By M. Avogadro. La Salle University. 2018.
This uncertainty may range from a nagging question about a health problem to an acute emergency like a heart attack or stroke order 100mcg rhinocort otc. The physician conducts an examination generic rhinocort 100mcg without a prescription, asks questions about the problem discount rhinocort 100mcg on line, then (usually) takes some action to manage the uncertainty and charges a fee for the service. For command of a vital knowledge base, American physicians have been able to charge several hundred billion dollars a year in what economists call “rent. By contrast, the resources on which consumers drew to frame their encounter with the physician were not terribly rich. What one could learn from one’s family, friends, neighbors, schools, cul- ture, and the popular press (for decades, Reader’s Digest has been a widely read resource for consumer health information) essentially exhausted the available sources of medical knowledge. As late as The Consumer 97 1998, women were more likely to get their medical information from media sources such as television, newspapers, and magazines than from physicians. Because it is difﬁcult or impossible to reach most physicians by telephone or e-mail, most people must make an ap- pointment to communicate with their physician. The gap between wanting medical knowledge and actually seeing the physician may range from days to weeks. For reasons explored in Chapter 4, this time lag could increase rather than diminish in the next decade as physicians of all specialties become increasingly scarce and difﬁcult to see. To see the physician, the consumer must take time off work, as physicians typically see patients during working hours. If the problem is with a child, the parent must take time off work and take the child out of school to meet the appointment. The time taken off work or out of school is a signiﬁcant cost to the patient or family member, as well as to employers, that is not entered into account in the national health expenditures. If the physician practices in an urban or suburban setting, the consumer then may get stuck in trafﬁc and may need to allow time for parking. Then they wait, often for minutes, but sometimes for hours, in the physician’s ofﬁce. Depending in major part on the consumer’s educational level, the actual question that brought him or her to the physician in the ﬁrst place may or may not get asked; if asked, the answer may or may not be understood. In a 1997 New York Times consumer survey, 51 percent of women left the physician’s ofﬁce with unanswered questions. For women with less than a high school degree, fully 65 98 Digital Medicine percent left the ofﬁce with unanswered questions. Some 56 percent felt that physicians talked down to them some or most of the time. In a couple of weeks, a bill arrives, which is frequently incorrect, requiring further interaction with the physician’s ofﬁce or the health plan. Shortly before he died of cancer, Avedis Donebedian, an eminent academic physician who pioneered the study of quality of healthcare, commented on his care experience at a large, distinguished academic health center:. Often, I couldn’t tell whether I was dealing with a nurse, a technician, an attending physician or an attendant. He went on to say, “The idea that patients should be involved in their care is not really practiced in a responsible way. Today people talk about patient autonomy, but it often gets translated into patient abandonment. Donald Berwick, compared the breakdown in teamwork (and the consequent shifting of the crushing responsibility for ensuring continuity of care to family members) to the Norman MacLean The Consumer 99 story, “Young Men and Fire. According to MacLean, the young smoke jumpers died because they could not function as a team under the pressure of a sudden cataclysmic ﬁrestorm. In Berwick’s narrative, his wife, who suffered from a mysteri- ous and potentially lethal spinal cord infection, was exposed to repeated mortal risk in the care process because crucial informa- tion on her health was not available to the clinical team taking care of her and because of continuous shifting of responsibility for making lifesaving care decisions. Berwick’s repeated intervention was needed to provide the continuity and common sense the care system lacked,8 despite the hospital’s state-of-the-art, computerized electronic patient record system. The not-surprising result of these problems is that consumer satisfaction with the health system experience is on a downward trend, as it is for notoriously customer-unfriendly sectors such as the airlines and insurance. The reality is that the logistics of medical care do not work for many American consumers, whether they simply need information about their health or require lifesaving care. The failure to manage the complexity of medicine and to care for people in a thoughtful and compassionate way has contributed to an emerging consumer revolt against medical institutions. The “shot heard round the world” in women’s health was ﬁred in 1970, when the Women’s Health Book Collective of Boston published a “user’s manual” for a woman’s body entitled Our Bodies, Ourselves. Since its initial publication, it has been trans- lated into 20 languages and has sold more than 4. In strident and conﬁdent tones, Our Bodies urges women to take responsibility for their own health and to confront what was then (but is no longer) a largely male cadre of obstetricians/gynecologists and other physicians in determining how medical care is deﬁned and delivered. This was at a time when only 7 percent of practic- ing obstetricians/gynecologists in the United States were women, according to the American Medical Association. It encouraged women to reject the surgical trappings of hospital-based childbirth in favor of a more natural ap- proach. Many older, male obstetricians bridled at the large numbers of demanding “new women” who came to their appointment with typed lists of exactly how they wanted their care (and their babies! In a major feat of twentieth century engineering, the Internet reversed the centuries-old ﬂow of health information.
There are some concerns that personalisation of medicine is going to be too expensive order 100 mcg rhinocort mastercard. On the other hand generic 100 mcg rhinocort free shipping, personalisation of medicine represents trying to get the best possible results for the individual patient 100 mcg rhinocort otc, and the issue of cost is something that comes after. The main reason for the slow progress is the lack of mature scientifc insights through which we have something to offer. In order to test a treatment in 100 patients we sometimes need dozens of centres, with one or two patients per centre. We really have to strengthen and reinforce in the future all the collaborative ways to work, without any – or minimal, at least – competitive ways of thinking. We have to work together to make the science evolve and forget about the national or regional representation of research that we have had in the past. The real advantages of personalised medicine are, of course, that we will be able to provide a given patient with a much higher level of care, a much higher level of therapeutic effcacy than we can attain now. There will also probably be other ways of monitoring patients, of maybe having repeat samples taken for doing molecular diagnosis; otherwise we cannot personalise the treatment. These are the two aspects that we will have to work on in the next few years to implement personalised medicine in clinical practice. For patients to beneft from these targeted therapies, a tumour sample must be sent for analysis, and this biomarker analysis can take one week or longer. The survey concluded that the majority of patients (74%) would be ready to delay treatment for this period to undergo additional tumour testing, in the hope that they may beneft from personalised therapy. The same survey found that the majority of patients would allow hospitals to retain their tumour samples for future research. This is a major topic, because patients must be aware that nowadays several new examinations can be performed on their tissues and tumour samples, but that these examinations can delay their treatment. Patients must be aware that the examinations are performed mainly on their biospecimens. Biospecimens are materials taken from the human body, such as tissue, blood, urine or saliva, which can be used in directing patient care or be processed and stored for future medical research. In the majority of cases these tissues are the same as used for the diagnosis of cancer. Therefore patients do not undergo any additional steps, other than to consent to the use of their biospecimens for the examination. In recent years an awareness has grown that the characteristics of tumours may change and patients may be asked to submit to a new biopsy to re-personalise their therapy. Therefore there is a clear value in collecting biological material for doing research. The term “biobanks” can be defned in many ways, but the defnition adopted here will be “an organised collection of human biological material and associated information stored for one or more research purposes”. In these libraries of stored biospecimens, personal information is highly protected and all the data are anonymised or “blinded”. These libraries are crucial to ongoing research for identifying new targets and new prognostic factors. In some institutions, patients are asked, for this reason, to donate their biospecimens for research. The biobanks need a high-quality standard of tissue samples for the development of personalised medicine. Unfortunately, nowadays research in this feld is hampered by the low quality of tissue samples and the poor level of their storage. Secondly, it is fundamental to identifying new prognostic factors, which means that patients, through their genetic characteristics, can receive the most appropriate and effective, or least toxic, drug. A prognostic marker is a tool which is able to predict prognosis, the length of life, and the possibility to be cured or to relapse. A predictive marker is linked to the treatment, because it is able to predict the treatment outcomes: if the treatment works, if the treatment harms or if the treatment is not likely to work. For these reasons, it is important that patients and families are aware of these developments and help physicians and researchers to spread the message of the importance to use and to donate their tissues for research purposes, because they can help other patients in the future. Advocate Perspectives in Tissue Collection and Research Question from Selma Schimmel: “One of the patient advocate and research perspectives is really the daunting task of trying to explain the importance of tissue and biospecimen collection to the very patients that you work with every day. We can ensure that patients comprehend the terminology involved by speaking a language that they understand and by connecting them to reliable resources that will help them fathom this brave new world of genetic profling, personalised medicine and diagnostics. We are seeing the development, too, of personalised vaccines and immunotherapies for which patients will need a piece of their tissue so that International Brain a vaccine can be made specifcally for that individual. We feel that information is the frst medicine for a cancer patient, and that even more information is required for personalised medicine. What I really think we should try to do is to let cancer patients know that personalised medicine is an additional treatment; it is not the only treatment. We should let the cancer patient know that chemotherapy is still a very good treatment and there are several hormonal treatments, surgery and so on available, because otherwise we are giving very bad information and giving a hope that cannot be satisfed. A patient should, frst of all, be able to learn the results of tissue analysis by himself/herself or from the general practitioner, and secondly, the patient should have the right to give the specimen under the condition that a piece of the specimen has to be kept for future need. I was surprised by the survey results because, working with patients, I had envisaged different answers to the questions.
Meliodosis and Glanders (Burkholderia pseudomalleri) Symptoms: Pneumonia with associated septicaemia generic rhinocort 100mcg mastercard. Primitive treatment: Ceftazidime for acute infection discount rhinocort 100 mcg overnight delivery, doxycycline to prevent recurrence purchase 100 mcg rhinocort mastercard. Psittacosis (Chlamydia psittaci) Symptoms: Atypical pneumonia with fever and cough. Primitive treatment: Doxycycline or Chloramphenicol Human transmission usually from inhaled dust infected with placental tissue or secretions from infected sheep, cows, or goats. Typhus fever (Rickettsia prowazekii) Symptoms: Fever, headaches, chills, generalised pain and rash. Second line bio agent Ricin (technically a chemical agent) Symptoms: Block protein synthesis within the body. This is the support of the body’s organ systems (heart, brain, liver, kidneys) to help them continue to function following damage but is not specifically aimed at treating the underlying injury or disease. It is usually delivered in an intensive care unit and consists of treatments such as oxygen, ventilation, dialysis, fluid therapy, nutrition, and using medications to maintain blood pressure. In an austere situation your ability to deliver supportive care will be minimal and potentially a massive drain on limited resources. Since it is likely any exposure would be the result of a terrorist attack it may be difficult to avoid. If dealing with a patient of suspected chemical agent poisoning ensure you are protected and that the patient is decontaminated. Where - 123 - Survival and Austere Medicine: An Introduction formal decontamination is not possible – remove and dispose of their clothes and wash them down with soap and water. If you suspect a chemical attack try and stay up wind from the location and on the high ground. Chemical agents will be carried by the wind and as most are heavier than air the chemicals will settle in low lying areas. Inside try and find a room with minimal windows (ideally an interior room with no windows), tape cracks around doors and windows and place a wet towel around the base of the door Equipment The single most important piece of equipment is a protective facemask and appropriate filters for all the members of your family. Ensure your filters meet the standard for both biologicals, and organic chemicals, and that you have spares. The following is the Australian commercial standard for mask filters which is the most appropriate for this application: A2B2E2K2 Hg P3. A protective over-suit protects you from liquid and dense vapour contamination on your skin. Usually liquid does not spread over a wide area while vapour can disperse over wide distances. Vapour is poorly absorbed from the skin but it can be if the vapour is dense enough but this is only likely close to the release point. For most people the priority is the purchase of appropriate gasmasks before considering over-suits. If you are unable to afford commercial chemical protective suits consider purchasing those recommended for spraying agricultural chemicals; they do offer the same level of protection but are cheaper, and many nerve agents are based around organophosphate agricultural sprays. Medical preparations In an austere situation Tincture of green soap (or another mild soap) is still the recommended low-tech decontamination agent for suits and bodies. They cause their effects by blocking the breakdown of acetylcholine – a communication chemical between nerves and muscles. When the enzyme, which breaks it down, is blocked, it accumulates, and causes the symptoms of nerve agent poisoning. Treatment: Pre-treatment: This consists of the administration of medication prior to exposure to a nerve agent to minimise the effect of the agent. This binds reversibly to the same receptors to which the nerve agents bind irreversibly helping to reduce their effects. This was tolerated for prolonged periods by troops during Gulf War 1 with minimal minor side effects. If exposure occurs then pre-treatment combined with post-exposure treatment significantly reduces the death rate. Post-exposure treatment: This should be administered immediately upon suspicion of exposure to nerve agents (i. Large amounts of atropine may be required, but the indications and administration are beyond the scope of this book. The dose is titrated against signs of atropinization: dry mouth, dry skin, and tachycardia > 90 min. In the complete absence of medical care and confirmed nerve agent exposure atropine can be continued to maintain atropinization for 24 hours (usually 1-2 mg Atropine 1-4 hourly). Atropine effects are essentially peripheral and it has only a limited effect in the central nervous system 2. Oxime treatment: While atropine minimises the symptoms it does not reverse the enzyme inhibition caused by the nerve agent. By administering oximes this encourages the reactivation of the enzymes required to breakdown the acetylcholine. Different oximes work better with different nerve agents usually a mix of Pralidoxime and Obidoxime is given.
A deficiency of which of the following enzyme activities is the most likely cause of the gastrointestinal symptoms in this patient? A married couple is screened to assess the risk for Gaucher disease in their children 100mcg rhinocort visa. The activities of glucocerebrosidase in the sera of the mother and father are 45% and 55% buy rhinocort 100 mcg visa, respectively order 100mcg rhinocort free shipping, of the reference value. Which of the following is the probability of the child possessing one or more alleles of the Gaucher mutation? The release of epinephrine from the chromaffin granules of the adrenal medulla into the bloodstream in response to neural stimulation is mediated by which of the following? During normal screening for phenylketonuria, a male newborn has a serum phenylalanine concentration of 35 mg/dL (greater than 20 mg/dL is considered a positive test). Enzymatic analysis using cultured fibroblasts, obtained after circumcision, shows normal activity of phenylalanine hydroxylase. A possible explanation for these findings is a deficiency in function of which of the following coenzymes? A 2-year-old boy with mental retardation has chewed the tips of his fingers on both hands and a portion of his lower lip. His serum uric acid concentration is increased, and he has a history of uric acid renal calculi. Which of the following abnormal enzyme activities is the most likely cause of these findings? A 14-year-old girl is brought to the physician because of a recent growth spurt of 15 cm (6 in) during the past year. Cardiac examination shows a hyperdynamic precordium with early click and systolic murmur. Abnormal synthesis of which of the following proteins is the most likely cause of this patient’s disorder? Native collagen is composed almost entirely of which of the following types of structures? An otherwise healthy 20-year-old woman of Mediterranean descent is given sulfamethoxazole to treat a bladder infection. Three days after beginning the antibiotic regimen, the patient has moderately severe jaundice and dark urine. Her condition worsens until day 6 of antibiotic therapy, when it begins to resolve. Which of the following conditions is the most likely explanation for these findings? Urinalysis shows increased concentrations of metanephrine and vanillylmandelic acid. The patient is most likely to have a neoplasm that secretes which of the following? An inherited disorder of carbohydrate metabolism is characterized by an abnormally increased concentration of hepatic glycogen with normal structure and no detectable increase in serum glucose concentration after oral administration of fructose. These two observations suggest that the disease is a result of the absence of which of the following enzymes? A 15-year-old girl limits her diet to carrots, tomatoes, green vegetables, bread, pasta, rice, and skim milk. She has an increased risk for vitamin A deficiency because its absorption requires the presence of which of the following? An increased concentration of fructose 2,6-bisphosphate in hepatocytes will have a positive regulatory effect on which of the following? During the processing of particular N-linked glycoproteins, residues of mannose 6-phosphate are generated. Which of the following proteins is most likely to undergo this step in processing? A 65-year-old man with coronary artery disease comes to the physician for a follow-up examination. Serum studies show a glucose concentration of 95 mg/dL and homocysteine concentration of 19. Which of the following amino acids is most likely to be decreased in this patient? Which of the following is required to transport fatty acids across the inner mitochondrial membrane? A 67-year-old man has a restricted diet that includes no fresh citrus fruits or leafy green vegetables. This patient’s disorder most likely results from a defect in collagen synthesis that involves which of the following amino acids? D - 16 - Gross Anatomy and Embryology Gross Anatomy Module (125 items) Systems Blood & Lymphoreticular System 1%–5% Nervous System & Special Senses 5%–10% Musculoskeletal System 10%–15% Cardiovascular System 20%–25% Respiratory System 10%–15% Gastrointestinal System 20%–25% Renal & Urinary System 1%–5% Female Reproductive System & Breast 5%–10% Male Reproductive System 1%–5% Endocrine System 1%–5% Embryology Module (20 items) Systems Blood & Lymphoreticular System 5%–10% Nervous System & Special Senses 5%–10% Musculoskeletal System 5%–10% Cardiovascular System 5%–10% Respiratory System 5%–10% Gastrointestinal System 10%–15% Renal & Urinary System 5%–10% Female Reproductive System & Breast 1%–5% Male Reproductive System 1%–5% Endocrine System 5%–10% - 17 - 1.