Diseases, Disorders information

Obstructive uropathy

Disorders — Wed, 19 Nov 2008 14:13:17 +0000

OBSTRUCTIVE UROPATHY

Obstructive uropathy lends itself to early detection with ultrasonography. Posterior urethral valves or bladder outlet obstructions are the most common of these disorders, but the obstruction may be at any level of the urinary tract.
In all cases of obstructive uropathy, the rationale behind treatment is that the obstruction itself will lead to permanent renal damage in the developing fetus. Obstruction of the urinary tract will lead to oligohydramnios and pulmonary hypoplasia, which is usually the cause of death in these neonates. Thus, the rationale for invasive therapy is that it will prevent a potentially fatal sequence of events and, if successful, will lead to a favorable long-term prognosis. Ideal candidates for the procedure are fetuses with isolated anomalies who are found in the second or very early third trimester with progressive oligohydramnios but good remaining renal function.

DIAPHRAGMATIC HERNIA

Diaphragmatic hernia is a serious fetal anomaly with a high perinatal mortality rate. Although it may be associated with other fetal anomalies, more frequently it is isolated. Death of neonates from pulmonary hypoplasia is believed to be due to compression of the normal lung in utero by herniated abdominal contents. Various methods of in utero repair have been proposed, including open fetal surgery. In this procedure, a hysterotomy is performed and the exteriorized fetus undergoes surgery to repair the defect and allow normal lung development.
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Fetal Therapy

Disorders — Wed, 19 Nov 2008 14:11:08 +0000

Medical Therapy
CONGENITAL ADRENAL HYPERPLASIA
Congenital adrenal hyperplasia is a recessively inherited disorder that results in salt wasting. Glucocorticoid replacement is lifesaving, and the long-term prognosis for these children is good. Androgenic cortisol precursors build up in the fetus, and female fetuses typically present with ambiguous genitalia. Mothers of previously affected offspring may be treated with steroids in suppressive doses beginning shortly after conception, which will decrease the production of androgenic steroids in the fetus. Chorionic villus sampling or amniocentesis is performed both to determine the sex of the fetus and for DNA testing for the responsible gene. If testing shows a normal female fetus or a male fetus, the steroids can be stopped; otherwise, steroid therapy is continued through term. Online pharmacy shop order viagra professional with special discounts.

FETAL TACHYARRHYTHMIA
In most cases of fetal tachyarrhythmia (ie, FHR > 180 beats per minute), there is no underlying anatomic congenital heart disease. Children with this condition respond well to treatment, and the long-term prognosis is good. Untreated fetuses may become hydropic, and the mortality under these circumstances is substantial. Digoxin is used to treat children; because it easily crosses the placental barrier, it may be given to a healthy mother to treat the fetus. Only about one third of fetuses respond to digoxin alone, and second-line or alternative regimens such as procainamide, flecainide, and verapamil may be necessary. All of these drugs have potential side effects for both the mother and the fetus.

NEONATAL ALLOIMMUNE THROMBOCYTOPENIA

When a fetus has neonatal alloimmune thrombocytopenia, the mother has a normal platelet count. Fetuses tend to have profound thrombocytopenia, which may result in spontaneous hemorrhage in utero. Various fetal therapies have been suggested, including repetitive platelet transfusions to the fetus. However, in addition to the invasive nature of this therapy, circulating platelets in the fetus have a short half-life. Suppression of maternal antibody production with immune globulin may result in normal platelet counts in the fetus and is protective against bleeding.
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Invasive Fetal Therapy
INTRAVENOUS THERAPY
The most successful and widely used form of invasive fetal therapy is the direct transfusion of erythrocytes to fetuses with erythrocyte isoimmunization. A transfusion can be directed into the fetal peritoneal cavity or intravenously. The latter route has been used more extensively in recent years.
Anemia is the most common other reason to give a fetus erythrocyte transfusions. Fetal anemia usually is discovered during examination of a fetus with nonimmune hydrops. If the fetus is found to be anemic from a reversible cause, fetal therapy may be warranted. The most common etiologies for reversible underlying anemia are a fetal-maternal hemorrhage or parvovirus B19 infection with a resultant fetal hemolytic crisis.

Summary. Candida

Disorders — Thu, 13 Nov 2008 16:40:36 +0000

The NNIS and the newly established SCOPE data indicate that the relative proportion of organisms causing nosocomial bloodstream infections has changed over the last decade, with Candida species now being firmly established as one of the most frequent agents. The epidemiology of nosocomial candidemia is continually being refined, but established predisposing factors including immunosuppression and malignancies, use of broad spectrum antibiotics, and use of indwelling central catheters remain as significant risk factors.
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The high cost of health care and greater attention to continuous quality improvement will stimulate better and more effective ways of diagnosing and treating candida infections using combined clinical and microbiologic acumen.
There is room for optimism as newer antifungal agents with reduced toxicities have impact on therapy of candidal infections. Aggressive development of still more agents and reformulations of older agents continue in earnest. Even greater consolation comes from the increased awareness of lay and medical personnel alike regarding the appropriate and judicious use of antimicrobial agents.

Flucytosine has been used with amphotericin

Disorders — Thu, 13 Nov 2008 16:39:06 +0000

Flucytosine has been used with amphotericin B in patients with endophthalmitis, renal candidiasis, overt central nervous system (CNS) infection, or persistent fungemia. Flucytosine is well absorbed from the gastrointestinal tract and is excreted mainly unchanged (90%) in the urine. Protein binding is minimal, and the half-life is 3 to 5 hours in the setting of normal renal function. CNS penetration is greater than 70%. Flucytosine is cleared by hemodialysis and requires dosage adjustment in renal insufficiency. Cialis professional pharmacy.
Patients with candida meningitis or hepatosplenic candidiasis seem to benefit from combined amphotericin and flucytosine. The initial dose of flucytosine is 150 mg/kg when renal function is normal. The use of miconazoles is limited because of several toxic effects, including anorexia, nausea and vomiting, headache, hepatitis, and pruritus.
Ketoconazole is available in an oral preparation; it is an N-substituted antifungal imidazole. Its metabolism occurs predominantly in the liver and it is excreted in bile as an inactive compound. No dose adjustment is required in renal or hepatic insufficiency. The presence of chlorhydria or the use of oral antacids or H-2 receptor blockers decreases its bioavailability. Concurrent administration of rifampin results in decreased ketoconazole serum concentrations. The main side effects are nausea and vomiting although endocrinologic abnormalities are infrequently seen. Canadian pharmacy viagra online without prescription.
Fluconazole is a bis-triazol-fiflourophenyl-2-propanol antifungal available for both parenteral and enteral administration. Excretion is predominantly renal. Protein binding is only 11%, and it penetrates the CNS when the meninges are inflamed. In a recent clinical trial, fluconazole seemed equally efficacious to amphotericin B in the therapy of serious candida infections.

Therapy of candidiasis

Disorders — Wed, 05 Nov 2008 18:20:41 +0000

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A wider array of antifungal agents has become available in the last 10 years (Table 3) (Table Not Available) . The availability of new agents or newer formulations of older agents have had a positive impact on the treatment of infections caused by Candida species.
The in vitro susceptibility of amphoteracin B in a clinical study by Powderly et al was better for blood isolates of yeasts in immunocompetent patients than immunocompromised patients (allogenic or autologous bone marrow transplantation and/or myelosuppressive chemotherapy). In that study, all episodes (10 of 10) of bloodstream infection in immunocompromised patients caused by isolates with minimum inhibitory concentrations (MICs) greater than 0.8 mug/mL were fatal, versus 8 of 17 episodes of bloodstream infection caused by yeast with MICs of 0.8 mug/mL or less ( p = 0.04).
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Many oncology units and infectious disease physicians now advocate the use of amphotericin B empirically in neutropenic patients on broad-spectrum antibiotics if they remain pyrexic after 4 to 7 days of antibiotic therapy. The use of amphotericin B, a polyene macrolide, is not without complications. Adverse problems include nephrotoxicity (which is usually reversible), electrolyte disturbance (decreased potassium, decreased magnesium), and pyrexia, sometimes with chills. Attention to hydration and close monitoring of renal function prior to and during amphotericin B therapy can reduce these adverse reactions. Use of antipyretics alone or in combination with antihistamines or meperidine can reduce or prevent the pyrexia response. The development of liposomal amphotericin B (a lipid formulation) has resulted in apparently equal efficacy with amphotericin B but without many of the associated complications, especially nephrotoxicity. Viagra super active erectile dysfunction treatment.
Amphotericin B is generally fungicidal against most strains of Candida species but less effective against those that are polyene deficient. Dosage adjustment for amphotericin B is not necessary in patients with extant renal failure (not caused by amphotericin B) or in patients with hepatic failure.
Hepatosplenic candidiasis is usually clinically resistant to amphotericin B and frequently requires a total dose of amphotericin B of several grams. Endocarditis caused by fungal agents requires surgical intervention with value resection. Removal of infected devices is advocated in fungal infections associated with central venous catheters, umbilical artery catheters, and dialysis catheters used in peritoneal dialysis.
Rifampin has no intrinsic antifungal property but augments the in vitro antifungal activity of amphotericin B against some Candida species including Candida albicans; however, this interaction is not apparent in in vivo studies.
Antagonism is observed in vitro between amphotericin B, which binds to ergosterol in the fungal cell membrane, and the antifungal imidazoles, which inhibit synthesis of ergosterol. There is, however, no consensus on the clinical significance of this issue. Cheap propecia 5 mg
The duration of amphotericin B therapy depends on the disease process being treated; in granulocytopenic patients it is continued until resolution of granulocytopenia. In patients with fungemia without another focus of infection, a total dose of 15 mg/kg (1 g) is usually adequate. In the nongranulocytic patient with fungemia, a total dose of 7 mg/kg (500 mg) is probably appropriate. Deep visceral infection is treated with a total dose of 22 mg/kg (approximately 1.5 g). Health news and articles

New dermatologic sings and symptoms

Disorders — Wed, 22 Oct 2008 18:01:47 +0000

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Traditional clinical findings in skin presentations of candida infection include erythematous papules and nodules, ecthyma-gangrenosum-like ulcerations and verrucous plaques. Purpura fulminans and disseminated intravascular coagulation were described by Silverman et al in a patient with candida sepsis. Purpura fulminans typically is associated with precipitous development of shock, fever, and symmetrically distributed purpuric plaques that form when the skin lesions, which initially are petechiae, rapidly coalesce. In the series of patients described by Silverman et al, the biopsy of skin lesions revealed characteristic histologic changes and pseudohyphae and budding yeast cells amid the necrosis deep in the reticular dermis. When the biopsy material was cultured, it yielded Candida tropicalis, the same organism that was also identified from the blood. Silverman et al concluded that purpura fulminans can provide an early diagnostic clue in patients with candida sepsis.
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Hemorrhagic bullae have been described in patients with Candida tropicalis sepsis. In these patients, it is postulated that the release of lytic enzymes by the invading organisms caused destruction of dermal collagen with resultant bullae formation. Candida tropicalis organisms were present in numerous foci within the cavity of the bullae and around surrounding collagen fibers. In immunocompromised patients, Suster and Rosen concluded that the development of bullous skin lesions could be a sign of disseminated candidiasis. Early diagnosis is enhanced by biopsy and histological examination of lesions.
DIAGNOSIS OF CANDIDEMIA
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The growing importance of fungal species as agents of septicemia-candidemia has resulted in increased efforts to diagnose these infections accurately. Stone et al evaluated the pathogenesis and principles of treatment of Candida species and demonstrated the remarkable efficiency with which the liver cleared candida from venous blood (ratio of 10,000:1); the lungs, striated muscle, and kidneys were less effective but also filtered yeasts from the blood. This phenomenon explains why some suggest that antemortem blood cultures drawn to confirm clinical diagnosis of candidemia should be obtained from a peripheral artery or the right atrium to minimize any influence of tissue filtration. Pizzo and Walsh noted that approximately 40% to 60% of patients with proven hematogenously disseminated candidiasis have negative blood cultures. Simultaneous bacteremia and fungemia reduce the recovery of Candida species in patients with these infections.
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Currently, there are no serodiagnostic tests that are available for widespread use in diagnosing hematogenously disseminated candidiasis. The latex agglutination test is insensitive. Systems designed to detect the presence of fungal D-arainitol in sera are more sensitive than the latex agglutination test but are still under development and thus not widely available. Candidal enolase assays are fraught with false-positive and false-negative results.
The use of calcofluor white, a nonspecific fluorochrome with affinity for chitin and cellulose, to detect fungal elements in clinical specimens was first introduced by Hageague and Harrington in 1984. The use of this technique has eliminated some of the inaccuracies inherent in potassium hydroxide use and has replaced india ink and potassium hydroxide preparations for fungal detection in many clinical microbiology laboratories. Newer techniques, including DNA probes and polymerase chain reaction (PCR), are being investigated for early diagnosis of fungal infections and are important adjuncts in epidemiologic investigations.

Candida osteomyelitis

Disorders — Thu, 16 Oct 2008 15:50:30 +0000

CANDIDA OSTEOMYELITIS
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Hematogenous dissemination of candida can result in Candida osteomyelitis. Gathe et al reviewed infections in 32 adults reported in the literature and reported on five patients with Candida osteomyelitis. They concluded that Candida osteomyelitis frequently occurred with hematogenously disseminated candidiasis or as a late sequela. Infrequently Candida osteomyelitis also has presented secondary to postoperative wound infections. Therapy with amphotericin B usually controls local infection but rarely eradicates concurrent osseous focus. The diagnosis of Candida osteomyelitis usually is delayed for several months or years because infection is insidious, with local pain being the most prominent feature. Complicating and further delaying the diagnoses are the nonspecific natures of laboratory and radiographic findings. Definitive diagnosis is usually made by culturing the organism from samples obtained using closed-needle or open-needle aspiration. Combination therapy including surgical debridement and antifungal therapy, usually with amphotericin B, is often successful at eradicating infection.
CANDIDA AND ANTIBIOTIC ASSOCIATED DIARRHEA
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Nosocomial diarrhea is a well-recognized problem in several hospitals across the United States, with Clostridium difficile being one of the most common etiologic agents. Candida species also are being associated with diarrhea. Danna et al evaluated the role of candida in antibiotic-associated diarrhea in elderly patients. The 24 patients with antibiotic-associated diarrhea were matched by age and sex with two selected controls who were either on antibiotics and had no diarrhea or were not on antibiotics and had no diarrhea. They concluded that 7 of 24 patients with stools negative for Clostridium difficile and other intestinal pathogens had intestinal overgrowth caused by Candida species (104 cfu/mL). None of the 24 matched, antibiotic-treated control patients without diarrhea had candida overgrowth. The five patients with diarrhea and candida overgrowth had resolution of their diarrhea and lowering of fecal counts to less than 104 cfu/mL within 7 days of antifungal therapy with nystatin despite continuation of the antibiotics. Two other patients who had overgrowth of candida were not treated with antifungal therapy, and the diarrhea resolved with lowering of fecal candida counts to less than 104 cfu/mL at the time antibacterial agents were withdrawn. In patients without candida overgrowth, diarrhea persisted until antibiotics were withdrawn, at a mean of 16 days after study entry. Several questions remain unanswered after reviewing this study. Why did patients recover despite overgrowth of candida in the stool in the absence of antifungal therapy? Were stool samples from patients without diarrhea accurately reflecting the true bioburden of candida (none of these stools had candida counts 105 cfu/mL)? Finally, can these samples be compared with watery stools obtained from patients with diarrhea?
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Neonates. New sings and symptoms

Disorders — Tue, 14 Oct 2008 15:14:32 +0000

NEONATES
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Weese-Mayer et al looked at factors important in the development of candidemia in 20 case patients less than 4 months of age who were matched with control infants by birth weight and date of admission to the neonatal intensive care unit. Univariate analysis identified duration of hyperalimentation, administration of fat emulsion, endotracheal intubation or tracheostomies or both ( p = 0.01), and antibiotic therapy ( p = 0.0002) as risks significantly associated with the development of candidemia. Antibiotic therapy had the greatest association with candidemia when discriminate function analysis was used to evaluate risk factors independently. No predictive discriminate function distinguishing infants at risk for candidemia was possible from the study. Fifteen of twenty-two episodes of candidemia were cured after two episodes, and death followed infection in five. Removal of catheters only resulted in clearance of infection in 9 of 22 patients (41%). Therapy with combination of amphotericin B and 5-fluorocytosine (5-FC) was successful in 4 of 5 patients (80%). Five of 20 infected patients (25%), compared with 1 of 20 (5%) control patients, died in this series.
NEW SIGNS AND SYMPTOMS
Differentiating infection from colonization is difficult and is a major handicap in the prevention and therapy of candidiasis in hospitalized patients. Helpful clinical findings that may be suggestive of infection caused by candida species include endophthalmitis, macronodular skin lesions, suppurative peripheral thrombophlebitis, hepatitis, purpura fulminans, bullous dermatitis, epiglottitis, and candida osteomyelitis. It usually is not possible to differentiate bacterial infections from local or systemic candidiasis by these clinical signs and symptoms. Neutropenia or the presence of nonalbicans species are factors associated with a reduced likelihood of candida endophthalmitis developing or becoming clinically recognizable infections.
HEPATIC CANDIDIASIS
Although not rare, hepatosplenic candidiasis is rarely recognized ante mortem. Immunocompromised patients are especially at risk for liver and spleen abscess caused by Candida species. This has been demonstrated by the increased number of the infections in these patients in the last 10 to 15 years. Thaler et al, using information from literature review and their own experience at the National Cancer Institute, concluded that the signs and symptoms of hepatosplenic candidiasis are reasonably characteristic. Useful findings in a cancer patient recently recovered from an episode of neutropenia include persistent fever, abdominal symptoms, and elevated alkaline phosphatase concentrations. Canadian viagra online
Ultrasonography is more specific than the more sensitive noninvasive technique of CT at detecting candida hepatosplenic abscesses; however, both techniques are subject to false-negative results. It is important to establish the diagnosis with certainty because the therapy required to ensure cure for hepatic candidiasis is a long course of amphotericin B (up to one year and 9 g). Liposomal amphotericin B or amphotericin B and 5-FC are options for therapy. Cure is documented by absence of symptoms, normalization of laboratory results, and disappearance of lesions by invasive and noninvasive techniques.

Candida

Disorders — Tue, 14 Oct 2008 15:10:29 +0000

IMPACT OF CANDIDA
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Opportunistic infections caused by Candida species have increased substantially over the past 10 to 15 years. National data from the Centers for Disease Control and Prevention (CDC) indicate that Candida species caused 7.7% of bloodstream infections nationwide from 1985 through 1988.
RISK FACTORS FOR ACQUISITION, DISEASE, AND DEATH
Seriously ill, immunocompetent patients and severely immunocompromised patients are at particular risk for nosocomial candidal infections. Included in these groups are neonates, patients with various forms of cancer who are leukopenic, and patients who have had major surgery (especially gastrointestinal and pancreatic), severe burns, or bone marrow transplants.
Given the presence of high-risk diagnoses (especially gastrointestinal and pancreatic), some identified risk factors for acquisition of candidemia include exposure to multiple antibiotics and steroids, presence of Swan-Ganz catheters, length of stay in the intensive care unit, artificial respiratory assistance, use of steroids, candida colonization, and repeated transfusions. In the study by Wey et al, four independent risk factors were identified by multivariate analysis: (1) number of antibiotics received, (2) isolation of Candida species from a site other than blood, (3) prior hemodialysis, and (4) prior use of Hickman catheter.

About the hallucinogens

Disorders — Sat, 11 Oct 2008 13:47:44 +0000

I want to say something about the hallucinogens. We are seeing LSD nowadays. It’s in lower concentrations than when we were teenagers and so people aren’t flying out the window thinking they can fly like Art Linkletter’s daughter did which is one of the things that turned people off to LSD. But acid is back in a lower concentration and kids are using it at parties and it is producing problems acutely. Tolerance showing it has a serotonergic effect. It can also produce an adrenergic state. PCP, while developed as an anesthetic, has a very interesting dose response and this is one line I would circle just so it stays in your head. At low dose, it acts like alcohol or the benzodiazepines with ataxia. At the middle dose you get illusions and a propensity to violent outbursts with paranoia. At a high dose, 70 mg or greater, you see coma so it’s a particularly bad therapeutic window assuming you think intoxication is therapeutic. So even there it’s bad.
Management. I still find the urine is the key issue and there are several ways to do this. 10% of mental health patients are abusing anticholinergics, particularly Cogentin and just review why because that’s a likely thing to show up on the test.
The final thing is anabolic steroids. One out of 10 high school kids is using them. Mark McGwire didn’t help because androstenedione, while not excluded from baseball, does increase testosterone levels and the withdrawal is the problem. The stimulus to mania is a problem. Rageful behavioral and aggression on withdrawal.