The assessment of treatment options must consider patient and partner satisfaction and other QoL factors as well as efficacy and safety buy baclofen on line amex muscle relaxant names. A significant improvement can be expected as soon as after 3 months of initiating lifestyle changes (8) quality 10 mg baclofen spasms sphincter of oddi. However cheap 25mg baclofen otc muscle relaxant herbs, these results have yet to be confirmed in well-controlled, long-term studies. Early compared with delayed erectile rehabilitation brings forward the natural healing time of potency (9). Intracavernous injections and penile implants are still suggested as second- and third-line treatments, respectively, when oral compounds are not adequately effective or contraindicated for postoperative patients (Sections 3. Erectile function was improved in 71% of patients treated with 20 mg tadalafil versus 24% of those treated with placebo, while the rate of successful intercourse attempts was 52% with 20 mg tadalafil versus 26% with placebo (22). Penile prosthesis remains a satisfactory approach for patients who do not respond to either oral or intracavernous pharmacotherapy or to a vacuum device (29). Testosterone deficiency is either a result of primary testicular failure or secondary to pituitary/hypothalamic causes, including a functional pituitary tumour resulting in hyperprolactinaemia. Testosterone replacement therapy (intramuscular, oral, or transdermal) is effective, but should only be used after other endocrinological causes for testicular failure have been excluded (30). There is limited evidence suggesting that such treatment may not pose an undue risk of prostate cancer recurrence or progression (32). Patients given androgen therapy should be monitored for clinical response, elevated hematocrit and development of hepatic or prostatic disease. Testosterone therapy is contraindicated in patients with untreated prostate cancer or unstable cardiac disease. The lesion must be demonstrated by duplex Doppler study of the penis and confirmed by penile pharmacoarteriography. Vascular surgery for veno-occlusive dysfunction is no longer recommended because of poor long-term results (35). Psychosexual therapy requires ongoing follow-up and has had variable results (36). The recommended starting dose is 50 mg and should be adapted according to the patients response and side effects. Adverse events (Table 8) are generally mild in nature and self-limited by continuous use. The recommended starting dose is 10 mg and should be adapted according to the patients response and side effects. Nevertheless diabetic patients remain poor responders to tadalafil on demand, with a successful intercourse rates incresing from 21. In vitro, it is 10-fold more potent than sildenafil, although this does not necessarily mean greater clinical efficacy (47). Adverse events (Table 8) are generally mild in nature and self-limited by continuous use, with a drop-out rate similar to that with placebo (48). Nevertheless, again, diabetic patients remain poor responders to vardenafil on-demand with a successful intercourse rates increasing from 23% with placebo to 49% and 54 % with 10 and 20 mg of vardenafil on-demand, respectively (51). Absorption is unrelated to food intake and they exhibit better bioavailability compared to film-coated tablets (52). Two major randomised double-blind studies, using 5 and 10 mg/day tadalafil for 12 weeks (n = 268) (64) and 2. An open-label extension was carried out for both studies in 234 patients for 1 year and 238 patients for 2 years. Tadalafil, 5 mg once daily, therefore provides an alternative to on-demand dosing of tadalafil for couples who prefer spontaneous rather than scheduled sexual activities or who anticipate frequent sexual activity, with the advantage that dosing and sexual activity no longer need to be temporally linked. Nevertheless, in the 1-year open-label 5 mg tadalafil extension study followed by 4 weeks wash-out, erectile function was not maintained after discontinuation of therapy in most patients (about 75%). This has been confirmed in another study of chronic sildenafil in men with type 2 diabetes (70). This regimen provides an alternative to on-demand treatment for some men with diabetes (71). Sildenafil does not alter cardiac contractility, cardiac output or myocardial oxygen consumption according to available evidence. The main ways in which a drug may be incorrectly used are: failure to use adequate sexual stimulation; failure to use an adequate dose; failure to wait an adequate amount of time between taking the medication and attempting sexual intercourse. Even though all three drugs have an onset of action in some patients within 30 min of oral ingestion, most patients require a longer delay between taking the medication, with at least 60 min being required for men using sildenafil and vardenafil, and up to 2 h being required for men using tadalafil (78-80). Absorption of sildenafil can be delayed by a meal, and absorption of vardenafil can be delayed by a fatty meal (81). Absorption of tadalafil is less affected provided there is enough delay between oral ingestion and an attempt at sexual intercourse (77). The half- life of sildenafil and vardenafil is about 4 h, suggesting that the normal window of efficacy is 6-8 h following drug ingestion, although responses following this time period are well recognised. It is important to check that the patient has had an adequate trial of the maximal dose of the drug. Data suggest an adequate trial involves at least six attempts with a particular drug (82). Patients taking tadalafil were advised to wait at least 2 h between oral ingestion and attempting intercourse. Erectile dysfunction is typically a symptom of an underlying condition, such as diabetes, hypertension, or dyslipidaemia. Modification of other risk factors may be also be beneficial as discussed in section 3. If drug treatment fails, then patients should be offered an alternative therapy such as intracavernosal injection therapy or use of a vacuum erection device. Thus, erections with these devices are not normal because they do not use physiological erection pathways. Men with a motivated, interested, and understanding partner report the highest satisfaction rates. Intracavernous alprostadil is most efficacious as monotherapy at a dose of 5-40 g; although the 40 g dose is not registered in every European country. An office-training programme (one or two visits) is required for the patient to learn the correct injection process. Complications of intracavernous alprostadil include penile pain (50% of patients reported pain but pain reported only after 11% of total injections), prolonged erections (5%), priapism (1%), and fibrosis (2%) (103). It can be alleviated with the addition of sodium bicarbonate or local anaesthesia (104,105). However, tunical fibrosis suggests early onset of La Peyronies disease and may indicate stopping intracavernosal injections indefinitely.
Mucosal damage can interfere with absorption cheap baclofen 10mg with amex spasms on right side of head, induce secretion and affect motility buy baclofen 25mg online spasms below middle rib cage, all of which contribute to diarrhea order 10mg baclofen with visa xanax muscle relaxant dosage. Infectious Diarrhea Microbes cause diarrhea either directly by invasion of gut mucosa or indirectly through elaboration of different types of toxins: Secretory enterotoxins, cytotoxins and inflammatory mediators. I) Secretory toxin induced diarrhea Patients seldom have fever or major systemic symptoms. Examples: a) Vibrio cholerae produces enterotoxins which stimulate adenylate cyclase which results in massive intestinal secretion. Examples: a) Shigella dysenterae produces Shiga toxin which causes destructive colitis. Common causes include : Acute shigellosis Feaco-orally transmitted, as few as 10 - 100 bacteria are enough to cause diarrhea Initially multiplies in the small intestine causing secretary diarrhea. Acute Salmonellosis Transmitted by ingestion of contaminated meat, dairy or poultry products. This is in marked contrast to the 3 - 4 wks febrile illness caused by Salmonella typhi and paratyphi, which are not usually associated with diarrhea. Campylobacter jejuni It may be responsible for up to 10% of acute diarrhea world wide. Norwalk and Rota viruses Invade and damage villous epithelial cells Cause diarrhea by interfering with absorption through selective destruction of absorptive villous tip cells with sparing of secretary crypt cells. Cysts or trophozoites can be identified in the stool, and treatment should be given in both cases. They may cause voluminous life threatening diarrheal diseases in patients with acquired immunodeficiency syndrome. Evaluation of a patient with diarrhea Careful interview of patients with diarrhea contributes in etiologic diagnosis, evaluation of severity of illness, and in designing treatment and preventive measures. Thus, the history should include Duration of illness: if the diarrhea lasts for 2 - 4 wks, acute diarrheal diseases are said to exist. However, if it lasts for more than 4 wks, consider chronic diarrheal diseases and infectious causes are unlikely. Bloody diarrhea is usually inflammatory or ischemic in origin and caused by invasive organisms, ulcerative colitis, or neoplasms Volume of diarrhea Large volume diarrhea indicates small bowel or proximal colonic diseases Scanty, frequent stools associated with urgency suggest left colon or rectal diseases Any association with specific meal? If diarrhea is associated with intake of Fat it is due to fatty intolerance Sweet diet it is due to osmotic diarrhea Milk and milk products - it is due to lactase deficiency Is there history of drug intake? Laxatives Chemotherapeutic agents 7) Presence of underlying diseases (like diabetes mellitus) or systemic symptoms Physical examination: Assess severity of dehydration, Wight loss and other associated signs in patient with chronic diarrhea. Diagnosis: Laboratory tests: 1) Culture and sensitivity testing to detect a pathogenic bacterial strains. Proctosigmoidoscopy: to exclude of confirm the diagnosis of inflammatory bowel diseases. Rehydration In patients with massive diarrhea and vomiting with hypotension intravenous fluids like Ringers lactate or Normal saline should be given in adequate amount. Antimicrobial therapy Antibiotics: Most acute infectious diarrheal diseases do not require antibiotic therapy because majority of them are self limited and viral in nature. In immunocompromized patients continue maintenance dose of the same drug three times a week. Anemia Learning objectives: At the end of this topic the student we be able to:- 1. Evaluate cases of anemia with appropriate history, physical examination and proper laboratory studies 4. Anemia: General approach a) Definition Functional definition: A significant reduction in red cell mass and a corresponding decrease in the 02 carrying capacity of the blood. For instance; 389 Internal Medicine Hgb or Hematocrite could be falsely elevated ( plasma volume) e. Clinical approach to the Patients with anemia Anemia is a manifestation of an underlying pathological condition. Multifactorial : a combination of these History: Accurate history provides information crucial to the diagnosis of the underlying cause. Cardiovascular adjustment Increased in cardiac output occurs at Hgb level of 7-8 gm% : the increased in cardiac output coupled with modest tachycardia creates a hyperdynamic state and hence systolic ejection murmur Peripheral vascular resistance decreases there by facilitating tissue perfusion; clinically is evidenced by wide pulse pressure. Local changes in tissue perfusion: Redistribution of blood flow to vital organs at the expense of reduced blood flow to less vital organs. Reduction of mixed venous O2 tension to increases the arteriovenous O2 difference O2 extraction at peripheral tissues 393 Internal Medicine Individuals tend to survive at extremely low hemoglobin levels (even as low as 3 gm %) due to these compensatory mechanisms. Therapeutic considerations and indications In the management of anemic patients carefully remember the following points Identify and correct the cause of anemia Administration of Hematinines such as Iron, Vit B12 or folate without correct diagnosis of the cause of anemia is an unacceptable practice in the treatment of anemia Therapeutic modalities include: Iron, folate, Vit. Identify possible reasons for inadequate response to therapy and indications for parenteral iron administration 8. Iron deficiency anemia Hypo chromic microcytic cells Etiologies of Iron deficnecy Anemia 1. Increased demands Prematurity in newborns Rapid growth ( as in adolescent ) growth spurt Pregnancy 3. Poor diet Contributory factor in many countries but rarely sole cause Clinical manifestation: Is insidious in onset and progressive in course Patients often present with nonspecific symptoms mentioned above with/without some specific symptoms. Inadequate response may imply Continuing hemorrhage non compliance to therapy Wrong diagnosis Mixed deficiency associated folate or vit. Inability or unwillingness to take orally Iron-dextran complex or iron sorbitol citrate can be used Intra-muscularly or intra-venous route. Correction of reversible contributors (iron, folate, cobalamine supplements if necessary) C) Sideroblastic anemia: Refractory anemia with hypochromia with marrow iron Many pathological ring sideroblasts are found in the bone marrow Is caused by defect in hem synthesis Classification: Hereditary (sex linked recessive trait) Acquired 399 Internal Medicine o Primary :Myelodysplasia o Secondary : - Malignant diseases of the marrow - Drugs e. Macrocytic Anemia Learning objectives: at the end of the student will be able to:- 1. Understand the management of Megaloblastic anemia and asses response to therapy properly Megaloblastic Anemia and other Macrocytic Anemia Pathogenesis: Its a descriptive morphologic term in which maturation of the nucleus is delayed relative to that of cytoplasm. Abnormalities of vitamin B12 or folate metabolism, transcobalamine deficiency, antifolate-drugs 4. B12 deficiency 1) Nutritional: especially in vegans 2) Malabsorption a) Gastric causes i) Adult (addisonian) pernicious anemia ii) Congenital lack or abnormality of intrinsic factor iii) Total or partial gastrectomy b) Intestinal causes i) Intestinal stagnant loop syndrome, jejunal diverticulosis, blind loop, stricture etc. Vit B12 Deficiency: is treated with Hydroxocobalamine which is given parentraly Dose: Initial dose: 6 x 1000 g over 2-3 weeks and Maintenance : 1000 g every 3 months Prophylactic therapy is indicated in patients with Total gastrectomy and Ileal resection 2. Folate deficiency: is treated with Folic acid preparation which is given orally Dose: 5 mg Po daily Prophylactic therapy is indicated in pregnancy, sever hemolytic anemia, in patients with dialysis, and premature newborns 3. Additional measures: Correct underlying cause Antibiotics for bacterial over growth and treatment of fish tapeworm Response to therapy Feeling of general well being is restored in 48 hrs Reticulocytosis begins in 3-4 days and peaks in 7-10 days. Leukemias Learning Objective: At the end of this unit the student will be able to 1) Define leukemia 2) Classify the different types of leukemias 3) Describe the possible etiologies and epidemiology of leukemia. Cell of origin : there are two types of leukemias Lymphoid leukemias Myeloid leukemias 2. But studies have demonstrated that both genetics and environmental factors are important in the causation of these diseases. Genetics There is a greatly increased incidence of leukemia in the identical twin of patients with leukemia. Environmental factors like Ionizing radiation: The relation between acute leukemia and ionizing radiation, has been established in those having occupational radiation exposure, patients receiving radiotherapy and Japanese survivors of atomic bomb explosions.
Those with Type 1 diabetes have to balance the risks of hypoglycaemia against the longer-term risks of hyperglycaemia cheap baclofen 10 mg on line muscle relaxant menstrual cramps. Those with Type 2 diabetes usually need to make changes in their lifestyle cheap 10 mg baclofen with visa spasms below middle rib cage, but this can be difficult to do if the individual does not feel ill or the impact of not doing so does not have immediate repercussions cheap 10mg baclofen with visa spasms sleep. People who take on greater responsibility for the management of their diabetes have been shown to have reduced blood glucose levels, with no increase in severe hypoglycaemic attacks, a marked improvement in quality of life and a significant increase in satisfaction with treatment. However, for a range of reasons, a significant proportion of people with diabetes do not understand key elements of their diabetes care. Additionally a diagnosis of diabetes can lead to poor psychological adjustment, including self-blame and denial, which can create barriers to effective self- management. The diagnosis can also create or reinforce a sense of low self-esteem and induce resistance and depression. While the health benefits of self-management and care are clear, a commitment to the person with diabetes having choice, voice and control over what happens to them means that this must be balanced with their autonomy in choosing how they live their life with diabetes. The health professionals role is to ensure that choices are informed by an understanding of, and information about, the risks and consequences of the choices being made. The provision of information, education and psychological support that facilitates self- management is therefore the cornerstone of diabetes care. People with diabetes need the knowledge, skills and motivation to assess their risks, to understand what they will gain from changing their behaviour or lifestyle and to act on that understanding by engaging in appropriate behaviours. Other beneficial factors include: q a family and social environment that supports behaviour change: families and communities provide both practical support and a framework for the individuals beliefs q the tools to support behaviour, for example, affordable healthier food options both at home and in the workplace q active involvement in negotiating, agreeing and owning goals 22 National Service Framework for Diabetes: Standards q knowledge to understand the consequences of different choices and to enable action. The Long Term Conditions Care Group Workforce Team, set up by the Department of Health, will review and make recommendations in this area. Standard 4 All adults with diabetes will receive high-quality care throughout their lifetime, including support to optimise the control of their blood glucose, blood pressure and other risk factors for developing the complications of diabetes. For most people with diabetes, coming to terms with their lifelong condition will be challenging. They may grieve for the loss of earlier identities as a healthy person and will need to adjust to the fact that they have a long-term condition, the treatment of which may involve fundamental changes in their lifestyle if they are to reduce their risk of developing long-term complications. Key to this will be their ability to control their blood glucose and, where necessary, to reduce their blood pressure. The treatment and care required will vary as peoples length of time living with diabetes increases and as they negotiate major life events. There is robust evidence that meticulous blood glucose control can prevent or delay the onset of microvascular complications. However, this requires effort and dedication on the part of the person with diabetes and the health professionals working with them. For people with Type 1 diabetes, insulin is the mainstay of blood glucose management and is essential for survival. Up to 70% of adults with Type 2 diabetes have raised blood pressure and more than 70% have raised cholesterol levels. Both increase the risk of developing cardiovascular disease as well as microvascular complications. Pre-menopausal women with diabetes do not have the same protection against coronary heart disease as other pre-menopausal women. Tight blood pressure control improves health outcomes in people with Type 2 diabetes. Results for people with Type 2 diabetes who participated in trials to assess the effectiveness of lipid-lowering therapy suggest that a reduction in cholesterol levels may also reduce their risk of cardiovascular 24 National Service Framework for Diabetes: Standards events. Stopping smoking is one of the most effective ways of reducing the risk of developing cardiovascular disease and also reduces the risk of developing microvascular complications. This is particularly so when combined with interventions targeted at the health professionals providing diabetes care, such as reminders to undertake annual reviews, the provision of guidelines and the opportunity to participate in continuing education. Key Interventions q Improving blood glucose control reduces the risk of developing the microvascular complications of diabetes in people with both Type 1 and Type 2 diabetes. Standard 6 All young people with diabetes will experience a smooth transition of care from paediatric diabetes services to adult diabetes services, whether hospital or community-based, either directly or via a young peoples clinic. Children and young people with diabetes are subject to all the normal pressures and pleasures of physical, emotional and social development. Their needs as an individual within a family or family system, and the role of their parents or carers and siblings in sustaining them from initial diagnosis through childhood to independence, are key. Those who develop Type 1 diabetes require lifelong insulin replacement therapy, which will need to be regularly adjusted as they grow. Good blood glucose control is essential for normal growth and development and to avoid the acute long-term complications of diabetes. The optimisation of diabetes control is also important for their intellectual and educational attainment. While physical maturity will be largely complete by the late teens, young people continue forming their identities into early adulthood. During this period, they face unique pressures to conform to social, cultural and sexual norms, which may challenge their ability to manage their diabetes. There has been a steady rise in the incidence of diabetes in children and young people in recent decades. The majority of children and young people with diabetes have Type 1 diabetes and the risk of developing Type 1 diabetes is similar for all ethnic groups. However, Type 2 diabetes is also increasingly being diagnosed in young people, particularly in those from minority ethnic groups. People who develop diabetes in childhood can have a reduced life expectancy their lifespan may be reduced by as much as 20 years and many develop the long-term complications of diabetes, such as nephropathy and retinopathy, before they reach middle age. Parents of young children with diabetes need to be actively involved in the day-to- day diabetes management of their children. Others, such as staff in nurseries and schools, will also be involved in the day-to-day care of children and young people with diabetes. Children and young people with diabetes need the support of a health service not only expert in child health and diabetes, but also able to support them through the transitions from childhood through adolescence to adulthood. Diabetes is often more difficult to control during the teenage years and in early adult life due both to the hormonal changes of puberty and to the emotional roller-coaster that often characterises adolescence. Young people have higher rates of diabetic emergencies and death rates are significantly higher than in young people without diabetes. Greater effort is required to ensure effective diabetes control at this time than at any other stage of life both by health professionals and by young people themselves. The transfer of young people from paediatric diabetes services to services for adults with diabetes often occurs at a sensitive time for the individual concerned, both personally and from the point of view of their diabetes. Many find the culture change unacceptable and non-attendance rates at adult diabetes clinics are often higher in young people and young adults. This may be exacerbated when young people leave home and adopt more mobile lifestyles. The forthcoming Childrens National Service Framework will identify issues relevant to the delivery of all childrens services. The Childrens National Service Framework will complement the National Service Framework for Diabetes.
B. Finley. Apache University.