By C. Rufus. Quincy University. 2018.
Which of the following statements regarding varicella-zoster virus (VZV) infection is true? Primary varicella infection is communicable and can result in her- pes zoster infection in a contact B order 120mg orlistat visa. Hospitalized patients with varicella or herpes zoster infection should be isolated to prevent spread of the virus to other susceptible persons C proven orlistat 120mg. There is no available medical therapy for herpes zoster eruptions D. Ramsay Hunt syndrome is a herpes zoster eruption in the first branch of the trigeminal nerve Key Concept/Objective: To know the clinical concepts and features of VZV infection Herpes zoster results from the reactivation of VZV infection. Varicella in one patient cannot produce herpes zoster in another; however, persons who are exposed to patients who have herpes zoster can contract varicella. Thus, hospitalized patients with varicella or herpes zoster should be iso- lated to prevent spread of the virus to other susceptible persons. High-dose oral acy- clovir (800 mg five times daily for 7 days), when begun early, may shorten the course and reduce the severity of herpes zoster in otherwise healthy hosts. Oral valacyclovir (1 g three times daily) or famciclovir (500 mg three times daily) may also be used. Ramsay Hunt syndrome is an infection of the geniculate ganglion of the seventh cranial nerve that produces facial paralysis; vesicles on the eardrum and side of the tongue can also occur. A 22-year-old man presents to your clinic with complaints of fever, sore throat, marked fatigue, and myalgias. He denies having had contact with anyone who was sick, and he denies ever having unprotected sexual intercourse. He has had only one sexual partner, with whom he has been having sexual relations for sever- al months. His sore throat has been improving, and he denies hav- ing cough or sputum production. On physical examination, mod- erate pharyngeal injection without exudates is noted, and the spleen tip is palpable and slightly tender. Laboratory testing shows a normal WBC, mild elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, a differential with 10% atypical lymphocytes, and a negative result on heterophil antibody screening. Which of the following statements regarding cytomegalovirus (CMV) infection is true? CMV pneumonitis is a common problem in patients during the first 4 months after organ transplantation 86 BOARD REVIEW B. Heterophil antibodies are formed in response to both CMV and Epstein-Barr virus (EBV) infections C. Despite profound immunosuppression, CMV is an uncommon cause of infection in patients with AIDS D. Detection of CMV in urine or saliva confirms active acute infection Key Concept/Objective: To know the clinical and diagnostic features of CMV infection This otherwise healthy young man has a mononucleosis-like illness and tests negative for heterophil antibodies. CMV mononucleosis occurs in patients of any age but is most common in sexually active young adults. Heterophil antibodies are not formed in response to CMV infection. CMV is recognized as an important pathogen in patients with AIDS. The virus often contributes to the immunosuppression observed in such patients and may cause disseminated disease affecting the eyes, the gastrointestinal tract, or the central nervous system. At least 50% of patients with AIDS have CMV viremia, and 90% or more have evidence of CMV infection at autopsy.
Fever and abdominal pain are characteristically absent in patients with V cheap orlistat 120 mg. The presence of blood in the stool would make Shigella and Campylobacter infections less likely diagnoses D order 60mg orlistat. The most common cause of bacterial gastroenteritis in the United States is Shigella E. For cases of acute infection, Campylobacter, Shigella, and Salmonella should grow on standard culture media Key Concept/Objective: To understand specific characteristics helpful in the diagnosis of bacte- rial gastroenteritis of various causes The presence of fecal leukocytes is helpful in determining whether or not the cause of the diarrhea is an invasive infection or an inflammatory process such as inflammatory bowel disease. Other features associated with invasive infection are fever, abdominal pain, or even blood in the stool. Diarrhea caused by Campylobacter, Shigella, or Salmonella is characteristically associated with fecal leukocytes, fever, abdominal pain, and blood in the stool. Thus, fecal leukocytes, fever, abdominal pain, and bloody stools are not expected. Many diagnos- tic features of diarrhea caused by Campylobacter, Shigella, and Salmonella overlap. The most common cause of bacterial gastroenteritis in the United States is Campylobacter (46%), followed by Salmonella (28%) and Shigella (17%). Stool culture can be helpful in identifying the specific etiologic agent if this is felt to be necessary. Campylobacter does not grow on standard media but will grow on specialized media. Shigella and Salmonella will grow on standard media. A 40-year-old man contracts a bacterial gastroenteritis associated with fever, severe abdominal pain, and profuse diarrhea. Which of the following statements accurately characterizes the complications that may ensue in this patient? As many as 40% of patients with Guillain-Barré syndrome had recent Shigella infection B. The arthritis associated with Campylobacter infection results from bacteremic spread of infection to joints C. Antibiotic treatment of infection caused by enterohemorrhagic E. HUS most commonly results from infection with Shigella E. The development of erythema nodosum suggests infection with Salmonella Key Concept/Objective: To understand the various complications of infectious diarrhea Infectious diarrhea can be associated with various complications. Postinfectious arthri- tis occurs in approximately 1% of patients with Campylobacter gastroenteritis. This is a sterile monoarticular or migratory polyarticular arthritis that particularly involves the knee. It begins 7 to 10 days after the onset of diarrhea and may persist for months. Up to 40% of patients with Guillain-Barré syndrome have evidence of recent Campylobacter infection. HUS is most commonly the result of infection with EHEC, but it can result from infection with Shigella. Antibiotic treatment of infection caused by EHEC may increase the risk of development of HUS. Thus, the clinician should not pre- scribe antibiotic therapy if EHEC is a real diagnostic possibility.
Ultrasonography buy orlistat 120 mg line, in use for many years in materials engineering generic 60mg orlistat mastercard, assesses material elasticity (Young’s modulus) and is related to mineral density and bone architecture – sound propagates more quickly through more dense, intact structures. Expressed as broadband ultrasound attenuation (in dB/MHz) and as speed of sound (in m/s), both values are used in a “stiffness index”. Sound waves must also travel through adjacent soft tissue, and for this and other reasons the calcaneus (heel) is commonly used. Broadband ultrasound attenuation and speed of sound can predict fracture as accurately as BMD, though each detects different aspects of the overall susceptibility to fracture. However, several problems remain to be resolved before both these values can be reliably used for screening or intervention purposes. Ultrasound technology is still grappling with variability between various machines, and with imprecision of measurements. Patient factors (variability in skin temperature, ultrasound beam attenuation at the skin surface, variation in soft- tissue thickness and density) also pose problems. Technological advances (coupling gels, uniformity in sound wave focussing, software to handle soft tissue artefact) are expected to overcome many of these limitations. Being portable, non-ionising and inexpensive, and as ultrasound machines are already widely available to the public, this will have a considerable impact on patterns of self-referral. Unfortunately, commercialisation is likely to hamper future research efforts, particularly in trying to achieve standardisation and improved reliability of measurements across various providers. The clinical value of ultrasound in the future therefore remains uncertain. Genetic influences Genetic factors account for 60–80% of the observed variation in bone mineral density. Osteoporosis is polygeneic (many different genes contributing) and involves a complex interaction between genetic inheritance and the environment (including nutrition, general health, exposure to drugs, etc. Associations between bone mineral density 85 BONE AND JOINT FUTURES and, in some studies fracture, and a number of polymorphisms (variations in the DNA sequence within a gene) have been identified. These are reviewed in detail elsewhere, but the following observations are of interest with respect to future developments: G Polymorphisms in the collagen type I gene (COLIA1) and the gene for transforming growth factor beta (TGF- ) have been directly associated with both bone mineral density and fracture risk. G Several polymorphisms in the vitamin D receptor gene have been identified and associations with bone mineral density reported, although these findings have not always been consistent. There is also evidence that polymorphisms in this gene may affect the response to vitamin D and calcium supplementation. G Polymorphisms in genes for other key regulatory growth factors are currently being investigated. Although the human genome has been recently published, searches at new sites will probably be driven by fresh discoveries in bone biology rather than the reverse. However, one can foresee that as this technology becomes more accessible, individuals will be screened for genetic variations predisposing to a variety of common diseases, perhaps driven by the health insurance sector. In future, single or multiple genetic variations may well aid in the identification of those most at risk, but overall risk assessment, incorporating other factors as discussed above, will continue to be required for treatment. If you know any better methods than these, be frank and tell them; if not, use these with me. For most people there is a considerable period between the age at which osteoporosis may be detected and that at which most fractures occur. Many people who fracture will not have osteoporosis, while others with osteoporosis will not fracture. This has considerable implications for therapeutic decisions, and for the allocation of resources. The latter will also be affected by differences between society’s (typically utilitarian) perspective and that of the individual increasingly empowered by the information age and directly targeted in the future by pharmaceutical advertising.
Fifteen percent of patients with neuropathy develop an ulcer in their lifetime discount orlistat 120 mg amex. Prognosis Prognosis is dependent on daily foot hygiene and care orlistat 60mg low cost. Feldman EL, Stevens MJ, Russell JW, et al (2001) Diabetic neuropathy. In: Becker KL (ed) References Principles and practice of endocrinology and metabolism, 3rd edn. Lippincott, Williams & Wilkins, pp 1391–1399 Feldman EL, Stevens MJ, Russell JW, et al (2002) Somatosensory neuropathy. In: Porte D Jr, Sherwin RS, Baron A (eds) Ellenberg and Rifkin’s diabetes mellitus, 6th edn. McGraw Hill, pp 771–788 Simmons Z, Feldman EL (2002) Update on diabetic neuropathy. Curr Opin Neurol 15: 595–603 Windebank AJ, Feldman EL (2001) Diabetes and the nervous system. In: Aminoff MJ (ed) Neurology and general medicine, 3rd edn. Churchill Livingstone, pp 341–364 256 Diabetic autonomic neuropathy Genetic testing NCV/EMG Laboratory Imaging Biopsy ++ ++ Anatomy/distribution Both sympathetic and parasympathetic fibers are affected in diabetic autonom- ic neuropathy (DAN). Like DPN, DAN is a length dependent neuropathy with loss of autonomic function that can vary from mild to severe. Symptoms Mild subclinical DAN is common and occurs in patients with DPN. Cardiac symptoms include fixed tachycardia, orthostatic/postprandial hypotension, arrhythmias, and in severe cases, sudden cardiac death. Gastrointestinal symptoms include constipation, nightime diarrhea and gastroparesis with early satiety, nausea and vomiting. Genitourinary symptoms are common in men, with impotence present in nearly all males after 25 years of diabetes. Abnormal pupillary responses and abnormal sweating occurs, with anhydrosis of the feet and hands, and gustatory sweating in more severe cases. Abnormal neuroendocrine responses likely contribute to hypoglycemic un- awareness in type 1 patients. Clinical syndrome/ Symptomatic DAN is more common in type 1 patients, although subclinical signs DAN (diagnosed by cardiovascular testing) is common in type 2 patients. Patients have an abnormal heart rate, poor cardiac beat to beat variation, orthostasis, weight loss from gastroparesis, urinary tract infections from urinary retention, poor pupillary responses and absent sweating. Pathogenesis Like DPN, it is generally held that hyperglycemia underlies the development of DAN. It is likely that the hyperglycemic state disrupts both the normal metab- olism and blood flow of autonomic ganglia and nerves. Electrophysiology: Standard measures of cardiac autonomic function are required for the diagnosis and include measures of heart rate (R) variability conducted in the supine position with the patient breathing at a fixed rate of 6 breaths per minute during a 6 minute period. The maximum and minimum R-R intervals during each breathing cycle are measured and converted to beats a minute. The heart rate response is determined on changing from the lying to standing position. The shortest R-R interval around the 15th beat and the longest R-R interval around the 30th beat upon standing is measured to calculate the ratio. Patients can also undergo a bladder cystoscopy, gastroesophageal manometry, sweat testing and an eye exam. Imaging: Positron emission tomography (PET) quantitates sympathetic cardiac innerva- tion and is an excellent measure of left ventricular function.
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