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•• advise the patient about when to expect onset of relief and that if symptoms continue or worsen to viagra commercial elevator seek further medical attention. •• develop a plan to assess the effectiveness of laxative use in cases of functional constipation. 338  section 3  |  gastrointestinal disorders diarrhea like constipation, diarrhea is a symptom of an underlying disorder, not a disease itself. It is characterized by increased stool frequency (usually greater than three times daily), stool weight, liquidity, and decreased consistency of stools compared with an individual’s usual pattern. Acute diarrhea is defined as diarrhea lasting for 14 days or less. Diarrhea lasting more than 30 days is called chronic diarrhea. Illness of 15 to 30 days is referred to as persistent diarrhea. Epidemiology and etiology most cases of diarrhea in adults are mild and resolve quickly. Infants and children (especially less than 3 years) are highly susceptible to the dehydrating effect of diarrhea, and its occurrence in this age group should be taken seriously. Acute diarrhea the terms acute diarrhea and acute gastroenteritis are not synonymous because diarrheal events do not invariably produce enteritis or involve the stomach. Acute diarrhea has many possible causes, but infection is the most common. Infectious diarrhea occurs because of transmission of contaminated food and water via the fecal–oral route. Viruses cause a large proportion of cases. Common culprits include rotavirus, norwalk, and adenovirus. Bacterial causes include escherichia coli, salmonella species, shigella species, vibrio cholerae, and clostridium difficile.

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With an appropriate antibiotic, medication-related diarrhea can be addressed by removal of the offending agent. Likewise, diarrhea secondary to malabsorption sometimes can be addressed by changing to an oligomeric en formula. Antiperistaltic agents (eg, loperamide) may be useful in some noninfectious diarrhea. On the other hand, constipation may occur in patients receiving en, especially the elderly. Increased provision of fluid or fiber may be useful. Constipation may be drug related, in which case discontinuation or replacement of the offending drug may be beneficial. Impaired gastric emptying is seen commonly in en patients receiving gastric feedings and may be associated with nausea and vomiting. Impaired emptying may be related to disease process (eg, diabetic gastroparesis or sequelae to head injury) or to drug therapy, most notably narcotics. Gastric residual checks frequently are measured in patients receiving gastric feedings (see table 101–8). To accomplish this, a syringe is attached to the feeding device, and as much liquid as possible is aspirated into the syringe. Debate is ongoing as to what constitutes a significant gastric aspirate, with numbers between 200 and 500 ml most commonly defended. A recent study indicated that residual checks are not necessary. 4,32–34 approaches to the patient with delayed gastric emptying might include changing to a formula containing less fat because dietary fat is associated with slower gastric emptying. Metoclopramide often is given to patients receiving gastric feedings to facilitate gastric emptying. Erythromycin is an alternative medication that may be useful, although it is associated with drug–drug interactions. Patients with consistently high residuals are considered to be at higher risk of aspirating feedings into their lungs and should be considered for transition to postpyloric feedings. Postpyloric feedings may help relieve en-related nausea and vomiting and are preferred for patients without an intact gag reflex. An important practice to help prevent aspiration is elevation of the head of the bed to at least 30 degrees during continuous feedings and during and for 30 to 60 minutes after intermittent and bolus feedings. Technical complications technical or mechanical complications are encountered frequently in en patients. Tube occlusion most commonly is related to formula occlusion or medication administration through the tube. An important practice to help prevent medication-related occlusion is adequate water flushing of the tube before, between, and after each medication is given through the tube. If intermittent feedings are used, water flushing after each feeding is recommended. Tube occlusion can increase cost of en if the tube has to be removed and replaced.

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R a pidlypr ogr es s ing dement ia s how does sspe present?. Four clinical stages have been described. Stage i. T ere is a prodromal phase o weeks to years where nonspeci c behavioral and learning di culties may mani est. Stage ii.

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Osteonecrosis of the jaw is a major concern with viagra commercial elevator bisphosphonate therapy. Risk factors are unclear, but osteonecrosis of the jaw is more common in patients receiving iv administration of bisphosphonates and having dental procedures performed. It is recommended that patients have dental restoration work before starting bisphosphonate therapy. Several consensus guidelines have been published on the use of bisphosphonates and myeloma. Recommendations on the duration of therapy and which bisphosphonate to use have largely been left up to the practitioner. 34,48 outcome evaluation newly diagnosed, asymptomatic patients with mm may be observed without treatment. This asymptomatic period may last for months to a couple years. All patients with mm become symptomatic, and when this occurs, treatment is required. All patients should be evaluated for an autologous stem cell transplant. For patients who are eligible for transplant, induction therapy often consists of thalidomide or lenalidomide, bortezomib, and dexamethasone. Maintenance therapy with an immunomodulatory agent may be used posttransplant. There are numerous treatment options for transplant ineligible patients including mpt, mpb, or mpl. Nearly all patients progress at some point, and second-line therapy usually includes bortezomib. Monthly bisphosphonates should be given to patients who have bone lesions with the hope of reducing pain and fractures. Abbreviations introduced in this chapter cll cml cr dvt fish hsct mgus mp mpb mpl mpt ph q-pcr tki wbc chronic lymphocytic leukemia chronic myelogenous leukemia complete response deep venous thrombosis fluorescence in situ hybridization hematopoietic stem cell transplantation monoclonal gammopathy of unknown significance melphalan–prednisone melphalan–prednisone–bortezomib melphalan–prednisone–lenalidomide melphalan–prednisone–thalidomide philadelphia chromosome qualitative and quantitative polymerase chain reaction tyrosine kinase inhibitor white blood cell references 1. Pinilla-ibarz j, bello c. Modern approaches to treating chronic myelogenous leukemia. Curr oncol rep. 2008;10:365–371. 2. Siegel r, ma j, zou z, jemal a. Cancer statistics, 2014. Ca cancer j clin. 2014;64:9–29. 3. National comprehensive cancer network clinical practice guide­ lines in oncology [internet]. Chronic myelogenous leukemia, version 3. 2014. Nccn. Org. 4.