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Apart from this clinical exposure discount repaglinide 0.5 mg line diabetes mellitus patient education, the student is also orientated to health care delivery services within the teaching hospital and the network of supporting hospitals and health centres in the region purchase repaglinide 2 mg diabetes symptoms with pictures. The aim is to inculcate a sense of professional responsibility and adaptability so that the student will function effectively when posted later to the various health care centres in the country effective repaglinide 2 mg diabetes symptoms before diagnosis. The teaching strategy implemented in this phase reflects these approaches:- 28 (i) Discipline - based (ii) Multi-diciplinary integration (iii) Problem - based and problem-solving (iv) Community-orientated (v) Clinical apprenticeship A order repaglinide 1 mg diabetes type 2 cdc. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of cell, tissue and embryology will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins 2. Snell, Clinical Anatomy, 7th Ed, (2003), Lippincott Williams and Wilkins Physiology 1. Kumar et al, Robbin and Cotran: Pathology Basis of Disease, 8th ed (2010), SaundersElsevier. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of molecular biology and pharmacology will be evaluated through continuous assessment using formative and summative approaches. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill,. Lectures and learning activities outside the lecture hall such as hospital placement with other health care workers and community projects will be used to help students understand and appreciate the importance, and practice basic medical ethics and communication. Lectures and practical basic first aid will be given to provide early exposure to students on patient care. Basic knowledge and understanding of the key principles of first aid and medical ethics will be evaluated through continuous assessment using formative and summative approaches. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of immunology, microbiology and pathology will be evaluated through continuous assessment using formative and summative approaches. Medical Microbiology, 25 edition (2010), McGraw-Hill Medical Publishing Division Immunology 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of respiratory system will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins th 2. Jawetz, Melnick&Adelberg’s, Medical Microbiology, 25 edition (2010): McGraw-Hill Medical Publishing Division th 2. Markell and Voge’sMedical Parasitology, 9 edition (2009), Saunder’s Elsevier Publishing Immunology th 1. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of haemopoietic and lymphoid system will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins th 2. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of cardiovascular system will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins th 2. Jawetz, Melnick&Adelberg’s, Medical Microbiology, 25 edition (2010): McGraw-Hill Medical Publishing Division th 2. Markell and Voge’sMedical Parasitology, 9 edition (2009), Saunder’s Elsevier Publishing Immunology th 1. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of gastrointestinal system will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins th 2. Jawetz, Melnick&Adelberg’s, Medical Microbiology, 25 edition (2010): McGraw-Hill Medical Publishing Division th 2. Markell and Voge’sMedical Parasitology, 9 edition (2009), Saunder’s Elsevier Publishing 36 Immunology th 1. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of genitourinary system will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins 37 th 2. Jawetz, Melnick&Adelberg’s, Medical Microbiology, 25 edition (2010): McGraw-Hill Medical Publishing Division th 2. Markell and Voge’sMedical Parasitology, 9 edition (2009), Saunder’s Elsevier Publishing Immunology th 1. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of nervous system and psychology will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins 2. Jawetz, Melnick&Adelberg’s, Medical Microbiology, 25th edition (2010): McGraw-Hill Medical Publishing Division 2. Markell and Voge’s Medical Parasitology, 9th edition (2009), Saunder’s Elsevier Publishing Immunology 1. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1.

Chronic conditions can occur with birds exhibiting depression 1mg repaglinide overnight delivery diabetes prevention book, diarrhoea and anorexia effective 2mg repaglinide diabetic accessories. Recommended action if Contact and seek assistance from animal and human health professionals suspected immediately if there is illness in birds and/or people order 2mg repaglinide fast delivery gestational diabetes symptoms 37 weeks. Diagnosis Isolation of the causative agent by health professionals is needed for a definitive diagnosis generic repaglinide 1mg with mastercard blood glucose percentage. When this is not possible, heart blood, liver tissue and bone marrow should be collected in a sterile manner. The samples must be refrigerated as soon as possible after collection and kept cool during shipment. Take care to ensure these measures do not cause the dispersal of infected birds out of the area. The addition of large volumes of water to a contaminated area can help dilute the bacteria to less dangerous levels. Livestock The disease in livestock may be avoided by employing good sanitation and animal management practices. Prevent the introduction of infection through movement controls, testing and quarantine. Detect any infected animals in the population as early as possible through surveillance and thoroughly investigate all suspect cases. Wildlife Quick and careful collection of carcases will reduce the exposure of migratory and scavenger bird species to the bacteria and minimise its transmission. Pick up dead birds by the head, preferably by the bill, and immediately placed into two plastic bags to prevent leakage of fluids. Remove carcases before there is a major arrival of scavengers which may spread the disease further. Take care to ensure these measures do not cause the dispersal of infected birds out of the area. Take care to avoid contaminating new areas whilst carcases are being transported to the laboratory and disposal site. Scavengers and predators can be attracted away from infected areas to other feeding sites using other food sources such as road killed carcases. These actions need careful evaluation of bird movement patterns and of the disease cycle to assess whether they are suitable. Moving infected or potentially infected birds from one geographical location to another is not advised. Vaccination to protect captive or endangered waterbirds may be appropriate however efficacy and safety information are often lacking. There is no practical method for immunising large numbers of free-living migratory birds. Monitoring and surveillance Regular monitoring of live and dead birds, particularly in endemic areas and areas where migratory birds are concentrated, can help identify early stages of an outbreak and allows disease control activities to be activated before the outbreaks develop further. Humans Wear gloves and thoroughly wash exposed skin surfaces after any contact with contaminated birds. When disposing of carcases by open burning, care should be taken to avoid direct exposure to smoke from the fire. Large gatherings of wild waterfowl are particularly affected with mortality known to exceed more than 1,000 birds per day. There may be a significant impact on wild bird populations when breeding birds are affected and through reduced survival rates of disease-carrying waterfowl. Avian cholera is becoming an increasing threat to endangered avian species due to increasing numbers of outbreaks and the expanding geographic distribution of the disease. The disease can result in negative perception and therefore unnecessary control measures directed at wildlife. Effect on livestock Causes significant mass mortality of poultry and can affect future viability of poultry flocks. Effect on humans Not considered a high risk disease for humans although infections are not uncommon. Economic importance Potential for significant economic impacts on the poultry industry through mass mortality of birds. Wetland environmental conditions associated with the risk of avian cholera outbreaks and the abundance of Pasteurella multocida. In: Field manual of wildlife diseases: general field procedures and diseases of birds. Avian influenza is a highly contagious disease caused by influenza A viruses, affecting many species of birds. These hosts and their viruses have become well-adapted to each other over time and infection does not usually cause overt disease. That said, recent studies indicate that some behavioural changes may occur in response to infection i. These low pathogenic viruses replicate mainly in the intestinal tract (and also in the respiratory tract) of aquatic birds. Mammals – most commonly pigs but also humans – can be infected with influenza A viruses. Broader public health concerns relate to the potential for these, or other, avian influenza viruses to mutate or reassort to create a pandemic strain (i. Viruses belonging to the H5 and H7 subtypes (in contrast to other virus subtypes), may become highly pathogenic. Species affected Poultry are very susceptible to avian influenza infection and the disease causes high mortality and/or loss of producitvity. Humans are, in general, relatively resistant to avian influenza viruses, but in some individuals infection can be severe. Geographic distribution Avian influenza is reported globally, including in the Americas, Asia, Middle East, Europe and Africa. How is the disease The viruses have evolved to be transmitted by the faeco-oral and/or transmitted to animals? How does the disease For poultry, infection is primarily spread through the movement and trade of spread between groups poultry and poultry products locally, nationally and internationally. The practice of outdoor poultry production, including grazing domestic ducks in rice paddies, is considered to be one way in which disease can easily transfer between wild and domestic birds (in both directions). The relative importance of these routes is often difficult to determine (and will differ by situation, location and time period). Scavenging and predatory birds and mammals may acquire infection by ingesting infected birds. How is the disease Humans can become infected via close contact with infected birds or inhalation transmitted to humans? However, situations where there is exposure to high levels of virus, such as during disease control activities or butchering or preparation of infected birds, are of higher risk and appropriate hygiene precautions should always be taken, including use of personal protective equipment. For waterbirds, other conditions such as lead poisoning can also cause these signs although this is more likely to be a longer term illness i. Symptoms include conjunctivitis, ‘flu-like symptoms (including fever), coughing and shortness of breath, diarrhoea, vomiting, and abdominal pain. Public health authorities should be contacted if there is suspicion of human infection.

Three underlying patholo- gies are in operation resulting in a number of clinical Clinical features r entities all with three possible outcomes (see Fig buy repaglinide 0.5 mg visa managing diabetes after kidney transplant. Perianal abscess is common and presents in well pa- tients with an acute tender swelling at the anal verge repaglinide 1mg line diabetes mellitus and exercise. Patients Localised bowel pathology may result in focal area of have significant systemic upset 0.5 mg repaglinide visa diabetes kidney problems. These are confirmed twists on itself usually around a fibrous peritoneal band on barium studies and require resection buy repaglinide 2 mg with mastercard diabetes prevention leaflet. Investigations Pathophysiology A barium enema can be used to show oedema or mu- The ischaemia results from venous infarction due to cosal sloughing. Mesenteric angiography will external pressure resulting in venous congestion and demonstrate the stenosis or occlusion. Management The condition generally is self-limiting within a few days Clinical features/management with uncomplicated cases managed conservatively. If blood flow is not restored, a progression to in- farction and necrosis necessitates bowel resection. Chronic intestinal ischaemia Definition Slow progressive ischaemia of the gut due to atheroma Ischaemic colitis generally occurring in the elderly. Definition Ischaemia of the colon due to interruption of its blood Aetiology supply. Risk factors: r Fixed: Age, sex, positive family history, familial hyper- Aetiology In most cases the underlying cause is thrombosis of the lipidaemia. Pathophysiology In around half the ischaemia is transient with damage Pathophysiology confinedtothemucosaandsubmucosa. Thesplenicflex- Progressive atheroma occludes the lumen of the vessels ure is most often affected due to the territories of the causing reduced blood flow. If the blood supply is not depends on the position and degree of occlusion and the restored, ischaemia progresses to gangrenous ischaemic presence of collateral blood supply. Clinical features Patients describe pain occurring after food, weight loss, Clinical features malabsorption and signs of vascular disease. The patient presents with lower abdominal pain, nausea, vomiting and bloody diarrhoea. There is lower abdom- Investigations inal tenderness and guarding in the lower abdomen. Microscopy Management There is ischaemic loss of mucosa, ulceration and later Surgical revascularisation depends on the results of an- healing with oedema and inflammatory infiltrate. A variant of this condition is coeliac axis Chapter 4: Gastrointestinal oncology 177 compression due to the median arcuate ligament of the Sex diaphragm. Definition Complete necrosis and gangrene of the midgut resulting Aetiology from cessation of blood flow in the superior mesenteric r Squamous carcinoma accounts for more than 90% of artery. These usually occur in the middle third of the oesophagus although the lower third may also be af- Clinical features fected. Aetiological factors include high alcohol con- There may be a preceding history of non-specific symp- sumption, smoking and chewing betel nuts. Signs of acute intestinal failure include ab- affects the lower third of the oesophagus particularly dominal tenderness, guarding, loss of bowel sounds and the gastrooesophageal junction possibly following ep- rigidity, due to perforation. Calcification within the abdominal aorta may be evident r Familial forms have been noted. Gas filled, thickened, dilated bowel loops and free gas within the peritoneal cavity due to Pathophysiology perforation may also be seen. Following adequate resuscitation laparotomy and resec- tion(whichmaybemassive)arerequired. Patients may present with progressive dysphagia, but of- Asecond look laparotomy can be performed 24 hours tenpresent late with weight loss, anaemia and malaise. If Barium swallow demonstrates an apple core defect or the patient survives they have considerable malabsorp- stricture without proximal dilatation. In the absence of metastases endoscopic ultrasound is useful to assess operability. Management r Wherever possible surgical resection is the primary Age treatment with those occurring in the lower third Rare below the age of 40 years. Anatomical 178 Chapter 4: Gastrointestinal system reconstruction requires either a gastric pull up, or Gastric adenocarcinoma asectionofcolononapedicle flap. Neoadjuvant Definition chemotherapy with cisplatin and 5-fluorouracil (5- Malignant tumour of the stomach. Sex Prognosis 2M > 1F Surgical resection carries an operative mortality of up to 20%. Benign gastric tumours Aetiology Definition Pre-malignant conditions include chronic atrophic gas- Benign tumours and polyps of the stomach. These can tritiswithintestinalmetaplasiaandadenomatouspolyps be divided into epithelial and mesenchymal derived tu- of the stomach. Hyperplastic polyps are common overgrowths of gas- r Dietary carcinogens possibly including nitrates and tric mucosa often resulting from the healing of an alcohol. Pathophysiology They have a significant risk of malignant change most Gastric adenocarcinomas are derived from mucus se- likely in large polyps. Tumours may be of three types: Mesenchymal derived benign tumours: r Ulcerating (most common) with appearance similar r Leiomyomas appear as mucosal or intramural nod- to benign ulcers but with raised edges and no normal ules. Most benign tumours are asymptomatic and found on r Infiltrating when fibrous tissue causes a firm non- endoscopy or barium meal. Rarely bleeding or obstruc- distendable or linitis plastica (leather bottle) stomach. Spread may be direct invasion to the liver and pancreas, Management transcoelomic spread resulting in a malignant ascites Allsuspiciouspolypsrequireexaminationbyendoscopic and ovarian Krukenberg tumour, lymphatic spread to excision biopsy, multiple polyps may require gastric re- regional and distant lymph nodes (Virkow’s node) and section. Chapter 4: Gastrointestinal oncology 179 Clinical features Aetiology/pathophysiology Patients tend to present late with non-specific weight Gastric lymphoma is a non-Hodgkin B cell lymphoma. There may be dyspepsia or Tumours arising in the mucosa associated lymphoid tis- haematemesis. Dermatomyositis and acanthosis nigricans may be manifestations of an underlying gastric malig- Clinical features nancy. Patients present similarly to gastric adenocarcinoma with non-specific weight loss, anaemia and malaise and Microscopy associated epigastric tenderness. Symptoms may be mild Histologically gastric adenocarcinomas may have an in- despite a large tumour mass. Investigations Diagnostic testing usually involves an endoscopy and Investigations biopsy,whichmaybeprecededbyabariummeal. Anaemia is a non-specific Management finding and liver metastases may cause a rise in liver Lymphoma often responds to H. Patients who do not respond to, or who relapse fol- Treatment of choice is surgical resection wherever pos- lowing eradication therapy are treated with single agent sible. Combination chemotherapy Prognosis may be used in disease not amenable to surgery. Overall Small intestine lymphoma 5-year survival in the United Kingdom is around 10% Definition due to late presentation. Anon-Hodgkin lymphoma which occurs within the small bowel particularly in the ileum.

Preliminary washing and rinsing are essential: the activity of chlorine is reduced in the presence of organic material (sputum cheap repaglinide 1 mg with visa diabetes kidney problems, vomit buy cheap repaglinide 1 mg online diabetes insipidus joint pain, faeces generic 2 mg repaglinide with visa diabetes insipidus vital signs, blood and other body fluids) cheap repaglinide 2 mg on-line blood glucose 68 fasting, and the detergent used may be incompatible with chlorine. Stainless steel surfaces should be rinsed with water after disinfection with chlorine solution. The use of detergent-disinfectant products reduces workload (cleaning and disinfection are carried out as a single procedure), but they have the disadvantage of being weak detergents and leaving a film, which causes dirt to build up on the floors. Disinfection of linen After hand washing, followed by rinsing: soak the clean linen in a solution of 0. Pre-disinfection of reusable medical devices/instruments – After use, soak medical devices (disassembled, forceps and scissors opened): • In a detergent-disinfectant solution intended for medical devices and instrumentsa. For correct dilution and soak times, follow manufacturer ’s instructions; use a timer. Comply with recommended soaking times and concentrations (risk of corrosion of metal instruments). Soaking for too long (> 15 minutes) and/or in a solution that is too concentrated will increase the risk of corrosion. Comply with recommended soak times and concentrations (risk of corrosion of metal instruments). Injection for spinal anaesthesia: 5% (hydrochloride) in  lidocaine 2‐ mL ampoule to be mixed with 7. Injection: 1 mg (as hydrochloride or hydrogen epinephrine (adrenaline) tartrate) in 1‐ mL ampoule. Injection: 5 mg/ mL (sulfate) in 20‐ mL ampoule or 1 g/ fomepizole mL (base) in 1. Parenteral formulation: 2 mg/ mL in 1‐ mL  lorazepam ampoule; 4 mg/ mL in 1‐ mL ampoule. Solution for oromucosal administration: 5 mg/mL; 10 mg/mL midazolam Ampoule*: 1 mg/ mL; 10 mg/mL *for buccal administration when solution for oromucosal administration is not available Injection: 200 mg/ mL (sodium). Powder for reconstitution with water: 125 mg/5 cefalexin [c] mL; 250 mg/5 mL (anhydrous). Powder for injection: 250 mg (as monohydrate) + 250 mg (as sodium salt); 500 mg (as monohydrate) + 500 mg (as sodium salt) in vial. Meropenem is indicated for the treatment of meningitis and is licensed for use in children over the age of 3 months. Powder for oral liquid: 125 mg/5 mL (as stearate or  erythromycin estolate or ethyl succinate). Injection: 80 mg + 16 mg/ mL in 5‐ mL ampoule; 80 mg + 16 mg/ mL in 10‐ mL ampoule. Injection for intravenous administration: 2 mg/ mL in 300 mL bag linezolid Powder for oral liquid: 100 mg/5 mL, Tablet: 400 mg; 600 mg Granules: 4 g in sachet. Scored tablets can be used in children and therefore can be considered for inclusion in the listing of tablets, provided that adequate quality products are available. Ritonavir is recommended for use in combination as a pharmacological booster, and not as an antiretroviral in its own right. Tablet: 75 mg; 400 mg; 600 mg; 800 mg darunavir a a >3 years Oral liquid: 400 mg + 100 mg/5 mL. Tablet: 200 mg + 300 mg (disoproxil fumarate equivalent to 245 mg tenofovir disoproxil). Tablet: 30 mg + 50 mg + 60 mg [c]; 150 mg + 200 mg lamivudine + nevirapine + zidovudine + 300 mg. Injection for intravenous administration: 800 mg and 1 g in 10‐ mL phosphate buffer solution. Injection: 100 mg/ mL, 1 vial = 30 mL or 30%, sodium stibogluconate or meglumine antimoniate equivalent to approximately 8. Injection: ampoules, containing 60 mg anhydrous artesunic acid with a separate ampoule of 5% sodium bicarbonate solution. Rectal dosage form: 50 mg [c]; 200 mg capsules (for pre‐referral treatment of severe malaria only; artesunate* patients should be taken to an appropriate health facility for follow‐up care) [c]. Injection: 80 mg + 16 mg/ mL in 5‐ mL ampoule; sulfamethoxazole + trimethoprim 80 mg + 16 mg/ mL in 10‐ mL ampoule. Medicines for the treatment of 2nd stage African trypanosomiasis Injection: 200 mg (hydrochloride)/ mL in 100‐ mL bottle. Dose form  leuprorelin  Early stage breast cancer  Metastatic prostate cancer Powder for injection: 100 mg (as sodium succinate) in hydrocortisone vial. Injection: 40 mg/ mL (as sodium succinate) in 1‐ mL single‐dose vial and methylprednisolone [c] 5‐ mL multi‐dose vials; 80 mg/ mL (as sodium succinate) in 1‐ mL single‐dose vial. Tablet: equivalent to 60 mg iron + 400 micrograms ferrous salt + folic acid folic acid (nutritional supplement for use during pregnancy). Complementary List [c] Injection: 4 micrograms/ mL (as acetate) in 1‐ mL desmopressin ampoule. Injection: 100 micrograms/ mL (as acid tartrate or epinephrine (adrenaline) hydrochloride) in 10‐ mL ampoule. Atenolol should not be used as a first‐ line agent in uncomplicated hypertension in patients >60 years  enalapril Tablet: 2. Its use in the treatment of essential hypertension is not recommended in view of the evidence of greater efficacy and safety of other medicines. Its use in the treatment of essential hypertension is not recommended in view of the evidence of greater efficacy and safety of other medicines. Injection: 140 mg to 350 mg iodine/ mL in 5‐ mL; 10‐  iohexol mL; 20‐ mL ampoules. However, as the stability of this latter formulation is very poor under tropical conditions, it is recommended only when manufactured for immediate use. Two‐rod levonorgestrel‐releasing implant, each rod levonorgestrel‐releasing implant containing 75 mg of levonorgestrel (150 mg total). Complementary List [c] Lugolʹs solution Oral liquid: about 130 mg total iodine/ mL. Selection of vaccines from the Model List will need to be determined by each country after consideration of international recommendations, epidemiology and national priorities. Complementary List epinephrine (adrenaline) Solution (eye drops): 2% (as hydrochloride). Tablet (enteric‐coated): 200 mg; 500 mg (sodium valproic acid (sodium valproate) valproate). Complementary List Concentrate for oral liquid: 5 mg/ mL; 10 mg/ mL (hydrochloride). Inhalation (aerosol): 100 micrograms per dose;  budesonide [c] 200 micrograms per dose. Injection: 1 mg (as hydrochloride or hydrogen epinephrine (adrenaline) tartrate) in 1‐ mL ampoule. Both computer and ebook reader need to be protected from the elements unless they are ‘ruggedized. Hesperian Foundation 2010 $17 for hard copy, pdf free (see below) The Hesperian site has ordering information for the hardcopy and all of the other hardcopy books.