Mazen S. Daoud, M.D.
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With increasingly severe stenosis symptoms depression pepcid 20mg order otc, the duration of the murmur increases and the opening snap occurs earlier during diastole as a result of higher left atrial pressure. If flow across the mitral valve is reduced because of heart failure, pulmonary hypertension, or aortic stenosis the murmur of mitral stenosis may be reduced in intensity or may be inaudible. Less common causes include severe calcification of the mitral annulus, infective endocarditis, systemic lupus erythematosus, rheumatoid arthritis, and carcinoid heart disease. Diagnosis On chest radiography, the characteristic findings of mitral stenosis are pulmonary congestion, enlargement of the main pulmonary arteries, and enlargement of the left atrium without cardiomegaly. The valve area may be measured by tracing the mitral valve opening in cross section by 2D echo. Echocardiography also allows assessment of pulmonary artery pressures, detection of other valve disease, visualization of left atrial thrombus, and identification of important differential diagnoses, such as left atrial myxoma. Transesophageal echo is superior to transthoracic echo at identifying left atrial thrombus in patients who are being considered for percutaneous mitral balloon valvotomy or cardioversion (Class I). An exercise mean transmitral gradient of more than 15 mm Hg and peak right ventricular systolic pressure PrevalenceandRiskFactors Although the incidence of rheumatic heart disease has steeply declined during the past four decades in the United States, it is still a major cause of cardiovascular disease in developing countries. Single or recurrent bouts of rheumatic carditis cause progressive thickening, scarring, and calcification of the mitral leaflets and chordae. This obstruction results in the development of a pressure gradient across the valve in diastole and causes an elevation in left atrial and pulmonary venous pressures. Elevated left atrial pressures lead to left atrial enlargement, predisposing the patient to atrial fibrillation and arterial thromboembolism. Elevated pulmonary venous pressure results in pulmonary congestion and pulmonary edema. In advanced mitral stenosis, patients develop pulmonary hypertension and right-sided heart failure. Medical treatment is directed toward alleviating pulmonary congestion with diuretics, treating atrial fibrillation, and anticoagulating patients who are at increased risk of arterial embolic events. Development of atrial fibrillation frequently leads to an acute deterioration in patients with mitral stenosis. The rapid ventricular response results in a decrease in the diastolic filling time. Beta blockers, calcium channel blockers, or digoxin may be used to control ventricular rate. An attempt to restore sinus rhythm with direct current electrical cardioversion or antiarrhythmic drugs may be considered. Anticoagulation with warfarin is indicated to prevent thromboembolism when atrial fibrillation is present, if there is a prior history of thromboembolism, or a thrombus is detected in the left atrium (Class I). Long-term secondary prophylaxis, preferentially with penicillin, is therefore recommended for all patients with a history of rheumatic fever or suspected rheumatic valve disease. In addition, balloon valvotomy should not be performed in patients who have left atrial thrombus or more than 2+ (moderate) mitral regurgitation, because the degree of mitral regurgitation usually increases following the procedure.
Spontaneous closure usually occurs in a small defect ok05 0005 medications and flying discount 20 mg pepcid with amex, in early childhood in about 50% of the patients. The chest radiograph of a patient with pulmonary hypertension shows marked enlargement of the proximal pulmonary arteries, rapid tapering of the peripheral pulmonary arteries, and oligaemic lung fields. Doppler echocardiography can identify the presence and location of the ven-tricular septal defect, and Doppler colour-flow mapping can identify the magnitude and direction of shunting. Cardiac catheterization and angiography can confirm the presence and location of the ventricular septal defect, as well as determine the magnitude of shunting and the pulmonary vascular resistance. The supracristal type (above the crista supraventricularis) is a high defect just below the pulmonary valve and the right coronary cusp of the aortic valve. The infracristal defect, which may be in either the upper membranous portion of the interventricular septum, or the lower muscular part (less than 5% of the defects): Small detects (maladie de Roger). The crista supraventricularis is a muscular ridge that separates the main portion of the right ventricular cavity from the infundibular or outflow portion. The natural history of ventricular septal defect depends on: (a) the size of the defect and (b) the pulmonary vascular resistance: Adults with small defects and normal pulmonary arterial pressure are usually asymptomatic, and pulmonary vascular disease is unlikely to develop. Such patients do not require surgical closure of their defect, but they are at risk for infective endocarditis and should therefore receive antibiotic prophylaxis. Surgical closure of such defects is recommended, if the magnitude of pulmonary vascular obstructive disease is not prohibitive. Henri Roger (1809-1891), a French paediatrician, described maladie de Roger in 1879 in a paper entitled Clinical researches on the congenital communication of the two sides of the hearts, but failure of occlusion of the interventricular septum. Moderate or large defects often have no symptoms until the third or lourth decades despite substantial left-to-right shunting (characterized by a ratio of pulmonary to systemic flow of 1. Ostium primum defect (in the lower part of the atrial septum) Patients may develop symptoms and heart failure in childhood: Failure to thrive. Wide, fixed, split second heart sound (occasionally a slight movement of P2 occurs). Infrequently, a mid-diastolic murmur may be heard in the tricuspid area (indicating a large left-to-right shunt). Atrial secundum defect is often confused with pulmonary stenosis (P2 is soft, delayed and moves with respiration). Sinus venosus type is a defect in the septum just below the entrance of the superior vena cava into the right atrium (leftward P wave axis so that P waves are inverted in at least one inferior lead).
Hospitalised and outpatient survivors had symptoms compatible with exposure to a suffocating gas medications safe in pregnancy buy pepcid 40mg. Many survivors had lost consciousness for hours (6 to 36 hours) after the incident. Cough, headache, fever, weakness or malaise, and limb swelling were frequently noted (10% or more incidence) among the victims. Evidence after the incident suggested a slow build-up of carbon dioxide deep in the lake, followed by its release as a cold, suffocating aerosol. Dogs, cats, cattle, goats, chickens, snakes, and frogs were also found dead in their tracks. Insect life was noted to be absent for approximately 24 hours following the incident. Excess levels of carbon dioxide, ammonia, and other asphyxiant gases have been theorised to accumulate at the face of a sleeping infant. Section 7 Aliphatic Hydrocarbon Gases Ethane is an odourless gas which is used as a refrigerant and as a component of natural gas. Conversion of domestic gas from coal gas (mostly carbon monoxide) to natural gas (mostly methane) has significantly reduced mortality from domestic gas leaks, since methane is much less toxic as compared to carbon monoxide. Methane being odourless, a stenching agent (alkyl mercaptan) is deliberately added to domestic gas so that leaks can be immediately recognised. Most explosions in mines (as well as homes using natural gas as fuel) occur because of this reason. Butane, liquefied petroleum gas, propane, and propylene have a faint petroleum-like odour and may be stenched with mercaptans for transport and storage. Butane is used as a raw material for automobile fuels, in organic synthesis, and as a solvent, refrigerant, and aerosol. Propane is used as a raw material in organic synthesis, as a component of industrial and domestic fuels, as an extractant, a solvent, and a refrigerant, and in the manufacture of ethylene. Incomplete combustion of these agents can release carbon monoxide into the ambient air. Butane is often abused by adolescents in the form of inhalation (see "glue sniffing", page no 576). Propylene is a raw material in polypropylene, isopropyl alcohol, isopropylbenzene, acetone, and propylene oxide manufacturing. Most of the aliphatic hydrocarbon gases act as simple asphyxiants (vide supra), in addition to additional specific toxicities. It is highly water soluble (forming ammonium hydroxide which is an alkaline corrosive). When heated to decomposition, it emits toxic fumes of ammonia and oxides of nitrogen. Uses Agriculture (fertiliser) Mining Manufacture of plastics and explosives Refrigerant Cleaning and bleaching agent Treatment of syncope in the form of smelling salts (page no 57). Management is best effected by immediate (and permanent) exclusion from the source of exposure and symptomatic measures, though the response to beta2 adrenergic agonist therapy is not as good as in occupational asthma.
Benzene has been classified as a human carcinogen by various international monitoring agencies conventional medicine generic pepcid 20mg online. The causal relationship between chronic exposure and a variety of haematologic disorders has been known for the last 50 years or more. These include aplastic anaemia, acute myeloblastic leukaemia, haemolytic anaemia, and pancytopenia. Benzene exposure is associated with translocations between chromosomes 8 and 21, and hyperploidy of 8 and 21 in the circulating lymphocytes of workers exposed to benzene. Headache, dizziness, irritability, nervousness, fatigue, anorexia and epistaxis may also occur with chronic benzene poisoning. An epidemiological study of pregnant women in a large petrochemical industry showed a positive correlation between reduced birth weight and exposure to benzene and work stress. Hydrocarbons and Pesticides Section 8 Forensic Issues Most cases of poisoning result from accidental exposure. In India, accidental kerosene poisoning is quite common in the paediatric age group, since it is a popular household fuel and is often negligently left around in the kitchen in bottles or cans. Suicidal ingestion of hydrocarbon products is not uncommon because of easy availability of many of these agents. Experimental animal studies and some studies on cancer incidence and mortality in human occupational groups suggest that hydrocarbon exposure is associated with renal neoplasia. Physical Appearance Colourless, volatile, inflammable liquid, with a strong, pleasant odour. Benzene can be recovered from coal tar and produced from the hydrodemethylation of toluene under catalytic or thermal conditions. A chief source of benzene is catalytic reformat, wherein the naphthenes and paraffins contained in naphtha are converted to aromatic hydrocarbons. Most of the benzene produced is generally derived from the petrochemical and petroleum-refining industries. Benzene is metabolised extensively in the liver and excreted in the urine, with 51 to 87% excreted as phenol, 6% as catechol, and 2% as hydroquinone. Monitoring benzene in expired air and urine phenol levels may be useful for observing workers exposed to benzene. Analysis of urinary t, t-muconic acid appears to be a better indicator than phenol for assessment of exposure to low levels of benzene. Gas chromatography head-space analysis is the preferred method for determining benzene in blood or urine. Toluene and Xylene produce similar (though milder) manifestations on acute exposure and are managed by supportive measures, with the same precautions in decontamination as for other hydrocarbons. Sources Treatment Acute exposure is treated on the same lines as in the case of aliphatic hydrocarbons.
It is contraindicated in patients with a history of depression because of the risk of precipitating suicidal behaviour treatment of bronchitis purchase 20mg pepcid overnight delivery. Patients may initially demonstrate hypertension and tachycardia for up to one day followed by hypotension and bradycardia. Coma may be long-term, but mild, often allowing the patient to be aroused when needed. Peripheral responses are biphasic: initially they may demonstrate catecholamine release, then depletion. Parkinsonism may develop in patients being treated with reserpine, particularly at higher dosages. Endocrine disorders causing breast engorgement, galactorrhoea, and gynaecomastia have been reported. Severe stuffy nose, lethargy, and respiratory depression may occur in infants of mothers ingesting reserpine during pregnancy. Since it is excreted in breast milk, serious adverse reactions are possible in nursing infants. Adrenaline and noradrenaline urine levels may be elevated one to two days after an acute ingestion. It has been recommended that overdosed patients should be observed for a minimum of 72 hours, due to the long duration of action. Section 6 Beta Adrenergic Antagonists (Beta Blockers) Beta-adrenergic blocking agents compete with endogenous and/or exogenous beta-adrenergic agonists for receptor sites. The clinical effects of hypoglycaemia (tachycardia and sweating) may be absent due to beta-blockade in such cases. Propranolol appears to cross the placenta and may result in intrauterine growth retardation, bradycardia, hypoglycaemia, respiratory depression and impaired response to anoxic stress. Acebutolol, atenolol, betaxolol, labetalol, metoprolol, nadolol, propranolol and timolol are excreted in human breast milk. First generation beta blockers (nadolol, propranolol, pindolol, labetalol, sotalol, timolol, etc. Second generation drugs such as acebutolol, atenolol, and metoprolol are selective for beta1 adrenoceptors, and therefore relatively safer. Recently, a new beta-adrenergic receptor referred to as beta3 adrenoceptor has been discovered. Complete atrioventricular block, bradycardia, hypotension and biventricular failure have been reported after therapeutic use of digoxin and propranolol. Quinidine inhibits metabolism of timolol and increases the degree of beta blockade experienced after use of timolol eye drops. Dystonia may develop if propranolol and gabapentin are given together, due to synergistic effect.
Hookworms medications 377 discount pepcid 40 mg buy on-line, threadworms, whipworms, and guineaworms are also common culprits in India. In some parts of the country filariasis (due to the nematode Wuchereria bancrofti), echinococcosis or hydatid disease (due to the tapeworm Echinococcus granulosis), and cysticercosis (due to the larval form of the tapeworm Cysticercus) are occasionally reported. The following discussion is centred around the common antihelminthic drugs available in India. Uses Benzimidazoles are effective in the treatment of cutaneous larva migrans (creeping eruption), strongyloidiasis (threadworm infestation), hydatid disease, and infestation due to Enterobius (pinworm), Ancylostoma and Necator (hookworms), Ascaris (roundworm), Trichuris (whipworm) and Taenia solium (tapeworm). Mebendazole has also been used as a fungicide for controlling spoilage in citrus fruits and Dutch Elm disease. Adverse effects include headache, nausea, metallic taste, anorexia, and occasionally vomiting and diarrhoea. Concomitant intake of metronidazole with alcohol induces a disulfiram-like reaction. Psychotic responses have also been reported with concurrent ethanol and metronidazole therapy. Alcoholic beverages or products containing ethanol or propylene glycol should not be used during tinidazole therapy also (and for 3 days after the cessation of therapy), because nausea, vomiting, abdominal cramps, headaches and flushing may occur. Common side effects include nausea, vomiting, and vertigo, while ocasionally there may be diarrhoea, headache, rash, fever, haematuria, and intrahepatic cholestasis. Colour vision disturbances and tinnitus have been reported during therapeutic use of thiabendazole. Sicca complex occurs rarely during thiabendazole therapy; symptoms include reduced tear production and dry mouth. Animal experiments suggest that these drugs are teratogenic and hence should not be administered to pregnant women. Single oral doses of metronidazole of 15 grams have been tolerated with only minimal clinical effects. However, standard treatment measures may be indicated in ingestions of greater than 1 to 2 grams. Activated charcoal/stomach wash may be helpful in the early stages of an overdose. Common worms encountered include nematodes (round worms), trematodes (flukes), and cestodes (tapeworms). Diethylcarbamazine It is a piperazine derivative and remains the drug of choice for filariasis and tropical pulmonary eosinophilia, more than 50 years after it was introduced into therapeutics. Diethylcarbamazine is also used in the treatment of loiasis,* onchocerciasis, and ascariasis.
Diseases
But it is metabolised in the body to cyanide and infusions exceeding the recommended dose can lead to cyanide toxicity medications on nclex rn pepcid 20 mg order without a prescription. Household: Household uses of cyanide include fumigation, silver-polishing, and as fertilisers, rodenticides, and insecticides. Warfare: Cyanogen and cyanogen halides (cyanogen bromide, cyanogen chloride, cyanogen iodide) release hydrogen cyanide and have been used as military chemical warfare agents. Plants: Cyanide is present in the form of cyanogenic glycosides in a wide variety of plants and plant parts (Table 26. Cyanide can be released by hepatic metabolism from various nitrile compounds, such as malononitrile, succinonitrile, acetonitrile, propionitrile and allynitrile following absorption into the body. Industrial: Electroplating, metal processing, extraction of ores, photographic processes, production of synthetic rubber, and manufacture of plastics. Specifically for potassium or sodium cyanide, the minimum lethal dose has been estimated to be about 3 mg/kg. Bitter almonds (derived from Prunus amygalis varamara, a plant which grows in Kashmir): 50 to 80 in number. Toxic Part Cyanogenic Glycoside Prunasin or amygdalin Dhurrin Amygdalin Linamarin Unclear Prunus species: cherry laurel, chokeberry, mountain mahogany, bitter almond, Leaf, bark, seed peach, apricot, plum and wild black cherry Sorghum species: sorghum, sudan grass, johnson grass, and arrow grass Apple, pear, crab apple Cassava, lima beans Grain, shoot Seed Bean, root Miscellaneous: christmas berry, velvet grass, jet berry bush, elderberry, bamboo, Bead, leaf, shoot, sprout cycad nut Apart from cytochrome oxidase, cyanide also inhibits succinic dehydrogenase, superoxide dismutase, carbonic anhydrase, and several other enzymes. Cyanide causes direct neurotoxicity through lipid peroxidation due to inhibition of antioxidant enzymes such as catalase, glutathione dehydrogenase, glutathione reductase, and superoxide dismutase. Cyanide is distributed to all organs and tissues via the blood, where its concentration in red cells is greater than that in plasma by a factor of 2 or 3. Toxicokinetics estimation in acute potassium cyanide poisoning treated with sodium nitrite-thiosulfate showed a volume of distribution (Vd) of approximately 0. Metabolism occurs mainly in the form of conversion to thiocyanate by the enzyme rhodanese (present in the mitochondria of liver and kidneys), which needs sodium thiosulfate for effective functioning. Half-life for the conversion of cyanide to thiocyanate from a nonlethal dose in man is between 20 minutes and 1 hour. Once the relatively nontoxic metabolite thiocyanate is formed it is excreted mainly in the urine. However, thiocyanate may accumulate in a patient with renal impairment resulting in thiocyanate toxicity. Some of the cyanide is converted to cyanacobalamin (vitamin B12) in the presence of hydroxocobalamin (vitamin B12a). Small amounts of cyanide are excreted in the breath and sweat producing the characteristic bitter almond odour. Mode of Action the toxic effect of cyanide is mainly attributed to its production of a histotoxic anoxia by inhibition of cytochrome oxidase. This is a metalloenzyme essential for oxidative phosphorylation which is responsible for aerobic energy production. Pyruvic acid no longer enters the krebs cycle, but is converted to lactic acid which accumulates and results in metabolic acidosis. Inhalation produces the most rapid and serious exposures resulting in almost immediate coma, while ingestion causes less rapid onset because of slower entry into the circulation, and passage of cyanide through the portal system where the liver metabolises some of it by the first-pass effect.
Semiurgent referral to the ophthalmologist for close follow-up to enable early detection and treatment of proliferative retinopathy treatment viral pneumonia 40mg pepcid order with amex. In later stages they are elevated and may be associated with a white fibrous component. There is a close relationship: in patients diagnosed as having diabetes before the age of 30 years, the incidence of retinopathy is about 50% after 10 years and 90% after 30 years. The Diabetes Control and Complications Trial compared intensive treatment for blood glucose control with conventional treatment in patients with and without retinopathy at baseline who were followed for a mean of 6. Intensive treat-ment has profound benefits in both subgroups and was associated with a reduction in the incidence of both the development of new retinopathy and the risk of pro-gression of existing retinopathy. An increase in capillary permeability, evidenced by the leakage of dye into the vitreous humour after fluorescein injection, is the earliest sign of retinal change in diabetes mellitus. It is not completely understood and current theories emphasize the production of angiogenic factors by areas of ischaemic and hypoxic retina. Photocoagulation is a technique whereby several thousand lesions are produced over a 2-week therapy period with lasers. The laser is used to ablate a portion of the retina and does not directly cauterize the neovascularization. It is believed that the regression of neovascularization due to laser is a result of the destruction of ischaemic and hypoxic retina with reduction in angiogenic factors. Photocoagulation decreases the incidence of haemorrhage or scarring in proliferative retinopathy. Photocoagulation is also useful in the treatment of microaneurysms, haemor-rhages and oedema. What surgical technique may be used for a non-resolving vitreous haemorrhage and retinal detachment Pars plana vitrectomy may be used hut is often complicated by retinal tears, retinal detachment, glaucoma, infection, cataracts and loss of the eye. Proceed as follows: Tell the examiner that you would like to: Check the blood pressure. Keith-Wagner-Barker classification (Am J Med Sci 1939; 197: 33243): Stage I - arteriolar narrowing. Dollery, was Dean of the Royal Postgraduate Medical School, Hammersmith Hospital, London; his interests include clinical pharmacology, hypertension and medical education. John Swales, contemporary Professor of Medicine, Leicester; his chief interest is hypertension. Petrie, Professor and Head of Medicine and Therapeutics, Aberdeen; his interests included hypertension and cardiovascular prevention. Examination There is swelling of the optic disc (look for haemorrhages and soft exudates;. The colour of the disc becomes redder, approximating to that of the rest of the retina; its contour becomes blurred and the cup and cribrosa are filled in. Papilloedema is always associated with enlargement of the blind spot with a con-sequent diminution of visual fields and gradual loss of visual acuity, but a fair degree of acuity may remain until papilloedema is marked. The appearance is typically flared and on focusing will reveal fibres traversing the area.
Examination Tendon xanthomata seen on the extensor tendons and becoming more prominent when the patient clenches his fist medicine abuse discount 20mg pepcid visa. Proceed as follows: Look at other tendons, particularly the patellar and Achilles tendon. They have a pre-disposition to ischaemic heart disease, which usually results in death before the age of 30 years. One view is that in these patients statin treatment should be started when boys are in their late teens and women from their late twenties. If the family history is par-ticularly adverse, however, then there is an increasing tendency for paediatricians to commence treatment (Lancet 2001; 357: 574). This uncontrolled diabetic has developed a profuse eruption; what are these lesions Examination Multiple, itchy, red-yellow vesicles or nodules which are seen over extensor surfaces, i. Proceed as follows: Tell the examiner that you would like to: Examine the fundus for lipaemia retinalis. What is the relationship between hypertriglyceridaemia and coronary artery disease The relationship of hypertriglyceridaemia with coronary artery disease is less clear than that with hypercholesterolaemia, but is said to increase risk when levels are greater than 500 mg/dl, when other risk factors are present or in familial combined hyperlipidaemia. Of what are patients particularly at risk when serum levels of triglycerides are markedly raised (> 1000 mg/dl) Proceed as follows: Look for the following signs: -Xanthelasmata around the eyes. A more generalized form may be associated with monoclonal gammopathy of myeloma or lymphoma. Fredrickson classification, depending on laboratory findings: Type l: raised levels of chylomicrons and triglycerides, normal cholesterol con-centration (pancreatitis, eruptive xanthomata and lipaemia retinalis). These cells have abundant and finely vacuolated cytoplasm giving them a foamy appearance. Cholesterol (both free and esterified), triglycerides and phospholipids are present within the cell. Often the cells are surrounded by inflammatory cells and fibrosis about the central zone of lipid-laden cells. Salient features History Family history (either autosomal recessive, which is most common, or autosomal dominant; the gene for both forms has been mapped to chromosome 16, Hum Mol Genet 1997; 6: 1823). Upper gastrointestinal haemorrhage, myocardial intarctton, stroke and inter-mittent claudication, visual loss. Salient features Small yellow papules arranged in a linear or reticular pattern in plaques on the neck, axillae, cubital fossae, periumbilical region and groin. Read: N Engl J Med 1993; 333: 1240; N Engl J Med 1997; 337:828 (candidates are encouraged to refer to this picture for characteristic features of this disease). What is the triad of pseudoxanthoma elasticum, angioid streaks and vascular abnormalities known as Arterial grafts should not be used for coronary artery bypass surgery in these patients because of possible calcification of the internal elastic laminae of the internal mammary artery. Bleeding compli-cations can be prevented by avoiding aspirin in patients with pseudoxanthoma elasticum.
Mixing of ammonia with hypochlorite bleach results in the formation of chloramine medications ritalin 20 mg pepcid buy amex, which causes a toxic pneumonitis (pulmonary oedema) following inhalation, and may produce residual pulmonary function abnormalities. The determination of ammonia in air may be done using an ammoniaspecific electrode, second derivatives spectroscopy, ion chromatography, or colourimetrically. There can be a four-fold or greater rise in blood ammonia in some toxic liver diseases because the urease needed to convert ammonia to urea is found only in the liver. Ocular exposure should be treated with prolonged irrigation with water (30 minutes or more) until the eye reaches neutral pH as tested with a litmus paper in the conjunctival sac. Dermal exposure requires washing with soap and water, followed by copious irrigation with water alone. Intubation or tracheostomy may be life-saving following severe exposure if stridor, indicating laryngeal oedema, is present. If bronchospasm and wheezing occur, consider treatment with inhaled sympathomimetic agents. In the case of ingestion, a small quantity of water or milk can be administered as a first-aid measure to dilute the chemical. Activated charcoal is of no benefit, and may induce vomiting and obscure endoscopy findings. Formaldehyde Synonyms Dormol, fannoform, formalin, formalith, formic aldehyde, formol, lysoform, methanal, methyl aldehyde, methylene oxide, morbicid, oxomethane, oxymethylene. Formalin is an aqueous solution of formaldehyde containing 37 to 40% formaldehyde and 10 to 15% methanol. Therefore 10% formalin would actually mean a 1: 10 dilution of such a commercial preparation and contains 3. Some formaldehyde aqueous solutions can be amber to dark brown or even reddish in colour. Formaldehyde is also available as a solid polymer, paraformaldehyde, in a powder or flaked form containing from 90 to 93% formaldehyde, and as its cyclic trimer, trioxane. Industrial/Household: Formaldehyde is used in fertilisers, pesticides, sewage treatment, paper-making, preservatives, embalming fluids, disinfectants, foam insulation, urea and melamine resins, artificial silk and cellulose esters, explosives, particle board, plywood, air fresheners, cosmetics, fingernail polishes, water-based paints, tanning and preserving hides, and as a chemical intermediate. It is also used as a preservative and coagulant in latex rubber, and in photograph developing processes and chrome printing. Medical/Veterinary: Therapeutically, formaldehyde has been used to treat massive haemorrhagic cystitis and hydatid cysts of the liver. Dialysis patients using dialyser machines sterilised with formaldehyde receive a small dose with each treatment.
Gelford, 63 years: The therapeutic dose varies between 100 and 200 gg per day taken as a single dose. Important examples of this group of drugs used widely in the treatment of peptic and duodenal ulcer, include cimetidine, ranitidine, famotidine, nizatidine and roxatidine.
Hurit, 54 years: These include the fluoroquinolones, gatifloxacin (Tequin), moxifloxacin (Avelox), and levofloxacin (Levaquin), especially if amoxicillin-clavulanate, cefpodoxime proxetil, and cefuroxime were previously prescribed. Patients who had glucose levels in the diabetic range had four-fold increased cardiovascular mortality as compared to normoglycemic patients.
Makas, 61 years: Permanent cardiac pacemakers have been tried, but they are rarely used now to treat a vasovagal event. Botulinum antitoxin is not recommended for infant botulism because of its serious side effects and lack of effect on toxin-producing organisms in the gut.
Sanuyem, 48 years: Ambulatory cardiac monitoring provides an attractive alternative to prolonged hospitalization and may ultimately lower health care costs and reduce mortality. The obvious advantage of this feature is that an arrhythmia can be terminated painlessly without delivery of a shock.
Kerth, 41 years: Studies involving low-dose aspirin and clopidogrel in combination are under way to evaluate their potential efficacy when used as alternatives to warfarin. What are the indications for treatment of patients with non-toxic multinodular goitre Surgery Standard therapy, especially when rapid decompression of vital structures is required.
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