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Prevalence rates seem to be around 10 to 20% of the population cheap ranitidine 300mg otc, but data are scarce and widely dispersed because of the wide diversity of the definitions used in epidemiological studies ranitidine 150 mg without prescription. To summarize, this report provides for the first time a valuable tool to assess the prevalence of some of the main gastrointestinal disorders and diseases worldwide. Many of current data point out consistenly to high prevalence of functional digestive disorders and diseases on the world population. A major limitation is the limited availability of data from African and some Asian countries. Further surveys coordinated by the National Societies, including prospective studies, will provide further insights into this interesting topic. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Recent developments in the pathophysiology and therapy of gastroesophageal reflux disease and nonerosive reflux disease. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Association of body mass index with heartburn, regurgitation and esophagitis: results of the Progression of Gastroesophageal Reflux Disease study. Fruit and vegetable intake and prevalence of colorectal adenoma in a cancer screening trial. Viruses are Kam L Hon1 responsible for approximately 70% of episodes of acute gastroenteritis in children and rotavirus 1 is one of the best studied of these viruses. Oral rehydration therapy is as effective as intravenous Department of Paediatrics, The Chinese University of therapy in treating mild to moderate dehydration in acute gastroenteritis and is strongly Hong Kong, Hong Kong Special recommended as the frst line therapy. Vomiting is one of the main reasons to explain the underuse of oral Department of Pediatrics, The University of Calgary, Calgary, rehydration therapy. Antiemetics are not routinely recommended in treating acute gastroenteritis, Alberta, Canada though they are still commonly prescribed. Ondansetron is one of the best studied antiemetics and its role in enhancing the compliance of oral rehydration therapy and decreasing the rate of hospitalization has been proved recently. The guidelines regarding the recommendation on antiemetics have been changed according to the evidence of these recent studies. Children in developing countries are particular at risk of both morbidity and mortality. Worldwide, gastroenteritis affects 3 to 5 billion children each year, and accounts for 1. In the United States, the admission rate is 9 per 1000, per annum, for children younger than 5 years old. The difference can also be Tel +852 26322861 explained by the fact that, the incidence of acute gastroenteritis is signifcantly higher Fax +852 26360020 Email ccm250@ha. This is an Open Access article 6554 which permits unrestricted noncommercial use, provided the original work is properly cited. Chow et al Dovepress is a developed city, and yet the admission rate is even higher the cause of 205,000 to 272,000 emergency department than many of the developing countries. By the age of 5 years, the cumulative risk is 1 in 24, a fgure Etiology that is 3 times higher than the that of the United States. The peak age for had diarrhea and vomiting, 7% had diarrhea and fever, 4% infection ranges from 6 months to 2 years. Other common had vomiting and fever, 3% had fever alone, 2% had vomiting viruses causing gastroenteritis include calicivirus, adenovirus alone and 0. Vomiting is one of the diarrhea episodes in hospitalized children, with detection most important symptoms for considering failure of oral rates varying from 3. However, less developed therapy in treating acute gastroenteritis, with mild to countries have a higher rate of parasites and Escherichia moderated dehydration, has been demonstrated by many coli infection which are both relatively uncommon in the randomized controlled trials. The data showed that there were no important clinical Rotavirus as a prototypic differences between oral hydration therapy and intravenous virus for gastroenteritis therapy for rehydration secondary to acute gastroenteritis Rotavirus is a prototypical virus because it is the most common in children; and that children treated with oral rehydration virus that causes acute gastroenteritis in children which therapy spent less time in hospitals. Moreover, patients results in hospitalization and treatment with intravenous fuid. Importantly, this 410,000 physician visits are due to the rotavirus infection, result is unlikely to change with further trials because there 98 submit your manuscript| www. In 1970s the diarrheal illness related deaths use oral rehydration therapy in scenarios of mild dehydration were 4. A crowded or emer- The oral rehydration solution is regarded as one of gency department with long waiting times would cause 22% the most important medical advances of the 20th century. Regarding Although there is much evidence to support the usage of the severity of dehydration, 49. In terms of symptoms, only 8% of the emer- oral rehydration solution is still described as an underused gency department physicians would consider intravenous simple therapy. Data from Europe, hand, patients refusing to drink was the most likely reason Australia and Canada show that 80% to 94% of hospitalized for choosing intravenous therapy (up to 96%). Vomiting children do not have any signs of dehydration and yet they was the second most important reason given for intravenous still receive intravenous therapy.

Meta-analysis: Chronic disease self- diabetes: A meta-analysis of the effect on glycemic control buy cheap ranitidine 150mg on line. Who can provide diabetes self-management vention on poorly controlled diabetes: A randomized controlled trial buy 150 mg ranitidine with mastercard. Mediating the effect of self-care management ioral intervention for Korean Americans with type 2 diabetes. Diabetes Educ intervention in type 2 diabetes: A meta-analysis of 47 randomised controlled 2009;35:98694. Meta-analysis of randomized nean lifestyle program: A randomized clinical trial for postmenopausal educational and behavioral interventions in type 2 diabetes. Diabetes self-management education: Miles care reduced all-cause mortality and cardiovascular diseases in patients with to go. Internet interventions to support lifestyle counseling and education in diabetes management. Diabetes Spectr 2014;27:235 modication for diabetes management: A systematic review of the evidence. Arch Intern Med 2010;170:1566 ing for glycemic control in adults with type 2 diabetes: A systematic review and 75. Can J Diabetes 2009;33:18 ness of diabetes self-management educational programs targeted to racial/ 26. Culturally appropriate health educa- diabetes self-management and control: A systematic review of the literature. Culturally competent interventions for Hispanic adults bolic control in patients with type 2 diabetes: A randomized controlled trial. The effectiveness of family interventions in Type 2 diabetes: A randomized, prospective trial. A systematic literature review of diabe- gramme for people with newly diagnosed type 2 diabetes: Cluster randomised tes self-management education features to improve diabetes education in women controlled trial. Interventions to improve diabetes outcomes for people life among Thai patients with type 2 diabetes. Nurs Health Sci 2007;9:135 with low literacy and numeracy: A systematic literature review. Diabetes Care tion education on dietary behaviors and health outcomes among Latinos: A sys- 2009;32:214955. Community health worker interventions looked factor in understanding racial disparities in glycemic control. Diabetes for Latinos with type 2 diabetes: A systematic review of randomized con- Care 2009;32:161419. Telephone intervention to improve based diabetes self-management education program. Diabetes Educ 2005;31:53 diabetes control: A randomized trial in the New York City A1c Registry. Evaluating the effect of a diabetes health diabetes: Development of the diabetes distress scale. Measuring diabetes self-care: A psy- lowing education, self-management and psychological interventions in diabe- chometric analysis of the Self-Care Inventory-Revised with adults. The summary of diabetes self-care activi- with type 2 diabetes: A systematic review and meta-analysis. A randomized controlled trial of a nurse short-message service by cel- lular phone for people with diabetes. A nurse short message service by cellular phone in type-2 diabetic patients for six months. Do mobile phone applications improve glyce- Citations excluded* N=5,341 N=4,650 mic control (HbA1c) in the self-management of diabetes? Impact of behavioral interventions in the management of adults with type 2 diabetes mellitus. Spanish diabetes self-management with and N=691 without automated telephone reinforcement: Two randomized trials. An assessment of lifestyle video education for people newly diagnosed with type 2 diabetes. Telecare in a structured therapeutic by chapter authors N=276 education programme addressed to patients with type 1 diabetes and poor N=295 metabolic control. Active care management supported by home telemonitoring in veterans with type 2 diabetes: The DiaTel randomized con- trolled trial. Clinical effects of home telemonitoring in new or revised the context of diabetes, asthma, heart failure and hypertension: A systematic recommendations review. Patients experience of a telephone booster interven- tion to support weight management in type 2 diabetes and its acceptability. Effectiveness of peer support for improving glycaemic control in patients with type 2 diabetes: A meta-analysis of randomized con- control or study design.

Cisplatin and Etoposide are the gold standards amongst the older agents Small Cell: 70 80% have metastasised at diagnosis Very rapid doubling time No place for surgery Mainly managed with chemo +/- radiotherapy (makes a dismal outlook a bit better) Sleep Apnoea See also: Treatment of Insomnia generic ranitidine 300mg on line, page 534 for Treatment of Insomnia See also Tiredness purchase 300 mg ranitidine, page 6 Sleepiness Varies according to circadian cycle: two sleep gates each day, 2 3 pm and 10 11 pm (correlates with melatoin) Obstructive sleep apnoea is the most common cause of excessive sleepiness. Variety of causes including neuromuscular and chest wall deformities Cheyne-Stokes Respiration: usually with advanced heart failure. Treatment: codeine or anti-Parkinson drugs Narcolepsy: Normal sleep at night and frequently going to sleep during the day. Can also be complicated by cataplexy (sudden loss of muscle tone in response to emotional stimuli). Need to titrate pressure Treat allergic rhinitis Medication: Sleeping pills make it worse stop them Dental devices Surgery: Kids tonsils and adenoids. Prone to infection so steroids worsen the condition by depressing the immune system. Bronchial lavage effective in acute episodes A number of vasculitis affect the lung. Usually found as incidental findings on X-ray Primary Pulmonary Hypertension: rare, usually in young women. A large histiocyte with one bland folded nucleus, abundant eosinophilic cytoplasm with indistinct cell borders. X-rays show multiple nodules scattered through both lungs Langhans giant cell: (not the same as Langerhans cell) multinucleated giant cell in granulomas, with nuclei arranged around the periphery of the cell in a horseshoe pattern Sequestration: Extralobular: Congenital. Mass of lung tissue not connected to bronchial tree and outside the visceral pleura Intralobar sequestration: usually acquired. Within the visceral pleura but not connected to the bronchial tree Differential of Solitary lung nodule: Tumour: benign (bronchial adenoma or pulmonary hamartoma) or malignant Tb Sarcoidosis Other granuloma: eg fungal Haematoma (ie blood clot, eg in cavity following lung contusion) th th 92 4 and 5 Year Notes Endocrine and Electrolytes History. Ketoacidosis will develop unless insulin given (if any endogenous insulin then no ketones) Incidence up to 20 yrs: 10 15/100,000 Prevalence: 0. So when start insulin replacement back titrate (after stabilised) type 1 may have honeymoon period until no endogenous insulin Currently being investigated for prevention in high risk individuals (ie have antibodies but not frank disease): Cows milk avoidance until 6 months of age Early oral insulin therapy autoimmune modulation Nicotinamide (vitamin B) supplementation Treatment goals: stable blood sugar, prevent/monitor complications, promote normal growth and development, maintenance of normal weight Investigations for both Type 1 and Type 2 Diabetes Glucose testing HbA1C. Dipsticks detect > 150 g/l (ie insensitive) Microalbuminuria hard to test (needs 24 hr urine). After 30 years 80% have background retinopathy and 7 8% are blind (see Focal Ischaemic Retinal Disease, page 145). Use normal saline, and reduce to hypotonic fluid once rehydrated and glucose < 15 mmol/l or if Na > 150 mmol/l Potassium 20 mmol in first 6 hours then 10 mmol/hr according to plasma levels. If plasma K high then delay adding K until this has normalised Insulin: actrapid 10 20 units. Involves significant education For Impaired Glucose tolerance and Impaired fasting glucose: lifestyle change and monitoring Diet: Saturated fats, low glycaemic index foods (sugar presented slower to liver, able to convert more to glycogen). Intensive therapy reduced risk in all categories, but hypoglycaemia and some weight gain Biguanides: eg metformin. Not in hypoxic lung disease or cardiac disease Sulphonylureas: insulin release from -islet cells (must have some left for it to work), gluconeogenesis and glycogenolysis. Only measure T3 in hyperthyroid (as it drives symptoms) Bound in plasma to thyroid binding globulin Intercurrent illness: fT4 rises (liver stops converting T4 to T3 straight away want to be catabolic) then T4 falls to subnormal levels as thyroid production slows. Does not parallel degree of toxicosis At presentation, patient may be euthyroid, hypothyroid or hyperthyroid Management: Early referral. Follicles same as in follicular carcinoma but carcinoma shows invasion of blood vessels Toxic adenoma (= Plummers Disease, Thyroid autonomy): a nodule producing T3 or T4 hot spot on scan Subacute Thyroiditis: = De Quervains Disease. If rapidly destructive then acute thyroiditis = Inflammation of the thyroid secondary to: Pregnancy: autoimmune. Usually self-limiting If severe, then 3 phases: Prodromal: may be 4 6 weeks longs Hyperthyroid: Release of preformed T3 and T4. Steroids work but prolong illness th th 98 4 and 5 Year Notes Histology: Neutrophils attack cuboidal epithelium (acute inflammation) Thyroglobulin leaks out granuloma formation Resolution Post-partum thyroiditis: hyper or hypo thyroid. Risk of agranulocytosis with Carbimazole and propylthiouracil Toxic multi-nodular goitre and toxic adenoma unlikely to remit following drugs Partial thyroidectomy: risk to recurrent laryngeal and parathyroids. Have oncocytes (cells with mitochondria) Spontaneous primary atrophic hypothyroidism. F:M = 6: 1 Woody Thyroiditis (Riedels Thyroiditis): fibrous replacement of the thyroid Iatrogenic: Following thyroidectomy and radio-iodine treatment Drug induced: eg amiodarone ( hypo or hyper), lithium, iodine in expectorants Not deep x-ray treatment to face and neck (does lead to nodular goitre), Juvenile: Dyshormonogenesis: eg partial deficiency of peroxidase gland hyperplasia restore deficiency. T = 7 days so adjusting dose takes long time Note: hypothyroid slow drug metabolism If pre-existing heart disease, introduce very slowly. False positives with depression, obesity and drugs affecting metabolism of dexamethasone (eg phenytoin, phenobarbitone) Midnight cortisol nearly as good: but must do as an inpatient (need to wake to do it and be unstressed) midnight is low point of diurnal cycle, if high then diurnal cycle depressed Do high dose dexamethasone test (8mg) to determine type of Cushings or if obese Causes and treatment: Exogenous corticosteroid administration: reduce as much as possible. In asthma, use inhaled steroids Cushings Disease: (adrenal hyperplasia secondary to pituitary tumour, F > M, peak age 30 50). Treatment: Surgical removal of pituitary adenoma Adrenal gland adenoma or carcinoma: No suppression of cortisol with high dose. Lack of cortisol will obscure adrenergic effects of hypoglycaemia), diarrhoea, libido, vitiligo (autoimmune mediated depigmentation of patches of skin).

Individual differences in the experience of sexual motivation: theory and measurement of dispositional sexual motives cheap 300mg ranitidine otc. Psychosexual functioning after treat- ment for gynecological cancer and integrated model cheap ranitidine 150 mg amex, review of determinant factors and clinical guidelines. Sexual functioning, mid age and menopause: a comparative study of 12 European countries. Female sexual desire disorders: subtypes, classication, personality factors, a new direction for treatment. Efcacy and safety of sildenal citrate in women with sexual dysfunction associated with female sexual arousal. Prevalence of sexual dysfunction in women: results of a survey study of 329 women in an outpatient gynecological clinic. The use of the multi axis diagnostic system for sexual dysfunctions in the assessment of hypoactive sexual desire. Transdermal testosterone treatment in women with impaired sexual function after oophorectomy. Effects of erotic stimuli on sexually functional and dysfunctional women: multiple measures before and after sex therapy. Sexual desire and the deconstruction and reconstruction of the human female sexual response model of Masters and Johnson. Gender, relationship stage, and sexual behaviour: the importance of partner emotional investment within specic situations. Sildenal effects on sexual and cardio- vascular responses in women with spinal cord injury. Psychiatric comorbidity in heterosexual couples with sexual dysfunction assessed with the composite international diagnostic inter- view. Denitions of womens sexual dysfunction reconsidered: advocating expansion and revision. Role of dopamine in anticipatory and consummatory aspects of sexual behavior in the male rat. Sexual experience sensitizes mating related nucleus encum- bens dopamine of responses of female Syrian hamsters. Areas of brain activation in males and females during viewing of erotic lm excerpts. Efcacy and safety of low, standard, and high dosages of an estradiol transdermal system (Esclim) com- pared with placebo on vasomotor symptoms in highly symptomatic menopausal patients. Climacteric 2002; Proceeding of the 10th International Congress on the Menopause, Berlin. Hysterectomy, oophorectomy and endogenous sex hormone levels in older women: the Rancho Bernardo Study. Twenty-four hour mean plasma testos- terone concentration declines with age in normal premenopausal women. Evidence for diminished mid cycle ovarian androgen production in older reproductive aged women. Changes in reproductive hor- mones in sex hormone binding globulin in a group of postmenopausal women measured over 10 years. A prospective longitudinal study of serum testosterone, dehydroepiandrosterone sulphate and sex hormone binding globulin levels through the menopause transition. Psychological reactions and sexual life after hysterectomy with and without oophorectomy. Vaginal atrophy in the postmenopausal woman: the importance of sexual activity and hormones. Transdermal testosterone therapy improves well-being, mood and sexual function in pre-menopausal women. Replacement of dehydroepiandrosterone in adrenal failure: no benet for subjective health status and sexuality in a 9-month randomized parallel group clinical trial. Improvement in mood and fatigue after dehydroepian- drosterone replacement in Addisons disease in a randomized, double blind trial. The effect of dehydroepiandrosterone supplementation to symptomatic perimenopausal women on serum endocrine proles, lipid parameters, and health-related quality of life. Female androgen insufciency: the Princeton consensus statement on denition, classication, and assessment. Physiological changes in dehydroepiandro- sterone are not reected by serum levels of active androgens and estrogens but of their metabolites: Intracrinology. A prospective study of the effects of oral contraceptives on sexuality and well being and their relationship to discontinu- ation. Children with classic congenital adrenal hyperplasia have elevated serum leptin concentrations and insulin resistance: potential clinical implications. Risks and benets of estrogen plus progestin in healthy postmenopausal women: principal results from the Womens Health Initiative randomized controlled trial.