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Hypersensitivity pneumonitis is a delayed-type hypersensitivity reaction that has a variety of presentations erectile dysfunction drugs viagra generic 20mg levitra professional mastercard. Others may present subacutely with worsening dyspnea on exertion and dry cough over weeks to months impotence of psychogenic origin generic 20mg levitra professional with amex. Chronic hypersensitivity pneumonitis presents with more severe and persistent symptoms with clubbing how does the erectile dysfunction pump work generic 20mg levitra professional. Progressive worsening is common with the development of chronic hypoxemia erectile dysfunction cures discount levitra professional 20 mg with visa, pulmonary hypertension erectile dysfunction medication patents safe 20 mg levitra professional, interstitial pulmonary fibrosis impotence yohimbe discount 20mg levitra professional with amex, and respiratory failure. Peripheral eosinophilia is not a feature of this disease as the disease is mediated through T-cell inflammation. Other nonspecific markers of inflammation may be elevated, including the erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, and serum immunoglobulins. If a specific antigen is suspected, serum precipitins directed toward that antigen may be demonstrated. However, these tests are neither sensitive nor specific for the presence of disease. Histopathologically, interstitial alveolar infiltrates predominate, with a variety of lymphocytes, plasma cells, and occasional eosinophils and neutrophils being seen. In patients with mild disease, removal from antigen exposure alone may be sufficient to treat the disease. It is notable that the exposure to asbestos could seem almost minimal, but still confer significant risk. While tobacco smoking in association with asbestos exposure increases the risk of lung cancer several fold, there is no additive or exponential risk of mesothelioma in those who smoke. Mesothelioma most often presents with a persistent unilateral pleural effusion that may mask the underlying pleural tumor. Even with large effusions, no mediastinal shift is seen on chest radiograph because the pleural thickening associated with the disease leads to a fixed chest cavity size and thoracic restriction. The most difficult diagnostic dilemma in these patients is to differentiate mesothelioma from metastatic lung carcinoma (usually adenocarcinoma), as many patients are at risk for both tumors, and lung cancer is far and away the most common malignancy seen in those individuals with asbestos exposure and cigarette smoking. Pleural fluid cytology is not adequate for the diagnosis of most individuals with mesothelioma, with samples being positive for the disease in less than 50% of individuals. Most often video-assisted thoracoscopy is required to directly visualize the pleural surfaces and direct biopsy sampling. Unfortunately, there is no proven effective therapy for mesothelioma, and most patients die from local extension of the disease. The chronic form of silicosis has been associated with an increased risk of a variety of diseases. Silica is known to be cytotoxic to alveolar macrophages and thus places patients at increased risk of pulmonary infections that rely on cellular immunity, including Mycobacterium tuberculosis, atypical mycobacteria, and fungus. In addition, silicosis is associated with the development of connective tissue disorders including rheumatoid arthritis with rheumatoid nodules (Caplan syndrome) and scleroderma. The inorganic dusts include asbestos, silica, coal dust, beryllium, and a variety of other metals. In areas near where asbestos mining has occurred, the general population also has shown an increased risk of asbestos-related lung disease. Clinically, asbestos exposure is associated with a range of clinical syndromes including asbestosis, benign pleural plaques and pleural effusions, lung cancer, and mesothelioma. Silica exposure is common among miners, stone masons, and individuals involved in sand blasting or quarrying. A variety of clinical syndromes can occur with silica exposure, the most severe being progressive massive fibrosis with masslike upper-lobe consolidating nodules (>1 cm). Coal mining is also associated with a clinical picture similar to silicosis and progressive massive fibrosis. Beryllium is a lightweight metal that is highly conductive and is used in high-tech industries. The classic disease associated with beryllium exposure is a chronic granulomatous disease similar in clinical appearance to sarcoidosis. Welders of galvanized metal who utilize zinc oxide are susceptible to metal fume fever and present with an acute self-limited influenza-like illness. Cotton milling and processing can present with a clinical syndrome known as byssinosis, which has asthma-like features. Typically, a specific antigen can be identified as the culprit for the development of hypersensitivity pneumonitis. Skin testing for allergies would not be likely to pinpoint the workrelated exposure. The patient does not require further testing to diagnose that he has asthma; therefore, a methacholine challenge is not indicated. Finally, the exercise physiology test is generally used to differentiate between cardiac and pulmonary causes or deconditioning as etiologies for shortness of breath. In this disorder, spores of actinomycetes in moldy hay are inhaled and produce a hypersensitivity pneumonitis. The exposure history will differentiate this disorder from other types of pneumonia. The primary purpose of the Gram stain is to ensure that the sputum is an adequate lower respiratory sample for culture with fewer than 10 squamous epithelial cells and more than 25 neutrophils per high-powered field. Generally, the yield from sputum culture is 50% or less, even in cases of bacteremic pneumococcal pneumonia. The most common antigen test that is performed is for Legionella pneumophila, as this organism does not grow in culture unless performed on specific media. The empiric antibiotic regimen recommended by the Infectious Diseases Society of America and the American Thoracic Society for individuals who are previously healthy and have not received antibiotics in the prior 3 months is either doxycycline or a macrolide such as azithromycin or clarithromycin. In outpatients with significant medical comorbidities or antibiotics within the prior 3 months, the suggested antibiotic therapy is either a respiratory fluoroquinolone or a beta-lactam plus a macrolide. Quantitative cultures have gained favor, as the quantitative nature is thought to discriminate better between colonization and active infection. A variety of approaches have been advocated including endotracheal aspirates yielding more than 106 organisms or protected brush specimens from distal airways yielding more than 103 organisms. However, the quantitative yield of these tests can be highly influenced by even a single dose of antibiotics, and antibiotic changes are common in critically ill patients, particularly when a new fever has emerged. Thus, the lack of growth on quantitative culture may be difficult to interpret in this setting. Alcohol use predisposes patients to anaerobic infection, likely due to aspiration, as well as S. Patients with structural lung disease, such as cystic fibrosis or bronchiectasis, are at risk for a unique group of organisms including P. The most common cause of diffuse bronchiectasis worldwide is prior granulomatous infection due to Mycobacterium tuberculosis. In the developed world, tuberculosis is a less common cause of bronchiectasis, with nontuberculous mycobacteria such as Mycobacterium avium-intracellulare complex being a more common cause, particularly in the midlung fields. Other potential etiologies of diffuse bronchiectasis include cystic fibrosis, postradiation pneumonitis, immunoglobulin deficiency, end-stage fibrotic lung disease, and recurrent aspiration. In inherited disorders such as cystic fibrosis, the symptoms of bronchiectasis most often begin in early childhood. However, in general, the incidence of bronchiectasis increases with age, typically affecting women more than men. Classically, the sputum is described as large volume with a thick tenacious character. The physical examination may demonstrate crackles or wheezing with mild to moderate airflow obstruction on pulmonary function testing. The chest radiograph may show tram tracking, but is frequently normal and is of insufficient sensitivity to definitively make the diagnosis. In addition, the airways fail to taper in the periphery, and airways may be identifiable within 1 cm of the pleural surface, which is clearly abnormal. Often individuals present with an indolent course and nonspecific symptoms including fever, fatigue, and weight loss. Individuals presenting with lung abscess often have risk factors for aspiration and evidence of periodontal infection. In more advanced cases, the lung abscess can erode into the pleura, creating an empyema with associated pleuritic chest pain. Bacterial, mycobacterial, and fungal cultures should be performed, but this should not delay treatment of the most likely cause of the lung abscess. A sputum culture on an expectorated sample will only detect aerobic organisms, and the detection of anaerobes would be confounded by the presence of multiple oral anaerobes that could contaminate an expectorated specimen. Potential complications include development of empyema or a bronchopleural fistula. In addition, one should consider performing bronchoscopy to rule out an obstructing lesion. Percutaneous or surgical intervention is generally not required unless the patient fails to respond to antibiotic therapy or has a lung abscess greater than 6 cm. A number of deficiencies have been described, including malfunction of dynein arms, radial spokes, and microtubules. The lungs rely on cilia to beat respiratory secretions proximally and subsequently to remove inspired particles, especially bacteria. In the absence of this normal host defense, recurrent bacterial respiratory infections occur and can lead to bronchiectasis. Cystic fibrosis is associated with infertility and bilateral upper-lobe infiltrates. It causes a decreased number of sperm or absent sperm on analysis because of the congenital absence of the vas deferens. Sarcoidosis, which is often associated with bihilar adenopathy, is not generally a cause of infertility. A patient will have recurrent respiratory infections with development of cystic bronchiectasis over time. The presenting manifestation in infancy is often meconium ileus and can lead to constipation and distal intestinal obstruction in adults. These symptoms can include recurrent lung and sinus infections, malnutrition, sinus disease, and infertility, especially absence of the vas deferens in men. In childhood, the most commonly isolated organisms are Haemophilus influenzae and Staphylococcus aureus. It is now recognized that chronic colonization with Pseudomonas, especially multidrug-resistant organisms, is associated with a more rapid decline in lung function. The Cystic Fibrosis Foundation recommends quarterly office visits with a physician, with assessment of respiratory cultures at each visit. When Pseudomonas is initially detected, attempts to eradicate the organism should be undertaken. Clinical trials have not definitively determined the best regimen for eradicating Pseudomonas, but the most common utilized treatment is the aminoglycoside antibiotic tobramycin given as a nebulized solution twice daily every other month with follow-up cultures at the next office visit to determine if the therapy should be continued. For all patients chronically colonized with Pseudomonas, inhaled tobramycin every other month should be continued on an indefinite basis. In addition, azithromycin 500 mg three times weekly or 250 mg daily is also utilized. Whether azithromycin primarily exerts its beneficial effect through anti-inflammatory or antimicrobial actions is not definitively known at the present time. As the patient is clinically well without any symptoms of acute exacerbation, the use of intravenous antibiotics is not required. Chest wall oscillation and hypertonic saline are both mechanisms to improve airway clearance. By history and lung function, the patient is achieving adequate airway clearance at the present time, so escalation of care in this area is not required. In childhood, the most frequently isolated organisms are Haemophilus influenzae and Staphylococcus aureus. Interestingly, Aspergillus fumigatus is found in the airways of up to 50% of cystic fibrosis patients. All these organisms merely colonize the airways but occasionally can also cause disease. Burkholderia (previously called Pseudomonas) cepacia can occasionally be found in the sputum of cystic fibrosis patients, where it is always pathogenic and is associated with a rapid decline in both clinical parameters and pulmonary function testing. Atypical mycobacteria can occasionally be found in the sputum but are often merely colonizers. Acinetobacter baumannii is not associated with cystic fibrosis; rather, it is generally found in nosocomial infections. This leads to early closure of airways in expiration with air trapping and hyperinflation. Finally, the loss of alveoli in emphysematous lungs leads to a progressive decline in gas exchange with alterations of ventilation-perfusion relationships. With hyperinflation, the total lung capacity increases with a concomitant increase in residual volume.
They will develop tachypnea erectile dysfunction treatment in urdu cheap levitra professional 20 mg visa, respiratory distress impotence gel discount 20mg levitra professional visa, and acidosis and die if not treated erectile dysfunction treatment himalaya effective 20 mg levitra professional. Prostaglandins keep the ductus arteriosus patent and help assist with the mixing of the circulations impotence from anxiety levitra professional 20 mg online, thereby improving oxygenation erectile dysfunction treatment blog buy cheap levitra professional 20mg online. In infants with d-transposition of the great arteries gluten causes erectile dysfunction buy 20 mg levitra professional with visa, how does a balloon atrial septostomy improve systemic oxygen saturation? The balloon atrial septostomy permits unrestricted bidirectional mixing of fully saturated blood in the left atrium with desaturated blood in the right atrium to achieve a higher net saturation of blood in the systemic circulation. Variations in oxygen saturation can be expected, although mixing is usually excellent. The most common clinical manifestation is a murmur secondary to obstruction across the right ventricular outflow tract. The different types of total anomalous pulmonary venous return depend on their drainage sites. The pulmonary veins usually drain into the right superior vena cava via a left vertical vein. Although generally nonobstructive, they can be obstructed in some cases (the vertical vein is "pinched" between the left pulmonary artery and the left bronchus, or at superior vena cava insertion). The pulmonary veins drain into the coronary sinus or directly into the right atrium. They can be obstructed (obstruction can occur at the site of the obligate right-to-left atrial shunt) or non-obstructed. The common pulmonary vein drains below the diaphragm into the portal venous system, ductus venosus, inferior vena cava, or hepatic veins. In infants with nonobstructed total anomalous pulmonary veins, tachypnea develops gradually, with a typical presentation occurring in approximately 4 to 6 weeks. Scimitar syndrome has the following components: right lung hypoplasia, anomalous connection of the right pulmonary veins to the inferior vena cava, right pulmonary artery hypoplasia, anomalous systemic arterial supply to the right lung, bronchial anomalies, and dextroposition of the heart, reflecting the hypoplastic right lung. The term scimitar syndrome derives from a feature on the chest x-ray: the right pulmonary veins cast a shadow resembling the handle of a scimitar in the right lower zone as they drain anomalously into the inferior vena cava. The coronary arteries, pulmonary arteries, and systemic arteries arise from a single common trunk. The pulses are bounding, and significant truncal regurgitation will generally produce a widened pulse pressure with a prominent diastolic murmur. DiGeorge syndrome with hypocalcemia is present in approximately one third of cases with truncus arteriosus. Attention to the presence of a thymic shadow should be sought on the chest radiograph. Common clinical signs are tachypnea, hepatomegaly, pulmonary rales, and a single second heart sound (S2). Closure of the ductus will result in decreased peripheral pulses and a "shock-like" picture. Echocardiography should assess the ventricular function, patency of the ductus, and adequacy of the inter-atrial communication. Under what circumstances can information from an electrocardiogram in a cyanotic neonate help indicate the presence of congenital heart disease? The differential diagnosis includes tricuspid atresia, pulmonary valve atresia with intact ventricular septum, critical pulmonary stenosis, or complex single left ventricle. What are some common chest x-ray findings in infants with cyanotic congenital heart lesions? Decreased pulmonary vascular markings, concave main pulmonary artery segment with an upturned apex (boot-shaped heart). With pulmonary venous obstruction there is radiographic evidence of pulmonary edema (diffuse reticular pattern). Ebstein anomaly of the tricuspid valve: In severe cases the heart is enormous, balloon shaped, and occupies almost the entire cardiothoracic area. Can have cardiomegaly with increased pulmonary vascular markings, or a relatively normal-sized heart with decreased pulmonary vascular markings. What cardiac lesions should one consider when the radiologist says the infant has a right-sided aortic arch? Four-chamber echocardiogram demonstrating an inferiorly displaced tricuspid valve (arrow). Name three conditions associated with persistent patency of the ductus arteriosus. What are three common obstructive heart lesions that can present in the newborn period? Pulmonary stenosis in a neonate that is sufficiently severe to cause cyanosis and acidosis (rare) with signs of right-sided heart failure (rare) is defined as critical pulmonary stenosis. Pulmonary balloon valvuloplasty, in the cardiac catheterization laboratory, is undertaken to relieve the stenosis after stabilization of the infant. In affected infants the systemic circulation depends on the patency of the ductus arteriosus with flow from the pulmonary artery into the descending aorta. In some infants inotropic support, ventilation, and correction of acidosis may be required. Echocardiography should assess not only the architecture of the aortic valve but also the mitral valve architecture and the degree, if any, of left ventricular hypoplasia. Most infants are palliated by an aortic balloon valvuloplasty; however, long-term follow-up is mandatory. Neonatal coarctation of the aorta is obstruction in the thoracic aorta or the transverse aortic arch and requires patency of the ductus arteriosus to maintain cardiac output. Four-extremity blood pressure measurements should be obtained, with careful attention to the right arm and lower extremities. In extreme cases affected infants have signs and symptoms of acute circulatory shock, with decreased or absent femoral pulses. Neonates with circulatory collapse should be fully resuscitated before surgery with correction of acidosis. Prostaglandins should be administered to reestablish ductal patency, because there is an obligate right-to-left ductal shunt. In neonates with critical coarctation (ductal dependent), surgery is required and can generally be performed by a left thoracotomy. If the apex of the heart is on the opposite side of the patient from the stomach, what is the likelihood that the patient has congenital heart disease? An aberrant right subclavian artery can also be seen in this condition (most common; approximately 40% of all cases) n Type C: Interruption is between the innominate artery and the left carotid artery 80. What genetic abnormality and clinical features are associated with interrupted aortic arch? DiGeorge syndrome (22q11 Deletion Syndrome) is a constellation of clinical symptoms that includes a lack of thymus gland and a lack of parathyroid (hypocalcemia), with certain common conotruncal heart defects. A similar syndrome (velocardiofacial syndrome) may have associated midline facial defects. Coarctation of the aorta from fetus to adult: curable condition or life-long process? Either computed tomography angiography or magnetic resonance imaging is typically considered the preferred definitive imaging modality in the diagnosis of a vascular ring. A complete vascular ring is formed by abnormal vascular structures completely encircling the trachea and esophagus. An incomplete vascular ring occurs when there is vascular compression of the trachea and esophagus without completely encircling these structures. Most infants with vascular rings present with symptoms within the first several weeks to months of life, with a double aortic arch and pulmonary sling being symptomatic earlier than the other rings. Infants may hold their heads hyperextended to alleviate the symptoms of airway obstruction. Symptoms of respiratory distress, stridor, "seal bark" cough, apnea, dysphagia, and recurrent respiratory infections may occur. Dysphagia may first be detected when infants transition from liquid formula to solid food. A right-sided aortic arch with a left ligamentum is the second most common vascular ring (30%). Surgical intervention is indicated in all symptomatic patients with vascular rings. Symptoms include respiratory distress, recurrent respiratory infections, dysphagia, and apneic spells. Additional imaging, including a barium swallow and echocardiogram, is helpful in this diagnosis of a vascular ring. However, computed tomography angiography, which can now be done rapidly and therefore does not require general anesthesia, is considered by most institutions to be the single best diagnostic test when a vascular ring is suspected. Dissection around the esophagus and trachea to lyse any residual adhesive bands is performed. A barium swallow will reveal an anterior indentation of the esophagous on the lateral projection. Rings, slings and other things: vascular structures contributing to a neonatal noose. Pediatric thoracic problems: patent ductus arteriosus, vascular rings, congenital tracheal stenosis, and pectus deformities. When using a chest x-ray to evaluate a patient with congenital heart disease, identification of the stomach bubble and liver shadow will help assess abdominal situs. Although electrocardiography may define the location of the sinoatrial node and ventricular mass, echocardiography is the diagnostic test of choice to define the cardiac segments. The segmental approach to the classification of congenital heart disease was originally proposed by Dr. The three main cardiac segments are (1) atria, (2) ventricles, and (3) great arteries. How can electrocardiography localize where the anatomic right and left ventricles are located? Because depolarization occurs in the left ventricle before the right ventricle, the presence/location of the Q waves over the precordium can assist in the anatomic location of the left ventricle and right ventricle. If Q waves are seen in V5 and V6, and lead 1, the left ventricle is D-looped and on the left side. If Q waves are seen in V4R, V1 and V2, but not seen in V5 and V6, it is likely that the ventricles are L-looped. The chest x-ray, electrocardiography, and echocardiogram are three modalities that can help locate the position of the atria. Polysplenia (associated with left atrial isomerism) or asplenia (right atrial isomerism) is present. These patients are at high risk for malrotation of the intestines, which should be investigated with ultrasound or barium study. The cardiac malformations are complex typically, with abnormal venoatrial connections. The umbilical arterial catheter and aortic knob likely confirm a right-sided aortic arch. The p wave axis on the electrocardiogram will determine from where the sinoatrial node pulse is originating and therefore where the sinoatrial node and right atrium are located. The coronary sinus and the suprahepatic portion of the inferior vena cava drain to the right atrium. In atrial situs solitus the systemic veins (superior and inferior vena cavae) drain to the right atrium, and the pulmonary veins drain to the left atrium. However, the most reliable echocardiographic marker of the right atrium is the drainage of the coronary sinus and the suprahepatic inferior vena cava. Dextrocardia is a condition in which the heart lies in the right side of the chest. It may occur with dextroposition, when the heart is pushed into the right side of the chest. It also may occur when the cardiac apex is directed to the right side of the patient. This term does not define the segmental atrioventricular or ventriculoarterial relationships. The nomenclature, definition and classification of cardiac structure in the setting of heterotaxy. Controversies, genetics, diagnostic assessment, and outcomes relating to the heterotaxy syndrome. Close clinical assessment is needed when feeding neonates with ductal-dependent congenital heart disease. Complexity of congenital heart defect and time of intubation are two predictors of postoperative feeding dysfunction. There are noticeable variations in strategies for preoperative feeding management between providers. Clinicians practicing outside the United States are eight times more likely to enterally feed ductal-dependent neonates than clinicians practicing in the United States. Clinical assessment, arterial blood gas assessment, blood lactate level, diastolic blood pressure, echocardiogram, abdominal x-ray, and abdominal near-infrared spectroscopy may be helpful in making this decision. Enteral feeding in neonates with prostaglandin-dependent congenital cardiac disease: international survey on current trends and variations in practice. What congenital heart lesions are treated with placement of a shunt in the newborn period? Examples include lesions with a hypoplastic pulmonary annulus, atretic pulmonary valve annulus, or severely hypoplastic main and branch pulmonary arteries.
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But when decompensation and cardiac failure supervene erectile dysfunction endovascular treatment buy levitra professional 20mg mastercard, there is eccentric hypertrophy (with dilatation) with thinning of the ventricular wall and there may be dilatation and hypertrophy of right heart as well erectile dysfunction caverject injection purchase levitra professional 20mg line. M/E the changes include enlargement and degeneration of myocardial fibreswithfocalareasofmyocardialfibrosis erectile dysfunction injections videos buy levitra professional 20 mg without prescription. Thus impotence kegel exercises 20 mg levitra professional overnight delivery, cor pulmonale is the right-sided counterpart of the hypertensive heart disease just described erectile dysfunction protocol download pdf levitra professional 20 mg amex. Depending upon the rapidity of development erectile dysfunction va disability cheap 20 mg levitra professional with visa, cor pulmonale may be acute or chronic: Acute cor pulmonale occurs following massive pulmonary embolism resulting in sudden dilatation of the pulmonary trunk, conus and right ventricle. Chronic cor pulmonale is more common and is often preceded by chronic pulmonary hypertension. Following chronic lung diseases can cause chronic pulmonary hypertension and subsequent cor pulmonale: i) Chronic emphysema ii) Chronic bronchitis iii) Pulmonary tuberculosis iv) Pneumoconiosis v) Cysticfibrosis vi) Hyperventilation in marked obesity (Pickwickian syndrome) vii) Multiple organised pulmonary emboli. The most common underlying mechanism causing increased pulmonary blood pressure (pulmonary hypertension) is by pulmonary vasoconstriction, activation of coagulation pathway and obliteration of pulmonary arterial vessels. Pulmonary hypertension causes pressure overload on the right ventricle and hence right ventricular enlargement. G/A In acute cor pulmonale, there is characteristic ovoid dilatation of the right ventricle, and sometimes of the right atrium. In chronic cor pulmonale, there is increase in thickness of the right ventricular wall from its normal 3 to 5 mm up to 10 mm or more. In spite of its name suggesting an acute arthritis migrating from joint to joint, it is the heart rather than the joints whichisfirstandmajororganaffected. The disease is seen more commonly in poor socioeconomic strata of the society living in damp and overcrowded places which promote interpersonal spread of the streptococcal infection. It is still common in the developing countries of the world, particularly prevalent in Indian subcontinent (India, Pakistan, Bangladesh, Nepal, Afghanistan), some Arab countries, subSaharan Africa and some South American countries. However, the mechanism of lesions in the heart, joints and other tissues is not by direct infection but by induction of hypersensitivity or autoimmunity in a susceptible host. Socioeconomic factors like poverty, poor nutrition, density of population, overcrowding in quarters for sleeping etc are associated with spread of infection. The geographic distribution of the disease, as already pointed out, shows higher frequency and severity of the disease in the developing countries of the world where the living conditions in underprivileged populationsaresubstandardandmedicalfacilitiesareinsufficient. The incidence of the disease is higher in subtropical and tropical regions with cold, damp climate near the rivers and waterways which favour the spread of infection. Cell wall polysaccharide of group A Streptococcus forms antibodies which are reactive against cardiac valves. Hyaluronate capsule of group A Streptococcus is identical to human hyaluronate present in joint tissues and thus these tissues are the target of attack. Membrane antigens of group A Streptococcus react with sarcolemma ofsmoothandcardiacmuscle,dermalfibroblastsandneuronsofcaudate nucleus. Initially, there is oedema of the connective tissue and increase in acid mucopolysaccharide in the ground substance. Intermediate (proliferative or granulomatous) stage It is this stage of the Aschoff body which is pathognomonic of rheumatic conditions. Theearlystageoffibrinoid changeisfollowedbyprolife ationofcellsthatincludesinfiltrationbylymphor cytes (mostly T cells), plasma cells, a few neutrophils and the characteristic cardiac histiocytes (Anitschkow cells) at the margin of the lesion. Late (healing or fibrous) stage the stage of healing by fibrosis of the Aschoff nodule occurs in about 12 to 16 weeks after the illness. Thisisfollowedby the formation of characteristic, small (1 to 3 mm in diameter), multiple, warty vegetations or verrucae,chieflyalongthelineofclosureoftheleafletsand cusps. Though all the four heart valves are affected, their frequency and severity of involvement varies: mitral valve alone being the most common site, followed in decreasing order of frequency, by combined mitral and aortic valve. The higher incidence of vegetations on left side of the heart is possibly because of the greater mechanical stresses on the valves of the left heart, especially along the line of closure of the valve cusps. M/E the inflammatory changes begin in the region of the valve rings (where the leaflets are attached to the fibrous annulus) and then extend throughouttheentireleaflet,whereasvegetationsareusuallylocatedonthe freemarginoftheleafletsandcusps. M/E the affected area shows oedema, fibrinoid change in the collagen, and cellular infiltrate of lymphocytes, plasma cells and macrophages with many Anitschkow cells. In the intermediate stage, the interstitial tissue of the myocardium shows small foci of necrosis. Later, tiny pale foci of the Aschoff bodies may be visible throughout the myocardium. M/E the most characteristic feature of rheumatic myocarditis is the presence of distinctive Aschoff bodies. These diagnostic nodules are scattered throughout the interstitial tissue of the myocardium and are most frequent in the interventricular septum, left ventricle and left atrium. G/A If the parietal pericardium is pulled off from the visceral pericardium, thetwoseparatedsurfacesareshaggyduetothickfibrincoveringthem. Characteristic Aschoff bodies may be seen which later undergo organisation andfibrosis. They are attached to deeper structures like tendons, ligaments, fascia or periosteum and therefore often remain unnoticed by the patient. With 266 subsequent streptococcal pharyngitis, there is reactivation of the disease and similar clinical manifestations appear with each recurrent attack. The long-term sequelae or stigmata are the chronic valvular deformities, especially the mitral stenosis, as already just explained. G/A Characteristic vegetations occur most frequently on the mitral and tricuspid valves. The vegetations of atypical verrucous endocarditis are small (1 to 4 mm in diameter), granular, multiple and tend to occur on both surfaces of affected valves. M/E TheverrucaeofLibman-Sacksendocarditisarecomposedoffibrinoid material with superimposed fibrin and platelet thrombi. Following diseases and conditions are frequently associated with their presence: 1. Occurrence of these lesions in young and well-nourished patients is explained on the basis of alternative hypothesis such as allergy, vitamin C deficiency,deepveinthrombosis,andendocardialtrauma. Otherlesscommonetiologicagents include other strains of streptococci and staphylococci. Bacteraemia, septicaemia and pyaemia: Bacteria gain entry to the blood stream causing transient and clinically silent bacteraemia in a variety of day-to-day procedures as well as from other sources of infection. Some of the common examples are: i) Periodontal infections ii) Infections of the genitourinary tract iii) Infections of gastrointestinal and biliary tract iv) Surgery of the bowel, biliary tract and genitourinary tracts v) Skin infections vi) Upper and lower respiratory tract infections vii) Intravenous drug abuse. Amongst the commonly associated underlying heart diseases are the following: i) Chronic rheumatic valvular disease in about 50% cases. Microscopy G/A the lesions are found commonly on the valves of the left heart, most frequently on the mitral, followed in descending frequency, by the aortic, simultaneous involvement of both mitral and aortic valves. These are as follows: i) Emboli originating from the left side of the heart and entering the systemic circulation affect organs like the spleen, kidneys, and brain causing infarcts, abscesses and mycotic aneurysms. Tuberculous endocarditis Though tubercle bacilli are bacteria, tuberculous endocarditis is described separate from the bacterial endocarditis due to specific granulomatous inflammation found in tuberculosis. It is characterised by presence of typical tubercles on the valvular as well as mural endocardium and may form tuberculous thromboemboli. The severest manifestation of cardiovascular syphilis is aortic valvular incompetence. Fungal endocarditis Rarely, endocardium may be infected such as from Candida albicans, Histoplasma capsulatum, Aspergillus, Mucor, coccidioidomycosis, cryptococcosis, blastomycosis and actinomycosis. Opportunistic fungal infections like candidiasis and aspergillosis are seen more commonly in patients receiving long-term antibiotic therapy, intravenous drug abusers and after prosthetic valve replacement. Valves of the left side of the heart are involved much more frequently than those of the right side of the heart. The mitral valve is affected most often, followed in descending frequency, by the aortic valve, and combined mitral and aortic valves. The valvular deformities may be of 2 types: stenosis andinsufficiency: Stenosis is the term used for failure of a valve to open completely during diastoleresultinginobstructiontotheforwardflowoftheblood. Insufficiency or incompetence or regurgitation is the failure of a valve toclosecompletelyduringsystoleresultinginbackfloworregurgitationof the blood. Various acquired valvular diseases that may deform the heart valves are listed below: 1. The latent period between the rheumatic carditis and development of symptomatic mitral stenosis is about two decades. G/A Generally,thevalveleafletsarediffu elythickenedbyfibroustissue s and/or calcific depo its, especially towards the closing margin. Pulmonary hypertension resulting from passive backward transmission of elevated left artial pressure which causes: i) chronic passive congestion of the lungs; ii) hypertrophy and dilatation of the right ventricle; and iii) dilatation of the right atrium when right heart failure supervenes. In non-inflammatory calcification of mitral annulus seen in the aged, there is irregular, stony-hard, bead-like thickening. Features of pulmonary hypertension such as: i) chronic passive congestion of the lungs; ii) hypertrophy and dilatation of the right ventricle; and iii) dilatation of the right atrium when right heart failure supervenes. Angina pectoris usually results from elevation of pulmonary capillary pressure and usually develops due to increased demand of hypertrophied myocardial mass. G/A the aortic valve cusps are thickened, deformed and shortened and fail to close. This leads to hypertrophy and dilatation of the left ventricle producing massive cardiac enlargement so that the heart may weigh as much as 1000 gm. Failure of the left ventricle increases the pressure in the left atrium and eventually pulmonary hypertension and right heart failure occurs. The lesions are characteristically located in the valves and endocardium of the right side of the heart. But in carcinoid tumour with hepatic metastasis, there is increased blood level of serotonin secreted by the tumour. Both pulmonary and tricuspid valves as well as the endocardium of the rightchambersshowcharaceristiccartilage-likefibrousplaques. Others have noted myxomatous degeneration in cases of Ehlers-Danlos syndrome and in myotonic dystrophy. G/A Any cardiac valve may be involved but mitral valve is affected most frequently. M/E the enlarged cusp shows loose connective tissue with abundant mucoid or myxoid material due to abundance of mucopolysaccharide. Itsexactincidenceisdifficult to ascerain as the histological examination has been largely confined to t autopsy material. G/A There are either abscesses in the myocardium or there is diffuse myocardial involvement. M/E Theexudatechieflyconsistsofneutro hils,admixedwithlymphocytes, p plasma cells and macrophages. Sarcoidosis, though not a bacterial infection, has histological resemblance to other granulomatous myocarditis. Toxoplasmosis caused by intracellularprotozoan,Toxoplasma gondii, sometimes causes myocarditis in children and adults. Echinococcus rarely produces hydatid cyst in the myocardium while the larvae of Trichinellaintrichinosiscauseheavyinflam ationinthe m myocardium as well as in the interstitial tissue. These include: candidiasis, aspergillosis, blastomycosis, actinomyosis, cryptococcosis, coccidioidomycosis and histoplasmosis. The condition is rapidly progressive and causes sudden severe cardiac failure or sudden death. M/E Two forms of idiopathic myocarditis are described: diffuse type and giant cell (idiopathic granulomatous) type. The condition occurs more often in adults and the average survival from onset to death is less than 5 years. The most characteristic feature is prominent dilatation of all the four chambers giving the heart typical globular appearance. M/E the endomyocardial biopsies or autopsy examination of the heart reveal non-specific and variable changes. The hypertrophy of the myocardium is typically asymmetrical and affects the interventricular septum more than the free walls of the ventricles. The designation of rhabdomyoma of the septum was applied to this form of cardiomyopathy. M/E the classical feature is the myocardial cell disorganisation in the ventricular septum. Thecommonfeaturein this heterogeneous group of conditions producing restrictive cardiomyopathy is abnormal diastolic function. The infantile form is clinically characterised by sudden breathlessness, cyanosis, cardiac failure and death whereas the symptoms in the adult form last for longer duration. G/A the characteristic feature is the diffuse or patchy, rigid, pearlywhite thickening of the mural endocardium. M/E Typical finding is the prolife ation of the collagen and elastic tissue r (fibroelastosis)comprisingthethickenedendocardium. The clinical manifestations consist of congestive heart failure of unknowncausejustasinadultvarietyofendocardialfibroelastosis. G/A Endomyocardial fib o is is characterised by fibrous scarring of r s the ventricular endocardium that extends to involve the inner third of the myocardium. M/E the endocardium and parts of inner third of the myocardium show destructionofnormaltissueandreplacementbyfibroustissue. However,itdiffersfromthelatterinfollowing respects: a) There is generally a peripheral blood eosinophilic leucocytosis. This,however,excludeswell-definedentitiessuchas ischaemic,hyperensive,valvular,pericardial,congenitalandinflam atory t m involvements of the heart. Considerablequantitiesoffluid(up to 1000 ml) can be accommodated in the pericardial cavity without seriously affecting the cardiac function if the accumulation is slow.
In contrast to radicular pain erectile dysfunction filthy frank purchase 20mg levitra professional with mastercard, the pain related to spinal cord metastases is worse with lying down impotence in xala generic 20 mg levitra professional overnight delivery. Patients presenting with back pain alone should have a careful examination to attempt to localize the lesion before development of more severe neurologic symptoms erectile dysfunction effects on women order levitra professional 20 mg mastercard. In this patient with paraplegia erectile dysfunction pills for sale levitra professional 20mg free shipping, there is an definitive level at which sensation is diminished erectile dysfunction klonopin generic levitra professional 20mg overnight delivery. In those with autonomic dysfunction erectile dysfunction first time purchase levitra professional 20 mg without prescription, bowel and bladder incontinence occur with decreased anal tone, absence of the anal wink and bulbocavernosus reflexes, and bladder distention. The most important initial step is the administration of high-dose intravenous corticosteroids to minimize associated swelling around the lesion and prevent paraplegia while allowing further evaluation and treatment. As the chemotherapeutic agents act on these cells, there is massive tumor lysis that results in release of intracellular ions and nucleic acids. This leads to a characteristic metabolic syndrome of hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia. Acute kidney injury is frequent and can lead to renal failure, requiring hemodialysis if uric acid crystallizes within the renal tubules. Hyperphosphatemia occurs because of the release of intracellular phosphate ions and causes a reciprocal reduction in serum calcium. This hypocalcemia can be profound, leading to 81 neuromuscular irritability and tetany. Hyperkalemia can become rapidly life threatening and cause ventricular arrhythmia. Knowing the characteristics of tumor lysis syndrome, one can attempt to prevent the known complications from occurring. Laboratory studies should be obtained no less than three times daily, but more frequent monitoring is often needed. If allopurinol fails to control uric acid to less than 8 mg/dL, rasburicase, a recombinant urate oxidase, can be added at a dose of 0. Throughout this period, the patient should be well hydrated with alkalinization of the urine to a pH of greater than 7. Prophylactic hemodialysis is not performed unless there is underlying renal failure before starting chemotherapy. The recommended estimated average requirement of vitamin X is 10 mg/d, two standard deviations below the amount published in the study. Two standard deviations above the estimated average requirement defines the tolerable upper limit. The study was not designed to assess safety and therefore should not influence practice. What is the optimal percentage of daily caloric intake derived from carbohydrates? When considering the nutritional requirements for an individual, what term is used to define the quantitative estimated nutrient intake? The resting energy expenditure is a rough estimate of total caloric needs in a state of energy balance. A 36-year-old man is admitted from the emergency room with cellulitis of the right leg. You are concerned about his nutritional state, as he has limited caloric intake other than alcohol. A 62-year-old man with a long-standing history of alcoholism is brought to the emergency department after being found wandering in a park without shirt or shoes in the winter. When asked about the circumstances that led to him being in the emergency room, he initially states that some men were chasing him. His daughter reports that he frequently seems confused and makes up stories all the time regarding his behavior. His only other complaint is a burning pain in his legs that is present at all times. He is college educated and worked as an accountant until his alcoholism led to the loss of his job. Acute alcohol intoxication Delirium tremens Lead intoxication Niacin deficiency Thiamine deficiency and complains of fatigue. Reviewing his chart you find that he had a hemarthrosis evacuated 6 months ago and has been lost to follow-up since then. He also has a diffuse hemorrhagic eruption on his legs that is centered around hair follicles. He has read that taking high doses of vitamin E can improve his sexual performance and slow the aging process. A 48-year-old man is diagnosed with carcinoid syndrome after presenting with diarrhea, flushing, and hypotension. With treatment, he experiences an appropriate response biochemically and with most of his symptoms; however, he continues to complain of diarrhea and mouth soreness. On examination, you notice his tongue is bright red and somewhat enlarged, and is tender to the touch. Dermatologically, he has a red scaly rash on sunexposed areas and around his neckline. You are seeing a pediatric patient from Djibouti in consultation who was admitted with a constellation of symptoms including diarrhea, alopecia, muscle wasting, depression, and a rash involving the face, extremities, and perineum. You astutely make the diagnosis of zinc deficiency, and laboratory tests confirm this (zinc level <70 L/dL). A diagnosis of marasmus or cachexia requires a more aggressive approach to nutritional replacement than kwashiorkor. Individuals with marasmus or cachexia have a starved appearance, whereas those with kwashiorkor typically appear well nourished. Marasmus and cachexia are associated with a higher risk of infection and poor wound healing compared to kwashiorkor. Marasmus develops over a period of weeks, whereas kwashiorkor takes months or years to develop. Vitamin A deficiency is associated with an increased risk of which of the following? A 51-year-old alcoholic man is admitted to the hospital for upper gastrointestinal bleeding. From further history and physical examination, it becomes apparent that his bleeding is from gingival membranes. Which of the following patients would be least likely to be at high risk of nutritional depletion? A 21-year-old woman with a history of anorexia nervosa in remission for 1 year with a body mass index of 19. He is not malnourished because he is not hypoglycemic after 6 days of no food or water. You are caring for a 54-year-old woman in the intensive care unit who was admitted for treatment of severe sepsis and pneumonia. You would like to initiate enteral nutrition and plan to calculate basal energy expenditure for the patient. On the second postoperative day, he requires repeat exploratory laparotomy due to bleeding complications. A 19-year-old woman with anorexia nervosa undergoes surgery for acute appendicitis. The postoperative course is complicated by acute respiratory distress syndrome, and she remains intubated for 10 days. Laboratory data show a white blood cell count of 4000/L, hematocrit 35%, albumin 2. Which of the following is true regarding the etiology and treatment of malnutrition in this patient? She has marasmic kwashiorkor, kwashiorkor predominant, and nutritional support should be aggressive. She has marasmic kwashiorkor, marasmus predominant, and nutritional support should be slow. Enteral feeding stimulates secretion of gastrointestinal hormones to promote trophic gut activity. Seventy percent of nutrients utilized by the gut are directly derived from food within the lumen of the gut. After being stranded alone in the mountains for 8 days, a 26-year-old hiker is brought to the hospital for evaluation of self-amputation of his right wrist. A 43-year-old woman develops hemorrhagic pancreatitis with severe systemic inflammation response syndrome. She is intubated and sedated in the medical intensive care unit with acute respiratory distress syndrome, hypotension, and renal dysfunction. A 55-year-old woman with a history of diabetic gastroparesis is intubated and on mechanical ventilation after a stroke. When the patient was suctioned that morning, she coughed profusely, with thick green secretions. You are concerned about the possibility of aspiration as a cause of her worsening respiratory status. She is being treated for hypertension and hypercholesterolemia, and is concerned about developing diabetes mellitus if she does not lose weight. What advice would you provide her regarding the benefits and risks of bariatric surgical procedures? A vertical-banded gastroplasty is the most effective restrictive surgical procedure. All types of bariatric surgery are associated with micronutrient deficiencies that require lifelong supplementation. Adopted children have body mass indices more similar to their biologic parents than their adoptive parents. Decreased levels of leptin and resistance to leptin are associated with the development of obesity. Identical twins have more similar body mass indices when compared to dizygotic twins. A 34-year-old woman sees her primary care physician for counseling regarding weight loss. She gained approximately 36 kg during her first pregnancy 6 years previously and has not lost this weight. She has always been a high-achieving student and is currently enrolled in an honors program at her university. She had initially joined a sorority, but she no longer participates and states that she is more focused on her studies at this point. She reports a normal diet and that she will occasionally eat an entire pizza or quart of ice cream when stressed. She cannot recall when her last menstrual period occurred, but states that these have been irregular throughout her life. Anorexia nervosa Binge eating disorder Bulimia nervosa Hyperthyroidism Patient is healthy and without a diagnosable medical condition consideration for inpatient treatment instead of scheduling an outpatient assessment? Which characteristic is more common in binge eating disorder than bulimia nervosa? She reports that her appetite began to decrease about 2 months ago when she noticed that food no longer had the same taste. Her daughter accompanies her to the visit and reports that her mother seems increasingly listless and withdrawn. Her daughter also notes that her mother seems more forgetful, and her home has become disorganized. Reassure the patient and her daughter that this degree of weight loss is not abnormal. The brain requires 100 g/d of glucose, with the rest of the body requiring about 50 g/d of glucose. Fats should comprise no more than 30% of caloric intake, and proteins typically should comprise about 15%. The estimated average intake is the amount of a nutrient estimated to meet the nutrient needs for half of the healthy individuals of a specific sex and age. Because this is a median value, it is generally not acceptable to set the estimated average intake as the benchmark for intake as, by definition, 50% of individuals would require more of the specific nutrient compared to this value. Adequate intake is determined based on observed or experimentally determined approximations of nutrient needs and is used for infants up to 1 year old, as well as for many minerals including calcium, manganese, chromium, and fluoride, among others. The tolerable upper limit of nutrient intake is the highest level of daily nutrient intake that is unlikely to cause adverse health effects. It is not useful clinically for estimating nutritional adequacy because it is a median requirement for a group: 50% of the individuals in a group fall below the requirement and 50% fall above it. Data on the tolerable upper limit of a vitamin are usually inadequate to establish a value for the upper limit of tolerability. The absence of a published tolerable upper limit does not imply that the risks are nonexistent. Alcoholism in general is associated with decreased intake of nutrients and may be associated with malabsorption or impaired storage. Other vitamins that may be deficient in alcoholics are niacin, vitamin B6, vitamin C, and vitamin A.