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In most patients 100mg kamagra effervescent, serial or previous spected cheap kamagra effervescent 100 mg on-line, and fibreoptic ureteroscopes can be passed up, measurements of creatinine are useful to monitor the to look for ureteric lesions such as stones or carcinoma. Clearance is defined as the ‘virtual’ volume of blood cleared (by the kidney) of solute per unit time. When nephrons are lost or are not func- where U = urinary concentration, V = urine flow rate tioning properly, there is compensation by the remain- and P = plasma creatinine. It is 24-hour urinary collections are inconvenient and in- higher following protein intake, in a catabolic state, af- accurate. The best known of these is the creatinine because it is avidly reabsorbed at the proximal Cockcroft and Gault formula: tubules in a fluid-depleted state. If the creatinine is also proportionally raised (creatinine is normally Forwomen multiply by 1. This is indicated in severe Chapter 6: Clinical 231 be performed in cases of deterioration of renal function in patients with known kidney disease, to help guide treatment, for example in systemic lupus erythemato- sus, and relatively frequently in renal transplant patients particularly to look for rejection. The biopsy can be performed percutaneously, or at open surgery (unusual unless the other method is not possible, or contraindicated, e. Ultrasound guidance is used, and usually two cores are obtained using a spring-loaded biopsy needle. These are examined under light microscopy, electron microscopy andimmunofluoresenceorimmunoperoxidasestaining. Serum creatinine Complications include haematuria, bleeding under the renal capsule and bleeding out into the retroperi- Figure 6. In up to 3% renal failure (creatinine clearance becomes inaccurate), of individuals, blood transfusion is required for bleed- for kidney donors and patients receiving chemotherapy. Contraindications to percutaneous renal biopsy: Anion gap calculation is useful in metabolic acidosis, to r Clotting abnormality or low platelets (unless cor- differentiate causes. The r Small kidneys (<9 cm), as this indicates chronic irre- formula used to calculate the anion gap varies from versible kidney damage. In metabolic acidosis, an increased anion gap occurs due Relative contraindications include obesity (technically to raised acid levels: r difficult), single kidney (except of a transplanted kidney) Lactic acidosis (exercise, shock, hypoxia, liver failure). In metabolic acidosis, a normal anion gap indicates that there is failure to excrete acid or loss of base: Dialysis r Failure to excrete acid occurs in renal tubular disease When the kidneys fail to a degree that causes symptoms and Addison’s disease. Despite advances in technology, these are still Renal biopsy is indicated when glomerular disease is sus- unable to completely mimic renal function, and none pected,andinunexplainedacuterenalfailure. Haemodialysis Although many patients cope very well with dialy- Blood has to be pumped from the patient, and passed sis, common symptoms include headache, joint pains through a ‘dialyser’, sometimes called an artificial kid- and fatigue during and after a dialysis session. The dialyser consists of an array of semi-permeable plications include hypotension, line infections, dialysis membranes. The blood flows past the membrane on one amyloid and increased cardiovascular mortality. Smallsoluteswithalarge and solutes across a highly permeable membrane and concentration gradient diffuse rapidly, e. Before the blood is returned to the body, atinine,whereasdiffusionisslowerwithlargermolecules fluid is replaced using a lactate or bicarbonate-based so- or if the concentration gradient is low. Proteins are too large to cross the mem- of fluid and changes in electrolyte concentration take brane. Underdialysis (lack changedacrosstheperitonealmembranebyputtingdial- of adequate dialysis) is associated with an increase in ysis solution into the abdominal cavity. Dialysateisrunundergravityintotheperi- toneal cavity and the fluid is left there for several hours. Blood from Blood to Small solutes diffuse down their concentration gradients patient patient between capillary blood vessels in the peritoneal lining and the dialysate. Patients often develop some consti- Dialysate out Dialysate in pation which can limit the flow of dialysate, they are treated with laxatives. Chapter 6: Disorders of the kidney 233 Blood Blood from patient to patient Semipermeable membrane Replacement fluid in (can be less than haemofiltrate to treat fluid overload) Haemofiltrate out e. There is a large degree of bacterial peritonitis are the most common serious com- redundancy in the kidney, so many nephrons may be lost plications. This can be treated by adding antibiotics to the It is useful when considering the causes of renal failure peritoneal dialysate. The kidneys have three important functions: 1 Fluid and electrolyte balance, including acid–base bal- ance. It consists of the glomerulus and its associated vascular supply and the tubules, loop Figure 6. High phosphates cause pruritus (itching), chronic r In prerenal failure, the kidney is not damaged but renal failure leads to renal osteodystrophy. Recovery may be possible, though if the disease is severe and scarring results, full Acute renal failure functional recovery is unlikely. The causes may be divided into prerenal, renal and postrenal, whilst they all have different mechanisms, the Renal failure causes result is loss of the three functions of the kidney: fluid 1 Arise in serum concentrations of urea, creatinine, hy- and electrolyte balance, excretion of waste products and drogen ions (causing a metabolic acidosis) and potas- toxins, and hormone synthesis (see Table 6.

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Follow-up 3 months later has a 50% re- Prostate cancer currence rate and regular follow-up is needed generic kamagra effervescent 100mg with visa, usu- Definition ally for 5–10 years generic 100 mg kamagra effervescent mastercard. Age ii Localised,muscle-invasivedisease(T2,butalsohigh- >50 years (40% > 70 years, 60% > 80 years) grade T1) is optimally treated by a radical cystec- tomy – malesaretreatedbycystectomywithproximal Sex urethral and prostate removal, females require cys- Male tectomy with the whole urethra removed and an ileal conduit with urinary diversion (ureters to ileum). In Geography males it is possible to use a piece of ileum to form Varies by population (90x). Most common in Afro abladder substitute ‘substitution urethroplasty’ be- Caribbeans, common in Europe, rare in Orientals. Predisposing factors include age, ethnicity, family his- iii Locally advanced disease (T3 and T4) is life threaten- tory,genetic factors and diet, with a diet high in ani- ing and requires radical cystectomy in combination mal fat, low in vegetables showing an increased risk, but with radiotherapy or chemotherapy. Morbidity results from radiation cystitis and proctitis leading to a small Pathophysiology fibrosed rectum. In females radiation vaginitis and/or The cancer is commonly androgen-dependent, but anasensatevagina,andinmalesimpotenceoccursdue there is no evidence that its growth is driven by a to nerve damage. However, popu- r Chemotherapy is increasingly used with surgery, or lation studies have shown that men with higher testos- may be used alone as a palliative measure. Neoad- terone levels appear to be at greater risk of prostate juvant chemotherapy (i. Depends on stage and grade at presentation and the age r In most cases it is diagnosed either on rectal exam- of the patient. Recurrence is common and may be of ination as the finding of an asymmetric prostate, a a higher grade (25%). Some patients appear to have a nodule or a hard, irregular craggy mass, often alter- few,minorrecurrences,whereasothershavewidespread, ing the median groove. T1 has an 80% 5-year survival and diagnosed because of the finding of a raised prostate T4 has 10% 5-year survival (but very age dependent). Macroscopy Management The tumours usually are in the peripheral zone of the This depends on the tumour staging, grade and also on prostate and appear as hard yellow-white gritty tissue the patient’s age and co-morbidity, as many of the treat- (see Table 6. Organ-confined, low-grade disease: r These tumours tend to grow slowly, in older patients Microscopy (>70 years) and those likely to die of co-morbidity be- Most are well differentiated and consist of small acini fore the cancer causes significant symptoms or metas- in a glandular pattern. However, rad- Gleason score: The biopsy material is examined under ical surgery is a major operation, with a 60% incidence a microscope and a Gleason grade 1–5 (grade 1 being of impotence (compared to 16% preoperatively) and most differentiated, grade 5 the least) is assigned to the anincreaseinurinaryincontinence. These also cause complications such as acute and chronic ra- two grades are then added together to give the Gleason diation proctitis (diarrhoea, urgency, bleeding), and score (2–10). Complications Metastatic or high grade local disease: Urinary tract infection and renal tract obstruction may r Treatment is for symptoms only (palliative). Chapter 6: Genitourinary oncology 281 iv Chemotherapy is not as effective and is used mainly Aetiology for non-responsive disease. Ten per r Throughout treatment a multidisciplinary approach cent of all testicular tumours develop in testes which is needed with regard to palliation of symptoms. A family phosphonates are used for bone pain and to prevent history is also a known risk factor as is infertility. Localised radiation is used for bone pain and recently bone-targeting radioisotopes have been Pathophysiology developed for those with multiple metastases. If confined to It appears that these atypical cells are formed early prostate: 80% have 5-year survival and 60% have 10- in gestation and may be influenced by events in utero. If metastases are present: 20% have 5-year They then lie dormant, until puberty, when they spread survival and 10% have 10-year survival. In some individuals, they become ma- lignant and either develop along the seminomatous or teratomatous line. Introduction to testicular tumours Definition Classification Tumours of the testis may be classified broadly into those The main components of the testis are the germ cells arising from the germ-cell line and those arising from (spermatogonia), the sex cords or seminiferous tubules non-germ cells. Leydig cells normally pro- ducetestosterone,soLeydigcelltumourshavethepoten- Sex tial to produce steroid hormones at levels high enough Males to have systemic effects. Both Leydig cell and Sertoli cell Germ Cell Tumours Seminoma (40%) Teratoma (32%) Mixed (14%) Arise from germ cells in the Embryonic Extraembryonic seminiferous tubules Tissue Tissue Figure 6. Other tumour types include nous spread leads to metastases most commonly in the lymphoma and metastases. A dull ache Scrotal biopsy should be avoided, as this increases the or dragging sensation in the lower abdomen or per- risk of local spread and recurrence. Associated gy- Management naecomastia or lymphadenopathy should be looked Testicular cancer is now one of the most curable solid for, as well as any evidence of metastases, e. A testicular prosthesis may iliac and para-aortic lymph nodes via the spermatic be placed at the time of surgery. Clinical features Howeverinhigher stage disease, this may be postponed As for testicular tumours. Macroscopy/microscopy The tumour appears as a homogeneous firm white mass, amidst normal, brown testis. There are three his- tological subtypes of seminoma, termed classic, anaplas- Definition tic and spermatocytic (British Testicular Tumour Panel) These are testicular tumours of germ-cell origin which depending on the microscopic features: have differentiated along the spermatocytic line. Sheets of large, polygonal cells with clear cytoplasm (vacuo- Incidence/prevalence latedandglycogencontaining)andsmallcentraldark- Mostcommontesticulartumour(40%);∼2/100,000p.

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Always remember that you do a disservice to your survival community by becoming the next casualty buy discount kamagra effervescent 100 mg. The first thing that the survival medic should perform in preparation for a collapse situation is a status assessment generic kamagra effervescent 100 mg free shipping. A number of questions must be asked and answered: What Will Your Responsibilities Be? It goes without saying that, as group medic, you will be responsible for the medical well-being of your survival community. It means that, as well as being the Chief Medical Officer, that you will be: Chief sanitation officer: It will be your duty to make sure that sanitary conditions at your camp or retreat don’t cause the spread of disease among the members. This will be a major issue in an austere setting, and will cause the most medical issues in any survival group. Some of your responsibilities will relate to latrine placement and construction, others will relate to the supervision of appropriate filtering and sterilization of water. Assurance of proper cleaning of food preparation surfaces will also be very important, as will be the maintenance of good personal and group hygiene. In areas of extreme climate, it is important to ensure that all members have adequate shelter. Careful attention to these details will be part of a preventative program that will keep your family or community healthy. Chief dental officer: Medical personnel in wartime or in remote locations report that patients arriving at Sick Call complained of dental problems as much as medical problems. Anyone who has had a bad toothache knows that it affects concentration and, certainly, work efficiency. You will need to know how to deal with dental issues (toothaches, broken teeth, lost fillings) if you are going to be an effective medic. Chief counselor: It goes without saying that any societal collapse would wreak havoc with peoples’ mindsets. You will have to know how to deal with depression and anxiety as well as cuts and broken bones. You will have to sharpen your communication skills as much as your medical skills. A good healthcare provider also understands, as mentioned earlier, the importance of confidentiality in all their patient contacts. Medical quartermaster: You’ve done your job and accumulated medical and dental supplies, but when do you break them out and use them? In a collapse situation, these items will no longer be produced, due to the complexity of their manufacture. Careful monitoring of precious supply stock and usage will give you an idea of your readiness to handle medical emergencies for the long term. Medical Archivist: You are in charge of writing down the medical histories of the people in your group. This record will be useful to remember all the medical conditions that your people have, their allergies, and medications that they might be taking. If your community is large, it would be almost impossible to memorize all of this information. Also, your histories of the treatments you have performed on each patient are important to put into writing. One day, you might not be there to render care; your archives will be a valuable resource to the person that is in charge when you’re not available. Medical education resource: You can’t be in two places at once, and you will have to make sure that those in your group have some basic medical knowledge. Also, providing all members an education in preventing injuries and infectious disease will give you a head start towards having a healthy survival community. These responsibilities are many, but may be modified somewhat by the makeup of your group. If you have a pastor or other clergy in your group, they can take some of the burden of psychological counseling away from you. If you have someone skilled in engineering, water treatment, or waste disposal, they might be able to use their knowledge to help maintain sanitary conditions at the retreat, or assure healthy filtered water. It’s important to accumulate medical supplies and knowledge that will work in any collapse situation, but what are you actually expecting to happen? Your preparations should be modified to fit the particular situation that you believe will cause modern medical care to be unavailable. There are many possible scenarios that could cause times of trouble, and each of them requires some specialized planning. Your readiness to deal with the most likely illnesses or injuries will increase your effectiveness exponentially. If you feel that we are on the verge of an economic collapse, you probably believe that the reliable transport of food from farms to the public will no longer exist (nobody is paying the truckers). Your responsibility as medic would be to make sure that your group’s food storage includes everything required to give good nutrition. Stockpiling vitamin supplements, commercial or natural, would be a good strategy in this situation.

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Herbs for Health 1998; concomitant use with anticoagulants buy kamagra effervescent 100 mg with amex, antiplatelets or anti- Sept/Oct:40-41 purchase kamagra effervescent 100 mg. Cycloartane triterpene Capsule—200 mg, 250 mg, 400 mg, 450 mg, 470 mg, 500 glycosides from the hairy root cultures of Astragalus mg, 520 mg membranaceus. Astragalus membranaceus and Polygonum multiflorum protect rat heart mitochondria against Tea Bag lipid peroxidation. Memory-improving effect of Daily Dosage: The dried root is administered as 2-6 grams aqueous extract of Astragalus membranaceus (Fisch. From flowering to dispersal: reproductive ecology of an endemic plant, Astragalus australis var. Action of Astragalus membranaceus on left ventricular function of angina pectoris. Secondary metabolites from of ischemic heart disease with Astragalus membranaceus. Cycloartane triterpene ingredients of Astragalus membranaceus in treating heart failure. Bone K: Clinical Applications of Ayurvedic and Chinese Herbs: Ma J; Peng A; Lin S. Mechanisms of the therapeutic effect of Monographs for the Western Herbal Practitioner. Phytotherapy astragalus membranaceus on sodium and water retention in Press, Queensland, Australia 1997. Seleno amino compounds from radical in acute myocardial infarction patients and mechanism Astragalus bisculcatus. Chung Kuo Chung Hsi I Chieh Ho glutamyl-Se-methyl-seleno-L-cysteine and Se-methylseleno-L- Tsa Chih 1995 Mar;15(3):141-3. Chinese medicinal herbs Atropa belladonna reverse macrophage suppression induced by urological tumors. Effect of Astragalus membranaceus on electrophysiological activities of acute experimental Coxsackie B3 viral myocarditis in mice. Treatment of leucopenia with pure Astragalus preparation—an analysis of 115 leucopenic cases. Studies on chemical constituents and immunological function activity of hairy root of Astragalus and outer perianth circles are 4 to 6 mm long and elliptical to membranaceus. Astragalus species See Astragalus (Huang-Qi) Leaves, Stem and Root: The avocado is a tree up to 40 m in height and with a trunk 60 cm in diameter. Athyrium filix-femina i See Lady Fern Habitat: The plant originated in central and southern South America and is cultivated in all tropical and subtropical regions today. Production: Avocado oil comes from the fruit of Persea Atractylodes japonica americana. Avocado oil is recovered from the pericarp of See Japanese Atractylodes Persea americana and refined if necessary. Mode of Administration: As an active or inactive ingredient in various preparations (bath oils, ointments, etc. The flesh is reddish, with Flower and Fruit: The flowers are at the tip of the leading numerous seeds covered in a layer of latex. The calyx tube is appressed to the ovary; the corolla is 5-lobed, Characteristics: The taste is mucilaginous and slightly sour. The 5 stamens are free and the ovary inferior with Habitat: This plant is native to India but has spread over numerous ovules. The seeds are ovoid, light to dark brown, Other Names: Bel, Bengal Quince smooth, 1. The leaves are almost sessile with a Hansel R, Keller K, Rimpler H, Schneider G (Ed), Hagers simple lamina, bluish-green above and gray-green beneath, Handbuch der Pharmazeutischen Praxis, 5. The antitussive, anti-inflammatory Medicinal Parts: The medicinal part is the fresh herb picked and sedative effects require further clinical testing for during the flowering season verification. The lower Chinese Medicine: Jie-Geng is mainly used as an expecto- lip is awned in the tube and the cordate anthers are downy. Efficacy as an expectorant is plausible due to the saponin content; efficacy for the other Leaves, Stem and Root: The plant is small and erect, and indications has not been proven. The leaves are opposite, oblong-lanceolate, on short administration of designated therapeutic dosages. Resin: (bitter-tasting) Chinese Medicine: The drug is used for asthma, coughs and disorders of the gallbladder. Habitat: The plant grows in most of Europe and in moderate Flower and Fruit: Greenish-yellow, round culms exceeding and arctic regions of Asia. Not to be Confused With: Helleborus niger is occasionally used as a substitute by mistake. Habitat: The plant is indigenous to the tropics, southern Other Names: Bugbane, Herb Christopher, Toadroot subtropics and Asia. The ovary is superior with a Homeopathic Uses: The drug is used in homeopathy for flat stigma. The edible fruit is a bright scarlet, oblong- w/ rheumatic conditions, especially those of the smaller joints.

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