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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Jonathan Mark Zenilman, M.D.
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0005115/jonathan-zenilman
The case fatality rate is less than 2%; on average impotence workup viagra 100 mg without a prescription, infants will spend 44 days in the hospital impotence homeopathy treatment proven viagra 75 mg. Key findings on his examination include external ophthalmoplegia impotence lisinopril purchase 100mg viagra fast delivery, reactive pupils erectile dysfunction doctors orange county discount viagra 75mg free shipping, ptosis, facial weakness, and weakness in the arms and legs. His examination reveals ptosis, impaired ocular motility, dilated pupils, symmetrical weakness in the arms and legs, and normal cognitive function. The presence of reactive pupils and normal deep tendon reflexes points away from infantile botulism. Fecal cultures and not pharyngeal cultures are the best way to diagnose infantile botulism. This case is illustrative of foodborne botulism, which is known to have normal sensation and normal cognitive function. Classic presentation for infantile botulism includes antecedent constipation with the ascending paralysis, ptosis, dilated or unreactive pupils, and weakness in the arms and legs. The best way to test for infantile botulism is through stool samples via a mouse bioassay. More than 70% of these infants with botulism will eventually require mechanical ventilation. His wife who has accompanied him feels that he is clumsier noting that he is often times tripping. The patient has also noticed that he is clumsier and that he is more forgetful and is having difficulty focusing at work. Depression could also present this way; however, one would not expect there to be problems with coordination. A cytokine called oncostatin M may be the most damaging of the cytokines, although it acts in concert with other cytokines. Finally, there is evidence to support oxidative stress and increases in excitatory amino acids and intracellular calcium. Dementia: A disorder characterized by a general loss of intellectual abilities involving memory, judgment, abstract thinking, and changes in personality. Neuropsychological testing: A battery of tests used to evaluate cognitive impairment. A few patients, however, present with only immunosuppression by laboratory criteria. The forgetfulness is present early on, and patients have increasing difficulty performing complex tasks. Personality changes begin to appear such as apathy, social withdrawal, and quietness. Tripping or falling along with poor handwriting are the more common motor symptoms. Myoclonic jerks, postural tremor, and bowel and bladder dysfunction can be present in the later stages of the disease. Patients at end stage of the disease are unable to ambulate, have incontinence, and are almost in a vegetative state. Early in the disease course, neuropsychologic testing can be normal; however, as time progresses there is evidence of a subcortical dementia. Typical abnormalities include difficulty in concentration, motor manipulation, and motor speed. Initially, the neurologic examination is normal, and at this time, subtle impairment in rapid limb and eye movements can be found. As the disease progresses, hyperreflexia, spasticity, and frontal release signs can be found. Additionally apraxia (inability to perform previously learned tasks) and akinetic mutism (severely decreased motor-verbal output) can develop. Some patients have white matter changes and abnormalities in the thalamus and basal ganglia. This will determine whether or not there is increased intracranial pressure so that a lumbar puncture can be safely performed. Although neuropsychologic testing is required, it is not meant to evaluate solely for a personality disorder. She had not noticed these symptoms until her coworkers and family pointed it out to her. Although these symptoms presented 4 months ago, she did not seek medical attention until now when they began interfering with her daily activities. She has noticed difficulty with problem solving, and her boss has witnessed inappropriate behavior. Her family reports that over the past month her memory has quickly deteriorated to the point that she is unable to recognize friends, is unable to drive, is not able to work, and forgets if she has eaten. She has also developed slurred speech and has been witnessed to "jerk" during the day. Her strength appears to be normal; however, she has dysmetria and a widebased gait. Be familiar with the clinical presentation of sporadic Creutzfeldt-Jakob disease and its variants. Considerations this 53-year-old woman presents with a rapidly progressive set of neurologic symptoms including memory loss, ataxia, behavioral changes, poor coordination, and myoclonus. At first, patients experience problems with muscular coordination; personality changes, including impaired memory, judgment, and thinking; and impaired vision. It affects approximately one person in every one million people per year worldwide; in the United States there are approximately 200 cases per year. Typically, onset of symptoms occurs approximately at 60 years of age, and approximately 90% of patients die within 1 year. In the early stages of disease, patients can have failing memory, behavioral changes, lack of coordination, and visual disturbances. As the illness progresses, mental deterioration becomes pronounced, and involuntary movements, blindness, weakness of extremities, and coma can occur. Spongiform refers to the characteristic appearance of infected brains, which become filled with holes until they resemble sponges under a microscope. Kuru was identified in people of an isolated Cannabalistic tribe in Papua, New Guinea, and has now almost disappeared. Initially, patients experience problems with muscular coordination, personality changes, including impaired memory, judgment, and thinking, and impaired vision. Affected patients also can experience insomnia, depression, or unusual sensations. Pneumonia and other infections often occur in these patients and can lead to death. Another variant, called the panencephalopathic form, occurs primarily in Japan and has a relatively long course, with symptoms often progressing for several years. Scientists are trying to learn what causes these variations in the symptoms and course of the disease. The harmless and infectious forms of the prion protein have the same sequence of amino acids (the "building blocks" of proteins) but the infectious form of the protein takes a different folded shape than the normal protein. These cases arise from a mutation, or change, in the gene that controls formation of the normal prion protein. The particular mutation found in each family affects how frequently the disease appears and what symptoms are most noticeable. However, exposure to brain tissue and spinal cord fluid from infected patients should be avoided. Some animal studies suggest that contaminated blood and related products may transmit the disease, although this has never been shown in humans. If there are infectious agents in these fluids, they are probably in very low concentrations. Scrapie, a disorder of sheep and goats, has been known for more than 300 years and is endemic in the British Isles. In 1938 experimental transfer of scrapie from one sheep to another by inoculation provided evidence of an infective etiology.
For the past 10 years erectile dysfunction pills australia discount viagra 100mg fast delivery, she has been a medical writer and consultant on highprofile reports and publications and has coauthored review articles in Science erectile dysfunction cream 16 buy viagra 50 mg low price, Journal of the American Medical Association erectile dysfunction treatment unani quality 25 mg viagra, and Neurology erectile dysfunction age young 100 mg viagra otc. She holds an adjunct faculty post at the George Washington University School of Public Health and Health Services. Hanson is a research associate in the Board on Health Sciences Policy at the Institute of Medicine. Prior to joining the Institute of Medicine, she served as research and program assistant at the National Research Center for Women & Families. Taylor is a senior project assistant for the Board on Health Sciences Policy working on the Sleep Medicine and Research project. Between college and graduate school, she studied abroad at the Glasgow School of Art on a Rotary International Scholars Fellowship. She previously served as a senior project assistant for the Clinical Research Roundtable. Other recent studies include Testosterone and Aging: Clinical Research Directions, Gulf War and Health, and Reducing the Burden of Injury. Her background is in medical library science, with previous positions at the National Agricultural Library and the Naval War College Library. She served as a research associate on the Sleep Medicine and Biology study until July 2005. See also individual structures activity during sleep, 21, 35, 36, 37, 39 blood flow and metabolism, 39, 80, 142, 227 emotional pathways, 80 imaging of cognitive impairments, 142 iron deficiency, 98-99, 227, 262 metastases, 103 pain circuitry, 101 sleep-wake regulation processes and structures, 40-41, 43, 76-77, 80, 101 suprachiasmatic nucleus, 39, 42-43, 261 Breathing. See Medical education in somnology; Professional training; Public education Elderly people. See National Institutes of Health Growth hormone, 39, 104 H Harvard University, 187, 236, 239, 298, 376-377 Harvard Work Hours Health and Safety Study, 139 Head trauma, 85, 87 Health care professionals. See also Professional training attraction to sleep field, 183 awareness about sleep disorders, 182183 board certification in sleep medicine, 197-201, 298, 314-315 Health insurance coverage, 28, 209, 219, 315 Healthy Sleep Handbook, 176 Heart attack. See also individual disorders cancer, 103, 105 grants for research, 270 infectious diseases, 102-104 pain, 100-101 treatment-related effects, 104-106 Medical education in somnology. See also Cognitive deficits Periodic limb movement disorder, 2, 20, 92, 98, 100, 220, 223, 273, 295, 355 Periodic limb movement index, 223 Physical activity education campaign, 177 Physicians. See Rapid-eye-movement sleep Renal disease, treatment-related sleep problems, 105-106 Research. Conte Centers to Develop Collaborative Neuroscience Research, 281 Sleep Academic Award program, 189-190, 240, 241, 352 Sleep apneas, 105. See Circadian rhythm; Insomnia; Medical disorders and sleep; Narcolepsy; Neurological disorders with sleep abnormalities; Parasomnias; Psychiatric sleep disorders with sleep disturbances; Restless leg syndrome; Sleepdisordered breathing; Sleep loss and sleep disorders Sleep drunkenness (inertia), 84, 342 Sleep Heart Health Study, 61, 67, 68, 6970, 71, 161, 223, 264 data coordinating center, 352 Sleep hygiene training, 78, 155, 184, 342 Sleep in America poll, 177 Sleep loss and sleep disorders, general. See Portable monitoring and therapeutic devices Sleep paralysis, 84, 87, 89, 90, 342 Sleep patterns age and, 44-47, 142, 143 circadian rhythm disruption, 21 temporal distribution, 108 Sleep Research Society, 2, 22, 25, 29, 177, 235, 237, 249 Sleep Research Society Foundation, 177 Sleep restriction therapy, 77, 342 Sleep, Sleep Disorders, and Biological Rhythms, 176 Sleep spindles, 36, 186, 342-343 Sleep terrors, 89, 90, 227, 343 Sleep-wake regulation brain processes and structures, 40-41, 43, 76-77, 80, 85, 92, 94, 261 iatrogenic effects of medical therapies, 104-106 immune system and, 102 phylogenetic studies, 261-262 two-process model, 39-40 Sleepiness, excessive daytime. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast feeding. Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work. Dedication For our families: Pip, Beth, and Ellen; Judith, Sarah, Michael, and Jennifer And from all the contributors: Thanks to our own families, and those we meet through our work, who support us and teach us so much. We have appreciated the very constructive suggestions for improvement of the first edition and followed them where we can. We have added respiratory consults to Chapter 5, and included more neuroradiology, diagrams, and images in situations where they offer clarity. A section on late-onset metabolic disease is added with an emphasis on how this group of disorders might catch us out. With an ever-increasing list of genes and autoantibodies to think about it is important to remember those everyday skills we carry, honed as juniors in our specialty: listening to what is truly being said, careful clinical examination, focused investigation, and above all the communication of understanding, reassurance, and hope to families and young people facing challenges they never dreamed existed. We also wanted to address a number of practical issues that occupy a lot of time in practice, but that are rarely addressed in more conventional textbooks. We are very grateful to Nuno Cordeiro, Christian de Goede, and Omar Kwaja who contributed so generously to the first edition. We are particularly grateful to Anna Basu, Ram Kumar, and Kate Riney for detailed proof-reading but any remaining errors are of course our responsibility. Setting the scene Make people feel welcome, greet them at the door, welcome them in. Consider providing open question sheets before the appointment with question prompts. In complex situations, it may be helpful to be able to reassure everyone that this will be the first of several opportunities to talk together. Review appointment issues 2 Again, encourage questions from the family to establish the consultation agenda. I shall do the best I can to explain something about it to you and then explain how we can help. Present it rather as maximizing developmental potential and limiting secondary complications. Remember that parents will recall little of what you said at a first consultation and misunderstand half of that. See if an advocate is available for them (health visitor, social worker, ward nurse, or a friend they know well). Examination findings, plus some neuroanatomical knowledge, locate the problem (the `where The signs you elicit at examination, evaluated in light of neuroanatomical knowledge and pattern recognition, indicate the site(s) of the problem. Again the time-course can be helpful: epileptic events tend to last seconds to a few minutes; migrainous events tend to evolve over tens of minutes and to last up to several hours.
No differences were found in cardiorespiratory parameters (heart rate statistics of erectile dysfunction in india order viagra 25 mg overnight delivery, respiratory rate best erectile dysfunction doctors nyc buy viagra 25 mg overnight delivery, blood pressure or oxygen saturation) within or between treatment groups (p>0 erectile dysfunction caverject injection cheap viagra 100mg online. The only statistically different finding was the time for regaining consciousness in children that presented unconscious to the emergency department trimix erectile dysfunction treatment purchase 75 mg viagra visa, for valproate 58. Summary: the evidence finds no difference between phenytoin and valproic acid in the setting of partial and generalized epilepsy (excluding myoclonus and absence seizures) in adults and children for a variety of outcome measures. No difference was found between intravenous valproate or phenytoin in an emergency room setting of children with acute motor focal or generalized seizures, although unconscious children regained consciousness significantly more rapidly with valproate. Phenytoin vs Carbamazepine A Cochrane Review117 compared phenytoin and carbamazepine monotherapy for the treatment of partial onset or generalized seizures in children and adults. A total of 12 trials were identified, of which 4 trials (N=595) included individual participant data and were included in the review. Trials were of overall good quality although the authors suggest that up to 30% of patients may have had their seizure type misclassified. Outcome measures included time to 6-month remission, time to 12-month remission, time to first seizure post randomization and time to treatment withdrawal as a measure of tolerability. No significant difference was found in any outcome measure between phenytoin and carbamazepine including serious adverse events. Adverse events reflected the product labeling with no serious or unusual events noted. Summary: Limited evidence which may be confounded by misclassified seizure type, finds no difference in efficacy between phenytoin and carbamazepine for 58 efficacy measures in children and adults with partial onset or generalized seizures. Carbamazepine use resulted in a higher discontinuation rate, suggesting lower tolerability. Phenobarbitone/Phenobarbital vs Phenytoin A Cochrane Review118 compared phenobarbitone vs phenytoin for monotherapy treatment of generalized, tonic-clonic seizures or partial onset seizures in adults of children. Individualized participant data was found in 4 of 8 identified trials for 599 participants reflecting 63% of the data. Care must be taken when interpreting the skewed data with 78% of participants having partial onset seizures and 22% generalized seizures. For every measure of time to treatment withdrawal (pooled participants, pooled by seizure type or stratified by seizure type) phenobarbitone treatment resulted in statistically more withdrawals than phenytoin. The time to 6- and 12-month remission did not differ between the two groups, however, summary statistics with wide confidence intervals do not support equivalence. The time to the first, post-randomization seizure did not differ between treatment groups. Overall, no difference in seizure control was identified between phenobarbitone and phenytoin although phenytoin therapy resulted in significantly fewer treatment withdrawals which may reflect better tolerability. Painter et al119 compared phenobarbital and phenytoin when dosed to predetermined serum concentrations in 59 neonates with seizures. Combination therapy resulted in similar results regardless of whether the patient received phenobarbital or phenytoin initially (57% vs 62%, respectively; p=0. Summary: the evidence suggests that phenobarbitone and phenytoin are not different in efficacy outcomes for neonatal seizures. Although response rates were not statistically different, the evidence is insufficient to prove equivalence in the treatment of generalized, tonic-clonic and partial seizures in adults and children with phenytoin better tolerated. Carbamazepine vs Valproate Marson et al120 performed a meta-analysis comparing valproate and carbamazepine therapy in the treatment of epilepsy in children and adults in which a misdiagnosis of epilepsy could not be ruled out. Assessed outcomes included the retention time, time to first post-randomization seizures and time to 12-month remission. In the setting of generalized-onset seizures no difference was found between treatments. Summary: Evidence, which may be confounded by misclassified seizure type, finds both carbamazepine and valproate were equally efficacious in the treatment of generalized and partial-onset epilepsy in adults and children. Methsuximide 59 Methsuximide was prospectively studied in an open-label protocol of 112 children with epilepsy refractory to first line antiepileptic drugs or combinations or antiepileptic drugs. Methsuximide serum concentrations were positively correlated with reversible ataxia and leukopenia when >45 mg/L. Tennison et al122 found methsuximide efficacious when added to the current regiment of children with intractable epilepsy on maximal, combination therapy. A reduction in seizure frequency was achieved in >50% of children and was maintained for a mean of 19 months although no patient achieved complete seizure remission. Dasheiff et al123 compared clorazepate, methsuximide and valproate treatment in 66 patients with medically refractive, complex partial seizures with secondary generalization or partial seizures with aura who failed phenytoin, carbamazepine or phenobarbital therapy. The elimination of seizures with tolerated side effects occurred in small numbers of patients similarly with each medication. Methsuximide and valproate use resulted in gastrointestinal and mental status changes and valproate therapy resulted in impaired coordination. Summary: In children and adults with refractory epilepsy who failed therapy with multiple medications, limited, low quality evidence suggests methsuximide can reduce the seizure frequency in ~ 1/3 of patients, although the effects do not appear to be long-lived. A small trial suggests methsuximide efficacy may compare favorably with clorazepate and valproate. Methsuximide is associated with gastrointestinal toxicity and mental status changes and at least some of methsuximide adverse effects are dose related (ataxia, leukopenia). Acetazolamide Acetazolamide was assessed for utility as adjunct therapy in 37 Japanese children with refractory epilepsy complicated by mental retardation currently failing therapy to a combination of at least two of the following medications, carbamazepine, clonazepam or sodium valproate124. Acetazolamide therapy was initiated at 10 mg/kg and increased to 20 mg/kg as indicated. No relationship was found between drug dosage or steady state serum concentrations and efficacy. A complete remission persisting > 3 years was observed in 4 patients with localization-related epilepsies. Remission persisting 6 months followed by failure was reported for 5 patients, 6 patients demonstrated a reduction in seizure frequency of at least 50%, and 22 patients did not respond to acetazolamide therapy. The medication combination of acetazolamide with clonazepam and carbamazepine performed statistically superior to other combinations (p=0. Acetazolamide was well tolerated with transient drowsiness common during the initiation of therapy. One patient reported passing a rice-grain-sized kidney stone during his 6 th year of effective acetazolamide therapy. Summary: Evidence suggests acetazolamide has utility as adjunctive therapy in refractory epilepsy. The combination of acetazolamide, clonazepam and carbamazepine performed statistically superior to other combinations. Although 60% of children did not respond to 60 therapy it is important to remember that the average non-response to antiepileptic therapy overall is 20-30% and demonstrating a benefit in 40% of difficult to treat, refractory, patients with mental retardation is important. Acid-base induced kidney stones are a potential complication of acetazolamide therapy, only one patient treated for 6+ years reported passing a stone. Acetazolamide was well tolerated with Transient drowsiness was the most common adverse event. Status Epilepticus There are currently no class I clinical trials which compare second-line therapy for status epilepticus. Agents recommended in practice guidelines include benzodiazepines, barbiturates, phenytoin/fosphenytoin, valproic acid, levetiracetam, thiopental and propofol. It aims to address the efficacy and tolerability of currently available treatments for established status epilepticus. Intravenous valproate was compared to intravenous phenobarbital by indirect comparison from two systematic reviews of intravenous phenytoin vs valproate and one systematic review of intravenous phenytoin vs phenobarbital. The most common adverse events included respiratory depression and liver dysfunction with phenytoin and valproate, hypoventilation and arrhythmias with phenobarbital and phenytoin and hypotension with phenytoin. Prevention of seizure recurrence within 24 hours after initial seizure control was statistically superior with valproate (p=0. Treiman et al128 compared 4 treatments (diazepam/phenytoin, lorazepam, phenobarbital or phenytoin) in overt or generalized, convulsive status epilepticus in adults. In patients with a verified diagnosis of overt status epilepticus, lorazepam was found superior to phenytoin (p=0. Of interest, the time required for complete infusion of lorazepam was significantly shorter than for all other regimens and significantly longer for phenytoin regimens (approximately 5 minutes for lorazepam vs 33 minutes for phenytoin).
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