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By L. Felipe. University of Minnesota-Morris.

Prophylaxis: Vaccines that include the prevalent strains of influenza viruses effectively reduce the incidence of infection purchase viagra plus 400mg without prescription impotence vs impotence. Amantadine 100mg orally bid (for adults) can be used prophylactically against influenza A buy discount viagra plus 400mg on line erectile dysfunction drugs uk. Treatment: Amantadine has a beneficial effect on fever and respiratory symptoms if given early in uncomplicated influenza order viagra plus 400mg fast delivery impotence drugs. It may develop after a common cold or other viral infection of the nasopharynx buy discount viagra plus 400mg on-line erectile dysfunction non prescription drugs, throat or tracheobronchial tree, often with secondary bacterial infection. Scattered rhonchi and wheezes may be heard, as well as occasional crepitations at the bases. Serious complications are usually seen only in patients with an underlying chronic respiratory disorder. Pneumonia Learning Objective: At the end of this unit the student will be able to 1. Refer complicated cases of Pneumonia Pneumonia is an acute infection of lung parenchyma including alveolar spaces and interstitial tissue. Other means include hematogenous dissemination, via the lymphatics, or directly from contiguous infections. Microbial Pathogen that cause Pneumonia: depend on the setting in which pneumonia is acquired 1. Community-acquired pneumonia o Streptococcus pneumoniae ( pneumococcal pneumonia ) commonest cause o Mycoplasma pneumoniae o Chlamydia pneumoniae o Haemophilus influenza o Oral anaerobic bacteria o Staphylococcus aureus o Legionella pneumophila o Mycobacterium tuberculosis 2. Aspiration pneumonia: This occurs when large amount of oropharyngeal or gastric contents are aspirated into the lower respiratory tract. Aspiration occurs more frequently in patients with: Decreased level of consciousness (alcoholism, seizure, strokes or general anesthesia) Neurologic dysfunction of oropharynx and swallowing disorders. Common Etiologic agents of Aspiration pneumonia: It is often polymicrobial o Anerobic organisms in the oral cavity o Enterobateriacae o S. Hospital-acquired pneumonia: a patient is said to have hospital acquired pneumonia if the symptoms begin 48 hours after hospital admission and not incubating at the time of admission. Common organisms that cause hospital-acquired pneumonia are:- o Gram-negative bacilli including Pseudomonas aeroginosa, K. Clinical Presentation of community acquired pneumonia Community acquired pneumonia can have typical or atypical presentations. The typical Community acquired pneumonia: is characterized by:- Sudden onset with a single shaking chill. Some viruses like influenza virus, Varicella zoster virus and cytomegalovirus may cause atypical pneumonia. Complications: Local: Parapneumonic effusion or pus in the pleural space (empyema). Diagnosis: Pneumonia should be suspected in patients with acute febrile illness, associated with chest pain, dyspnea and cough. Response In mildly ill patients who are treated early, fever subsides in 24 to 48 hrs. Treatment: Acutely ill patients who have suspected bacterial infections are often treated with antibiotics selected on the basis of probabilities and the findings with sputum gram stain and culture. Later treatment is adjusted on the basis of more definitive diagnostic evaluation. Bronchial Asthma Learning Objective: At the end of this unit the student will be able to 1. Definition: Bronchial asthma is defined as chronic inflammatory disease of airways characterized by increased responsiveness of the tracheobronchial tree to a multiplicity of stimuli. It is associated with widespread airway obstruction that is reversible (but not completely in some patients), either spontaneously or with treatment Epidemiology: Asthma is a common disease The prevalence of asthma is rising in different parts of the world. About 50% of patients develop asthma before the age of 10 and another 35% before the age of 40. Most cases of asthma are associated with personal or family history of allergic disease such as eczema, rhinitis and urticaria. Etiology Asthma is a heterogeneous disease and genetic ( atopic ) and environmental factors such as viruses, occupational exposure and allegens contribute to its initiation and continuance. In general asthma which has its onset early in life tends to have strong allergic component, where as asthma that develops late in life tends to be nonallergic or to have mixed etiology. The cells thought to play important part in the inflammatory response are mast cells, eosinophils, lymphocytes and airway epithelial cells. These cells release inflammatory mediators which may result Bronchoconstriction (spasm of airways smooth muscles ) Vascular congestion and edema of airways mucosa Increased mucus production Injury and desquamation of the airways epithelium and impaired muco-ciliary transport Symptom and Signs The symptoms of each asthmatic patient differ greatly in frequency and degree. Psychological factors particularly those associated with crying, screaming or hard laughing may precipitate symptoms. On physical examination Varying degrees of respiratory distress tachypnea, tachycardia, and audible wheezes are often present. However, low grade wheezing maybe heard at any time in some patients, even when they claim to be completely asymptomatic. Complications during an Acute Attack of Asthma Pneumothorax: It may present as sudden worsening of respiratory distress, accompanied by sharp chest pain and on examination, hyperresonant lung with a shift of mediastinum. A family history of allergy, rhinitis or asthma can be elicited in most asthmatics. Physical examination should search for heart failure and signs of chronic hypoxemia (clubbing). Treatment General principles Assessing the severity of the attack is paramount in deciding management Bronchodilators should be used in orderly progression Decide when to start corticosteroids Treatment of the Acute Attack Mild acute asthmatic attack: Most patients can be managed as an outpatient st Salbutamol aerosol (Ventolin) two puffs every 20 minutes for three doses is the 1 line of treatment. However, over hydration may cause pulmonary edema and one should be cautious in fluid administration. However this can be overcome when underlying hypoxia and feeling of asphyxiation is treated. Maintenance Therapy for Asthma (Chronic Treatment) Goal of Therapy: To achieve a stable, asymptomatic state with the best pulmonary function, using the list amount of medication. Step wise approach for managing Asthma in adults Severity Symptoms Medication Alternative day/night treatment in resource limited setting Mild 2 days/wk and 2 No daily medication intermittent nights /month needed Treat when there is acute exacerbation Mild > 2days /week but < Low dose inhaled steroids Theophedrine tablets Persistent 1 per day and > 2 or or Salbutamol tabs nights/month Cromolyn Moderate Daily symptoms and Low-medium does inhaled Theophylline Persistent more than 1 night /wk steroid and long acting B- sustained release agonist inhaler Salbutamol Tabs Prednisolone tablets (low dose Sever Continual daily High dose inhaled steroid Theophylline Persistent symptoms and and long acting inhaled B- sustained release 183 Internal Medicine frequent night agonists and Oral steroids Salbutamol Tabs symptoms (if needed ) Prednisolone tablets (high dose) or Celestamine tabs References: 1) Kasper L. Both these diseases occur together in the same individual in a variable proportion but the manifestations of one often predominates the clinical picture. Etiology Emphysema: Any factor leading to chronic alveolar inflammation would encourage development of an emphysematous lesion. Congenital enzyme defects such as 1- antitrypsin deficiency are also risk factors for the disease. In developing countries household smoke from fire wood is said to be a major contributing factor. Nowadays, the incidence of this disease in females is increasing because of the increasing smoking habit. Pathological changes and pathophysiology Chronic bronchitis is characterized by hypertrophy of mucus glands in both large and small airways with thickening of walls and accompanying excess production of mucus and narrowing of airway lumen. This leads to abnormal V/Q (arteriovenous shunt) and patients usually suffer from hypoxemia (manifested with cyanosis) and acidosis, which causes pulmonary hypertension and right heart failure in the long term. Moreover, emphysema causes mucus production and airway narrowing with accompanying reduction in ventilation. This leads to retention of carbon dioxide in the blood and severe dyspnea from reduced tissue perfusion. However, these patients dont suffer from hypoxia and acidosis, and have less chance of development of pulmonary hypertension and cor-pulmonale. However, patients usually have a mixed picture of emphysema and chronic bronchitis. In patients with chronic bronchitis, severe hypoxemia may be noted relatively early. The course can be repeated at the first sign of recurrence of bronchial infection. Oxygen should be given in such patients with hypoxia, and in severe cases a portable oxygen therapy ( 16 hrs /day) for home use is recommended. Antidepressants may be necessary but they should be used cautiously to avoid sedation. If sputum becomes purulent, a course of broad-spectrum antibiotics should be given. Phlebotomy 189 Internal Medicine should be done when the hematocrit level is very high (above 55%) and patients are symptomatic. Design appropriate methods of prevention of bronchiectasis Definition: It is a pathologic, irreversible destruction and dilatation of the wall of bronchi and bronchioles, usually resulting from suppurative infection in an obstructed bronchus. Etiology and pathogenesis: Small bronchi of children are susceptible to recurrent infections and obstruction by foreign body, lymph node, or impacted secretions, all of which lead to persistent infection and the development of bronchiectasis. Clinical features Chronic cough productive of copious and offensive purulent sputum is the cardinal feature of bronchiectasis. The sputum typically forms three layers when collected in a glass container: the upper layer is foam (mucus), the middle one is liquid and the lower one is sediment. Obtaining a history of recurrent pulmonary infections ultimately followed by chronic recurrent cough and production of copious purulent sputum may suggest a diagnosis of bronchiectasis. Additional findings like cyanosis, clubbing and signs of right heart failure appear late. Segmental lung collapse may be observed in parts of the lung affected by bronchiectasis. However, medical therapy is the mainstay of treatment and include 1) Control of respiratory infections : a. Broad spectrum antibiotics that should be given whenever signs of pulmonary infection appear and symptoms are exacerbated (Ampicillin, tetracycline or erythromycin), b.

Staphylococcus aureus with a novel mecA homologue resistance in daptomycin-naive rabbits with methicillin- 48 purchase cheapest viagra plus and viagra plus penile injections for erectile dysfunction side effects, 16301639 (2004) generic viagra plus 400 mg free shipping erectile dysfunction drugs lloyds. Salmonella gene rma (ramA) and multiple- cassette chromosome mec: recent advances and new enterococci order viagra plus 400 mg fast delivery doctor for erectile dysfunction in chennai. Rapid detection viagra plus 400 mg cheap bpa causes erectile dysfunction, differentiation and daptomycin reveals an ordered progression to 64. Whole-genome analyses of Enterococcus system confer different levels of antimicrobial (2012). Bacterial resistance to antibiotics: faecalis diverts the antibiotic molecule from the versatile -lactamases. Antibiotic resistance is prevalent in an Multiresistant Gram-negative bacteria: the role of high- producing Klebsiella pneumoniae in China. The role of the natural support and diversity of acquired extended-spectrum antibiotic resistance mechanism in India, Pakistan, and environment in the emergence of antibiotic resistance -lactamases in Gram-negative rods. The authors would like to acknowledge the Medical Research Persistence of transferable extended-spectrum-- 132. Acinetobacter baumannii in France, January to May Competing interests statement 56, 33763377 (2012). Local antibiotic resistance patterns and input from local infectious disease specialists, medical microbiologists, pharmacists and other physician specialists were considered in their development. These guidelines provide general recommendations for appropriate antibiotic use in specific infectious diseases and are not a substitute for clinical judgment. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Cultures: prefer tissue specimens post-debridement and Canada: Foot Care. Can J Diabetes 37(2013) S145-S149 cleansing of wound; surface or wound drainage swabs not 2. Lancet 2005; 366:1695 1703 Imaging: recommend plain radiography (radionuclide imaging 4. Begin Infection Control Precautions - Accommodate patient in a private room (if possible) - Gowns and gloves (masks unnecessary) - Perform hand hygiene (preferably soap and water) 4. Onset with persistent symptoms or signs compatible with acute rhinosinusitis, lasting for greater than or equal to 10 days without any evidence of clinical improvement 2. Onset with severe symptoms or signs of high fever (greater than or equal to 39 C) and purulent nasal discharge or facial pain lasting for at least 3 to 4 consecutive days at the beginning of illness 3. Too loose an interpretation of severe pneumonia levofloxacin + ampicillin levofloxacin alone amoxicillin contributes to overprescribing third generation cephalosporins and respiratory fluoroquinolones Please note, oral monotherapy vs combined therapy (atypicals) clinical judgment. Patient dosing should be individualized and based on pharmacokinetic and clinical evaluation where possible. Recommendations for renal dose adjustment are made according to estimated creatinine clearance (CrCl) calculated using the Cockroft-Gault equation, which is used in practice. The two equations may result in different antimicrobial dosing 20 recommendations in up to 20 to 36% of cases with potential clinical significance. Recommendations for renal dose adjustment in the table below are for modifications of the maintenance doses; no adjustments required for loading doses where applicable. The dosing schedule should be adjusted on dialysis days so that the scheduled dose is administered immediately after dialysis. Please consult your local pharmacy department for guidance in patients receiving peritoneal dialysis, continuous veno- venous hemofiltration, continuous veno-venous hemodiafiltration or continuous renal replacement therapy. In critically ill patients (ex: sepsis), antimicrobial pharmacokinetics can be significantly altered and unstable potentially resulting in sub-optimal dosing. A pharmacy consultation could be considered to optimize antimicrobial doses in this patient population. For 80 mL/min) 15 mg/kg q24h 15 mg/kg q48h prolonged therapies (CrCl 20 40 (CrCl 10 20 (Adjust maintenance doses consider pharmacy consult 15 mg/kg q12h mL/min) mL/min) based on pre-dialysis for appropriate dosing and (CrCl 40 80 vancomycin trough levels) monitoring mL/min) C. Obesity: defined as an actual body weight greater than 20% above patients calculated ideal body weight. Lexi-Comp Drug Information: (See specific drug monograph) Accessed online May 2015 2. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Therapeutic drug monitoring of vancomycin in adult patients: A consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Horizon Health Network Standard Operating Practice Nephrology & Hypertension Services, Hemodialysis. Guidance on the use of antiviral drugs for influenza in acute care facilities in Canada, 2014-2015. Treatment of Aspergillosis: Clinical Practice Guidelines of the Infectious Diseases Society of America. Cefazolin and Enterobacteriaceae: Rationale for Revised Susceptibility Testing Breakpoints. Comparison of the Modification of Diet in Renal Disease and Cockcroft-Gault Equations for Antimicrobial Dosage Adjustments. Dry Weight: A Concept Revisited in an Effort to Avoid Medication- Directed Approaches for Blood Pressure Control in Hemodialysis Patients. These rashes are usually not allergic and are not a contraindication to the use of a different beta-lactam The frequently cited risk of 8 to 10% cross-reactivity between penicillins and cephalosporins is an overestimate based on studies from the 1970s that are now considered flawed Expect new intolerances (i. Expect a higher incidence of new intolerances in 1 patients with three or more prior medication intolerances. Avoid the unnecessary use of antimicrobials, particularly in the setting of viral infections. Patient has a documented severe non-IgE mediated hypersensitivity reaction to a beta-lactam (e. Patient has a documented severe type-1 immediate hypersensitivity reaction to a penicillin (e. Patient has a documented severe type-1 immediate hypersensitivity reaction to a cephalosporin (e. Yes No Positive Penicillin Negative Penicillin Convincing history of Skin Test Skin test an IgE-mediated Avoid all penicillins as Consider oral reaction: well as beta-lactams challenge in a Avoid all penicillins as with a similar side monitored setting; if well as beta-lactams chain (see figure 2) or negative, penicillin with a similar side consider class antibiotics may chain (see figure 2) or desensitization or be used consider select a non-beta- desensitization or lactam antibiotic select a non-beta- lactam antibiotic. Therefore, it has been commonly recommended that patients with a severe 9 allergic reaction to one class of beta-lactam antibiotic should not receive any beta-lactam antibiotic. This historic over-estimation of cross-sensitivity between classes of beta-lactams is inaccurate and 12 based on flawed methodologies. Studies have shown that physicians are more likely to prescribe antimicrobials from other classes 13,14 when patients have a documented penicillin or cephalosporin allergy. The inaccurate documentation of a penicillin allergy can lead to undesirable patient outcomes. For example, one study showed that patients with a documented penicillin allergy at admission spend more time in hospital and are more 18 likely to be exposed to antibiotics associated with C. Practice however is changing because allergies have been better defined and the role of the chemical structure on the likelihood of cross-reactivity is now better understood. Recent data shows that the rate of allergic cross-reactivity between penicillins and other beta-lactams is much lower than previous 4,5,9,11 estimates. Determining the nature of the patients reaction is an important step in differentiating between an 5,9 allergic reaction and an adverse drug reaction such as nausea, vomiting, diarrhea and headache. Immunologic reactions to medications are generally classified according to the Coombs and Gell 5,9 classification of hypersensitivity reactions (see table 2). The onset and presentation of the reaction can be used to help classify the reaction and determine whether or not a beta-lactam antibiotic may be 5,9 used (table 2). Type-1, immediate hypersensitivity reactions, are immunoglobulin (Ig) E-mediated reactions and are the only true allergic reactions where the potential risk of cross-reactivity between 5,9 beta-lactams should be considered. Penicillins 20,21,22 Penicillin is the most frequently reported drug allergy and is reported in 5-10% of the population. While inconvenient, these reactions have not been associated with anaphylaxis and pose no risk of 26 cross reactivity with other beta-lactams. An example is the nonpruritic maculopapular rash commonly seen after the administration of ampicillin or amoxicillin to children suffering from infectious 27 mononucleosis secondary to the Epstein-Barr virus. Available literature suggests that the skin test using both major and minor antigenic determinants are roughly 50-60% predictive of penicillin hypersensitivity with a 97-99% negative 4 predictive value. When penicillin skin testing is not available, the approach to penicillin allergic 28 patients is based on their reaction history and the need for treatment with a penicillin. While patients with a convincing reaction history are more likely to be allergic, those with vague histories cannot be 28 discounted as they may also be penicillin allergic. The time passed since the reaction is useful because 50-80% of penicillin allergic patients lose their sensitivity after 5 and 10 years 2,29,30 respectively. Early analysis of cephalosporin use in penicillin allergic patients was complicated by the uncritical 5,9,11 evaluation of allergic reaction. This, accompanied with possible penicillin contamination in early cephalosporin 5,9 production, resulted in overestimations of cross sensitivity. Investigations have shown that individuals with a penicillin allergy are three times more likely to develop new 5,9,10 allergies to unrelated compounds, leading to further overestimations of cross-reactivity. Cross-reactivity between penicillins and cephalosporins is due to similarities in side chains at the C-3 or C-7 position as shown in table 3 and not similarities in beta-lactam ring structure as previously 4,5,9,11 speculated. The American Academy of Pediatrics states that the likelihood of a penicillin allergic patient reacting to a cephalosporin with a different side chain is similar to that of a non-penicillin 5 allergic patient. Meanwhile the risk of cross-reactivity may be up to 40% between 3,33 penicillins and cephalosporins with the similar R-group side chains. Cross-reactivity between cephalosporins is low because of the significant heterogeneity of the side 9,34 chains at the C-3 and C-7 positions. Therefore, if a patient has a cephalosporin allergy, one can 34 safely prescribe another cephalosporin that has dissimilar side chains at both C-3 and C-7 positions.

The en- Prognosis (of pulmonary sarcoid) larged lymph node may be obvious in the neck or Complete clinical resolution in 34 months discount viagra plus 400mg without prescription erectile dysfunction vascular disease, and ra- cause obstruction to a bronchus with consequent diological resolution in 12 years generic 400mg viagra plus fast delivery erectile dysfunction protocol book, occurs in 7080% of collapse buy viagra plus 400mg cheap erectile dysfunction doctors jacksonville fl. The chestX-ray remainsabnormalin about half rarely from the primary complex to cause widespread of all cases (Table 11 order 400mg viagra plus overnight delivery best erectile dysfunction pills 2012. Of more Primary tuberculosis specic symptoms, the most common is cough, often with mucoid sputum. Other symptoms include re- This is the syndrome produced by infection with peated small haemoptysis, pleural pain, slight fever M. Thereisamild diagnosis is made presymptomatically on routine inammatory response at the site of infection (sub- chest radiography. Signs also occur late in the disease pleuralinthemid-zonesofthelungs,inthepharynxor and are not very specic, e. Diagnosis It may be necessary to treat on clinical grounds alone and response to specic therapy is taken as proof of Clinical suspicion should be particularly high in high- diagnosis. Pakistani and Indian immigrants (lymph node mycobacteria, particularly in urine specimens. Atleastthreesputumsamples, failure including one early morning sample, should be sent. In interferon-gamma assays blood from the These are radiographic diagnoses made in the light person being tested is incubated with mycobac- of the patients known occupational hazards; the terial antigens, including early secretory antigen shadows are caused by the metals themselves, e. In people with latent or active Mycobacte- the Industrial Injuries Scheme, administered by the rium tuberculosis infection, T lymphocytes within Department for Work and Pensions. In 2010 there the blood sample produce interferon-gamma as a were 345 new assessed cases of coal workers pneu- marker of infection or active tuberculosis. People identied by screening as having latent tuberculosis are usually treated with 3 In the early stages there are no symptoms but X-ray months of rifampicin or isoniazid, or 6 months of changes occur; later there is dyspnoea on exertion, isoniazid. Rifampicin 450600mg/day: abnormal liver func- Occupational asthma can occur in response to pre- tion tests. Ethambutol 15mg/kg/day: optic neuritis with col- ics industry (colophony in solder ux), paint sprayers our vision and acuity reduced. Streptomycin 1g/day by intramuscular injection: epoxy resins or platinum salts, and those in the vertigo and nerve deafness. All these are recognised presence of raised blood urea, the dosage is reduced to for compensation under industrial injuries legislation 0. Respiratory disease 125 Aetiology is associated with male gender, obesity and evening alcohol consumption. It is a risk factor for the devel- Exposure to mouldy hay (Micropolyspora faeni) opment of hypertension and has been associated with causes farmers lung, to mouldy sugar cane causes type 2 diabetes, ischaemic heart disease and stroke. Management involves taminated malting barley (Aspergillus clavatus) slimming and alcohol reduction, followed by contin- causes malt workers lung. There is little or no mutation in the factor V gene causes resistance to obstruction. A deep vein throm- bosis should be regarded as potential pulmonary em- Obstructive sleep apnoea bolus and must be suspected, diagnosed and treated as an emergency. The sleep apnoea syndrome has been dened as absence of airow in periods of at least 10s occurring at least 5 times per hour during sleep, with daytime Clinical features drowsiness. The clinical features of deep venous thrombosis There are repeated episodes of upper airways ob- include: struction during sleep with hypoxaemia and sudden arousal. Swelling of the calf also Lung perfusion scan occurs in rupture of a Bakers cyst behind the knee. An Thismayshow underperfusionofoneormorepartsof effusion of the knee makes this more likely. The cyst the lung that are radiologically normal (and ventilated can often be shown on ultrasound. Combined ventilation and perfusion scans Clinical presentation (of pulmonary These may be helpful in pre-existent lung disease in embolus) which ventilation and perfusion defects are usually matched. A normal scan virtually excludes pulmonary This depends upon the size of the embolus. Transient faints and dyspnoea, with slight cases presenting difculty in diagnosis. Usuallyresultsininfarctionandproduces, rate for the evaluation of pulmonary embolism. Investigation Chest X-ray Treatment This may demonstrate: Prophylaxis is given pre- and postoperatively, espe-. For established deep vein thrombosis or pulmon- Electrocardiogram changes usually occur only with ary embolism, patients are usually treated with low larger emboli but are then common. The character- molecular weight heparin initially, followed by war- istic changes are as follows (see also p. Lung biopsy, either open by thoracotomy ortransbronchialviaabronchoscope,maybediagnos-. Thereisalveolitiswithlymphocyticandplasmacell failure inltration and diffuse pulmonary brosis. Lung The chest X-ray may appear normal in all of these at transplantation shouldbe considered, althoughabout the time of presentation. Hyperventilation syndrome may be the presenting symptomofpsychiatricdiseaseandthepatientshould be asked about symptoms of anxiety and depression and enquiries made about personality previously. The Adult respiratory distress breathlessness is usually episodic and not directly related to degree of exertion (often even occurring at syndrome rest). It is frequently described as an inability to take a deep breath or shortage of oxygen. These include sepsis, trauma (lung contusion or Tetanymayoccur withcarpopedalspasm. It can occur in association with pneumonia, and may be drug-induced (heroin, barbiturates). The pulmonary Fibrosing alveolitis oedema is caused by capillary leakage rather than the elevated left atrial pressure of heart failure. Clinical features It is characterised by: The disease begins in middle age and presents with. Thereisanassociation with autoimune diseases, particularly rheumatoid Treatment arthritis. This should be aimed at the underlying condition, although in many cases the lung injury has already Investigation occurred. Ventilation with positive end-expiratory ThearterialPaO2isreducedandhyperventilationmay pressure is usually necessary. In clinics most are a result of disturbances in motility and over one-third of cases It is usually impossible, on the basis of history and may have irritable bowel syndrome. Pain may be retrosternal or epigastric or occur anywhere in the anterior upper abdomen. Gastric and duodenal ulceration Examination Aetiology The patient characteristically puts the hand over the Infection with Helicobacter pylori and the use of upper abdomen when asked where the pain is, and anti-inammatory drugs, both steroidal and non- there may be epigastric tenderness. The presence of steroidal (including aspirin), are the most common an epigastric mass suggests a carcinoma. Smoking increases the rate of splash (or succussion) indicates the rare pyloric ob- ulcer recurrence and slows ulcer healing. Very rarely, struction caused by benign duodenal stricture or due ulceration is associated with ZollingerEllison syn- to carcinoma of the pyloric antrum. Production of Endoscopy with gastric biopsy is important in estab- urease and cytotoxins and disruption of the gastric lishing the diagnosis and allows identication of mucosal barrier are thought to contribute to disease H. In the rapid urease test Gastric ulcer 4 2 a gastric biopsy is placed in a solution containing. Urease present in the T persistent haemorrhage biopsy hydrolyses urea to ammonia causing a rise. If are those of a gastric ulcer in the early stages, but this has not occurred the presence of a carcinoma dysphagia may occur. Approximately 10% of patients fail treat- Weakness of the diaphragmatic sphincter allows the ment due to either poor compliance or antibiotic lower oesophagus and cardia of the stomach to rise resistance to metronidazole or to a lesser extent into the thorax. In patients with a history of bleeding duodenal ulcer, Symptoms long-termtreatmentwithH2-antagonistsappearssafe and effective in preventing recurrent haemorrhage. It is relieved Misoprostol, a synthetic prostaglandin analogue, by milk and antacids. Bleeding may give positive is effective in reducing gastrointestinal damage in- occult blood tests and anaemia. Oesophagitis may duced by non-steroidal anti-inammatory drugs lead to ulceration and/or stricture. Investigations Indications for surgery If persistent and symptoms are severe or if associ- Duodenal ulcer ated with dysphagia (to exclude benign or malignant Acute indications include: stricture) or weight loss (to exclude oesophageal or. Metoclopramide increases Rectal bleeding / oesophageal sphincter contraction and increases Passage of mucus / gastric emptying. It is a dopamine antagonist and or pus may induce acute dystonic reactions which respond Disease conned to procyclidine. A course of an H2-receptor antag- to large bowel onist or a proton-pump inhibitor usually relieves Bowel obstruction / symptoms if severe. Surgery for hiatus hernia is very rarely indicated in Extra-intestinal the absence of stricture formation as it is a major manifestations procedure and the results are uncertain. In Barretts Transmural oesophagus, reux is associated with columnar inammation metaplasia of the normal stratied squamous epi- Granulomas thelium of the lower oesophagus. It can progress to Antineutrophil low-grade dysplasia, high-grade dysplasia and carci- cytoplasm antibodies noma.

Since the criteria for sexual aversion disorder overlap with symptoms of both panic disorder and hypoactive sexual desire disorder discount viagra plus 400 mg with visa erectile dysfunction of organic origin, even experts in treating sexual disorders remain somewhat unclear regarding how and when to diagnose sexual aversion best purchase viagra plus vodka causes erectile dysfunction. In response to these criteria order viagra plus no prescription erectile dysfunction treatment in kuwait, The Sexual Function Health Council of the American Foundation for Urologic Disease convened the Consensus Develop- ment Panel on Female Sexual Dysfunction (10) purchase viagra plus once a day erectile dysfunction in a young male. Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner B. Second, the panel specically distinguished between psychogenic and organically based disorders. This revised classication system includes sexual aversion under the category of sexual desire disorders along with hypoactive sexual desire disorders (Table 5. The consensus panel developed a very detailed document to describe and justify their new classication system. Sexual aversion disorder, however, was given little attention and by virtue of being placed in the category of sexual desire disorders, is likely to be overlooked. This is a distinction that, in light of Mowrers two-factor theory (8), is difcult to defend. From the perspective of learning theory, aversion must, by denition, be acquired. Lifelong sexual aversion must still have been acquired at some point along the way. Crenshaw (1) denes lifelong aversion as a negative or unenthusiastic response to sexual inter- actions from earliest memories to present. However, no matter how absent the memory of life before the aversion, the aversion was certainly learned, either directly or vicariously. Crenshaw observes that patients presenting with primary aversion often were raised in strict religious and moral environments, which supports our contention that the aversion was learned, albeit vicariously. She also suggests that there may have been some history of psychosexual trauma, which again would have been learned and not lifelong. We suggest that these early authors may have intended that primary refers to aversion developed so early in life that the individual did not have the opportunity to experience normal partnered sexual behavior before acquiring the aversion. C (2) and case histories 1 and 2 (1)] typically involve early, presexual negative conditioning of sex in childhood, mediated by environmental learning but specically not by sexual abuse. Secon- dary aversion, in contrast, would be diagnosed in cases of specic recollection of childhood abuse or later negative sexual experience that is the proximate cause of current sexual aversion. Sexual Aversion Disorder 115 It is further possible that this secondary descriptor has been maintained in the taxonomies because sexual aversion has been confounded with hypoactive sexual desire. Hypoactive sexual desire may legitimately be either a biologic or a learned condition. The biologic contribution could well have been present since birth or early in life and thereby represent a primary or lifelong condition. Moreover, a patient with hypoactive sexual desire may become avoidant of sexual activity. Sexual disinterest in the context of the demands of a relationship could evolve into irritation or anger and appear clinically very much like aver- sion. This presentation, however, would be absent in the fear and anxiety response to sexual behavior, which is critical for the aversion diagnosis. This proposed classication maintains the distinction between primary and secondary sexual aversion. However, this distinction will only be useful for the diagnostic differentiation of the acquisition of aversion early in life and the lifelong presence of hypoactive sexual desire (Table 5. With this modied taxonomy in mind, we will describe a case of primary sexual aversion. Case Example: Joyce Joyce is a 38-year-old woman who has been married for 8 years. She presents with a long, intermittent history of bulimia and other features consistent with Table 5. Her bulimic symptoms responded rather readily to an exposure-based cognitive behavioral treatment strategy. Over the course of therapy she gradually was able both to cease purging and to expose herself to foods she had previously restricted and to situations she had avoided. During the course of treatment she eventually acknowledged a history of sexual abuse as an early adolescent. She had denied any abuse history during the initial evaluation, but was able to reveal her history as she became more trusting of and comfortable with her therapist. She reported that she had never revealed her abuse to anyone other than a cousin and that her immediate family, including her husband, were unaware of her history of abuse. She describes her parents as caring and involved, yet not particularly emotionally disclosing. She categorizes her family as supportive and celebrative of personal successes while tending to avoid discussion of emotionally difcult issues. Joyce reports feeling that if she had revealed her abuse, her parents would be devastated and retrospectively guilty over not having protected her better as a child. When she was 12 a 17-year-old neighbor began seeking her out during neighborhood games and activities, encouraging her to spend increasing amounts of time with him. He became increasingly sexually aggressive, progressing from touching her rela- tively quickly to forced fellatio and intercourse, and she recalls feeling that she did not want to resist him for fear that he would be disappointed or angry with her. The abuse continued for about 2 years until, at age 14, she threatened to inform his parents of his actions and he ceased his abuse of her. Joyce began dating at age 15 and was sexually active fairly quickly in each of a succession of relationships. The majority of her relationships are characterized by relatively early onset of physical intimacy, which included intercourse and oral sex (both fellatio and cunnilingus). Sexual behavior always began as pleasurable for her but fairly rapidly became unpleasant. She reports that she felt very sexually attracted to her male partners initially, but at the point in the relationship that sex became routine or expected, her respon- siveness declined and sexual behavior became aversive to her. Intercourse became painful and disgusting to her and she experienced revulsion at even the idea of sex with her current partner. Importantly, she maintained sexual drive such that she masturbated to orgasm on a regular (once a week) basis and she also continued to experience sexual attraction and desire for men other than her partner. She was frustrated when their sex became aversive to her but decided to tough it out, assuming, she supposes in retrospect, that her sexual response would improve given enough time and love. Joyce also hoped that the state of being married would also help her response since she had some guilt over nonmarital sex and expected to feel a postmarital reduction in the anxiety she associated with sexual behavior. Joyce reports that at no point during marriage did her sexual aversion dis- sipate. On the contrary, Bill became increasingly frustrated with her avoidance of sex and demanded more frequent intercourse. Joyces attempts to explain her aversive response to him were not helpful and he became irritated and verbally abusive of her. At the point that she disclosed her history of sexual abuse in therapy, she and Bill were in considerable marital distress. Their frequency of intercourse had declined to roughly monthly, and then only with considerable endurance of distress from Joyce and verbal intimidation from Bill. Joyce also meets the Con- sensus Panel criteria that emphasize personal rather than partner distress as the relevant feature. Her symptoms are clearly related to the acquisition of fear and subsequent avoidance. Joyce did not evidence or report particular fear or avoidance of sexual interactions until sexual behavior was paired with abuse and victimization. She retained sexual drive and desire even while she felt pressured into sex in each of her relationships after her childhood sexual abuse. In each case, including her marriage, sexual interactions after the early relationship phase (limerance) became negatively conditioned. Joyce acquired an aversion response which then was maintained by sexual avoidance. General Treatment Considerations In Joyces case, effective treatment rst required relating her history of sexual abuse to her husband, Bill, so that we could begin to interpret her aversion to him in the context of her adolescent experience. This revelation evoked some sensitivity to Joyces response from Bill and temporarily tempered his insistence on intercourse. We used this period to assess more fully their sexual history, to describe her sexual disorder to them both, and to develop a treatment plan. The theory and methods that characterize systematic desensitization were reviewed and the couple agreed to the treatment plan. In addition, Joyce was taught diaphragmatic deep breathing and an autogenic relaxation technique. The least anxiety-provoking stimuli were addressed rst, with Joyce imagining each situ- ation and reporting being able to remain relaxed and anxiety-free before each stimulus was subsequently approached in vivo. Importantly, sexual situations were designed to remain fully in her control; Bill had agreed to allow Joyce to determine the rate at which each of the items on the hierarchy was engaged. Fifteen sessions conducted over a period of 5 months were needed to help Joyce and Bill resume the healthier sexual life that had characterized their early history. The persistence of avoidance behavior was rst articulated by Freud (14); Mowrer (15) subsequently described this phenomenon as the neurotic paradox. The common observation that avoidance is remarkably difcult to extinguish has been explained by the theory of conservation of anxiety.