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Carlo Tornatore, M.D.

• Assistant Professor of Neurology
• Georgetown University Medical Center
• Washington, DC

Ticagrelor is preferred over clopidogrel in the management of patients with acute coronary syndromes when possible 39-6 birth control vaccine buy alesse 0.18 mg cheap. No meaningful differences in bleeding risk have been observed with fondaparinux over enoxaparin C birth control pills zenchent discount generic alesse canada. The risk of catheter-related thrombotic complications is higher in patients referred for percutaneous coronary artery intervention who were initially treated with enoxaparin versus fondaparinux D birth control for female buy alesse amex. She undergoes coronary angiography birth control 101 discount alesse 0.18 mg amex, which demonstrates only a 60% stenosis in the circumflex artery. She undergoes coronary angiography and ventriculography, which is shown in Figure 39-2. Assessment of clinical features in transient left ventricular apical ballooning, J Am Coll Cardiol. Emotional stress in the presence of symmetric T-wave inversion in most leads is diagnostic for the condition C. When it is a constant finding with or without chest pain, it is less specific (option A is incorrect). Deeply negative T waves across the precordial (anterior) leads suggest a proximal, severe, left anterior descending coronary artery stenosis as the culprit lesion and are considered a marker of high risk. The angina index is scored as: 0 points if no angina occurs, 1 point if nonlimiting angina occurs, and 2 points if angina occurs that limits exercise. The other answer choices confer a high risk (Table 39-2; options B through E are incorrect). Those with high-risk findings should undergo coronary arteriography; those with negative or low-risk results can be treated medically. Low-risk patients who complete a stay in a chest pain unit without objective evidence of myocardial ischemia can safely undergo stress testing for diagnosis and prognostic purposes either immediately or, when possible, within 48 hours as an outpatient. In patients who cannot exercise, pharmacologic testing with dipyridamole, adenosine, regadenoson, or dobutamine can be used to provide the stress, and sestamibi imaging or echocardiography can be used as a method of assessment. Ticagrelor has several known, usually self-limited, side effects, which likely arise 3 from its interference with adenosine uptake (options A through C are incorrect). However, major bleeding events were reduced by 48% with fondaparinux, and mortality trended lower in the fondaparinux group at 30 days (2. Major bleeding risk was particularly high among patients treated with weight-adjusted enoxaparin who had a creatinine clearance below 30 mL/min (9. Third, the long half-life of fondaparinux may create logistical problems in centers that perform early cardiac catheterization. Finally, among patients undergoing cardiac catheterization, an excess in catheter-related thrombotic complications was observed, a finding that has also been observed in other trials using fondaparinux (option C is incorrect). For many, conservative management may be quite effective, particularly if flow is present in the coronary artery at the time of diagnostic coronary angiography; spontaneous healing of the dissection may be seen at the time of follow-up angiography. It is thought that coronary spasm is a result of abnormalities in endothelial function and nitric oxide activity at sites of coronary spasm. Patients with variant angina are often difficult to treat because attacks are unpredictable and often occur without an obvious precipitating factor. For example, long-acting nifedipine (90 mg/d), diltiazem (360 mg/d), verapamil (480 mg/d), and amlodipine (20 mg/d) are commonly used. Statin therapy is indicated (option C is incorrect), given beneficial effects on endothelial function and the common presence of atherosclerosis underlying focal spasm. Management of patients with stress cardiomyopathy is typically supportive; patients most often recover rapidly after presentation, though shock at presentation is not uncommon. All of the following electrocardiographic findings can potentially support the diagnosis of a myocardial infarction in the presence of a known old left bundle branch block except: A. A 55-year-old man with a history of coronary artery disease is brought to the emergency room with chest pain by his wife. Patients treated successfully with fibrinolysis do not require follow-up angiography 40-3. Fibrinolysis should generally be considered up to 6 hours following symptoms onset E. Failure of T waves to invert within 48 hours following the administration of fibrinolysis E. Which of the following is true about the epidemiology of cardiogenic shock complicating myocardial infarctionfi No trials have successfully demonstrated improvement in outcomes in patients with cardiogenic shock D. A 52-year-old man presents with myocardial infarction and undergoes placement of a pulmonary artery catheter, which 2 demonstrated a cardiac index of 2. Nitroglycerine is beneficial to relieve symptoms of chest pain and to decrease endogenous catecholamine release B. Atrioventricular synchrony should be achieved, and bradycardia should be corrected C. Inotropic support should be used for hemodynamic instability not responsive to volume challenge 40-10. When papillary muscle rupture occurs, the posteromedial papillary muscle is more often involved than the anterolateral muscle D. Additionally, patients with contraindications to fibrinolysis, including ischemic stroke within 3 months (option D is incorrect), should be transferred, as well as those with cardiogenic shock (option B is incorrect). Fibrinolysis should be considered up to 12 hours following symptoms onset (option D is incorrect). While the R wave may initially increase in height but then soon decrease, this finding is not specific for left main coronary artery disease (option C is incorrect). Failure of the T wave to invert within 24 to 48 hours suggests early postinfarction regional pericarditis (option D is incorrect). There was a trend toward increased in-hospital survival in the midto late 1990s, which correlated with the increased application of reperfusion technologies. In most recent studies, the mortality from cardiogenic shock remains approximately 50% (option D is incorrect). The basic goals of this approach include adjustment of the intravascular volume status to bring the pulmonary artery capillary wedge pressure from 18 to 20 mm Hg and optimization of cardiac output with inotropic and/or vasodilating agents. Severely hypotensive patients can be temporarily aided by intra-aortic balloon pumping or possibly by a ventricular assist device. However, the benefits from these mechanical treatments are often temporary, and there may be a significant risk of complications. In some patients, this alone is sufficient to improve cardiac output and systemic pressure. Patients requiring temporary pacing for heart block may also benefit from arteriovenous sequential pacing rather than lone ventricular pacing. Rupture may be complete or partial, and it usually involves the posteromedial papillary muscle because its blood supply is derived only from the posterior descending artery, whereas the anterolateral papillary muscle has a dual blood supply from both the left anterior descending and the circumflex coronary arteries. Most patients have relatively small areas of infarction with poor collaterals, and up to half of the patients may have single-vessel disease. The clinical presentation of papillary muscle rupture is the acute onset of pulmonary edema, usually within 2 to 7 days after inferior myocardial infarction (option A is incorrect). The characteristics of the murmur vary; as a result of a rapid increase of pressure in the left atrium, no murmur may be audible (option B is incorrect). Thus a high degree of suspicion, especially in patients with inferior wall infarction, is necessary for diagnosis. Two-dimensional echocardiographic examination demonstrates the partially or completely severed papillary muscle head and a flail segment of the mitral valve (option D is incorrect). The cornerstones of successful therapy are prompt diagnosis and emergency surgery (option E is incorrect). The current approach of emergency surgery accrues an overall operative mortality of 0% to 21%, but this appears to be decreasing, and the late results of this approach can be excellent. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography.

Diseases

• Rasmussen Johnsen Thomsen syndrome
• Mucopolysaccharidosis type VII Sly syndrome
• Allergic bronchopulmonary aspergillosis
• Lehman syndrome
• Vestibulocochlear dysfunction progressive familial
• Hing Torack Dowston syndrome
• Streptococcus, Group B

Only 63% of travellers who reported having diarrhoea had sought treatment birth control pills do what cheap alesse express, indicating that many travellers self-treated their complaints birth control loryna order alesse 0.18 mg line. Gastro-intestinal disorders were also identifed as the most common complaint in travellers returning to Scotland from abroad (Cossar et al birth control patch xulane reviews order alesse cheap. Rogers and Reilly (2000) report that 6% to 18% of tourists report accidents and injuries birth control 77070 purchase 0.18mg alesse with amex. One study reporting on pre-hospital deaths caused by trauma on a tourist island in Greece (Gatsoulis, Tzafestas, & Damaskinos, 2000) found that road traffc accidents caused the majority of deaths. A survey undertaken to assess the safety of adventure tourism throughout New Zealand, indicated the incidence of serious client injury was very low (Bentley, Page, & Laird 2000). Highest incidence of injury was found for activities that involved a risk of falling, for example cycle tours, horse riding and white-water rafting. This corresponds to results from the practice studied, where slips, trips and falls on level ground were commonly reported. A signifcant number of accidents and injuries were found to be related to the client, particularly from client failure to attend to and follow instructions. Individuals in the older age group had a higher occurrence of respiratory, cardiovascular problems and death, whereas the younger age group had more incidents of drug abuse and gastrointestinal problems. Francis (2005), reports that personal safety and security have become issues for rural health professionals. It is suggested that the primary care provider seek assistance from Ambulance, Police and Fire Brigade for security (Ministry of Health, 2002a). Rural nurses tend to know their local community population and they use this knowledge to enhance the care of their patients. However, when providing health care to tourists, the rural nurse encounters complete strangers and has no knowledge of their previous health problems, medications or allergies. The nurse needs to have an approachable manner and effective communication skills in order to develop a trusting relationship during the consultation. This will assist in accessing suffcient personal and health background information from the patient to enable safe and appropriate treatment to be given. For many of these people English is a second language and some may have a very limited understanding and vocabulary in English. Seasonal workers Although tourists and their health care needs are a signifcant factor in nursing practice the health care needs of the people who service the tourist industry make an equally signifcant impact on this nursing practice. The young age of migrant and seasonal workers, and the issues associated with this, creates another facet of rural nursing in a tourist area. Analysis of my experience in 2004 demonstrates that there were approximately 300 permanent residents plus 130 temporary/seasonal residents living in the tourist town. This imposes a signifcant number of young people on a population that already had a younger average age than New Zealand as a whole. It is my experience that young women frequently present with urinary tract infections which are normally assessed, diagnosed and treated by the nurse, with medication being dispensed under standing orders. The seasonal workers eat on the job, have long and disruptive hours of work, reduced sleep, and a tendency to party on their day off rather than participate in exercise, all factors that tend to contribute to developing upper respiratory tract infections. Injuries that have occurred as a result of intoxication are one of the most common reasons that seasonal workers seek health care from the nurse. Nursing involvement is initially attending to the injuries that result from alcohol and drug indulgence and education on safe use of alcohol is opportunistic. The challenge for the nurse is to use the expertise available at a distance to promote educational opportunities on alcohol and drug use and abuse, otherwise the nurse attends to these educational requirements. The challenge for all primary care health professionals in meeting the needs of a large group of young people is to minimise the barriers to accessing health care identifed by young people and to make health care accessible and acceptable to them. For a nurse working in isolation in a small community, the challenges are personal, professional and political. As the demand for health services increases, the nurse has less time for community population health work. Health promotion initiatives that involve considerable time in planning and execution are less likely to be undertaken. For example it is the tourism industry that brings diversity into the community and to the nursing practice. Demographic changes in a small community can disrupt the informal networks, and create a need for new services to be delivered locally (Bushy, 1998). Rural nursing and advanced Practice the nature of rural nursing, made more unpredictable by the infuence of tourism, requires a nurse to be adaptable and fexible. Not only is a broad and generalist knowledge necessary, but also advanced skills in assessment, diagnosis and treatment of patients are required. In this advanced role, nurses have intersected with the boundaries of other health professionals such as medical practitioners, midwives, pharmacists, pre-hospital emergency care providers. Scharff (1998) writes about rural hospital nurses making decisions and initiating treatments that are normally the prerogative of doctors. Hegney (1997) argues that this is advanced rural nursing practice rather than nurses practising medicine. However, Hegney found that this role was identifed as stressful for many nurses, due to lack of appropriate education and training. It is clear that retention of skills, up-dating knowledge, and acquisition of new skills, orientation and education are essential components of providing nursing and health care to a community where tourism is the major industry. The geographical isolation of the area makes accessing postgraduate education a challenge, at considerable fnancial and personal cost. The impact of tourism on nursing in a tourist region illustrates the multi-faceted and complex nature of practice that is the reality for rural nurses. Conclusion Nurses are practising as primary care health providers in remote and isolated settings. In a rural community where tourism has now become a major industry, nursing faces new and unique challenges. Yet the number of rural nurses in New Zealand is still very small compared to the national population of nurses and so the voice of the rural/remote nurse tends to be lost within the larger group. It is hoped that this chapter will in some small way contribute to the overall knowledge and awareness of the unique and diverse practice that is rural nursing in a tourist rural New Zealand context. Self-reported illness and risk behaviour amongst Canadian travellers while abroad. Rural nursing in the United Stated: Where do we stand as we enter the new millenniumfi A cumulative review of studies on travellers, their experience of illness and the implications of these fndings. Online Journal of Rural Nursing and Health Care, retrieved August 13, 2005 from. Nursing practice in rural and remote Canada: Final report to Canadian health services research foundation. Sexual and reproductive health: A resource book for New Zealand health care organisations. Health problems associated with international business travel: a critical review of the literature. Incidence of health crises in tourists visiting Jamaica, West Indies, 1998 to 2000. In New Zealand the rapidly growing demographic population of older people is placing often unsustainable fscal pressures on the current health care systems, especially acute, tertiary, and secondary in-patient systems (Ministry of Health, 2002a, Ministry of Health, 2002b). Transitional care (or intermediate care as it is commonly known in the United Kingdom) is reported by international research to supply a viable alternative to secondary hospital inpatient care (Department of Health, 2002). Transitional care occupies centre stage because it fulfls the crucial function of supporting people transitioning between acute health care (inpatient) and primary healthcare (home). People who may otherwise face prolonged stays or inappropriate admission to acute in-patient or long term residential facilities should be admitted to transitional care (Andrews, Manthorpe, & Watson, 2004). Transitional care has an advantage in rural communities as it empowers those communities to provide the appropriate rehabilitative care within these smalllocalised environments, by utilising services already available to their maximum. The patient perception or satisfaction of transitional care is scarce or unknown especially in rural New Zealand (Nygren, Iwarsson, Isacsson, & Dehlin, 2001).

What is required is the communication of health information and skills to people birth control pills 1 week after period generic alesse 0.18 mg without prescription, arguing for health changes and providing social and environmental support for such changes birth control missed pill purchase discount alesse online. From a health policy point of view this calls for a sound policy framework that is based on careful analysis of the local environment and on relevant birth control pills known for weight loss discount alesse uk, research-based theoretical approaches birth control vs abortion buy alesse, that leads to appropriate policy decisions (Puska, 2002; Swinburn, 2002). Maori and food One hundred and ffty years ago after settlers arrived when hapu moved from hilltop pa (fortifed place built by Maori) to low-lying kainga (a native town or village), major dietary changes occurred. Fern roots, kumara, fsh, birds and berries which are all diffcult to obtain but nutritious and protein-rich, gave way to four, sugar, tea, potatoes and salted pork. Bread and potatoes became the mainstay for many whanau, often leading to malnutrition. However, with urbanisation came new patterns of nutrition, with malnutrition being less of a problem than overeating, and the balance of adding natural food resources to the diet was lost to an almost exclusive reliance on foods readily available from fast food outlets and supermarkets (Durie, 2003). It appears the lifestyle factors that lead to diabetes have developed, even fourished, despite the known risk. Health promotion experts have emphasised the importance of better public information and education about diet though without any major breakthrough (Durie). Maori society was also affected by the loss of mahinga kai (traditional food-gathering areas), especially with the pollution of coasts, lakes, rivers, and the destruction of forest (Ministry of Health, 2002b). Contemporary consumers prefer foods that are tasty, inexpensive and convenient that tend to be energy dense foods that are high in fat and sugar (Swinburn, 2002). In general, people in such groups face problems in obtaining the quantity and quality of food needed for a healthy diet, which is shown in the strong association between socio-economic deprivation and obesity (Ministry of Health, 2002a). Geography and availability of foods in the Southern Lakes District the ecological scan undertaken for this study found that all areas had access to bread, milk and butter except one (which had one takeaway store). Some had a wide-ranging selection of food outlets, service stations, dairies, fruit shops, butchers and supermarkets. The mean prices and availability of foods were comparative to the larger town of Taupo. One had limited availability to healthy food options and the prices of these were found to be more expensive than energy dense foods. Milk Although milk was found to be cheaper than both bottled water and sugary drinks, it is known that households in New Zealand of lower socio-economic groups tend to have a diet lower in diary products (Ministry of Health, 2004). Milk and milk products provide important nutrients at all stages in life and are particularly important sources of protein and calcium. As some milk and milk products are major sources of total and saturated fat intake in the New Zealand diet it is recommended that people choose low-fat milk and low cholesterol spreads (Russell, Parnell & Wilson, 1999). However it is diffcult to advise people to eat low-fat foods, when the food supply supporting such diets is restricted, indicating a need to increase availability of foods that are low in fat and low in energy density. Sugary drinks and bottled water Increasing consumption of sugary drinks, carbonated beverages (soft drinks), sports drinks and fruit juices have contributed to the increase in carbohydrate and increased total energy intake. The increased availability and consumption of highly palatable, sugar-based drinks has also been linked to increasing the energy content of the diet and a contributing factor in the obesogenic environment (Chacko, McDuff & Jackson, 2003; Ministry of Health, 2002b). However, the mean price similarity may well be due to supply and demand, which has been associated with the decreasing cost of sugary drinks due to the consumption in New Zealand having increased by approximately 45% in the past fve years (Ministry of Health, 2003a). Bread Wholemeal bread was available in all areas except one, yet white bread was cheaper in all areas. Less than one-sixth of all New Zealanders eat the recommended servings of breads and cereals. Yet, consumption of bread is higher among Maori in more deprived areas (Ministry of Health, 2002b). Encouraging people to buy wholegrain bread requires the price to be less than white bread. Butter and low cholesterol spread About 44% of discretionary fat (calories that a person adds to food) is from butter or margarine, most of which is added to bread products (Ministry of Health, 2004). To decrease this percentage people need to use low cholesterol spread, which has less saturated fat content compared with butter. However, low cholesterol spread was more expensive than butter, with the highest prices in smaller rural areas. Chicken, pork and beef Historically, the New Zealand diet has been high in the consumption of red meat. To help reduce total and saturated fat intake, meat and chicken should be lean (Ministry of Health, 2004). Availability of lean beef, pork and chicken without skin is limited to larger towns. Trim pork and beef was generally a similar price to regular pork or beef, but chicken without skin was double the price of that with skin. The answer may lie in educating people to remove the skin from chicken, as the price per kilogram is a great deal cheaper. Healthy and unhealthy snacks Energy-dense snacks have been linked to the rising obesity rates (Drewnowski, 2004). This relates to added sugars and fats being easier to produce, process, and transport than perishable foods and fresh produce. Similarly Wilson and Mansoor (2005) found that foods with the highest saturated fat were cheaper than low saturated fat equivalents for eight out of the nine comparisons. In addition most outlets had available different portion sizes, which was a positive fnding as food companies have long known the commercial benefts of promoting larger portion sizes. Low calorie dressings were also common, however grilled vegetables, meats and seafood were the least available. Although the World Health Organisation (2002) acknowledged that extensive marketing of energy-dense foods and fast food outlets is a probable cause of obesity, Simmons et al. In a society where there is easy availability of food, the key to the obesity epidemic relates strongly to reduced physical activity and not to the consumption of takeaway food. Study Limitations As this was a small study in the Southern Lakes District of the North Island the results are not able to be applied to the rest of the country. Nevertheless, the pricing gradient and availability of low fat options has been shown to be poor, especially for the smaller towns. Future studies need to refect nutritional recommendations recently developed in the United States, although a defnition of unhealthy foods was not given (U. Nevertheless, the inclusion of unhealthy foods surveyed appeared to have been the same throughout the data collection. Recommendations Altering the environment to encourage behaviours that prevent obesity may appear an insurmountable challenge. Historically epidemics have only been controlled after environmental factors have been modifed. Similarly, reductions in population levels of obesity seem unlikely until the environments that facilitate its development are modifed. A paradigm shift to understanding obesity as normal physiology within a pathological environment signposts the direction for a wider public health approach to the obesity epidemic (Egger & Swinburn, 1997). The major economic infuences are the costs of food production, manufacturing, distribution, and retailing. These costs are largely determined by market forces, but some opportunities exist for public health interventions (Swinburn et al. A number of approaches have been put forward by various authors (Durie, 2003; Maher et al. Without a supportive environment, treatment programmes are likely to be ineffectual and diabetes prevention programmes will be restricted to mass education strategies (Swinburn). Put simply, we need to focus more on the causes of the causes, and less on the individual (Quigley & Watts, 2005). Conclusion Obesity and its co-morbities, especially type 2 diabetes, have reached epidemic proportions in New Zealand and globally. There is no doubt that an environment that promotes excessive food intake is a major contributing factor to the obesity epidemic (Mann et al.

Single dose good for prevention of exercise induced asthma Respiratory 79 fi Anti-leukotrienes: Leukotrienes fi fivascular permeability birth control myths order alesse 0.18 mg without a prescription, fimucus production birth control ring side effects purchase 0.18 mg alesse, fimucus transport birth control pills in shampoo order alesse online from canada, etc birth control pills 60s purchase generic alesse pills. If not using spacer, need to rinse, gargle and spit otherwise risk of thrush and croaky voice. Instructions for use: fi Shake an inhaler between each puff fi Remove cap fi Hold it upright and pointed backwards fi Breath out st fi Fire during 1 25% of long slow inhalation fi Hold breath fi Breath out after removing inhaler from mouth fi Inhalers through a spacer: fi As effective as a nebuliser. Need smaller spacer as they have a small tidal volume fi Volumatic without facemask. So wash in detergent once a week and do not rinse bubbles off (fi microfilm of detergent) fi If using a new space without washing, need to prime it (10 puffs). Disadvantages: cost, require high respiratory flow fi Accuhaler: 60 doses, easy to use, has dose meter fi Disk haler: 6 doses fi Turbohaler: easier to use than disk haler. Sputum will be clear/white, only occasionally will be infected (yellow/green) fi [Cf Chronic infective bronchitis with green sputum fi bronchiectasis] fi Pathogenesis: fi Chronic irritation (eg inhaled substances such as smoking) and microbiological infections fi hyper-secretion of mucus obstructing airways. Hypertrophy of submucosal glands in larger bronchi and hyperplasia of goblet cells in small airways. Reid index (ratio of mucous gland layer to thickness of epithelium to cartilage) greater than 0. If severe fi luminal obliteration Emphysema fi Enlargement of air-spaces distal to terminal bronchioles and destruction of alveolar walls without fibrosis Respiratory 81 fi Moderate to severe emphysema is rare in non-smokers fi Aetiology: fi Cigarettes: usually had a 20-pack year history. Neutrophils also release free radicals that inhibit fi1-antitrypsin fi Types: fi Centriacinar (Centrilobular): enlargement of respiratory bronchioles, distal alveoli are spared. Seen in smokers and coal workers pneumoconiosis fi Panacinar (Panlobular): acinus is uniformly involved from respiratory bronchiole to terminal alveoli. Treatment same as for smoking induced fi Paraseptal (distal acinar): proximal acinus is normal, distal part affected. Often seen in cases of spontaneous pneumothorax in young people fi Irregular emphysema: acinus irregularly involved. Associated with scarring fi Macroscopic appearance: voluminous lungs fi Microscopic appearance: large abnormal airspaces, blebs and bullae. Bronchitis and bronchiolitis fi Clinical features: fi 60 years or older fi Prolonged history of exertional dyspnoea fi Minimal non-productive cough fi Usually have lost weight fi Use accessory muscles for respiration fi Prolonged expiration period (lungs collapse due to fielastin) fi Pink puffers: firespiratory rate maintains O2. Rarely cor pulmonale, metastatic brain abscesses and amyloidosis Restrictive/Interstitial Pulmonary Disease fi = Reduced expansion of the lung parenchyma fi British and Americans give them different names fi Over 150 different disease processes primarily affecting alveoli epithelium, interstitium and capillary endothelium, not airways Restrictive Lung Diseases Affecting chest wall or Interstitial or infiltrative diseases pleural space fi fibellows function. Heavy lungs due to fluid accumulation (interstitial and later alveolar) fi Microscopic appearance: fi Early change: interstitial oedema, few cell infiltrates fi Acute exudative stage: microvascular injury fi breakdown of basement membrane fi leakage of plasma proteins into alveoli. Fibroblasts lay down collagen in interstitium and alveolar spaces fi interstitial and intra-alveolar fibrosis fi Prognosis: 50% mortality. Filling of alveolar with alveolar macrophages (not desquamated as originally thought). See Types of Lung Cancer, page 88 fi Laryngeal and perhaps extrapulmonary neoplasms fi When asking about occupational exposure, need to go back a long time. Serpentine crysotile form (curly, flexible) is more common, less dangerous, cleared more easily from bronchi and more soluble so donfit persist in the alveoli. Monocytes recruited fi granuloma formation fi Macroscopic appearance: Chest X-ray shows bilateral hilar lymphadenopathy and/or diffuse interstitial disease. Tightly clustered epithelioid histiocytes, multiple giant cells, and a few peripheral lymphocytes fi Clinical course: Treat with steroids. Contain lots of cholesterol fi Pharyngeal pouch: Mucosa herniates out through triangle between the cricopharyngeus and thyropharyngeal muscles under pressure from swallowing when upper oesophageal sphincter doesnfit relax properly. Treatment: radiotherapy unless spread through cartilage fi Supraglottic: 30%, above chords, involves false chord. More aggressive, metastasise to cervical lymph nodes fi Transglottic: < 5%, crosses from one chord to another fi Infraglottic < 5%, below chords, more aggressive fi Donfit usually metastasise elsewhere, but lymph node infiltration common fi Treatment: radiotherapy (fi dry mouth) +/surgery (superficial, hemilaryngectomy, laryngectomy, laryngectomy +/radical neck resection. Quitline 0800 778 778 Epidemiology of Lung Cancer fi Commonest cancer in the world fi In New Zealand, leading cause of cancer death in men (23%, bowel 15%, prostate 14%) and third most common in women. Maori women have the highest death rate from lung cancer of any female population in the world fi Males predominate. Fragile fi crushed causing blue streaks fi Complications: metastatic disease to lymph nodes, brain, liver and adrenals fi Two year survival 25% fi Treatment: chemotherapy. Grows by expansion rather than infiltration fi Mesothelioma: fi Primary pleural tumours, including benign and malignant (also tumours of the peritoneum, tunica vaginalis and pericardium) fi Benign mesothelioma does not produce pleural effusion and has no relationship to asbestos fi Malignant mesotheliomas arise in either visceral or parietal pleura, produce pleural effusion (can be unilateral) and are related to asbestos. Aggressive, bulky, peripheral tumour fi Pancoast tumour/syndrome: lung cancer (usually squamous) in the apex extending to supraclavicular th st nd nodes and involving 8 cervical and 1 and 2 thoracic nerves fi shoulder pain radiating in ulnar distribution. Surgical studies are highly selected and not representative of the general population fi Majority will require radiotherapy. Can be used prior to surgery/radiotherapy to control micro-metastases/improve operability, or palliatively. Variety of causes including neuromuscular and chest wall deformities fi Cheyne-Stokes Respiration: usually with advanced heart failure. Treatment: codeine or anti-Parkinson drugs fi Narcolepsy: Normal sleep at night and frequently going to sleep during the day. Can also be complicated by cataplexy (sudden loss of muscle tone in response to emotional stimuli). Prone to infection so steroids worsen the condition by depressing the immune system. Bronchial lavage effective in acute episodes fi A number of vasculitis affect the lung. Usually found as incidental findings on X-ray fi Primary Pulmonary Hypertension: rare, usually in young women. A large histiocyte with one bland folded nucleus, abundant eosinophilic cytoplasm with indistinct cell borders. X-rays show multiple nodules scattered through both lungs fi Langhans giant cell: (not the same as Langerhans cell) multinucleated giant cell in granulomas, with nuclei arranged around the periphery of the cell in a horseshoe pattern fi Sequestration: fi Extralobular: Congenital. Mass of lung tissue not connected to bronchial tree and outside the visceral pleura fi Intralobar sequestration: usually acquired. Within the visceral pleura but not connected to the bronchial tree fi Differential of Solitary lung nodule: fi Tumour: benign (bronchial adenoma or pulmonary hamartoma) or malignant fi Tb fi Sarcoidosis fi Other granuloma: eg fungal fi Haematoma (ie blood clot, eg in cavity following lung contusion) th th 92 4 and 5 Year Notes Endocrine and Electrolytes History. Can test for these in prodromal stage fi Insulin autoantibodies fi Acute presentation: hyperglycaemia (polyuria when glucose > 10 mmol/l, thirst, polydypsia), tiredness, weight loss.

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