Metabolic Hyper- or hypothyroidism buy micardis 20mg low cost blood pressure lower number, pheochromocytoma buy generic micardis 80 mg on line heart attack the song, nutritional (or endocrine): (Beri-Beri and alcoholism) order micardis amex blood pressure chart mayo, Cushing’s disease. Neuromuscular: Progressive muscular dystrophy, Friedreich’s ataxia, myotonic muscular dystrophy. Collagen Diseases: Scleroderma, dermatomyositis, systemic lupus erythematosus, rheumatoid arthritis F. Toxins, drugs and Adriamycin, emetine, carbon tetrachloride, physical: phosphorus, radiation, Adriamycin, emetine, carbon tetrachloride, phosphorus, cobalt, others G. Infiltrative: Amyloidosis is the only common condition in this category and cases fall into two distinct groups: 1) Classical primary type which occurs in patients 45-70 years of age, in which cardiomegaly is prominent and amyloid is plentiful in other organs. In glycogen and lipid storage diseases, mucopolysaccharidoses and oxalosis enzyme deficiencies are present, while in hemachromatosis the deficiency is in iron absorption. Calcium deposition occurs in generalized metabolic abnormalities in which the serum calcium is high, or in localized areas of degenerative myocardium. Inflammatory: Inflammatory myocardial disease (myocarditis) has been reported with almost every known pathogenic organism. Coxsackie viruses group B, and to a lesser extent, Group A, are implicated most commonly. Of the protozoal diseases, toxoplasma myocarditis is well recognized and Chagas’ disease (T. Giant cell granulomatous reactions are of unknown etiology, but mycobacteria may be a cause. Excessive deposits of adipose tissue are found in patients with hyperadrenocorticism. Focal myocarditis and fibrosis have been observed in patients with pheochromocytoma. In beri-beri (thiamine deficiency) the heart is enlarged and the myocardial institium edematous and focally fibrotic. Neuromuscular Diseases: In Friedreich’s ataxia there is a reported incidence of cardiac involvement in 90% of the cases. The heart is enlarged with hypertrophy of both ventricles and there is a diffuse, reticular fibrosis with a non-inflammatory retrogressive alteration of myofibrils. There is approximately 50% of patients with progressive muscular dystrophy under myocardial changes with diffuse myocardial fibrosis, but with only minor changes in myocytes. In myotonic muscular dystrophy, 60% of patients have cardiac enlargement and failure in which myocyte atrophy and fatty infiltration may occur. Rheumatic fever, rheumatoid arthritis, and systemic lupus erythematosus often have a greater effect on the cardiac valves than the myocardium. Toxins and Physical Forces: Trauma (contusions) and radiation are well recognized causes of myocardial cell damage or interstitial myocardial fibrosis, or both. Many drugs, such as digitalis, isoproterenol, ephedrine, antibiotics and emetine, damage myocardial cells. The anti-neoplastic drug Adriamycin and its analogs may produce cardiotoxicity in large Cardiomyopathy, Myocarditis & Atrial Myxoma - Gerald Berry, M. Cobalt, arsenic, antimony, fluoride, mercury and lead alter myocardial structure and function. Hypersensitivity and Immunologic Cardiac Diseases: The evidence for the existence of immune mechanisms in myocardial disease to date is inconclusive. The presence of the various anti-heart antibodies, whether circulating or bound to the myocardium, does not necessarily provide a mechanism for an immune disorder of the heart. Several reports of heart-reactive antibodies in patients with cardiomyopathy have shown gamma and immunoglobulins, as well as Complement, bound to the myocardium. Figure 1: Diagram illustrating the various types of cardiomyopathies, compared to the normal, discussed herein. In the hypertrophic type of cardiomyopathy the left ventricular cavity is small, and in the constrictive variety, as illustrated by amyloidosis, the left ventricular cavity is of normal size. In the dilated type the largest circumference of the left ventricle is not at its base but midway between the apex and base. Please note: The tumors are listed for completeness but only myxomas and rhabdomyomas are clinically important. In common with tumors elsewhere in the body, tumors of the heart pericardium may be classified as benign or malignant. Myxomas: An exophytic tumor which may fill a cardiac chamber or prolapse through one of the A-V valves. Microscopically: Irregular vacuolization of cell cytoplasm producing “spider cells. Tumor is circumscribed, sessile, polypoid or intramuscular and are often symptomless. Fibromas (Fibrohistiocytomas): More often occur in the interventricular septum of the anterior wall of the left ventricle. They are nonencapsulated and consist of interlacing bundles of fibrous tissue of varying cellularity. Tumors of the heart valves: Fibromas, myxomas, hamartomas and papillary tumors have a predilection for heart valves. One variety is polypoid or flat and occurs in children and the other is papillary and occurs in adults. Sarcomas: Either of smooth or skeletal muscle, appear to be the commonest cardiac malignant tumors. Malignant vascular tumors (angiosarcomas), Kaposi’s sarcoma, malignant hemangioendothelioma and malignant hemangiopericytomas have been reported. Primary lymphoma: Involvement may be diffuse, nodular or rarely as an endocardial polypoid growth. Rare examples of primary cardiac neoplasms include granular cell myoblastoma, neurogenic sarcoma, ganglioneuroma and malignant mesenchymoma. Of all patients with disseminated malignant disease, up to 15 percent have cardiac lesions. The commonest primary sites of origin are carcinomas of the lung, breast, large bowel and stomach, followed by malignant lymphoma. While metastases are often asymptomatic, patients may present with cardiac failure, arrhythmias or a pericarditis. Frequency of Metastases to the Heart from Various Tumors Melanoma 50% Leukemia 36% Bronchogenic carcinoma 41% Breast 20% Sarcoma 12% (Remember: melanoma is much less common than lung carcinoma! The entire circulatory system is lined by a continuous, single-cell- thick layer --- the vascular endothelium. Despite its microscopic dimensions (often less than 1 micron in thickness), this living membrane is a multifunctional organ whose health is essential to normal vascular physiology and whose dysfunction can be a critical factor in the pathogenesis of vascular disease. Anatomically, the endothelium forms the physical boundary separating the intravascular compartment from all of the tissues and organs of the body.
In others there is nervous excitement order 20mg micardis with mastercard pulse pressure of 100, restlessness buy cheapest micardis and micardis pre hypertension low pulse, headache buy micardis 40 mg with mastercard hypertension means, tremors, general distress and an increase of pain. Given under the conditions we have named as contraindications, it will often produce these phenomena; where there is an absence of idiosyncrasy, and where given under the proper conditions, the effects would be desirable. Itching of the skin, inducing an apparent miliary eruption, is one of the unpleasant effects of its use, which, like any one of the others, may be always greatly exaggerated in certain individuals. By using water as a solvent, or combining opium with ipecac or camphor, or in some cases with the bromides, these unpleasant effects can, in great measure, be overcome. It has poisoned infants while nursing, the mother either taking it as medicine or habitually. Caution—All of the effects of these agents are especially marked in infants and early childhood. The nervous system is profoundly impressed by them, and the dose, if given at all to very young babes, should be infinitesimal. Its administration can be avoided in nearly all cases with these little patients, as we have access to many agents which, while not working actively in adults, produce most satisfactorily soothing, anodyne or pain- relieving properties in childhood. Opium addiction is acquired by continued use of the agent, and is debasing and deadly in its effects. Another serious objection to its administration in large doses often is that it conceals or obscures the actual condition, the diagnostic symptoms or the specific disease indications, and permits disease to advance to formidable proportions before its real character is known. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 317 This agent is so convenient and produces such immediate effects that it is often used by the indolent, careless physician, when other agents would produce better after results, and would more speedily promote a permanent cure. It is, therefore, proper to caution the young physician, against depending, upon it to too great an extent, and to urge him to study well all other agents acting synergistically, so that when his knowledge of the other agents permits him to choose between them he will prefer them. He may thus be able to select an agent with a single direct influence, where, with the administration of this, he has undesirable side influences to overcome in addition to the treatment of the other conditions. Administration—Opium may be administered by the mouth, by the rectum or vagina, by the hypodermic injection of its alkaloids, by application to a portion of the surface of the body after removal of the cuticle, by inhalation or by insufflation. Where there is a temporarily apparent contraindication for its use, the aqueous extract or the deodorized tincture (aqueous) or other aqueous preparations, may be used, as water does not dissolve the narcotine, which is believed to be the irritating and depressing principle of the alkaloids. Or it may be given in conjunction with some agent which will overcome the antagonizing conditions. The inactive secretions may be partially reestablished by pilocarpine or jaborandi, or the bromides may be given in conjunction to soothe the nervous system, or ergot to unload the brain of an excess of blood. The hypodermic use of morphine is demanded and is justifiable where great pain is present. This method is preferable because the chemical influences of the gastric secretions upon the salt are avoided. Veterinarians find it necessary to always administer morphine in this manner, as often no desirable effects are produced if brought in contact with the stomach and intestinal secretions. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 318 Specific Symptomatology—When opium is given carelessly or promiscuously, unfavorable results may occur. The conditions under which the administration of opium or its narcotic salts are admissible are as follows: There is pain without cerebral engorgement; there is an absence of flushed face, but not pallor; there is a relaxed, cool and perhaps moist skin; the tongue is moist and the pupils are not contracted. Extreme wakefulness or restlessness, painful, spasmodic conditions, excessive passive discharges of whatever character and local inflammations with the above conditions all indicate the use of the agent. The agent can often be substituted in mild cases, and with children, and the causes of pain can often be removed by other agents; but severe, persistent, racking pain has no other antidote except anesthesia. It, is, therefore, contra-indicated where there is an irritated and overstimulated nervous system, with flushed face, bright eyes with contracted pupils, dry, hot skin, dry, coated tongue and inactivity of the excretory functions. Administered under these circumstances, it will increase the restlessness and induce general distress and painful wakefulness. Therapy—In sudden acute pain, in pain from wounds or injury, or from burns, the contra-indications are seldom present, and morphine can be administered usually hypodermically. Pain, like a persistent high temperature; will in time produce serious impressions upon the system which, in themselves, will be hard to overcome. When pain is not extreme equally good results, however, can be obtained in many cases from smaller doses of this agent, as from larger ones, with much less impression upon excretion. In the successful and highly satisfactory treatment of peritonitis, appendicitis, pleuritis, ovaritis or metritis, this author early adopted the uniform method of giving the indicated remedies as indicated, and for general or local soreness or tenderness increased on pressure or on movement of the bed or clothes, he frequently gives from two to five drops of the deodorized tincture of opium every two hours; seldom more. This acts in harmony with bryonia, which is specifically indicated, especially Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 319 if there be occasional quick, sharp darting or shooting pains, with the soreness. In from six to twelve hours the distress is relieved, and in twenty-four hours the patient is in every way improved. This is accomplished without producing dullness, drowsiness or undue sleep, or without locking up the secretions and excretions, in fact, without exhibiting but few if any of the physiological influences of the remedy. Where distress or wakefulness is present, and of such a character that morphia is directly indicated, a small dose often repeated in the stomach will sometimes do better than large doses. In these cases, if half a grain be dissolved in two ounces of water, and a teaspoonful be given every fifteen minutes, the patient will soon become soothed and quiet and will sleep naturally without knowing what has induced it; a much smaller quantity than is usually given, being found necessary. It reduces congestion and engorgement of serous membranes most rapidly, and is thus specific in the above-named inflammatory conditions, when small, sharp, stabbing pains and diffused tenderness are the leading symptoms. It is for this latter effect that it is useful in catarrhs of all characters, in diarrheas and excessive activity of all secreting organs. It controls irritation of the peripheral nerves in the intestinal canal, and thus arrests diarrhea and controls undue peristaltic action, which in these cases is often necessary. In surgical diseases of the intestinal canal and after operations this effect is quickly and essentially obtained. It promotes excretion from the skin to a marked degree, exercising this function often, while it locks up the intestinal and renal secretions. It is common practice to use opium or morphia in solution for eye washes—collyria. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 320 Opium and its alkaloids are powerful antispasmodics, and are of general use in local spasm and in convulsion. Specifically, it is useful in colic from biliary or renal calculi, in uterine and ovarian colic and in the pains of labor, properly adapted; also in lumbago, sciatica, angina pectoris, gastrodynia, pleurodynia and other forms of neuralgia. In puerperal convulsions morphine, hypodermically, was by some considered a most superior agent, although those familiar with veratrum prefer the latter. It locks the secretions preventing elimination, obscures actual conditions and encourages stasis. Many physicians use opium to control passive hemorrhage, hemorrhages from the kidneys and womb, from the lungs and bronchi, and from the stomach, and from the bowels in typhoid. It may, however, usually be dispensed with in these cases, as it is not desirable to lock up the natural secretions of these organs, a common result from the use of this agent. It was advised by Pavy as an important agent in the treatment of diabetes, to control all unpleasant conditions, especially the elimination of sugar and the extreme thirst. It is used also in spermatorrhea, and will temporarily reduce sexual erethrysin and unload the organs of blood and restrain abnormal losses and discharges, but it is not usually curative and cannot be persisted in without injury. For gonorrheal injections and as bladder washes and in leucorrhea, it is incorporated in liniments and is used as a cataphor. In the form also of suppositoria, introduced into the rectum or vagina, it is useful for painful conditions in the rectum and lower bowel, and in painful pelvic disorders. It is also applicable in this manner to painful kidney and certain bladder troubles, in stone and gravel, and in obstinate vomiting.
If you understand the following three equations micardis 80mg sale heart attack 45 years old, you will have a pretty good understanding of the bases for these fluxes buy micardis 80 mg hypertension meds. Goldman-Hodgkin-Katz equation: Similar to the Nernst equation buy micardis in united states online arteria differential, tells you where the membrane potential will rest when more than one ion is involved. Pion = the permeability of the membrane for an ion Nernst Potential and Osmosis - Daniel Madison, M. A round cell has equal concentrations K+ and Cl- inside, equal concentrations of Na+ and Cl- outside. Consider also that you are recording the electrical potential difference (voltage) between the inside and outside of the cell. In this condition, the voltage across the membrane will be zero, because all charges in this system are fully compensated (i. When given the opportunity, K+ will flow down its concentration gradient from the inside to the outside of the cell. For an uncharged species, this flow would continue until the concentration gradient is fully dissipated. However, since K+ is charged, it’s movement will result in the separation of + and – charges across the membrane, since the Cl- ions are not free to follow K+ out of the cell. This voltage, also known as the membrane potential, will resist the further net flow of K+ out of the cell (the uncompensated negative charges will slow the efflux of K+ charges out of the cell). Thus, there are now two forces acting on the K+ ion; a) the concentration gradient pulling K out, and b) the membrane potential resisting its outward flow. Eventually, as K+ flows out, the inward force of this voltage will grow to exactly compensate the outward concentration force. At this point, the system will be in equilibrium, with outward and inward rates of K+ flow being equal. The value of the equilibrium potential depends on the size of the concentration gradient. Seriously, they are all names for the same thing – the value of the membrane potential where an ion is in equilibrium. Equilibrium potential, because its value tells you where the ion is in equilibrium. Reversal potential, because knowing this value lets you predict which direction ions will flow across the membrane. The concept of a reversal potential is one of the most important parts of understanding the electrical behavior of cells such as heart cells. But if you perturb that equilibrium by injecting charges into the cell (never mind how, for now), you will change the voltage across the membrane. Injection of positive charges will dissipate the membrane potential (or depolarize it). This will decrease the inward voltage force, putting it at a disadvantage relative to the outward concentration force, and the net flow of K will be out of the cell. On the other hand, if you instead inject negative charges, this will increase the membrane voltage (hyperpolarize), and put the voltage at the advantage, driving K+ into the cell. Thus, depending on which way you perturb the membrane potential from its equilibrium value, K ions will flow in the opposite direction across the membrane. The net size of an ion current is determined by two factors: 1) The conductance of the membrane for that ion, and 2) The driving force for that ion. If the membrane potential of the cell is moved away from the reversal potential, then there will be an unbalanced force driving ions across the membrane. The net size of that force will be determined by how far from the reversal potential the membrane potential is moved. In other words, the difference between the membrane potential and the reversal potential will be the driving force on that ion (Em – Eion). But even a large driving force won’t push ions across a membrane if the membrane is impermeable to that ion. Thus, the amount of current that flow across the membrane is given by: Isob ion=gion(Em – Eion) (the current equals the conductance times the driving force). Where: Isob ion = the current carried by an ion across the membrane gion = the membrane conductance for that ion (proportional to the number of ion channels for that ion that are open) Em = the membrane potential Eion = the reversal potential for that ion Nernst Potential and Osmosis - Daniel Madison, M. The basis for understanding a cell’s membrane potential at any instant in time, including at rest. In our original example, even though there was a large concentration gradient for sodium ions, we set the conditions such that the membrane was impermeant to sodium. An important point to understand is that regardless of any concentration gradient, if there is no permeability for an ion, that ion will not contribute to the cell’s membrane potential. Think of it this way: Even though there is sodium outside but not inside the cell (in our artificial example), all the charges on that sodium are compensated by the paired chloride ions, so no voltage is generated by sodium, let alone a cross membrane voltage. Consider the reverse of our earlier artificial example: a cell that is impermeable to potassium but permeable to sodium. For sodium ions, the concentration gradient is directed toward the inside of the cell, so as sodium flows down it’s concentration gradient, the opposing voltage that develops will be in the opposite direction as it was for potassium (i. If a cell is permeable to only one ion, then it’s membrane potential will be equal to the equilibrium potential for that ion. If both ions are permeant, then both will make a contribution to the membrane potential of the cell. How much of a contribution each makes, depends on the equilibrium potential for each ion, on the membrane conductance for each ion, and on the driving force exerted on each ion. Consider a case where we set the conductance for K+ and Na+ at equal non-zero values. If gNa+ and gK+ are equal, then the membrane potential will Nernst Potential and Osmosis - Daniel Madison, M. This is because a cells resting permeability to potassium is much higher than its permeability to sodium. However, during the early phase of a cardiac cell’s action potential, the sodium permeability of the cell’s membrane is higher than its K permeability. Of course, real cells have membrane conductance to several ions, not just K+ and Na+. Every ion that is permeant will contribute something to the resting potential, in proportion to its equilibrium potential and membrane permeance. One common misconception is that the concentration gradient and the membrane voltage will depend on each other in a circular fashion. For example, that the initial movement of K+ out of the cell will dissipate the concentration gradient, which will in turn, change the equilibrium potential. Because the charges are separated across only the very small thickness of the membrane, only a few thousand charges need move before the system reaches equilibrium. Because a cell has trillions of K+ ions inside, the concentration changes negligibly. However, if a cell is held in a non-equilibrium condition for a long period of time, the concentration gradients can eventually be dissipated. An important point, particularly with regard to resting membrane potentials in a multi-ion system, is that the resting potential, while stable, does not represent a true equilibrium condition. But in this case, the cell is at the equilibrium potential for neither ion, so neither ion is in equilibrium.
Graduate and mature Interview method applicants buy generic micardis 40mg on line blood pressure chart malaysia, if short-listed quality 20mg micardis heart attack 43 year old woman, are invited for interview generic micardis 80 mg online hypertension stage 2. Refecton on their experiences with the diseased, disadvantaged Work experience and disabled is assessed. Applicants from a widening partcipaton background are subject to diferent minimum academic requirements. Work experience Work experience is not outlined as part of the entry requirements. On receipt of an applicaton, contextual informaton is fagged for Widening partcipaton consideraton, including but not exclusive to care leavers, extenuatng circumstances, neighbourhood partcipaton and school performance. Total score of 38 to include Chemistry at a score of 6 at Higher level, Biology at a score of 6 at Higher level and either Maths or Physics at Higher level Internatonal Baccalaureate (if it is not possible to sit Maths or Physics at Higher level, then Standard level will be considered at 6 points). Experience in a medical setng is not necessary but it is expected that candidates will have at least spoken to a doctor about a career in medicine or have found out about a medical career through reading. An awareness Work experience of current issues facing the medical profession is also expected. Candidates must show an interest which can be demonstrated through voluntary/paid work in a community setng. Widening partcipaton candidates are identfed immediately afer submission of applicaton. Candidates not on widening partcipaton Widening partcipaton programmes can check eligibility directly with the university. Applicants must have Internatonal Baccalaureate 6,6,5 in three Higher level subjects, including Biology and Chemistry. No prescribed experience required but applicants should try to obtain a realistc understanding of the demands of medical training and practce. Work experience Applicants may fnd it useful to get some experience in a range of caring situatons, observing or working alongside healthcare staf, in either a voluntary or paid capacity. Evidence of motvaton to study medicine, understanding of medicine as a Personal statement career, community actvites, leadership qualites, ability to work in a team and general interests. Widening partcipaton candidates are fagged at applicaton stage and this Widening partcipaton may be a factor at short-listng stage. A minimum of 35 points from six academic subjects, including Chemistry or Biology plus a second science at Higher Level. Grades of 6,6,6 at Higher Internatonal Baccalaureate Level and 6,6,5 at Standard Level usually required. Applicants are required to complete a post-applicaton roles Personal statement and responsibilites form. This may involve work with customers or clients requiring support, assistance Work experience or service. Experience in caring role is preferred if the applicant has had opportunites to undertake this. Experience in a health-related setng which is verifed in the personal Work experience statement. Biology and Chemistry plus one other subject at Higher Internatonal Baccalaureate level (minimum of 6 in each Higher level subject) plus three subjects at Standard level (minimum of 5 in each Standard level subject). Specifc work experience not required though applicants must showcase evidence of research into a career in medicine. Insight is more important Work experience and voluntary placements in hospices, residental homes etc, where there is interacton with vulnerable people, is just as valuable as shadowing doctors. Those who atend the summer school and impress medical school staf are made a guaranteed interview if they meet the academic entry requirements. Biology taken with Human Biology and Maths taken with Further Maths are not accepted. Six subjects at minimum grade B including English Language, Maths, Double/Additonal Science or Chemistry and Biology. Overall score of 35 points with a mark of 6 in three Higher level subjects one of which must be Chemistry. Uses the Access to Leeds Programme, and accepts Access to Medicine Widening partcipaton courses from two colleges. No minimum graduate applicants) A level grades required but used they are used in pre-interview scoring. Healthcare-related work experience is not required but applicants, partcularly those who are borderline, must showcase refecton in Work experience whatever type of work they have encountered (voluntary, paid work in retail, catering, health or social care). Currently scored against non-academic criteria of healthcare awareness Personal statement and insight, caring contributon to the local community and writen communicaton skills. No specifc work experience is required though experience in addressing Work experience non-academic criteria is considered. Liverpool medical school gives special consideraton to Liverpool Scholars and students on the Realising Opportunites programme. There are also specifc reduced entry criteria for those who ofer non-traditonal courses Widening partcipaton such as Open University modules and locally approved Access courses. The medical school is pilotng the use of contextual data in the admissions process but it is not currently used in making ofers. Grades A in Chemistry and either Biology, Physics or Maths are required at Advanced Higher. Chemistry is required at Higher level as well as a second science plus a third subject. Three Internatonal Baccalaureate subjects are required at Standard level with a minimum of 5,5,5 including English. Widening partcipaton applicants and Manchester Access programme applicants are fagged. A minimum of 38 points, no subject should be graded less than 5 and with Internatonal Baccalaureate Higher level in Chemistry or Biology of at least grade 6. Not used prior or at interview, read prior to ofers being made but is not Personal statement scored. Emphasis on applicants being able to show a commitment to caring which can be accomplished in a number of ways other than in a hospital or Work experience General Practce setng e. Those made an ofer must pass a summer school and would have received a lower A level conditonal ofer. Assessment is based Personal statement on motvaton, experience of helping others, commitment, voluntary experience, extracurricular actvites, school/college contributon and supportng evidence in reference. Applicants who are fagged as widening partcipaton candidates by the Widening partcipaton university are considered in a separate group when selectng for interview. Internatonal Baccalaureate Candidates are required to take Chemistry and a second science (Biology or Physics) and/or Maths to Higher level. No specifc requirement, although some work experience (whether paid or Work experience voluntary) in the health or related sectors is valuable. Internatonal Baccalaureate 38–36 points overall including 6 in Higher level Biology and Chemistry.
X. Nerusul. Inter American University of Puerto Rico.