By R. Boss. California State University, Long Beach.
The basics of the potential role of genetic information in therapeutic decision making discount 750 mg cephalexin. Accessing and utilizing discount cephalexin 500mg, when appropriate buy 250mg cephalexin free shipping, information resources to help develop an appropriate and timely therapeutic plan purchase 250 mg cephalexin. Explaining the extent to which the therapeutic plan is based on pathophysiologic reasoning and scientific evidence of effectiveness buy 500 mg cephalexin with mastercard. Beginning to estimate the probability that a therapeutic plan will produce the desired outcome. Counseling patients about how to take their medications and what to expect when doing so, including beneficial outcomes and potential adverse effects. Recognizing when to seek consultation for additional diagnostic and therapeutic recommendations. Recognizing when to screen for certain conditions based on age and risk factors and what to do with the results of the screening tests. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based consideration in the selection of therapeutic interventions. Demonstrate ongoing commitment to self-directed learning regarding therapeutic interventions. Seek feedback regularly regarding therapeutic decision making and respond appropriately and productively. Incorporate the patient in therapeutic decision making, explaining the risks and benefits of treatment. Respect patients’ autonomy and informed choices, including the right to refuse treatment. Demonstrate an understanding of the importance of close follow-up of patients under active care. Recognize the importance of and demonstrate a commitment to the utilization of other health care professionals in therapeutic decision making. During the internal medicine core clerkship, the student can put into practice some of the ethical principles learned in the preclinical years, especially by participating in discussions of informed consent and advance directives. Additionally, the student learns to recognize ethical dilemmas and respect different perceptions of health, illness, and health care held by patients of various religious and cultural backgrounds. Basic ethical principles (autonomy, beneficence, nonmaleficence, truth- telling, confidentiality, and autonomy). The role of the physician in making decisions about the use of expensive or controversial tests and treatments. Circumstances when it may be unavoidable or acceptable to breach the basic ethical principles. Participating in a preceptor’s discussion with a patient about a requested treatment that may not be considered appropriate (e. Participating in family and interdisciplinary team conferences discussing end- of-life care and incorporating the patient’s wishes in that discussion. Recognize the importance of patient preferences, perspectives, and perceptions regarding health and illness. Demonstrate a commitment to caring for all patients, regardless of the medical diagnosis, gender, race, socioeconomic status, intellect/level of education, religion, political affiliation, sexual orientation, ability to pay, or cultural background. Recognize the importance of allowing terminally ill patients to die with comfort and dignity when that is consistent with the wishes of the patient and/or the patient’s family. Recognize the potential conflicts between patient expectations and medically appropriate care. Therefore, they must master and practice self- directed life-long learning, including the ability to access and utilize information systems and resources efficiently. Key sources for obtaining updated information on issues relevant to the medical management of adult patients. Key questions to ask when critically appraising articles on diagnostic tests: • Was there an independent, blind comparison with a reference (“gold”) standard? Key questions to ask when critically appraising articles on medical therapeutics: • Was the assignment of patients to treatments randomized? Performing a computerized literature search to find articles pertinent to a focused clinical question. Summarizing and presenting to colleagues what was learned from consulting the medical literature. Recognize the value and limitations of other health care professionals when confronted with a knowledge gap. Appropriate care by internists includes not only recognition and treatment of disease but also the routine incorporation of the principles of preventive health care into clinical practice. All physicians should be familiar with the principles of preventive health care to ensure their patients receive appropriate preventive services. Criteria for determining whether or not a screening test should be incorporated into the periodic health assessment of adults. General types of preventive health care issues that should be addressed on a routine basis in adult patients (i.
In more severe disease portal hypertension cephalexin 250mg overnight delivery, low serum r Clear ﬂuid is seen in liver disease and hypoalbu- albumin and other complications occur buy cephalexin 500mg online. Signsofdecompensated cirrhosis: r Ascitic ﬂuid amylase is raised in pancreatic ascites cheap 750 mg cephalexin fast delivery. The progress of ascites can be monitored using repeated Ascites weight and girth measurements order cephalexin 250mg fast delivery. Sodium intake should be restricted but protein and calorie intake should be Deﬁnition maintained purchase cephalexin 250 mg amex. Water restriction is only necessary if the Ascites is the accumulation of ﬂuid within the peritoneal serum sodium concentration drops below 128 mmol/L. The combination of spironolactone and furosemide is effective in the majority of patients. Patients who not Aetiology/pathophysiology respond to this treatment may require Ascites may be a transudate or an exudate dependent on r therapeutic paracentesis, the removal of ﬂuid over a the protein content (see Table 5. If more than1Lofﬂuid is removed then intravenous albumin or plasma expander is re- Clinical features quired to prevent hypovolaemia. Chapter 5: Clinical 189 Investigations and procedures Obstruction r Bilirubin: Raised bilirubin levels indicate abnor- Liver function testing malities in its synthesis, metabolism or excretion. It often rises in causes of obstructive (cholestatic) Liver function testing includes blood tests to look for ev- jaundice, but it is not speciﬁc for obstruction or idence of hepatocyte necrosis, as well as assessing the even for liver disease (see Table 5. For assessing the synthetic function surement is also raised as it shares a similar pathway of the liver, two other blood tests are needed, the pro- of excretion. Alternatively, it is possible to r Aminotransferases: Two are measured, aspartate differentiate the bone and liver isoenzymes. These are raised by most causes of this enzyme even when there is no liver damage. It liver disease, but paradoxically, in severe necrosis may be used to detect if patients continue to drink or in late cirrhosis levels may fall to normal in- alcohol,butitdoeshavealonghalf-life. It falls Haemolysis in both acute and chronic liver disease, although Bilirubin Haemolysis levels may be normal early in the disease. Other osteomalacia, metastases, causes of hypoalbuminaemia include gastroin- hyperparathyroidism) testinal losses or heavy proteinuria. IgM is Albumin Malnutrition Nephrotic syndrome particularly raised in primary biliary cirrhosis, Congestive cardiac failure whereas IgG is raised in autoimmune hepatitis. Parenteral gallbladder, or may be seen after endoscopic or surgical replacementofvitaminKshouldleadtoimprovementof instrumentation. It is partic- Pancreatic function tests ularly useful in patients who have r jaundice or abnormal liver function tests where it is Exocrine function r Serum amylase is a marker for pancreatic damage. Ultrasound may also be the more complex triglyceride is not, then the steator- used for liver biopsy, and doppler ultrasound is used to rhea is caused by pancreatic disease. Tests for endocrine function in this context taken in case of allergy or risk of contrast nephrotoxicity. Pancreatic polypeptide is raised in all of useful for assessing focal lesions of the liver, staging of these types of tumour and see page 222 for speciﬁc malignancy, and it is more sensitive for pancreatic le- tests. Pancreaticcalciﬁcationmay times used as a non-invasive alternative to endoscopic be seen in chronic pancreatitis. Complications include haemorrhage, patients suspected of having biliary obstruction, stone bile leakage, bacteraemia and septicaemia. This is followed by checked and a sample sent to transfusion for group real-time radiography. Hepatitis B and C surface antigen sta- Further diagnostic and therapeutic manoeuvres: r tus should be known. Percutaneous aspiration of an abscess is approximately 1%, but this rises with any therapeutic occasionally performed. Haemorrhage and perforation occur less cedure the patient should rest on their right side for 2 commonly. Ascending cholangitis may be prevented by hours in bed and should gently mobilise after bed rest antibiotics, which are given prophylactically to all pa- for a further 4 hours. However, in many cases of Percutaneous transhepatic cholangiography is used to malignant tumours only complete removal of the liver image the biliary tree, particularly the upper part, which and liver transplantation is curative. Localised metas- is not well outlined by endoscopic retrograde cholan- tases may also be resected. For example in obstruc- The liver is composed of several segments, as deﬁned tive jaundice with obstruction of the upper biliary tree by the blood supply and drainage, this is important in and when malignancy of the biliary tract is suspected liver resection. Prior to the procedure the clotting have a left and right branch and these supply the left and proﬁle is checked and the patient is given prophylactic righthemi-livers respectively. The im- comprises of the remainder of the right lobe and is also age can be followed by real-time radiography and still further divided into four segments (see Fig. The T-tube allows drainage of Right lobe Left lobe bile and also allows a cholangiogram later.
Nonpregnant prediction equations based on weight are not accurate during pregnancy since metabolic rate increases disproportion- ately to the increase in total body weight cheap 250 mg cephalexin mastercard. In late gestation cheap cephalexin 750 mg, the anti-insulinogenic and lipolytic effects of human chorionic somatomammotropin purchase 250mg cephalexin free shipping, prolactin buy cephalexin 500mg line, cortisol purchase 500 mg cephalexin, and glucagon contrib- ute to glucose intolerance, insulin resistance, decreased hepatic glycogen, and mobilization of adipose tissue (Kalkhoff et al. Although levels of serum prolactin, cortisol, glucagon, and fatty acids were elevated and serum glucose levels were lower in one study, a greater utilization of fatty acids was not observed during late pregnancy (Butte et al. These observations are consistent with persistent glucose production in fasted pregnant women, despite lower fasting plasma glucose concentrations. After fasting, the total rates of glu- cose production and total gluconeogenesis were increased, even though the fraction of glucose oxidized and the fractional contribution of gluco- neogenesis to glucose production remained unchanged (Assel et al. Until late gestation, the gross energy cost of standard- ized nonweight-bearing activity does not significantly change. In the last month of pregnancy, the energy expended while cycling was increased on the order of 10 percent. The energy cost of standardized weight-bearing activities such as treadmill walking was unchanged until 25 weeks of gesta- tion, after which it increased by 19 percent (Prentice et al. Stan- dardized protocols, however, do not allow for behavioral changes in pace and intensity of physical activity, which may occur and conserve energy during pregnancy. Gestational weight gain includes the products of conception (fetus, placenta, and amniotic fluid) and accretion of maternal tissues (uterus, breasts, blood, extracellular fluid, and adipose). The energy cost of deposition can be calculated from the amount of protein and fat deposited. The total energy deposition between 14 and 37+ weeks of gestation was calculated based on an assumed protein deposition of 925 g of protein, and energy equivalences of 5. Total energy deposition during pregnancy was estimated from the mean fat gain of 3. Lactation Evidence Considered in Determining the Estimated Energy Requirement Basal Metabolism. The increased energy expenditure is consistent with the additional energy cost of milk synthesis. Theoretically, the energy cost of lactation could be met by a reduction in the time spent in physical activity or an increase in the efficiency of performing routine tasks. The energetic cost of nonweight-bearing and weight-bearing activities has been measured in lac- tating women (Spaaij et al. Adaptations in the level of physical activity are not always seen in lactating women. Reduc- tions in physical activity have been reported in early lactation (4 to 5 weeks postpartum) in the Netherlands (van Raaij et al. Physical activity increased in the lactating Dutch women from 5 to 27 weeks post- partum (van Raaij et al. While a decrease in moderate and discretionary activities appears to occur in most lactating women in the early postpartum period, activity patterns beyond this period are highly variable. These sources of error may be attributed to isotope exchange and sequestration that occurs during the de novo synthesis of milk fat and lactose, and to increased water flux into milk (Butte et al. Milk energy output is computed from milk pro- duction and the energy density of human milk. Beyond 6 months post- partum, typical milk production rates are variable and depend on weaning practices. The energy density of human milk has been measured by bomb calorimetry or proximate macronutrient analysis of representative 24-hour pooled milk samples. The changes in weight and therefore energy mobilization from tissues occur in some, but not all, lactating women (Butte and Hopkinson, 1998; Butte et al. In general, during the first 6 months postpartum, well-nourished lactating women experience a mild, gradual weight loss, averaging –0. Changes in adipose tissue volume in 15 Swedish women were measured by magnetic resonance imaging (Sohlstrom and Forsum, 1995). In the first 6 months postpartum, the subcutaneous region accounted for the entire reduction in adipose tissue volume, which decreased from 23. Mobilization of tissue reserves is a general, but not obligatory, feature of lactation. In the 10 lactating British women, the total energy requirements (and net energy requirements, since there was no fat mobilization) were 2,646, 2,702, and 2,667 kcal/d (11. In 23 lactating Swedish women, the total energy requirement at 2 months postpartum was 3,034 kcal/d (12. In nine lactating American women, the total energy requirement was 2,413 kcal/d (10. The women in the above studies were fully breastfeeding their infants, who were less than 6 months of age.
Case-Control Studies Eight of eleven reported case-control studies showed a protective effect of Dietary Fiber against breast cancer (Baghurst and Rohan buy cephalexin 500mg, 1994 buy discount cephalexin 500mg online; De Stefani et al order 500mg cephalexin mastercard. For studies that showed this protection cephalexin 250 mg fast delivery, the range of the odds ratio or relative risk was 0 generic 750 mg cephalexin with amex. Intervention Studies Most intervention studies on fiber and breast cancer have examined fiber intake and plasma or urinary indicators of estrogen (e. Since certain breast cancers are hormone dependent, the con- cept is that fiber may be protective by decreasing estrogen concentrations. Rose and coworkers (1991) provided three groups of premenopausal women with a minimum of 30 g/d of Dietary Fiber from wheat, oats, or corn. After 2 months, wheat bran was shown to decrease plasma estrone and estradiol concentrations, but oats and corn were not effective. Bagga and coworkers (1995) provided 12 premenopausal women a very low fat diet (10 percent of energy) that provided 25 to 35 g/d of Dietary Fiber. After 2 months there were significant decreases in serum estradiol and estrone concentrations, with no effects on ovulation. In a separate study, the same researchers again provided a low fat (20 per- cent of energy), high fiber (40 g of Dietary Fiber) diet to premenopausal African-American women and observed reduced concentrations of serum estradiol and estrone sulfate when compared with a typical Western diet (Woods et al. Mechanisms A variety of different mechanisms have been proposed as to how fiber might protect against breast cancer, but the primary hypothesis is through decreasing serum estrogen concentrations. Fiber can reduce the entero- hepatic circulation of estrogen by binding unconjugated estrogens in the gastrointestinal tract (Shultz and Howie, 1986), making them unavailable for absorption (Gorbach and Goldin, 1987). Goldin and coworkers (1982) reported decreased plasma concentrations of estrone and increased fecal excretion of estrogens with increasing fecal weight. Alternatively, certain fibers can modify the colonic microflora to produce bacteria with low deconjugating activity (Rose, 1990), and deconjugated estrogens are reabsorbed. Another related hypothesis is that fiber speeds up transit through the colon, thus allowing less time for bacterial deconjugation. In fact, Petrakis and King (1981) noted abnormal cells in the mammary fluid of severely constipated women. Also, fiber sources contain phytoestrogens, which may compete with endogenous estrogens and act as antagonists (Lee et al. Finally, one report showed that Dietary Fiber intake was negatively correlated with total body fat mass, intra-abdominal adipose tissue, and subcutaneous abdominal adipose tissue in 135 men and 214 women (Larson et al. Since estrogen synthesis can occur in lipid stores, a decreased lipid mass should result in decreased synthesis. In addition to decreasing serum estrogen concentrations, fiber may be protective by adsorbing carcinogens or speeding their transit through the colon and providing less opportunity for their absorption. Carcinogens known to be related to breast cancer that may be affected include hetero- cyclic amines (Ito et al. Summary There are no reports on the role of Functional Fibers in the risk of breast cancer. Because of the lack of evidence to support a role of Dietary Fiber in preventing breast cancer, this clinical endpoint cannot be used to set a recommended intake level. Dietary Fiber and Other Cancers Although the preponderance of the literature on fiber intake and cancer involves colon cancer and breast cancer, several studies have shown decreased risk for other types of cancer. Because Dietary Fiber has been shown to decrease serum estrogen concentrations, some researchers have hypothesized a protective effect against hormone-related cancers such as endometrial, ovarian, and prostate. Studies on Dietary Fiber intake and endo- metrial cancer have shown both significant and nonsignificant decreases in risk (Barbone et al. In addition, studies have shown a decreased risk in ovarian cancer with a high intake of Dietary Fiber (McCann et al. However, no significant associations have been observed between Dietary Fiber intake and risk of prostate cancer (Andersson et al. Although interesting to note, this literature is in its infancy and cannot be used to set a recommended intake level for Dietary Fiber. Dietary Fiber and Functional Fiber and Glucose Tolerance, Insulin Response, and Amelioration of Diabetes Epidemiological Studies Epidemiological evidence suggests that intake of certain fibers may delay glucose uptake and attenuate the insulin response, thus providing a protective effect against diabetes. Evidence for the protective effect of Dietary Fiber intake against type 2 diabetes comes from several prospective studies that have reported on the relationship between food intake and type 2 diabetes (Colditz et al. One study examined the relationship between specific dietary patterns and risk of type 2 diabetes in a cohort of 42,759 men, while controlling for major known risk factors (Salmerón et al. The results suggest that diets with a high glycemic load and low cereal fiber content are positively associated with risk of type 2 diabetes, indepen- dent of other currently known risk factors (Figure 7-1). In a second study, diet and risk of type 2 diabetes in a cohort of 65,173 women were evalu- ated (Salmerón et al. Of particular importance is that this combination resulted in a relative risk of 2. In theory, the hypothesis as to how Dietary Fiber may be protective against type 2 diabetes is that it attenuates the glucose response and decreases insulin concentrations. This theory is supported by results from the Zutphen Elderly Study, where a negative relationship was observed between Dietary Fiber intake and insulin concentrations (Feskens et al. Intervention Studies In some clinical intervention trials ranging from 2 to 17 weeks, con- sumption of Dietary Fiber was shown to decrease insulin requirements in type 2 diabetics (Anderson et al.