By: Charles D. Ponte, BS, PharmD, FAADE, FAPhA, FASHP, FCCP, FNAP
A patient presents with cortical thickening and cortical expansion of the bone with sclerotic areas hypertension kidshealth buy lozol with visa. Questions 461 to blood pressure normal yahoo cheap lozol 463 For each description hypertension jnc8 buy lozol 2.5 mg on-line, select the type of lesion with which it is most likely to hypertension 4 stages generic lozol 2.5 mg without prescription be associated. A radiograph shows a circumscribed, densely sclerotic mass limited to the metaphysis of the lower femur. X-ray demonstrates an aggressive lesion with a permeative pattern of bone lysis and periosteal reaction. The knee is held in slight extension and while holding the thigh steady with one hand the tibia is pulled anteriorly with the other hand. The posterior drawer test is used to evaluate for a posterior cruciate ligament injury and is essentially the reverse of the Lachman test with a slightly flexed knee. A “locked knee” occasionally occurs with a displaced meniscal tear and prevents full extension of the knee. Excessive valgus laxity (outward deviation of the leg) is associated with a medial cruciate ligament injury while excessive varus laxity can be seen with a lateral cruciate ligament injury. Debridement requires meticulous removal of all foreign material and resection of all nonviable tissue from the wound to reduce the bacterial count. The wound is aggressively explored because the area of injury is always larger than expected from merely observing the wound. Irrigation with copious amounts of saline is performed with repeat debridements 48 to 72 hours later to assess for further necrosis. Given the significant amount of muscle damage in open fractures, fasciotomies are liberally performed during debridement. Compared to cast and splints, internal or external fixation allows greater access to wound care and is the preferred method of stabilization. The pathogenesis is thought to involve a period of ischemia in the proximal femoral epiphysis followed by revascularization. Plain radiographs show a small and denser-than normal femoral head on the affected side. Slipped capital femoral epiphysis is a disorder involving dissociation between the epiphysis and metaphysis of the proximal femur. The physical examination is most remarkable for limitation of internal rotation of the hip. Developmental dysplasia of the hip involves a spectrum of disorders with differing degrees of instability of the hip and underdevelopment of the acetabulum. The most definitive study to differentiate between the 2 diagnoses is synovial fluid aspiration. In septic arthritis, synovial fluid aspirate demonstrates bacteria and white blood cells with high neutrophils on differential count. A bone scan would target the area of inflammation but not give any information as to the source of the inflammation. It is bounded laterally by the powerful deltoid muscle; superiorly, the acromion process precludes upward dislocation. However, anteriorly and inferiorly the pectoralis major and the long head of the biceps do not completely stabilize the glenohumeral joint; in this region the articular ligaments and joint capsule provide the major structural support. Thus, the joint is not strongly supported in its anteroinferior aspect and consequently anterior (or anteroinferior) dislocations are the most common glenohumeral dislocations. The humeral head is driven anteriorly, which tears the shoulder capsule, detaches the labrum from the glenoid, and produces a compression fracture of the humeral head. Most glenohumeral dislocations result from a posteriorly directed force on an arm that is partially abducted. Posterior dislocation is much rarer and should raise the possibility of a seizure as the precipitating cause. Clinical suspicion and physical examination are important in diagnosis of glenohumeral joint dislocations; diagnosis can be confirmed by radiologic plain films (anteroposterior, scapular lateral, and axillary views). The radial nerve runs in a groove on the posterior aspect of the humerus as it courses into the forearm compartment and is therefore at high risk of injury. If the nerve injury is apparent before any manipulation has been done, the fracture should be reduced; the nerve injury should be observed, since the nerve function will likely improve with time. If the nerve injury is present only after reduction, immediate surgical exploration is warranted because the nerve might be trapped in the fracture site. At this level of the arm, the ulnar and median nerves are well protected by muscle. The posterior interosseous nerve is a distal branch of the radial nerve and may be injured in fractures near the radial head, but it is in no danger from injuries at the level seen in this radiograph. The dorsum of the hand from the radial aspect of the fourth digit over the thumb, including the thenar pad and thumb web, becomes insensate after severance of the radial nerve at the wrist. Radial injuries more proximally would impair extension of the wrist and digits as well as forearm supination. The cast needs to be immediately removed and the upper extremity needs to be thoroughly assessed. If the symptoms do not improve with removal of the splint then surgical decompression with fasciectomy is warranted. Compartment syndromes result from increasing pressures in the fascial compartments. Capillary blood flow is compromised first resulting in loss of oxygen delivery to tissues and increased extremity edema because of increased capillary permeability. Arterial flow is the last to be compromised and therefore pulse changes are a late finding and normal pulses do not rule out a compartment syndrome. Extreme pain (out of proportion to the injury), pain on passive extension of the fingers or toes, pallor of the extremity, motor paralysis, and paresthesias are all components of the syndrome. The diagnosis can be confirmed by measuring intracompartmental pressures, but, whenever physical findings or symptoms are suspicious, the patient should be taken immediately to surgery. Observation, repeated imaging, and elevation would waste precious time and are not appropriate measures for a patient who is suspected of having a compartment syndrome. Surgical fixation, as compared to closed treatment, provides better control of alignment, allows motion of the foot and ankle, and the possibility of earlier weight bearing. Multiple large clinic trials have demonstrated that unreamed nailing strategies have higher incidence of nonunion and malunion as opposed to fracture fixation with reamed cannulated nails. External fixation is most often used in the setting of high energy trauma with significant soft tissue injury, vascular injuries needing repair, and in polytrauma patients as a “damage control” procedure. Plate fixation of tibial fractures is generally reserved for periarticular injuries too proximal or distal for intramedullary nailing. Closed treatment is the method of choice for tibial shaft fractures of minor severity and dislocation. Dislocation of the radial head with a fracture of the proximal third of the ulna is known as Monteggia deformity. It is most often repaired with internal fixation of the ulna with closed reduction of the radial head. Late complications include heterotopic ossification and redislocation of the radial head. Fractures of the navicular (scaphoid) bone of the wrist should be suspected in anyone, particularly a young person, who falls on an outstretched hand. Although x-rays are mandatory, it is important to realize that the fracture may not be seen on the initial x-ray and that a presumptive diagnosis can and should be made on clinical grounds alone. A night stick fracture refers to fractures of the ulnar shaft that result from a direct blow to the ulnar forearm by a club or night stick. Fractures with significant involvement of the glenoid require open reduction and internal fixation. Increased bone turnover in this condition can be determined with an elevated serum alkaline phosphatase level. Osteomalacia is characterized by lower bone turnover than osteitis fibrosa cystica. Osteogenesis imperfecta is a genetically determined disorder in the structure or processing of type I collagen. Osteitis deformans, or Paget disease, is characterized by large abnormal osteoclasts involved in increased bony resorption causing local lysis of bone.
Despite the alcoholism be often associated with a chronic pancreatitis hypertension 140 90 buy lozol with amex, there are several reports of bouts of acute pancreatitis resulting of alcohol abuse prehypertension occurs when purchase 2.5 mg lozol. This could be due to arrhythmia gif purchase lozol with amex the 110 Acute Pancreatitis association of the raised gut permeability with alcohol intake and the concomitant endotoxemia heart attack heartburn purchase 1.5 mg lozol fast delivery. In other view, the pancreatic stellate cells could be activated by the alcohol consumption. The role of these cells in pancreatic injury is similar to the liver injury during alcoholism, with the fibrosis establishment. Thence, the mechanism related to these cells is more evident in the chronic pancreatitis. The molecular mechanism of gallstone – associated pancreatitis seems to be simpler. The pancreatic duct obstruction confine the zymogen and lysosomal granules causing the condensing vacuoles and impeding the acinar exocytosis. Consequently, the trypsinogen is activated to trypsin and triggers the cascade of enzyme activation leading to the pancreatic injury. Pancreatitis induced by hypertriglyceridemia is associated to amylase release and the cell injury due to the free acids released because its detergent properties. Molecular biology of multiple organ failure during acute pancreatitis the local and systemic complications during pancreatitis aggravate the prognostic of the disease. The morbidity and the mortality pancreatitis-associated occur due the systemic inflammation and the multiple organ dysfunctions, mainly lung, liver and kidney. The intra and extra pancreatic events of the acute pancreatitis are responsible by the complexity of the disease. Subsequently, the trypsine activates other enzymes those turn begin to digest the pancreatic tissue, whose content leaks into the abdominal cavity, causing cytokine release, activation of the immune system, coagulation and fibrinolysis. The ascitic fluid released in response to pancreatic inflammation could lead to activation of Kupffer Cells that will produce cytokines and others mediators, such protelytic enzymes, establishing the hepatic inflammation. The lung is often a target of these mediators and the dominant cause of mortality. It has been shown that severe acute pancreatitis correlates with the incidence of hepatic injury. Although the liver is known to be a primary target of cytokines released in pancreatic blood, the liver itself releases inflammatory substances, such as reactive oxygen species, thereby leading to the injury of distant organs. The oxidative stress is important in the early stages of the systemic inflammation that occurs in pancreatitis and the liver is a target of this event. Multiple hepatic cells, including hepatocytes, Kupffer cells, stellate cells, endothelial cells can generate nitric oxide, superoxide, and peroxynitrite. The extracellular matrix degradation could be responsible by the amplification of the inflammatory mediators release and the systemic Molecular Biology of Acute Pancreatitis 111 inflammation (Figure 1). Moreover, the oxidative and nitrative stress are responsible by the alteration in the mitochondrial respiration and the consequent apoptosis induction. The liver is both a source and target of the inflammatory mediators systemically released during pancreas inflammation. These mediators activate several hepatic cells causing oxidative stress, mitochondrial dysfunction and consequently apoptosis and synthesis of inflammatory proteins that will aggravate the involvement of distant organs. Molecular signaling of the oxidative stress Despite the initial cause of pancreatitis, the oxidative stress is the mainly contributing factor to the destruction of the pancreatic tissue. Moreover, the dysbalance redox participates of hepatocellular injury as well as the pulmonary lesion. Among the effects of the pancreatitis in the liver it was demonstrate the reduction of oxygen consume by the mitochondria in animals that received samples of ascitic fluid from rats with acute pancreatitis. Furthermore, lipid peroxidation products are chemotactic and might lead to amplification of the inflammation process. It is known that the Nitric Oxide Synthases exhibit different profiles during the pancreatic inflammation. Recent studies have shown an increase of lipid peroxidation, which indirectly indicates the release of oxidative products, during pancreatitis. Peroxynitrite can exert its toxic effect through the nitration of macromolecules or as a selective oxidant, contributing to either necrosis or apoptosis. The formation of nitrotyrosine is a consequence of peroxynitrite activity, and increased nitrotyrosine levels have been detected in human diseases associated with oxidative stress. There are various ways in which peroxynitrite-induced impairment of endothelial function might contribute to the pathogenesis of organ failure due to circulatory shock: by exacerbating local vasospasm, increasing local neutrophil adhesion, and increasing neutrophil migration into inflamed tissues; by exacerbating platelet activation and aggregation; or by promoting hypoperfusion of certain parts of various organs. During pancreatitis, it was shown that the hepatocytes around the central vein were apparently the most susceptible to aggression. Molecular biology of cell death in acute pancreatitis Acute pancreatitis–associated distant organs injury is mediated by inflammatory cytokines that are produced within tissue resident macrophages. These organs, in turn, participate in the systemic inflammation releasing several inflammatory mediators leading to amplification of the injury of distant organs. The apoptotic cell death may play a considerable role in Molecular Biology of Acute Pancreatitis 113 affecting mortality and morbidity in severe acute pancreatitis. Apoptosis pathway, by death receptors or the mitochondrial pathway, activates the final caspase to cell death. Death Receptors signaling has been associated with apoptosis in several hepatic diseases such as ethanol-induced liver injury and cholestatic liver disease. Apoptosis related to the severe acute pancreatitis injury is known to be triggered through the mitochondrial pathway. Cell death has been seen in both apoptotic and necrotic forms, in clinical as well as experimental acute pancreatitis. Current evidence suggests that the amount and the balance between apoptosis and necrosis influence the severity of acute pancreatitis. There are two apoptotic pathways: the extrinsic pathway is activated by death receptors and is subjected to caspase-8 activation. On the other hand, the pancreatitis can activate directly the caspase-9, which forms a complex with Activator Protease Factor-1 and cytochrome c, priming the mitochondrial pathway. The mitochondria are the determining factor to modulation of cell death during pancreatitis, defining whether the cell death will occur by necrosis or apoptosis. While the necrosis is often observed in severe pancreatitis, apoptosis is more evident in the pancreatitis of medium gravity. Important proteins signaling during acute pancreatitis the family of protein associated to the membrane fusion machinery includes receptors bind to proteins attachment to N-ethylmaleimide-sensitive fusion proteins and donor vesicles. Some isoforms of this multiprotein complex are present in the pancreatic acinar cells where they mediated the granule-granule fusion as well as the membrane-granule fusion. It is important to mention that this basolateral plasma membrane activity is intermediated by protein kinase C family proteins, which are activated by carbachol stimulation. Recently, heat-shock proteins and their cofactors have been revealed associated to apoptotic and necrotic pathways. Heat shock proteins are molecular chaperones that stabilize and refold damaged intercellular proteins, preventing the intracellular protein aggregation and making the cells resistant to stress-induced cell damage. Throughout the neutrophylic invasion, there is the release of enzymes responsible by the tissue digestion, such as metalloproteinases, which in turn could enhance the injury due the release of signaling molecules after the extracellular matrix digestion. These cytokines are released via portal vein and lymph fluid drainage to the circulation. In turn, it occurs the vascular endothelium activation and the leukocyte migration. This event could explain the multiple organ failure often related to the pancreatitis. Molecular biology in the treatment of the acute pancreatitis Currently, the treatment of the acute pancreatitis aims the hemodynamic balance, nutrition, control of the pain and complications. However, the major events in the pancreatitis are: Systemic Inflammatory Response Syndrome, microcirculatory disturb and translocation of bacteria. The water loss could modify the cytoskeleton structure leading to activation of a protein cascade triggering specific gene transcription. Fluid resuscitation is a necessary therapeutic intervention in severe pancreatitis. Patients with pancreatitis present volume extravasation to the peritoneum and retroperitoneum, and some have hemodynamic inestability. However, the infusion of large volumes can induce pulmonary interstitial edema and can increase intra-abdominal pressure.
Glomerulosa—aldosterone (mineralo adrenal cortex and their corticoid) corresponding hormone 2 hypertensive urgency treatment buy 2.5mg lozol. Adrenal Cushing syndrome secondary carcinomas may also require mitotane to heart attack 5 days collections generic lozol 2.5mg on-line adrenal adenomas and therapy blood pressure medication that causes hair loss order lozol pills in toronto, although this is controversial arrhythmia surgery discount lozol amex. What are the most common Prior exogenous glucocorticoids (which causes of adrenal insuf may suppress endogenous adrenocortical ciency The adrenal insuf ciency is mineralocor cortex maintains responsiveness to the ticoid secretion intact What are the clinical Nausea, vomiting, weakness, fatigue, features of adrenal lethargy, weight loss, anorexia, and insuf ciency What is the treatment for Glucocorticoid replacement (with hydro primary adrenal insuf cortisone or similar synthetic glucocorti ciency Juxtaglomerular cells of the glomerular afferent arteriole What are renin stimuli What are the causes of Adrenal adenoma (60%), bilateral adrenal primary aldosteronism What is the preferred treat Unilateral adrenalectomy ment for an aldosterone secreting adrenal adenoma In patients with Ingestion of tyramine-containing foods pheochromocytomas, what (especially in patients taking monoamine may provoke paroxysms of oxidase inhibitors), iodine-containing hypertension How is the diagnosis of Clinical suspicion, demonstration of ele pheochromocytoma made Thyroid hormone is synthesized when 4 iodide molecules combine with 2 tyrosine residues. Chapter 4 / Endocrinology 157 What peptide do the Calcitonin parafollicular cells of the thyroid secrete What is the differential diag Benign colloid nodule (50%–70%), nosis of a solitary thyroid benign adenoma (15%–30%), malignant nodule What are the risk factors for History of external irradiation, male malignancy in a thyroid gender, extremes of age, family history of nodule Most benign and nearly all malignant lesions will be “cold” (hypofunctioning), making differentiation dif cult. What are the causes of Subacute thyroiditis, exogenous thyroid hyperthyroidism associated hormone ingestion (thyrotoxicosis facti with a low radioiodine tia), ectopic thyroid tissue (struma ovarii), uptake Warm, moist, diaphoretic, clubbing of ngers and toes (thyroid acropachy), pretibial myxedema (in Graves disease) Head, ears, eyes, nose, In ltrative ophthalmopathy (in Graves throat Wide pulse pressure, sinus tachycardia, cardiomegaly, high-output heart failure Pulmonary Hyperkinesia, resting tremor, emotional lability, proximal muscle weakness Skeletal What are the indications for To assist in determining the etiology of a thyroid scan What is the gender distribu More women than men are affected, and tion of Graves disease A life-threatening condition manifested by marked increase in the signs and symptoms of hyperthyroidism What factors precipitate Infection, trauma, emergency surgery, thyroid storm Why isn’t potassium iodide Most patients “escape” from its action used for long term When is surgery favored for Usually reserved for patients who fail to hyperthyroidism What are the risks of surgery Hypothyroidism and hypoparathyroidism for hyperthyroidism Hypothyroidism at birth, resulting in developmental abnormalities What is myxedema Severe hypothyroidism with deposition of mucopolysaccharides in the dermis, leading to doughy appearance of the skin What are the causes of Autoimmune disease (Hashimoto’s hypothyroidism A stuporous, potentially fatal state caused by severe hypothyroidism What are the risk factors for Advanced age, exposure to cold, infection, myxedema coma A Marfanoid body habitus develops, as do benign neuromas of the eyelids, lips, tongue, buccal mucosa, intestines, bronchus, and bladder. Which form of calcium is Ionized calcium; therefore, alterations in physiologically active These hormones regulate the activity of osteoclasts, distal renal tubules, and intestinal epithelium. Chapter 4 / Endocrinology 163 What is the calcium cycle of When ionized calcium levels decrease, homeostasis In extreme settings, mithramycin, bisphos phonates (pamidronate, ibandronate, zoledronate), or calcitonin are used. What is the differential Hypoparathyroidism—idiopathic, diagnosis of hypocalcemia Where are the most the distal forearm (Colles fracture), common fractures seen in thoracic and lumbar spine, and proximal osteoporosis What is the incidence of In the United States today, 20–30 million osteopenia and individuals have osteopenia and 10 osteoporosis What is the incidence of Osteoporosis is responsible for more than fracture related to 1. One in 2 women and 1 in 8 men older than 50 years will have an osteoporosis-related fracture in their lifetime. What are the risk factors for Family history (genetic), increasing age, osteoporosis Once peak bone mass is achieved (in the 3rd to 4th decade of life), the formation of new bone lags behind the resorption of old bone, and with each successive remodeling cycle, more bone is lost. D intake, avoidance of smoking and excess alcohol, and avoidance of medica tions such as glucocorticoids (if possible) What strategies are available Hormone replacement (estrogen in for treating osteoporosis A defect in the mineralization of osteoid (bone matrix) in adults (termed “rickets” in children). What are the symptoms and Diffuse bone pain that may be localized signs of osteomalacia A waddling gait is often present, attributable to pelvic deformation and bowing of the long bones of the legs. Thin radiolucent pseu dofractures (Looser zones), which are focal accumulations of nonmineralized osteoid, are a distinguishing feature. Neurologic complications, including deafness, are caused by compres sion of nerves by abnormal bone. How are bone scans helpful They are the most sensitive method to in Paget disease What are the medical treat Bisphosphonates (which reduce bone ments for active and/or resorption and may improve pain and symptomatic Paget disease What is the most common Pregnancy cause of secondary amenorrhea in women aged 15–40 years Excessive growth of androgen-dependent hair Chapter 4 / Endocrinology 169 What is virilization Ovarian androgen excess Testosterone usually results in increased levels of what compound The inability to attain an erection of suf cient rigidity for vaginal penetration What are the common Vascular insuf ciency (either arterial or causes of erectile venous), neuropathic disease. Enlargement of the male breast tissue What are causes of gyneco Can be seen during infancy and adoles mastia What are the physiologic Promotes gluconeogenesis, ketogenesis, actions of glucagon Fasting plasma glucose level between 100 and 125 mg/dL and/or a 2-hour plasma glucose level between 140 and 200 mg/dL after an oral glucose load (75 g) (impaired glucose tolerance); individuals are at an increased risk for progressing to diabetes and are at an increased risk for cardiovascular disease. The higher the percentage of cells with glycated products, the higher the plasma glucose levels over the past 2–3 months. What are the general Younger ages (20 years), Caucasian, thin characteristics of patients body habitus, often no family history of presenting with type diabetes mellitus, usually an abrupt pres 1 diabetes mellitus
A tial oncologic care team to high blood pressure medication toprol xl generic 2.5mg lozol particularly de ne needed stud family cancer syndrome should be particularly suspected ies and intervals of care; rigorous health maintenance arteria hepatica propia purchase lozol with amex, when cancer appears in multiple family members or affects focusing especially on atherosclerosis risk reduction and particularly young individuals (those! Pediatric cancer survivors should addition cancer but should be pursued in conjunction with an estab ally have access to blood pressure chart 40 year old male generic lozol 1.5mg amex multidisciplinary health care resources lished genetics clinic blood pressure medication starting with c order lozol cheap. The same risk factors that led to the rst cancer leave (Continued on page 288) 288 A. In the initial discussions of diagnosis and treatment, receiving chest irradiation or previous potentially potential late consequences of treatment choices cardiotoxic chemotherapy. Genetic counseling and potential follow-up testing and preexisting medical conditions. Particular attention intervention should be offered to selected patients and should be given to reproductive issues, and patients their families with a high-risk context and breast, should be offered the possibility of banking sperm or colon, or ovarian malignancies. As primary cancer therapy is completed, a speci c fol in one individual or groups of primary relatives, those low-up plan designed based on the initial diagnosis and in which cancer presents at an unusually early age treatment should be developed in collaboration be (! Ap should be counseled as to signs or symptoms they proaches are described at Particular design of follow-up must include not only maintenance procedures as appropriate for age, gen appropriate monitoring for relapse of the primary der, and general medical history, but this should in malignancy but also new cancers in the same organ clude particularly vigorous evaluation of and action system and speci c secondary malignancies for which directed toward cardiovascular risk factors, smoking the patient may be at risk based on primary therapy. Patients and families may need lifelong access to psy cancer detection examination in all patients; periodic chosocial counseling and support services. This evaluation should be References conducted in conjunction with the oncology care team. Second cancer following lymphatic and hematopoi etic cancers in Connecticut, 1935–1982. Cancer: Principles and Practice of Oncology, 7th least annually in patients following radiotherapy to ed. Secondary cancers after the neck, reproductive counseling and evaluation, bone marrow transplantation for leukemia or aplastic anemia. However, should con rmation be therapeutic objectives of improved quality of life and needed, this can be safely accomplished with either prolonged survival. Nuclear venography is and symptoms that should be palliated in a timely preferable because of a lower injection volume of con fashion. However, because many such patients may trast, but both are associated with low complication have lung cancer or lymphoma together with a de nite rates. A reassessment of the clinical implications of the superior disorders, in addition to the increasing incidence of vena caval syndrome. Tumors that most commonly affect the spinal cord are of after the diagnosis is established. Myeloma, detected and treated, the better the functional out melanoma, and genitourinary tract tumors less com come. Pain is present in 97% of all there is (1) no histologic diagnosis and cord compres cord compressions, followed in frequency by weakness sion is the presenting sign of cancer, (2) history of (76%) and paresthesias (57%) along a bilateral or unilat radiation therapy to the affected area, (3) neurologic eral dermatomal distribution. Associated bowel and progression of disease despite steroids and radiother bladder dysfunction is seen in 51% of patients with more apy, (4) instability requiring xation, or (5) a high advanced disease. This is a consideration especially in pa signs of spinal cord compression, obtain plain radio tients who are expected to have longer life expectancy graphs of the painful region to rule out neoplastic and are in general good physical condition to tolerate involvement. After surgery, give radiotherapy to nonneoplastic causes (rheumatoid arthritis, aortic aneu avoid recurrences. Initial response to combined sur rysm, spondylosis, herniated disc, spinal tuberculosis, gery and radiation is 20%–100%, depending on tumor osteoarthritis, osteomyelitis). The best prognostic in workup if there is pain with tenderness to percussion dex for eventual recovery of function is pretreatment over the affected vertebral body, bilateral muscle weak status: 60% of patients who are ambulatory at diagno ness in the extremities, sensory changes, loss of deep sis remain so postoperatively, whereas only 7% of tendon re exes, or bowel or bladder incontinence. Myelography is an invasive procedure is not de nitive, adjust pain medications and observe. Direct decompressive surgical lesion and ascertains whether there is more than one resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. If a complete block is found on lumbar myelog 643–638; comment Lancet 2005;366(9486):609–610. Two questions must be asked in the initial evaluation of Saudi Arabia requires that Hajj and Umrah visitors have a traveler: What is the patient’s health status, and a certi cate of vaccination. Variables to consider in ing to areas where rabies is relatively common but the clude countries to be visited, whether travel will be immune globulin and vaccine would not be immedi rural or urban, planned activities, and duration of visit. Japanese encephalitis vac visit their country of origin after living in the United cine may be indicated in some cases for travelers to States are also at risk for endemic infections, some Southeast Asia. The cholera vaccine is currently not times more so because they may not feel the need to recommended. Infections are acquired through exposure to contami deavor, including remaining in screened areas when nated food and water, exposure to vectors, such as ticks possible and using a mosquito net at night, minimizing and mosquitoes, and person-to-person transmission. They should consume only bottled beverages has the advantage of requiring a weekly (rather than and use bottled water for ice cubes and for brushing daily) dose but has the not uncommon downside of teeth, etc. As a result of the emer potential source of infections, such as schistosomiasis and gence of chloroquine resistance, chloroquine prophy leptospirosis. Patients should be cines because these infections have been acquired over given at least a 3-day supply of antibiotics to take with seas. All overseas travelers should be encouraged to be them and instructed to take them in case of moderate vaccinated against hepatitis A, hepatitis B, polio, and to severe diarrhea with fever or pus, mucus, or blood typhoid. If treatment is initiated promptly, even a and tropical South America, and many countries in single dose may reduce the duration of the illness to a these regions require proof of vaccination for entry. Pepto-Bismol taken every 30 minutes for meningitis vaccine is recommended for those traveling eight doses has also been shown to decrease stool fre to areas in the meningitis belt across central Africa, and quency and shorten illness duration. If a patient returns with diarrhea, stool should history) through thick and thin blood smears. If ma be sent for culture (Escherichia coli, Salmonella, Shi laria parasites are seen on smear but no speciation is gella, Campylobacter) and ova and parasite (O&P) possible, treatment should be targeted to Plasmodium three times. Respiratory symptoms may result from falciparum, which is the most virulent species, and viral infections and should be evaluated in much the should be assumed to be drug resistant. Blood cultures for should be more seriously considered in those having typhoid should be obtained (regardless of vaccination been abroad for months or years and an acid-fast bacil status). A partial list of illnesses that can be seen in returning with compatible symptoms and returning from af travelers is provided in the algorithm; when in doubt, fected areas should be reported to local health depart patients should be referred to a specialized travel clinic ments immediately. Once investigation is under way for malaria and the useful websites listed in the references. N Engl rhagic fever, manifesting with plasma leakage, plate J Med 2002;347:505–516. In normal adult hosts "60 years, the most common mended to rule out a mass lesion for patients with focal organisms are Streptococcus pneumoniae, Neisseria neurologic de cits, abnormal level of consciousness, meningitidis, and (more rarely) Haemophilus in uen papilledema, seizure in the past 7 days, or history of zae. These include Cryptococcus neoformans, 30 minutes) in any patient with suspected bacterial Mycobacterium tuberculosis, Staphylococcus species, meningitis. Closed head trauma and basilar skull fractures are temporal lobe abnormalities should be treated empiri linked to infections with S. Intraventricular shunt devices are at high risk of causing the subarachnoid space. The most common organism is Staphylococ administered after antibiotics have already been given. Antibiotics should be administered empirically and diphtheroids, and Propionibacterium acnes are also fre without delay. Blood cultures treated bacterial or fungal meningitis remains a possi will also be positive in 50%–75% of patients with bacte bility. If no bacteria are seen on Gram stain, other organisms elucidate common viral entities that cause meningitis. Empiric antimicrobials should be contin before lumbar puncture in adults with suspected meningitis. N Engl J ued and viral studies, such as enterovirus polymerase Med 2001;345(24):1727–1733. Lymphoma, toxoplasmosis, cysticer signs suggestive of meningeal irritation that have cosis, sarcoidosis, and other lesions can have character been present for at least 4 weeks. An eosinophilic broad (Table 1) and includes infections, malignancies, pleocytosis is seen with cysticercosis after cyst rupture, in ammatory disorders, and iatrogenesis. Head imaging is essential to evaluate for structural tous meningitis; sarcoidosis; connective tissue disor lesions that can cause chronic head pain and menin ders; and infections such as neuroborreliosis, syphilis, geal irritation, such as brain abscesses, tumors, hydro tuberculosis, and Cryptococcus. Chronic meningitis is more common among patients who fungal disease, and malignancy. Abnormalities identi ed are immunocompromised because of their increased sus outside the brain might be more amenable to biopsy ceptibility to infection.
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