By C. Kasim. State University of New York College at Potsdam.

Wound/skin diphteria occurs chiefly in the tropics and forms membrane-covered wound that fails to heal order tizanidine 2 mg mastercard. Laboratory diagnosis: Specimen: Swabs from the nose buy 2 mg tizanidine overnight delivery, throat discount tizanidine 2 mg with mastercard, or suspected lesion Smears: Beaded rods in typical arrangement when stained with alkaline methylene blue or gram’s stain Culture: Small, granular,and gray, with irregular edges with small zone of hemolysis on blood agar Selective media are necessary for isolation from cilincal specimens Selective media 1. Blood tellurite agar: Produce characteristic grey-black colonies due to their ability to reduce potassium tellurite to tellurium Characteristics of C. Gel-precipitation (Elek) test: a filter paper strip previously immersed in diphteria antitoxin is incorporated into serum agar; the strain of C. Incubate at 37 c for 1-2 days, and observe for lines of precipitation in the agar indicating toxin-antitoxin interaction. Schick test: a skin test to demonstrate immunitydue to immunization or natural infection Method: Intradermal injection of toxin into the anterior aspect of one forearm and heat-inactivated toxin into the other. Reactions due to the toxin are slower and longer lasting than those resulting from hypersensitivity. Listreriolysin( hemolysin) Pathogenesis and clinical features: Transmitted to humans through ingestion of poorly coooked meat and unpasteurized milk and milk products 1. Swine is major reservoir Pathogenicity and clinical features: Most human cases of disease are related to occupational exposure, i. Diagnosis: Specimen: Blood Culture: Shows α-hemolysis on Blood agar Biochemical reaction:. Neisseria gonorrhoea Antigenic structure: antigenically heterogeneous and capable of changing its surface structures. Pili: Hair-like appendages extending from bacterial surface and enhance attachment to host cells and evade human defense. Fbp(Iron binding protein):Expressed when there is limited available iron supply 8. IgA1 protease:Splits and inactivates major mucosal IgA(IgA1) Clinical manifestation: Route of infection: Sexual contact Male:. Gonococcal urethritis If complicated: Urethral stricture Gonococcal epididymitis Gonococcal epididymo-orchitis Infertility. Gonococcal salpingitis If compicated: Gonococcal tubo-ovarian abscess 215 Pelvic peritonitis Infertility Infant (When delivered through the infected birth canal). Gonococcal ophthalmia neonatorum If untreated and complicated leads to blindness Laboratory diagnosis: Specimen: Urethral swab, cervical swab, eye swab Smear: Gram-negative intracellular diplococci More than five polymorphs per high power field. Culture of urethral exudate from men are not necessary when the gram stain is positive but culture should be done for women Biochemical reaction:. Drug of choice: Ceftriaxone Ciprofloxacin Prevention and control • Avoid multiple sexual partner • Using mechanical protection methods (condom) • Early diagnosis and prompt treatment of cases • Contact tracing • Screening of high risk population groups • Ophthalmic ointment application of erythromycin or tetracycline to the conjunctiva of all new borns 217 Neisseria meningitidis Characteristics: • Gram-negative intra cellular diplococci. Capsular carbohydrate It is important for serogrouping of meningococci and there are 13 serogroups. The most important serogroups associated with disease in humans are A, B, C, Y and W135. Outer membrane protein Analogous to por protein of gonococci and responsible for the formation of por in the meningococcal cellwall 20 known serotypes It is responsible for serotype specificity of meningococci. Lipopolysaccharide Responsible for the toxic effects found in meningococcal disease Clinical manifestation:. Serology: Latex agglutination test/ Hemmagglutination test Treatment: Penicillin Penicillin-allergic patients are treated with third- generation cephalosporins or chloramphenicol Prevention and control. Rifampicin is used as prophylactic drug to reduce the carrier state during epidemics and given to house hold and other close contacts. Lipo-oligosaccharide 222 Clinical features: The bacteria causes disease most commonly in young children. Acute pyogenic arthritis Laboratory diagnosis: Specimen: Cerebrospinal fluid, sputum, blood, pus Smear: Gram-negative short rods. Culture: Chocolate agar contain both X and V factor; blood agar contain only X factor. Serology: Quellung reaction (using specific antisera) Immunofluorescence stain 223 Treatment: Ampicillin Chloramphenicol Cotrimoxazole Third generation cephalosporins H. Clinical features: Incubation period: 2 weeks Route of transmission is respiratory from early cases and possibly carries. Convalescence stage During catarrhal stage, the patient is highlyinfectious but not very ill manifesting with mild coughing and sneezing. During paroxysmal stage, the patient presents with explosive repetitive cough with characteristic ‘whoop’ upon inhalation leading to exhaustion, vomiting, cyanosis and convulsion. Laboratory diagnosis: Specimen: Saline nasal wash (Preferred specimen) Nasopharyngeal swab or cough droplets on cough plate Smear: Small, non-motile, capsulated, gram-negative cocobacilli singly or in pair, and may show bipolar staining. Culture: Inoculate the primary specimen on Bordet-Gengue agar o medium and incubate for 2-6 days at 37 c in a moist aerobic atmosphere which produces small, raised, shiny, mucoid colonies. Most of them are catalase positive Serology: Direct fluorescent antibody test is most helpful, in identifying B. Treatment: Erythromycin Adminstration of erythromycin during the catarrrhal stage of disease promotes elimination of the organism and limits rate of transmission. Treatment after the onset of paroxysmal stage does not alter the clinical course of the disease. Acute stage: Fever, malaise, sweating, hepatosplenomegally, lymphadenopathy Associated with 80% spontaneous recovery 227 2. Chronic stage: Generally associated with hypersensitivity manifestations like fever, chest pain, and arthritis. High agglutinin titier Complication: Brucella spondylitis( Vertebral brucellosis) Lab. Ulceroglandular tularemia: Ulceration of arms and hands with lymphadenitis after tick bite or direct contact of broken skin with infected tissue or blood 3. Oculoglandular tularemia: Accidental contamination of the conjunctiva with infected droplets/aerosols 4. Dignosis: Specimen: Skin lesion, lymphnodes, sputum, conjunctival scrapings Culture: grow in blood-cysteine-gextrose agar incubated at 37 0c under aerobic condition Serology: Agglutination test Single titer of ≥ 1:160 is highly suggestive of tularemia Paired serum samples collected two weeks apart can show a rise in agglutination titer Treatment: Streptomycin or gentamicin Tetracycline Prevention and control: Immunization of high risk persons (eg. Heat labile and sensitive to alcohol May interfere with agglutination by O antisera.

Pharmacists are an essential part of the medication use process and better integration of e- Prescribing and pharmacy information systems through cheap tizanidine 2 mg on-line, at a minimum order 2mg tizanidine amex, one-way complete electronic data interchange should be a focus of further research buy discount tizanidine 2 mg line. Prescribers were also concerned 95 that notification by pharmacies of prescription fill status (filled or not filled) could 839 increase their exposure to malpractice claims. Nearly all of the systems evaluated in the United States described the use of prescription writing software limited to generating e-Prescriptions, but without any other clinical record keeping 736,839 functionality. These systems generated prescriptions and retrieved pharmacy dispensing histories while requiring providers to concurrently maintain paper-based medical records. Evidence from the limited set of one-way e- Prescribing studies was extrapolated to identify possible key facilitators and barriers to completely electronic, two-way e-Prescribing systems. Possible facilitators include monetary or other incentives to providers, a permissive regulatory environment, and the existence of enabling technical standards necessary for e-Prescribing. These studies involved 4,709 providers and approximately 828,441 patients in total (numbers were not specified in all articles). Patients included were primarily adults, with only two studies addressing issues specific to children. All studies assisted with at least the prescribing (71 percent) or monitoring (29 percent) phases of medication management. Notably, none concentrated solely on the order communication, dispensing, or administering phases of medication management. The studies were much more likely to focus on process changes than clinical (patient­ important) outcomes. Furthermore, many studies did not report directly which outcome was their 96 main endpoint—a fundamental flaw. Only five of 34 studies measuring clinical outcomes, whether a main endpoint or not, had a statistically significant impact on a clinical outcome. Where clinical outcomes were thought to be designated main endpoints, 12 of 16 studies showed no differences in clinical outcomes between intervention and control 403,518-520,526,528,624,630,637,697,699,700 groups. Strengths and Limitations As per our inclusion criteria, all trials used randomization for allocation. One of the most important features to avoid bias, allocation concealment was only described to a minimally acceptable degree by 25 studies. Twenty articles scored six or more and none of the studies scored the maximum nine points. Cluster numbers are often small, and therefore, if clusters initially randomized to control group drop out, or participants within the clusters (who are known to be in the intervention or control group) are selected in a biased manner, trial results may not be valid. Only a small minority of these focus on clinical outcomes—those outcomes that are most important to guide decisions of patients’ providers and policymakers about these interventions. General Study Characteristics Of the 77 trials, 46 (60 percent) were rated as impacting primarily the prescribing phase of medication management, 12 (16 percent) aimed primarily at medication monitoring, 15 (19 percent) tried to impact both phases and one addressed administering. Three trials (4 percent) attempted to influence a mix of prescribing, monitoring, order communication, and administering phases of medication management. The setting for the studies was judged to be ambulatory care in 53 (69 percent), or hospital- based in 19 (25 percent), with a small minority based in long term care (two (3 percent)), or other settings (three (4 percent)) such as community or home. Approximately half (36 or 47 percent) of these studies were identified as associated with academic institutions. However, many studies did not address the specific type of provider targeted by the intervention. Three studies identified pharmacists as one of the 97 intervention targets and one study targeted nurses specifically. Patients were named as targets of the intervention in 22 studies, 13 of which exclusively targeted patients. Drug topics were evaluated in 42 studies—19 were vascular medications, 13 antibiotics or vaccines, and five addressed multiple medications. Similarly, we were not able to critique the suitability of control groups in this systematic review, which were typically described as usual care. Outcomes Of the 77 studies, 54 indicated in some way that they had a primary or main outcome and only 16 appeared to have designated a clinical outcome as a main endpoint. Two studies with the highest methodologic quality (six out of nine) are further described. The other used a university affiliated managed care plan data to identify gaps in recommended drug therapy and monitoring to recommend drugs to stop or add, or for monitoring to take place. However, this analysis was based on a post-hoc outcome applied to a subgroup of the original participants and the changes in hospitalization are very high given the small change in recommendation use. In 26 cases, the process was judged to be positively affected; with improvement in at least 50 percent of the process measures reported. The changes in process measured in these studies generally dealt with 403,404,407,410,509,525,530,535,536 reminders about recommended medications or vaccines, dose 398,412 adjustments, recommended laboratory monitoring for medications prescribed or chronic 412,504,513,516,612,619,771 disease management, ‘inappropriate’ medications 397,413,416,507,508,512,533 avoided, and other similar outcomes. Some of the alerts or reminders were based on established guidelines, while others were assessing more locally derived quality measures and standards of care. This implicates a major publication bias, a result of not requiring studies to measure and report on harm. In terms of costs, 11 studies reported that they had intended to measure costs or cost- effectiveness. Three hundred and sixty-one of these articles were only listed in the bibliography of this report and were not synthesized because they did not include comparative data, statistical methods, or qualitative methods. The remaining 428 articles were synthesized after being identified from an initial retrieval of 40,582 articles. The majority were based on observational methods, often with identifiable opportunity for bias (e. Changes in workflow, improvements in communication, and improved efficiencies such as time reductions are also positive, although fewer studies addressed these types of outcomes. A number of unintended consequences of the technologies were found, some of which were unfortunate and some of which were beneficial. However, given the uncertainty that surrounds the cost and outcomes data, and limited study designs available in the literature, it is difficult to reach any definitive conclusion as to whether the additional costs and benefits represent value for money.

We would not expect to effect a cure in dropsy from heart disease order tizanidine 2 mg online, or ascites from structural disease of the liver tizanidine 2 mg overnight delivery, neither would we where there was a frequent buy discount tizanidine 2 mg online, hard pulse, and other evidences of febrile action. Still in these cases, if we can partially remove the obstruction in the first case, and after an arrest of febrile action in the second, the Apocynum will remove the deposit. It seems to strengthen the circulation, and as absorption takes place there is an increased flow of urine. It may be especially recommended in those cases in which the flow is constantly too profuse, to long, and too frequently repeated. Latterly it has been used as an anti-rheumatic, with excellent results in some cases. With this, as with many other remedies, there are special symptoms indicating its use. Thus in rheumatism, if there is a tendency to œdema, even slight puffiness of the skin, or a peculiar blanched glistening appearance, the Apocynum will be found a valuable remedy. It will also be found a valuable remedy in chronic metritis, with uterine leucorrhœa. In one case with profuse watery discharge from the uterus, it proved curative after other plans of treatment had failed. I would suggest a tincture of the recent bark, in dilute alcohol, and in the proportion of ℥viij. It undoubtedly influences the cerebro-spinal centers, controlling epileptiform movements. It has been administered in cases of epilepsy with success, though the discoloration of the skin caused by the large doses given, was a serious objection. It also exerts an influence in chronic gastritis and enteritis, and has been given in some cases of dysentery with advantage. It has been employed in ague and malarial disease, when there was marked confusion of intellect, with headache and burning of the face and eyes. In ague the chill is prolonged, with great pain in the bones, and a feeling as if bruised. In large doses it has been extensively used as a stimulant diaphoretic, and is a most excellent remedy. In small doses it is indicated by a relaxed atonic skin, cold extremities, cold perspiration, difficult respiration, and difficult deglutition. It is not necessary to refer to the common local use of this agent, or discuss the question whether a tincture of arnica is preferable to alcohol alone as a local application. It is a valuable stimulant in many grave diseases where a stimulant is most required. But if used as a general stimulant, like alcohol, it would be as apt to do harm as good. It is a specific stimulant to the spinal nervous system, and will be found useful where there is want of innervation from this. I have seen most marked benefit from it in advanced stages of disease, where there was feeble respiratory power; difficulty of sleeping from impeded respiration; want of control over the discharge of urine and feces, etc. I have frequently prescribed it for lame back, back-ache, and feelings of debility and soreness, in the small of the back. It is only useful in those cases where there is feebleness, with deficient circulation; but in these the influence is direct and permanent. The cases reported, so far as I can learn, were asthenic with an enfeebled circulation. The use of Arsenic in the early part of this century, though limited, was in large and many times poisonous doses. Being a powerful excitant to the vegetative nerves, this use, if continued long, would produce a peculiar form of fever - “febris arsenicum” - with its attendant impairment of vital function. Finally, with impaired blood-making and nutrition, there would be developed arsenical dropsy, and in some rare cases death was the result. The arsenical fever bears a very close resemblance to quinism, or quinine poisoning, in its symptoms, though there is not, in a majority of cases, such disturbance of the nervous system. We have long since determined that the mere matter of dose in medicine might be the difference between a poison and a remedy. If, for instance, we give one grain of Strychnia, we poison our patient, whilst if the dose had been but the fortieth or thirtieth of a grain, it would have proven a vital stimulant. If we administer five grains of morphia, the result is death; whilst a medicinal dose of one-fourth of a grain would have produced refreshing sleep. If we give large doses of Aconite, (say five drops of a tincture of the root,) frequently repeated, it increases the frequency of the pulse, impairs the circulation, and irritates the nervous system. But, in medicinal doses, it lessens the frequency of the pulse, gives freedom to the circulation, and relieves irritation of the nervous system. If we give large doses of Veratrum, it impairs the circulation, arrests vital processes, and produces death; whilst medicinal doses give increased freedom to the circulation and diminish the frequency of the pulse. It seems strange to me that these things have not had due consideration, and that the remedial action of drugs has not been kept distinct from their poisonous effects when given in large doses. We have already seen, that the dose of medicine should be the smallest quantity that will give the desired influence, and that in a rational system of medicine, its influence should always be to restore normal function, and not as a disturbing element. A drug which may be poisonous in health, or in some conditions of disease, will be curative in other conditions of disease. Thus we regard the disease as antagonizing the remedy, quite as much as the remedy antagonizes the disease, and the influence is toward the restoration of healthy function. Thus, if we give Quinine to cure malarial fever, its influence is kindly, but if there is no malarial disease, it causes irritation of the nervous system. If we give Belladonna when there is an enfeebled capillary circulation, the influence is kindly and curative, but it is the reverse if we already have capillary spasm. This is especially the case with the more powerful remedies, with which Arsenic should be classed, and they should never be employed unless the symptoms indicating them are very distinct. Such a brief statement of facts I have deemed necessary in this case, on account of the prejudice of our school to these agents - a prejudice which grew out of their abuse. This prejudice is so strong now, that one hardly dare risk making a study of the tabooed articles, and yet common honesty demands that it be done. In small doses, and when indicated, Arsenic may be regarded as a vital stimulant, and one of the most powerful of this class.

Patients with acute pyelonephritis or obstructing renal calculi complain of severe pain when the flank is percussed buy discount tizanidine 2 mg on line, so it is important to tap lightly in order to maintain patient confidence tizanidine 2 mg amex. To rule out a musculoskeletal etiology for the flank pain discount tizanidine 2mg with mastercard, the lower extremities should be examined for motor and sensory function. Laboratory and Diagnostic Studies Laboratory Studies The history and physical examination help determine the most probable etiology of the flank pain and guide the clinician toward the selection of the most appropriate laboratory and diagnostic tests. Evaluation of Flank Pain 689 In almost all cases, a urinalysis should be performed as the initial diagnostic test. In contrast, patients with uric acid stones tend to have an acidic urine, since these stones do not form when the urine is alkaline. A Gram stain should be done in the emergency room or clinic and can help determine if infection is present. The shape of the crystal can be used by the laboratory technician to help identify its composition. The urinalysis may be normal if the etiology of the flank pain is due to cardiac, intraabdominal, musculoskeletal, or psychological problems. Anemia and a low or high platelet count might be seen in the presence of bleeding urologic tumors. The impaired function could be due to dehydration, obstruction, tumor, infarct, or medical renal disease. Moreover, an elevated serum creati- nine indicates bilateral renal disease or disease involving a solitary kidney, since only one healthy kidney is required to maintain a normal serum creatinine. In long-standing renal compromise, it is not un- common to see a fall in serum bicarbonate along with hyperkalemia. Hyponatremia results from volume overload and can cause nausea, vomiting, and seizures. Hyperkalemia especially is dangerous, since it could result in cardiac arrhythmias. Other useful tests might include a serum uric acid level and serum calcium level, if a urinary calculus is suspected. Barone Diagnostic Studies Following the history, physical exam, and laboratory analysis, a plain film of the abdomen can help identify urinary calculi (Fig. The entire film should be viewed for intestinal gas pattern, gallstones, bony structure, and free air, which may provide insight into the etiology of the pain. Renal cell carcinomas are osteolytic tumors, and this can be seen radiographically in metastatic disease. An abnormal intestinal gas pattern, gallstones, or free air suggest intraabdominal pathology. Aortic calcifications and aneurysms should be determined, since they might suggest renal artery disease as the etiology of the flank pain. Urinary calculi typically are seen as calcifications overlying the kidney shadow or along the course of the ureter (Fig. Small stones, 1 to 2mm in size, can cause severe flank pain if they obstruct the flow of urine into the bladder. Following the history, physical examination, urinalysis, and abdom- inal plain film, a preliminary diagnosis is possible in most instances. However, more detailed imaging studies often are performed to confirm the diagnosis and to help plan appropriate therapy. These reactions can be severe and have resulted in hemodynamic and respiratory collapse. These tests demonstrate anatomy, not function, and this con- sideration may be important in a patient’s evaluation. In this instance, the kidney looks normal; however, it is no longer functioning due to the recent infarct. Summary The urologist frequently evaluates patients with flank pain and diag- noses and treats conditions that may have local or systemic ramifica- tions. Nonurologic causes for the pain always are considered during the initial evaluation. Although the history and physical examination are the most important aspect of the evaluation, laboratory and diag- nostic tests help confirm the diagnosis. Since this is a commonly encountered clinical problem, all practitioners should have some famil- iarity with the diagnosis and management of flank pain. To generate a list of potential diagnoses for the patient who presents with pain or a mass in the scrotum. Be sure to: • Discuss testicular versus extratesticular origins • Discuss benign versus malignant causes • Discuss emergent versus nonemergent causes 3. Be sure to discuss the following issues: • Pain—presence, absence, onset, severity • Palpation—distinguish testicular from extrates- ticular (adnexal) mass • Transillumination 4. Cases Case 1 A mother brought her 15-month-old son in for evaluation because he has “only one testicle. Weiss Case 2 A 15-year-old boy presented to the emergency department with acute testis pain and nausea. Testicular development and descent are controlled intricately by the hypothalamus-pituitary-gonad axis (Fig. Testosterone regulates its own production by regaling feedback on the hypothalmus and pituitary. Scrotal development in males is a result of the testis and epididymis descending, causing the skin to stretch. Sperm fertility is enhanced by being stored in a cooler region within the scrotum rather than in the abdomen. Cryptorchid or “undescended testis” results in infertility if the testis is not placed in the scrotum. Scrotal Disorders 695 During early development, the testes originates in the abdomen near the kidney. During early embryologic development, the processus vaginalis is an invagination at the inguinal ring. The gubernac- ulum attaches superiorly onto the Wolffian duct and inferiorly into the inguinal canal.

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