By H. Abbas. Polytechnic University of New York.
Lateral displacement of the mediastinal pleura by mediastinal air cre- ates a linear density paralleling the mediastinal contour 60 caps pilex amex. On the lateral pro- jection buy pilex mastercard, mediastinal air can be seen in the retrocardiac space purchase pilex 60 caps without a prescription. Chest Pain and Cardiac Dysrhythmias Answers 27 (a) Aspiration pneumonia is an inflammation of lung parenchyma pre- cipitated by foreign material entering the tracheobronchial tree. Alcoholics are prone to aspiration pneumonia because of ethanol’s sedating effect. Chest radi- ograph findings are often delayed with atelectasis typically being the first finding. The rub may be caused by friction between inflamed or scarred visceral and parietal pericardium or may result from friction between the parietal pericardium and adjacent pleura. Aortic dis- section (e) usually occurs in patients with chronic hypertension or con- nective tissue disorders. It can be quickly per- formed at the bedside and does not require radiation or contrast. If β-adrenergic receptors are antagonized, α-adrenergic receptors are left unopposed and available 28 Emergency Medicine for increased stimulation by cocaine. This may worsen into coronary and periph- eral vasoconstriction, hypertension, and possibly ischemia. Therefore, benzodi- azepines, which decrease central sympathetic outflow, are the cornerstone in treatment to relieve cocaine-related chest pain. Patients may present with fever, cardiac murmur, cough, pleuritic chest pain, and hemoptysis. Right-sided murmurs, which vary with respiration, are typically pathologic and more specific for the diagnosis. In patients with right-sided endocarditis and septic pulmonary emboli, pul- monary complaints, infiltrates on chest radiographs, and moderate hypoxia have been described in greater than 33% of patients; these symptoms and signs may mislead the physician to identify the lung as the primary source of infection. Diagnosis generally requires microbial isolation from a blood culture or to demonstrate typical lesions on echocardiography. Initial antibiotic treatment should be directed against S aureus and Streptococcus species. However, mononucleosis does not cause a heart murmur or patchy infiltrates on chest radiograph. However, it does not cause valvular abnormalities leading to a murmur and pulmonary infiltrates. Although Lyme disease does not lead to valvular abnor- malities, patients may present with cardiac conduction abnormalities, the most worrisome being complete heart block. Patients typically have risk fac- tors for tick exposure, such as hiking in a wooded area. Any of the seven costochondral junctions may be affected, and more than one site is affected in 90% of cases. In contrast to myocardial ischemia or infarction, costochondritis is a benign cause of chest pain, often with an insidious onset, and is an important consideration in the differential diagnosis for chest pain. Of note, 5% to 7% of patients with cardiac ischemia also have chest-wall ten- derness. Chest-wall pain with a history of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture) is common. The most dangerous circumstance is in atrial fibrillation where impulses occur at a rate greater than 300 beats per minute. At any moment the patient’s rhythm can go into ventricular fib- rillation or asystole. There are many symptoms of hyperkalemia that are often difficult to discern from those of the primary condition that precipi- tated the hyperkalemia. Patients may begin with lethargy and weakness and progress to paralysis and areflexia. However, this patient requires immediate adminis- tration of calcium because he has an unstable cardiac rhythm. Calcium (glu- conate or chloride) antagonizes the effects of potassium in the myocardium and briefly stabilizes the cardiac membrane. However, calcium will not lower the potassium level; in order to promote transcellular shifts and removal from the body, other measures will also be required. Sodium polystyrene sulfonate (Kayexalate) is a definitive treatment for hyperkalemia because it removes potassium from the body. However, the process is not immediate and takes between 30 minutes and 2 hours for the results to show. Administration of glucagon may cause enough relaxation of the esophageal smooth muscle to allow passage of the bolus in approximately 50% of patients. Its relaxant effect is limited to smooth muscle and therefore can only be used for impactions in the lower esophagus. Meat tenderizer (b), once used for this situation, is now contraindi- cated secondary to the possibility of perforation as a result of its proteolytic effect on an inflamed esophageal mucosa. Also, vomiting should be avoided in our patient to avoid risk of esophageal perforation. The Heimlich maneuver (d) can be a lifesaving procedure but is not necessary in this patient who is not in respiratory distress. Respiratory compromise may occur when a foreign body lodges in the oropharynx, proximal esophagus, or is large enough that it impinges on the trachea. Contraindications to fib- rinolytic therapy are those that increase the risk of hemorrhage. Any patient with unstable vital signs with a tachydysrhythmia should receive a dose of sedation and undergo synchronized cardiover- sion starting at 100 J. If the patient was not hypotensive or exhibiting signs of heart failure, diltiazem is used to slow the ventricular response. It is also used to anticoagulate stable patients who have been in atrial fibrillation for longer than 48 hours and are going to be pharmacologically or electrically cardioverted. Cardioversion of atrial fibrillation (if longer than 48 hours) carries the risk of thromboembolism. Nitrates increase venous capacitance, including venous pooling, which decreases preload and myocar- dial oxygen demand. However, morphine 34 Emergency Medicine sulfate is a respiratory depressant and may lead to hypoventilation. It does not act as rapidly or as effectively as nitroglycerin in preload reduction. In the acute setting this patient should be placed on a nonrebreather with 100% oxygen flowing through the mask.
It is manu- factured in the liver and also obtained from consuming saturated and trans fats purchase genuine pilex. Cholesterol is not all bad—the body requires it to produce sex hormones order 60 caps pilex with visa, maintain cell membranes cheap 60caps pilex with mastercard, and for a healthy nervous system. It is possible for triglycerides to be high even when blood cholesterol is normal, so get your levels checked regularly. These macronutrients provide us with the energy and nutrients needed for proper growth, development, and many body processes. In a later chapter I will outline principles for a healthy diet—my top recommendations for a nutritional plan for optimal health and disease prevention. They assist in energy-producing reactions, growth and development, protect against free radical damage, and perform many vital functions. Micronutrients are essential for health, and a deﬁciency can lead to health problems and disease. In this chapter I have outlined the essential vitamins, minerals, and trace elements; their functions in the body; their role in disease prevention and treatment; deﬁciency symptoms; drugs that deplete; and supplement guidelines. The table at the end of this chapter summarizes food sources, recommended in- take levels, and possible side effects and toxicity for the various nutrients. There are many factors that cause nutrient depletion, such as poor diet, stress, exer- cise, use of prescription drugs, environmental toxicity, and excessive alcohol intake. This is why supplements are so important in making up for short- comings in the diet and preventing deﬁciencies. The B-vitamins and vitamin C dissolve in water and are easily eliminated from the body. Adverse reactions, even with high-dose supplements, are rare with these vi- tamins. Fat-soluble vitamins (A, D, and E) are not readily excreted from the body and have the potential to accumulate in the tissues and cause adverse effects at high doses. Vitamin A • Found in animal foods and converted from beta-carotene in plant foods. To avoid this risk, choose a multivitamin that contains beta-carotene, which is converted to vitamin A in the liver, but is not as- sociated with health risks. Vitamin B1 (Thiamine) • Required for energy production, nerve and muscle function, enzyme reactions, and fatty acid production. Micronutrients | 15 • Drugs that deplete vitamin B1: furosemide, antibiotics, oral contraceptives, and phenytoin. Vitamin B2 (Riboﬂavin) • Required for energy metabolism, enzyme reactions, vision, and skin/hair/nail health; functions as an antioxidant; activates vitamin B6, niacin, and folate. Deﬁciency may impair iron absorption and increase risk of pre-eclampsia in pregnant women. Vitamin B3 (Niacin) • Required for energy metabolism, enzyme reactions, skin and nerve health, and digestion. Vitamin B5 (Pantothenic Acid) • Required for carbohydrate metabolism, adrenal function, enzyme reactions, and production of fats, cholesterol, bile acids, hormones, neurotransmitters, and red blood cells. Pregnant women with deﬁciency have increased risk of giving birth to a child with neural tube defects. It can also occur in those who consume raw egg white for prolonged periods (weeks to years) because a protein found in egg white (avidin) binds biotin and prevents its absorption or in those given intravenous feeding without biotin supplementation. Micronutrients | 17 Folate (Folic Acid) • Part of the B-vitamin family; known as folate when it occurs in foods, or as folic acid when present in supplements or added to foods. Pregnancy or cancer results in increased rates of cell division and metabolism, in- creasing the need for folate. Vitamin C (Ascorbic Acid) • Required for synthesis of collagen (structural component of blood vessels, tendons, and bone), norepinephrine (neurotransmitter), and carnitine (amino acid involved in energy production); promotes wound healing; supports immune function and gum health; and has antioxidant properties. Symptoms include fatigue, easy bruising, poor wound healing and appetite, anemia, and sore joints. Elderly, dark-skinned, obese people, or those with inﬂammatory bowel disease and fat-malabsorption syndromes (celiac disease and cystic ﬁbrosis) are also at greater risk. Those with limited sun exposure, osteoporosis, multiple sclerosis, psoriasis, and those over age 65 should consider additional vitamin D. Micronutrients | 19 Vitamin K • Essential for blood clotting; required for bone formation and cell growth. The body cannot make minerals so they must be obtained through the diet and/or supplements. Animals get minerals from the plants they eat, and then we get these minerals indirectly by eat- ing the animal products. There are also some minerals present in drinking water, but this varies with geographic location, as does the mineral content of plants. Calcium, magne- sium, and phosphorus are considered major minerals since we require a substantial amount of these for health and wellness. The trace minerals, which are required in smaller amounts, are chromium, copper, ﬂuoride, iodine, iron, manganese, mo- lybdenum, selenium, and zinc. The minerals potassium and sodium are known as electrolytes, substances that dissociate into ions (charged particles) in solution, mak- ing them capable of conducting electricity. Most multivitamin/mineral supplements provide a small amount of calcium because it is quite bulky. Therefore, a separate calcium supplement may be necessary, especially for those at risk of osteoporosis and those with high blood pressure. Cooking these foods releases calcium that is bound to oxalic acid, thus improving the amount you can absorb. Phytic acid, which is found in wheat bran or dried beans, also reduces calcium absorption. Micronutrients | 21 • Other interactions: Magnesium reduces absorption of digoxin, nitrofurantoin, anti- malarial drugs, quinolone antibiotics, tetracycline, chlorpromazine, alendronate, and etidronate, so separate intake of magnesium from these foods by two hours. Most studies involving chromium were done with the picolinate form, which is readily absorbed and utilized by the body. Certain individuals (diabetics and those at risk for diabetes) may require an additional supplement. Others at risk: Premature and low birth- weight infants with diarrhea; infants fed only cow’s milk formula, which is low in copper; those with malnutrition, malabsorption syndromes (celiac disease), cystic ﬁbrosis, and those receiving intravenous feeding. Iodine • Required to make thyroid hormones, which regulate metabolism, energy produc- tion, and body temperature, and are essential for growth and reproduction. Micronutrients | 23 • Other interactions: Amiodarone (heart drug) contains high levels of iodine and may affect thyroid function; potassium iodide may decrease the anticoagulant effect of warfarin. These foods are a concern only for those who are iodine deﬁcient and consume high amounts of them.
More frequent review may be necessary cheap pilex 60caps fast delivery, depending on the working procedures of each individual ethics committee Final clinical report/summary of study pilex 60 caps for sale. At the beginning of a terms ‘protocol violations’ and ‘protocol amend- study cheap pilex 60 caps with visa, monitoring may be even more frequent. Perhaps the easiest way to The monitor will be ever-vigilant for protocol explain the difference is to stress that violations violations which can occur during a study and are not planned changes (hopefully) to the proto- which can have a serious impact on eligibility col, whereas protocol amendments are planned and evaluability. Many researchers confuse the changes and are enacted through a formal approval Table 12. The person receiving the information and giving consent must sign the consent form. This is usually the study subject, but may be the study subject’s legally acceptable representative (depending on national regulations) in the event that the study subject is incapable of providing informed consent, for example the subject is unable to write or understand the consent documents, or the study subject is in a ‘vulnerable’ population, for example children, elderly. Informed consent must be obtained before the start of the study The person providing the information and obtaining consent must sign the consent form. This person should be an investigator who must be qualiﬁed to adequately inform the study subject, and her/his signature also indicates personal involvement in the consent process. If other personnel, for example study nurses assist in providing information or obtaining consent, they should also sign the consent form, clearly describing their role in the consent procedure A witness or patient advocate should be present during the consent procedure at the times of providing information and giving consent, and should sign the consent form. The witness will ensure that there was no coercion in the obtaining of informed consent and that the study subject was given adequate time to consider participation in the study. The witness must be able to conﬁrm that the consent procedure was adequate and must have no vested interest in the clinical study, that is the witness should be impartial, independent, or neutral, as far as this can be achieved. The relationship of the witness to the study subject and to the investigator and the study should be documented All participants should personally date their signatures and all dates should precede the start of the study (for each subject) 12. Information about the consent procedure: Consent to be given by the study subject’s free will Adequate time (which should be deﬁned in advance in the protocol) must be allowed for the study subject to decide on participation in study Adequate time must be allowed to ask questions Statement that participation is entirely voluntary Statement that refusal to participate will involve no penalties or loss of usual beneﬁts Description of circumstances under which participation would be terminated Right to withdraw at any time without prejudice or consequences Study subject is allowed to keep the written explanation (information sheet and consent form) for future reference 2. Experimental procedures might include those which are not normally used for the presentation under consideration or procedures which are new or have never been used before Comparator treatments (including placebo) described. Randomization is not easily understood by many subjects and should also be explained in simple terms Expected duration of participation Required number of visits Reason for selection of suitable subjects Approximate number of other study subjects participating in the study 3. Information about the risks/beneﬁts: Foreseeable risks, discomforts, side effects and inconveniences Known therapeutic beneﬁts, if any. Patients, whether receiving therapeutic beneﬁt or not, are not usually paid for participation in clinical research, except for incidentals such as travel costs. Some subjects may not be comfortable with this requirement, for example in a study of sexually transmitted diseases, they may not wish the doctor, perhaps a family friend, to be aware of their situation. If this is the case, the subject is not eligible for the study as it is vital to conﬁrm history with the primary care physician The information sheet must be written in language which is understandable, for example technically simple and in the appropriate national language, to the study subject process (if violations are deliberate or planned, a All research personnel must search for clues case of fraud should be considered! Where discrepancies are found, arrangements must be made for corrections and resolution. Resolve any outstanding queries, ensuring completion of any issued data queries, since the last monitoring visit Verify compliance with entry criteria and procedures, for all study subjects, as speciﬁed in the protocol. If subjects are found to be ineligible or unevaluable, these events must be immediately brought to the attention of the investigator. Check the study site ﬁle to ensure that all appropriate documents are suitably archived. If a pharmacy is involved in the study, the pharmacy and pharmacist must be visited. Check that the medication/device is being dispensed in accordance with the protocol. Check that the medication/device is being stored under appropriate environmental conditions and that the expiry dates are still valid. Check that the medication/device is securely stored in a separate area that is not accessible to individuals not involved in the study. Check that any supplies shipped to the site since the last visit were received in good condition and are properly stored. If applicable, ensure that randomization procedures are being followed, blind is being maintained, randomization codebreak envelopes are intact (sealed and stored properly) and a chronological sequence of allocation to treatment is being followed Verify correct biological sample collection (especially number, type, and timing), correct procedures for assays (if applicable), and labeling, storage and transportation of specimens or samples. The dates of sample collection, receipt, analysis and reporting should be checked to ensure that samples are analyzed promptly, and that investigators are informed of results and review them promptly Ensure continued acceptability of facilities, staff and equipment. Ensure that the reference range, documentation of certiﬁcation and proﬁciency testing, licensing, and accreditation, for the clinical laboratory are still current. Document any changes in clinical site personnel and, if changes have occurred, collect evidence of suitability of new personnel. Ensure that new staff are fully briefed on the requirements of the protocol and study procedures and arrange any training of new personnel, if necessary. This may be acceptable, if these data would not normally be entered in medical records, and if knowledge of such data is not required by the 12. Other restricted methods Source data veriﬁcation is the process of verifying of access to source documents (e. Thereafter, review by the data management onto computers or direct entry of patient informa- department is another extremely important means tion onto computers by physicians). It is a lengthy and complex The primary purpose of source documents is process and there are few guidelines and regula- for the care of the study subject from a clinical tions for reference. As time goes lection forms) generally cannot substitute as by, it becomes more and more difﬁcult to correct source documents. Slow processing usually means that data lose generally be supported by source data in source credibility. The medical ﬁle should clearly indicate the full name, birth date, and hospital/clinic/health service number of the study subject Eligibility of study subjects. At a minimum, demographic characteristics, for example sex, weight and height, diagnoses, for example major condition for which subject was being treated, and other ‘hard’ data, for example laboratory results within a speciﬁed range or normal chest X-ray, should be clearly indicated. If the medical ﬁle has little or no information concerning medical history, it would not support selection of the subject Indication of participation in the study. The medical ﬁle should clearly show that the subject was in a clinical study in case the information is necessary for future clinical care Consent procedures. The original signed consent form should be maintained with the subject’s medical ﬁles or in the investigator ﬁles and an indication that consent was obtained (with the date speciﬁed) should be noted in the medical ﬁles. Signatures and dates must be checked carefully to ensure that the correct individuals were involved in the consent procedure and that consent was obtained prior to any study intervention Record of exposure to study medication/device. The medical ﬁle should clearly indicate when treatment began, when treatment ﬁnished, and all intervening treatment dates Record of concomitant medications/devices. Concomitant medication/device use must be explicable by an appropriate indication and must be consistent from visit to visit. The medical history should be reviewed to determine whether medical conditions arising during the study already existed at baseline. The dispensing records, which are normally separate from the medical ﬁle, must also be examined to determine consistency Visit dates. Present and future clinical care of the study subject is the most important factor in determining whether or not measured variables should be recorded in the medical ﬁle. The investigator should record what he/she would normally record to care for the study subject, but also take into account any recording needed because of the special circumstances of a clinical study.
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