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One cannot become an effective Scholar and Medical academic half-days) buy 250 mg biaxin mastercard gastritis relief, between supervisors and residents order biaxin 500 mg without a prescription no xplode gastritis, and Expert without sharing information with peers discount 500mg biaxin visa gastritis symptoms in cats. As a body buy 250 mg biaxin visa gastritis diet ayurveda, residents be an effective Health Advocate without the cooperation of can decide on a topic concerning physician health that could one s supervisors and peers which will itself be shaped by be mediated by increased collegial relations (e. One learns stress related to time pressures in training) and invite a faculty effective approaches through the wisdom and example of member who feels comfortable sharing personal experience to other practitioners. In addition to supporting these domains feedback is often perceived as less critical and constructive of competency, collegiality by defnition engenders the kind of in criticism, when discussing topics of communication with mutual respect and support that helps to prevent the intimida- colleagues. This kind of evaluation process can ensure that the tion and harassment of colleagues. Moreover, where healthy resident is evaluated fairly by all members of the team and collegiality exists, physicians will not only support one another removes pressure off of the physician preceptor who may during good times, but will also protect one another s health by have challenges providing critical feedback. For the residents recognizing when colleagues are in trouble and helping them involved, it builds skills in giving feedback on professional to get the support they need. Ottawa: departments that do not foster collegiality suffer from poor The Royal College of Physicians and Surgeons of Canada. Collegiality is an important predictor of job satisfaction, and Bulletin of the New York Academy of Medicine. For example, learning can be facilitated by group ac- and tivities such as workshops and tutorials. When well organized, discuss the broader responsibilities associated with col- these activities expose each learner to a range of beliefs and legiality, especially with regard to physician colleagues. By serving both to broaden perspectives and foster the mutual Case respect of both, teacher and learner, this approach can also Although a second-year resident has been an important in- provide an important model for maintaining respect within novator and leader among their peers, over the past three the physician patient relationship. By fostering collegiality, months they appear to have become more withdrawn and academic medicine has the opportunity to enhance the quality isolated. A formerly vibrant personality seems to have of medical graduates as well as, to provide a good basis for been replaced by moodiness and introversion. Some of the resident s peers notice practised in a health care system that is constantly changing the resident drinking more alcohol than usual one night and increasingly demanding. There are also rumours that the effective communication to the delivery of quality medical care resident may have been in some sort of trouble with the is well recognized, and the term collegiality has come to refer law recently. In addition, a legal proceeding involving one to professionals working together as equals and sharing in de- of the resident s cases, which had an adverse outcome two cision-making. Care of the patient can be a complex challenge years ago, is scheduled in civil court soon. In speaking of multidisciplinary care, we can forget that such care involves more than a multidisciplinary group comprised Introduction of physicians. True collegiality involves collaboration with Like college and colleagues, the word collegiality derives from other health care disciplines, and there is much that each can the Latin collegere: to read together. Having said that, collegiality between collaborators in common pursuits, or having common duties and interests, is not automatic. It needs to be fostered and nurtured with re- and sometimes, by charter, peculiar rights and privileges. When a collegial atmosphere exists in an academic centre it can create a safe and productive setting for both teachers and Collegiality offers the beneft of a safe and protective com- learners. Collegiality can create a culture in which uncertainty, munity that can help us to cope in the face of stressful work lack of knowledge and feelings of incompetence are both tol- environments. It maximizes open communication and or advantaged club: it implies certain duties and responsibilities. In such a setting, Society does not appreciate a self-protective collegiality that a collegial faculty would be one that values a commitment to circles the wagons around questionable professional behav- the sharing of knowledge. And so it is important to remember that, like everyone else, physicians get sick and grow old, and that in the process their competence can be compromised. As is discussed elsewhere in this handbook, certain aspects of the culture of medicine, together with typi- cal attributes that otherwise hold physicians in good stead, can make physicians reluctant to admit when they fnd themselves in diffculty. However, the physician s responsibility to maintain his or her own health in order to practise safely also extends to a collegial duty to be aware of the health and ftness of others. Case resolution In the past, ill physicians, worried that their medical licence It is important for any organization or group to cultivate might be put in jeopardy, remained silent until a complaint was collegiality and mentorship. In this case, rumours are reported to a regulatory body or an adverse event occurred. Nor is it a colleague s role wait until problems are of such severity that regulatory bodies to try to diagnose or to treat the resident. Workplaces should have mechanisms in however, for a trusted colleague or colleagues to respect- place to ensure that potentially impaired practitioners promptly fully ask to meet with the resident privately and to present cease practice until their ftness to practise can be assessed. It would be appropriate to offer assistance Too often, however, a misguided sense of collegiality makes in connecting the resident with a personal physician if the physicians hesitate to respond to a colleague in diffculty or resident doesn t have one. In this case it would be appropriate for the colleague or colleagues to research contact information for the local An organized and responsible method for dealing with mat- physician health program and assist the resident in orga- ters of potential physician impairment would involve early nizing an appointment with medical staff there. It might identifcation of physicians who might require assistance and even be ftting for a colleague to accompany the resident to the provision of timely and caring intervention when it is such an appointment, but not to be part of that meeting. Academic departments or group It is to be hoped that incapacitated colleagues will respond practices should cultivate a resource list of primary care appropriately to support and advice, but at the end of the day physicians who are community based and not necessarily we cannot ignore our legal and ethical obligations to report associated with academic departments. These providers to the appropriate bodies impaired physicians who insist on should have experience in caring for physician colleagues practising despite reasonable offers of assistance. A supportive collegial group works proactively as a team to ensure the optimal function of all members. It is not focused Key references only on the individual practitioner s health, but also on the Brown G, Rohin M, Manogue M. Effective Learning & Teaching in Medical, Dental & Veterinary contribute to the stress of health care staff, but also encour- Education. Given that interpersonal confict is discuss collaborative attitudes and communication skills potentially all around us, it is important to learn strategies that that support the creative resolution of confict. Case Most instances of confict appear to have had an immediate, Two enthusiastic and ambitious residents seem to have observable trigger, a hot-button issue of some kind. In reality, butted heads regularly on several issues during their three the problem is usually more complex. Conficts occur repeatedly, other variables, of which the parties involved might not be whether it surrounds organizing the on-call rota, holiday fully aware. Such variables include the power relationships, true schedules, or topics for grand rounds. The confict seems needs as opposed to apparent wants, and styles in dealing with to be escalating, and each sees the other s behaviour confict. As is typical of unresolved it is important to be aware of our own typical responses to confict, the situation is becoming personalized, and both confict our confict styles. It is normal The situation is becoming diffcult for the department as to make presumptions and assumptions on the basis of experi- a whole, as both residents each seek to recruit colleagues ence. In this module we focus on interpersonal con- When we are in confict we can demonstrate behaviour that fict, which occurs when human need or interest is frustrated. A defensive style is usually more has been defned as a situation in which one or both persons adversarial, and refects the extent to which we are attempting in a relationship are experiencing diffculty in working or living to satisfy our own needs.
Diseases
- Osteolysis hereditary multicentric
- Odontophobia
- Pyelonephritis
- X chromosome, monosomy Xp22 pter
- Thanos Stewart Zonana syndrome
- Short limb dwarfism Al Gazali type
- Microcephaly autosomal dominant
- Porphyria, Ala-D
- Glossopharyngeal neuralgia
- Testes neoplasm
Polypoid ethmoid mucocele is a process that involves bilaterally all the ethmoid cells purchase 250mg biaxin gastritis diet 500, with diffuse expansion of the sinus generic 500 mg biaxin mastercard gastritis gastritis. Its appearance is similar to the diffuse sinus abnormality seen with polyposis order biaxin 250 mg online gastritis diet öèòðóñ, except that the polypoid mucocele preserves the ethmoid septa and lamina papyracea buy biaxin 500 mg lowest price gastritis diet íùãåãèó. Acute or fulminant invasive fungal sinusitis is a rapidly progressive disease seen in the immunocompromised host. Chronic or indolent invasive fungal sinusitis occurs in an immunocompetent patient; the fungus proliferates in the sinus cavity and penetrates the mucus. A mycetoma or fungal ball is also seen in immunocompetent nonatopic individuals; the fungus is found in the secretions without penetration of the mucosa. Lastly, allergic fungal sinusitis occurs when the fungi colonize the sinus of an atopic immunocompetent host and act as an allergen, eliciting an immune response. The inflammation results in obstruction of the sinus, stasis of secretions, and further fungal proliferation. The diagnostic criteria for fungal sinusitis are as follows: the presence of allergic mucin at endoscopy; identification of fungal hyphae within the allergic mucin; absence of fungal invasion of the submucosa, blood vessels, or bone; immunocompetency; and radiologic confirmation ( 35,36 and 37). The air-fluid levels associated with acute bacterial sinusitis are less common in fungal sinusitis; in fact, the absence of fluid levels is suggestive of fungal disease. In this same study it was noted that 96% of the patients had more than one sinus involved by the disease process. If more than one sinus is involved, it may difficult to distinguish fungal sinusitis from sinonasal polyposis. This is felt to be secondary to the presence of calcium, heavy metals (iron and manganese), and inspissated secretions ( 36,38). A similar appearance may occur with the inspissated secretions in chronic bacterial sinusitis. However, one study ( 39) demonstrated that the calcifications seen in fungal sinusitis are more commonly central in location and more likely to be punctate in morphology. The calcifications in nonfungal sinusitis are more likely at the periphery (near the wall) of the sinus. Nonfungal calcifications are often smoothly marginated with a round or eggshell appearance. Unfortunately, calcifications that are noted to be nodular or linear in shape can be seen with either process. A T2-weighted image from a brain magnetic resonance image (A) shows opacification of the sphenoid sinus ( large white arrows). The majority of the secretions are isointense, but centrally there are serpiginous, linear areas of signal void ( small white arrows). A computed tomographic examination of the sinuses was subsequently obtained (B narrow/soft tissue window and C wide/bone window). The sphenoid sinus (large black arrows) is completely opacified with central areas of linear calcification ( small black arrows). As a result of the presence of calcification or paramagnetic ions within the inspissated secretions, T2-weighted images show a markedly low signal and often a signal void ( 38). A mycetoma, or fungus ball, may resemble a calcification or concretion within an opacified sinus. Fungal sinusitis may cause areas of bone erosion from pressure remodeling ( 36,38). Often it is this aggressive nature that identifies the sinus process as more complicated than bacterial/inflammatory disease. This occurs prior to bone destruction, and may be an early sign of an invasive process. Invasive fungal sinusitis demonstrates an enhancing mass with bone erosion that extends beyond the sinus walls to involve the superficial soft tissues, orbit, or intracranial contents. Imaging of sinonasal neoplasms is no exception, although some generalizations can be made. Hydrated secretions and hypertrophic mucosa are generally more hyperintense on T2-weighted imaging. Neoplasms often demonstrate homogenous enhancement, but sinusitis does not; this is a key finding. Normal mucosa also enhances, but an obstructed sinus demonstrates more peripheral mucosal enhancement with central low signal intensity. However, in a small sinus cavity where the walls are apposed, the appearance of sinusitis may still suggest a solid lesion ( 16). The problem with using bone destruction and extension to surrounding structures as a distinguishing feature is apparent, because this may be seen in aggressive nonneoplastic processes as well. Inverted papilloma is an epithelial tumor that occurs in individuals 50 to 70 years of age. This tumor is unusual in that the epithelium grows (inverts) into the underlying stroma, rather than growing exophytically. It is usually a unilateral mass that arises from the lateral nasal wall adjacent to the middle turbinate, and commonly extends into the maxillary sinus. There is an association between inverted papilloma and malignancy; the prevalence ranges from 2% to 56%. The malignancy may arise directly from the inverted papilloma, adjacent to the papilloma (synchronous tumor) or in the same anatomic site as a previously resected papilloma (metachronous tumor) ( 41,42,43 and 44). Juvenile angiofibroma begins as a unilateral mass that arises in the nasal vault, near the choana and sphenomaxillary fissure. This tumor presents in the second decade of life in men, often with epistaxis or nasal obstruction. It commonly extends into and widens and destroys the pterygopalatine fossa and the pterygoid plates as it extends into the nasopharynx. When they do occur they most often involve the maxillary sinus, then the ethmoid sinuses, and finally the nasal cavity. Olfactory neuroblastoma, also known as esthesioneuroblastoma, is a neural crest tumor that arises from the olfactory epithelium of the nasal cavity. There is a bimodal age distribution affecting teenagers and individuals in their sixth decade of life. The imaging findings are not unique other than the characteristic location of this tumor in the superior aspect of the nasal cavity, adjacent to the cribriform plate (46,47). Melanotic tumors are hyperintense on T1-weighted images and hypointense on T2-weighted images ( 16). The left maxillary sinus (L) is completely opacified by a mass that also completely fills the adjacent nasal cavity and extends back toward the nasopharynx. On the left only a portion of the lateral pterygoid plate remains ( open white arrow), the medial plate has been eroded by tumor. Note that the mass extends into and nearly completely fills the nasopharynx ( np). A noncontrast T1-weighted coronal magnetic resonance image (C) shows the isointense mass (black arrows) filling the left maxillary sinus, nasal cavity, and ethmoid air cells.
Syndromes
- Sputum smear (KOH test)
- Allergic reactions to medicines
- Loss of sweating in any part of the body
- Active histoplasmosis
- Dehydration from difficulty swallowing fluids
- Rapid breathing
This is still an important problem around the world: it is estimated that 250 500 000 children are blinded each year because of eye damage brought about by severe vitamin A deciency generic biaxin 500mg without prescription gastritis red wine. It is the single most important cause of blindness in low and middle income countries order 500 mg biaxin chronic gastritis symptoms stress. Vitamin A deciency develops quite quickly in children with measles quality biaxin 250 mg gastritis keeping me up at night, as infections make the body consume its vitamin A stores much more quickly order 250 mg biaxin mastercard severe erosive gastritis diet. Children between six months and four years old are most vulnerable to vitamin A deciency. An estimated 100 million pre-school children globally are estimated to have vitamin A deciency and 300 000 are estimated to die each year because of vitamin A deciency. In order to prevent child deaths and childhood blindness, many low income countries have inte- grated vitamin A supplementation into their immunization programmes. Vitamin B complex deciencies The B vitamins generally are coenzymes in the energy metabolism in the body. Vitamin B decien- cies have occurred in extreme situations in the past, such as in the 19th century when the steam mills in South-East Asia started to provide polished rice. Suddenly, people had enough energy but insufcient supply of B vitamins and developed beri-beri, a Sinhalese word for I cannot. It may also occur today in refugee populations, if they are provided with a very limited choice of food items with enough energy but decient in B vitamins. Similarly, it may also happen to alcoholics and people with other types of very monotonous diets. The different deciency syndromes of vitamin B overlap and are sometimes very difcult to dis- tinguish from one another. A recent example is the Cuban neuropathy in the mid-1990s, in which over 50 000 people suffered from a gait and visual disturbance, technically a polyneuropathy (8, 9). It is now known that the population that experienced the epidemic had an extreme diet (tea with sugar as the main source of energy; which is likely to generate a vitamin B deciency) and the epidemic stopped as soon as universal distribution was made of tablets with vitamin B complex. This led the scientists to conclude that it was a vitamin B complex deciency, without being able to distinguish the vitamins from each other. From a public health perspective, therefore, the B vitamins may as well be treated together, the only exceptions being vitamin B12 and folate. Beri-beri is one form of vitamin B1 deciency, and the main symptom is a polyneuropathy in the legs (10). In severe cases, one can suffer from cardiovascular complica- tions, tremor, and gait and visual disturbances. An acute form of the syndrome seen in alcoholics is Wernicke s encephalopathy (discussed in the section on alcohol). It is characterized by a seri- ous confusion, unsteadiness and eye movement disorders. It can be rapidly reversed if correctly diagnosed and immediately treated with high-dose thiamine. Deciency of niacin leads to pellagra, an Italian word for rough skin, which was common in Italy and Spain in the 19th century when large populations were sustained on a maize diet. Neuropsychiatric disorders including seizures, migraine, chronic pain and depression have been linked to vitamin B6 deciency (11). Some studies have suggested that neurological development in newborns could be improved by supplementation in pregnancy, but this is still a hypothesis (12). Vitamin B6 deciency may occur especially during intake of some drugs which antagonize with the vitamin (i. Folate (or folic acid) plays an important role for rapidly dividing cells such as the blood cells, and a folate deciency causes a special type of anaemia called megaloblastic anaemia which is reversible when folate is given. Folate supplementation for women at the time of conception protects against neural tube defects (13). Supplementation of folate in wheat our is therefore common in Europe and North America, with the objective of reducing the risk of neural tube defect (14 16). In Canada, Chile and the United States, mandatory fortication of our substantially improved folate and homocysteine status, and neural tube defect rates fell by between 31% and 78% (17 ). Thus additional creative public health approaches need to be developed to prevent neural tube defects and improve the folate status of the general population. The vitamin B12 or cobalamine is like folate important in the formation of blood cells, particularly the red blood cells. Vitamin B12 is different from the other B vitamins because it needs an intrinsic factor produced by the gut in order to be absorbed. This means that people with gut disorders and also elderly people may experience vitamin B12 deciency. Vitamin B12 deciency also causes a megaloblastic anaemia which is reversible when vitamin B12 is given. What is worse is an insidious irreversible damage to the central and periph- eral nervous systems. In a severe form it may also cause a psychiatric disorder with irritability, aggressiveness and confusion. It has been suggested that vitamin B12 deciency might contribute to age-related cognitive impairment; low serum B12 concentrations are found in more than 10% of older people (18) but so far there is insufcient proof of benecial effects of supplementation. The most serious problem with vitamin B12 deciency still seems to be the irreversible progressive myeloneuropathy, which is difcult to diagnose. Iodine deciency disorders Iodine deciency does not cause one single disease, but many disturbances in the body. These are denoted by the term iodine deciency disorders: their effects range from increased mortality of fetuses and children, constrained mental development in its worst form, cretinism to impaired school performance and socioeconomic development, as detailed in Table 3. Goitre indicated by a swelling of the thyroid gland is present in 740 million people, and some 300 million suffer from lowered mental ability as a result of a lack of iodine. At least 120 000 children every year are born cretins mentally re- tarded, physically stunted, deaf-mute or paralysed as a result of iodine deciency. At that time, the scale and severity of the iodine problem was only just being realized. Since then, several surveys have shown even more severe damage than was estimated from this deciency in many regions of the world. Work to eliminate iodine deciency disorders has made enormous progress and is becoming a success story in the prevention of a nutritional deciency. The main intervention strategy for control of iodine deciency disorders is universal salt io- dization. Over the last decade, extraordinary progress has been made in increasing the number of people consuming iodized salt. Now, more than two thirds of households living in countries affected by iodine deciency disorders consume iodized salt. Because of active programmes of salt fortication, iodine deciency disorders are rapidly declining in the world. In 1990, 40 million children were born with mental impairment attributable to iodine deciency and 120 000 cretins were born, which was substantially more than just seven years later.
