Regis W. Haid Jr., MD

• Medical Director
• Piedmont Spine Center
• Piedmont Hospital
• Director
• Neuroscience Service Line
• Piedmont Healthcare System
• Atlanta, Georgia

Myocarditis should be considered in any patient with a viral syndrome and signs of cardiac disease erectile dysfunction statistics cheap viagra 100mg mastercard. Staph is now the most common cause of native valve endocarditis (no longer streptococci) erectile dysfunction by race buy viagra pills in toronto. Prophylaxis for endocarditis is recommended in high risk patients that are undergoing a dental procedure that involve manipulation of the gingival tissue erectile dysfunction caused by high blood pressure medication buy viagra without a prescription. Prevention of Bacterial Endocarditis: Recommendation by the American Heart Association erectile dysfunction pills from canada buy viagra once a day. Hamptons Hump: Triangular pleural-based density with rounded apex that points towards the hilum impotence at age 30 cheap 100mg viagra. May radiate to the back (interscapular) and then the mid and low back as the dissection propagates distally impotence medical definition viagra 25 mg. Pseudo-hypotension due to compression of the true lumen by the false lumen resulting in reduced blood flow to the subclavian arteries with a difference in blood pressures between the arms (systolic difference of >15 mmHg is significant). Renal artery occlusion may result in uncontrolled hypertension, decreased urinary output and rising creatinine. Esmolol (Brevibloc) 500 mcg/kg bolus, 50-200 mcg/kg/min infusion (nice due to rapid onset and only has a 5 minute half life). Ideal study to evaluate symptomatic, but you need a hemodynamically stable patient. Option for elective or emergent repair includes percutaneous trans-femoral intraluminal graft for patients with co morbidities. Pathogenesis: intimal tear with dissection into the media resulting in 2 channels true and false lumen. Classification: Stanford Type A ascending (75%) managed surgically; Stanford Type B distal (25%) managed medically. Transesophageal echocardiography: Demonstrates involvement of ascending aorta, aortic insufficiency, pericardial effusion. Pathogenesis: localized dilation resulting from weakening of vessel wall; 98% infrarenal. Clinical Policy: Critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Mulcare M, Sharma R: Abdominal Aortic Aneurysms; Critical Decisions in Emergency Medicine; Lesson 30; January 2013. Clinical manifestations of and diagnostic strategies for acute pulmonary embolism. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. Delayed hemolytic reaction: Minor blood group incompatibility resulting in extravascular (liver, spleen) hemolysis days later. Potential bleeding below 50,000 with a high risk of spontaneous bleeding below 20,000. May have severe (< 1% activity), moderate (1-5% activity), or mild (5-30% activity) disease. An imbalance between hemostasis (excessive clotting) and fibrinolysis (excessive bleeding). Due to activation of the Hematology/Oncology Page 70 Notes clotting cascade with consumption of clotting factors and platelets with fibrinolysis and fibrin deposition in the microvasculature causing tissue ischemia. Multiple etiologies: trauma, burns, sepsis, cancer, snake bites, obstetric complications (amniotic fluid embolism, abruptio placenta, retained products of conception), transfusion rxn. Splenic sequestration: shock in children due to microvascular obstruction resulting in splenomegaly, hypovolemia. Painful occlusive crisis: extremity, chest, abdominal pain often precipitated by dehydration, hypoxia, infection, trauma, stress. Obstruction of the lumen by extrinsic compression, vein wall invasion by tumor or intraluminal thrombosis. Symptoms: headache, hoarseness, nausea, dyspnea, visual and mental status changes. Nausea/vomiting, anorexia, polyuria, polydipsia, dehydration, weakness, lethargy, coma, constipation and abdominal pain. Consider bisphosphonates (etidronate, pamidronate), gallium, steroids, calcitonin, mithramycin, and dialysis. Decompressive laminectomy only if a tissue diagnosis is needed, the spine is unstable or the patient has failed radiation therapy. Pericardial fluid compresses the heart, resulting in decreased diastolic filling and circulatory collapse. Subxiphoid pericardial window with catheter placement for drainage and sclerotherapy. Fever may develop due to infection (60%), chemotherapeutic agents, tumor necrosis, transfusions or antibiotics. Impaired inflammatory response from neutropenia makes it difficult to localize the source of infection. Examine for sinusitis, dental abscess, perirectal abscess (do not perform rectal exam), meningismus, cellulitis. Retinopathy with sausage-link or boxcar segmentation due to venous hemorrhage. Occurs 1-5 days following chemotherapy in rapidly growing tumors such as leukemia and lymphoma. Cell lysis results in hyperuricemia, hyperkalemia, hyperphosphatemia and subsequent hypocalcemia. Chemotherapy pretreatment with hydration and allopurinol or rasburicase (recombinant urate oxidase enzyme). Urinary alkalinization is controversial as it improves uric acid diuresis, but may worsen hypocalcemic tetany. Von Willebrands disease is due to platelet dysfunction resulting in a prolonged bleeding time. Patients with sickle cell disease are prone to infections by encapsulated organisms. Acute chest syndrome is the most common cause of death in patients with sickle cell anemia. Superior vena cava syndrome presents with facial plethora, dilated veins over the chest and arms, headache, visual difficulty and dyspnea, but does not require emergent treatment. Initial therapy of neoplastic spinal cord compression is intravenous steroids and radiation therapy. Pain is the most common complaint with spinal cord compression; weakness and sensory changes are late findings. The incidence of infection increases in neutropenic patients when the 3 neutrophil count drops below 500/mm. Remember to consider autotransfusion of blood in patients with traumatic hemothoraces. Kahn, S, Ander D: Trauma Updates-Fluid resuscitation in traumatic hemorrhagic shock; Trauma Reports, Mar/April 2013. Cardiac arrhythmias are common though the actual prevalence is difficult to calculate, as many arrhythmias are silent. Sudden cardiac death may be the first presenting complaint in 40 50% of cases of coronary artery disease. Symptoms attributable to arrhythmias are common presenting complaints in the emergency department. Orthodromic type: the impulse conducts normally antegrade and then up the accessory pathway. Atrial fibrillation is more deadly and nodal blocking agents alone should be avoided. Poor blood flow through atria increases risk of atrial clot formation and thereby increases stroke risk from embolic source. Often associated with anteroseptal infarct and may progress to Cardiac Arrhythmia Page 86 Notes complete block. A ventricular rhythm characterized by three or more complexes at a rate between 40 and 120 beats per minute. Also observed in patients with rheumatic heart disease, dilated cardiomyopathy, acute myocarditis, hypertensive heart disease, digitalis intoxication, and cocaine intoxication, as well as in patients without structural heart disease. Intermittent failure of sinus impulse conduction, manifested by intermittent loss of a P wave. Causes include infarct, drugs, electrolyte disturbances, infection, amyloidosis, myocardial disease. Ventricular tachycardia (sustained or nonsustained with precipitants as below): 1. In the general population, pharmacologic treatment should be initiated when blood pressure is 150/90 mmHg or higher in adults 60 years and older, or 140/90 mmHg or higher in adults younger than 60 years. In patients with hypertension and diabetes, pharmacologic treatment should be initiated when blood pressure is 140/90 mmHg or higher, regardless of age. If target-organ dysfunction does exist, then it must be determined if chronic and at risk for further impairment. Because a common cause of this process is noncompliance with medications, restarting their meds is a reasonable starting regimen. Any patient with a diagnosis of hypertensive urgency should be started on an antihypertensive medication with follow-up in 24 hours. Admission decisions depend on comorbid condition, and impression of the patients response to therapy. This should be done in a controlled, graded manner, using improvement in the patients condition as a guide. However, cerebral autoregulation is maintained at different levels for normal and chronic hypertensives. Although fast acting nifedipine had been widely used in the past for symptomatic hypertension, numerous serious adverse effects related to uncontrolled hypotension have been reported. Excessive reduction of blood pressure must be avoided to prevent the increased cerebral ischemia that results if the pressure falls below autoregulation. Patients present with altered mental status, vomiting, seizures and focal neurological deficits which may progress to coma and death. Labetalol, fenoldopam, and nicardipine are now also widely used, and are second-line agents for hypertensive encephalopathy. These agents shift cerebral autoregulation while preserving cerebral blood flow at lower pressures. Medical therapy consists of lowering both the blood pressure and heart rate to decrease shearing forces. The ganglionic blocker trimethaphan and the combined alpha and beta blocker labetalol have also been used successfully. Most important cardiovascular complication of chronic renal failure is hypertension and these two are intrinsically related. Nitroprusside is the drug of choice, with the calcium channel blocker nicardipine a reasonable alternative. Usually, these elevations do not lead to life-threatening immediate complications. Nitroprusside should only be used as a last effort if others have failed due to the potential accumulation of cyanide in the uterus. Post-traumatic injury leads to increased levels of catecholamines and increased sensitivity of central sympathetic receptors. Indications: virtually all of the hypertensive emergencies (not the drug of choice for pregnancy or acute coronary syndromes). Advantages: immediate onset, short duration of 1-2 minutes, no effect on cardiac output or renal blood flow. Disadvantages: coronary steal syndrome, inhibits hypoxia induced pulmonary vasoconstriction, and cyanide toxicity (worse in renal insufficiency, prolonged infusions over 48 hours, higher doses and fetal toxicity). Advantages: dilates large and small coronary arteries (no coronary steal), no increased V/Q mismatch. Action: selective dopamine-1 agonist dilates renal, splanchnic, and skeletal muscle beds. Indications: not clearly established but promising for pregnancy-induced and renal hypertensive emergencies. Disadvantages: may increase intraocular pressure and may give rise to hypokalemia. Action: selective alpha-1 blocker and nonselective beta blocker with ratio of alpha: beta of ~1:5. Action: stimulation of postsynaptic alpha 2 receptors in vasomotor center of brainstem decreased sympathetic outflow > vasodilation. Advantages: titratable, less negatively inotropic, less tachycardic than nifedipine. Advantages: hypotension has not been reported in literature, peak effects shown in 15 minutes. Disadvantages: no dose related response, angioedema, cough, renal failure in patients with bilateral renovascular disease. Indications: combination therapy with other antihypertensives which cause fluid retention. Tunica media: made up primarily of smooth muscle cells arranged in concentric layers. Tunica adventitia: poorly defined outer layer of connective tissue in which nerve fiber and small, thin walled nutrient vessels are dispersed.

Patients with cation providers be alert to escalating blood gastrointestinal disturbances may only be alcohol levels in these patients erectile dysfunction devices discount viagra. A patient who is a vegetarian may have ratory depressants erectile dysfunction doctor nyc buy viagra without a prescription, respiratory support may additional nutritional deficiencies erectile dysfunction diet buy cheapest viagra and viagra, especially if be needed can you get erectile dysfunction age 17 order viagra with american express. Thus impotence following prostate surgery trusted viagra 25 mg, ensuring that children have a important that the abused person erectile dysfunction in young men generic viagra 50 mg with amex, whether safe place to stay while their mothers are in male or female, not be allowed to talk to the detoxification is of vital importance. How does your family view your present condition/situation (as it relates to substance use) One of the most In the contemplation stage, the individual has critically important roles the clinician can some awareness that substance use presents a play in this stage is to assist the patient in problem. In this stage, the patient may developing a plan of action or a behavioral express a desire or willingness to change, but contract, taking into account the individual has no definite plans to do so in the near needs of the patient. As part of this process future, which generally is considered to be the clinician should help the patient enlist the next 2 to 6 months. This includes making modifications to with the expectation that the scale of balance his habits and environment, such as not tips in favor of adopting new behavior. These stance abuse with other problems, including changes may even continue to be made 3 to 6 health, legal, employment, parenting, and months after substance abuse has ceased. A therapeutic alliance should treatment program is needed and, if so, which be developed in the context of an ability to one. Strong consistent, dependable, trustworthy, and alliances, in turn, have been associated with available, even when the patient is not. Emphasis also should be given to the alliance with a social support network, which can be a powerful predictor of whether the Referrals and Linkages patient stays in treatment (Luborsky 2000). Many of the guidelines listed teristics, strengths, and vulnerabilities that will above for enhancing motivation apply to influence recommendations for substance establishing this rapport. Newman (1997) abuse treatment; (2) preparing the patient to makes some additional recommendations for participate in treatment; and (3) successfully developing the therapeutic alliance, such as linking the patient to treatment as well as other discussing the issue of confidentiality with needed services and resources. Biomedical Conditions and Complications al willingness to change (Stages of Change 3. Administering these highly intensive substance abuse counseling instruments requires varying degrees of and clients may participate in the upkeep of sophistication on the part of the clinician. Peer support is critical to the instruments should be considered for their treatment delivered. Patients return home in the substance abuse treatment centers, as well as evenings.

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Adolescents and adult patients requiring fixed appliances should be referred to an orthodontist impotence in young men order viagra cheap. The commonest causes are alls (in sports and play) at home or school and motor accidents erectile dysfunction kansas city buy viagra 100mg overnight delivery. Table 1: Diagnosis Type Presentation Tooth Concussion Injury to supporting tissues of tooth erectile dysfunction ginseng buy viagra 75 mg free shipping, without displacement impotence lotion buy viagra 100 mg without a prescription. Subluxation partial displacement acupuncture protocol erectile dysfunction order viagra 25 mg with visa, but is commonly used to describe loosening of a tooth without displacement Luxation Displacement of tooth (laterally erectile dysfunction quiz test discount 75mg viagra amex, labially, or palatally). Often accompanied by fracture of alveolar bone Avulsion Complete loss of the tooth from the socket Soft tissue injuries Abrasion: does a friction between an object and the surface of the soft tissue cause a wound. This wound is usually superficial, denudes the epithelium, and occasionally involves deeper layer. Contusion: is more commonly called a bruised and indicates that some amount of tissue disruption has occurred within the tissues, which resulted in subcutaneous or sub mucosal hemorrhage without a break in the soft tissue surface. It is perhaps the most frequent type of soft tissue injury, is caused most commonly by a sharp object Treatment Give tetanus toxoid (0. Antibiotic cover in cases of suspected contamination or extensive damage (Amoxicillin (oral) 500 mg 8hrly for 5 days). Refer to a dentist, where available orthodontics or endodontic specialist depending on the need of advanced treatment Note: Referral to oral and maxillofacial surgeon is done to patients with complicated maxillofacial injuries. Prevention Proper design of playing grounds, observe road traffic rules, early orthodontic treatment 12. Non Odontogenic Benign tumors Benign osteogenic tumors (arise from bone): Osteomas, Myxomas, Chondromas, Ewings tumor, Central giant cell and Fibro-osteoma. Benign soft tissues non-Odontogenic tumors Papilloma, Fibroma, Fibrous Epulis, Peripheral Giant Cells, Pregnancy Tumors, Hemangioma, Lymphangioma, Lipoma and Pigmented nerves Treatment: Tumors enucleation or excision in the treatment of choice depending on the type. Can be hemimandibulectomy, total mandibulectomy, hemimaxillectomy or total maxillectomy Note:the tumors or oral and maxillofacial regions are of wide range and variable presentation, a dental surgeon is trained in identification and diagnosis. Treatment of most of these condition need expertise of oral and maxillofacial surgeon and patients should be referred early enough Malignant soft and bone tumors Squamous cell carcinoma, Sarcoma, Lymphosarcoma, Myosarcoma, Chondrosarcoma, Fibrosarcoma, Adenosarcoma, Adenocystic carcinoma and Epidermoid carcinoma. Lymphomas 34 P a g e Burkitts tumor is an undifferentiated lymphoblastic lymphoma. This can be through hematogenous spread as septic emboli from the gut wall or sub diaphragmatic abscess rapture into the pleural space or pericardium. Infective cysts can be found in fecally contaminated food and water supplies and contaminated hands of food handlers. Sexual transmission is possible, especially in the setting of oral-anal practices. Diagnosis of Amebic colitis Gradual onset of bloody diarrhea Abdominal pain Fever Spanning several weeks duration Rectal bleeding without diarrhea can occur, especially in children Fulminant or necrotizing colitis usually manifests as severe bloody diarrhea and diffuse abdominal pain with evidence of peritonitis and fever. Children (below 12 years to 1 year) 30mg/kg as a single dose Diagnosis of Amoebic liver abscess Fever, right upper quadrant pain, and tenderness of less than 10 days duration. Treatment Drug of choice: A: Metronidazole; Adult 400-800mg (O) 8 hourly for 10 days. In few cases malabsorption syndrome may occur Extra intestinal manifestations are rare and include allergic manifestations such as urticaria, erythema multiform, bronchospasm, reactive arthritis, and biliary tract disease Investigation: Microscopic stool examination of Giardia intestinalis trophozoites or cysts of infected patient, sensitivity increases on serial 3 samples examination. Indicatively: 1-3 years 500mg/day; 3-7 years 600-800 mg/day; 7-10 years 1g/day for 3 days. Diagnosis Most patients are asymptomatic When symptoms occur, they are divided into 2 categories: early (larval migration) and late (mechanical effects) In the early phase (4-16 days after egg ingestion): Fever, Nonproductive cough, Dyspnea, Wheezing. It is one of the main causes of anaemia in the tropics which is also the major clinical feature. Diagnosis the majority of patients are asymptomatic 38 P a g e the major clinical manifestations are iron deficiency anemia and hypoalbuminaemia. The most common and clinically important pathogenic species in humans is S stercoralis. Distinctive characteristic of this parasite is its ability to persist and replicate within a host for decades while producing minimal or no symptoms in individuals with an intact immune system and its potential to cause life-threatening infection (hyperinfection syndrome, disseminated strongyloidiasis) in an immunocompromised host associated with high mortality rates. Children give the same dose same as for adults Note: Tablets must be chewed Alternatively A: Albendazole: Adults 400mg (O) 12 hourly for 3 days, the medicines may be repeated after 3weeks. Children over 2 years give 15mg/kg/day in 2 divided doses for 3 days (7-10 days for disseminated infection) Note: Provide antibiotic therapy directed toward enteric pathogens if bacteremia or meningitis is present or suspected Provide supportive treatment as indicated (eg, intravenous fluids if volume depletion, blood transfusion if gastrointestinal or alveolar hemorrhage, mechanical ventilation if respiratory failure) Symptomatic treatment should be initiated 40 P a g e Pruritic dermatologic manifestations should be treated with antihistamines Inhaled beta-agonists may improve wheezing 1. Less commonly cestode includes Diphyllobohrium latum (poorly cooked fish) and Hymenolepsis nana (fecal oral contamination by both human and animals especially dogs). Diagnosis Most tape worm infections are symptomless the commonest way of presentation is the appearance of proglottides or segments in the stool There may be mild epigastric discomfort, nausea, weight loss and diarrhea More specific features depend on the type of the parasite Laboratory Diagnosis: Macro and Microscopic stool examination for ova and parasites. It is indicated for some of the cestodes that release eggs or worm segments directly into the stool. Children 2-6 years, 1g as a single dose after a light meal, followed by a purgative after 2 hours; Children under 2 years, 500mg as a single dose after a light meal, followed by a purgative after 2 hours 41 P a g e For Hymenolepsis nana Adult and children over 6 years C: Niclosamide 2g as a single dose on the first day, then 1g daily for 6 days. Children 2-6 years C: Niclosamide 1g on the first day as a single dose, then 500mg once daily for 6 days. Latum Adults and children over 2 years C: Niclosamide 5 10mg/kg as a single dose. A: Albendazole 400mg every 12 hours is recommended for 1-3 months before surgical intervention. Note: Administer parenteral vitamin B-12 if evidence of vitamin B-12 deficiency occurs with Diphyllobothrium infections Tablets should be chewed thoroughly before washing down with water. Diagnosis the clinical manifestation and duration of illness vary markedly from one patient to another 42 P a g e the major clinical features are fever, severe headache, drowsiness and muscle pains (myalgia) the course of paratyphoid tend be to shorter and less severe compared to typhoid Untreated, typhoid fever is a grueling illness that may progress to delirium, obtundation, intestinal hemorrhage, bowel perforation, and death Survivors may be left with long-term or permanent neuropsychiatric complications. Laboratory diagnosis:the diagnosis of typhoid fever (enteric fever) is primarily clinical. Culture is the criterion standard for diagnosis of typhoid fever with 100% specificity. Culture of bone marrow aspirate; blood and stool cultures should be done within 1 week of onset. Chloramphenicol is contraindicated in the third trimester of pregnancy; it may also cause aplastic anaemia which is irreversible. Infection is through the larval forms of the parasite which is released by freshwater snails. Some of the eggs are passed out of the body in the feces or urine to continue the parasite life-cycle. Others become trapped in body tissues, causing an immune reaction and progressive damage to organs. Diagnosis Schistosoma mansoni There may be abdominal pain and frequent blood stained stool 43 P a g e In chronic form of Schistosoma mansoni; abdominal distention, and vomiting of blood and liver fibrosis (Portal hypertension) People co-infected with either hepatitis B or C and S mansoni have been shown to have rapid progression of liver disease. Schistosoma hematobium the main clinical feature is painless terminal hematuria In chronic and complicated situations can lead to renal failure due to obstructive uropathy, pyelonephritis, or bladder carcinoma (10-20 years after the initial infection) In addition, immune complexes that contain worm antigens may deposit in the glomeruli, leading to glomerulonephritis and amyloidosis. Laboratory diagnosis Perform stool or urine analysis to identify and specify the eggs in the stool or urine. Kato Katz thick fecal smear technique is needed for chronic disease stage of the iintestine and liver. Diagnostic yields are improved by repeated stool samples and from biopsies at sigmoidoscopy. Treatment Drug of choice C: Praziquantel: 40mg/kg (O) as a single dose or in 2 divided doses. Mansoni infections Medicines will usually arrest progression of clinical features, but will not reverse them Surgical interventions may be necessary. They are grouped into 4 species: Shigella dysenteriae, Shigella flexneri, Shigella boydii, and Shigella sonnei, also known as groups A, B, C, and D, respectively. Shigellosis is spread by means of fecal-oral, ingestion of contaminated food or water. Diagnosis Sudden onset of severe abdominal cramping, high-grade fever, emesis, anorexia, and large-volume watery diarrhea; seizures may be an early manifestation. Laboratory diagnosis Perform microscopic stool examination isolation of Shigella from feces or rectal swab specimen. Treatment Drug of choice A: Ciprofloxacin (O): Adult, 500mg 12 hourly for 5 days Children (where the benefit outweighs the risk); 5-10mg/kg/dose. Note Nalidixic acid is neurotoxic so should be used with caution in older patients; it is contraindicated in epilepsy and renal failure. Diagnosis After a 24 to 48 hours incubation period, cholera begins with the sudden onset of painless watery diarrhea that may quickly become severe with profuse watery stools (rice water), vomiting, severe dehydration and muscular cramps leading to hypovolemic shock and death the stool has a characteristic rice water appearance (non bilious, gray, slightly cloudy fluid with flecks of mucus, no blood and inoffensive odor) Laboratory Diagnosis Dark field microscopy on a wet mount of fresh stool for identification of motile curved bacillus. V) fluid immediately to replace fluid deficit; Use lactated Ringer solution or, if that is not available, isotonic sodium chloride solution. If signs of some dehydration are present, continue as indicated below for some dehydration. If no signs of dehydration exist, maintain hydration by replacing ongoing fluid losses. Although the disease is self limiting, an effective antibiotic will reduce the volume of diarrhea and shorten the period during which Vibrio cholera is excreted. Antibiotic prophylaxis may be given to all close contacts in the same dosage as for treatment. For confirmation at the beginning of an outbreak, take rectal swab or stool specimen, handle properly and transport carefully to laboratory. This situation typically implies an increased frequency of bowel movements, which can range from 4-5 to more than 20 times per day. The augmented water content in the stools is due to an imbalance in the physiology of the small and large intestinal processes involved in the absorption of ions, organic substrates, and thus water. Childhood acute diarrhea is usually caused by infection; however, numerous disorders may cause this condition, including a malabsorption syndrome and various enteropathies. Acute onset diarrhea is usually self-limited; however, an acute infection can have a protracted course. Diarrheal episodes are classically distinguished into acute and chronic (or persistent) based on their duration. Acute diarrhea is thus defined as an episode that has an acute onset and lasts no longer than 14 days; chronic or persistent diarrhea is defined as an episode that lasts longer than 14 days. It is most practical to base treatment of diarrhea on the clinical types of the illness, which can easily be determined when a patient is first examined. Four 47 P a g e clinical types of diarrhea can be recognized, each reflecting the basic underlying pathology and altered pathology: Acute Watery Diarrhoea (including Cholera): which lasts several hours or days. The main danger is dehydration and malnutrition if feeding is not continued Bloody Diarrhoea (Dysentery): the main dangers are damage of intestinal mucosa, sepsis, and malnutrition. Other complications including dehydration may also occur Persistent (Chronic) Diarrhoea: Last for 14 days or longer, the main danger is malnutrition and serious non-intestinal infections, dehydration may also occur Dirrhoea with Severe Malnutrition (Marasmus or Kwashiorkor): the main dangers are severe systemic infection, dehydration, heart failure, vitamin and mineral deficiency. Note:the basis for the management of each type of dirrhoea is to prevent or treat dangers that present. Management of diarrhea in adultsthe principles of management of diarrhea in adult are the same as in children in correction of fluid deficit. However, the most common cause for diarrhea in adult is food poisoning which is normally self-limiting. This may account to 5% but may be under estimation as many patients dont seek medical attention. Treatment Guide: Correct volume status, electrolyte disturbances and vitamin deficiencies. They have in common the involvement of acid-pepsin in their pathogenesis leading to disruption of the mucosal integrity causing local defect or excavation due to active inflammation. Peptic ulcer may present in many different ways, the commonest is chronic, episodic pain present in many different ways, and may persist for months or years. However, the ulcer may come to attention as an acute episode with bleeding or perforation, with little or no previous history. As with duodenal ulcer, epigastric pain is the commonest symptom of gastric ulcer. Diagnosis Heartburn and regurgitation of sour material into the mouth are specific symptoms Symptoms for persistent disease may include odynophagia, dysphagia, weight loss and bleeding Extra esophageal manifestation are due to reflux of gastric contents into the pharynx, larynx, trachealbrochial tree, nose and mouth causing chronic cough, laryngitis, pharyngitis. Treatmentthe goals of treatment are to provide symptom relief, heal erosive esophagitis and prevent complication. Drug of choice is H2 Receptor blockers which are effective in symptoms relief and are considered as first line C: Ranitidine 150mg (O) 12 hourly for 14 days; Children 2 -4mg/kg 12 hourly for 14 days. Alternatively D: Esomeprazole 40mg (O) once daily for 4-8 weeks, then 20mg once daily for maintenance to prevent relapse. Referral Refer to specialized centers for all cases with persistent symptoms and/or new complications despite appropriate treatment above. Management of Helicobacter pylori infection Gastric infection with the bacterium H. Diagnosis Diagnosis clinically as above, plus endoscopic exclusion of esophagitis, peptic ulceration, or malignancy Treatment Eradicate H. Include the following in history, description of bleeding, duration and frequency, prior bleeding, cormobidities, medications, previous surgery, recent polypectomy or prior radiation. Diagnostic procedures: Do baseline investigation, Full hemogram, Coagulopathy profile, liver and renal functions. While Tagged red cell scan and Angiography would be indicated for rapidly or obscure bleeding patients. Correct severe thrombocytopenia with packed platelet concentrates, while overt coagulopathy should be corrected with fresh frozen plasma, and Vitamin K S. Non Pharmacological Endoscopy done within 24 hours could confirm diagnosis and provide sustained hemostasis control. Therapeutic modalities include variceal band ligation, Hemocliping, sclerotherapy, injectional tamponade therapy, thermocoagulation and angiographic embolization.

Common signs include vomiting erectile dysfunction can cause pregnancy order viagra in united states online, signs of encephalopathy erectile dysfunction at age 20 order generic viagra on-line, neutropenia and thrombocytopenia zyprexa impotence viagra 50 mg generic. Hereditary tyrosinemia can present in the neonate with a bleeding diathesis due to liver disease erectile dysfunction pumps side effects order viagra from india, or later in infancy with a renal Fanconi syndrome impotence def buy viagra online. The severe form of nonketotic hyperglycinemia presents as unremitting seizures with hypotonia and hiccoughs herbal erectile dysfunction pills review proven viagra 25 mg. They may manifest with hypoglycemia, hepatosplenomegaly, lactic acidosis or ketosis. Common features of Zellweger syndrome include large fontanel, organomegaly, Down-like facies, seizures and chondrodysplasia punctata. Others include disordered steroidogenesis (congenital adrenal hyperplasia or Smith Lemli-Opitz), disorders of metal metabolism (Menkes syndrome, neonatal hemochromatosis). Transient hyperammonemia of the newborn is more prevalent in slightly premature infants receiving mechanical ventilation; onset is usually within the first 24 hours of life. The cause is unknown and, if the newborn survives, there is no further evidence of impaired ammonia metabolism. Blood ammonia, lactate and pyruvate should be collected without a tourniquet, kept on ice and analyzed immediately. These flow charts are guides to the differential diagnosis of hyperammonemia 1) and metabolic acidosis th 2) in newborns. Not all inborn errors of metabolism will present with acidosis, hyperammonemia, 156 Inborn Errors of Metabolism or hypoglycemia. Withhold all protein for 48 to 72 hours, while the patient is acutely ill, and until an aminoacidopathy, organic aciduria or urea cycle defect has been excluded. Special special enteral formulas and parenteral amino acid solutions are available for many disorders. The severity of neurological impairment in infants with urea cycle defects depends upon the duration of the hyperammonemic coma. Alcohol should be used to clean the skin; do not use betadine, as it will inhibit cell growth. Place skin sample in sterile saline at room temperature and send to the cytogenetics lab for culture and processing. Como consecuencia, estos enfermos presentan niveles disminuidos de IgG e IgA y niveles normales o elevados de IgM. La forma mas comun se hereda como rasgo genetico ligado al cromosoma X y afecta unicamente a los varones. Muchas otras formas del Sindrome de HiperIgM se heredan como rasgos autosomicos recesivos y afectan tanto a mujeres como a varones. Como consecuencia, los enfermos de esta inmunodeciencia primaria presentan niveles disminuidos de IgG e IgA en suero y niveles normales o elevados de IgM. Los linfocitos B pueden producir anticuerpos IgM por su propia cuenta, pero requieren la interaccion de los linfocitos T para cambiar la produccion de anticuerpos del tipo IgM a los tipos IgG, IgA e IgE. El Sindrome de HiperIgM se debe a diversos defectos geneticos que afectan a esta interaccion entre los linfocitos T y los linfocitos B. La forma mas comun del Sindrome de HiperIgM se debe a un defecto o una deciencia de una proteina que se encuentra en la membrana de los linfocitos T activados. Por tanto, esta inmunodeciencia primaria se hereda como rasgo recesivo ligado al cromosoma X y por lo general solo afecta a los varones. Estos enfermos presentan, entre otras anormalidades, inmunodeciencia, cabello escaso y dientes conicos. Por tanto, estos varones afectados son propensos a padecer diversas infecciones graves. El problema mas comun es una mayor propension a padecer infecciones, incluidas las infecciones recurrentes del tracto respiratorio superior e inferior. Las infecciones pulmonares tambien pueden ser causadas por virus como el citomegalovirus y hongos como el criptococo. Tambien se han observado en algunos pacientes dolencias gastrointestinales, mas comunmente diarrea y malabsorcion intestinal. La neutropenia se relaciona comunmente con ulceras bucales, proctitis (inamacion y ulceracion del recto) e infecciones de la piel. Como consecuencia, los pacientes suelen presentar amigdalas, bazo, ganglios linfaticos e higado aumentados de tamano. Sus manifestaciones pueden incluir artritis cronica, recuento bajo de plaquetas (trombocitopenia), anemia hemolitica, hipotiroidismo y enfermedades renales. Sin embargo, algunos pacientes con otras formas de inmunodeciencia pueden presentar una expresion notablemente disminuida de este ligando, aunque su gen sea perfectamente normal. Ya que son enfermedades hereditarias, transmitidas como rasgos recesivos ligados al cromosoma X, es posible que un paciente tenga hermanos o tios por parte de madre (hermanos de la madre) que presenten un cuadro clinico similar. Al igual que en otros trastornos ligados al cromosoma X, tambien es posible que ningun otro miembro de la familia del paciente se vea afectado. Si se conoce la mutacion exacta del gen afectado en una determinada familia, es posible realizar un diagnostico prenatal o hacerles pruebas a los demas familiares para comprobar si son portadores de la mutacion. Un tratamiento regular substitutivo con inmunoglobulinas cada 3 o 4 semanas es ecaz para reducir el numero de infecciones. Las inmonuglobulinas compensan el decit de IgG y a menudo da lugar a la reduccion o normalizacion del nivel de IgM en suero. Es tambien importante reducir la posibilidad de beber agua contaminada con Criptosporidio, ya que la exposicion a este organismo puede provocar sintomas gastrointestinales graves y enfermedades cronicas del higado. Los familiares del paciente deben adoptar un actitud proactiva, ponerse en contacto con las autoridades responsables del suministro de agua local y preguntar si el agua es segura y ha sido analizada para comprobar la ausencia de Criptosporidio. Es posible que el tratamiento con inmunoglobulinas no proteja por completo a estos pacientes contra todas las infecciones. En los ultimos anos, se han recomendado los trasplantes de medula osea y de celulas madre del cordon umbilical. El trasplante de celulas madre del cordon umbilical, compatibles total o parcialmente, se ha efectuado tambien con exito, obteniendose una reconstitucion completa del sistema inmunologico. By reportng any unusual cine, University Tunis El Manar, Tunisia or severe treatment related accident, we try to enlarge our background in order to manage beter any similar case. Here we report a case of leukopenia induced by an Received: Sep 03, 2018 ant-tuberculosis oral treatment. Accepted: Sep 25, 2018 Our 43 years old patent was diagnosed with pleural tu Published Online: Sep 28, 2018 berculosis. Biological tests were ordered prior to the onset of the treatment and were all normal. The decision of the multdisciplinary staf under the terms of Creatve Commons Atributon 4. The second challenge afer suppres various, some of them are frequent and some others may be sion of the causal molecule is to keep the patent on a treat come life threatening. The diagnosis was established using direct sputum smear rate of agranulocytosis due to ant-tuberculosis drugs was est microscopy and positve culture in the pleural liquid. In the context of ant-tuberculosis ther tests were ordered prior to the onset of the treatment and were apy, neutropenia is recognized as being most frequently hap all normal. Our patent was In the vast majority of cases during ant-tuberculosis therapy, put on a combinaton of Isoniasid 300 mg once a day, Rifampi the occurrence of neutropenia is due to asingle agent [13]. By cin 600 mg once a day, Pyrazinamid 1500 mg once a day and re-challenging the patent with each antbiotc individually, the Ethambutol 1200 mg once a day. Usually, medical staf try tomatc and the physical examinaton revealed only conjunctval to suppress the molecule causing the side efect and come up jaundice. Blood tests were checked repeatedly every week untl with a combinaton of frst line or second line ant-tuberculo they normalized (20 days later). This combinaton must guarantee a bactericidal toxic background regimen while stopping Pyrazinamid. Managing cases with neutropenia related to more than one molecule is problematc since therapeutc optons of ef Day 1: Ethambutol was introduced and biological tests two cient combinatons get narrowing. Difculty of our case Day 10: Ciprofoxacin was introduced with normal blood Afer receiving only one month of ant-tuberculosis treat cells count ment, our patent showed an hepato-biliary toxicity and a se Day 17: Rifampicin was introduced. The decision of the mult therapeutc regimen must keep as much as possible the major disciplinary staf was to introduce a combinaton of three drugs: bactericid molecules, guarantee the eradicaton of quiescent Isoniazid, Ethambutol and Ciprofoxacin for a duraton of eight intra-macrophage mycobacteria and prevent the development months while stopping Rifampicin. Chest X ray exam showed no of mult-resistant strains of Mycobacterium Tuberculosis. Drug-induced hematological disorders Severity can span almost the entre spectrum of hematology, afectn Severity of this accident and its repercussion on the treat gred cells, white cells, platelets, and the coagulaton system [1]. Neutropenia and/or leukopenia can Drug-induced neutropenia can occur in associaton with various arise and keep mild to moderate even with no treatment cessa analgesics, psychotropics, antconvulsants, antthyroiddrugs, an ton [16]. Lees retrospectve study described the frequency, the thistaminics, non-steroidal ant-infammatories,antmicrobials, severity and the outcome of patents who were diagnosed with cardiovascular drugs, and, as expected, with chemotherapy tuberculosis, whose count of blood cells showed leukopenia af drugs. Immune-mediated mechanisms are associated with some ter administraton of frst-line ant-tuberculosis medicaton [17]. Drugs such as lactam antbiotcs, carbamazepine,and these 109 patents who contnued on their medicaton, leukope valproate have a dose-dependent inhibiton of granulopoiesis. Journal of Tuberculosis 2 MedDocs Publishers No clinically signifcant episode of infecton developed in any of 8. A case of agranulocytosis caused by rifampicin dur ant-tuberculosis treatment with frst line drugs was relatvely ing treatment of tuberculous lymphadenits in a chronic renal common. Agranulocy tosis Induced by Ethambutol in a Patent with Pulmonary Tuber Conclusion culosis. There are three subtypes that are differentiated microscopically using Wrights stain (contains acidic and basic dyes). Normal Range, Segmented: 45% 73% Bands: 3% 5% these cells do not stain well with Wrights stain and are considered neutral. They undergo apoptosis unless they engage a foreign particle, specifically bacteria and fungi. Blood -> Tissue -> Neutrophils are attracted to the site of infection by cytokines that are released by activated cells ~ endothelial, mast, and macrophage cells; chemotaxis). They phagocytize opsonized microorganisms and digest the particle within a phago-lysosome. In addition to phagocytosis, neutrophils also release cytokines, which amplify the response. Also note that an increase in the percentage of neutrophils by necessity decreases the percentage of lymphocytes. These granulocytes contain basic proteins that stain with the red acidic dye (eosin). Eosinophils primarily reside in the intestine and lungs and have limited phagocytic capacity. They recognize the Fc portion of IgE antibodies bound to the parasite, which triggers degranulation and release of compounds that are toxic to both parasite and host tissues (peroxidases, nucleases, histamine, etc. Eosinophils are attracted to the site of an allergic reaction by mast cell degranulation (histamine, heparin, eosinophil chemotactic factor). They thus play a role in modulation of the allergic inflammation, rhinitis, and asthma. Basos are also associated with allergic responses and basophilia can be observed in cases of chronic inflammation. They are present in skin (Langerhans cells) lymph nodes, alveoli (dust cells), spleen (sinusoidal cells), liver (Kupffer cells), and bone marrow (osteoclasts). They play a major role in removing cellular aged neutropils, cellular debris, pathogens, and in the destruction of damaged erythrocytes, plasma proteins, and plasma lipids. They digest the particle and present peptides on their surface (antigen presenting cell). Upon target recognition, they secrete cytotoxic compounds that can lyse the cell and/or induce apoptosis. Glucocorticoids, adrenaline and exercise can lead to neutrophilia without a shift to the left. Steroids interfere with production of cytokines and thus the proliferation and interaction of T cells. Steroids interfere with the binding of interleukins to B cells, which means that the B cells have a hard time proliferating and making antibodies. Steroids inhibit just about everything that neutrophils do: adhesion, chemotaxis, phagocytosis, and the release of toxic substances. Drugs that can cause neutropenia include penicillins, chloramphenicol, ganciclovir and phenothiazines. This is observed with parasitic infections, allergic disorders (asthma), chronic disease (rheumatoid arthritis), and malignant diseases (Hogkins disease).