By Y. Elber. University of Alabama, Huntsville.

Epidemiology The prevalence of diabetes mellitus has risen dramatically in the past two decades order 60 caps mentat amex; it is also projected that the number of individuals with diabetes mellitus will continue to increase in the near future order mentat 60caps. The prevalence of diabetes mellitus is reaching epidemic proportions buy generic mentat 60 caps online, in large part because of obesity and sedentary life style in both adults and children The incidence and prevalence of diabetes mellitus in the general Ethiopian population are unknown. A population based study done near Gondar on 2381 individuals using glycosuria screening with blood glucose confirmation showed glucose intolerance in 12 only 0. Patient education, dietary management and exercise play a central role in managing diabetic patients in addition to pharmacologic therapy. Patient Education • It should be viewed as a continuing process with regular visits for reinforcement and not just a one-time affair. The majority of these individuals are obese, and weight loss is strongly encouraged and should remain an important goal • Food intake must be spread evenly throughout the waking hours and taken at regular times in relation to the insulin dose. Despite its benefits, exercise presents several challenges for individuals with diabetes mellitus because they lack the normal glucoregulatory mechanisms. If the insulin level is too low, the rise in catecholamines may increase the plasma glucose excessively, promote ketone body formation, and possibly lead to ketoacidosis. To avoid exercise-related hyper- or hypoglycemia, individuals with type 1 diabetes should • monitor blood glucose before, during, and after exercise • delay exercise if blood glucose is > 250 mg/dL, <100 mg/d), or if ketones are present • eat a meal 1 to 3 hours before exercise and take supplemental carbohydrate feedings at least every 30 min during vigorous or prolonged exercise • decrease insulin doses (based on previous experience) before exercise and inject insulin into a nonexercising area. Insulin formulations are available as U-100 (1ml of solution equivalent to 100 units) or U-40 (1ml of solution equivalent to 40units). It is very important that one designs and implements an insulin regimen that mimics physiologic insulin secretions. Twice daily administration of a short acting and intermediate acting insulin, given in combination before breakfast and the evening meal, is the simplest and most commonly used regimen. Therapy is initiated with one class of agent, depending on patient characteristics and a second agent is added if adequate glycemic control is not achieved. Many patients with type 2 diabetes mellitus have one or more of diabetes mellitus related complications at diagnosis. For the above reasons, it is recommended to screen those at risk of developing diabetes mellitus using fasting blood glucose. High risk individuals should be encouraged to • Maintain a normal body mass index • Engage in regular physical exercise The morbidity and mortality of diabetes mellitus related complications can be greatly reduced if detected and treated at an early stage. It is most commonly seen in patients with type 1 diabetes mellitus, but it can also be seen in type 2 diabetics especially during acute illness. Abdominal pain may be severe and sometimes may be mistaken for an acute abdominal condition like pancreatitis or ruptured viscous. Reduced insulin levels, in combination with elevations in catecholamines and growth hormone, lead to an increase in lipolysis and release of free fatty acids. Mortality is related more to the underlying or precipitating event, such as infection or myocardial infarction. Non-ketotic heperosmolar coma is characterized by marked hyperglycemia and loss of water up to 25% of body weight in severe cases. Incidence increases with attempts to achieve euglyemia with tight control of glucose concentrations Other causes in patients with diabetes include • Overdose of insulin or oral agents • ill timed administration of insulin or oral agents • administration of the wrong type of insulin • Missed or delayed meals or snacks • Uncompensated exercise • Alcohol consumption • Concomitant chronic renal failure • insulin clearance is reduced in patients with chronic renal failure Hypoglycemia can cause significant morbidity and can be lethal, if severe or prolonged. It should be considered in any patient who presents with confusion, altered level of consciousness, or seizures. The central nervous system can not synthesize glucose or store enough glycogen for more than a few minutes’ glucose supply. The brain cannot use free fatty acids as an energy source, and ketone bodies, which are generated late, are not useful in acute hypoglycemia. Autonomic signs and symptoms Result from increased autonomic nervous system activity They include • Palpitations • Tremor or shaking • Nervousness, Anxiety • Irritability • Sweating • Hunger • Nausea, vomiting • Tingling, Paresthesias • Tachycardia • Hypertension 28 Adrenergic symptoms are mediated by norepinephrine released from sympathetic postganglionic neurons and the release of epinephrine from the adrenal medullae. Neuroglycopenic signs and symptoms Neuroglycopenic symptoms are the direct result of central nervous system neuronal glucose deprivation. Signs and symptoms include • Confusion • Odd behavior • Inability to concentrate • Drowsiness • Visual disturbance • Tingling around the mouth • Convulsions • Focal neurologic deficits e. Blood should be drawn, whenever possible, before the administration of glucose to allow documentation of the plasma glucose level. Oral treatment with glucose tablets or glucose-containing fluids, candy, or food is appropriate if the patient is able and willing to take these. Intravenous glucose (25 g) should be given using a 50% solution followed by a constant infusion of 5 or 10% dextrose. If intravenous therapy is not practical, subcutaneous or intramuscular glucagon can be used, particularly in people with type 1 diabetes mellitus. Because it acts primarily by stimulating glycogenolysis, glucagon is ineffective in glycogen-depleted individuals (e. These treatments raise plasma glucose concentrations only transiently, 29 and patients should be encouraged to eat as soon as they are alert in order to prevent a recurrence. Evidence implicating a causative role for chronic hyperglycemia in the development of macrovascular complications is less conclusive. Three major theories have been proposed to explain how hyperglycemia might lead to the chronic complications of diabetes mellitus.

Chronic cough and recurrent pneumonia are often the manifestations of a foreign body when there is no known history of aspiration buy 60caps mentat. Epiglottitis Epiglottitis is an acute buy generic mentat 60 caps on line, life-threatening infection of the supraglottic area discount mentat 60 caps amex, usually due to H. The patient should be kept calm and comforted by the parents as agitation worsens the ventilatory state. A physician with the ability to perform emergent cricothyrotomy/tracheostomy in children should always be in attendance. Direct laryngoscopy and oral endotracheal intubation are performed using an endotracheal tube one size smaller than normal. Similar presentations include bacterial tracheitis, laryngeal foreign body, retropharyngeal abscess, and diphtheria. Basic guidelines for care include keeping the patient calm and providing oxygen in a cold steam/croup tent/. Racemic epinephrine may temporarily improve symptoms but one should always remember rebound obstruction often occurs 4- 6 hours later. Severe pharyngeal swelling, trismus, distortion of pharyngeal anatomy and airway obstruction can occur. If significant trismus or difficult intubation is anticipated, an inhalation induction with spontaneous ventilation can be performed. Myringotomy with placement of tubes helps to control recurrent otitis media in children and may improve hearing loss. Lacerations, bleeding, edema, and fractures of the maxillofacial area make airway management extremely difficult. Open or closed injuries to the larynx and trachea can occur from direct trauma but are unusual in children. Subcutaneous emphysema, dyspnea, hoarseness, cough, hemoptysis and in particular, voice changes indicate the possibility of laryngeal damage. Anesthesia for ophthalmic surgery The presence of an ocular abnormality always should alert the anesthesiologist to the possibility of other associated anomalies. It is triggered by pressure on the globe or traction of the extraocular muscles, the conjunctiva, or orbital structures. After pretreatment with a nondepolarizing agent, rapid-sequence induction is generally the method of choice. Anesthetic implications of topical ocular drugs Systemic absorption occurs from either the conjunctiva or nasal mucosa. Topical ocular drugs with systemic toxicity to which the anesthesiologist should be alert are found among commonly used mydriatics/atropine, scopolamine, cyclopentolate/as well as antiglaucoma agents/echothiophate iodide,epinephrine, timolol, betaxolol/, and vasoconstictors/cocaine, phenylephrine/. Cocaine should not be administered in combination with epinephrine because of the facilitation of dysrhythmias (especially in the presence of halothane). Cocaine is contraindicated in patients with hypertension or those receiving drugs which modify the adrenergic nervous system. The main anesthetic management concerns are positioning and blood loss, which can be minimized by hyperventilation/vasoconstriction, hemodilution, autologous storage, and controlled hypotension. Both awake intubation and mask inhalation induction with spontaneous ventilation have been used successfully. Juvenile rheumatoid arthritis is an autoimmune disease associated with chronic nonsuppurative inflammation of synovium and connective tissue. Perioperative stress steroid coverage is indicated if the patient is on chronic steroid therapy or if there is a history of recent steroid use. Neuromuscular disorders Von Recklinghausen disease/ neurofibromatosis/: The hallmark of the disease is café-au-lait spots/more than 6 that are greater than 1,5 cm in diameter/ and neurofibromas. Associated conditions are laryngeal and tracheal compression, a high incidence of kyphosis and progressive scoliosis, an increased incidence of neural tumors, compression of spinal roots, and an increased incidence of cancer. Patients may have increased intracranial pressure or a prolonged response to nondepolarizing muscle relaxants. Anesthetic considerations include respiratory compromise in the presence of scoliosis, antiepileptic medications, and considerations for patients with seizure disorders. Clinical features include poor sucking and swallowing, muscle atrophy, facial weakness, ptosis, cataracts, frontal baldness, gonadal atrophy, endocrine failure, and mental retardation. These patients are predisposed to aspiration, atelectasis, and pneumonia, bradycardia and intraventricular conduction delays, and hypoxemia and hypercapnia. Nondepolarizing agents can be used safely but reversal with neostigmine and an antimuscarinic can precipitate contracture. Muscular dystrophy, Duchenne is an X-linked recessive trait that usually presents with waddling gait in a child between the ages of 3 and 5 years. As the disease progresses patients are unable to protect their airways from secretions, pneumonias occur, kyphoscoliosis occurs, and cardiac muscle degenerates. There was report about propofol infusion causing rhabdomyolisis in patient with Duchenne muscular dystrophy.

Pulmonary resection as an adjunct in the treatment of multiple drug-resistant tuberculosis cheap mentat 60 caps fast delivery. Sources for further reading Textbook Chapters Chapter 20: Lung Infections and Diffuse Interstitial Lung Disease purchase mentat 60caps free shipping. Chapters 17 and 18: Thoracic Infections Caused by Actinomycetes buy mentat 60 caps without a prescription, Fungi, Opportunistic Organisms, and Echinococcus; Surgical Treatment of Tuberculosis and Other Pulmonary Mycobacterial Infections. Epidemiology of Lung Cancer 190,000 new cases in 2000 149,000 patients will die of lung cancer 50 deaths per 100,000 per year 5 yr survival 1981-87 - 13%. Squamous cell carcinoma · Most common (40-70%), centrally located, more common in men · Local metastases, plentiful eosinophilic cytoplasm, keratin "pearls", bridging. Adenocarcinoma · Less common (5-15%), peripherally located, more common women · Distant metastases, vacuolization, mucus synthesis, glandular differentiation C. Undifferentiated carcinoma · Two subtypes (20-30%) · Large cell carcinoma: aggressive clinical behavior, moderate cytoplasm, no mucus or keratin · Small cell carcinoma: nonsurgical lesion, high incidence of metastases, spindle or oat shaped cells, dense nuclei, sparse cytoplasm D. Bronchoalveolar carcinoma · Uncommon (3-7%) adenocarcinoma variant, favorable prognosis, alveolar "scaffolding", tends to recur as a second primary tumor E. Complete Pulmonary Resection Surgeon is morally certain he or she has encompassed all tumor disease Proximal margins of resected specimen are microscopically free of tumor Within each major lymphatic drainage region, the most distal node is microscopically free of tumor Capsules of resected nodes are intact. Manifestations of Preoperative Inoperability Distant metastases (absolute) Malignant pleural effusion (absolute) Superior vena caval syndrome Horners syndrome Vocal cord paralysis Phrenic nerve paralysis 15. Neoadjuvant Therapy for Lung Cancer Neoadjuvant therapy has been successful in anal, bladder and esophageal cancers. Head and neck cancers do not respond to neoadjuvant therapy Rationale for neoadjuvant therapy Surgical resection disrupts blood supply and adjuvant therapy may not be deliverable Preoperative therapy may minimize seeding Preoperative therapy may accomplish downstaging Tumor growth is inversely related to size. Conclusions from randomized trials Well tolerated with high response and resectability rates (70%) Trend towards increased disease free survival and even overall survival I believe some form of neoadjuvant therapy is the best we have to offer today and recommend it to every patient with N2 disease 19. Tumor promoters (or cocarcinigens) a) Fatty acids, phenols, N-methylated indoles, insecticides b) Low-dose nicotine c) N-nitrosamines 3. Complete carcinogens a) Nickel, arsenic b) Radioactive plutonium (80 pk-yr = 1300 rem from polonium) - enough to cause Ca C. Stem cell theory - cells may differentiate and lose differentiation Small Cell Adenocarcinoma Squamous Cell Carcinoma 2. Hyperplasia a) growth factors à # of basal (reserve) cells in bronchial epithelium b) Cells are benign, respond to normal control mechanisms 2. Metaplasia a) Reversible b) Ciliated bronchial epithelial cells àgoblet or squamous cells 3. Central tumors can be dx’d by sputum cytology - most common neoplasm detected in screening program D. Non-ciliated bronchiolar epithelial cell (Clara cell) may be common cell of origin D. Radiographically, may be an infiltrate rather than a mass, may not change for years 4. Is excision of a long-standing scar warranted if there is a slight radiographic D? Need adequate bx specimen to establish dx (vs atypical carcinoid, lymphoproliferative dz) 6. Jensik - Peripheral Stage I (n=168) a) Wedge or segmentectomy b) 53% 5-year c) 45 pts died of disease, 16/45 - local recurrence 2. Ginsberg & Rubinstein a) Randomized: lesser resection vs lobectomy b) Loco-regional recurrence: 17. Recommendation (Glenn’s): May be useful for high-risk, elderly pt with limited reserve D. Mediastinal lymph node dissection - necessary for pathologic + surgical staging 1. A-P window - Left a) Supraaortic and superior mediastinal palpable nodes excised 3. T2 = >3cm or any size w/ visceral pleural invasion or atelectasis extending to hilum and >2cm distal to carina E. Prognostic factors a) tumor size and # of nodes b) Not -age sex, pleural involvement c)? Radiation a) No randomized, controlled data b) Patterson (retrospective) - 56% vs 30% 5-yr C. Sleeve pneumonectomy a) Bulky central tumor in proximity to or involving carina or tracheobronchial angle b) 4-31% operative mortality c) Anastomotic dehiscence à 100% mortality d) 16-23% 5-yr survival D. Pearson’s mediastinoscopic contraindications to resectability a) Contralateral nodal dz b) Extranodal extension c) High paratracheal nodal dz 4. Cytology negative, non-bloody, not an exudate - exclude this pleural effusion for staging purposes 3. Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. A twenty-five-year follow-up of ninety-three resected typical carcinoid tumors of the lung.