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Q. Wenzel, M.A., M.D.

Co-Director, University of Massachusetts Medical School

Such factors include obesity, high-calorie diets, certain drugs, oral contraceptives, multiple pregnancies, and increasing age. If a gallstone travels and obstructs the common bile duct or the cystic duct, pain can develop in the epigastric region, right upper quadrant, or both and sometimes radiate to the upper right back area. Surgery involves incisions in the abdomen so that a tiny video camera and surgical instruments can be inserted. The surgeon views the video pictures on a monitor and removes the gallbladder by manipulating the surgical instruments. Liver Small bile ducts Hepatic duct Stones in gallbladder Cystic duct Stone in common bile duct Duodenum Pancreas Pancreatic duct Sites of gallstones. Endoscopy can also be used to obtain samples for cytological and histological examination and to follow the course of a disease, such as the assessment of the healing of gastric and duodenal ulcers. A camera or video recorder is commonly used during endoscopic procedures to provide a permanent record for later reference. For example, visual examination of the esophagus is known as esophagoscopy, visual examination of the stomach is known as gastroscopy, and visual examination of the duodenum is known as duodenoscopy. It includes endoscopy of the esophagus (esophagoscopy); stomach (gastroscopy); duodenum (duodenoscopy); and esophagus, stomach, and duodenum (esophagogastroduodenoscopy). Endoscopy is also used to confirm the presence and extent of varices in the lower esophagus and stomach in patients with liver disease. The illustration that follows shows the location of a colonoscopy and a sigmoidoscopy. Colonoscopy (Examination of entire length of colon) Polyp End of sigmoidoscopy (Examination of lower third of colon) Sigmoid colon Anus Sigmoidoscopy and colonoscopy. For example, in esophagogastroduodenoscopy, most patients tolerate the procedure with only topical anesthesia of the oropharynx using lidocaine spray. Complications are rare but can include perforation of an organ under inspection with the endoscope or biopsy instrument. Medical Vocabulary Recall Match the medical terms below with the definitions in the numbered list. Competency Verification: Check your answers in Appendix B, Answer Key, on page 377. Studying and completing the terminology and chart notes sections below will help you learn and understand terms associated with the medical specialty of gastroenterology medicine. Terminology the following terms are linked to chart notes in the specialty of gastroenterology. If needed, refer to the Terminology section on page 182 for correct pronunciations and meanings of terms. This 50-year-old white man has lost approximately 40 pounds since his last examination. The patient says he has had no dysphagia or postprandial distress, and there is no report of diarrhea, nausea, emesis, hematemesis, or constipation. The patient has had a history of regional enteritis, appendicitis, and colonic bleeding. The regional enteritis resulted in an ileostomy with appendectomy about 6 months ago. On 5/30/xx, a sigmoidoscopy using a 10-cm scope showed no evidence of bleeding at the anorectal area. Impression: Rectal bleeding caused by a polyp, bleeding diverticulum, or rectal carcinoma. Obese patients who fail to lose weight may consider surgery. An incision into the upper sphincter of the stomach is a surgical procedure known as 8. A person with experiences infrequent passage of hard, dry feces. Cholangiography is a radiographic examination of the to identify or confirm gallstones or other obstructions. A test performed using the reagent "guaiac" requires a sample. Because some urinary structures in the male perform a dual role (both urinary functions and reproductive functions), the urologist also treats male reproductive disorders. These male disorders include, but are not limited to , treatment of bladder cancer, infertility, and sexual dysfunctions.

Diseases

• Charcot Marie Tooth disease type 1B
• D-plus hemolytic uremic syndrome
• Usher syndrome
• Pyruvate decarboxylase deficiency
• Inhalant abuse, aromatic hydrocarbons
• Macrothrombocytopenia with leukocyte inclusions
• Multiple pterygium syndrome

The advice given may include recommendations for care to be provided at home, instructions regarding when to seek medical help, and referral to the appropriate healthcare facility. This explains the common use of the term telephone triage to describe telephone nursing. Wilson and Hubert (2002) described telephone triage nursing as "telephone-mediated care. All of these tasks facilitate continuity of care and the nurse-patient relationship. Telephone medicine as part of the healthcare system has been the object of study since its inception. Multiple researchers have examined the volume of patient telephone calls to physicians both during and after hours. Researchers repeatedly have found that telephone calls account for a large volume of work for physicians and their staff in outpatient clinics. Telephone calls may account for 10%­26% of all patient contacts by physicians (Hannis et al. Other researchers studied after-hours calls and found that up to 99% of all pediatric population and 83% of all mixed patient population calls could be managed over the telephone (Greenberg, 2000). A study by Hildebrandt and Westfall (2002) collected after-hours calls to a family practice clinic for one year. The calls came not only from the patients (33%) but also from family members or caregivers (31%) or from other parties, such as a nurse, pharmacist, or unidentified party (36%). Although these studies have been conducted in family practice clinics, the results are similar to the call patterns in other outpatient settings. Multiple researchers have examined the quality of telephone care because of the high volume of telephone medicine calls and the integral role of the telephone triage nurse in an ambulatory setting. Many of these studies, which were published around the same time (Johnson & Johnson, 1990; Margolis et al. Overall, the conclusions from these studies were similar in that assessments were inadequate because of insufficient talk time. This limitation combined with time pressures and abbreviated talk time create significant challenges (Car & Sheikh, 2003). Negative patient outcomes combined with poor physician-patient communication are the two key ingredients for a malpractice suit. One study found that primary care physicians who never had a malpractice suit spent an average of 3. Although increased time spent with a patient on the telephone or in the office is not a guarantee to preventing lawsuits, this study provides food for thought regarding a potential link between the time shared with patients and families and lawsuit prevention. As physicians and other healthcare providers struggle to manage their time while providing adequate care for each patient, the volume of telephone calls during and after clinic hours can be overwhelming. The time demand of telephone calls has been described in multiple studies of physician practices. Physicians have been dissatisfied with the extra time pressures associated with the volume of calls during regular clinic hours and after hours (Fosarelli & Schmitt, 1987; Pitts & Whitby, 1990). It seems that physicians are faced with a conundrum: time spent engaged on the telephone seems to improve patient satisfaction, but time that physicians spend on the telephone distracts them from the time they are able to spend with patients in the clinic, which also improves patient satisfaction. One specialty headache clinic reported three calls for every clinic hour scheduled (Loder & Geweke, 2002). As noted earlier, most of the calls are legitimate, and many of them are focused on patient clinical concerns. These calls account for repeated interruptions of the physician and pull the physician away from the time he or she is able to spend with patients who have scheduled appointments. Another reason for physician dissatisfaction is that managing patient complaints over the telephone removes the physician and staff from providing billable services to patients in the office. Fee-for-service reimbursement for telephone encounters is not available from most third-party payers. Major payers specifically exclude telephone, e-mail, and fax communications from reimbursement.

In some high-income countries where restrictions on public smoking have increased and smoking prevalence has decreased, tobacco companies have marketed oral tobacco products to smokers. However, the impact of this trend on smoking behavior, and possible dual or poly-tobacco use, remains uncertain. At the same time, multinational tobacco companies have an increasing presence among low- and middle-income countries with both smoked and smokeless products. Prices are lower, warning labels are weaker, surveillance is less developed, fewer proven interventions are available, and fewer resources are devoted to prevention and control programs. The Global Challenge of Smokeless Tobacco Significant challenges exist in monitoring the use and health effects of smokeless tobacco. The Global Challenge of Smokeless Tobacco Chapter 1 introduces and provides a framework for this report, summarizes its chapters, and sets out its major conclusions. Smokeless tobacco use prevalence varies significantly across individual countries and regions, between youth and adults, and between males and females. Among youth and adults, males generally show higher prevalence of use than females. However, among adults, use by women is similar to or greater than use by men in some countries, including Bangladesh, Thailand, Cambodia, Malaysia, Vietnam, and some African countries, such as South Africa, Mauritania, and Sierra Leone. Although data were available to measure overall prevalence for many countries, longitudinal data and data on patterns of use are lacking in most regions. Premade products range from manufactured products made in factories or large production facilities to cottage industry products made in market stalls or shops. The chapter builds on previous reports and systematic reviews that have provided thorough assessments of the evidence. The Economics of Smokeless Tobacco Chapter 5 summarizes the literature and available data on the economics of smokeless tobacco. Little is known about the comparability of tax levels between smoked and smokeless products. The current best practice for cigarette taxation favors the use of a specific excise tax that is regularly adjusted for inflation. A standard unit may be based on dosage (average amount of a product used in a single session), the weight of the dry tobacco leaf used in a product, or the weight of a product (weight of the tobacco, water content, and all other additives). Lack of standardization complicates not only tax collection but also scientific research, as it hinders the use of econometric methods. These marketing strategies may have an adverse public health impact if they encourage dual use or use of multiple tobacco products, discourage cessation, or encourage new tobacco use initiation. In low- and middle-income countries, product innovations may also make sale and use of products more convenient. For example, in India the gutka industry has promoted a packaged ready-to-use product based on a traditional custom-made mixture. Products are designed to appeal to targeted consumers, they are offered at a desirable price, and they are promoted effectively using multiple communication and placement channels. Understanding consumer perceptions of and responses to novel products is essential to assessing the public health impact of changing product and marketing strategies. Greater monitoring and research is needed regarding marketing practices in low- and middle-income countries. Prevention and Cessation Interventions Chapter 7 describes evidence-based prevention and treatment programs that have been tested in a range of countries. The interventions vary from community, to organizational, to individual levels of treatment. Key findings: School-based and community-based prevention programs lead to short-term reductions in prevalence. Involvement of youth in the planning and implementation of programs is an important contributor to their success. School programs that are supplemented by effective family-based and mass media programs improve success over school programs alone. Phone counseling and oral exam feedback appear to be key elements of an effective intervention. For resource-constrained countries, mailed self-help materials with follow-up contact by telephone or using mobile technology may be a cost-effective intervention method. Educational efforts on these harmful effects through media or health care systems are essential to support implementation of large-scale interventions.

Alpha-Keto Acid (Pyruvate). Inderal.

• What is Pyruvate?
• Dosing considerations for Pyruvate.
• Are there safety concerns?
• Weight loss and obesity, improving athletic performance, cataracts, and cancer.
• Aging skin. Pyruvic acid is sometimes applied to the skin as a facial peel.
• How does Pyruvate work?

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