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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

It is the brain that suffers from all the consequences of alteration in water metabolism asthma symptoms exercise-induced buy discount albuterol on-line. In hyponatremia asthma treatment wiki albuterol 100mcg for sale, there is an inability of the kidney to asthma definition 14th cheap 100mcg albuterol otc generate dilute urine and excrete free water asthma in babies order generic albuterol on-line. It is also a significant risk factor for sensorineural hearing loss and cerebral palsy. Hospital-acquired hyponatremia may be iatrogenic and in large part are due to the administration of hypotonic fiuids to sick children who may have elevated arginine vasopressin levels. Nearly 60 % is reab sorbed at the proximal tubule, 30–40 % at thick ascending limb of loop of Henle and 5–10 % actively at the distal tubule. Mild hyponatremia (serum Na+ <135 mEq/l) occurs in 25 % of hospitalized children, while moderate hyponatremia (Serum Na+ <130 mEq/l) is seen in 1 % of hospitalized children. Rarely, excess ingestion of free water or excess loss of urinary sodium causes hyponatremia. Hypervolemic hyponatremia (increase in effective circulating volume or increased salt and water retention) Nephrotic syndrome Renal failure (acute/chronic) Congestive cardiac failure Cirrhosis of liver 2. Readings obtained by ion selective electrode method may not have an effect on lipid or protein levels in the serum. The treat ment of hypertonic and pseudohyponatremia is directed at the underlying disorder. Management of Asymptomatic Hyponatremia (Chronichyponatremia) Treat the underlying cause Fluid restriction (fi to 2/3 maintenance fiuids/day) Oral salt supplementation Furosemide (to increase free water loss) + 0. Step 1: Assess the volume status: if the child is hypovolemic, treat with isotonic saline in sufficient amounts to restore the intravascular volume. Step 2: Calculate the rise in sodium required using the formulae and the optimal rate. Step 3: Once symptom-free, hyponatremia can be corrected more slowly over a period of 48 h with a goal of not to increase the serum Na+ concentration by more than 10–20 mmol/l over 24–48 h by using the same formulae. Type C – resetting of the osmostat, plasma sodium concentration is normally regulated at a lower level (between 125 and 135 mmol/l). Fluid restriction to less than 2/3 of main tenance and decreased to fi maintenance or lower if no improvement in 4–6 h. However, it has unpredictable renal clearance, and onset of the response varies and ranges between 5 and 8 days. In hypernatremia, there is a net deficit of water in relation to sodium, and it may be caused by water loss or sodium gain or a combination of both. Water deficit in excess of sodium (clinically dehydrated) Diarrhea, emesis/nasogastric tube suction, burns 2. Sodium excess (clinically normal hydration/mild hypervolemia) Improperly mixed formula or rehydration solutions Excessive sodium bicarbonate administration Hypertonic saline enema Primary hyperaldosteronism 2. Signs and symptoms of dehydration may be masked because of bet ter preservation of intravascular volume. If urine osmolality is >600 mOsm/kg in a child with hypernatremia, suspect extrarenal hypotonic fiuid losses. Insulin treatment is not recommended because it may increase brain “idiogenic osmoles” content. Phadke • Hypocalcemia is common; addition of calcium gluconate to rehydration fiuid is often indicated. Volume of fiuid to be administered over 48 h = 2 fi maintenance fiuid + calculated total body free water deficit. Ninety-eight percent of the potassium in the body is within cells, primarily in skeletal muscles and to a lesser extent in liver. The ratio of intracellular and extracel lular potassium is the primary determinant of the resting membrane potential. All of the excitable cells (muscle cells, nerve cells) rely upon this resting membrane poten tial or K+ gradient to set their basal voltage for their function. Hence, there are profound clinical effects whenever this K+ gradient gets disturbed. A combination of low mineralocorticoid and low distal delivery of sodium leads to low K+ secretion and hyperkalemia, classically seen in Addison’s disease. The volume depletion then leads to an increase in mineralo corticoids leading to increased K+ secretion, resulting in hypokalemia. However, 24-h urine collection is often difficult in children and is prone to errors because of inaccuracies in timing and collection. However, the ratio can vary with age, renal failure, and muscle mass and hence should be interpreted with caution. FeK + = urinary potassium/serum potassiumfi serum creatinine/urinary creatinine fie100 96 A. Phadke Potassium excretion in normal infants is slightly higher than in older children and adults. It can also cause life-threatening cardiac arrhythmias and respiratory paralysis due to weakness of respiratory muscles. Acute Skeletal muscle weakness involving limbs, trunk, and respiratory muscles Smooth muscle weakness: paralytic ileus and gastric dilatation Cardiac arrhythmia: premature ventricular contractions, sinus bradycardia Ventricular tachycardia or fibrillation Atrioventricular block Rhabdomyolysis Chronic Growth failure Tubulointerstitial and cystic changes Polyuria Metabolic alkalosis Impaired glucose tolerance 2. Management in Nonemergent Situations the infusion rate of potassium chloride should not exceed 0. Asymptomatic Hypokalemia • the mainstay of therapy is oral potassium supplementation (3–4 mmol/Kg/ day). The insulin glucose infusion causes cellular shifts of potassium which occur by 30 min and lasts for 2–4 h. Long-Term Treatment • Measure aldosterone levels, and if they are low treat with fiudrocortisone. If the volume is low, treat with fiudrocortisone, and if the patient is volume expanded, treat with a diuretic. A change in serum albumin of 10 g/l causes a change in serum calcium in the same direction by 0. In children with symptoms, the signs and symptoms are related to the severity and duration of hypocalcemia. Acute hypocalcemia often results in symptoms due to neuromuscular irritability or car diac arrhythmias. A positive sign is fiexion of the wrist and metacarpophalangeal joints and extension of the interphalangeal joints and adduction of the fingers due to carpope dal spasms. Trousseau’s Sign Tap gently and repeatedly with a forefinger on the lateral cheek over the course of the facial nerve 0. A positive sign is twitching of the corner of the mouth on the ipsilateral side due to contractions of the circumoral muscles. Once the symptoms have resolved, oral supplements can be initiated at 50–100 mg/kg/day of elemental calcium in 3–4 divided doses. While administering the intravenous dose, ensure patency of the venous access as calcium extravasations can cause tissue necrosis. The intravenous infusion should be immediately discontinued if there is a gradual decrease or sudden slowing of heart rate. Etiology Hyperparathyroidism Primary – adenoma, multiple endocrine neoplasia, calcium-sensing receptor mutation (loss of function) Secondary and tertiary hyperparathyroidism. It is given as an infusion over 4 h initially and later over 2–4 h for three consecutive days. Repeat infusion every 2–3 weeks or every 2–3 months according to the degree and severity of hypercalcemia. The effect, although rapid, is short lasting, and prolonged use may lead to tachyphylaxis. Frequency urgency syndrome, recurrent uri nary tract infections, and decreased bone density have been loosely associated with idiopathic hypercalciuria. Some genetic conditions associated with hypercalciuria are given at the end of this chapter. Evaluation of Hypercalciuria An evaluation for secondary disorders should be considered in the presence of positive family history, failure to thrive, growth retardation, rickets, acid–base disturbances, renal dysfunction, proteinuria, electrolyte imbalance, dysmorphic features, or poor response to therapy. Clinical Features In children, hypercalciuria can cause manifestations such as recurrent hematuria, voiding dysfunction (frequency–dysuria syndrome), fiank pain, abdominal pain, nephrolithiasis, urinary tract infection, and decreased bone mineral density.

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It is obtained from the leaves of the plant Cannabis sativa It is excreted via kidneys asthma treatment houston buy albuterol 100mcg lowest price. Nervous system: the changes are as under: Opioids are derived from the poppy plant asthmatic bronchitis 36 buy albuterol 100 mcg with amex. Heroin and In children asthma short definition buy discount albuterol 100 mcg on line, lead encephalopathy; oedema of brain asthma treatment cartoon discount albuterol online, morphine are self-administered intravenously or flattening of gyri and compression of ventricles. Following are a few common drug abuse lead-protein complex in the proximal tubular cells. At the site of injection—cellulitis, abscesses, ulcers, manifests as acute abdomen presenting as lead colic. These substances exert their toxic Thermal and electrical burns, fall in body temperature below effects depending upon their mode of absorption, 35°C (hypothermia) and elevation of body temperature above distribution, metabolism and excretion. Environmental chemicals may have slow systemic injury and death as occurs on immersion in cold damaging effect or there may be sudden accidental exposure water for varying time. Hyperthermia likewise, may be localised as in cutaneous Some of the common examples of environmental burns, and systemic as occurs in fevers. The most serious complications of burns pesticides, fungicides, herbicides and organic fertilisers are haemoconcentration, infections and contractures on which may pose a potential acute poisoning as well as long healing. The problem is particularly alarming in developing countries like India, China and Mexico where Electrical burns may cause damage firstly, by electrical farmers and their families are unknowingly exposed to these dysfunction of the conduction system of the heart and death hazardous chemicals during aerial spraying of crops. During radiotherapy, some normal cells coming vapours are used in industry quite commonly and their in the field of radiation are also damaged. In general, exposure may cause acute toxicity or chronic hazard, often radiation-induced tissue injury predominantly affects by inhalation than by ingestion. Such substances include endothelial cells of small arteries and arterioles, causing methanol, chloroform, petrol, kerosene, benzene, ethylene necrosis and ischaemia. Pollution by occupational exposure to toxic organs: metals such as mercury, arsenic, cadmium, iron, nickel and 1. Gastrointestinal tract: strictures of small bowel and contaminant in several preservatives, herbicides and oesophagus. Haematopoietic tissue: pancytopenia due to bone marrow combustion of plastic, silk and is also present in cassava and depression. These substances causing injury as sunburns, chronic conditions such as solar keratosis pneumoconioses are discussed in chapter 17 while those and early onset of cataracts in the eyes. In the Western world, nutritional Their deficiencies result in a variety of lesions and deficiency imbalance is more often a problem accounting for increased syndromes. Water intake is essential to cover the losses in health problem, particularly in children. Although body’s water needs to know the components of normal and adequate nutrition. In order to retain stable weight cellulose, hemicellulose and pectin, though considered non and undertake day-to-day activities, the energy intake must essential, are important due to their beneficial effects in match the energy output. The average requirement of energy lowering the risk of colonic cancer, diabetes and coronary for an individual is estimated by the formula: 900+10w for artery disease. Since the requirement Pathogenesis of Deficiency Diseases of energy varies according to the level of physical activities the nutritional deficiency disease develops when the performed by the person, the figure arrived at by the above essential nutrients are not provided to the cells adequately. Dietary proteins provide the body with amino decreased amount of essential nutrients in diet. Secondary or Nine essential amino acids (histidine, isoleucine, leucine, lysine, conditioned deficiency is malnutrition occurring as a result methionine/cystine, phenylalanine/tyrosine, theonine, of the various factors. These are as under: tryptophan and valine) must be supplied by dietary intake i) Interference with ingestion. The such as malabsorption syndrome, chronic alcoholism, recommended average requirement of proteins for an adult neuropsychiatric illness, anorexia, food allergy, pregnancy. Fats and fatty acids (in particular linolenic, linoleic and arachidonic acid) should comprise about 35% of diet. A healthy individual requires Dietary imbalance and overnutrition may lead to diseases 4 fat-soluble vitamins (A, D, E and K) and 11 water-soluble like obesity. Obesity is defined as an excess of adipose tissue that vitamins (C, B1/thiamine, B2/riboflavin, B3/niacin/nicotinic imparts health risk; a body weight of 20% excess over ideal weight 244 for age, sex and height is considered a health risk. Insufficient pushing of oneself out of the chair leading to inactivity and sedentary life style. Secondary obesity may result following a number of under lying diseases such as hypothyroidism, Cushing’s disease, insulinoma and hypothalamic disorders. The lipid storing cells, adipocytes comprise the adipose tissue, and are present in vascular and stromal compartment in the body. Besides the generally accepted role of adipocytes for fat storage, these cells also release endocrine-regulating molecules. Adipose mass is increased due to enlargement of adipose cells due to excess of intracellular lipid deposition as well as 2. Obesity often important environmental factor of excess consumption of exacerbates the diabetic state and in many cases weight nutrients can lead to obesity. A strong association between hyperten observations that obesity is familial and is seen in identical sion and obesity is observed which is perhaps due to twins. Weight reduction leads to and its protein product leptin, and db gene and its protein significant reduction in systolic blood pressure. Total blood and pathological changes described below and illustrated in cholesterol levels are also elevated in obesity. As a result of atherosclerosis and increased adipose stores in the subcutaneous tissues, hypertension, there is increased risk of myocardial infarction skeletal muscles, internal organs such as the kidneys, and stroke in obese individuals. Many obese individuals exhibit hyper this is characterised by hypersomnolence, both at night and glycaemia or frank diabetes despite hyperinsulinaemia. This during day in obese individuals along with carbon dioxide is due to a state of insulin-resistance consequent to tissue retention, hypoxia, polycythaemia and eventually right-sided insensitivity. The term pickwickian 245 syndrome was first used by Sir William Osler for the sleep apnoea syndrome). These individuals are more prone to develop degenerative joint disease due to wear and tear following trauma to joints as a result of large body weight. Diet rich in fats, particularly derived from animal fats and meats, is associated with higher incidence of cancers of colon, breast, endometrium and prostate. Its causes may be the following: i) deliberate fasting—religious or political; ii) famine conditions in a country or community; or iii) secondary undernutrition such as due to chronic wasting Figure 9. After about one week of starvation, protein A starved individual has lax, dry skin, wasted muscles breakdown is decreased while triglycerides of adipose tissue and atrophy of internal organs. The following metabolic changes by most organs including brain in place of glucose. Starvation take place in starvation: can then continue till all the body fat stores are exhausted 1. This results in of primary dietary deficiency or conditioned deficiency may release of glycogen stores of the liver to maintain normal cause loss of body mass and adipose tissue, resulting in blood glucose level. Protein stores and the triglycerides of adipose socioeconomic factors limiting the quantity and quality of tissue have enough energy for about 3 months in an dietary intake, particularly prevalent in the developing individual. Proteins breakdown to release amino acids which countries of Africa, Asia and South America. The impact of are used as fuel for hepatic gluconeogenesis so as to maintain deficiency is marked in infants and children. Feature Kwashiorkor Marasmus Definition Protein deficiency with sufficient calorie intake Starvation in infants with overall lack of calories Clinical features Occurs in children between 6 months and 3 years Common in infants under 1 year of age (Fig. Marasmus is starvation in infants occurring due to overall nutrients are common due to generalised malnutrition of lack of calories. In the developed countries, individual vitamin the salient features of the two conditions are contrasted deficiencies are noted more often, particularly in children, in Table 9. However, it must be remembered that mixed adolescent, pregnant and lactating women, and in some due forms of kwashiorkor-marasmus syndrome may also occur. General secondary causes of conditioned nutritional deficiencies listed already above.

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Syndromes

  • Poor judgment
  • Platelet aggregation test
  • Diarrhea
  • Peak flow values of 50% - 80% of your best results are a sign of a moderate asthma attack. Numbers below 50% are a sign of a severe attack.
  • Herpes simplex keratitis is a serious viral infection. It may cause repeated attacks that are triggered by stress, esposure to sunlight, or any condition that impairs the immune system.
  • Thymus tumor
  • Fluids through a vein (by IV)
  • Pat the area dry or allow to air-dry.