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By J. Urkrass. Benedictine University.

If blood ow is not restored discount 100mg lady era overnight delivery, a progression to in- farction and necrosis necessitates bowel resection discount lady era 100mg fast delivery. Chronic intestinal ischaemia Denition Slow progressive ischaemia of the gut due to atheroma Ischaemic colitis generally occurring in the elderly. Denition Ischaemia of the colon due to interruption of its blood Aetiology supply. Risk factors: r Fixed: Age, sex, positive family history, familial hyper- Aetiology In most cases the underlying cause is thrombosis of the lipidaemia. Pathophysiology In around half the ischaemia is transient with damage Pathophysiology connedtothemucosaandsubmucosa. Thesplenicex- Progressive atheroma occludes the lumen of the vessels ure is most often affected due to the territories of the causing reduced blood ow. If the blood supply is not depends on the position and degree of occlusion and the restored, ischaemia progresses to gangrenous ischaemic presence of collateral blood supply. Clinical features Patients describe pain occurring after food, weight loss, Clinical features malabsorption and signs of vascular disease. The patient presents with lower abdominal pain, nausea, vomiting and bloody diarrhoea. There is lower abdom- Investigations inal tenderness and guarding in the lower abdomen. Microscopy Management There is ischaemic loss of mucosa, ulceration and later Surgical revascularisation depends on the results of an- healing with oedema and inammatory inltrate. Denition Complete necrosis and gangrene of the midgut resulting Aetiology from cessation of blood ow in the superior mesenteric r Squamous carcinoma accounts for more than 90% of artery. These usually occur in the middle third of the oesophagus although the lower third may also be af- Clinical features fected. Aetiological factors include high alcohol con- There may be a preceding history of non-specic symp- sumption, smoking and chewing betel nuts. Signs of acute intestinal failure include ab- affects the lower third of the oesophagus particularly dominal tenderness, guarding, loss of bowel sounds and the gastrooesophageal junction possibly following ep- rigidity, due to perforation. Calcication within the abdominal aorta may be evident r Familial forms have been noted. Gas lled, thickened, dilated bowel loops and free gas within the peritoneal cavity due to Pathophysiology perforation may also be seen. Following adequate resuscitation laparotomy and resec- tion(whichmaybemassive)arerequired. Patients may present with progressive dysphagia, but of- Asecond look laparotomy can be performed 24 hours tenpresent late with weight loss, anaemia and malaise. If Barium swallow demonstrates an apple core defect or the patient survives they have considerable malabsorp- stricture without proximal dilatation. In the absence of metastases endoscopic ultrasound is useful to assess operability. Management r Wherever possible surgical resection is the primary Age treatment with those occurring in the lower third Rare below the age of 40 years. Neoadjuvant Denition chemotherapy with cisplatin and 5-uorouracil (5- Malignant tumour of the stomach. Sex Prognosis 2M > 1F Surgical resection carries an operative mortality of up to 20%. Benign gastric tumours Aetiology Denition Pre-malignant conditions include chronic atrophic gas- Benign tumours and polyps of the stomach. These can tritiswithintestinalmetaplasiaandadenomatouspolyps be divided into epithelial and mesenchymal derived tu- of the stomach. Hyperplastic polyps are common overgrowths of gas- r Dietary carcinogens possibly including nitrates and tric mucosa often resulting from the healing of an alcohol. Pathophysiology They have a signicant risk of malignant change most Gastric adenocarcinomas are derived from mucus se- likely in large polyps. Tumours may be of three types: Mesenchymal derived benign tumours: r Ulcerating (most common) with appearance similar r Leiomyomas appear as mucosal or intramural nod- to benign ulcers but with raised edges and no normal ules. Most benign tumours are asymptomatic and found on r Inltrating when brous tissue causes a rm non- endoscopy or barium meal. Rarely bleeding or obstruc- distendable or linitis plastica (leather bottle) stomach. Spread may be direct invasion to the liver and pancreas, Management transcoelomic spread resulting in a malignant ascites Allsuspiciouspolypsrequireexaminationbyendoscopic and ovarian Krukenberg tumour, lymphatic spread to excision biopsy, multiple polyps may require gastric re- regional and distant lymph nodes (Virkows node) and section. There may be dyspepsia or Tumours arising in the mucosa associated lymphoid tis- haematemesis. Dermatomyositis and acanthosis nigricans may be manifestations of an underlying gastric malig- Clinical features nancy. Patients present similarly to gastric adenocarcinoma with non-specic weight loss, anaemia and malaise and Microscopy associated epigastric tenderness.

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Dyspnea on exertion has been found to be the most sensitive complaint generic 100mg lady era with visa, yet the specificity for dyspnea is less than 60% 100mg lady era mastercard. Prevention of deterioration of myocardial function (slowing progression of heart failure ) 5. General measures : Dietary sodium restriction should be implemented in all patients with congestive heart failure to < 3 g/d. Control of the Congestive state Diuretics: are useful in relieving congestion and reduce or prevent edema. Most patients with heart failure have some degree of symptomatic congestion and benefit from diuretic therapy. Usually a loop diuretic is required, with the addition of a Thiazide diuretic in patients refractory to the loop diuretic alone. Loop and thiazide diuretics are useful for symptomatic relief; however they have not been shown to improve survival. Spirinolactone: is an aldosterone inhibitor, reduces mortality in patients with advanced heart failure. Through vasodilatation they reduce the peripheral resistance and after load and improve cardiac performance. Prevention of deterioration of Myocardial function : The following drugs prevent deterioration in myocardial function by inhibiting the neurohumeral mechanism which causes cardiac remodelling and progression of heart failure. It is contraindicated in a patient with creatinine >3mg/dl o Cough Contraindications: o Angioedema or anuric renal failure o Pregnancy o Hypotension 216 Internal Medicine o Creatinine > 265 mol/L (3mg/dl) N. B The first two side effects are serious and necessitate immediate cessation of the drug. Lasortan: Dose: - 25-50 mg once 0r twice daily 3) Beta Adrenorecepter blockers Administration of these drugs with gradually increasing dose has been reported to improve symptoms of heart failure, the need for hospitalization and reduce mortality. Introduction Valvular heart disease from chronic rheumatic fever is still the commonest cardiac disease in the developing world, occurring at the younger age. In contrast, patients with regurgitate valvular lesions require careful echocardiographic monitoring for left ventricular function and may require surgery even if no symptoms are present. However surgical management is unavailable for most patients who are suffering from valvular heart diseases in Ethiopia. Clinical features Initially there is an extended latent period during which the patient is asymptomatic. Later in the disease, the carotid upstrokes become diminished and delayed (parvus et tardus) Echocardiography Echocardiography with Doppler provides an accurate assessment of aortic valve area and transvalvular gradient and also can be used to estimate left ventricular hypertrophy and ejection fraction. Management Medical Therapy: Is not effective and treatments with digitalis or cautiously administered diuretics may only reduce symptoms. Prognosis: The survival of patients with aortic stenosis is nearly normal until the onset of symptoms, when survival rates decrease sharply. Common causes of aortic regurgitation include: Endocarditis Rheumatic fever Collagen vascular diseases Aortic dissection Syphilis Bicuspid aortic valves are also prone to regurgitation. The afterload in aortic regurgitation may be as high as that occurring in aortic stenosis. The initial signs of aortic regurgitation are subtle and may include decreased functional capacity or fatigue. As the disease progresses, the typical presentation is that of left-sided heart failure: orthopnea, dyspnea and fatigue. Over time, however, progressive chamber enlargement with decreased contractility make recovery of left ventricular function and improved survival impossible, even with surgery. Therapy with long acting nifedipine in particular has been shown to delay the need for surgery by two to three years. Compelling evidence supports surgical correction before the onset of permanent left ventricular damage, even in asymptomatic patients. Patients may also present with hemoptysis, signs of right-sided heart failure, and embolic phenomena like stroke. Physical Examination An apical rumbling, mid-diastolic murmur is characteristic and will immediately follow an opening snap, if present. The rumble is loudest in early diastole but, in patients with mild mitral stenosis or mitral stenosis with low cardiac output, the murmur may be difficult to hear. It can be accentuated by placing the patient in the left lateral decubitus position and using the bell of the stethoscope. This compensated phase of mitral regurgitation varies in duration but may last many years. The prolonged state of volume overload may eventually lead to decompensate mitral regurgitation. This phase is characterized by impaired left ventricular function, decreased ejection fraction and pulmonary congestion. The common symptoms are: Fatigue, Exertional dyspnea and orthopnea are the most common complaints. Physical Examination A soft first heart sound ( S1 is generally absent ) and a widely split second heart sound may be present. Echocardiography Echocardiography can be used to determine the etiology and morphology of mitral regurgitation, which are important in determining suitability for mitral valve repair.

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Diabetes Care 2006 cheap 100mg lady era amex;29:1918 once-weekly dulaglutide in patients with type 2 diabetes aged 65 and <65 20 buy lady era 100mg low cost. Lixisenatide therapy in older patients tion with metformin, is effective and well tolerated in treatment-naive elderly with type 2 diabetes inadequately controlled on their current antidiabetic treat- patients with type 2 diabetes. Lixisenatide in patients with type 2 dia- and safety of sitagliptin in elderly patients with type 2 diabetes: Post hoc betes and acute coronary syndrome. Ecacy and safety of canagliozin com- treatments: A randomised, double-blind, placebo-controlled trial. Lancet pared with placebo in older patients with type 2 diabetes mellitus: A pooled 2013;382:141323. Ecacy and safety of canagliozin treat- 1, 2 and 3 studies: Glycaemic control and hypoglycaemia with new insulin ment in older subjects with type 2 diabetes mellitus: A randomized trial. Optimizing insulin absorption and insulin injection taneous insulin infusion and multiple daily injections of insulin on glucose vari- technique in older adults. A short easy test can detect ability neous insulin infusion in older patients with long-standing type 1 diabetes. Pre-lled insulin pen in newly insulin- and safe in elderly and young type 1 diabetes patients. Systolic Hypertension in the Elderly Program Coop- of biphasic insulin aspart in elderly type 2 diabetes patients. Systolic Hypertension in China (Syst-China) collabora- injections on blood glucose uctuations in the postprandial period in elderly tive group. Safety and effectiveness of biphasic insulin blockade in older patients with diabetes and systolic hypertension. Comparison of antihypertensive treat- patients with Type 2 diabetes: Ecacy and safety of lispro mix 25 vs. Diabet Med 2009;26:1147 from the Swedish Trial in Old Patients with Hypertension-2. Follow-up of renal function in treated repaglinide and insulin aspart 30 in treating aged type 2 diabetes mellitus. J Clin betes mellitus on glycaemic control with twice-daily injections of biphasic Hypertens (Greenwich) 2004;6:11625. Renal outcomes in high-risk hyperten- Retrospective reanalysis of a 6-month, randomized, open-label, multicentre sive patients treated with an angiotensin-converting enzyme inhibitor or a trial in Japan. Arch Intern subjects: Open label, randomized clinical trial of insulin glargine added to oral Med 2005;165:93646. Arch Intern Med of nine open-label, randomized controlled trials in patients with type 2 dia- 2005;165:14019. Effects of angiotensin-converting enzyme inhibition with perindopril combined with Glucobay treatment in elderly patients with type 2 diabe- on left ventricular remodeling and clinical outcome: Results of the random- tes mellitus controlled by oral hypoglycaemic agents: A randomized study. Cardiovascular events during differ- insulin versus premixed insulin alone in randomized elderly patients with type 2 ing hypertension therapies in patients with diabetes. Effects of ramipril detemir than with neutral protamine hagedorn insulin in older persons with on cardiovascular and microvascular outcomes in people with diabetes mel- S294 G. Intervention to decrease glyburide use in lowering treatment: Prospective meta-analysis of data from 90,056 participants elderly patients with renal insuciency. Diabetes management in the nursing home: A system- simvastatin on stroke and other major vascular events in 20536 people with atic review of the literature. Prevalence of diabetes and the in 20,536 high-risk people: A randomised placebo-controlled trial burden of comorbid conditions among elderly nursing home residents. Guidelines for improving the care of of cholesterol lowering with simvastatin in 20,536 high-risk individuals: the older person with diabetes mellitus. Dia- aged 6575 years at randomization: Collaborative Atorvastatin Diabetes Study betes Spectr 2014;27:920. Undiagnosed diabetes mellitus and meta- Group, The Antihypertensive and Lipid-Lowering Treatment to Prevent bolic control assessed by HbA(1c) among residents of nursing homes. Major outcomes in moderately hypercholesterolemic, hyper- Endocrinol Diabetes 2001;109:3269. National glucose-lowering treatment com- atorvastatin in 2,532 patients with type 2 diabetes: Anglo-Scandinavian Cardiac plexity Is greater in nursing home residents than community-dwelling adults. Effects of combination lipid residents with non-insulin-dependent diabetes mellitus. The use of a no-concentrated-sweets diet with type 2 diabetes mellitus: The Fenobrate Intervention and Event Low- in the management of type 2 diabetes in nursing homes. Successful use of a sucrose-containing erectile function in elderly patients with erectile dysfunction: A subgroup enteral formula in diabetic nursing home elderly. Lispro insulin treatment in comparison with regular human insulin tes: A multicenter double-blind placebo-controlled xed-dose study. Type 1 and type 2 diabetes and incident hip frac- nursing home patients with tight glycaemic control.

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Int J Clin Pract Frequency and determinants of erectile dysfunction in 1999 safe lady era 100 mg;Supplement order 100mg lady era with visa. The Scandinavian Prostate Cancer Group Ozdel O, Oguzhanoglu A, Oguzhanoglu N K et al. Sympathetic methylprednisolone on return of sexual function after nerve- activation by sildenafil. The role of endothelial dysfunction in the pathophysiology of erectile Pittler M, Ernst E. Trials have shown yohimbine is dysfunction in diabetes and in determining response to effective for erectile dysfunction [14]. Clinical sildenafil on retinal blood flow and flicker-induced & Laboratory Haematology 2004;26(5):335-340. General quality of life 2 years following treatment for prostate cancer: what influences Pollack Mark H, Reiter Stewart, Hammerness Paul. Sexuality and intimacy following radical prostatectomy: Patient Pomara G, Morelli G, Montorsi F et al. Vardenafil for the treatment of erectile dysfunction: A critical review of Perimenis P, Athanasopoulos A, Papathanasopoulos P et al. Gabapentin in the management of the recurrent, refractory, Eur Urol 2005;47:612-21 (multiple letters). Drug devices for intracavernosal pharmacotherapy: operational Benefit Trends 2002;14(10):33+40 classification and safety considerations. Eau Update Series moclobemide and doxepin in major depression with special 2004;2(2):56-63. Re-dosing of prostaglandin-E1 versus prostaglandin-E1 plus phentolamine in male erectile Philipp M, Tiller J W G, Baier D et al. Int moclobemide with selective serotonin reuptake inhibitors J Impot Res 2000;12(2):134-135. Switching to moclobemide and Safety of Once-a-Day Dosing of Tadalafil 5 mg and 10 mg to reverse fluoxetine-induced sexual dysfunction in in the Treatment of Erectile Dysfunction: Results of a patients with depression. Thalidomide and to reverse fluoxetine-induced sexual dysfunction in sexual dysfunction in men. Aldosterone antagonism: An emerging strategy for effective Reyes J A, Tan D A, Quimpo J A et al. Journal of Psychiatric Practice pituitary magnetic resonance imaging in men with 2004;10(6):375-385. Oral terbutaline in the management of pharmacologically induced prolonged erection. Int J Androl 2001;7(5):302 findings from a prospective, multi-institutional, phase 305. Cardiology and erectile dysfunction receiving intracavernous injection vascular disorders. Quality of therapy in acute promyelocytic leukemia and beyond: From life in patients with erection difficulties: Evaluation of bench to bedside. Overview of phosphodiesterase 5 Dehydroepiandrosterone treatment in the aging male - inhibition in erectile dysfunction. The efficacy of tadalafil in improving sexual satisfaction and overall satisfaction Safarinejad M R. Prevalence and risk factors for in men with mild, moderate, and severe erectile dysfunction: A erectile dysfunction in a population-based study in retrospective pooled analysis of data from randomized, placebo- Iran. A sexually compulsive male with AndroGel (testosterone gel) with sildenafil to treat erectile erectile dysfunction treated with Viagra: Case report. Safety pathophysiology of erection: Consequences for and tolerability of oral erectile dysfunction treatments in the present medical therapy of erectile dysfunction. Sildenafil medical and scientific meeting: From diabetes to mixed preserves intracorporeal smooth muscle after radical hyperlipidaemias. Effect of lifestyle changes on erectile of prostaglandin E1 on erectile dysfunction. From aspiration to achievement: action of neurotropin for penile pain associated with Assessment and noninvasive treatment of erectile intracavernous injection of prostaglandin E1 assessed using the dysfunction in aging men. Male and female sexual function and therapy and surgical therapy in diabetic patients with erectile dysfunction; andrology. Journal of Sex Education & Hypergonadotropic Hypogonadism as First Evidence of Therapy 1991;17(4):283-289. Two additional uses for sildenafil Schiavi Raul C, Schanzer Harry, Sozio Giampaolo et al. Sexual function in patients taking bupropion after autologous blood or marrow transplantation.

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