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These two symptoms occurred in association with abdominal pain generic female cialis 20mg visa, fever and dehydration. About 5% of all cases 30 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar were severely dehydrated. Ringer lactate solution is being used with success as a rehydrating fluid at Infectious Diseases Hospital. Tetracycline is also used as an adjunct in severely dehydrated patients, no antibiotic is given to mild or moderate cases. Specific drugs are given to diseases like enteric fever, helminthiasis, amoebic dysentery and etc. Surveillance of contacts, disinfection of environment and health education are principal parts of this programme. Summing up The study of intestinal helminthiasis increased in scope, depth and complexity. The epidemiology of Ascariasis as well as the biology of Ascaris lumbricoides was studied in depth. Cross-sectional and longitudinal surveys were carried out in villages to determine distribution of worm load, the basic reproductive rate and transmission dynamics. Epidemiological models of Ascaris infection and theoretical simulation of the effect of mass chemotherapy were done, followed by a pilot experiment to examine the possibility of reducing Ascaris transmission to insignificant level by mass chemotherapy. The impact of periodic age-targeted mass chemotherapy on prevalence, intensity and morbidity due to Ascariasis was studied in village children. The impact of regular de-worming on nutrition and growth of school children was studied in a large experiment covering 21 villages. Result of these studies helped to fill the gap in contemporary scientific knowledge about the interrelationship between Ascaris infection and nutrition and provided information helpful in choosing between various public health options for preventing and controlling Ascaris infection in the community in Myanmar. It was realized that diarrhoea as distinct from cholera was one of the foremost causes of mortality and morbidity in Myanmar especially in children, and it became the first priority disease in People s Health Plan (1982-86). Prior to 1981 little was known regarding the etiology of acute diarrhoea in Myanmar apart from the fact that V. Important etiological agents, hitherto not known to be present in Myanmar were identified including Enterotoxigenic E. Rotaviruses as etiological agent of diarrhoea in children was studied for the first time in Myanmar and found to be prevalent during the cold season. The relative frequency of these etiological agents for diarrhoea was studied in children including neonates. The biological properties of these pathogens were studied such as invasiveness and adherence. The application of microbial genetics to the study of pathogenesis of gastro- intestinal infections was started beginning with plasmid profile analysis of E. Personal hygienic practices that affect diarrhea incidence were studied in particularly home and hand contamination in relation to diarrhoea and demonstration that hand washing with soap and water 33 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar after defecation and before meals reduced diarrhoea incidence; The role of fomites such as paper currency notes in the person to person transmission of diarrhoes was investigated. The effect of diarroea on gut function, bio-availability and pharmacokinetics of drugs was studied. Also, clinical trials were done of traditional herbal remedies like berberine and commonly used home remedies like activated charcoal for the treament of diarrhoea. During this period, scientific studies of patho-physiological mechanism related to gut function and nutrient absorption were carried out in the laboratory, hospital and in the field. The study of recurrent cholangitis showed the importance of bile duct stone, rather than gall stones, as a cause of obstructive jaundice. Previous studies in the 1970 s have shown the importance of ascaris infection as etiology of bile duct stones. Previous reports have also mentioned that Ascaris adult worms may sometimes be found in the common bile duct. Furthermore, the application of newly introduced diagnostic methods and new technology was studied - in particular, the utility under local conditions of endoscopy of the stomach and gut and ultrasonography of the hepato-biliary system; and the experience from the performance of large series of such investigations were reported. New laboratory techniques were introduced including cell culture for bacteriological studies, plasmid profile analysis for genetic studies and radioactive tracers for biochemical studies. Also describes the clinical manifestation and presentations of common intestinal helminth infections in the hospitalized children. Basal hour secretion of volume, pH, and acidity in preoperative and postvagotomy in chronic duodenal ulcer 14 cases were studied. There are 14 cases in Group I in which study is done on preoperative and postoperative cases after 2 weeks. Basal hour secretion, there is a atistically significant reduction in volume and acidity and also in pH change. Therefore completeness of vagotomy is an important factor in reduction of the volume and acidity of the gastric juice. But there is a slightly greater increase in volume and acidity after 3 months than after 2 weeks but it is not satistically significant. Serum amylase determinations are nonspecific and not diagnostic for acute pancreatitis even when the values were more than 1000 Somogyi Units, Renal clearance of amylase from the blood, expressed as a proportion of simultaneous creatinine clearance, is 2.

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Both of these methods are used for other inhalant and food allergens cheap female cialis 10mg, and clinicians generally must communicate in terms of these standards. Unfortunately, neither the weight per volume method nor the protein-nitrogen unit truly measures allergenic activity, because not all measured proteins and extractable components in the solution are allergenic. In addition, many complex allergens are destroyed during the harsh extraction procedure. Such problems have been circumvented through the use of biologic assays of functional allergen reactivity. It is essential for anyone devising immunotherapy regimens to have an appreciation for the biologic assays of allergenicity. Characterization of Allergens Many methods are available to characterize an allergen. Several categories of tests, however, are restricted to studying molecules responsible for IgE-mediated symptoms. Although primarily used in the quantitation of antigen-specific IgE, the test may be adapted to determine antigen concentrations. To measure potency, the unknown allergen is immobilized onto solid-phase supports (cellulose disks or beads) and reacted with a known quantity of antigen-specific IgE in a standard test system. For comparison, the extracts are compared with a reference standard, which should be carefully chosen ( 31). The quantity of extract required to obtain a specified degree of reactivity is determined. By definition, in this assay, the greater the binding of IgE to the antigen, the greater the allergenicity. Serum from an allergic individual (containing IgE) is first mixed with the soluble unknown allergen. The more potent the fluid phase allergen, the less IgE is free to bind to the solid-phase allergen ( 32). The arguments concern the fact that the choice of antigen for the solid-phase reaction is variable and may influence results. In addition, the finite supply of allergenic reference sera limits reproducibility: without identical reference sera and immobilized allergen, comparisons are impossible. Further development of monoclonally derived IgE and recombinant allergens may help with this problem. Assessment of Allergenicity Biochemical methods for analyzing allergens, such as protein composition and concentration, are practical but tell nothing about the allergenicity of the extract. Immunologic reactivity with IgE antibodies as assessed in vitro and in vivo provide this information. Of the several antigens in a mixture, usually one or more dominate in both frequency and intensity of skin reactions in sensitive persons. Not all persons allergic to a certain pollen allergen react to the same antigens from that pollen allergen extract, however. The antigens of tree, grass, and weed pollens are immunologically distinct, and this agrees with the clinical and skin test data. As more allergens are isolated and purified, it is hoped that correlations between immunogenicity and biochemical structure will emerge. Marsh (12) proposed that a major allergen be designated when 90% of clinically allergic persons react by skin test to a concentration of 0. Others suggest that a component that binds IgE in 50% or more of sensitive patient sera tested by radioimmunoelectrophoresis (another immunologic assay) should be considered a major allergen ( 34). Naturally occurring atopic allergens have few physiochemical characteristics to distinguish them from other antigens. All are proteins or glycoproteins, although high molecular weight polysaccharides that react with IgE have been obtained from Candida albicans. Most protein allergens that have been identified are acidic, with molecular weights ranging from 5,000 to 60,000 daltons. It has been postulated that larger molecules cannot readily penetrate the mucous membranes. Highly reactive allergens of lower molecular weight are described in conjunction with ragweed and grass pollens. The antigenic determinants that react with IgE antibody molecules have not been clearly identified for most allergens, although it is postulated that there must be at least two such groups on each allergen molecule to trigger the allergic response. The sequence of amino acids in some determinant groups, with less regard for conformation of the protein molecule, is most important for the major codfish antigen Gad c 1 (codfish antigen M) (35). In other allergens, such as ragweed Amb a 3 (Ra 3) and Amb a 5 (Ra 5), the conformation of the native protein is critical for allergenicity ( 36). Individual plants, their common and botanical names, geographic distributions, and relative importance in allergy are considered elsewhere in this book. Anatomy Seed-bearing plants produce their reproductive structures in cones or flowers. Gymnosperms ( naked seeds ; class Gymnospermae) are trees and shrubs that bear their seeds in cones. Angiosperms produce seeds enclosed in the female reproductive structures of the flower.

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Modifications to the conventional design include the open vent design order female cialis 20mg line, the dosimetric design with a manually operated valve to interrupt gas flow into the nebulizer during expiration, combinations of the open vent and dosimetric features, and the more recent breath-assisted open vent nebulizers designed to combine the advantages of the open vent design with the convenience of continuous operation and the efficiency of intermittent nebulization excluding the expiratory phase ( 92). Rapid expansion of air causes a negative pressure, which sucks fluid up the feeding tube system, where it is atomized. Larger particles impact on baffles and the walls of the chamber and are returned for renebulization. Negative pressure generated as compressed air expands at the Venturi and draws air in through the open vent, resulting in more airflow through the chamber than provided by the compressor; therefore more aerosol is generated in a given period of time. This nebulizer design has been combined with a manual interrupter that the patient operates to allow aerosol generation only during inspiration. For a given medication dose placed into the nebulizer, the use of the manual interrupter results in greater delivery to the airways but with prolongation of the nebulization time (92). With the breath-assisted open vent nebulizers, the vent is designed to be open only during inspiration, enhancing aerosol generation only during the inspiratory phase. Aerosol generation continues as a result of the continuous gas flow from the compressor during expiration, but is not enhanced by the vent, which is closed during expiration (Fig. The primary advantages of this design include significantly improved delivery of drug placed into the nebulizer into the airway and the convenience of continuous operation without the need for patient coordination of actuation of a manual interrupter. Other benefits include the generation of a greater fraction of smaller particles due to increased evaporation from droplets due to the additional airflow, and the need for less powerful compressors with this category of nebulizer (92). On inspiration the valve located at the top of the chamber opens, allowing extra air to be sucked through the vent on inspiration. The main effect of this is to pull more aerosol from the nebulizer on inspiration, increasing the dose to the patient. On expiration the vent closes and aerosol exits via a one-way valve near the mouthpiece. Aerosol lost from the nebulizer on expiration is thus proportionally less than that from a conventional nebulizer. Nebulization times will be faster and the drug dose received by the patient will be significantly greater than with conventional nebulizers but not as fast as with the open vent nebulizer. In one study using nebulized budesonide, four different nebulizer devices, and tidal volumes ranging from 75 to 600 mL, the estimated percentage of the dosage placed into the nebulizer to be inhaled by the patient varied over a fourfold range depending on these factors ( 94). With proper use, the mask (or mouthpiece) with its attached tubing provides a critical function as a reservoir containing aerosol-laden air from the nebulizer. During each tidal inhalation, much of the air that the patient inspires comes from this reservoir. Without the reservoir, nearly all of the air that the patient inhales is unmedicated room air; nearly all of the aerosol simply escapes into the atmosphere. Even with proper use of a mask or mouthpiece, significant entrainment of room air occurs (95). When nebulizers are used in older children and adults, the use of a mouthpiece in preference to face mask may reduce unwanted systemic effects ( 96). Most drugs used for nebulization are now supplied in single-use ampoules, largely eliminating the need for preservative additives, some of which have been documented to have significant bronchoconstrictor effects. When multiple use vials are used, the clinician should be aware of the additives present and any bronchoconstrictor potential that they may have with repetitive dosing ( 97). Choice of nebulizer is important when corticosteroid suspensions are administered, but is less critical with other medications used in the treatment of asthma. Age 3 to 4 is usually the appropriate time to wean children who first developed asthma at a younger age from nebulized therapy. For clinic and emergency room use in this situation, the choice between the two modalities depends on the preferences of the staff and the equipment available. However, all patients for whom inhaled controller medications are prescribed also require a rescue bronchodilator ( 98). Priorities for Inhaled Drug Delivery in Clinical Practice For the busy clinician barraged by competing claims from marketers of various modalities of delivery of inhaled medication, the practical issue to be addressed is summarized by the following question: is there a delivery system that is clearly clinically superior to the others? As the preceding discussion and references indicate, there are well-documented differences in the characteristics of various devices in terms of delivery of drug to the airways, but consistent clinically relevant ramifications of these differences are more difficult to establish. A delivery system that is clinically highly efficacious for delivery of one drug formulation may show inferior performance with a different drug or formulation. Data comparing clinical effects of specific drug formulations administered via specific delivery devices in side-by-side trials must be evaluated to conclusively prove the relative merits of one drug device combination over another. Preferences of individual patients, as well as economic considerations, must be taken into account; in many situations such issues may supersede recommendations based on purely scientific considerations. Many patients adhere poorly to complicated treatment programs involving multiple inhaled medications, each administered with a different type of device on a different schedule. Attention directed to minimizing the number of daily doses administered and the number of different categories of devices used for such patients is often dramatically effective in restoring adherence with resultant attainment of satisfactory asthma control. A dissertation on the properties and effects of the Datura stramonium, or common thornapple [Dissertation]. Historical review of the use of parasympatholytic agents in the treatment of respiratory disorders.

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Patients may also complain of a sore mouth and tongue (glossi- Clinical features tis) order female cialis 10mg. Patients may also have neurological complications of vitamin B Investigations 12 deciency (see page 471). In many cases the cause is not obvious and further investigations may have to be Investigations undertaken including barium follow through or upper Full blood count will demonstrate a macrocytic anaemia gastrointestinal endoscopy and biopsy. The Schilling test is used to differentiate the causes of vitamin B12 deciency Management (see Table 12. Prior to treatment with oral folic acid Management supplements, concurrent vitamin B12 deciency must be Parenteral vitamin B12 replacement is required for life. Prophylaxis is advised in preg- reticulocytosis can be demonstrated 2 3 days after com- nancy, haemolytic anaemias, premature babies, dialysis mencing therapy. Causes of The causes of haemolytic anaemia are shown in Table folic acid deciency: r 12. Low intake is most common in elderly, people living in poor social conditions and chronic alcoholics. Folic acid is found in fresh vegetables and meat, but may Pathophysiology be destoyed by overcooking. Shortening of the life span of red cells does not always r Malapsorption occurs due to small bowel disease (es- cause anaemia. If the increased loss can be compen- pecially if affecting the jejunum) such as coeliac dis- sated for by an up-regulation of the bone marrow (which ease. In addition to ditions, myeloproliferative disorders, other rapidly bone marrow up-regulation, reticulocytes (red cell pre- growing tumours and severe inammatory disease. Inherited haemolytic anaemia Complications Achronically high serum bilirubin predisposes to the Hereditary spherocytosis formation of pigment gallstones. Chronic haemolysis predisposes to folate deciency and thus levels should Denition be monitored and replacement given as required. Par- An autosomal dominant condition in which the red cells vovirus infections that cause a temporary bone marrow are spherical. Hereditary elliptocytosis is an autosomal failure may result in an aplastic crisis. Investigations r Haemolysis is suggested by a rise in bilirubin, high Incidence urinary urobilinogen (due to bilirubin breakdown Commonest inherited haemolytic anaemia; 1 in 5000. In intravascular haemolysis, red cell fragments are Aetiology/pathophysiology seen in the blood lm, whereas spherocytes may be There is a high new mutation rate with 25% of patients present in extravascular haemolysis. The underlying cause is cell life span can be demonstrated using labelled red aweakness in the link between the cytoskeleton and cells. These cells are more rigid than normal and As HbF synthesis is normal, it presents at 6 months. Sex Clinical features M = F Spherocytosis may present as neonatal jaundice or anaemia with chronic malaise and splenomegaly. Nor- Geography mal infections cause a relative increase in haemolysis and Occurs most frequently in Africa, Middle East, India and may result in jaundice. Aetiology Investigations Apoint mutation on chromosome 11 results in a sub- Anaemia is usually mild. A blood lm will demonstrate stitution valine for glutamine at the sixth codon on the the spherocytes, but this cell morphology is not diagnos- globin chain to form haemoglobin (Hb)S. Thediagnosiscanbeconrmedbydemonstratingthe dehydration, hypoxia and cold may precipitate a sickle osmotic fragility of the red blood cells. Patients are given Pathophysiology pneumococcal vaccinations and prophylactic antibiotics HbS molecules, when deoxygenated tend to aggregate post splenectomy. The red blood cells become inex- ible and sickle shaped and become trapped in the mi- Haemoglobinopathies crocirculation, especially within bones, resulting in mi- Haemoglobinopathies are abnormalities in the nor- crovessel occlusion. Normal haemoglobin is made up of four polypeptide chains Clinical features each containing a haem group. HbA is the main adult Sickle cell trait (the carrier state) is asymptomatic, but form comprising two chains and two chains. Sickle cell also have a minor haemoglobin HbA2,which makes up anaemia is a clinical spectrum ranging from asymp- around 2% of the circulating haemoglobin and con- tomatic to severe haemolytic anaemia and recurrent sists of two chains and two chains. Painful vascular occlusive crises typically haemoglobins result from: produce symptoms of bone pain and pleuritic chest pain r Abnormal globin chain production such as thalas- with a low-grade fever. Other patterns of crisis: r Acute sequestration (pooling of blood in liver and Sickle cell anaemia spleen) requires transfusion for apparent hypo- Denition volaemia. Autosomal recessive condition in which there is abnor- r Pulmonary infarction may occur in association with mal structure of the globin chain. Transfusionsmayalso streptococcal infections and osteomyelitis often due be indicated in patients with regular severe crises and to salmonella.

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