<TITLE: Abdominal Complaints 1
ACADEMIC DOMAIN: medicine
DISCIPLINE: internal medicine
EVENT TYPE: seminar discussion
FILE ID: USEMD070
NOTES: recording incomplete (USEMD080 is part of the same course)

RECORDING DURATION: 80 min 32 sec

RECORDING DATE: 7.10.2004

NUMBER OF PARTICIPANTS: 10

NUMBER OF SPEAKERS: 10

S1: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: junior staff; GENDER: female; AGE: 31-50

S2: NATIVE-SPEAKER STATUS: Italian; ACADEMIC ROLE: masters student; GENDER: female; AGE: 17-23

S3: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: masters student; GENDER: male; AGE: 24-30

BS4: NATIVE-SPEAKER STATUS: Finnish, English (Australia); ACADEMIC ROLE: masters student; GENDER: male; AGE: 24-30

S5: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: undergraduate; GENDER: female; AGE: 24-30

S6: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: undergraduate; GENDER: female; AGE: 24-30

S7: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: undergraduate; GENDER: female; AGE: 17-23

S8: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: masters student; GENDER: female; AGE: 24-30

S9: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: undergraduate; GENDER: male; AGE: 24-30

S10: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: masters student; GENDER: male; AGE: 31-50

SU: unidentified speaker

SS: several simultaneous speakers>


<S9> pancreatitis then . so how common is it </S9>
<P:05>
<S6> mhm it's the third com- common (xx) disease after mhm erm arteriosclerosis diseases and erm artheritis . more common in in men than in women </S6>
<S7> is it now 70 70 per cent of of the cases is caused by alcohol , [(xx)] </S7>
<S3> [(xx)] test well it was 80 per cent <S7> [yeah] </S7> [but] i think it doesn't matter <S7> [yeah] </S7> [was] it so high i don't know [and] </S3>
<S7> [and] from 15 to 20 per cent er is caused by the the gall stones <P:10> the other causes are tumours in the er (xx) and the (xx) </S7>
<S3> was there also inabdominal trauma and then ERCP like a <S7> [yeah] </S7> [iatro-] mhm genic </S3>
<S7> and also these hypercalcaemia and hydro tri- [(xx) yeah] </S7>
<S3> [@glycerin (xx)@] </S3>
<SS> @@ </SS>
<S6> what was the first </S6>
<S7> hypercalcaemia <S6> yes </S6> uh-huh yeah <COUGH> </S7>
<S2> and those infectuous diseases such as er parotitis er or er influenza virus , herpes virus </S2>
<S7> and also some autoimmune diseases and , and some drugs </S7>
<S10> and with few exceptions the paten- patient is a heavy drinker and who has consumed 150 to 175 grams of pure alcohol daily over ten to 15 years before disease <SIC> onsets </SIC> </S10>
<S6> but actually <COUGH> <S10> [pardon] </S10> [the] actually in this book it was said that the aetio- aetiology is not not so clear and they don't exactly know how much you have to drink to get it </S6>
<S3> yeah 'cause i have the er i i think er sometimes it's possible to g- get it like from just er </S3>
<S5> have a bottle of wine or [something] </S5>
<S3> [yeah] something like that almost so er was it in the chronic pancreatitis that you have to [ri- drink] </S3>
<S10> [yeah the chronic] yes <SS> yeah </SS> the [chronic pancreatitis] </S10>
<S3> [for this much] but then </S3>
<S10> yes </S10>
<S1> in acute that's </S1>
<S10> in acute it's </S10>
<S1> the same </S1>
<S10> but </S10>
<S5> the [same yes] </S5>
<S3> [but do you] have to drink that much to get [acute] </S3>
<S1> [yes] </S1>
<S5> not [always] </S5>
<S1> [yes] no then it's not ac- alcoholic pancreatitis <S3> so [it] </S3> [if] if it's not alcoholic pancreatitis then it needs to have er background of two years of heavy alcohol com- consumption </S1>
<S3> was it and was it this 100 150 grams per day [consumption] </S3>
<S1> [er no] the heavy alcohol consumption is er </S1>
<S10> or [three years] </S10>
<S1> [for men it's] it's er </S1>
<S10> [36] </S10>
<S1> [three times] yeah </S1>
<S10> 36 [grams maybe] </S10>
<S1> [yeah yeah] and for females a little bit less <S3> okay </S3> but that kind of consumption for two years </S1>
<S3> two years </S3>
<S5> but can a smaller amount of alcohol [a month] </S5>
<S1> [er at] the moment well we don't know basically but er if the num- er the amount is small then it is not considered as alcoholic an an alcohol induced pancreatitis [then it's something else (xx)] </S1>
<S3> [so it's] [so it's does it] </S3>
<S5> [but still] you should stop <S1> yeah </S1> [even even with small amount] </S5>
<S1> [because we we wouldn't know if if] <S5> yeah </S5> er after having one pancreatitis episode we don't know what would be the er mhm amount required for that sing- singular pers- person to get another attack that's why it it's a little bit vague how to say it but this is kind of international guidelines what we consider is alcoholic pancreatitis </S1>
<S3> so before that those huge amounts and long drinking is (just a) pretty exposing factor then <S1> yeah </S1> , minor use </S3>
<P:05>
<S9> what are the symptoms of , this pancreatitis </S9>
<S6> mhm er upper abdominal pain with with with mhm back pain also mhm it it's like erm belt-type , pain in abo- abdomen in from this book (a- according) [(xx)] </S6>
<S3> [was it so] that when it when it develops it first it might be just lo- local ab- gastral pain and then when it causes oedema in the pancreas then it might start to radiate in the back to the back and then i don't know <S6> [yeah] </S6> [but bet-] in a belt-like yeah when it's when it's the worst kind it it's (xx) </S3>
<S10> i think the most important er symptom is the impergeneral condition </S10>
<S6> [excuse me] </S6>
<S3> [@@] [@(xx)@] </S3>
<S10> [impergeneral condition er as with] with associated er that that is associated with er longer heavy alcohol use . a- and epigastric pain al- also as you as you said but but associated with impergeneral condition . the the symptoms are not er that clear so </S10>
<S7> vomiting is also typical for this </S7>
<S9> i don't understand this er difficulty of breathing why why is it a symptom </S9>
<S8> <COUGH> because of the pain or something </S8>
<S3> 'cause of that diaphragmatic irritation </S3>
<P:05>
<S10> yeah but but it says here that that <SIGH> with the rea- er real bad situation so ma- maybe if the situation is that bad </S10>
<S1> why is it why would it be that what would make it difficult to breath in pancreatitis </S1>
<S6> i read that necrosity if there is necrosis in pancreas [it can] </S6>
<S10> [ketoacidosis] is </S10>
<S1> no </S1>
<S6> it can be spread in in other tissue also </S6>
<S1> how do you mean </S1>
<S6> i'm not sure if i understood right but <S1> mhm-hm </S1> mhm to the mhm colon mhm to the wall of the colon and and to the peri- peritoneum the <S1> mhm </S1> the necrosis can be spread at , the mhm diaphragma is not [so far from pancreas] </S6>
<S10> [there is (xx) distress] </S10>
<S6> maybe it can go also there i don't know </S6>
<S1> no it usually doesn't diaphragma usually stays with there are problems in that sense but it is true that the er mhm inflammation goes towards colon very easily , what is the problem with the pancreatitis and breathing </S1>
<S7> is it this er when it er goes fur- further is it the pancreatitis causes system system problems <S1> [mhm-hm] </S1> [and] problems in the kidneys and in the lungs </S7>
<S1> yes what kind of problems they are with the lungs </S1>
<S7> i don't i don't know specifically about this i mean </S7>
<S1> does anybody else have idea so there's mhm often plura- pleural of- effusion and also collapsing of the of the (xx) in in the lungs and er sometimes when it's a very bad er multiorgan failure happening they n- er can have the A-R-D-S problems so there [have been] </S1>
<S6> [i don't understand] A- [R-D-S] </S6>
<S1> [A-R] -D-S <FOREIGN> keuhko </FOREIGN> </S1>
<S6> mhm-hm </S6>
<S3> adult respiratory distress syndrome <S6> uh-huh thanks </S6> was it yeah <S1> yeah yeah </S1> yeah </S3>
<S1> sorry i didn't @understand you@ [i didn't get the] </S1>
<S6> [i didn't] know <S1> [okay] </S1> [yes] mhm </S6>
<S1> it's okay keep your eye er ears open then when you have a lung diseases coming </S1>
<S6> alright </S6>
<S3> and how er well , i'm stupid again but the pleural effusion er , er i don't know the mechanism of that is it 'cause of the plasma changes in plasma concentrations or er i- is there effusion v- via the va- vasculature or </S3>
<S1> i should to try to find this er for the next time </S1>
<S6> they're (xx) problems </S6>
<S1> yeah maybe <S6> [it's here] </S6> [the (xx)] problem </S1>
<S6> er because of the capular <COUGH> er , problems erm the wall capular goes mhm broken and when the , in- inflammatory enzymes and and cytocines </S6>
<S3> oh yeah and the extravasation <S6> yeah </S6> after al- the w- whole body extravasation and the mhm mhm explaining the ab- . er peritonal changes and hypovolemia <S6> yeah </S6> erm </S3>
<S10> could you repeat the (xx) one </S10>
<S3> bleeding to the third space and </S3>
<S7> it's it's the damage in the endothelium of the capulars </S7>
<S10> locally a- and what other </S10>
<S7> sys- [systemic] </S7>
<S6> [systemic] @@ </S6>
<S10> i- it it it becomes systemic <S6> yeah </S6> after [the] </S10>
<S3> [ascites] and all those oedema </S3>
<P:09>
<S9> well then diagnostics <P:08> that means there are some laboratory tests , er taken from urine its trypsinogen and was there something else </S9>
<S7> this wasn't this trypsinogen , that er it was good for this kind of screening or something that it's not very specific but , but quite good in some cases . there was also abot- about this amylase in the , blood that it had a sensitivity of over 90 per cent if it's taken like <SIGH> in 48 hours of the beginning of the disease in acute pancreatitis and it goes down after two days </S7>
<S3> in three or fours four days it's normal then </S3>
<S7> even though the di- disease is going </S7>
<S3> was there also the r- mhm ratio of amylases depending on the , origin like S and P [amylase] </S3>
<S2> [mhm yes] pancreatic er iso-enzyme </S2>
<S3> yeah so that ratio of those , was also possible to measure but i don't know . perhaps the , history of the patient combined with the alcohol abuse </S3>
<S2> there is also lipase lipase <S3> yeah </S3> that is more specific for pancrea for pancreas than er amylases </S2>
<S3> is lip- er lipase used <S2> mhm </S2> in finland </S3>
<S2> i i don't know anybody here [(xx)] </S2>
<S1> [not as much no] <SOMEONE LOOKS INTO THE ROOM, SAYS SORRY> it it could very well be but at the moment i guess this is not used as much it's more expensive than (implase) it doesn't really give that huge advantage , <COUGH> trypsin would probably be the best </S1>
<S6> trypsin </S6>
<S1> yeah but that's maitl- <S6> [inviral] </S6> [mainly for] the research yeah <S6> yeah </S6> mainly for the research work we use you don't have to remember that </S1>
<S9> are there any radiological methods </S9>
<S6> yeah (xx) tromo- tomography it's the the best according to this </S6>
<S7> it's after when there has been a few days of the beginning of the symptoms </S7>
<S10> but of course we must take the nat- native pictures plain and radiant </S10>
<S3> wasn't it so that in in the native , x-ray you could perhaps see the chronic pancreatitis with the calcifications and <S10> yeah </S10> perhaps </S3>
<S10> and and you can make a distinctions distinction between pancreatitis and something else </S10>
<S3> something [else] </S3>
<S10> [because] that's not so [(it's obvious)] </S10>
<S7> [it it] it it was important to distinguish this er pancreatitis which is caused by er gall stones , because it needs to be treated like immediately , and . it was said said here that er with the ultrasound you can check if there's stones in the gallbladder and then that could give indications whether there are stones in the ducts also , and then there if there's these liver laboratory values and , er if they're high then <SIGH> in er they do this colonography and if it's not available then this ERC- ERCP </S7>
<P:09>
<S3> and er er while giving the ERCP perhaps also sphincter (xx) and removing of the stones </S3>
<S7> yeah </S7>
<S9> so treatment of of mild pancreatitis </S9>
<S6> <COUGH> the , first important is the <COUGH> fluid mhm giving fluid to the patient mhm it was huge amoun- amount i i read it (xx) this is about seven litres what you you give for him in in the first day during the first day can it be true </S6>
<S3> eight to 12 i've heard </S3>
<S7> that's er the this about seven litres erm about normal sized adult <S6> yeah </S6> if you're a little bit bigger then you need <S6> [even more] </S6> [a lot lot] [even more] <S3> [yeah] yeah </S3> lots of more </S7>
<S6> it it is it true </S6>
<S1> mhm-hm yeah from six to if it's severe if it's mild then you well you obviously then monitor how how the urinating goes and you just don't pump er liquids in if it doesn't come out at all <SU> @@ </SU> then you have to think , think wha- how to do it but basically yes </S1>
<S6> but it wasn't explained here why why so m- much </S6>
<S1> it's er there's a shock kidney situation that happens we could actually study that (xx) , an important issue , part of this multiorgan failure </S1>
<S6> mhm-hm </S6>
<P:06>
<S7> it's important to start this this treatment even before the diagnosis ist- is , certain </S7>
<P:12>
<S9> so when is operative treatment an option or is it an option </S9>
<S6> yes it is especially when the necrosis is mhm bacterial </S6>
<S7> or if the necrosis is s- spread wide but there is also this , official treatment for the for the gall stones </S7>
<S6> the mhm operation was quite , tough @@ er did you did you have a look at the pictures here if <SU> mhm </SU> they ye- may even left a leave the <COUGH> wound open , to to clear it every day [to to] </S6>
<S3> [this was in bacterial] <S6> [yeah yeah] </S6> [pancreatitis yeah] mhm sure </S3>
<P:08>
<S7> erm about this conservative treatment besides these fluids there's also antibiotics . which are . i think this is ciprofloxacin and metronidazole which are . <SIC> combinated </SIC> and also if there's more severe case than this imipenem <S6> cilastatin </S6> treatment . no it was also said that , that <SIGH> cephalosporins can also treat some way </S7>
<S1> what do the antibiotics help , wha- what's their function pan- in pancreatitis why why use and when use cephalosporins when use imipenem cilastatin </S1>
<S3> was it so that er in aseptic pancreatitis you you can try to prevent it from getting like bacterial , a pancreatitis so it might compli- <FOREIGN> @komplisoitua@ </FOREIGN> </S3>
<S1> be complicated </S1>
<S3> @be complicated yeah@ er , from the mhm like in- in- inflammatory pancreatitis to infectuous pancreatitis </S3>
<S1> er er that's exactly if it's for prophylactic use what is the <COUGH> what kind of sterile pancreatitis you would treat with the antibiotics </S1>
<P:07>
<S6> i think every time they're in there is necrosis and it it lasts <S1> yeah </S1> more than few days </S6>
<SU> mhm </SU>
<S1> well there's necrosis <S6> yeah </S6> or strong suspicion for it </S1>
<S6> [because] </S6>
<S1> [and] the CRP value is very high over [150] </S1>
<S6> [yeah] it was <COUGH> told here that mhm when time goes the risks er to that mhm necrosis to be bacterial inflammation mhm it goes it rise rises , during the time , i i thought i think it's 70 per cent or something after two weeks or something , i don't remember exactly </S6>
<S1> so when would you use imipenem and when would you use cephalosporins </S1>
<P:23>
<S2> in biliar pancreatitis we use er cephalosporins <S1> mhm </S1> in biliar er pancreatitis </S2>
<S1> yeah <S2> [(xx)] </S2> [that can] be one one idea when you think that there's cholangitis and <S2> [mhm] </S2> [no] er and that's what you're aiming for then you can use cephalosporins , but if you just think about pancreas tissue when when would you think that it would be necessary that you use cephalosporins and or when when would be that when that would be enough and , what's the [use of imini- imipenem] </S1>
<S7> [there's there's the- there] is nothing more here than this that if there is , er mhm intensive care or and and the <SIGH> a a danger for a sepsis <S1> yeah </S1> then er , there's been some use with this er cefuroxim treatment </S7>
<S1> was it the lecture i told you this there </S1>
<P:05>
<SU> well @actually@ @@ </SU>
<SU> @we're just@ </SU>
<SS> @@ </SS>
<S1> er the uh main thing er ideological background for the antibiotic treatment is that since the aim is trying to prevent the necrosis to be infected then we have to use antibiotics that goes into the pancreatic tissue it's no use if the if the er antibiotics doesn't go into the pancreatic tissue so if we wanna er prevent the infec- er er the infection of the pancreatic necrosis then we have to use imipenem which goes into the pancreas tissue but the cephalosporins goes very poorly to the pancreas and if we would just wanna pru- prevent er (xx) sepsises or something like that then we can use cephalosporins , but we don't really treat the or or aim to the pancreatic pancreas then </S1>
<P:12>
<S9> what is the prognosis of this pancreatitis does it even have numbers </S9>
<S7> er the total mortality was only from from two to three per cent , but <P:06> there was this er er was that er in conservative treatment er two thirds of the patients get complications , with er for example bleeding in the in the G-I tract or obstructions or . this kind of things also there was diabetes that wa- was one of the complications and then . if the patient have has a this multiorgan organ er damage over 80 per cent of them die <P:07> and if you're like under 70 years old old and no system system damag- damages and other there was only ten per cent mortality </S7>
<P:10>
<S10> there was something mild pancreatitis is good er they're treated conservatively but necrotiti- necrotise- s- necrotisi- -sising pancreatitis er the outcome is not that bad erm because (xx) mortality i'm just repeating @what you said@ . erm in necrotising pancrea if you have necrotising pancreatitis you should be taken to university hospit- hospital <P:08> to a unit er that have that has this a specialised , this uh er that that they have possibility to for for intensive care if needed . i don't know whether these are taken to intensive care imi- immediately but . this fluid resuscitation suggest that they should be taken to intensive care unit are they taken to intensive care [unit] </S10>
<S3> [well] i think er that first you can first like see how how the , how how the pancreatitis pro- progresses and start the fluid resuscitation air to control lev- lab lab value CRP and so on and in a total clinical picture of it er but then i don't know if it worsens in er 24 hours i don't know maybe then , s- send further </S3>
<S10> because i think always when you give that much extra fluid you must consult the specialist @@ </S10>
<S3> at least in </S3>
<S10> anaesthesiologist </S10>
<S3> at least in hatanpää they are treared treated there the mild ones and i don't know </S3>
<S10> they have their own anaesthesiologist there </S10>
<S3> yeah but i don't ner- know where you need anaesthesiologist in there surgeons treat them , deal the with the fluid resuscitation and , i don't know what's the truth then </S3>
<S1> yeah there's some <SIGH> well you just would have to know which ones are going to be the severe ones and which ones not , @and er@ and er basically most of the especially the first pancreatitis epis- er mhm the patients who have their first acute pancreatitis episode are referred here since there's a possibility for the I-C-U treatment but b- but er if they have like a several recurring attacks and and and don't usually have them very severe then in those cases it's okay to tre- er treat those patients in a in a small hospitals and refer them then in just in case either or in in the case of , the disease getting more severe </S1>
<P:05>
<S9> okay then we're moving on to chronic pancreatitis is there a definition for the disease , does it mean that if you have two acute periods then is it chronic or does chronic mean that if if the inflammation goes on for two years is there a definition </S9>
<P:08>
<S1> if you don't know the answer now i can con- @consult you in a little bit@ nobody really knows [@@] </S1>
<S9> [yeah we know] </S9>
<SS> @@ </SS>
<S1> but that's a very good @question@ i was smiling here about that if somebody of you know knew then it would be very good thing <SS> [@@] </SS> [@@] but you can say what's the hype- er the most er er <SIGH> well the hypothesis that it's that is getting most , er er most er favoured now <P:12> why did you bring this u- up er where did you find the question </S1>
<S9> it was an impulse </S9>
<SS> [@@] </SS>
<S1> [@@] no i'm sure that kind of impulse doesn't really happen @@ because it's a very very er widely spoken question </S1>
<P:05>
<S9> well you better believe it [@@] </S9>
<SS> [@@] </SS>
<S1> okay </S1>
<S3> well this is er well aren't there like possible to have exacerbations of the like chronic stage and then it might worsen and then like (malign) up again <S1> mhm-hm </S1> but er er how it was mhm like diagnosed the whole process that it's chronic was there , i don't know because the amylase (labs) er don't they like normalise in those couple of days and then but there was some . i think you know <SS> @@ </SS> some some lab result that is constantly bit changed </S3>
<SU> help </SU>
<SS> [@@] </SS>
<SU-2> [(xx) some help] </SU-2>
<S10> diabetes . high blood sugar <SS> @@ </SS> because of [(xx)] </S10>
<S3> [yeah yeah er] the death mhm death of the acinar cells of the pancreatic tissue , and then also glucagon , concentrations </S3>
<S10> but that's not as important as insulin </S10>
<S3> why not well of course it's mhm because there are multiple factors that affect mhm sort of like glucagon but <S10> mhm </S10> well </S3>
<S10> and there is nothing else </S10>
<S3> i'd miss my [alpha cells] </S3>
<S10> [like] insulin [but if if @@] </S10>
<SS> [@@] </SS>
<S3> yeah there's nothing like insulin but i i'd i would really miss my alpha cells [well] </S3>
<SS> [@@] </SS>
<S1> we hope you won't will never @get pancreatitis@ [@@] </S1>
<SS> [@@] </SS>
<S3> i hope too </S3>
<S5> how does CRP , change in if you have a chronic pancreatitis </S5>
<S1> how do you mean </S1>
<S5> like does it stay in higher level or <S1> [(xx)] </S1> [is it only] acute </S5>
<S1> well basically well the hypothesis of the path of genesis of chronic pancreatitis what is thought now is that there's this necrosis fibrosis er er thinking behind it that from the ac- er er repeated acute bursts there starts to be this scarring tissue so much in the pancreas that it's er it's er that there is starting to develop a chronic pancreatitis after that and er , then but there er with all patients' history it's not the same some have already chronic pe- er pancreatitis and had never had an acute burst but er then in a chronic pancreatitis you han- can have these acute bursts every now and again and er the CRP value usually is elevated when those acute bursts happen but sometimes it can be a little not probably well it depends what a- act- activity there is in a in the inflammation sometimes it can be all normal even though there's chronic pancreatitis but i guess in those cases we would start call it er calling the problem as more of a pancreatic insufficiency and that's what i think what you were implying to </S1>
<S3> was there also like er the change in faeces like the excretion of more , well @@ fatty faeces and almost </S3>
<S10> (xx) i don't [know what the prognosis (xx)] </S10>
<S3> [(xx) and] <SS> @@ </SS> and then , well , er changes in cholesterol values and something like that i don't know </S3>
<S5> maybe last point </S5>
<S10> i think that first first mark is that blood cholesterol is very low </S10>
<S3> yeah @@ <SS> @@ </SS> @like@ decide whether you have hypercholesterolemia or chronic prancea- pancreatitis it's an option you could mhm put a add in the paper and i i'd like to change my , okay i'll shut up </S3>
<S9> so what are the long-term complications of chronic pancreatitis </S9>
<S3> a death </S3>
<S9> okay <SS> [@@] </SS> [@@] that's warm </S9>
<S10> diabetes <S9> yeah </S9> , low [cholest-] </S10>
<S6> [why] </S6>
<S10> blood cholesterol </S10>
<S6> why didn't (xx) sort of sick patient </S6>
<S9> which (xx) </S9>
<S6> A-D-E and mhm <S8> K </S8> K K </S6>
<S8> and maybe (xx) </S8>
<SU> yeah okay </SU>
<S9> so how to treat these patients </S9>
<S8> no alcohol </S8>
<SS> [@@] </SS>
<S9> [okay] </S9>
<S10> what what about the cancer , i think , i have an idea that if if you got inflammation somewhere @@ then sooner or [later i think you're in a risk] </S10>
<S3> [yeah isn't there a clear] clear , <S10> [(xx)] </S10> [connection between] pancreatitis and <S10> yeah </S10> pancreatic cancer </S3>
<S10> yeah chronic [pancreatitis and cancer] </S10>
<S3> [was it yeah] wasn't there er first year when we've studied that . bloody pancreatic cancer , (xx) </S3>
<P:11>
<S5> well and . the part of the conservative treatment is it's small . er amount of fluid they give you divide your fluids into smaller amounts (xx) which helps for the pain and the (pancric) diarrhoea and </S5>
<S3> as i i read somewhere that you you might al- also well perhaps it's mhm p- might might be a little over-exaggeration but like total parenteral nutrition for a couple of weeks almost , it sounds pretty awful but pre- perhaps in the necrotising pancreata- -titis and the I-C-U patients it might be . necessary i don't know <P:05> but then again in this finnish , finnish text it said that the enteral nutrition could ease ease the mhm , <SIGH> ease the mhm symptoms in acute pancreatitis but i don't know , maybe in small doses it's okay </S3>
<S9> was it so that the invasive treatment focuses mainly on relieving pain , and well , well then you @@ what is the other option <S10> [(xx)] </S10> [(xx)] @okay@ @@ mhm </S9>
<S10> er the treating the diabetes if you get it er divide the insulin to small amounts to avoid the hypoglycemia , and er avoid fat only 20 to 30 per cent of energy should come from fat , but that (xx) [<COUGH>] </S10>
<S5> [then you should] er not eat a lot of fibre </S5>
<P:05>
<S9> should or shouldn't </S9>
<S5> shouldn't </S5>
<S10> yeah it shouldn't contain fibre that that <S5> yeah </S5> that doesn't (xx) er because fibres inhibit pancreatic (xx) , and ener- energy should come from carbohydrates mainly </S10>
<P:05>
<S9> [this is] </S9>
<S5> [and not] protein or or do you </S5>
<S10> protein i don't [i don't know] </S10>
<S3> [the less] protein less fat and protein </S3>
<P:08>
<S5> you should eat less protein as well </S5>
<S3> yeah i think </S3>
<S10> that's that's like a normal recommendations but er less fibre that's how i , i interpret this </S10>
<S9> and what is the reason for these diet changes do you want to prevent something with these changes </S9>
<S3> i think 'cause is it's because like er lessen the excretion of pancreatic enzymes trypsinogen and (apellous) lipase </S3>
<S5> and the more fat you consume the worse your erm <S10> [it's that] </S10> [fatty] diarrhoea is </S5>
<S10> [mhm-hm mhm-hm yeah] </S10>
<SS> [@@] </SS>
<S5> yes </S5>
<S3> 'cause i i think it's it's is it so that well if you if the enzymes are excreted more and they activate in the pancreatic tissue it's also causing destruction in the pancreas and necrosis and all the funny things that happen </S3>
<S10> and of course this is individual from case to case you must find the right levels of so maybe someone else has problems er with insulin er someone else has a problem with enzymes i don't know that's a one case @@ <COUGH> but that's all- always in in the pancreas </S10>
<S3> and pain shouldn't be treated with morphine </S3>
<S10> (xx) the right doses of food , just kidding </S10>
<S9> alright then er moving on to kidney stones or is there something someone wishes to contribute @@ . and there was an estimate that in the U-S of A at least ten per cent of population has these urinary stones during their lifetime , er did anyone find what what is the , er , <FOREIGN> koostumus </FOREIGN> @@ </S9>
<S10> constitution </S10>
<S9> okay . [@@] </S9>
<SS> [@@] </SS>
<S10> calcium <SU> erm </SU> <S9> okay </S9> er 75 85 per cent of all stones and then there are compounds that i have no idea er <P:07> cystine stones </S10>
<S2> uric acid </S2>
<S10> yeah uric acid </S10>
<P:06>
<S2> [or mixed] </S2>
<S9> [or what is the] pa- pathology behind stone form </S9>
<S10> <SIGH> if you don't drink enough you must drink water because if you drink i i mean water (xx) if you drink fluids enough you don't get these stones those of you (xx) , two to three litres of water daily </S10>
<P:09>
<S9> do the these people have metabolic changes </S9>
<S10> well in the cystine cystine stones there's an , inherited metabolic disorder but s- it's only one per cent of all stones </S10>
<P:12>
<S9> and apparently there are conditions when , there is <FINNISH PRONUNCIATION> hypercalciuria </FINNISH PRONUNCIATION> , and </S9>
<S1> do you understand </S1>
<S2> mhm no @@ </S2>
<S1> please explain in english </S1>
<S9> @@ @okay@ </S9>
<SS> @@ </SS>
<S10> hypercalciuria </S10>
<SS> @@ </SS>
<S2> calciuria i don't understand </S2>
<S1> okay hyper </S1>
<S10> [hyper] </S10>
<S2> [hyper] hypercalciuria </S2>
<S10> yeah well in in finnish <FINNISH PRONUNCIATION> hypercalciuria </FINNISH PRONUNCIATION> </S10>
<SS> [@@] </SS>
<S2> [in italy italy it's <ITALIAN PRONUNCIATION> hypercalciuria </ITALIAN PRONUNCIATION> it's the same] international word <P:05> and then there could be mhm hyperparathyroidism if that is an english @word@ that er cause hypercalciuria </S2>
<P:07>
<S3> wasn't the hyperparathyrosis also one mhm well might be er in the background of pancreatitis also , <S1> mhm-hm [mhm mhm] </S1> [because of that] hypercalcaemia and yeah okay </S3>
<S7> yeah and it worsens the <S3> yeah </S3> pancreatitis also </S7>
<S3> mhm-hm </S3>
<S9> what were these infection stones what is that , they were somehow related to infections </S9>
<S2> proteus </S2>
<S9> is that a bacteria [@@] </S9>
<SS> [@@] </SS>
<S2> [yes @@] klebsiella and pseudomonas can erm prod- they produce urease and so they i think er they rise the PH of urine and may cause er stones </S2>
<P:13>
<S9> what to do with to a patient who has an acute attack of renal stones </S9>
<P:06>
<S2> <COUGH> at first er we treat the pain with er er non-steroid er anti-inflammatory drugs and then we mhm we have to decide er if er let the stone go out by himself if t- he it is er little more than er four or five millimetres less than four five millimetres and if it is er bigger than er six millimetres er we need er an er operation </S2>
<S10> yeah and the anti- (xx) drug must be given intramusculars </S10>
<S2> <COUGH> no er [intravenous] </S2>
<S10> [or I-V] </S10>
<S3> is there a reason why opiates aren't , [suggested] </S3>
<S2> [a reason] </S2>
<S10> er [opiates are] </S10>
<S3> [yeah 'cause like] er i have the , er well well er i think the pain might be so severe that NSH <S10> yeah </S10> don't well they aren't effective enough </S3>
<S10> that's a good question </S10>
<S3> 'cause well , comes thing- mhm perhaps almost well i don't know opiates might be the effective ones the fast ones </S3>
<S9> it has something to do with the a prostaglandin secretion i i think prostaglandins contract yeah the muscles <S3> [ah okay] </S3> [if if if] if the stone is in the urethra so it could release the constriction </S9>
<S3> that was a </S3>
<S9> and the pain goes away </S9>
<S3> that was nice to hear yeah okay </S3>
<S9> er teuvo tammela suggested s- that we should use petidine but it says in <FINNISH SPELLING> Y-K-T </FINNISH SPELLING> that you shouldn't use it @@ </S9>
<S3> [okay] </S3>
<S10> [i think] the Y- Y-K-T is not that </S10>
<S3> so who to trust <S10> yeah </S10> and well he is a uro- urologist so i think he knows </S3>
<S10> is t- it says here that patient will be painless within one to two weeks even if the stone doesn't go away </S10>
<S9> [(xx)] </S9>
<S3> [but isn't there then hydro- hydronefrosis] and renal <S10> [yeah] </S10> [necrosis] and <S10> yeah </S10> so </S3>
<S10> exactly </S10>
<SU-5> but [in pain @@] </SU-5>
<S3> [nice nice to be] painless <SS> [@@] </SS> [but] mhm </S3>
<S10> but how come my feet are so swollen </S10>
<S3> [@yeah@ @@] </S3>
<SS> [@@] </SS>
<S9> so how do we er , what is the er radiological method or how do you investigate these stones </S9>
<S10> you mhm er you only see well you see 90 per cents of stones in . in x-ray investigation but you don't see ten per cent </S10>
<S3> but I-V urography with , x-rays over the abdomen , shouldn't the er like obstruction be seen and perhaps the hydronefrosis or pelvic enlargement </S3>
<S10> spiral CT is is taken </S10>
<P:08>
<S9> then can this patient be treated in a health care centre or do we have to , send this patient @away@ </S9>
<S10> but in symptoms , well i don't i don't know whether they are typical but <P:07> i would send him away too <SS> @@ </SS> next (xx) </S10>
<S3> i think 'cause [erm] </S3>
<S8> [let go home] @@ </S8>
<S10> send everyone away </S10>
<S3> @@ out out out go home but . in a health centre is there a possibility like , for hundred one hundred per cent , specificity to [diagnose that] </S3>
<S10> [no yeah] you you should you should <SIGH> take this CT but i don't know how how acute (xx) always are </S10>
<S3> and (xx) </S3>
<S10> if there is nothing else than terrible bain pain in er testicles , and you suspect this renal stone there's nothing else </S10>
<S3> but then can you be sure that it isn't <S10> [yeah] </S10> [testicular] torsion and you have to operate it . so send [away] </S3>
<S10> [but] but if there is no cremaster reflex </S10>
<SS> @@ </SS>
<S9> okay it says here @that@ @@ that you can use an ultrasound and if if the stones is smaller than five millimetres and there is no signs of hydronefrosis and the creatinine is normal then one can treat it in a health care centre but if the stones stone is larger than five millimetres and if the patient has fever or ur- urinary infection or the patient has only one kidney or is pregnant or this is a recovering er re- the patient has had it er the stones before then you send send it to a urologist </S9>
<S3> so in the end if you see a stone there or the radiologist sees please say it's over five mi- five millimetres so we can refer him </S3>
<S1> @@ mhm-hm </S1>
<S9> and the treatment was to drink , lots of water every day and avoid a diet that that contains oxalate or things @@ </S9>
<P:05>
<S3> no more oxalate pizza for you </S3>
<SS> @@ </SS>
<S9> yeah i'm tired of this should we move on </S9>
<S5> i have a question that er isn't @@ very important one but er a friend of mine er a man near in his thirties had a renal s- renal stones and he was told that the pain that the man experiences then is the nearest thing to what a woman experiences during deliver </S5>
<S1> yeah that's often said it's the the urinary st- urinary tract stones are very painful <S5> yeah </S5> or can be they are not all the time painful but they can be very painful </S1>
<S5> okay </S5>
<S3> so if a man is having renal stones can can we put him like an epidural </S3>
<SS> [@@] </SS>
<S1> [@@ yeah you could do that @@] it probably would take care of the pain (very well) i think the chairman job was done very well </S1>
<S3> [yeah me too] </S3>
<S1> [yes it has been] done several times past now you really got the idea of it , how to go through these different topics </S1>
<S10> yeah this was good </S10>
<S2> who's the chairman </S2>
<S1> he was now but </S1>
<S3> who's now </S3>
<S1> who wants these </S1>
<S5> <FOREIGN> ooks sää parempi tänään </FOREIGN> </S5>
<S7> <FOREIGN> minä olin viimeeks sihteeri </FOREIGN> </S7>
<S5> <NAME S2> and <NAME S6> here </S5>
<S3> congratulations </S3>
<S1> do you wanna be a secretary or a chairman </S1>
<S2> what do you prefer </S2>
<S3> <NAME S2> was last time chairman i think </S3>
<S2> mhm-hm maybe it's better [the secretary] </S2>
<S3> [wasn't this] </S3>
<S1> you wanna use that yellow text first @@ please </S1>
<P:05>
<SS> <CONVERSATION IN FINNISH P:08> </SS>
<S8> you gave us er additional information [already they were give them back] </S8>
<S1> [oh please take them give them back @@] </S1>
<SS> [@@] </SS>
<S9> [close your eyes close your eyes] </S9>
<S1> how did that happen <SS> [@@] </SS> [@@] oh yeah there's one the extra , well thank you </S1>
<EVERYONE READING SILENTLY, P:60>
<S1> sorry i need to give you a time frame my next teaching starts at one </S1>
<S8> and i should go too is it <S1> [mhm] </S1> [okay] i should go too also </S8>
<S1> okay </S1>
<S6> i know he is a manager does it mean at sport manager </S6>
<BS4> no probably a business manager </BS4>
<S6> when he's sport manager maybe he uses also himself er steroids </S6>
<SS> [@@] </SS>
<S10> [i don't think it's so] </S10>
<BS4> jumped into [conclusions there] </BS4>
<SU> [@why@ @@] but maybe he's a bodybuilder because he's so </SU>
<S8> bodybuilder </S8>
<SU> @@ </SU>
<S6> it's all sheer muscle the <SS> [@@ yeah] </SS> [25 kilograms] it's usually men when they gain weight <S8> @yeah@ [that's true] </S8> [and muscles] </S6>
<S3> sure </S3>
<S8> in recent years </S8>
<S3> yeah 50 [years old] </S3>
<S8> [two years] </S8>
<S3> yeah </S3>
<SS> @@ </SS>
<P:08>
<S3> hepatitis A </S3>
<BS4> mhm-hm </BS4>
<P:06>
<S6> why not B </S6>
<S3> @or@ C after all like </S3>
<S6> maybe he uses intravenous steroids <SS> @@ </SS> [@okay@] </S6>
<S3> [okay] we got on this road then yeah </S3>
<SS> @@ </SS>
<S8> he's 50 year old </S8>
<SS> @@ </SS>
<S6> maybe A [A B C and] </S6>
<S8> [@he wanna be@] </S8>
<SU> everything </SU>
<S5> okay </S5>
<S3> it said they taken gamma glutamyl transferase <SIC> alzo </SIC> also so is there something in in his habitus that that says that he drinks more than he admits two three beers are they like one litre of beer or </S3>
<S6> every day [but] </S6>
<S5> [plus] one litre of wine at dinner </S5>
<S3> [yeah] </S3>
<S6> [(it's okay)] but can gamma-GT rise , from other reasons </S6>
<S3> wasn't there that </S3>
<S2> [biliar biliar reasons cholestasis] </S2>
<S3> [also yeah there are biliar reasons yes] </S3>
<S6> yeah [and maybe] </S6>
<S2> [but he] has not er icterus </S2>
<S3> yeah and there's well okay there's no bilirubin measured but the alkaline phosphatase well it's normal okay mhm okay </S3>
<INAUDIBLE TALK IN FINNISH, P:20>
<S6> do you you can get also fatty liver even er when you gain weight and when you eat eat badly </S6>
<S5> at least aquarium fish get fatty liver @so@ if you feed them too much </S5>
<SU> who </SU>
<S5> fish in a fish tank in a aquarium </S5>
<SS> @@ </SS>
<S5> i have read that @somewhere@ <SS> @@ </SS> they don't get fat they don't procreate it just causes them fatty liver i don't know <SU> mhm-hm </SU> oh sorry </S5>
<P:07>
<S10> causes overweight also gives er higher values of A-L-T , but maybe not that high </S10>
<P:12>
<BS4> his mother has diabetes should we take this into consideration [(xx)] </BS4>
<S3> [so is there panc-] some kind of pancreatic factor (or issue) [(xx)] </S3>
<BS4> [mhm-hm] (xx) </BS4>
<S2> what </S2>
<S3> <WHISPERING> nothing </WHISPERING> </S3>
<SS> @@ </SS>
<S5> <FOREIGN> hyi </FOREIGN> </S5>
<BS4> take responsibility for your own actions </BS4>
<S3> i said nothing <P:06> at least when the KGB is listening </S3>
<SS> @@ </SS>
<S6> what does this [meta-] </S6>
<S1> [can you] do this today or @should we pick another day for this@ </S1>
<S6> what does this metabolic symptom (grow) , can it cause also , higher , le- lever liver mhm levels <P:07> everybody knows </S6>
<S3> you mean the me- metabolic syndrome <S6> yeah </S6> well er didn't <NAME S10> just say that that mhm well overweight can cause elevated enzymes wasn't it so </S3>
<S10> yeah <S3> [yeah] </S3> [elevated] A-L-T but i don't know <SIGH> if if it can be that high <SU> [yeah] </SU> [without] any other reasons (xx) , there must be a combination of , something else and overweight and that something else </S10>
<S6> maybe diabetes </S6>
<S10> is quite clearly could be alcohol he was so . i would ask him to fill in the audit test </S10>
<S6> but i believe that er he's not alcohol abuser that he drinks only </S6>
<S10> you can believe @what you want@ </S10>
<S3> [yeah] </S3>
<S5> [to trust] the patient or not to trust the @patient@ </S5>
<S6> [good good but] </S6>
<S10> [but but] we we al- we always must <SIC> intervent </SIC> er and ask about alcohol is it it's not a matter of what we believe </S10>
<S7> but what was this this er lab test test this CDT or [CD-] </S7>
<S3> [CDT] it can be yeah [carbohydrate] </S3>
<S7> [it is more] specific for this alcohol <S3> [yeah] </S3> [abuse] that can give [give some hint] </S7>
<S10> [was that] CDT </S10>
<S7> yeah <S1> mhm </S1> , but but i think also that you should take these <S3> [(xx)] </S3> [antibodies] for for [hepatitis or] </S7>
<S10> [hepatitis A] hepatitis er what about you you're italian is is there A hepatitis </S10>
<S2> mhm yes er </S2>
<S10> there's also A [hepatitis in finland] </S10>
<S2> [but A is acute] </S2>
<BS4> pardon </BS4>
<S2> A A hepatitis is acute [and] </S2>
<S10> [it's more] er more acute </S10>
<S2> but there is er if you eat er mussels er or something from the sea maybe could be and also hepatitis C is er spread but er if er he hasn't got er transfusion i don't think it's the C </S2>
<S10> yeah </S10>
<S3> [there was a] </S3>
<S5> [you can] get hepatitis A in finland </S5>
<S10> but that's ex- excluded too because one year ago it was </S10>
<S7> but but you can <S5> <FOREIGN> [ai] </FOREIGN> </S5> [it] was said already for like two times that you can get this hepatitis A also in finland </S7>
<BS4> it's everywhere it's not just in the other countries finland isn't safe </BS4>
<S10> isn't it so @@ i thought [that it was safe] </S10>
<S3> [it's it's just] marketed the way if you travel to mediterranean so you should always get the but it's not (even true) . but are these like acute changes or , more chronic </S3>
<S6> we can't know it i think </S6>
<S3> he has had no surgery so there's no operation with the gallbladder or so on concerning liver that might , but also some sort of malignant disease perhaps </S3>
<P:08>
<S10> yeah it could be </S10>
<S3> although weight gain might not fit into the but perhaps , some kind of malignant [disease with with met- metabolic] </S3>
<S10> [it it can be yeah] liver metastase to the liver <SIGH> and er that's the bad situation the , so that's why you should exclude the alcohol </S10>
<S3> (and why not) </S3>
<S10> but but what about this ESR it's three only three </S10>
<S3> it's only three so </S3>
<S10> in malignancies you you don't see you don't really see the </S10>
<S3> is well the case we tal- [talked about before] </S3>
<S5> [yeah we talked about it earlier] </S5>
<S3> it's not always elevated the ESR ESR </S3>
<S10> what about CRP </S10>
<S3> and it was even worse in in cases of malignancies wasn't it it [well] </S3>
<S5> [doesn't] help [(xx)] </S5>
<S3> [they aren't] that specific <S5> mhm </S5> with malignan- malignancies wasn't it so </S3>
<S5> yeah </S5>
<S10> the ultrasound of liver </S10>
<S3> ultrasound yeah </S3>
<S10> it must be done </S10>
<S6> do we have to do it if we find that he has hepatitis A do we have to still do the ultrasound </S6>
<S10> <SIGH> </S10>
<S3> well the radiologist needs a job too so </S3>
<SS> @@ </SS>
<S10> and they will call you an ask what did you have on mind </S10>
<SS> @@ </SS>
<P:13>
<S6> what would we do if he had hepatitis A </S6>
<S3> @remove the liver@ </S3>
<S5> isolate him </S5>
<SS> @@ </SS>
<S2> treat </S2>
<S5> couldn't we isolate him and <SU> [isolate] </SU> [him to a] to a <S3> mhm yeah </S3> to a room by himself </S5>
<SS> @@ </SS>
<S3> to city of turku </S3>
<S5> yeah [that would be a good option] </S5>
<S3> [send him @away@] </S3>
<S5> but no in a in a hospital you put him in his own room would you </S5>
<S2> no <S5> no </S5> i don't think so </S2>
<S3> no </S3>
<S2> no no @@ </S2>
<S5> fine </S5>
<SS> [@@] </SS>
<S3> [okay we can try if you want] </S3>
<S2> and which are the way of transmission of er hepatitis A , i don't know is necessary to isolate the patient </S2>
<S6> and i think it can be treated also oup- as outpatient </S6>
<S10> yes </S10>
<S3> yeah yeah sure </S3>
<S7> mhm-hm depending on the [severity] </S7>
<S3> [yeah] severity of course [it is] </S3>
<S6> [yeah but] he's not so sick </S6>
<SU> yes yeah </SU>
<S10> and if you have written prescription [to the (xx)] </S10>
<S3> [okay she is laughing] i want to </S3>
<S1> no í'm not <S3> [yeah] </S3> <SS> [@@] </SS> [@@] @i think it this is good conversations@ </S1>
<BS4> they're holding back information <S3> yeah </S3> [we'll need to] </BS4>
<S1> [well obviously] [they've had (much too much)] </S1>
<S3> <BANGING ON TABLE> [we want to know] </S3>
<S1> that's [what i should do @@] </S1>
<S6> [hardcore] we want more </S6>
<SS> @@ </SS>
<BS4> you're supposed to participate like everybody else </BS4>
<S1> @no no i've been told to to be quiet@ </S1>
<SS> @@ </SS>
<S3> who said that </S3>
<S1> the tutor guides @@ </S1>
<S3> oh they don't they know nothing </S3>
<BS4> we'll get them (xx) let's get them <SS> @@ </SS> so what are we doing we're checking for hepatitis er and the ultrasound anything else </BS4>
<S3> of course the alcohol [anamnesis] </S3>
<BS4> [and the alcohol] </BS4>
<S3> and perhaps CDT too if it's possible . and glucose perhaps because [of this diabetes] </S3>
<BS4> [yeah the dia- yeah] </BS4>
<S3> er er and the basic labs of course </S3>
<S6> and bilirubin </S6>
<S3> and the bilirubin </S3>
<S6> yeah </S6>
<S5> i have another stupid @question@ but when my friend was small she had jaundice and she was put in a closet room in the hospital because it was the only room where she could be alone like the cleaning room </S5>
<BS4> so was it [that] </BS4>
<S3> [perhaps] </S3>
<S5> so why why was she er [(what if we had)] </S5>
<S3> [erm maybe she] was there for other reasons like cuckoo </S3>
<SU> @@ </SU>
<S5> no she had jaundice </S5>
<BS4> maybe she was a bad girl </BS4>
<S6> what was the reason of jaundice </S6>
<S3> [cuckoo] </S3>
<S5> [i can't] remember i should know it okay i said it was a stupid question </S5>
<S1> it's not a stupid question maybe you should @find out@ </S1>
<S5> yeah maybe @i will@ call her <P:08> maybe we should look at the [the secretary has] </S5>
<BS4> [additional information] </BS4>
<S5> oh the additional [information] </S5>
<BS4> [additional information] </BS4>
<S1> yeah it comes after </S1>
<S5> okay </S5>
<S3> (tomorrow okay) </S3>
<S5> after the papers or after </S5>
<S1> yeah </S1>
<S2> so i [have to show] </S2>
<S1> [maybe it's near] </S1>
<BS4> yeah show us </BS4>
<SU> yeah </SU>
<P:06>
<S3> <WHISPERING> show us your (memory). we won't tell anything </WHISPERING> </S3>
<P:08>
<BS4> <WHISPERING> cut the wire @@  </WHISPERING> </BS4>
<S2> mhm so these are are the hypotheses fatty liver diabetes hepatitis malignant diseases and er er sport manager <SS> [@@] </SS> [@that are using steroids@] then er er we have to check er if he abuses mhm alcohol with the CDT but i don't know what (do we said) and then then we have to the check CRP the [antibodies for] </S2>
<S1> [who can tell you] the what's the CDT </S1>
<BS4> [it's a] </BS4>
<S3> [carbohydrate] deficient [transferrous] </S3>
<BS4> [transferrous] </BS4>
<S2> mhm-hm okay because i know mhm transferring <S1> [yeah] </S1> [for] a collision </S2>
<S1> yeah that's [the same yeah] </S1>
<S2> [it's another thing] <BS4> [same] </BS4> [and] er glucose the bilirubin and then we have to do ult- ultrasound and to check the treatment of er hepatitis A and if a patient er has been isolated to the room or not @has to be isolated or not@ </S2>
<SS> @@ mhm </SS>
<S1> can i ask you one thing do you know maybe he has drug abuse background or something do do you take that into consideration </S1>
<S6> yeah </S6>
<S10> drug abuse </S10>
<S1> does he i'm sorry that i missed him </S1>
<S3> for all ten years he has worked as a manager mhm manager of a drug company <SS> @@ </SS> yeah </S3>
<S10> of course you you would get B hepatitis also </S10>
<S7> <COUGH> hepatitis C also </S7>
<S3> mhm [mhm mhm] </S3>
<S5> [actually] </S5>
<S10> B and C i think that B is m- more common with drug users </S10>
<S5> but actually C is also nowadays very common </S5>
<S3> wasn't there like accompanied wh- when er if you get the one you get the other almost <S7> yeah </S7> for sure but [which way was it] </S3>
<S7> [it's here it says] E was always <SIC> combinated </SIC> with </S7>
<S10> B </S10>
<SU> B </SU>
<S10> [E and B is (xx)] </S10>
<S2> [it doesn't want to stay] </S2>
<S3> yeah okay we er we'll do this fast so </S3>
<SU> funny </SU>
<SS> @@ </SS>
<S1> okay i'll give you the additional </S1>
<S2> er alright </S2>
<S6> one guy once asked me do you kna- do you know something about hepatitis C yes i think why <BS4> uh </BS4> i i had once that </S6>
<S3> once [yeah] </S3>
<SS> [@@] </SS>
<S10> yeah , okay </S10>
<S3> that's nice </S3>
<S1> here you go </S1>
<S10> uh-huh </S10>
<S3> thank you </S3>
<EVERYONE READING SILENTLY, P:43>
<S10> quite high cholesterol values , but not heredary hereditary er it must be something wrong with his diet </S10>
<S5> (xx) high cholesterol </S5>
<S10> eating lot of fat [maybe sausage] </S10>
<S6> [it's it's not so high] </S6>
<S10> sausage and <S3> er [sausage] </S3> [just a] couple of beers <SS> @@ </SS> french fries and (xx) </S10>
<S3> so is fat seen as bright in ultrasound </S3>
<S6> what fat seen as bright </S6>
<S3> bright [yes enlarged bright liver] </S3>
<S6> [@@ oh bright @@] </S6>
<P:07>
<S3> it's raining [paper] </S3>
<S10> [low] (xx) </S10>
<P:09>
<S3> [do they] </S3>
<S10> [but] where to take the biopsies (xx) , so if if you don't know where to take the biopsy you shouldn't take the biopsy i think so </S10>
<S3> off the bright part of it @@ </S3>
<S10> the who- whole liver is bright <S3> yeah </S3> do not </S10>
<P:11>
<S6> <COUGH> is is there any information about hepatitis A in this paper </S6>
<P:10>
<S2> mhm what about immunoglobulins <S3> yeah </S3> which er kind of immunoglobulins [were] <S10> [mhm] yes </S10> in general </S2>
<S10> there is no acute neither chronic situation going on I-T-G and I-G-M are (xx) </S10>
<S6> hey i know he has familiar hemochromatose </S6>
<S10> no </S10>
<SS> @@ </SS>
<S2> but the serum iron is normal </S2>
<S10> [serum iron] </S10>
<S6> [i didn't mean] <S2> [and transfe-] </S2> [it doesn't] depend on serum iron </S6>
<S10> i think it does </S10>
<S2> <SIGH> and transferrin saturation also is normal </S2>
<S6> alright </S6>
<P:08>
<S3> [because liver is] </S3>
<S10> [this is no] wonder for of lifestyle </S10>
<S3> yeah because the the liver is quite loose the tissue and then you think i don't know how the ultrasound really shows the tissues but could we think that well okay it's or both are like , soft tissue fat and then that normal liver parenchyma but could be like brighter than normal liver tissue 'cause of the more intensive . reflection or what's that well , i don't know </S3>
<S10> or er maybe he has a fatty liver </S10>
<S3> yeah yeah that that's just what i mhm </S3>
<S10> <SIGH> and and this [is the place] </S10>
<S1> [something i guess] i have to break you up because i have to go but do you wanna do the <SS> yeah mhm </SS> or decide the goals for the next [time] </S1>
<S6> [yeah] we don't know what what what's wrong with this guy </S6>
<S1> @@ </S1>
<S10> but this is the best point . of prevention the other disease er </S10>
<S1> your next <S10> [we we] </S10> [information] will come tomorrow </S1>
<S10> we were talking about NBS , <S6> yeah </S6> and , s- when are we gonna start it <S6> so </S6> now now as a doctors [we should give give him information how to prevent] </S10>
<S6> [(we can conventional) medicine] </S6>
<S5> [everything to do with a liver and its dysfunction] </S5>
<S10> possible [diseases (xx)] </S10>
<BS4> [one at a time please like] listen to three people </BS4>
<S10> in my time </S10>
<S5> liver dysfunction @@ </S5>
<SU> yes </SU>
<S2> [fat-] </S2>
<S10> [fatty] liver </S10>
<S2> fatty liver yeah </S2>
<S5> yeah there is only hundred sides in that book </S5>
<S2> and hemochromatosis </S2>
<SU> [yes] </SU>
<S10> [yes] could could follow </S10>
<S2> hepatitis </S2>
<S3> you're too fast slow down </S3>
<P:10>
<S7> hemo- what was it </S7>
<S3> hemochromatosis </S3>
<P:09>
<S6> and mhm indications for biopsy </S6>
