By D. Armon. Concord College.

These include  Paint thinners and removers  Dry cleaning fluids  Petrol  Glues  Correctional fluids  Felt-tip marker pens y Aerosols – these are spray cans which contain propellants and solvents and include  Spray paints  Deodorants  Hair sprays  Vegetable oil sprays used in cooking  Fabric protector sprays 40 Drug Facts y Gases – these include medical anaesthetics such as ether order super viagra 160 mg, chloroform and nitrous oxide buy discount super viagra 160mg on-line. The more frequently available domestic products which contain gases include  Butane lighters  Propane gas cylinders48 y Nitrites – the key difference between nitrites and the substances in the previous categories is that unlike them, nitrites do not act on the central nervous system. It has a number of clinical applications, including treating cyanide poisoning and can also be used to treat angina attacks. Amyl and butyl nitrite use is associated with the promotion of disinhibition whilst dancing and as a muscle relaxant during sex and are available as ‘poppers’ through clubs and sex shops. Administration All of the above are administered by inhalation, with the product design dictating how this is achieved. Desired Effects The initial effects of solvent misuse are very similar to those produced by alcohol. These may include: y Euphoria y Dizziness y Light-headedness y Visual and auditory hallucinations, ranging from pleasant to unpleasant y Delusions, such as believing one can fly49 Duration of Effects The inhaled vapours are rapidly absorbed through the lungs into the blood stream and, from there, to the brain and other organs. However, the mood altering effects diminish as quickly as they peak, disappearing within a couple of minutes to half an hour. The lim ited duration of the effects of solvent m isuse is a challenge in identifying those abusing solvents. However, the sm ell of the solvent inhaled m ay rem ain on the breath for up to a day. Although som e of the following sym ptom s m ay be m ore appropriately associated with a serious solvent m isuse problem , their absence does preclude experim ental or sporadic use. Surveys of newspaper reports indicate that butane gas is implicated in most of the recorded deaths “… followed by aerosols and typewriter correcting fluid. With solvent use, there is the potential for dependence but the reality is that, for most young people, solvent use happens within the context of the peer group and is not sustained. Long-term, habitual use of solvents will see the development of tolerance and an increase in the amount of solvents inhaled. Side effects from regular use may include: y Disturbed sleep patterns y Loss of appetite y Loss of weight y ‘Glue sniffer rash’ due to the ongoing application of plastic bags to the face, especially around the nose and mouth Side effects from long-term use include: y Depression y Being moody and suspicious y Being forgetful with a diminished ability to concentrate which will obviously impact on school performance59 These problem s will tend to clear up for m ost young people shortly after the solvent use ceases. In term s of withdrawals, sym ptom s m ay include: y Sleep disturbance y Nausea and stomach cramps y General irritability y Facial tics60 The other risks associated with solvent m isuse relate to behavioural problem s which arise from use or which can be exacerbated by use. As with alcohol, the disinhibiting qualities of volatile substances will im pact on judgem ent and self-control and this m ay prom ote aggressive and violent behaviour. Regular use m ay also feature theft of either solvent based products or of m oney to purchase such products. A young person m ay start to encounter problem s in school in term s of both attendance and a deterioration in perform ance, in som e cases leading to early school leaving. All of these issues can contribute to fam ily disruption as parents and siblings attem pt to deal with an intoxicated child and the attendant problem s detailed here. Someone found guilty of such an offence under Section 74 of the 1991 Child Care Act maybe fined up to B1,270, imprisoned for twelve months or both. Risk can be reduced by looking at the consequences and dangers of solitary use and in some circumstances it “… may be appropriate to advise teenagers about first aid procedures in the event of an accident involving one of a group of solvent abusers. The fam iliarity of m any of the products m isused can m ean that adults, whether in the hom e, at school or in a retail setting m ay not be as proactive in securing and lim iting access to them as they would with substances or products which present m ore obvious risks to the health and safety of young people. This m ay be an area that can be addressed in a school’s substance use policy through a section detailing: y How products will be securely stored y How limited access to products will be maintained y How products which do not have a legitimate use within the school are not permissible y Use of solvent free products where possible 44 Drug Facts Cannabis The use of cannabis is well-established throughout the time of human civilisation, with archaeological evidence pointing to its cultivation in a Neolithic settlement in Taiwan. However, as with all psychoactive substances, it has the potential for m isuse and causing harm to those who use it: “… a cannabis dependence syndrom e m ay occur in long-term regular users and, internationally, it has been suggested that one in ten of those who ever use cannabis will m eet the criteria for cannabis dependence. Cannabis takes the form of one of the following: 45 Drug Facts 1 Herbal cannabis (marijuana, grass, weed, ganja) consisting of the dried leaves and female flower heads. Desired Effects Cannabis is a sedative with hallucinogenic properties whose mood altering effects depend on the strength of the cannabis, the length of time it has been stored (potency is effected by time and exposure to light and air), the amount used, the way it is taken and the experience, mood and expectations of the user. This is particularly apparent in relation to visual images/colours and music/sounds arising from the hallucinogenic effects of cannabis leading to the intensification of ordinary sensory experiences such as eating, watching films and listening to music. W hether or not cannabis is central to any branch of m usic appreciation or creativity is a m oot point.

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Consumption and sources of sugars in the diets of British school- children: Are high-sugar diets nutritionally inferior? Adverse metabolic effect of omega-3 fatty acids in non-insulin-dependent diabetes mellitus 160mg super viagra otc. Metabolic precursors and effects of obesity in children: A decade of progress generic super viagra 160mg without prescription, 1990–1999. Breast-cancer incidence and mortality rates in different countries in relation to known risk factors and dietary practices. Diets containing soluble oat extracts improve glucose and insulin responses of moderately hypercholesterolemic men and women. Effect of exercise on coronary endothelial function in patients with coronary artery disease. Interruption of vascular thrombus forma- tion and vascular lesion formation by dietary n-3 fatty acids in fish oil in non- human primates. Fish oils and plasma lipid and lipoprotein metabolism in humans: A critical review. Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. Cereals, cereal fibre and colorectal cancer risk: A review of the epidemiological literature. Exercise and physical training: Effects on insulin sensitivity and glucose metabolism. The relation- ship between dietary fat intake and risk of colorectal cancer: Evidence from the combined analysis of 13 case-control studies. Plasma lipid and lipoprotein responses to dietary fat and cholesterol: A meta-analysis. A prospective study of egg consumption and risk of cardiovascular disease in men and women. A controlled clinical trial with special reference to serum high- density lipoproteins. Whole-grain intake may reduce the risk of ischemic heart disease death in postmenopausal women: The Iowa Women’s Health Study. Relationship between dietary fiber and cancer: Metabolic, physi- ologic, and cellular mechanisms. Effects of low-fat, high-carbohydrate diets on risk factors for ischemic heart disease in postmenopausal women. Dietary fat and breast cancer in the National Health and Nutrition Examination Survey I. Physical activity and physical demand on the job and risk of cardiovascular disease and death: The Framingham Study. Dietary and anthropometric determinants of plasma lipo- proteins during a long-term low-fat diet in healthy women. Weight loss on a low-fat diet: Consequence of the imprecision of the control of food intake in humans. Does childhood and adolescence provide a unique opportunity for exer- cise to strengthen the skeleton? Exercise pre- vents the accumulation of triglyceride-rich lipoproteins and their remnants seen when changing to a high-carbohydrate diet. Diet, prevalence and 10-year mortal- ity from coronary heart disease in 871 middle-aged men. The inverse relation between fish consumption and 20-year mortality from coronary heart disease. The protective effect of a small amount of fish on coronary heart disease mortality in an elderly population. Cell cycle arrest and induction of apoptosis in pancreatic cancer cells exposed to eicosapenta- enoic acid in vitro. No change in glucose tolerance and substrate oxidation after a high-carbohydrate, low-fat diet. Nutrient intakes and body weights of persons consuming high and moderate levels of added sugars. Effect of the glycemic index and content of indigestible carbohydrates of cereal-based breakfast meals on glu- cose tolerance at lunch in healthy subjects.

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Key: b Ref: Heart Failure (Page 545) Davidson’s Principles and Practice of Medicine cheap super viagra 160mg line. A fifty year old man is admitted in emergency ward with acute myocardial infarction buy super viagra 160 mg fast delivery. Key: d Ref: Myocardial Infarction (Page 595) Davidson’s Principles and Practice of Medicine. A fifty year old smoker presents with history of cough productive of mucoid sputum in every winter for last three years. Key: d Ref: Chronic Obstructive Pulmonary Disease (Page 679) Davidson’s Principles and Practice of Medicine. A forty year old lady presents with history of severe, constant upper abdominal pain that does not radiate and is associated with vomiting. On examination temperature is normal and there is marked tenderness in epigastrium. Key: c Ref: Peptic Ulcer Disease (Page 885) Davidson’s Principles and Practice of Medicine. An important physical sign of portal hypertension in a patient of cirrhosis of liver is: a) Gynecomastia. Key: e Ref: Portal Hypertension (Page 957) Davidson’s Principles and Practice of Medicine. A forty year old diabetic man presents with history of sudden onset of pain in right loin which radiates towards right iliac fossa. Key: e Ref: Acute Pyelonephritis (Page 470) Davidson’s Principles and Practice of Medicine. In a patient with history of haematemesis, the clinical feature which suggests that peptic ulcer is the underlying cause is: a) Ascites. Key: d Ref: Peptic Ulcer (Page 885-890) Davidson’s Principles and Practice of Medicine. Which o the following features suggests that she has irritable bowel syndrome: a) Anaemia. Key: b Ref: Irritable Bowel Syndrome (Page 920) Davidson’s Principles and Practice of Medicine. Key: b Ref: Chronic Hepatitis B Infection (Page 370, 371) Clinical Medicine Kumar and Clark 40. Which of the following serum electrolyte level is most likely to be low: a) Calcium. A young boy presents in outdoor with history of sudden painful swelling of joints after minor trauma since childhood. Key: d Ref: Haemophilia (Page 1057) Davidson’s Principles and Practice of Medicine. In a patient with history of jaundice, pruritis and clay-colored stools, which of the following enzyme level is expected to be markedly elevated: a) Alkaline aminotransferase. Key: b Ref: Cholestatic Jaundice (Page 946) Davidson’s Principles and Practice of Medicine. A patient presents with history of intermittent fever, abdominal pain and headache. Key: b Ref: Antimalarials (Page 211) Davidson’s Principles and Practice of Medicine. When such a science is applied to a dynamic human being that is being continuously run with food – Thiruvalluvar, The Kural 1072. Human When one enters the medical college the first thing that body is not only non-linear,it follows the holistic rules of happens is that the person is made to forget his/her the universe. All these make the present the present educational system; even as early as entry to medical science a square plug in a round hole. In the practice of bedside medicine, progress and if we want to progress in medical science however, common sense is not just common but it is we have to think deeply of changing our mind set and commoner than what one thinks it is. The statistical science follow the new science of chaos-of non-linearity and of medicine can, at best, manage to size up cohorts of holism. It is basically status quoists wanting the comfort of the existing the past experience of the doctor with his clinical acumen order.

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The abstracts are good if you want only the bottom line super viagra 160mg otc, but you won’t get any of the details and be able to decide for yourself if the review is valid or potentially biased discount super viagra 160mg with amex. The seven modules covering Information Mastery, Critical Appraisal and Knowledge Transfer can be done in a total of about 14–20 hours total. The website has an excellent list of links for physicians and non- physicians who are interested in child health. In most cases when the patient is fluid inapatientwhoisvomitingandonlydrinkingwateror depleted, there is decreased circulating volume; however only given intravenous 5% dextrose or dextrosaline), in fluid overload, there may either be increased circulat- hyponatraemia results, which can lead to confusion, ing volume or decreased circulating volume depending drowsiness, convulsions and coma (see page 4). The plasma osmolality rises and history of losses or reduced intake, but this can be un- hypernatraemia occurs. Symptomsofthirstandanyposturaldizziness sopressin release, which increases water reabsorption should be enquired about. Pure water depletion is rare, but many include a mild tachycardia, reduced peripheral per- disorders mostly lead to water loss with some sodium fusion (cool dry hands and feet, increased capillary loss. Initially water moves from the cells into the extra- refilltime >3seconds), postural hypotension and/or cellular compartment, but then both the intracellular hypotension, and reduced skin turgor (check over the and extracellular compartments become volume de- anterior chest wall as the limbs are unreliable, partic- pleted, causing symptoms and signs of fluid depletion ularly in the elderly). Breathless- fluid balance depends on the relative excess of sodium ness is an early symptom. Sodium excess > water excess there may be crackles heard bilaterally at the bases of causes hypernatraemia (see page 3) whereas water ex- the chest because of pulmonary oedema. This invariably causes hyponatraemia (see ure the blood pressure often falls with worsening fluid page 4). Pleural effusions and ascites suggest fluid is also some degree of sodium excess there may be overload, but in some cases there may be increased symptoms and signs of fluid overload. Assessing fluid balance Urine output monitoring and 24-hour fluid balance This is an important part of the clinical evaluation of charts are essential in unwell patients. Daily weights are patients with a variety of illnesses, which may affect the useful in patients with fluid overload particularly those Chapter 1: Fluid and electrolyte balance 3 with renal or cardiac failure. Oliguria (urine output cardiac failure, and these patients may require in- below 0. A lowurine output may be due to prere- Further investigations and management depend on the nal (decreased renal perfusion due to volume depletion underlying cause. Baseline and serial U&Es to look for or poor cardiac function), renal (acute tubular necrosis renal impairment (see page 230) should be performed. In previously fit patients, particularly if there is raymay show cardiomegaly and pulmonary oedema. However, the management is hypoxia due to underlying lung disease or pulmonary verydifferent in fluid overload or in oliguria due to other oedema. In cases of doubt (and where Hypernatraemia appropriate following exclusion of urinary obstruction) afluidchallengeof∼500mLofnormalsalineoracolloid Definition (see page 9) over 10–20 minutes may be given. Incidence previous history of cardiac disease, elderly or with renal This occurs much less commonly than hyponatraemia. Patients should be reassessed regularly (initially usually within 1–2 hours) as to the effect of treatment on Sex fluid status, urine output and particularly for evidence M = F of cardiac failure: r If urine output has improved and there is no evidence Aetiology of cardiac failure, further fluid replacement should be This is usually due to water loss in excess of sodium loss, prescribed as necessary. Those r If the urine output does not improve and the patient at most risk of reduced intake include the elderly, infants continues to appear fluid depleted, more fluid should and confused or unconscious patients. The normal physiological response to a rise in extracel- r If hypotension persists despite adequate fluid replace- lular fluid osmolality is for water to move out of cells. Pa- ment, this indicates poor perfusion due to sepsis or tients become thirsty and there is increased vasopressin 4 Chapter 1: Principles and practice of medicine and surgery release stimulating water reabsorption by the kidneys. Urine output and plasma Changes in the membrane potential in the brain leads to sodium should be monitored frequently. The under- impaired neuronal function and if there is severe shrink- lying cause should also be looked for and treated. Cellsalsobegintoproduceorganicsolutes allowedtodrinkfreelyasthisisthesafestwaytocorrect after about 24 hours to draw fluid back into the cell. Patients may be irritable or tired, pro- is less hypertonic than the plasma so this will help to gressing to confusion and finally coma. Signs of fluid over- load suggest excessive administration of salt or Conn’s normal saline (0. There may be neurological worsening hyperglycaemia which can alter the osmo- signs such as tremor, hyperreflexia or seizures.

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