Nancy Hutton, M.D.

• Medical Director, Harriet Lane Compassionate Care
• Professor of Pediatrics

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0001938/nancy-hutton

E Women with preexisting diabetes who are planning pregnancy or who have become pregnant should have a comprehensive eye examination and be counseled on the risk of development and/or progression of diabetic retinopathy fungus gnats larvae control generic butenafine 15 gm on line. Eye examination should occur in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum trichophyton fungus definition generic 15gm butenafine free shipping. B Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes fungus nail treatment 15 gm butenafine with visa, with prevalence strongly related to the duration of diabetes fungus around genital area buy 15gm butenafine free shipping. Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20­74 years antifungal dog food buy generic butenafine 15gm on-line. In addition to diabetes duration fungus cerebri butenafine 15gm without prescription, factors that increase the risk of, or are associated with, retinopathy include chronic hyperglycemia (42), nephropathy (43), and hypertension (44). Intensive diabetes management with the goal of achieving near-normoglycemia has been shown in large prospective randomized studies to prevent and/or delay the onset and progression of diabetic retinopathy (11,45). Lowering blood pressure has been shown to decrease retinopathy progression, although tight targets (systolic,120 mmHg) do not impart additional benefit (45). Several case series and a controlled prospective study suggest that pregnancy in type 1 diabetic patients may aggravate retinopathy (46,47). Screening in a population with well-controlled type 2 diabetes, there was essentially no risk of development of significant retinopathy with a 3-year interval after a normal examination (49). Retinal photography, with remote reading by experts, has great potential in areas where qualified eye care professionals are not readily available (50). It also may enhance efficiency and reduce costs when the expertise of ophthalmologists can be used for more complex examinations and for therapy (51). Inperson exams are still necessary when the photos are unacceptable and for follow-up if abnormalities are detected. Photos are not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional. Because retinopathy is estimated to take at least 5 years to develop after the onset of hyperglycemia, patients with type 1 diabetes should have an initial dilated and comprehensive eye examination within 5 years after the diabetes diagnosis (48). Patients with type 2 diabetes who may have had years of undiagnosed diabetes and have a significant risk of prevalent diabetic retinopathy at the time of diagnosis should have an initial dilated and comprehensive eye examination shortly after diagnosis. Examinations should be performed by an ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing diabetic retinopathy. Subsequent examinations for type 1 and type 2 diabetic patients are generally repeated annually. Exams every 2 years may be cost-effective after one or more normal eye exams, and One of the main motivations for screening for diabetic retinopathy is the longestablished efficacy of laser photocoagulation surgery in preventing visual loss. Laser photocoagulation surgery in both trials was beneficial in reducing S62 Position Statement Diabetes Care Volume 38, Supplement 1, January 2015 the risk of further visual loss, but generally not beneficial in reversing already diminished acuity. Other emerging therapies for retinopathy include sustained intravitreal delivery of fluocinolone (55) and the possibility of prevention with fenofibrate (56,57). Specific treatment for the underlying nerve damage, other than improved glycemic control, is currently not available. Major clinical manifestations of diabetic autonomic neuropathy include resting tachycardia, exercise intolerance, orthostatic hypotension, gastroparesis, constipation, erectile dysfunction, sudomotor dysfunction, impaired neurovascular function, and, potentially, autonomic failure in response to hypoglycemia. E the diabetic neuropathies are heterogeneous with diverse clinical manifestations. The early recognition and appropriate management of neuropathy in the patient with diabetes is important for a number of reasons: 1. Nondiabetic neuropathies may be present in patients with diabetes and may be treatable. The most common symptoms are induced by the involvement of small fibers and include pain, dysesthesias (unpleasant abnormal sensations of burning and tingling), and numbness. Clinical tests include assessment of pinprick sensation, vibration threshold using a 128-Hz tuning fork, light touch perception using a 10-g monofilament, and ankle reflexes. In patients with severe or atypical neuropathy, causes other than diabetes should always be considered, such as neurotoxic medications, heavy metal poisoning, alcohol abuse, vitamin B12 deficiency (66), renal disease, chronic inflammatory demyelinating neuropathy, inherited neuropathies, and vasculitis (67). The standard cardiovascular reflex tests (deep breathing, standing, and Valsalva maneuver) are noninvasive, easy to perform, reliable, and reproducible, especially the deep breathing test, and have prognostic value (69). Gastroparesis should be suspected in individuals with erratic glucose control or with upper gastrointestinal symptoms without another identified cause. Evaluation of solidphase gastric emptying using doubleisotope scintigraphy may be done if symptoms are suggestive, but test results often correlate poorly with symptoms. Constipation is the most common lower-gastrointestinal symptom but can alternate with episodes of diarrhea. Genitourinary Tract Disturbances the symptoms and signs of autonomic dysfunction should be elicited carefully during the history and physical Diabetic autonomic neuropathy is also associated with genitourinary tract disturbances. Evaluation of bladder dysfunction should be performed for individuals with diabetes who have recurrent urinary tract infections, pyelonephritis, incontinence, or a palpable bladder. While the evidence is not as strong for type 2 diabetes, some studies have demonstrated a modest slowing of progression (74,75) without reversal of neuronal loss. Several observational studies further suggest that neuropathic symptoms improve not only with optimization of glycemic control but also with the avoidance of extreme blood glucose fluctuations. Diabetic Peripheral Neuropathy Treatment of orthostatic hypotension is challenging. The therapeutic goal is to minimize postural symptoms rather than to restore normotension. Most patients require the use of both pharmacological and nonpharmacological measures. There is limited clinical evidence regarding the most effective treatments for individual patients given the wide range of available medications (77,78). Given the range of partially effective treatment options, a tailored and stepwise pharmacological strategy with careful attention to relative symptom improvement, medication adherence, and medication side effects is recommended to achieve pain reduction and improve quality of life (62). Gastroparesis symptoms may improve with dietary changes and prokinetic agents such as erythromycin. In Europe, metoclopramide use is now restricted to a maximum of 5 days and is no longer indicated for the longterm treatment of gastroparesis. Erectile Dysfunction c c For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. B Patients with insensate feet, foot deformities, and ulcers should have their feet examined at every visit. B A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet. C Treatments for erectile dysfunction may include phosphodiesterase type 5 inhibitors, intracorporeal or intraurethral prostaglandins, vacuum devices, or penile prostheses. Loss of 10-g monofilament perception and reduced vibration perception predict foot ulcers (78). Early recognition and management of risk factors can prevent or delay adverse outcomes. Examination All adults with diabetes should undergo a comprehensive foot examination at least annually to identify high-risk conditions. Clinicians should ask about history of previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, tobacco use, and foot care practices. A general inspection of skin integrity and musculoskeletal deformities should be done in a well-lit room. The last test listed, vibration assessment using a biothesiometer or similar instrument, is widely used in the U. Patient Education Patients with diabetes and high-risk foot conditions should be educated about their risk factors and appropriate management. Patients with visual difficulties, physical constraints preventing movement, or cognitive problems that impair their ability to assess the condition of the foot and to institute appropriate responses will need other people, such as family members, to assist in their care. Wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. Foot ulcers and wound care may require care by a podiatrist, orthopedic or vascular surgeon, or rehabilitation specialist experienced in the management of individuals with diabetes. Early progressive renal decline precedes the onset of microalbuminuria and its progression to macroalbuminuria. Microalbuminuria: marker of vascular dysfunction, risk factor for cardiovascular disease. Long-term renal outcomes of patients with type 1 diabetes mellitus and microalbuminuria: an analysis of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications cohort. Development and progression of renal insufficiency with and without albuminuria in adults with type 1 diabetes in the Diabetes Control and Complications Trial and the Epidemiology of Diabetes Interventions and Complications Study. Calluses can be debrided with a scalpel by a foot care specialist or other health professional with experience and training in foot care. Effect of intensive therapy on the development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial. Effect of candesartan on microalbuminuria and albumin excretion rate in diabetes: three randomized trials. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The effect of protein restriction on albuminuria in patients with type 2 diabetes mellitus: a randomized trial. The effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: a meta-analysis. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. A meta-analysis of the effects of dietary protein restriction on the rate of decline in renal function. Effect of pregnancy on microvascular complications in the diabetes control and complications trial. Canadian Ophthalmological Society evidencebased clinical practice guidelines for the management of diabetic retinopathy. The sensitivity and S66 Position Statement Diabetes Care Volume 38, Supplement 1, January 2015 specificity of nonmydriatic digital stereoscopic retinal imaging in detecting diabetic retinopathy. Fluocinolone acetonide intravitreal implant for diabetic macular edema: a 3-year multicenter, randomized, controlled clinical trial. Neuropathy and related findings in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study. Neuropathy among the diabetes control and complications trial cohort 8 years after trial completion. Use of the Michigan Neuropathy Screening Instrument as a measure of distal symmetrical peripheral neuropathy in type 1 diabetes: results from the Diabetes Control and Complications Trial/ Epidemiology of Diabetes Interventions and Complications. Association of metformin, elevated homocysteine, and methylmalonic acid levels and clinically worsened diabetic peripheral neuropathy. Recommendations for the use of cardiovascular tests in diagnosing diabetic autonomic neuropathy. Epidemiologic relationships between A1C and all-cause mortality during a median 3. Systematic review and meta-analysis of pharmacological therapies for painful diabetic peripheral neuropathy. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Clin Infect Dis 2012;54:e132­e173 Diabetes Care Volume 38, Supplement 1, January 2015 S67 10. E Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E Older adults ($65 years of age) with diabetes should be considered a highpriority population for depression screening and treatment. Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illnesses, such as hypertension, coronary heart disease, and stroke, than those without diabetes. Older adults with diabetes are also at a greater risk than other older adults for several common geriatric syndromes, such as polypharmacy, cognitive impairment, urinary incontinence, injurious falls, and persistent pain. Screening for diabetes complications in older adults also should be individualized. Older adults are at an increased risk for depression and should therefore be screened and treated accordingly (1). Please refer to the American Diabetes Association consensus report "Diabetes in Older Adults" for details (2). The care of older adults with diabetes is complicated by their clinical and functional heterogeneity. Some older individuals developed diabetes years earlier and may have significant complications; others are newly diagnosed and may have had years of undiagnosed diabetes with resultant complications; and still other older adults may have truly recent-onset disease with few or no complications. Some older adults with diabetes are frail and have other underlying chronic conditions, substantial diabetes-related comorbidity, or limited physical or cognitive functioning. Life expectancies are highly variable for this population but are often longer than clinicians realize.

A widely used set of diagnostic criteria for breakthrough pain is by Russell Portenoy antifungal toenail cream best 15 gm butenafine, from Memorial Sloan-Kettering Cancer Center fungus ball definition discount butenafine 15 gm online, New York fungus gnats perlite 15gm butenafine free shipping. The criteria are: · the presence of stable analgesia in the previous 48 hours · the presence of controlled background pain in the previous 24 hours fungus gnats dryer sheets discount butenafine 15gm with visa. Breakthrough pain is common in cancer patients fungus vegetable garden order butenafine 15gm on-line, and also in patients with other types of pain antifungal baby powder discount butenafine 15gm. Unfortunately, it is underdiagnosed and under-recognized by health care professionals. It is a good idea to combine opioids with nonopioid analgesics such as metamizol, ibuprofen, or diclofenac, if the patient is not already taking them regularly. Currently, there is no validated assessment tool for breakthrough pain, but the assessment of breakthrough pain should involve: · Taking a pain history · Examining the painful area · Appropriate investigations. As always, the best strategy for treatment of breakthrough pain would seem to be treatment of the cause of the pain, but unfortunately, most of the time, a cause of pain that could be eliminated immediately is not apparent. Breakthrough pain is a heterogeneous condition, and its management therefore may involve the use of a variety of treatments, rather than the use of a single, standard treatment. The most appropriate treatment(s) will be determined by a number of different factors, including the etiology of the pain. First, you should evaluate whether breakthrough pain may be lessened by nonpharmacological methods, such as repositioning or bed rest, rubbing or massage, application of heat or cold, and distraction and relaxation techniques. Also, never forget to check the fullness of the bladder in cases of acute pain exacerbation in the lower abdominal region, especially in noncommunicating or sedated patients. Unfortunately, there is relatively little evidence to support the use of these interventions in the treatment of breakthrough pain episodes. Second, if pharmacological intervention is essential, the drug class of choice in nociceptive pain Practical questions about breakthrough pain I am afraid of respiratory depression. As long as the pain and the opioid dose are balanced, there will be only tolerable sedation and no respiratory depression. Since the principle of breakthrough pain management is opioid titration, this balance between pain intensity and opioid side effects can be found easily. However, in rare instances, pain intensity may not change, but the patient may become more and more sedated. In these extreme situations, the patient must be woken up to be able to tell you that the pain is still excruciating. The explanation is that a patient can have pain that is not "opioid sensitive," meaning that because of the type of pain. If an anesthesiologist is available, regional or neuraxial blocks using catheters should be evaluated. Gona Ali and Andreas Kopf hours times four, which would equal the supplemental daily dose). Therefore, the basic principle of breakthrough medication application is "titration. By asking the patient each time, 5­10 minutes after the opioid application, about pain intensity, you can decide whether titration has to be continued. If your patient has a prior continuous opioid medication, the titration dose should be around 10­15% of the daily cumulative dose of the opioid. Typical indications for other nonopioid medication in breakthrough pain would be spasmatic pain or neuralgic pain. Neuralgic pain exacerbations, such as in trigeminal neuralgia, are best treated acutely with fast-release carbamazepine (200 mg). However, there is relatively little evidence to support the use of these interventions in the treatment of breakthrough pain episodes. All drug regimes for cancer patients should include a breakthrough pain medication from the start. As a rule of the thumb, the patient should be allowed to use extra ("demand") doses of his regular opioid as needed. The minimum time interval between two demand doses should be 30 minutes to allow the effects of morphine to develop fully. Again, 10­15% of the total daily dose is calculated, and that titration dose is offered to the patient every 30 minutes until pain intensity is under control. Can I use the average number of daily demand doses to estimate the true opioid requirement of my patient? If your patient needs five demand doses daily, you should add the cumulative daily demand dose to the "background" medication. A frequency of fewer than four demand doses daily is considered to be "normal," and therefore the dosing scheme may be maintained. If there is no need for demand doses, maybe a (small) reduction of "background" medication may be tried. Can I use the acute titration dose to estimate the future opioid needs of my patient? Yes, in cancer patients you can pretty well foresee the future opioid demand of your patient. Rescue medication is taken as required, rather than on a regular basis: in the case of spontaneous pain or nonvolitional incident pain, the treatment should be taken at the onset of the breakthrough pain; in the case of volitional incident pain or procedural pain, the treatment should be taken before the relevant precipitant of the pain. In many patients the most appropriate rescue medication will be a normal-release ("immediate-release") opioid analgesic. Oral transmucosal, sublingual, and intranasal fentanyl, which has become available in some countries, would be a good choice for all patients for whom the onset of effect of oral morphine is too slow and the duration is too long. It may be that certain activities your patient does during the day are going to lead to more pain. Your patient needs to be prescribed medications for this kind of activity, to be taken before engaging in this extra activity. The other type of pain that is somewhat like breakthrough pain, but is a bit different, is called end-of-dose failure. These patients are taking an analgesic that becomes ineffective after a few hours, and then pain returns. The answer to that problem is to choose a different-longer-acting- agent, choose a higher dose of the same agent, or change the dosing interval to avoid low serum levels with consecutive "end-of-dose" failure. Usually breakthrough pain has a different etiology than in cancer pain since there is no obvious continuous tissue destruction. Therefore, the patient should not receive "free access" to demand doses to avoid dose escalations in pain etiologies where long-term analgesia by opioids is very rare. An exception to the rule would be inflammatory pain, as in advanced rheumatic arthritis or systemic scleroderma. The degree of interference seems to be related to the characteristics of the breakthrough pain. Breakthrough pain is associated with greater pain-related functional impairment, worse mood, and more anxiety. Generally, breakthrough pain happens fast, and may last anywhere from seconds to minutes to hours. Breakthrough pain episodes have the following four key features: high frequency, high severity, rapid onset, and short duration. It is possible to experience breakthrough pain just before or just after taking the regular pain medication. They are the cornerstone for the management of breakthrough Pearls of wisdom · About one-half to two thirds of patients with chronic cancer-related pain also experience episodes of breakthrough cancer pain. Although it has a delayed onset of action, and a prolonged duration of effect, studies 282 show that the majority of patients have sufficient breakthrough pain control with this approach. Consensus conference of an Expert Working Group of the European Association for Palliative Care. Optimization of opioid therapy for preventing incident pain associated with bone metastases. Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain. Prevalence and characteristics of breakthrough pain in cancer patients admitted to a hospice. He had been the driver of a car that was involved in a head-on collision, and he was trapped in the car (no seat belt or air bag) for about 30 minutes. When first assessed in the receiving accident and emergency care unit, he was rousable but confused and in considerable pain. His injuries were as follows: Bilateral pneumothoraces (intercostal drains were inserted in the accident and emergency unit by the resuscitation team). Estimated blood loss of about 5 L, coagulopathic, with a platelet count of 50,000 postoperatively. He was transferred to the intensive care unit for elective ventilation and management. The middle ground, to gain the benefits without the disadvantages can only be achieved by regular assessment of pain along with a "sedation vacation" (a break from sedation) and adjustment of the regime on a daily basis. Even under normal circumstances, assessment and quantification of pain are difficult. If the patient is paralysed, it is important to ensure that adequate sedation and analgesics are given to avoid a patient who is awake but unable to move! If the patient is able to speak, a routine history about the pain and its severity can be taken. Where no communication is possible, signs of sympathetic drive can be noted-tachycardia, hypertension, and lacrimation. Clinical practice guidelines state: "Patients who cannot communicate should be assessed through subjective observation of pain related behaviors (movement, facial expression and posturing) and physiological indicators (heart rate, blood pressure and respiratory rate) and the change in these variables following analgesic therapy. Pain Management in the Intensive Care Unit Pain is exacerbated by movement, which may evoke pain of a quite different character. Moving, turning the patient, and the effects of endotracheal tube suction and physiotherapy give valuable information about the effectiveness of analgesia. For children, scales have been developed specifically for neonatal and pediatric use. Thus, patients with very poor gas exchange, particularly those requiring inverse I:E ratios or the initial stages of permissive hypercapnia, may Movements - Moves easily - Restless body movements - Moderate agitation - Thrashing, flailing Cry - None - Whimpering - Crying - Screaming, high-pitched - Winces with touch - Cries with touch - Difficult to console - Screams when touched - Inconsolable Touch Whatever method of assessment is selected, it should be regular. Both the patient and the response to drugs are constantly changing, so drugs and doses need regular adjustment. The use of a nerve stimulator to monitor the extent of neuromuscular blockade may be useful in some situations. Morphine and fentanyl were the preferred analgesic agents, and midazolam or propofol were recommended for short-term sedation, with propofol being the agent of choice for rapid awakening. Shorter-acting fentanyl and alfentanil, as well as ultra-short-acting remifentanil, are also used, but they are more expensive. Propofol and benzodiazepines are used for sedation, with diazepam, lorazepam, and midazolam all being widely used. The objective should be a cooperative, pain-free patient, which implies that the patient is not unduly sedated. The United Kingdom Intensive Care Society guidelines on sedation state the following: 1) All patients must be comfortable and pain free: Analgesia is thus the first aim. The most important way to reduce anxiety is to provide compassionate and considerate care; communication is an essential part of What are the available application routes for pharmacological agents? Small frequent intravenous bolus 286 doses or an intravenous infusion are the best routes for analgesics. Bolus doses should be regular without waiting until another dose is obviously essential. In all situations, it is important to review the requirement regularly, for example daily, by discontinuing the infusion or stopping the boluses. In this way, pain can be assessed, accumulation can be avoided, and the dose can be adjusted accordingly. Another important reason for discontinuing drugs and allowing the patient to recover from the effects is the great variations in drug handling in the critically ill patient. There are a variety of explanations for this variation, but discontinuing drugs allows the effect to wear off and reduces the tendency to accumulation. Gastrointestinal absorption can be unpredictable, and absorption of opioids is poor. Rectal administration, for drugs that are available in suppository form, may give better absorption, although the side effects of the enteral route remain. Some classes of analgesics have only become available in parenteral form relatively recently. In renal impairment, if there is no alternative, the dose and dosing interval should be reduced. Systemic effects of opioids within the context of intensive care are: · Central nervous system: morphine, diamorphine, and papaveretum have sedative properties, but excessive doses would be required to achieve sedation. Addiction is not a problem with the use of opiates in severe pain and is not a concern in patients who have survived intensive care. However, withdrawal symptoms and signs are possible after several days of continuous therapy or if therapy is stopped suddenly. An initial reduction of 30% followed by a 10% reduction every 12­24 hours thereafter should help to avoid withdrawal phenomena. Diamorphine or papaveretum could be used instead of morphine if more readily available. Fentanyl is a synthetic opioid that was introduced as a short-acting agent, but it can accumulate when given as an infusion in intensive care. Its onset is faster than that of fentanyl, and even as a prolonged infusion, it is less cumulative; it would be the drug of choice in renal impairment. Like fentanyl, it is particularly useful for additional short-term analgesia, lasting around 10­15 minutes. Remifentanil, although quite expensive, is currently used in the intensive care arena, especially for weaning and tube tolerance. It is rapidly metabolized and does not accumulate regardless of time or in renal or hepatic dysfunction.

Early osteolytic lesions show histological features suggesting a subacute inflammatory condition; in longstanding cases there may be bone thickening and round cell infiltration fungus cerebri cheap butenafine 15gm with visa. Despite the local and systemic signs of inflammation antifungal krem buy butenafine 15 gm, there is no purulent discharge and micro-organisms have seldom been isolated mold fungus definition purchase 15gm butenafine mastercard. Patients develop recurrent attacks of pain fungus on hands 15gm butenafine visa, swelling and tenderness around one or other of the long-bone metaphyses adequately covered with skin antifungal medications order 15 gm butenafine with visa. For small defects splitthickness skin grafts may suffice; for larger wounds local musculocutaneous flaps antifungal coconut oil buy 15gm butenafine with amex, or free vascularized flaps, are needed. Aftercare Success is difficult to measure; a minute focus of infection might escape the therapeutic onslaught, only to flare into full-blown osteomyelitis many years later. Prognosis should always be guarded; local trauma must be avoided and any recurrence of symptoms, however slight, should be taken seriously and investigated. There is no abscess, only a diffuse enlargement of the bone at the affected site ­ usually the diaphysis of one of the tubular bones or the mandible. The patient is typically an adolescent or young adult with a long history of aching and slight swelling over the bone. Occasionally there are recurrent attacks of more acute pain accompanied by malaise and slight fever. There are small lytic lesions in the metaphysis, usually closely adjacent to the physis. Biopsy of the lytic focus is likely to show the typical histological features of acute or subacute inflammation. In longstanding lesions there is a chronic inflammatory reaction with lymphocyte infiltration. Although the condition may run a protracted course, the prognosis is good and the lesions eventually heal without complications. Clinical and radiological changes are usually confined to the sternum and adjacent bones and the vertebral column. As with recurrent multifocal osteomyelitis, there is a curious association with cutaneous pustulosis. Vertebral changes include sclerosis of individual vertebral bodies, ossification of the anterior longitudinal ligament, anterior intervertebral bridging, end-plate erosions, disc space narrowing and vertebral collapse. Radioscintigraphy shows increased activity around the sternoclavicular joints and affected vertebrae. There is no effective treatment but in the long term symptoms tend to diminish or disappear; however, the patient may be left with ankylosis of the affected joints. It usually starts during the first few months of life with painful swelling over the tubular bones and/or the mandible. Infection may be suspected but, apart from the swelling, there are no local signs of inflammation. X-rays characteristically show periosteal new-bone formation resulting in thickening of the affected bone. After a few months the local features may resolve spontaneously, only to reappear somewhere else. The lesions gradually cleared up, leaving little or no trace of their former ominous appearance. In infants it is often difficult to tell whether the infection started in the metaphyseal bone and spread to the joint or vice versa. In practice it hardly matters and in advanced cases it should be assumed that the entire joint and the adjacent bone ends are involved. The causal organism is usually Staphylococcus aureus; however, in children between 1 and 4 years old, Haemophilus influenzae is an important pathogen unless they have been vaccinated against this organism. Occasionally other microbes, such as Streptococcus, Escherichia coli and Proteus, are encountered. In adults the effects are usually confined to the articular cartilage, but in late cases there may be extensive erosion due to synovial proliferation and ingrowth. If the infection goes untreated, it will spread to the underlying bone or burst out of the joint to form abscesses and sinuses. With healing there may be: (1) complete resolution and a return to normal; (2) partial loss of articular cartilage and fibrosis of the joint; (3) loss of articular cartilage and bony ankylosis; or (4) bone destruction and permanent deformity of the joint. The baby is irritable and refuses to feed; there is a rapid pulse and sometimes a fever. The joints should be carefully felt and moved to elicit the local signs of warmth, tenderness and resistance to movement. Special care should be taken not to miss a concomitant osteomyelitis in an adjacent bone end. All movements are restricted, and Pathology the usual trigger is a haematogenous infection which settles in the synovial membrane; there is an acute inflammatory reaction with a serous or seropurulent exudate and an increase in synovial fluid. As pus appears in the joint, articular cartilage is eroded and destroyed, partly by bacterial enzymes and partly by proteolytic enzymes released from synovial cells, inflammatory cells and pus. In infants the entire epiphysis, which is still largely cartilaginous, may be (a) (b) (c) (d) 2. Widening of the space between capsule and bone of more than 2 mm is indicative of an effusion, which may be echo-free (perhaps a transient synovitis) or positively echogenic (more likely septic arthritis). However, special investigations take time and it is much quicker (and usually more reliable) to aspirate the joint and examine the fluid. A white cell count and Gram stain should be carried out immediately: the normal synovial fluid leucocyte count is under 300 per mL; it may be over 10 000 per mL in non-infective inflammatory disorders, but counts of over 50 000 per mL are highly suggestive of sepsis. Samples of fluid are also sent for full microbiological examination and tests for antibiotic sensitivity. Differential diagnosis Acute osteomyelitis In young children, osteomyelitis may be indistinguishable from septic arthritis; often one must assume that both are present. Other types of infection Psoas abscess and local infection of the pelvis must be kept in mind. Trauma Traumatic synovitis or haemarthrosis may be associated with acute pain and swelling. Irritable joint At the onset the joint is painful and lacks some movement, but the child is not really ill and there are no signs of infection. Ultrasonography may help to distinguish septic arthritis from transient synovitis. It is essential to look for a source of infection ­ a septic toe, a boil or a discharge from the ear. In adults it is often a superficial joint (knee, wrist, a finger, ankle or toe) that is painful, swollen and inflamed. The patient should be questioned and examined for evidence of gonococcal infection or drug abuse. Rheumatic fever Typically the pain flits from joint to joint, but at the onset one joint may be misleadingly inflamed. Juvenile rheumatoid arthritis this may start with pain and swelling of a single joint, but the onset is usually more gradual and systemic symptoms less severe than in septic arthritis. Sickle-cell disease the clinical picture may closely nase-resistant penicillins. If the initial examination shows Gram-negative organisms a third-generation cephalosporin is added. More appropriate drugs can be substituted after full microbiological investigation. Antibiotics should be given intravenously for 4­7 days and then orally for another 3 weeks. A small catheter is left in place and the wound is closed; suction­irrigation is continued for another 2 or 3 days. This is the safest policy and is certainly advisable (1) in very young infants, (2) when the hip is involved and (3) if the aspirated pus is very thick. For the knee, arthroscopic debridement and copious irrigation may be equally effective. Older children with early septic arthritis (symptoms for less than 3 days) involving any joint except the hip can often be treated successfully by repeated closed aspiration of the joint; however, if there is no improvement within 48 hours, open drainage will be necessary. If articular cartilage has been preserved, gentle and gradually increasing active movements are encouraged. If articular cartilage has been destroyed the aim is to keep the joint immobile while ankylosis is awaited. Splintage in the optimum position is therefore continuously maintained, usually by plaster, until ankylosis is sound. Gout and pseudogout In adults, acute crystal-induced synovitis may closely resemble infection. On aspiration the joint fluid is often turbid, with a high white cell count; however, microscopic examination by polarized light will show the characteristic crystals. Treatment is then started without further delay and follows the same lines as for acute osteomyelitis. Once the blood and tissue samples have been obtained, there is no need to wait for detailed results before giving antibiotics. If the aspirate looks purulent, the joint should be drained without waiting for laboratory results (see below). The initial choice of antibiotics is based on judgement of the most likely pathogens. Neonates and infants up to the age of 6 months should be protected against staphylococcus and Gram-negative streptococci with one of the penicilli- Complications Infants under 6 months of age have the highest incidence of complications, most of which affect the hip. The most obvious risk factors are a delay in diagnosis and treatment (more than 4 days) and concomitant osteomyelitis of the proximal femur. Subluxation and dislocation of the hip, or instability of the knee should be prevented by appropriate posturing or splintage. Damage to the cartilaginous physis or the epiphysis in the growing child is the most serious complication. Sequelae include retarded growth, partial or complete destruction of the epiphysis, deformity of the joint, epiphyseal osteonecrosis, acetabular dysplasia and pseudarthrosis of the hip. Articular cartilage erosion (chondrolysis) is seen in 45 2 older patients and this may result in restricted movement or complete ankylosis of the joint. Even in affluent communities the incidence of sexually transmitted diseases has increased (probably related to the increased use of non-barrier contraception) and with it the risk of gonococcal and syphilitic bone and joint diseases and their sequelae. The infection is acquired only by direct mucosal contact with an infected person ­ carrying a risk of greater than 50% after a single contact! The usual organisms are Staphylococcus aureus and Streptococcus; however, opportunistic infection by unusual organisms is not uncommon. The patient may present with an acutely painful, inflamed joint and marked systemic features of bacteraemia or septicaemia. In some cases the infection is confined to a single, unusual site such as the sacroiliac joint; in others several joints may be affected simultaneously. Opportunistic infection by unusual organisms may produce a more indolent clinical picture. Patients with staphylococcal and streptococcal infections usually respond well to antibiotic treatment and joint drainage; opportunistic infections may be more difficult to control. Clinical features Two types of clinical disorder are recognized: (a) disseminated gonococcal infection ­ a triad of polyarthritis, tenosynovitis and dermatitis ­ and (b) septic arthritis of a single joint (usually the knee, ankle, shoulder, wrist or hand). If the condition is suspected, the patient should be questioned about possible contacts during the previous days or weeks and they should be examined for other signs of genitourinary infection. Joint aspiration may reveal a high white cell count and typical Gram-negative organisms, but bacteriological investigations are often disappointing. Samples should also be taken from the various mucosal surfaces and tests should be performed for other sexually transmitted infections. Lyme disease, which also originates with a spirochaetal infection, is better regarded as due to a systemic autoimmune response and is dealt with in Chapter 3. The organism can also cross the placental barrier and enter the foetal blood stream directly during the latter half of pregnancy, giving rise to congenital syphilis. In acquired syphilis a primary ulcerous lesion, or chancre, appears at the site of inoculation about a month after initial infection. This usually heals without treatment but, a month or more after that, the disease enters a secondary phase characterized by the appearance of a maculopapular rash and bone and joint changes due to periostitis, osteitis and osteochondritis. After a variable length of time, this phase is followed by a latent period which may continue for many years. The term is somewhat deceptive because in about half the cases pathological lesions continue to appear in various organs and 10­30 years later the patient may present again with tertiary syphilis, which takes various forms including the appearance of large granulomatous gummata in bones and joints and neuropathic disorders in which the loss of sensibility gives rise to joint breakdown (Charcot joints). In congenital syphilis the primary infection may be Treatment Treatment is similar to that of other types of pyogenic arthritis. Patients will usually respond fairly quickly to a third-generation cephalosporin given intravenously or intramuscularly. However, bear in mind that many patients with gonococcal infection also have chlamydial infection, which is resistant to cephalosporins; both are sensitive to quinolone antibiotics such as ciprofloxacin and ofloxacin. If the organism is found to be sensitive to penicillin (and the patient is not allergic), treatment with ampicillin or amoxicillin and clavulanic acid is also effective. The ones who survive manifest pathological changes similar to those described above, though with modified clinical appearances and a contracted timescale. The baby is sick and irritable and examination may show skin lesions, hepatosplenomegaly and anaemia. Several sites may be involved, often symmetrically, with slight swelling and tenderness at the ends or along the shafts of the tubular bones. Late congenital syphilis Bone lesions in older children Infection Clinical features of acquired syphilis Early features the patient usually presents with pain, swelling and tenderness of the bones, especially those with little soft-tissue covering, such as the frontal bones of the skull, the anterior surface of the tibia, the sternum and the ribs. X-rays may show typical features of periostitis and thickening of the cortex in these bones, as well as others that are not necessarily symptomatic.

In addition antifungal face wash cheap butenafine 15 gm with visa, the spleen is the major producer of antigen-specific IgM antibody which is important in the early response to infection antifungal bath soap purchase butenafine 15gm with visa. Absence of these important blood and immune monitoring functions places asplenic individuals at risk for life-long infectious and thrombotic complications fungus nail polish purchase butenafine 15 gm otc. Appreciation for the immunologic and blood monitoring functions of the spleen has resulted in a trend toward splenic preservation in both trauma and hematologic disorders can fungus gnats make you sick buy butenafine 15 gm mastercard. The last category of patients is considered high risk for thrombotic complications (see Vascular Complications below) fungus gnats malathion 15 gm butenafine with visa. Other alterations in blood content and viscosity can also occur and include leukocytosis fungus medical definition quality 15gm butenafine, thrombocytosis, increased lipid levels, intravascular hemolysis and endothelial dysfunction. The full effect these vascular changes on late vascular complications has not been completely studied or measured. Severe forms of parasitic infections with malaria and babesiosis, ehrlichiosis and cytomegalovirus have also been documented. Mortality can be as high as 50-80% and occur within 48 hours of hospital admission. The risk is higher in children because they lack pre-existing immunity and is estimated at one per 175 patientyears. The risk for adults is highest in the first two years following splenectomy and is estimated at one per 400-500 patient-years. Meningococcal booster with the conjugate vaccine is recommended if the polysaccharide vaccine was received 3-5 years in the past. Vaccinations should be given at least fourteen days before surgery or fourteen days after surgery when not elective. Adult patients should have at least one dose of an anti-pneumococcal antibiotic immediately available if fever and rigors develop and proceed for emergency care without delay. Prophylactic antibiotics have been shown to decrease the incidence of infection by 47% and the mortality by 88%. Studies have shown an alarming lack of unawareness among asplenic patients marked by failure to comply with vaccine and antibiotic recommendations. Patients should be counseled before and after splenectomy and be encouraged to wear a medical alert bracelet. Vascular complications include thrombosis, thromboembolism, vascular smooth muscle remodeling, vasospasm or atherosclerosis and occur on the arterial and venous sides of the circulation. The risk appears to vary by cause for splenectomy and underlying disease states, but none are without increased risk. The highest risk is in those with underlying myeloproliferative disorders or in hematologic disorders with on-going intravascular hemolysis. Currently, there are no clear guidelines for prophylactic anti-platelet or anticoagulation medications in splenectomized patients. Increased free hemoglobin has direct inflammatory and cytotoxic effects on endothelium and scavenges nitric oxide needed for vascular smooth muscle relaxation. The incidence may be as high as 50%, but symptomatic thrombosis occurs in approximately 5-10% of cases. The incidence did not increase above controls until after 30 years of age, then increased incrementally: 3-6% at age 30, 5-7% at age 40, 10-13% at age 50 and 19-20% at age 70. Other reported arterial events in this population included acute ischemic optic neuropathy and pulmonary hypertension. The series by Jaпs included a majority of trauma splenectomies (12/22) with a mean age of 34 years at the time of surgery. Aeromedical concerns of the underlying medical conditions are discussed in the appropriate waiver guide for that particular condition. The lifelong risk of overwhelming sepsis and vascular complications apply to all splenectomized patients regardless of cause. The splenectomized aviator should not delay treatment with antibiotics and care in an appropriate medical facility. Aviators should carry at least one dose of prophylactic antibiotics to take if symptoms occur while in flight. The aeromedical impact of the lifelong risk of vascular complications is more difficult to determine not only because the risk has not been well-defined but also because there are no clear recommendations for anti-platelet or anticoagulation prophylaxis. The incidence of venous thromboembolic events is greatest in the early postoperative period and remains below 10% for several years but appears to increase as the patient gets older. Unfortunately, the overall incidence of pulmonary hypertension in splenectomized patients has not been reported, but is likely very low. These symptoms are due to impaired oxygen transport and reduced cardiac output which is not compatible with aviation duties. In addition, hypoxia as may be present in the aviation environment is a potent stimulant of pulmonary vasoconstriction and may worsen the development of disease. Cost-effectiveness of a post-splenectomy registry for prevention of sepsis in the asplenic. Prospective Study of the Incidence and Risk Factors of Postsplenectomy Thrombosis of the Portal, Mesenteric, and Splenic Veins. Pulmonary Hypertension in Thalassemia: Association with Platelet Activation and Hypercoagulable State. The Effects of Splenectomy and Splenic Autotransplantation on Plasma Lipid Levels. Incidence of septic and thromboembolic related deaths after splenectomy in adults. Medical conditions increasing the risk of chronic thromboembolic pulmonary hypertension. Splenectomy sequelae: an analysis of infectious outcomes among adults in Victoria. Waiver Consideration Spondylolysis is a defect involving the pars interarticularis of the vertebrae. Spondylolisthesis is a condition in which there is anterior slipping of a vertebrae. The most common location for these conditions occurs at the lower lumbar vertebrae. Spondylolysis and spondylolisthesis are often associated with other spinal pathologies. Initial Waiver Request: 1 History ­ Presentation, course, and a thorough back history including: 835 Distribution A: Approved for public release; distribution is unlimited. If aviator had past or present symptoms, document nature of pain and treatment received. Aeromedical Concerns Spondylolisthesis and spondylolysis represent structural abnormalities of the lumbar spine and may be manifested by low back pain. Such pain is unlikely to cause sudden incapacitation but can cause distraction during flight operations. Spondylolysis may be caused by a stress fracture and lead to occasional or chronic low back pain. Additionally, the affected portion of the spine may be particularly vulnerable to accelerative stress. Spondylolisthesis can be secondarily caused by degenerative disc disease or spondylolysis. Monofixation/Microtropia management and the Prospective Defective Stereopsis management groups have been closed as the requisite data has been collected and interpreted. If depth perception capability has declined from the previously waivered level or if binocular fusional control has diminished. More extensive work up for waiver 838 Distribution A: Approved for public release; distribution is unlimited. If spectacles were needed to pass depth perception testing, regardless of unaided visual acuity. There were a total of 904 cases disqualified, the majority which were either for another unrelated diagnosis or for untrained assets. Of those, 540 were analyzed with 213 excluded from analysis for not having follow-up exams (178), not meeting study criteria (32), or uninterpretable findings (3). Information Required for Waiver Submittal the most common cause of an acquired depth perception defect is uncorrected refractive error. Depth perception testing should not be attempted until optimal correction has been achieved. Failure of depth perception with best corrected visual acuity is disqualifying, but may be considered for waiver. Underlying conditions such as microtropia, monofixation syndrome, and anisometropia that are identified during evaluation by the local optometrist or ophthalmologist should be listed as a separate disqualifying condition along with a diagnosis of defective stereopsis. Complete ocular history noting particularly any history of eye patching, spectacle wear at an early age, strabismus, eye surgery and previous depth perception testing performance. Ductions, versions, cover test and alternate cover test in primary and six cardinal positions of gaze. Aeromedical Concerns Stereopsis is generally not considered to be a factor in the perception of depth beyond 200 m, as monocular cues tend to prevail at these distances. In aviation, accurate perception of spacing or depth within 200 m is critical in a number of situations, such as aerial refueling, formation flying, holding hover rescue type operations, taxiing, and parking. Microtropia and monofixation syndrome may be intermittent in nature and susceptible to decompensation in the aerospace environment due to such exposure as relative hypoxia and fatigue over time. While there is a chance of decompensation, it is well below the acceptable aeromedical risk of 1%. To be eligible for waiver, it is recommended the member display a period of Clinical Stability for 6 months after reaching "Best Baseline" functioning. Underlying conditions that exacerbated suicidal behavior must be treated successfully and the aviator or aviator candidate must not have a higher risk of suicidal behavior than does the general military population. Initial Waiver Request: 11 See Mental Health Waiver Guide Checklist 12 If the local base is unable to provide all required items, they should explain why, explaining reason to waiver authority. If the local base is unable to provide all required items, they should explain why, explaining reason to waiver authority. Aeromedical Concerns Suicidal behavior must always be taken seriously in any Airman, especially those who are required to meet enhanced medical standards. Not only is the individual aviator at risk, but the safety of others in the air and on the ground must be considered, as well as the conservation of valuable national assets, and the implications of access to nuclear and other weapons. Especially concerning is the performance requirements of military aviators for readiness and mission completion. While suicide behavior may be a single act, it often represents a distinct, overt pattern of behavior in a long, debilitating process. By and large, aviators are known to demonstrate emotional composure and may deny, suppress and/or otherwise defend against emotional turmoil. Because of this, the need for peers and flight surgeons to carefully monitor aircrew for early signs of emotional conflict, despair, and intimate relationship deterioration is essential. A history of attempted suicide or suicidal behavior is disqualifying (referred to generally as suicidal behavior in the waiver guide). Of great concern in aviators with suicidal ideation is the possibility of suicide by aircraft, which is rare, but has occurred in civilian and military settings. Appropriate action should be taken in regard to the Personnel Reliability Program, if applicable. Another closely related behavior is non-suicidal self-injury which involves cutting, burning, severe scratching, and hitting. Severe cases of nonsuicidal self-injury may involve bone breaking and ocular enucleation. Those attempting suicide most often engage in medication overdose, while suicide completers most often die from self-inflicted gunshot wounds or strangulation. Suicides committed by members of the military has raised concerns among policymakers, military leaders, and the population at large. The number of suicides among all active duty members was 145 in 2001 and began a steady increase until more than doubling to 321 in 2012, the worst year in recent history for service members killing themselves. The suicide rate for the Army in 2012 was nearly 30 suicides per 100,000 soldiers, well above the national rate. Factors contributing to suicidal ideation include distressing life circumstances combined with feelings of hopelessness or helplessness, a recent significant emotional loss, a history of suicide in a family member or close associate, substance abuse, the presence of a psychiatric disorder, and chronic or terminal illness. The overall rate for officers has consistently been lower than that of enlisted members. From the current known information about aviator suicide, the incidence is small, and probably much less than most other military or civilian occupational groups. Specifically, four pilots tested positive for alcohol, one for benzodiazepines, two positive for unapproved antidepressants, and two were positive for diphenhydramine. Six of the eight had reported thoughts of suicide, attempted suicide before and/or left a note. Additionally, 88% had experienced domestic problems, 13 % had legal issues, and 25% suffered from depression. Breakdown of 844 Distribution A: Approved for public release; distribution is unlimited. Airplane pilot mental health and suicidal thoughts: a cross-sectional descriptive study via anonymous web-based survey. Nonsuicidal Self-Injury: A Review of Current Research for Family Medicine and Primary Care Physicians. Air Force Guide For Suicide Risk Assessment, Management, and Treatment, June 27, 2014. Major Depressive Disorder in Military Aviators: A Retrospective Study of Prevalence.

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