardio- vascular disease events. The charts can also be used to explain to patients the likely impact of interventions on their individual risk of developing cardiovascular disease. The use of charts will help health care professionals to focus their limited time on those who stand to benefit the most.

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The disease apparently was unknown in the New World prior to the appearance of the Spanish and Portuguese conquistadors cheap 100mg lasix otc blood pressure different in each arm. Cortez was routed in battle in 1520 but was ultimately victorious as smallpox killed more than 25% of the Aztecs over the next year purchase 100 mg lasix blood pressure solutions. He reported that 1000 persons per day died in Tlaxcala, with ultimately 150,000 total dead. At the least, it was appreciated that the skin lesions and scabs could transmit the disease. It was known that survivors of the infection were immune to reinfection after further exposure. The practice of inoculation, or variolation, whereby people were intentionally exposed to smallpox was practiced in China, Africa, and India centuries before the R1 practice would be adopted in Europe and the Americas. Syphilis became epidemic in the 1490s as a highly contagious vene- real disease in Spain, Italy, and France. One theory proposes that it began as a tropical disease transmitted by direct (nonsexual) contact. After the frst accounts of syphilis, it was reported to spread rapidly through Europe and then North America. In keeping with the hypothesis that syphilis was a recently emerged disease, mortality from syphilis was high in these early epidemics. In his treatise Airs, Water and Places, Hippocrates dismissed supernatural explanations of disease and instead attributed illness to characteristics of the climate, soil, water, mode of life, and nutrition surrounding the patient. Galen combined his practical experience caring for gladiators with experiments, including vivisections of animals, to study the anatomy and physiology of man. It was over a thousand years before Andreas Vesalius (1514–1564), who based his work on dissections of humans, was able to correct Galen’s errors in anatomy. Plague was rec- ognized to be contagious; however, the control measures focused primarily on quarantine and disposal of the bodies and the possessions (presumably contaminated) of the victims. Although it was observed that large numbers of rats appeared during an epidemic of plague, the role of rats and their feas was not appreciated. Given that leprosy progresses slowly, quarantine of cases late in disease likely had little effect on the epidemic spread. In the Middle Ages lepers were literally stricken from society as leprosy became increasingly equated with sin. Some R1 even required lepers to stand in a dug grave and receive the “Mass of Sepa- © Jones and Bartlett Publishers. I forbid you to leave your house unless dressed in your recognizable garb and also shod. I forbid you to wash your hands or to launder anything or to drink at any stream or fountain, unless using your own barrel or dipper. I forbid you to enter any tavern; and if you wish for wine, whether you buy it or it is given to you, have it funneled into your keg. I command you, if accosted by anyone while traveling on a road, to set yourself downwind of them before you answer. I forbid you, wherever you go, to touch the rim or the rope of a well without donning your gloves. Fracastoro (1478–1553) was much more than just an author of the popular poem on syphilis. Although revolutionary, Fracastoro did not realize that the seeds of a disease were microbes, and he held to ancient beliefs that they were infuenced by planetary conjugation particularly “nostra trium superiorum, Saturni, Iovis et Martis” (our three most distant bodies: Saturn, Jupiter, and Mars). He postulated that the environment became polluted with seminaria and that epidemics occurred in association with certain atmospheric and astrologic conditions. The Observation and Care of Patients Medical practice was gradually transformed by the introduction of disease- specifc treatments during the Renaissance era. Peruvian bark, or cinchona, was imported into Europe for the treatment of malaria around 1630. Based on the observation that smallpox disease conferred immunity in those who survived, intentional inoculation of healthy people to induce immunity was attempted. This process was known as variolation and was advocated by Thomas Jefferson (1743–1826), Benjamin Franklin (1706–1790), and Cotton Mather (1663–1728). Mather learned of it from a man he enslaved, Onesimus, who was innoculated with smallpox in a cut as a child in Africa.

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Localised metas- is not well outlined by endoscopic retrograde cholan- tases may also be resected order 40 mg lasix fast delivery heart attack young adults. For example in obstruc- The liver is composed of several segments best lasix 40 mg hypertension questionnaire questions, as defined tive jaundice with obstruction of the upper biliary tree by the blood supply and drainage, this is important in and when malignancy of the biliary tract is suspected liver resection. Prior to the procedure the clotting have a left and right branch and these supply the left and profile is checked and the patient is given prophylactic righthemi-livers respectively. The im- comprises of the remainder of the right lobe and is also age can be followed by real-time radiography and still further divided into four segments (see Fig. The T-tube allows drainage of Right lobe Left lobe bile and also allows a cholangiogram later. Laparoscopic cholecystectomy requires three or four cannulae inserted through the anterior abdominal wall, Caudate and for visualisation and access with operative instruments. Open cholecystecomy often requires quite a long stay Gallbladder Hepatic artery and in hospital, possibly a week or more, whereas laparo- portal vein scopic cholecystectomy may be conducted as a day case. Laparoscopic tech- This means that right hepatectomy, left hepatectomy nique reduces the incidence of respiratory problems and and extended right hepatectomy (right lobe plus cau- surgical site infection. The appropriate vessels for the segment(s) Disorders of the liver are ligated and divided before the segment(s) are dis- sectedawayfromtheremainderoftheliver. Carefuliden- Introduction to the liver and tification and ligation of biliary ducts and smaller vessels liver disease is required to reduce blood loss and therefore morbidity and mortality. Drainage is required postoperatively, to Introduction to the liver prevent bile from pooling intra-abdominally. It has two blood supplies: 25% of Cholecystectomy its blood originates from the hepatic artery (oxygenated) Surgical removal of the gallbladder and associated stones and 75% originates from the portal vein that drains the in the biliary tract may be by open surgery or laparo- gastrointestinal tract and spleen. Cholecystectomy is also considered in The functions of the liver are carried out by the hepa- younger patients with asymptomatic gallstones in or- tocytes, which have a special architectural arrangement. Blood enters the liver through the portal tracts, which Carcinoma of the gallbladder is treated by wider resec- contain the triad of hepatic artery, portal vein and bile tion, including neighbouring segments of the liver and duct. The lobule is classically used to Open cholecystectomy is usually performed through describe the histology of the liver (see Fig. Cholangiography may be used to The hepatocytes in zone 1 of the acinus receive well- visualise the duct system. The gallbladder is removed oxygenated blood from the portal triads, whereas the with ligation and division of the cystic duct and artery. The liver has multiple functions, which may be im- Aetiology paired or disrupted by liver disease: The causes of acute hepatitis: r Carbohydrate metabolism: The liver is one of the ma- r Acute viral hepatitis may be caused by the hepa- jor organs in glucose homeostasis under the control totrophic viruses (A, B and E) or other viruses such as of pancreatic insulin. Excess glucose following a meal Epstein–Barr virus, cytomegalovirus and yellow fever is converted to glycogen and stored within the liver. The liver is also involved in the breakdown of amino acids producing ammonia, which is converted Pathophysiology to urea and excreted by the kidneys. Cellular damage results in impairment of normal liver r Fat: The liver is involved in synthesis of lipoproteins function: bilirubin is not excreted properly resulting in (lipid protein complexes), triglycerides and choles- jaundice and conjugated bilirubin in the urine, which terol. Swelling of the liver results in stretching of the liver capsule which may result in pain. Patterns of liver disease Clinical features The features of acute liver damage are malaise, jaundice, Acute hepatitis anorexia, nausea, right upper quadrant pain and in se- Definition vere cases, evidence of liver failure. However,itissometimesdiagnosed may be an enlarged, tender liver, pale stools and dark earlier than this. Stigmata of chronic liver disease should be looked for to exclude acute on chronic liver disease. Aetiology The main causes of chronic hepatitis: Microscopy r Viral hepatitis: Hepatitis B virus (+/− hepatitis D), Acute viral hepatitis has a histological appearance which hepatitis C virus. Cell r Toxic:Alcohol-inducedhepatitis(rare),drug-induced death is by apoptosis and results in the formation of hepatitis (methyldopa, isoniazid, ketoconazole, anti- Councilman bodies. Complications Clinical features Fulminant liver failure, chronic hepatitis, and cirrhosis. Patients may present with non-specific symptoms (malaise, anorexia and weight loss) or with the compli- Investigations r cations of cirrhosis such as portal hypertension (bleed- Serum bilirubin and transaminases (aspartate ing oesophageal varices, ascites, encephalopathy).

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The writing of the Strategy was informed by an extensive national consultation process buy lasix 100mg with amex blood pressure infant normal value, which included key informant interviews buy cheap lasix 100mg on-line blood pressure dehydration, online survey feedback and stakeholder forums. This process identified priorities for the next ten years, which will be vital in reducing drug-related harm. These are detailed in the Strategy, but can be summarised as: • increasing processes for community to identify and respond to key alcohol, tobacco and other drug issues • improving national coordination • developing and sharing data and research that supports evidence-informed approaches • developing innovative responses to prevent uptake, delay the first use and reduce harmful levels of alcohol, tobacco and other drug use • restricting or regulating the availability of alcohol, tobacco and other drugs • enhancing harm reduction approaches. National Drug Strategy 2016-2025 3 Measures for improving stakeholder and community engagement have been identified in the Strategy as a result of the consultation feedback process. Opportunities for consumers and communities, service providers, peer organisations and other interested parties to be engaged in alcohol, tobacco and other drug strategies over the next ten years will increase. The health and law enforcement sectors demonstrate an excellent working relationship for managing alcohol, tobacco and other drug issues and initiatives, which can be used as a model for improving engagement with other parts of the sector. During the period of the National Drug Strategy 2010-2015, evidence informed demand, supply and harm reduction strategies yielded positive results. In 2011-12, police reported 76,083 drug seizures; the highest number of drug seizures in the last 1 decade. The same year, 809 clandestine laboratories were detected nationwide; the highest number 2 ever detected in Australia. There was also a decline in the proportion of people exceeding lifetime risk guidelines for consuming alcohol from 20% in 2010 to 18. There were declines in the use of some illicit drugs between 2010 and 2013, including heroin and ecstasy and a decrease in the proportion of people injecting drugs during this period. While those people with the lowest socio-economic status were more likely to smoke and consume alcohol at risky quantities, the proportion of daily smoking declined for this group from 22% in 2010 5 to 19. The embedding of harm minimisation principles into the day-to-day operations of police, health services and other interested parties is also a worthy achievement. The Strategy takes Australia into the fourth decade with a consistent national drug policy framework, which has earned high international regard for its progressive, balanced and comprehensive approach and has made considerable achievements. The term ‘drug’ in this document refers to a substance that produces a psychoactive effect when consumed by humans, including tobacco, alcohol, pharmaceutical drugs and illicit drugs. It also takes 6 account of performance and image-enhancing drugs, and substances such as inhalants. This includes health harms such as injury, lung and other cancers; cardiovascular disease; liver cirrhosis; mental health problems; road trauma; social harms including violence and other crime. It also includes economic harms from healthcare and law enforcement costs, decreased productivity, associated criminal activity, reinforcement of marginalisation and disadvantage, domestic and family violence and child protections issues. Harmful drug use is also associated with social and health determinants such as discrimination, unemployment, homelessness, poverty and family breakdown. Since 1985, activities for the original National Campaign Against Drug Abuse and preceding National Drug Strategy iterations have demonstrated many of these harms can be minimised through coordinated, multi-agency approaches and community responses that address the harmful use of drugs and the underlying determinants of use. Cooperation between the law enforcement and health sectors is fundamental to drug harm responses and ongoing engagement with other key stakeholders is increasingly necessary for positive outcomes. Collaboration of this nature has facilitated referral pathways to alcohol and other drug treatment and supported less harmful substance use. The Strategy describes the national approach to prevent, minimise and address the drug harms to individuals, families and communities. It provides a national framework and guidance for action by Commonwealth, state and territory governments in partnership with service providers, local government and the community. As well as outlining the national commitment to the harm minimisation approach, the Strategy describes priority actions, groups and drug types and summarises effective demand, supply and harm reduction strategies. Trends in alcohol, tobacco and other drug use change regularly and the evidence base for effective responses to drug-related harm is constantly evolving. As a consequence, priority populations and drug types, including forms and delivery, change over time. Interventions should change with them and be informed by the latest available evidence. The Strategy is informed by current evidence on drug use and effective strategies.

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