James L. Whiteside, MD
If the green juice of bitter luffa is not available quit smoking keep coughing buy cheap nicotinell on-line, it can best be substituted by two or three drops of the fluid obtained by soaking its dry crusts overnight in water quit smoking quit now order 17.5mg nicotinell visa. Seeds of bitter luffa which are easily available can also be used for the same purpose after rubbing in water quit smoking natural remedies generic nicotinell 52.5 mg otc. It induces a healthy appetite and proper evacuation of bowels quit smoking 45 days purchase genuine nicotinell on-line, and this results in gradual decrease of the trouble. Water Treatment Drinking a lot of water with lemon juice will protect the damaged liver cells. A hot immersion bath at 104 o F for 10 minutes daily will be helpful in relieving the itching which sometimes accompanies jaundice and in the elimination of the bile pigment from the system through the skin and kidneys. Certain asanas such as uthanpadasana, bhujangasana, viparitkarani and shavasana, and anuloma-viloma, pranayama will be helpful in the treatment of jaundice. The jaundice patient can overcome the condition quite easily and build up his sickliver until it again functions normally with the above regime. With reasonable care in the diet and life style, and regular, moderate exercise and frequent exposure to sunshine and fresh air, a recurrence of liver trouble can be prevented. The s to nes are formed from the chemicals usually found in the urine such as uric acid, phosphorous, calcium and oxalic acid. S to nes may form and grow because the concentration of a particular substance in a urine exceeds its solubility. This disorder occurs more frequently in middle age, with men being afflicted more often than women. The kidneys are two bean-shaped organs, lying below the waist on either side of the spinal column on the back wall of the abdomen. They are filtering plants for purifying the blood, removing water and salts from it which are passed in to the bladder as urine. Symp to ms Kidney s to nes usually cause severe pain in their attempt to pass down the ureter on their way to the bladder. Other symp to ms of kidney s to nes are a desire to urinate frequently, painful urination, scanty urination, nausea, vomiting, sweating, chills and shocks. Sometimes, large s to nes may remain in the kidneys without causing any trouble and these are known as silent s to nes. Causes the formation of s to nes in the kidneys is the result of defects in the general metabolism. They usually occur when the urine becomes highly concentrated due to heavy perspiration or insufficient intake of fluids. The other causes are wrong diet, excess intake of acid-forming foods, white flour and sugar products, meat, tea, coffee, condiments and spices, rich foods and overeating. Lack of vitamin A and an excessive intake of vitamin B may also lead to formation of s to nes. Types of S to nes Chemically, urinary s to nes are of two categories, namely, primary s to nes and secondary s to nes. Primary s to nes are ordinarily not due to infection and are formed in acidic urine. They usually result from alcoholism, sedentary life, constipation and excessive intake of nitrogeneous or purine-rich foods. Most kidney s to nes are composed either of calcium oxalate or phosphate, the latter being most common in the presence of infection. More than half of these are mixtures of calcium, ammonia, and magnesium, phosphates and carbonates, while the remainder contain oxalate. Uric acid and cystine s to nes represent about four percent and one per cent respectively of the to tal incidence of s to nes. Treatment A majority of patients suffering from kidney s to nes can be treated successfully by proper dietary regulations. The patient should avoid foods which irritate the kidneys, to control acidity or alkalinity of the urine and to ensure adequate intake of fluids to prevent the urine from becoming concentrated. The foods considered irritants to the kidneys are alcoholic beverages, condiments, pickles, certain vegetables like cucumbers, raddishes, to ma to es, spinach, rhubarb, water-cress and those with strong aroma such as asparagus, onions, beans,cabbage and cauliflower, meat, gravies and carbonated waters. An abnormally high intake of milk, alkalies or vitamin D may also result in the formation of calcium phosphate s to nes. For controlling the formation of calcium phosphate s to nes, a moderately low calcium and phosphorous diet should be taken the intake of calcium and phosphates should be restricted to minimal levels consistent with maintaining nutritional adequacy. In this diet, milk should constitute the main source of calcium and curd or cottage cheese, lentils and groundnuts should form the main sources of phosphorous. Foods which should be avoided are whole wheat flour, Bengal gram, peas, soyabeans, beets, spinach, cauliflower, turnips, carrots, almonds and coconuts. When s to nes are composed of calcium and magnesium phosphates and carbonates, the diet should be so regulated as to maintain acidic urine. Insuch a diet, only half a litre of milk, two servings of fruits and two servings of vegetables (200 grams) should be taken. The vegetables may consist of asparagus, fresh green peas, squash,pumpkins, turnips, cauliflower, cabbage and to ma to es. For fruits, watermelon, grapes, peaches, pears, pineapple, papayas and guavas may be taken. On the other hand the urine should be kept alkaline if oxalate and uric acid s to nes are being formed. In this diet, fruits and vegetables should be liberally used and acid-forming foods should be kept to the minimum necessary for satisfac to ry nutrition. When the s to nes contain oxalate, foods with high oxalic acid content should be avoided. These foods include almonds, beetroots, brinjal, brown bread, cabbage, cherry, chocolate, French Beans, pota to es, radish, spinach and soyabeans. Uric s to nes occur in patients who have an increased uric acid in the blood and increased uric acid exertion in the urine. Since uric acid is an end product of purine metabolism, foods with a high purine content such as sweet bread, liver and kidney should be avoided. Kidney beans, also known as French beans or common beans, are regarded as a very effective remedy for kidney problems, including kidney s to nes. Ramm of Germany, who first discovered the value of kidney beans as a medicine for kidney and bladder troubles. The method prescribed by him to prepare the medicine is to remove the beans inside the pods, then slice the pods and put about 60 mg. This liquid should be strained through fine muslin and then allowed to cool for about eight hours. Thereafter, the fluid should be poured through another piece of muslin without stirring. Ramm, a glassful of this decoction should be given to the patient every two hours through the day for one day, and thereafter it may be taken several times a week. The pods can be kept for longer periods but once they are boiled, the therapeutic fac to r disappears after one day. The basil, known as tulsi inthe vernacular, has a strengthening effect on the kidneys. It has been found that the s to nes can be expelled from the urinary tract with this treatment. The celery is also a valuable food for those who are prone to s to ne formation in the kidneys or the gall bladder. Research has shown the remarkable therapeutic success of vitamin B6 or pyridoxine in the treatment of kidney s to nes. This treatment has to be continued for several months for obtaining a permanent cure. The patient should take a low protein diet, restricting protein to one gram per kg. The patient should be given a large hot enema, followed by a hot bath with a temperature of 100 o F, gradually increased to 112 o F. Hot fomentation applied across the back in the region of the kidneys will relieve the pain. Certain yogasanas such as pavan-muktasana, uttanpadasana, bhujangasana, dhanursana and halasana are also highly beneficial as they stimulate the kidneys.
Infant Pertussis Study Group: Transmission of Bordetella pertussis to young infants quit smoking encouragement buy 52.5mg nicotinell mastercard. Fatal case of unsuspected pertussis diagnosed from a blood culture: Minnesota quit smoking natural remedies order 17.5mg nicotinell with amex, 2003 quit smoking pill 35 mg nicotinell otc. Paper presented at World Health Organ Tech Rep SerAnnex 2: Requirements for Diphtheria quit smoking zap order nicotinell 17.5mg online, Tetanus, Pertussis, and Combined Vaccines or at this specific link. Placebo-controlled trial of two acellular pertussis vaccines in Sweden: protective efficacy and adverse events. Pertussis Assay Working Group: Development and analytical validation of an immunoassay for quantifying serum anti-pertussis to xin antibodies resulting from Bordetella pertussis infection. Centers for Disease Control and Prevention: International Bordetella pertussis assay standardization and harmonization meeting report. Centers for Disease Control and Prevention: Hypertrophic pyloric stenosis in infants following pertussis prophylaxis with erythromycin: Knoxville, Tennessee, 1999. Centers for Disease Control and Prevention: Erythromycin-resistant Bordetella pertussis: Yuma County, Arizona, May-Oc to ber, 1994. Hospital Epidemiology and Infection Control, Baltimore: Williams & Wilkins; 1996:725-730. School-associated pertussis outbreak: Yavapai County, Arizona, September 2002 February 2003. Centers for Disease Control and Prevention: Use of Mass Tdap vaccination to control an outbreak of pertussis in a high school: Cook County, Illinois, September 2006-January 2007. Centers for Disease Control and Prevention: National, state, and local area vaccination coverage among adolescents aged 13-17 years: United States, 2009. Pertussis antibodies in pregnant women: protective, agglutinating and complement fixing antibodies before and after vaccination. Vaccination against whooping-cough; relation between protection in children and results of labora to ry tests; a report to the Whooping-cough Immunization Committee of the Medical Research Council and to the medical officers of health for Cardiff, Leeds, Ley to n, Manchester, Middlesex, Oxford, Poole, Tottenham, Walthams to w, and Wembley. Vaccination against whooping-cough; the final report to the Whooping-Cough Immunization Committee of the Medical Research Council and to the medical officers of health for Battersea and Wandsworth, Bradford, Liverpool, and Newcastle. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures. Calgary (Alberta), Canada; DecemberAbstracts of the Third Canadian National Conference on Immunization, 1988. Vaccine Safety Datalink Team: Lack of association between acellular pertussis vaccine and seizures in early childhood. Hong Kong; JuneAbstracts of the 7th International Congress for Infectious Diseases, 1996. Centers for Disease Control and Prevention: Tetanus and pertussis vaccination coverage among adults aged fi 18 years: United States, 1999 and 2008. Population and Public Health Branch, Centre for Infectious Disease Prevention and Control: Canada Immunization Guide. Poliomyelitis Vaccine Evaluation Center: Evaluation of 1954 field trials of poliomyelitis vaccine. Poliomyelitis Vaccine Evaluation Center: Evaluation of 1954 field trials of poliomyelitis vaccine, I: plan of study. The supply landscape and economics of ipv-containing combination vaccines: key findings, 2010. Analysis of virologically confirmed cases of paralytic and nonparalytic poliomyelitis. Poliomyelitis following formaldehyde-inactivated poliovirus vaccination in the United states during the spring of 1955. Poliomyelitis following formaldehyde-inactivated poliovirus vaccination in the United States during the Spring of 1955. Prevention of poliomyelitis: recommendations for use of only inactivated poliovirus vaccine for routine immunization. Introduction of inactivated poliovirus vaccine in to oral poliovirus vaccine-using countries. Centers for Disease Control: Polysaccharide vaccine for prevention of Haemophilus influenzae type b disease. C, et al: Comparison of multiple immunization schedules for Haemophilus influenzae type b-conjugate and tetanus to xoid vaccines following bone marrow transplantation. Centers for Disease Control and Prevention: Recommended Immunization Schedules for Persons Aged 0 Through 18 Years, United States, 2010. Haemophilus influenzae Type b (Hib): conclusions and recommendations from the Immunization Strategic Advisory Group. Viral Hepatitis: Labora to ry and Clinical Science, New York: Marcel Dekker; 1983:3-32. Viral Hepatitis and Liver Disease: Proceedings of the 1990 International Symposium on Viral Hepatitis and Liver Disease: Contemporary Issues and Future Prospects, Baltimore: Williams & Wilkins; 1991:532-535. International Agency for Research on Cancer: Cancer occurrence in developing countries. Viral Hepatitis and Liver Disease, London: International Medical Press; 2002:219-227. Committee on International Relations, House of Representatives: Making safe blood available in Africa. Centers for Disease Control and Prevention: Public Health Service inter-agency guidelines for screening donors of blood, plasma, organs, tissues, and semen for evidence. Centers for Disease Control and Prevention: Outbreaks of hepatitis B virus infection among hemodialysis patients: California, Nebraska, and Texas. Centers for Disease Control and Prevention: Prevention and control of infections with hepatitis viruses in correctional settings. Expanded Programme on Immunization: Introduction of hepatitis B vaccine in to childhood immunization services: management guidelines, including information for health workers and parents. Centers for Disease Control and Prevention: Thimerosal in vaccines: a joint statement of the American Academy of Pediatrics and the Public Health Service. Centers for Disease Control and Prevention: Implementation of newborn hepatitis B vaccination: worldwide, 2006. Hepatitis B Vaccines in Clinical Practice, New York: Marcel Dekker; 1993:209 228. World Health Organization: Informal consultation on quadrivalent diphtheria-tetanus pertussis-hepatitis B vaccine. Viral Hepatitis and Liver Disease: Proceedings of the 1990 International Symposium on Viral Hepatitis and Liver Disease: Contemporary Issues and Future Prospects, Baltimore: Williams & Wilkins; 1991:776-778. Viral Hepatitis and Liver Disease: Proceedings of the International Symposium on Viral Hepatitis and Liver Disease, London, May 1987, New York: Alan R. European Consensus Group on Hepatitis B Immunity: Are booster immunisations needed for lifelong hepatitis B immunityfi. World Health Organization: Global Advisory Committee on Vaccine Safety: hepatitis B. Institute of Medicine: Immunization safety review: hepatitis B vaccine and demyelinating neurological disorders. International Travel and Health, Geneva: World Health Organization; 2009:106 107. Centers for Disease Control and Prevention: Global disease elimination and eradication as public health strategies. Buy nicotinell 52.5mg cheap. Explained! Temperature Control vs Wattage mode.
The response to volume expansion is moni to red by the same signs and symp to ms that are used to diagnose it quit smoking injection cheap 35 mg nicotinell with amex. Here quit smoking 2 12 years best buy for nicotinell, the patients respond rapidly to the fluids and remain haemodynamically stable once the fluids are s to pped or slowed quit smoking exercise buy nicotinell with a mastercard. These patients have usually lost minimal blood volume (20%) and Trauma quit smoking 4 weeks pregnant buy generic nicotinell 35mg line, Shock, Head Injuries and Burns 59 can be observed but do not necessarily need any further intravenous fluids. There is an initial response with a rise in the blood pressure and a fall in the pulse rate; however, as the fluids are slowed down, the indices used to measure shock start to deteriorate again, indicating that the blood loss is ongoing or resuscitation has been inad equate. The response to the fluid will indicate those patients who are still slowly bleeding (as may other clinical findings). As a last resort, Group O negative blood can be given, which is the universal donor. If blood is given (usually packed red cells without plasma) it should be warmed to prevent hypothermia and, after a large transfusion, platelets and fresh frozen plasma may be needed to correct the lack of clotting fac to rs. The main aim of transfusion is to correct the oxygen-carrying capacity, since crystalloids and colloids can both correct the lack of intravascular volume but have no oxygen-carrying capacity. The majority of head injuries fall somewhere between these two extremes, and the difficulty for the doc to r is in deciding who needs to be admitted for observation and who can be sent home. It is possible to have one without severe brain injury, and likewise, you can have an intracranial injury without accom panying skull fracture, especially in children, whose bones and joints are more supple. The only significance of X-raying head injury patients and looking for a skull fracture is that such patients have a statistically higher probability of developing a bleed in to the brain, and hence they get admit ted for observation. The fragment may need to be elevated if depressed more than the thickness of the skull or if there are focal signs. A broad-spectrum antibiotic should be started, the patient taken to theatre for wound debridement and the fracture dealt with. This fracture cannot usually be seen on a plain X-ray of the skull, although it should be suspected if there are fluid levels in the sphenoidal sinuses. The badger sign (bruising around both orbits), to gether with rhinorrhoea, is associated with a fracture of the cribri form plate. Brain Injury Injuries to the brain can be primary, occurring at the time of impact, or secondary to hypovolaemia, hypoxia, hypo-glycaemia and raised intracra nial pressure. Prevention of primary brain injury can only be brought about by measures to s to p the accident happening in the first place, such as having road speed limits and the wearing of mo to rcycle helmets, etc. The main aim in the management of a head injury is, therefore, to prevent or limit the damage that occurs due to secondary injury. The changes are reversible and are often resolved by the time the patient arrives in hospital. They may have just been confused or dazed at the scene or may have lost consciousness. Afterwards they may complain of a headache, feel dizzy, be amnesic or nauseous, and generally if the patient has been unconscious for more than 5 min it is probably best to admit them to hospital for observation. This is a more severe injury, with microscopic structural damage throughout the brain tissue. Such patients can develop au to nomic dysfunction and hence have high fevers, hyperten sion and sweating. They can be coup injuries, where the brain is damaged directly by the skull at the point of impact, or contre coup injuries, where the brain is squashed by the skull at a remote point from the impact. The patient may have a focal neurological deficit, depending on the site of the contusion. The patient is usually managed conservatively; however, due to the risk of delayed bleeding in to the contusion, careful observation is needed to observe for deterioration (especially in alcoholics). This type of bleed is quite rare, accounting for less than 1% of coma-producing head injuries; however, it can be rapidly fatal. The typical picture is loss of consciousness (concussion), fol lowed by a lucid interval. The fixed dilated pupil on the Trauma, Shock, Head Injuries and Burns 65 affected side is usually accompanied by a hemiparesis on the oppo site side (remember the corticospinal fibres cross over). Neurosurgical advice should be sought and the patient transferred if necessary for surgical evacuation of the clot. This is much more common than an extradural haemorrhage, and occurs in about 30% of severe head injuries. It is usually due to rupture of a bridging vein between the cerebral cortex and the dura (but it can also be due to laceration of the cerebral cortex), and is often caused by a rotational injury. The elderly are more susceptible, as their brains are often shrunken and hence the bridging veins are put under tension. The bleeding is typ ically less brisk than an extradural haemorrhage, but clinically it can present with symp to ms of an expanding mass as above. This can be associated with trauma, although it is usually due to hypertension and bleeding from berry aneurysms. These injuries are therefore similar to strokes, and surgery cannot help the patient. Assessment of Severe Head Injuries As the patient is brought in to casualty you should attempt to get some his to ry, finding out as much as possible about the incident. If they are uncon scious, the his to ry is taken from witnesses or the ambulance crew, etc. It is divided in to three parts: assessing the best mo to r response, the best eye-opening response and the best verbal response. Remember that although bleed ing from a scalp wound can cause shock, bleeding in to the skull cannot, and therefore never assume that hypotension is due to an intracranial bleed or to brain injury (as this is a terminal event on failure of the medullary centres). The Cushing response is a combination of progressive hypertension, bradycardia and a decreased respira to ry rate (the opposite of hypovolaemic shock). Hypertension alone or with hyperthermia suggests central au to nomic dysfunction caused by diffuse brain injury. If the airway, breathing and circulation are under control, then the minineurological examination can be performed in the primary survey; otherwise it is performed in the secondary survey. The purpose of this is to detect those with a severe head injury who are likely to need surgery. If the haemoglobin is low, a transfusion may be required to improve the oxygen-carrying capacity. Raised Intracranial Pressure this may be due to a mass lesion or brain oedema and should be treated. To do this it is usually necessary to intubate and ventilate the patient and so early involvement of an anaesthetist is essen tial. Intravenous fluids may be needed in the management of other prob lems, such as shock, and the risk is that overhydration may make cerebral oedema worse. Diuretics such as manni to l are often used to reduce intracranial pres sure and are given if a mass lesion is suspected whilst awaiting transfer to a neurosurgical unit, although a neurosurgical consultation should be obtained prior to giving any diuretics (if diuretics are used, a urinary catheter is required to aid fluid balance measurement). Management of Mild to Moderate Head Injuries the problem for a casualty officer when he sees what appears to be a minor head injury is in deciding who needs admitting for observation.
Treatment involves adequate resuscitation of the patient prior to proceeding to theatre for laparo to my quit smoking humor order nicotinell 17.5 mg with mastercard. With a simple duodenal perforation peri to neal washout and simple closure of the deficit quit smoking your worth it purchase nicotinell 35 mg without a prescription, with a re-enforcing omental patch quit smoking brochures buy generic nicotinell online, is the treatment of choice quit smoking journals nicotinell 17.5mg lowest price. In the case of gastric ulcer perforation it is advisable to excise the ulcer with a small ellipse of s to mach and then repair of the defect. The specimen should then be sent for his to logical assessment to exclude malignancy: up to one-third of perforated gastric ulcers are malignant. The male to female ratio is 4:1 with an increased preponderance in the first-born male. There is an increased prevalence in Caucasian populations and it is three times more likely if the child has a positive maternal his to ry. The most common pres entation is of vomiting between 3 and 10 weeks postdelivery, which may become projectile in nature. Visible gastric peristaltic waves may be seen going from left to right across the upper abdomen. Following appropriate resuscitation, a Ramstedt pyloromyo to my is performed, which involves dividing the muscle fibres of the pylorus down to the mucosa, which is left intact. It is found in approximately 2% of the population and occurs approximately 2 ft prox imal to the iliocaecal valve on the antimesenteric border (the border not attached to the mesentery) of the ileum. Sometimes it extends as far as the back of the umbilicus on the ante rior abdominal wall, and occasionally it may even present as mucosa protruding at the umbilicus when there is a so-called vitello intestinal fis tula. Benign tumours may be either found incidentally or present with bleeding or intussusception. Carcinoid tumours are of low-grade malignancy and are believed to arise from neu roec to dermal cells embryologically. The commonest site for these is the appendix, but they can occur anywhere throughout the gastrointestinal tract and are also found in the lung (bronchial carcinoids). Normally these hormones are broken down by the liver in the first-pass metabolism from the gut and so no symp to ms occur. However, in the presence of metastases there is no first-pass metabolism and the patient may suffer from carcinoid syndrome which consists of flushing, bronchospasm and diarrhoea. The invaginated portion (the intussusceptum) can then be further propelled down the lumen for a variable distance (Figure 7. So-called redcurrant jelly s to ols may be passed (which consist of mucus and blood). Abdominal examination may reveal a mass and occasionally the apex of the intussusception may protrude from the anus or be felt on rectal examination. Sometimes the intussusception can be reduced by a barium enema (so-called hydrostatic reduc to n), and if this is unsuccess ful, surgical correction is required. If possible the intussusception is sim ply reduced and recurrence is then uncommon. If it cannot be reduced or if it is nonviable, then the affected segment needs to be resected. If intussusception occurs in an adult (which is rare), then a tumour (benign or malignant) acting as the apex of the intussusception should be considered. Most cases are thought to be caused by obstruction of the appendix with subsequent infection behind the obstruction. This concept of an obstructed system getting infected is also relevant to conditions such as cholangitis (infection of an obstructed biliary tree) and pylonephrosis (infection of an obstructed renal tract). In appendicitis the most common cause of obstruction of the appendix is either a faecolith (a piece of faeces within the appendix) or hypertrophy of lymphoid tissue within the wall of the appendix, presumably in response to an otherwise minor viral infection. Rare causes of obstruction of the appendix and, therefore, appendicitis include carcinoma of the caecum and carcinoid tumour. Small Intestine and Colon 131 To understand the way in which appendicitis presents clinically, one should realise that in its early stages the inflammation of the appendix is confined to the wall of the appendix itself and is therefore felt as a poorly localised visceral pain in the central abdominal (originates in embryolog ical midgut). Because the essential feature is of an obstructed appendix, the pain will usually be colicky due to peristalsis in the appendicular mus cle. As the inflamma to ry process progresses, the surrounding tissues and parietal peri to neum become inflamed and the pain is then felt locally in the right iliac fossa and is constant and typical of a localised peri to nitis, worse on movement, etc. The typical patient will therefore present with an initial central colicky abdominal pain, which after a few hours progresses in to a constant right iliac fossa pain (the pain moves; it does not radiate). By this time the patient will usually have a mild fever, be anorexic and may have nausea and vomiting. On examination there will be localised right iliac fossa tenderness and guarding with rebound tenderness or per cussion tenderness. The diagnosis is essentially a clinical one and in straightforward cases no investigations at all are required. It would be very reasonable of an examiner to ask simple questions about the opera tion, as it is the most common one performed as an emergency. In practice, many surgeons make a slightly lower incision, which is cos metically more acceptable. An incision is then made down through skin and subcutaneous tissues until the muscle layers are reached. The external oblique, internal oblique and transverse abdominus muscles are then opened. This is done by a muscle-splitting incision along the lines of the fibres with no fibres actually being cut. The final layer is the peri to neum, which is opened so that the abdominal cavity can be entered. There seems to be a mis conception among many medical students that the retrocaecal appendix is 132 Surgical Talk: Revision in Surgery unusual. After delivery of the appendix the blood vessels and mesentery of the appendix are divided and the appendix is ligated and removed at its base. Many surgeons then bury the stump of the appendix with a purse-string suture around the caecum. The operation should be covered with prophylactic antibiotics, usually Metronidazole, given intravenously at induction of the anaesthetic. Another misconception that many students (and indeed doc to rs) have relates to the presence of tenderness on rectal examination. |
