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Clinical features Investigations Palpitations with an associated rapid buy cheap clarithromycin 250 mg line, regular pulse rate best 500 mg clarithromycin. In addition anti-arrhythmic drugs may be required to Management controlanytachycardia discount clarithromycin 250mg otc. Atrial arrhythmias Sinus node disease Atrial ectopic beats Denition Sinusnode disease or sick sinus syndrome is a tachy- Denition cardia/bradycardia resulting from damage to the sinus Atrial ectopic beats include extrasystoles and premature node. Aetiology/pathophysiology Aetiology Sinusnode disease is relatively common in the elderly Atrial ectopics are common in normal individuals. All dueto ischaemia, infarction or degeneration of the sinus cardiac cells have intrinsic pacemaker ability. The condition is characterised by prolonged in- ually depolarise until a threshold is reached at which tervals between consecutive P waves (sinus arrest) and point rapid depolarisation occurs and a cardiac action periods of sinus bradycardia. This is most rapid in the sinoatrial may allow tachycardias (typically atrial brillation) from node, the normal pacemaker of the heart. This combination of fast and slow or group of cells the gradual depolarisation is more rapid supraventricular rhythms is known as tachy-brady syn- than usual, or if the voltage threshold for rapid depolar- drome. Clinical features Atrial utter presents with palpitations, dizziness, syn- Investigations cope or cardiac failure. Massage of the Management carotid sinus causes a transient increase in block with Atrial ectopic beats do not require treatment, although consequent slowing of the ventricular rate. If atrial ectopic beats are fre- Investigations quent they may progress to other atrial arrhythmias. Atrial utter produces a characteristic regular sawtooth utter waves at a rate of 300 bpm seen best in lead V1. Atrial utter is a rapid atrial rate between 280 and 350 bpm, most commonly 300 bpm. It may be caused by thyro- logical assessment, recurrence may be prevented by ra- toxicosis. Normally once a cardiac cell has been depolarised it is refractory to re-stimulation for a short period. This pre- vents waves of cardiac depolarisation owing in a retro- Atrial brillation grade direction. If, however, the conduction through the myocardiumisslow(usuallyduetomyocardialdamage), Denition adjacent cells may have recovered from their refractory Atrial brillation is a quivering of atrial myocardium period allowing restimulation and hence the formation resulting from disordered electrical and muscle activity. Incidence rate,inthe elderly who depend on atrial function to Common achieve sufcient ventricular lling, or if there is associ- ated signicant cardiac damage. Patients may Sex present with palpitations, acute cardiac failure or the M > F gradual onset of increasing shortness of breath. On ex- amination there is an irregularly irregular pulse with Aetiology varying pulse volume. There is also loss of the a wave of Causes may be divided into cardiac and systemic. Inacuteatrialbrillation,underlyingischaemia ease, mitral valve disease, cardiomyopathies and pul- such as a recent myocardial infarction or unstable monary disease. Thelonger the atrial brillation has been present, merous circuits have different cycle times, the result is a the less the likelihood of restoring sinus rhythm. Digoxin does not missions, but an irregularly irregular pulse of between prevent recurrence. Atrial brilla- r Control of the ventricular rate is achieved with drugs tion may be paroxysmal with attacks lasting minutes to such as digoxin, calcium channel blockers and/or - hours. Aetiology/pathophysiology The majority of junctional tachycardias are due to re- Investigations/management entry circuits. If Usually there is a slow anterograde pathway from atria the retrograde pathway is slow with delayed atrial con- to ventricles and a fast retrograde pathway back to the traction, inverted P waves appear between complexes. The re- may produce an immediate cessation of the arrhyth- entrant circuit is concealed as it slow, close to the mia. Complications Aetiology Sudden cardiac death may rarely occur if atrial brilla- Abnormalconnectionbetweenatriumandventricle(e. Pathophysiology Management r Re-entrant tachycardias are treated with drugs that NormallythefastconductionthroughthebundleofKent allows the adjacent area of ventricle to be rapidly depo- block retrograde conduction through the accessory larised (preexcitation), whilst the remainder of the ven- pathway, e. Verapamil and digoxin are contraindicated as two pathways may form a re-entry circuit with the fast they accelerate anterograde conduction through the accessory pathway causing a retrograde stimulation of accessory pathway. Clinical features Prognosis In sinus rhythm Wolff Parkinson White syndrome is With age the pathway may brose and so some patients asymptomatic. Denition Aventricular ectopic/extrasystole/premature beat is an extramyocardial depolarisation triggered by a focus in Prognosis the ventricle. Ventricular ectopics worsen the prognosis in patients with underlying ischaemic heart disease but there is no evidence that anti-arrhythmic drugs improve this.

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Correlation between maximal acid output (15-60) minutes and change in urine acid output/hr is -0 order clarithromycin 250 mg with visa. Since the results of both noninvasive and invasive tests were well correlated purchase clarithromycin 500mg with visa, it was concluded that Oral Magnesium Breath Hydrogen Concentration and urine acid output determination (non-invasive tests) can be used as alternative to Ryle s tube intubation (invasive test) in studying the gastric acid secretion discount clarithromycin 250mg with mastercard. After overnight fasting, they ingested 150mg of Magnesium Mg metal suspended in 3ml of glucose and 100ml of 7% ethanol on the first day and alcohol without Mg on second day. Another 11 samples of gastric juice and breath H2 were collected after meal for 180 minutes at 15 minutes intervals. Correlation between maximal acid output (45-90 minutes) and urine acid output per/hr is 0. Since the results of both non-invasive and invasive test were well correlated, it was concluded that Ryle s tube intubation (invasive) can be replaced by non invasive test (Oral Magnesium Breath Hydrogen Test and urine acid output determination) in studying the gastric acid secretion. In this paper the causes of such a problem, their common clinical presentation, diagnosis and different forms therapy are presented as encountered in one s own clinical experience during the past 25 years. This study is aimed to determine the factors which contribute to or associated with early post-operative mortality and morbidity in perforated peptic ulcer disease. In the univariate analysis, factors associated with increase morbidity and mortality were; (1) older age (p=<0. Serum creatinine level is the most significant prognostic factor regarding post operative complications. In view of the influence on morbidity and mortality of factors in this study, risk stratification of patients with perforated peptic ulcers may facilitate their management and improve survival rates. Review of the literature discloses an apparent propensity of these tumors to occur in any age group and had no predilection for either sex and to be associated with upper gastrointestinal bleeding. The importance of sub-clinical malabsorption as a contributing factor to poor nutrition is poorly documented as is its pathogenesis. This thesis evaluates the absorption of rice carbohydrate with respect to 123 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar nutritional status and examines the factors affecting the relationship. Prevalence of rice malabsorption is explored, as is that of another carbohydrate, lactose. Intestinal permeability studies were undertaken, and the concept of altered transit time and its influence on the absorption studied. The impact of sub-clinical malabsorption and its effect on stool frequency was explored and attempts made to correlate abnormalities in the small bowel intestinal mucosal morphology with altered absorption. These changes were set against a background of the general growth pattern of Myanmar children over the past 50 years. Intestinal permeability indices were impaired even in healthy children and small intestinal mucosa abnormalities were detected even at a very young age. However, the bowel function and orocaecal transit time differ little from that of European children. Conclusion: Rice carbohydrate malabsorption is common, as is malabsorption of the disaccharide, lactose. Lactose malabsorption is common at an early age, implying abnormalities of small bowel function and morphology. Small bowel bacterial overgrowth has been documented and associated with rice malsborption, this in turn having an impact on deficits of height, weight and nutritional indices. Abnormalities of small intestinal mucosa have been documented at an early age and there has perhaps been sub-optimal nutrition in Myanmar during the past 50 years. Sub-clinical malabsorption appears to have no impact on the frequency of defaecation. It is likely that improvement in absorption and nutritional indices will depend upon improvements in hygiene, sanitation and health education. Emphasis is made on the research findings which will be of interest to the medical practitioners at the primary and secondary health care levels. A field study was performed to determine the prevalence of lactose malabsorption in Myanmar children and to evaluate the possibility of using breath methane excretion to indicate lactose malabsorption in a field situation. A hydrogen breath test after a lactose meal (2g/kg, maximum 50g) was used as a standard test. Lactose malabsorption was more prevalent when children were weaned before 4 months of age (87. Compared with lactose-tolerant children, those with lactose malabsorption had significantly higher concentrations of breath hydrogen excretion 60 minutes after the lactose test meal. Breath methane excretion was also significantly higher in samples at 120 minutes in children with lactose malabsorption. Breath methane excretion of greater than or equal to 2 parts per million at 180 minutes as a diagnostic test for lactose malabsorption had a sensitivity of 61. The diagnosis is dependent on the use of rice breath hydrogen test which has potential limitations.

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Elfriede Grabner discount clarithromycin 250mg without prescription, Volksmedizin: Probleme und Forschungsgeschichte (Darmstadt: Wissenschaftliche Buchgesellschaft discount clarithromycin 500 mg online, 1974) buy clarithromycin 250mg fast delivery, provides an anthologv of critical studies on the history of ethnomedicine. Muhlmann, "Das Problem der Umwelt beim Menschen," Zeitschrift fr Morphologia und Anthropologia 44 (1952): 153-81. Arnold Gehlen, Die Stele im technischen Zeitalter, Sozialpsychologische Probleme in der industriellen Gesellschaft (Hamburg: Rowohlt, 1957). Ackerknecht, "Natural Diseases and Rational Treatment in Primitive Medicine," Bulletin of the History of Medicine 19 (May 1946): 467-97, is a dated but still excellent review of the literature on the functions of medical cultures. Ackerknecht provides convergent evidence that medicine plays a social role and has a holistic and Unitarian character in primitive cultures that modern medicine cannot provide. Fred Binder, Die Brotnahrung: Auswahl-Bib-liographie zu ihrer Geschichte und Bedeutung, Donau Schriftreihe no. Lucia, Wine and the Digestive System: A Select and Annotated Bibliography (San Francisco: Fortune House, 1970). Michler, "Das Problem der westgriechischen Heilkunde," Sudhoffs A rchiv 46 (1962): 141 ff. Heyer- Grote, Atemschulung als Element der Psychotherapie (Darmstadt: Wissen- schaftliche Buchgesellschaft, 1970). Kilton Steward, "Dream Theory in Malaya," Complex: The Magazine of Psychoanalysis and Related Matters 6 (1951): 21-33. Writing towards the end of the 15th century Ibn Khaldun observed the conflict between the craft of medicine required by sedentary culture and its luxury and Bedouin medicine, which was based mainly upon tradition and individual experience. Carlyle suggests that both ideas first took recognizable form in the toast of the victorious Alexander to the homo-ousia (like-naturedness) of men. Combined with the idea of progress, the Utopia of healthy mankind came to prevail over the ideal of concrete and specific patterns of functioning characteristic for each tribe or polis. Sidney Pollard, The Idea of Progress: History and Society (New York: Basic Books, 1968), deals with the ideology of human progress in relation to concrete history and the politico-economic aspects complementing philosophy. Ashburn, The Ranks of Death: A Medical History of the Conquest of America (New York: Coward-McCann, 1947). No comprehensive study of the imperialism of European medical ideology in Latin America is available. For a first orientation, see Gonzalo Aguirre Beltran, Medicina y magia: El proceso de aculturacin en la estructura colonial (Mexico: Institute Nacional Indigenista, 1963). Wilhelm Scherer, Der Ausdruck des Schmerzes and der Freude in der mittelhochdeutschen Dichtung der Bltezeit (Strassburg, 1908). Ernst Hannes Brauer, Studien zur Darstellung des Schmerzes in der antiken bildenden Kunst Griechenlands and Italiens, inaugural dissertation, Univ. People differ in the intensity with which they modulate experience; some reduce and others increase what is perceived, including pain. Jarvik, "Relationship Between Superficial and Deep Somatic Threshold of Pain, with a Note on Handedness," American Journal of Psychology 77 (1964): 589-99. Contains much information on the impact of culture on the level of fear and the relationship between fear and the pain experience. Beecher, Measurement of Subjective Responses: Quantitative Effects of Drugs (New York: Oxford Univ. Opiates exert their principal action, not on the pain impulse, which is transmitted through the nervous system, but on the psychological overlay of pain. Severe postsurgical pain can be relieved in about 35% of patients by giving them a sugar or saline tablet instead of an analgesic. Since only 75% are relieved under such circumstances with large doses of morphine, the placebo effect might account for 50% of drug effectiveness. Scott, "The Effect of Early Experience on the Response to Pain," Journal of Comparative and Physiological Psychology 50 (April 1957): 155-61. On the importance and practical utility of religion and superstition in early modern England in the relief of suffering. Jahrhundert in ihren Vorraussetzungen und Folgen," Medizinhistorisches Journal 6 (1971): 707-61. Ferdinand Sauerbruch and Hans Wenke, Wesen und Bedeutung des Schmerzes (Berlin: Junker & Dnnhaupt, 1936). An invaluable guide to the history of physiology since the 16th century, which comes as close as possible to a history of the medical perception of pain. Rothschuh, Vm Boerhaave bis Berger: Die Entwicklung der kontinentalen Psychologie im 18. Jahrhundert mil besonderer Beruecksichtigung der Neurophysiologie (Stuttgart: Fischer, 1964). Frenzen, Klagebilder und Klagegebrden in der deutschen Dichtung des hfischen Mittelalters, dissertation, Univ.