By O. Grobock. Bethel College, Mishawaka, Indiana. 2018.

Chronic Thyroiditis (Hashimoto thyroiditis) Etiology: it is an autoimmune disorder that mainly affects women 20mg olanzapine free shipping. Clinical features Thyroid gland enlargement: is the main clinical manifestation buy cheap olanzapine 5 mg on line, is the result of autoimmune damage that leads to lymphocytic infiltration buy olanzapine 7.5mg online, fibrosis and weakens ability of the thyroid to produce hormone. Types/ Classification: Papillary carcinoma : which accounts for 60 % of all thyroid cancer o Affects younger age group 50 % of patients are younger than 40 years o Papillary Ca metastasize through the lymphatic system Follicular carcinoma; comprises 25 % of all thyroid cancer o Histologicaly resembles normal thyroid tissue, o Follicular Ca metastasizes hematogenously Medullary carcinoma: which accounts for 5 % of all thyroid cancers. Diseases of the adrenal gland Learning objectives: at the end of this lesson the student will be able to: 1. Identify the clinical manifestation of diseases of the adrenal gland, with special emphasis on Cushings syndrome and Addisons diseases. Disease of the adrenal cortex a) Resulting from excess production of hormones Cushings syndrome : excess cortisol production Primary hyperaldosteronism : excess production of aldosteron b) Inadequate production; Addisons diseases : inadequate production of cortisol and aldosteron 2. Disease of the adrenal medulla Pheochromocytoma: excess production of catecholamine Cushings Syndrome ( Hypercortisolism) Cushings syndrome: is caused by excessive concentration of cortisol or other glucocorticoid hormones in the circulation Etiology: a) Bilateral adrenal hyperplasia (Cushings diseases) is the commonest cause of Cushings syndrome. Pituitary tumors large enough to be seen by skull x-ray, are present in more than 10 % of these patients, and smaller basophilic adenomas are found in more than 50 % of patients. It is an expected complication in patients receiving long term glucocorticiod treatment for asthma, arthritis, and other conditions. Clinical features Central obesity is caused by the effect of excess cortisol on fat distribution. The moon face, buffalo hump ( cervical fat pad ) and supraclavicular fat pads contribute to the Cushingiod appearance Hypertension : result from the vascular effects of cortisol and sodium retention Decreased glucose tolerance: is common, 20 % of patients have overt diabetes. This is a result of hepatic gluconeogenesis, and decreased peripheral glucose utilization. Because this test is sensitive, the diagnosis of Cushings syndrome need not be considered further in these cases. Serum cortisol level: in normal in individuals is highest in early morning and decreases throughout the day, reaching a low point at about midnight. Although the morning level may be increased in patients with Cushings syndrome, a loss of the normal diurnal variation and an increase in the evening level are more consistent findings. The 24 hrs urinary free cortisol excretion rate: is increased in most patients with Cushings syndrome 6. Other tests: lukocytosis, with relatively low percentage of lymphocytes and eosinophils 7. Skull x-ray: enlargement of sella turcica in 10 % of patients with Cushings syndrome who have macroadenoma. Adrenal adenoma : complete surgical resection of the adenoma cures the disease, but patients may need cortisol replacement post operatively for several months 2. Pituitary radiation : is effective in children but it cures fewer than 1/3 of adult patients b. Disadvantages Patients will develop Addisons disease and need lifelong Cortisol replacement Nelsons syndrome: in which pituitary adenomas undergo rapid growth, perhaps because it is no longer inhibited by above normal level of cortisol. Hyperaldosteronism Aldosteronism: is a syndrome associated with hypersecretion of the mineralocorticoid, aldosterone. Primary aldosteronism: the cause of excess aldosterone production resides with in the adrenal gland Aldosterone producing adrenal adenoma (Conns syndrome): in most cases, unilateral small adenoma which can occur on either side Adrenal carcinoma: rare cause of aldosteronism Bilateral cortical nodular hyperplasia /idiopathic hyperaldosteronism 2. Secondary aldosteronism: the stimulus for excess aldosterone production is outside the adrenal gland. Signs and symptoms: Moat patients have diastolic hypertension resulting from sodium retention. Patients may complain headache and symptoms of other organ damage Hypokalemia and associated symptoms: muscle weakness and fatigue. While raised aldosteron level with reduced plasma renin activity suggests primary aldosteronism. Surgery: removal of solitary adenoma results cure of hypertension in about 60 % of cases and improvement in another 25 %. Adrenalectomy is done after 4 week treatment with spironolactone (in case of adenoma, hyperplasia) In contrast only 20%-50 % of patients with bilateral hyperplasia are improved with surgery, even if bilateral adrenalectomy is performed. Medical Therapy: Spironolactone inhibits the effects of aldosteron on renal tubule. In idiopathic form: Spironolactone (50-100 mg/d), possibly combined with potassium- sparing diuretics correct the hypokalemia and with anti-hypertensive medication, high blood pressure can be controlled. Anterior pituitary diseases may result from:- i) Insufficient production of pituitary hormones: hypopituitarism ii) Excess production of pituitary hormones: a. Posterior Pituitary diseases I) Hypopituitarism ( Insufficient production of anterior pituitary hormones) Hyposecretion may be generalized (hypopituitarism) or caused by the selective loss of one or more pituitary hormones. Generalized hypopituitarism Definition: Endocrine deficiency syndromes due to partial or complete loss of anterior lobe pituitary function.

Genetic (inherited): Features olanzapine 20 mg free shipping, such as eye color order 5 mg olanzapine with amex, that are passed from both parents to After the initial damage discount olanzapine 7.5 mg visa, many factors may children. Thus, the stress of the automobile Identical twins: Twins that come from the accident may have been the final precipitating same egg. All their features (genetics) are event, but it was most likely only one of several exactly alike. Islet cell (pronounced eye-let): The groups of cells within the pancreas that make insulin. What is the role of inflammation in Q Islet cell antibody: The material we measure causing diabetes? A onset of type 2 diabetes, gestational (pregnancy) diabetes and in some, not all, young infants prior to the onset of type 1 diabetes. In the young infants (Diabetes 53,2569, 2004) the inflammatory markers correlated with who was most apt to progress to diabetes. In studies examining the endocrinological and metabolic effects of exercise, it has been demonstrated that physical exercise promotes the utilization of blood glucose and free fatty acids in muscles and lowers blood glucose levels in well-controlled diabetic patients. Long-term, mild, regular jogging increases the action of insulin in both carbohydrate and lipid metabolism without inuencing body mass index or maximal oxygen uptake. Health insurance system in Japan recently changed so that doctors can be reimbursed for lifestyle interventions. An active lifestyle is essential in the management of diabetes, which is one of typical lifestyle- related diseases. In the area of research on the clinical This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol. The Japanese text is a transcript of a lecture originally aired on November 16, 2001, by the Nihon Shortwave Broadcasting Co. Thus, evi- Health and Welfare introduced the concept dences demonstrating the usefulness of exer- of lifestyle-related diseases to describe these cise therapy have been gradually increasing. As factors common to these dis- Related to this, the Japanese Ministry of eases, the importance of insulin resistance and Health and Welfare (currently the Ministry of accompanying compensatory hyperinsulinemia Health, Labor and Welfare) introduced the have been stressed. Prevention of type-2 diabetes mellitus and factors such as diet and exercise, in addition to the role of physical exercise genetic factors, are involved in the develop- The results of various follow-up studies have ment of so-called adult diseases, including revealed that the proper diet combined with type-2 diabetes and obesity. Health insurance physical exercise are not only useful in prevent- system in Japan was altered to provide addi- ing type-2 diabetes mellitus and improving tional remuneration for the guidance and man- disease status but are also effective in the agement of exercise for the treatment of hyper- prevention and treatment of all other insulin- tension in April 1996 and for diabetes mellitus resistance-related diseases (lifestyle-related and hyperlipidemia in April 2000. If diabetic prescribed, and by 42% when a combination control is extremely poor, physical exercise of diet and exercise therapy was prescribed is contraindicated. Training effect Effects of Physical Exercise (1) Physical exercise and insulin sensitivity 1. Thus, may lead to better control of diabetes by sup- dietary restriction combined with physical pressing the rapid postprandial elevation of exercise is more useful for improving insulin blood glucose. Aerobic exercise such as jogging is more and ketone bodies may increase further after useful in improving the in vivo insulin sensitiv- exercise. High-intensity exercise may aggravate However, mild resistance exercise, if carried abnormal carbohydrate metabolism through out in an aerobic manner, is also useful for increased secretion of insulin-counter regula- improving insulin sensitivity in patients with tory hormones such as glucagon and catechola- type-2 diabetes and in the elderly. Indications of physical exercise and 4 medical check-up 3 Before patients undertake programs of physical exercise, various medical examina- 2 tions are needed to determine that they have 1 good diabetic control and are without progres- sive complications. Type and intensity of exercise Diet therapy exercise therapy The effect of exercise that manifests in Weight loss (kg) 4. As noted previously, moderate or rate) in patients on diet therapy alone and on lower intensity exercise is preferable. Implementation of exercise improves of exercise are aerobic exercises that use physical tness and lipid metabolism. However, since metabolic exercise is adopted, the level of the load should status can vary on a daily basis in patients with be low. It is necessary to instruct patients to (2) Mechanisms of training effects incorporate some exercise into their daily life, a. Muscular factors destination and walking the rest of the way including postreceptor steps, such as muscle (Table 1). Adipose tissue factors such as decreases the outpatient clinic, with the goal set at 10,000 in body fat and the size of fat cells cannot be steps (or at least 7,500 steps) per day. Precautions in implementing physical adipose tissue may decrease, resulting in im- exercise proved in vivo insulin sensitivity. It should be used as a yardstick for supplementary feeding in patients on insulin therapy. General precautions including the use of Dietary restriction should be instructed. If hypo- important in the treatment of lifestyle-related glycemia occurs during exercise, a cola drink diseases, initiated a new system of reimburse- or glucose (pet sugar) dissolved in lukewarm ment for the guidance and management of water should be taken. Cookies, cheese, and physical exercise (charges for the guidance and milk are suitable before and after exercise to management of lifestyle-related diseases) in prevent hypoglycemia.

Without talking to your doctor purchase olanzapine 2.5mg mastercard, never mix different types of medications buy olanzapine 10mg low cost, even those you can buy over the counter cheap 5 mg olanzapine with visa, with antidepressants. Some antidepressants, while safe when taken alone, may cause problems when mixed with other drugs. These substances interfere with the nerve impulses when the impulses travel between nerve cells in the positive and negative emotion centers of the brain. If you have side effects: Antidepressants may cause mild, usually temporary, side effects in some people. These are not usually serious but should be reported to your doctor as soon as possible. The most common side effects and some suggestions for dealing with them include: Dry mouth - Take sips of water or chew sugarless gum. Bladder problems You may experience some mild problems emptying your bladder fully. Blurred vision This is usually temporary and doesnt usually require any special glasses or treatment. Agitation (jittery feelings) If this does not go away after a short time, consult your doctor. If you look at your life and see only the bad parts, you are more likely to stay depressed. But if you can teach yourself to look for the good things in life, this often reduces depression. Seeing only the bad parts of your life and worrying about them can easily become a habit. But if you can practice thinking of good things you would like to happen in the future, you may feel less depressed. A mental health therapist can help you recognize thoughts and actions that can lead to depression. He or she can help you to learn ways of thinking and acting that help you feel better. Changing thoughts that can make you feel bad Some thoughts and expectations lead to bad feelings and depression. It takes the same amount of energy to say to yourself, I will do well at this as to say I will fail at this. Once you catch yourself doing this, practice talking back with positive good messages. Practice recognizing all of the reasons for a situation and fgure out what you can do about it. Dont go on and on complaining about hard times or diffculties, even going as far as making things seem worse than they really are. A Story A well known therapist and workshop leader tells workshop audiences a wonderful story about her grandmother who went to live on the shore overlooking a harbor. Look at the pelicans and how sleek they are as they dive into the water looking for fsh. Look at the many colors of the fshing nets and how they glisten in the sun like rainbows. After a while, she didnt see the ugly fshing boats or the rusty barrels, she saw only the beauty. Many times during her childhood, the girl would visit her grandmothers house by the harbor. And when she grew up and had a daughter of her own, she took her to her grandmothers house by the harbor. Look at the many colors of the fshing nets and how they glisten in the sun like rainbows There is beauty in our lives, even when, because of stress and depression, all we see is ugliness. Sometimes we just need someone to point out the good things to us so we can remember to see them. Focus on activities that help you to feel better It often helps to change activities and usual routines. Focus on learning to cope with sadness, anger, and anxiety Focus on thoughts and activities that are not upsetting to you. When you wake up, what things would you notice different about your life that would let you know that this miracle has happened? For example, if the miracle happened, someone might say that they would make an appointment to get their hair cut. Make a list of things you might notice that were different about your life if a miracle happened and all your troubles and depression disappeared. For example, if one of the things you would do if you didnt feel depressed is go for a walk, make an effort to schedule a walk tomorrow. If your list included dressing up and meeting a friend for lunch, try to schedule that.

The mechanism for the predisposition of certain people to develop cirrhosis is still unknown order 5 mg olanzapine fast delivery. The amount of alcohol ingested has been shown in epidemiological studies to be the most important factor in determining the development of cirrhosis cheap olanzapine 2.5 mg otc. Males drinking in excess of 60 gm and females in excess of 40 gm of alcohol per day for 10 years are at a high risk of developing cirrhosis order olanzapine 2.5mg online. The alcohol content rather than the type of beverage is important and binge drinking is less injurious to the liver than continued daily drinking. They are likely to develop cirrhosis at an earlier age, present at a later stage and have more severe liver disease with more complications. Social factors such as the availability of alcohol and social acceptance of alcohol use can also encourage the liberal use of alcohol, thereby increasing the risk for the development of alcoholic liver disease in susceptible individuals 2. Alcohol Metabolism Alcohol is metabolized to acetaldehyde by alcohol dehydrogenase in the hepatocyte cytosol, and then to acetate by acetaldehyde dehydrogenase in the mitochondria. Some studies have reported an increased frequency of the gene that encodes for alcohol dehydrogenase in patients with alcoholic liver disease, leading to increased production of acetaldehyde. Alcoholics with decreased acetaldehyde dehydrogenase activity also develop alcoholic liver disease at a lower cumulative intake of alcohol than others. Alcohol has a direct hepatotoxic effect and does not require pre-existing malnutrition, but malnutrition may play a permissive role in producing alcohol hepatotoxicity. There is a threshold of alcohol toxicity beyond which no dietary supplements can offer protection. Obesity may also be an independent risk factor for the development of alcoholic liver disease. Finally, viral hepatitis, whether hepatitis B or hepatitis C infection, appears to play a role in the development of advanced alcoholic liver disease. Patients with alcoholic liver disease and viral hepatitis infection tend to develop their disease at a younger age, have more severe histological features and decreased survival. In addition, the presence of viral hepatitis is a major risk factor for the development of hepatocellular carcinoma in patients with alcoholic cirrhosis. Schematic representation of the progression of the different stages of alcoholic liver disease 3. Alcoholic Fatty Liver This is the most frequent hepatic abnormality found in alcoholics. It is a toxic manifestation of alcohol ingestion, appearing within three to seven days of excess alcohol intake. This results in the accumulation of triglyceride in the hepatocytes, mainly in the terminal hepatic venular zone. The fat may be macrovesicular (large droplets) or microvesicular (small droplets), which represents more active lipid synthesis by the hepatocytes. Fatty liver may occur alone or be part of the picture of alcoholic hepatitis or cirrhosis. Clinically, the patient is usually asymptomatic and examination reveals firm smooth hepatomegaly. Occasionally the fatty liver may be so severe that the patient is anorexic, nauseated and has right upper quadrant pain or discomfort. Attribution of fatty liver to alcohol use therefore requires a detailed and accurate patient history. In the case that the fatty liver is related to excess alcohol intake, this usually follows a prolonged heavy alcoholic binge. In the absence of a super-imposed hepatic process, stigmata of chronic liver disease such as spider angiomas, First Principles of Gastroenterology and Hepatology A. Liver biopsy is required to make a definitive diagnosis and to exclude the presence of steatohepatitis. When fatty liver is not associated with alcoholic hepatitis, the prognosis is excellent. Complete abstinence from alcohol and a nutritious diet will lead to disappearance of the fat over four to six weeks. Alcoholic Hepatitis Alcoholic hepatitis may occur separately or in combination with cirrhosis. This oxidative stress promotes hepatocyte necrosis and apoptosis, which is exaggerated in the alcoholic individual who is deficient in antioxidants such as glutathione and vitamin E. Free radicals then initiate lipid peroxidation, which causes inflammation and fibrosis. Inflammation is also incited by acetaldehyde that, when bound covalently to cellular proteins, forms adducts that are antigenic.

This increase has been o European Surveillance of antimicrobial Consumption driven by factors such as economic growth and increased access Network to antibiotics olanzapine 20 mg low cost. Percentage change in antibiotic consumption per capita 2000-2010 Center for Disease Dynamics buy cheap olanzapine 20 mg on-line, Economics & Policy buy olanzapine 2.5mg low cost. Penicillins and cephalosporins account for around 60% of total global antibiotic consumption. Between 2000-2010 their usage Interactive Map on antibiotic consumption at a increased by around 40% as did carbapenems, a reserve group country and global level. Prevalence of use Prevalence of antibiotic use in the community varies between countries from less than 20% to over 40% of the population dispensed at least one antibiotic each year. Prescribers In Europe, Australia and Canada general practitioners prescribe the majority of antibiotics in the community, dentists account for 3 -10% and nurses and other health professionals < 6%. Whilst penicillins are the most frequently used antibiotics with 30 Use in the community is highest in the very young (0-9 years) to 60% of use, the pattern of use of other antibiotic groups varies and the elderly (65+ years). For example, cephalosporins Common indications for use in the community and other beta lactams (including carbapenems) account for In developed countries, the majority of the use of antibiotics in 0. In 2015 the consumption of systemic antibiotics in European acute hospitals ranged from 1. For example, in the community or unnecessary use where an antimicrobial is not indicated outpatient setting: and there is no health beneft for the patient (e. Best practice is < 5% Antibiotic Use in the United States, 2017: Progress In low income countries antibiotics are often prescribed and Opportunities after surgical procedures, using 7 times more antibiotics. In Diagnostic uncertainty and fear of poor clinical outcomes much of the world antibiotics are sold without prescription. Non- - leading to increased use of broad spectrum agents or prescription use: unnecessary prescription of antibiotics e. Med 2003;57:733-44 psychosocial determinants such as attitudes, beliefs and social norms. In hospitals there is a culture and etiquette around prescribing set by senior medical staf that is rooted in the autonomy of decision making and a culture of medical hierarchy. Health professionals are often reluctant to question prescribing decisions of colleagues and in some sectors, such as private hospitals, senior prescribers have complete autonomy in deciding what antibiotic to use, how much to use and for how long. Cultural factors, (patient, practitioner and organisational) may also contribute to the 2 to 3 times variation in prescribing within countries and across institutions. The local drivers of antibiotic use need to be assessed as part of any local eforts to improve antibiotic use. Improving antibiotic use in low-income countries:An overview of evidence on determinants. Consumption of antibiotics and occurrence of income countries: An overview of evidence on determinants. Canadian Antimicrobial Resistance Surveillance System Report 2016 Center for Diseases Control. National Centre for Antimicrobial Stewardship and Australian Commission on Safety and Quality in Health Care. Antimicrobial prescribing and infections in Australian residential aged care facilities; Results of the 2015 aged care National Antimicrobial Prescribing Survey pilot. Discuss possible unintended consequences of In this YouTube video animation you will: antimicrobial stewardship. After 48 hours, she started to feel tired and was not able to go to work that day. Four days later she started to have watery diarrhoea and abdominal pain and thought that she had a stomach virus from one of the kids in school. Within 6 days she was admitted to the hospital in septic shock where she was diagnosed with severe Clostridium difcile colitis complicated with a toxic megacolon requiring total colectomy. She consequently developed short gut syndrome dependent on total parenteral nutrition. All cultures from blood an abdomen grew In chapter 1 you learnt about the overall clinical, microbial Klebsiella pneumoniae: and economic impact of infections with drug resistant bacteria. Antibiotic resistance not only happens in acute hospitalised patients but can start in the community. In this case, an antibiotic prescribed in the outpatient setting by a dentist lead to signifcant complications and possible mortality. Perhaps you will be the next healthcare provider caring for a patient with a multidrug resistant infection or, worse (depending on ones perspective), you yourself could contract a multidrug resistant organism for which there is no efective antimicrobial therapy available. Unfortunately, this is not science fction, or a new unknown infection from an exotic land. We use this terms as resistance to bacteria is common and the focus of this chapter. These amazing drugs have revolutionised how we care for patients in the 21st century. We are able to care for premature babies, critically ill patients with sepsis, transplant solid organs and provide chemotherapy to patients with cancer among other miracles. Unfortunately, the appropriate and inappropriate use of these drugs has consequences.