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By: O. Lee, M.B. B.CH., M.B.B.Ch., Ph.D.
Medical Instructor, Ohio University Heritage College of Osteopathic Medicine
Lipodermatosclerosis is the combination of induration antibiotic xifaxan colitis discount 250mg zi-factor fast delivery, hemosiderin deposition antibiotics gram positive order zi-factor with mastercard, and inflammation antibiotic effects purchase generic zi-factor on line, and typically occurs in the lower part of the leg just above the ankle. Atrophie blanche is a white patch of scar tissue, often with focal telangiectasias and a hyperpigmented border; it usually develops near the medial malleolus. A phlebectasia corona is a fan-shaped pattern of intradermal veins near the ankle or on the foot. A venous ulcer is often shallow and characterized by an irregular border, a base of granulation tissue, and the presence of exudate. Bedside maneuvers can be used to distinguish primary varicose veins from secondary varicose veins caused by deep venous insufficiency. With the contemporary use of venous ultrasound (see below), however, these maneuvers are employed infrequently. The Brodie-Trendelenburg test is used to determine whether varicose veins are secondary to deep 1651 venous insufficiency. As the patient is lying supine, the leg is elevated and the veins allowed to empty. Then, a tourniquet is placed on the proximal part of the thigh and the patient is asked to stand. Filling of the varicose veins within 30 s indicates that the varicose veins are caused by deep venous insufficiency and incompetent perforating veins. Primary varicose veins with superficial venous insufficiency are the likely diagnosis if venous refilling occurs promptly after tourniquet removal. A tourniquet is placed on the midthigh after the patient has stood, and the varicose veins are filled. A patent deep venous system and competent perforating veins enable the superficial veins below the tourniquet to collapse. Deep venous obstruction is likely to be present if the superficial veins distend further with walking. Differential Diagnosis the duration of leg edema helps to distinguish chronic venous insufficiency from acute deep vein thrombosis. Lymphedema, as discussed later in this chapter, is often confused with chronic venous insufficiency, and both may occur together. Other disorders that cause leg swelling should be considered and excluded when evaluating a patient with presumed venous insufficiency. Unilateral causes of leg swelling also include ruptured leg muscles, hematomas secondary to trauma, and popliteal cysts. Leg ulcers may be caused by severe peripheral artery disease and critical limb ischemia; neuropathies, particularly those associated with diabetes; and less commonly, skin cancer, vasculitis, or rarely as a complication of hydroxyurea. The location and characteristics of venous ulcers help to differentiate these from other causes. It also broadly categorizes the etiology as congenital, primary, or secondary; identifies the affected veins as superficial, deep, or perforating; and characterizes the pathophysiology as reflux, obstruction, both, or neither (Table 303-1). Diagnostic Testing the principal diagnostic test to evaluate patients with chronic venous disease is venous duplex ultrasonography. A venous duplex ultrasound examination uses a combination of B-mode imaging and spectral Doppler to detect the presence of venous obstruction and venous reflux in superficial and deep veins. Obstruction may be diagnosed by absence of flow, the presence of an echogenic thrombus within the vein, or failure of the vein to collapse when a compression maneuver is applied by the sonographer, the last implicating the presence of an intraluminal thrombus.
Immunotherapy Specific immunotherapy using injected extracts of pollens or house dust mites has not been very effective in controlling asthma and may cause anaphylaxis antimicrobial benzalkonium chloride order 100mg zi-factor amex. It is not recommended in most asthma treatment guidelines because of lack of evidence of clinical efficacy virus 10 states generic 500 mg zi-factor visa. Alternative Therapies Nonpharmacologic treatments bacteria belong to what kingdom buy zi-factor 100mg without prescription, including hypnosis, acupuncture, chiropraxis, breathing control, yoga, and speleotherapy, may be popular with some patients. However, placebocontrolled studies have shown that each of these treatments lacks efficacy and cannot be recommended. However, they are not detrimental and may be used as long as conventional pharmacologic therapy is continued. Future Therapies It has proved very difficult to discover novel pharmaceutical therapies, particularly because current therapy with corticosteroids and 2-agonists is so effective in the majority of patients. There is, however, a need for the development of new therapies for patients with refractory asthma who have side effects with systemic corticosteroids. Antagonists of specific mediators have little or no benefit in asthma, apart from antileukotrienes, which have rather weak effects, presumably reflecting the fact that multiple mediators are involved. However, these drugs, which act on signal transduction pathways common to many cells, are likely to have troublesome side effects, necessitating their delivery by inhalation. Triggers that worsen asthma control, such as allergens or occupational agents, should be avoided, whereas triggers, such as exercise and fog, which result in transient symptoms, provide an indication that more controller therapy is needed. In particular, they need to understand how to recognize worsening of asthma and how to step up therapy. Written action plans have been shown to reduce hospital admissions and morbidity rates in adults and children, and are recommended particularly in patients with unstable disease who have frequent exacerbations. Clinical Features Patients are aware of increasing chest tightness, wheezing, and dyspnea that are often not or poorly relieved by their usual reliever inhaler. In severe exacerbations, patients may be so breathless that they are unable to complete sentences and may become cyanotic. A chest roentgenogram is not usually informative but may show pneumonia or pneumothorax. Stepwise Therapy For patients with mild, intermittent asthma, a short-acting 2-agonist is all that is required. However, use of a reliever medication more than twice a week indicates the need for regular controller therapy. The dose of controller should be adjusted accordingly, as judged by the need for a rescue inhaler. In patients with severe asthma, low-dose oral theophylline is also helpful, and when there is irreversible airway narrowing, the long-acting anticholinergic tiotropium bromide may be tried. If asthma is not controlled despite the maximal recommended dose of inhaled therapy, it is important to check compliance and inhaler technique. Occasionally omalizumab may be tried in steroid-dependent asthmatics who are not well controlled. Once asthma is controlled, it is important to slowly decrease therapy in order to find the optimal dose to control symptoms. A nebulized anticholinergic may be added if there is not a satisfactory response to 2-agonists alone, as there are additive effects. In patients who are refractory to inhaled therapies, a slow infusion of aminophylline may be effective, but it is important to monitor blood levels, especially if patients have already been treated with oral theophylline.
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Neutron particles are heavy and uncharged and are often emitted during nuclear detonation antibiotic resistance symptoms buy discount zi-factor 500 mg on line. They possess a wide energy range; their ability to penetrate tissues is variable antibiotic 7 days to die best order for zi-factor, depending on their energy antibiotic resistant bacteria in meat purchase 250mg zi-factor overnight delivery. They are less likely to be present in most scenarios of radiation bioterrorism than are the other forms of radiation discussed above. Radiation damage can lead to cell death; the cells that recover may be mutated and at higher risk for subsequent cancer evolution. Cell sensitivity increases as the replication rate increases and cell differentiation decreases. The rad (radiation absorbed dose) is energy deposited within living matter and is equal to 100 ergs/g of tissue. While 1 Sv is equal to 1 joule/kg, Sv and Gy are not interchangeable units: Sv refers to the biologic effect of the radiation, while Gy refers to the physical energy being transferred. During a whole-body exposure, alpha and beta particles have limited penetration and do not cause significant noncutaneous injury unless emission results from an internalized source. Whole-body exposure from gamma rays, x-rays, or neutrons, which can penetrate through the body (the degree of which depends on their energy), can result in damage to multiple tissues and organs. The damage is proportional to the radiation exposure of the specific organ or tissue. External contamination is a result of fallout of radioactive particles that land on the body surface, clothing, skin, and hair. This is the dominant element to consider in the mass-casualty situation resulting from a radioactive terrorist strike. Alpha particles do not penetrate beyond the skin and thus have minimal systemic effects. Due to their ability to penetrate tissue, gamma emitters can cause not only local damage but also whole-body radiation exposures and injury. Medical treatment primarily entails decontamination of the body, including wounds and burns, to prevent internalization of radioactive contaminants. Removal of contaminated clothing reduces levels of contamination significantly and is a first step in the decontamination process. Generally, patients do not constitute a significant radiation hazard to health care providers, and lifesaving treatment should not be delayed for fear of secondary contamination of the medical team. Although risk is relatively low, any damage to health care personnel will depend directly on the duration of exposure and will be inversely proportional to the square of the distance from any radioactive source. Internal contamination occurs when radioactive material is inhaled or ingested or enters the body through open wounds or burns or via skin absorption. In principle, any externally contaminated casualty should be evaluated for internal contamination. Because of their chemical properties, some isotopes may exert toxic effects on specific target organs in addition to causing radiologic injury. The respiratory system is the main portal of entry for internal contamination, and the lung is the organ at greatest risk. Aerosol particles <5 m in diameter can reach the alveoli, whereas larger particles will remain in the proximal airways. Radioactive material entering the gastrointestinal tract is absorbed according to its chemical structure and solubility.
Because bicuspid valves may develop stenosis or regurgitation with time or be the site of infective endocarditis antibiotic probiotic generic zi-factor 100 mg visa, the lesion may be difficult to distinguish in older adults from acquired rheumatic or degenerative calcific aortic valve disease bacteria types order zi-factor 100mg fast delivery. The dynamics of blood flow associated with a congenitally deformed best antibiotics for sinus infection doxycycline generic zi-factor 100mg mastercard, rigid aortic valve commonly lead to thickening of the cusps and, in later life, to calcification. The ascending aorta is often dilated, misnamed "poststenotic" dilatation; this is due to histologic abnormalities of the aortic media and may result in aortic dissection. Diagnosis is made by echocardiography, which reveals the morphology of the aortic valve and aortic root and quantitates severity of stenosis or regurgitation. A dilated aortic root may require beta blockers, angiotensin receptor blockers, or angiotensin-converting enzyme inhibitors. In asymptomatic children or adolescents or young adults with critical aortic stenosis without valvular calcification or these features, aortic balloon valvuloplasty is often useful (Chap. If surgery is contraindicated in older patients because of a complicating medical problem such as malignancy or renal or hepatic failure, balloon valvuloplasty may provide short-term improvement. This procedure may serve as a bridge to aortic valve replacement in patients with severe heart failure. The jet impact from the subaortic stenotic jet on the underside of the aortic valve often begets progressive aortic valve fibrosis and valvular regurgitation. Echocardiography demonstrates the anatomy of the subaortic obstruction; Doppler studies show turbulence proximal to the aortic valve and can quantitate the pressure gradient and severity of aortic regurgitation. In most patients, a genetic defect for the anomaly is located in the same chromosomal region as elastin on chromosome 7. Supravalvular aortic stenosis is the most commonly associated cardiac defect in Williams-Beuren syndrome, typically comprising the following: "elfin" facies, low nasal bridge, cheerful demeanor, mental retardation with retained language skills and love of music, supravalvular aortic stenosis, and transient hypercalcemia. Clinical manifestations depend on the site and extent of obstruction and the presence of associated cardiac anomalies, most commonly a bicuspid aortic valve. Most children and young adults with isolated, discrete coarctation are asymptomatic. Headache, epistaxis, chest pressure, and claudication with exercise may occur, and attention is usually directed to the cardiovascular system when a heart murmur or hypertension in the upper extremities and absence, marked diminution, or delayed pulsations in the femoral arteries are detected on physical examination. Enlarged and pulsatile collateral vessels may be palpated in the intercostal spaces anteriorly, in the axillae, or posteriorly in the interscapular area. The upper extremities and thorax may be more developed than the lower extremities. A midsystolic murmur over the left interscapular space may become continuous if the lumen is narrowed sufficiently to result in a high-velocity jet across the lesion throughout the cardiac cycle. Additional systolic and continuous murmurs over the lateral thoracic wall may reflect increased flow through dilated and tortuous collateral vessels. Chest x-ray may show a dilated left subclavian artery high on the left mediastinal border and a dilated ascending aorta. Indentation of the aorta at the site of coarctation and pre- and poststenotic dilatation (the "3" sign) along the left paramediastinal shadow are essentially pathognomonic. Notching of the third to ninth ribs, an important radiographic sign, is due to inferior rib erosion by dilated collateral vessels. Two-dimensional echocardiography from suprasternal windows iden- 1525 tifies the site of coarctation; Doppler quantitates the pressure gradient. In adults, cardiac catheterization is indicated primarily to evaluate the coronary arteries or to perform catheter-based intervention (angioplasty and stent of the coarctation). Late postoperative systemic hypertension in the absence of residual coarctation is related partly to the duration of preoperative hypertension. Follow-up of rest and exercise blood pressures is important; many have systolic hypertension only during exercise, in part due to a diffuse vasculopathy and to noncompliance of the stented or surgically reconstructed region.
