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By B. Murak. Gutenberg College.

Quantitative Synthesis No meta-analysis could be performed because of substantial degree of clinical heterogeneity across the trials with regard to patient characteristics order generic indinavir on-line treatment canker sore, interventions 400mg indinavir with mastercard symptoms 5 months pregnant, and the assessed outcomes buy 400mg indinavir with amex treatment for plantar fasciitis. Overview of Trials 322,323,326 Three trials used crossover, and the remaining 17 used parallel design. Treatment 319,321,323,330 316 duration in several trials was 6 months and in one trial 12 months. Racial characteristics were reported in only three trials with the majority of the subjects being Caucasians. While trials generally enrolled men with hypogonadism and/or andropause, the specific sexual dysfunction and testosterone entrance criteria across trials varied widely. With respect to 145,323,326 testosterone, all but three trials mandated that participants have levels below a specified threshold. Five trials studied testosterone in combination with a 5,77,145,231 phosphodiesterase inhibitor. Two other trials studied a cream combining testosterone, 322,329 isosorbide dinitrate and co-dergocrine. Several trials 231 reported that adverse effects were absent or were negligible and without a difference in 77,145,319 frequency between treatment groups. In one open label trial outcomes for efficacy and 324 harms were compared between oral testosterone and no treatment. Subjects were excluded from the trial if they had prostate abnormality or any illness considered likely to impair sexual function. The outcomes for efficacy and harms associated with the 316,319 use of oral testosterone versus placebo were compared in two trials. In the first trial, the difference in the occurrence of adverse events between the two treatment groups was not statistically significant. In the second trial, 86 percent and 93 percent of men in the testosterone and placebo group, respectively, reported that their 316 erections were less strong at 12 weeks of the followup. One trial evaluated and compared the efficacy and harms between oral testosterone alone and oral testosterone combined 145 with sildenafil. These men were randomized to 2 months of treatment with either oral testosterone undecanoate alone (120 mg/d) or oral testosterone undecanoate (120 mg/d) plus sildenafil (50-100 mg). Patients with prostate hypertrophy, prostate cancer, and mammary carcinoma were excluded. The study reported that apart from mild headache occurring in three patients taking 145 sildenafil 100 mg, no serious adverse events were observed. One trial evaluated and compared the efficacy and harms for oral testosterone versus propionyl-L 319 carnitine plus acetyl-L-carnitine. Results comparing testosterone and propionyl-L-carnitine plus acetyl-L-carnitine are reported here. The occurrence of adverse events was not statistically significantly different between the two treatment groups. The corresponding median score in those assigned to the propionyl-L carnitine plus acetyl-L-carnitine group changed from 8 (range 522) to 24 (range 829) (within group difference: p <0. One trial evaluated and compared the efficacy and harms outcomes of oral testosterone plus sildenafil compared with sildenafil 93 145 alone. The men were randomized to receive a 2-month treatment with either oral testosterone undecanoate (120 mg daily) plus sildenafil (50-100 mg) or sildenafil alone. Apart from mild headaches occurring in three patients taking sildenafil 100 mg, no serious adverse events were observed. The active treatment arms each lasted for at least 6 months, while the placebo treatment lasted for 2 months. Patients with major disorders, a history of substance abuse, obesity, or major psychopathology were excluded from the trial. Patients with psychiatric disorders or abnormal prostate exam result (men aged > 50 years) were excluded. In the third trial, men who received testosterone were more likely to report acne (testosterone: 20. Differences between men in the testosterone and placebo groups with respect to the occurrence of irritability (17. In the first trial, weekly frequency of erections in the testosterone and placebo treatment groups were 7. There was no difference in the degree of erection during 94 sex with partner (scale 16, with = none and 6 = full), with a mean score of 5. The weekly frequency of erection was not different between the two groups of testosterone and human chorionic gonadotropin treatment (7. The efficacy and harms of gel testosterone versus placebo 317 were compared in one trial In this trial, 406 hypogonadal men (total T <300 ng/dL) aged 20 80 years (mean age: 58 years) reporting one or more symptoms of low testosterone deficiency (i. One participant from the group treated with 50 mg gel testosterone, five in the group treated with 100 mg gel testosterone, and none treated with placebo withdrew due to an adverse event. At day 30, among men with sexual partners (63 percent of randomized men), 24 percent of placebo-treated men reported an increase from baseline in the number of days in the past week with sexual intercourse, compared with 31 percent of 50 mg gel testosterone-treated men (p <0. The efficacy and harms of gel testosterone 317,320,327 327 versus patch testosterone was compared in three trials. In the first trial, 227 men aged 19-68 years (mean age: 58 years) with total testosterone levels <10. Both trials randomized men to 50 mg gel testosterone (Testim) daily versus 100 mg gel testosterone (Testim) daily (deliver a daily dose of 5 and 10 mg testosterone, respectively). The first of these trials included an additional group randomized to 5 mg patch testosterone 320 (Andropatch), and the second trial randomized two additional groups to 24. The second of these trials reported that withdrawals due to adverse events occurred in one 50 mg gel testosterone subject, five 100 mg gel testosterone subjects, and 15 patch testosterone subjects. In the same trial, two patients in the patch testosterone arm were diagnosed 317 with prostate cancer. In the first trial, patients in the gel testosterone group experienced slightly greater sexual enjoyment compared with those receiving the testosterone patch (p = 0. Similarly, all three groups significantly improved from baseline, but without between- group differences for the domains of sexual motivation and sexual desire. Although spontaneous erections were significantly increased in frequency compared with baseline in both gel testosterone groups, and not in the patch testosterone group, there were no significant between- treatment group differences. At day 30, among men with sexual partners for whom these data were reported (61 percent of randomized men), 31 percent of 50 mg gel testosterone men reported an increase from baseline in the number of days in the past week with sexual intercourse versus 39 percent of 100 mg gel testosterone men (versus 50 mg, p 0. One trial compared the efficacy and 231 harms of gel testosterone versus gel testosterone plus tadalafil. Men were randomized to 50 mg gel testosterone (Testogel) 96 daily for 4 weeks followed by concurrent treatment with tadalafil 20 mg twice weekly for 9 weeks versus 50 mg gel testosterone (Testogel) daily for 10 weeks followed by concurrent treatment with tadalafil 20 mg twice weekly for 3 weeks.

Republic representative Epidemiology of Helicobacter pylori population study in infection in the Czech Republic purchase 400 mg indinavir with visa medicine organizer box. Republic 2309 persons aged 5- Epidemiology of Helicobacter pylori in the 100yrs order cheap indinavir line medicine just for cough, representative Czech Republic purchase discount indinavir on line medicine 600 mg. Frecuencia de patients infeccin benigna por Helicobacter pylori en pacientes con patologa gastrointestinal benigna (abstract). Decreasing representative sample seroprevalence of Helicobacter pylori of population infection during 1993-2003 in Guangzhou, southern China. Indigenous Greenlanders have a higher sero- prevalence of IgG antibodies to Helicobacter pylori than Danes. Results of a southern Germany from the general representative cross-sectional study. Seroepidemiology of 21,1%(group aged randomly selected Helicobacter pylori infection in an urban, 12-20 years) urban upper class upper class population in Chennai. The a rural area in Northern Loiano-Monghidoro population-based Italy (792 men, 741 study of Helicobacter pylori infection: women, age range 28- prevalence by 13C-urea breath test and 80 years) associated factors. Risk factors for acquiring Helicobacter pylori infection in a group of Tuscan teenagers. Seroprevalence of consecutive volunteer Helicobacter pylori infection among blood donors blood donors in Torino, Italy. Japan 29%(children aged 2001 Comparative study Yamashita Y, Fujisawa T, Kimura A, Kato H. Helicobacter pylori group) healthy individuals in infection in Kazakhstan: effect of water Kazakhstan source and household hygiene. A relatively low children prevalence of Helicobacter pylori infection in a healthy paediatric population in Riga, Latvia: a cross- sectional study. A community-based seroepidemiologic study of Helicobacter pylori infection in Mexico. Mexico 66% 2007 Serology Data from Asociacin Mexicana de Gastroenterologa Netherlands 1% (children) 2007 Seroprevalence study Mourad-Baars, P. Low population prevalence of Helicobacter pylori infection in young children in the Netherlands. The effects of environmental factors on the prevalence of Helicobacter pylori infection in inhabitants of Lublin Province. Portugal 80% in 1998 Cross-sectional study Data from Sociedade Portuguesa de asymptomatic Gastroenterologa Portugal 52,9% in children 1999 Cross-sectional study Data from Sociedade Portuguesa de aged 6-11 years. Gastroenterologa Republic of 55-76% 1995-2004 Comparison in adults Data from Department of Belarus (dependent from and Childhood gastric Gastroenterology and Nutrition, diseases) 50-60% mucous lesion in same Byelorussian Medical Academy (health person) 10- population sources Postgraduate Education. Dramatic changes in the prevalence of Helicobacter pylori infection during childhood: a 10-year follow-up study in Russia. Journal of Gastroenterology & Hepatology 2005; 20: 1603-9 Spain 69% 2006 Breath test Data from Sociedad Espaola de Patologa Digestiva. Macerelle et al, Rev Esp Enf Dig 2006 Spain 60% 2007 Breath test Data from Sociedad Espaola de Patologa Digestiva. Sanchez-Ceballos et al, Rev Esp Enf Dig 2007 Spain 52% 2002 Blood sera Data from Sociedad Espaola de Patologa Digestiva. Arch Pediatr 10:204-7 Turkey 49% (children) 2003 Small study to estimate Ertem, D. Helicobacter pylori determinants and infection in Turkish preschool and school associations of children: role of socioeconomic factors Helicobacter pylori and breast feeding. Enzyme 9years)100%(60- and immunoblotting immunoassay and immunoblotting 69)80%(over 70 analysis of analysis of Helicobacter pylori infection in years) Helicobacter pylori Turkish asymptomatic subjects. Diagn infection in 309 Turkish Microbiol Infect Dis2004;50:1737 asymptomatic subjects aged 1-82 years Turkey 82% 2008 Country wide study on Data from Ege University School of 5640 subjects Medicine, Sect Gastroenterology (Turkish Gastroenterology Association). Relation of adult lifestyle and local primary care socioeconomic factors to the prevalence centre. Helicobacter pylori infection in from 10 licensed day asymptomatic children: impact of care centers from epidemiologic factors on accuracy of various locations in diagnostic tests. As pointed out by previous surveys, differences between countries appear to be associated to socio economic development. Interestingly, the current survey detected much lower prevalence rates in the young population as compared to adults, due to a reduced acquisition of the bacteria in early childhood thanks to the improvement of hygienic conditions. One fourth of the countries reported prevalence rates in the young population at 10% or below. Colorectal cancer is the third most common cancer type and the second mortality cancer-related cause in the Western countries with over 600. Colorectal cancer frequently presents no symptoms until the disease has reached a relatively advanced stage. Monitoring of anal macroscopic bleeding, as well as periodical screening by colonoscopy, or fecal occult blood testing are designed to detect colorectal cancer occurence. Annual screening with high-sensitivity fecal occult blood test is considered an acceptable alternative option for average-risk patients. Risk factors At present, the role of the different factors contributing to colorectal cancer is not well known. Data are age-standardized rates of annual incidence (newly diagnosed cases per year per population normalized by standard age-structure). This correction is convenient for comparisons between countries because age has a powerful influence on the risk of colorectal cancer. Such age-standardized data demonstrate that incidence of colorectal cancer is 10 to 20 times higher in countries in the top quartile (North America & Western Europe) as compared to those in the lowest quartile (India, Africa). In general, the figures correlate well with socio-economic development but not in a strictly linear relationship. The precise pathological origin of functional dyspepsia remains unclear, although a combination of visceral hypersensitivity, gastric motor dysfunction, and psychological factors has been suggested to induce this condition (55). Complications and seriousness Functional dyspepsia is not a life-threatening disorder and has not been associated with any increase in mortality. Diet and functional dyspepsia The role of diet in functional dyspepsia has not been thoroughly studied. Republic Study) Denmark Anual Incidence 1998 National Health Insurance Meineche-Schmidt V, Krag E. Functional selected from the Campania gastrointestinal disorders in children: an region of the Italian National Italian prospective survey. Functional bowel symptoms in a general Dutch population and associations with common stimulants. Turkey 28,40% 2007 Questionnaires Data from Ege University School of Medicine, Sect Gastroenterology (Turkish Gastroenterology Association). Prevalence and interviews Consultation Behavior of Self-Reported Rectal Bleeding by Face-to-Face Interview in an Asian Community.

Since 2007 cheap 400 mg indinavir amex symptoms nausea, breast cancer death rates have been steady in women younger than 50 purchase 400mg indinavir overnight delivery symptoms nicotine withdrawal, but have continued to decrease in older women buy cheap indinavir line medicine express. These decreases are believed to be the result of finding breast cancer earlier through screening and increased awareness, as well as better treatments. Survival rates are discussed in the section on breast cancer survival rates by stage. Visit the American Cancer Societys Cancer Statistics Center for more key statistics. Last Medical Review: July 1, 2017 Last Revised: January 4, 2018 Breast Cancer Signs and Symptoms Knowing how your breasts normally look and feel is an important part of breast health. Finding breast cancer as early as possible gives you a better chance of successful treatment. But knowing what to look for does not take the place of having regular mammograms and other screening tests. Screening tests can help find breast cancer in its early stages, before any symptoms appear. For this reason, it is important to have any new breast mass, lump, or breast change checked by a health care professional experienced in diagnosing breast diseases. Other possible symptoms of breast cancer include: q Swelling of all or part of a breast (even if no distinct lump is felt) q Skin irritation or dimpling (sometimes looking like an orange peel) q Breast or nipple pain q Nipple retraction (turning inward) q Redness, scaliness, or thickening of the nipple or breast skin q Nipple discharge (other than breast milk) Sometimes a breast cancer can spread to lymph nodes under the arm or around the collar bone and cause a lump or swelling there, even before the original tumor in the breast is large enough to be felt. Although any of these symptoms can be caused by things other than breast cancer, if you have them, they should be reported to a health care professional so that the cause can be found. Because mammograms do not find every breast cancer, it is important for you to be aware of changes in your breasts and to know the signs and symptoms of breast cancer. Last Medical Review: July 1, 2017 Last Revised: September 22, 2017 Whats New in Breast Cancer Research? Researchers around the world are working to find better ways to prevent, detect, and treat breast cancer, and to improve the quality of life of patients and survivors. Here are a few examples: q Several studies are looking at the effect of exercise, weight gain or loss, and diet on risk. Gene variants typically have only a modest effect on risk, but when taken together they could possibly have a large impact. While much of the science on this topic is still in its earliest stages, this is an area of active research. Reducing breast cancer risk Researchers continue to look for medicines that might help lower breast cancer risk, especially women who are at high risk. More recent studies with another class of drugs called aromatase inhibitors (exemestane and anastrozole) have shown that these drugs are also very effective in preventing breast cancer q Other clinical trials are looking at non-hormonal drugs for breast cancer reduction. Some drugs that help treat the spread of cancer to the bones (such as bisphosphonates and denosumab), might also help reduce the chances of the cancer coming back. Studies done so far seem to suggest that postmenopausal women may benefit the most from giving these bone- modifying drugs after breast surgery, but more studies are needed to say for sure. It might be some time before meaningful results on any of these compounds are available. In other women, though, the cells just stay within the ducts and never invade deeper or spread to lymph nodes or other organs. Although these tests can help predict which patients may have breast cancer that has spread beyond the breast (metastatic disease), it isnt clear if the use of these tests can tell whether the cancer will come back after treatment (recur) or help patients live longer. New imaging tests Newer imaging methods are now being studied for evaluating breast changes that may be cancer. Scintimammography (molecular breast imaging) In this test, a slightly radioactive drug called a tracer is injected into a vein. This technique is still being studied to see if it will be useful in finding breast cancers. Some doctors believe it may be helpful in looking at suspicious areas found by regular mammograms, but its exact role is still unclear. Current research is aimed at improving the technology and evaluating its use in specific situations such as in the dense breasts of younger women. Breast cancer treatment Chemotherapy It is known that chemotherapycan be helpful for many breast cancer patients. Sometimes there are significant side effects (long- and short-term) from chemotherapy, so having tests that can determine who really needs chemo would be useful. Many studies are being done to evaluate different tests that can more accurately tell which patients would benefit from chemo and which patients could avoid it. Oncoplastic surgery Breast-conserving surgery (lumpectomy or partial mastectomy) can often be used for early-stage breast cancers. For larger tumors, it might not even be possible, and a mastectomy might be needed instead. Some doctors are addressing this problem by combining cancer surgery and plastic surgery techniques, known as oncoplastic surgery. This typically involves reshaping the breast at the time of the initial surgery, such as doing a partial breast reconstruction after breast-conserving surgery or a full reconstruction after mastectomy. Oncoplastic surgery may mean operating on the other breast as well to make the breasts more alike. Other potential targets for new breast cancer drugs have been identified in recent years. Targeted therapy drugs Targeted therapies are a group of drugs that specifically target gene changes in cancer cells that help the cells grow or spread. Supportive care There are trials looking at different medicines to try and improve memory and brain symptoms after chemotherapy. Other studies are evaluating if certain cardiac drugs, known as beta-blockers, can prevent the heart damage sometimes caused by the common breast cancer chemotherapy drugs, doxorubicin and epirubicin. Thinking about taking part in a clinical trial Clinical trials are carefully controlled research studies that are done to get a closer look at promising new treatments or procedures. If you would like to learn more about clinical trials that might be right for you, start by asking your doctor if your clinic or hospital conducts clinical trials, or see Clinical Trials to learn more. Therapeutic Bone-Modifying Agents in the Nonmetastatic Breast Cancer Setting: The Controversy and a Value Assessment. A multigene expression assay to predict local recurrence risk for ductal carcinoma in situ of the breast. The efficacy and safety of the addition of ibandronate to adjuvant hormonal therapy in postmenopausal women with hormone-receptor positive early breast cancer. Ex vivo culture of circulating breast tumor cells for individualized testing of drug susceptibility. The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment. This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

There is currently no standard methodology for conducting community-based surveillance in resource-constrained settings order 400mg indinavir with visa medications ok during pregnancy. This document describes ve pilot surveillance projects that were set up in India (three sites) and South Africa (two sites) buy generic indinavir 400mg line symptoms breast cancer, with the aim of developing a model for undertaking integrated community-based surveillance in resource-constrained settings and generating baseline data effective 400 mg indinavir medications used to treat migraines. One of these sections Resistance to other vancomycin- addresses bacterial agents resistant to antibiotics. They are provided for use as supplementary Resistance to cloxacillin or additional codes when it is desired to identify the ucloxacillin, oxacillin antibiotic to which a bacterial agent is resistant, U82. For example, South Africa assigned the codes U51 and U52 to multidrug-resistant U82. Manual for the laboratory identication and antimicrobial susceptibility testing of bacterial pathogens of public health importance in the developing world. Geneva, Centers for Disease Control and Prevention and World Health Organization, 2003. Antimicrobial resistance surveillance: Questionnaire for assessment of national networks. Community-based surveillance of antimicrobial use and resistance in resource-constrained settings. Recommendations of a group of experts: Standards for the use of automated identifcation systems for bacteria and susceptibility to antimicrobials (Brasilia, Brazil, 2628 October 2004). Mortality and causes of death in South Africa, 2010: Findings from death notifcation. For purposes of this paper, we define diagnostic tests as those tests performed on samples taken on and from the body, and used in a broad range of applications. Diagnostic tests are often the least expensive component of the health care pathway, yet they influence more than 70 percent of health care decisions. Some tests are used for risk assessment purposesto determine the likelihood that a medical condition is, or will become, present. Other tests are used to monitor the course of a disease or to assess a patients response to treatments, or even to guide the selection of further tests and treatments. Most often, test results provide information that along with the patients history and other medical information helps the physician work with the patient so they can decide what might be the appropriate actions for additional testing or treatment. On some occasions, the information from a single test is enough to convince physician specialists that a cascade of sophisticated medical interventions are in order; and sometimes it is all that is needed to end them. Diagnostics can help assess information that has an impact on the public health as well as individual patient health. Diagnostic tests can be used during public emergencies often at the point of care, to provide rapid information needed to triage patients and to confirm the presence of communicable disease. Diagnostic tests are also increasingly used to assess the quality of patient care that is provided for medical conditions like diabetes, heart failure, and colon cancer. Over the years, technological advances and automation have made tests easier to use and more accurate, and have led to more precise and more timely results. These advances have led to point-of-care tests that facilitate more rapid decision-making by medical practitioners. Another advance, made possible by discoveries about the human genome, has opened the door to personalized medicine approaches that can tailor medical treatments to individual patient needs, transforming modern medicine. Diagnostic tests are performed close to 7 billion times each year in the United States. They influence most of the dollars that are spent on health care delivery while accounting for only a small fraction of U. The current environment for diagnostic tests is dampening incentives for continued product innovation, and it is threatening patient access to tests that can improve patient outcomes. The level of evidence required to demonstrate safety and effectiveness, as well as clinical utility continues to grow. Further challenges have led to difficulties in securing insurance coverage when insurers insist on direct evidence of clinical utility, the impact of a specific test on patient outcomes. Second, the current process of securing billing codes is lengthy and complex and the codes themselves have not kept pace with the development of promising and innovative new diagnostic tests. Third, the Medicare fee schedule that assigns payment rates for these tests, and provides a foundation for the rates paid by both public and private payers, is in desperate need of modernization. The current rate-setting process is slow and inefficient, the rates paid for some tests likely do not cover the costs of providing the service, and the rate-setting structure for new tests does not provide the return on investment needed to generate the evidence that insurers prefer. These tests are a key component of modern health care, and they are used for a wide range of patient conditions. The information these tests provide helps physicians and caregivers prevent, diagnose, treat, and manage disease. Diagnostic tests involve the instruments, equipment, and/or other items used to analyze specimens (which range from hand-held devices to desk-top analyzers to items of capital equipment used in large clinical laboratories), as well as the reagents used in performing diagnostic tests. Reagents are essential to tests because these are the substances that cause a reaction with the sample (e. These tests are commonly relied on by physicians and caregivers to prevent, diagnose, treat, and manage disease. Table 1 provides a number of examples of the health conditions for which diagnostic tests are used, as well as their prevalence and impact (i. As these tests are performed more commonly, they may no longer be considered to be esoteric. Sample of Priority Health Conditions, Associated Tests, and Impact Number of Americans Spending on Health Condition Test Examples Affected Condition Heart Disease Lipid panel 79. Wide Range of Tests and Uses There are thousands of diagnostic tests, and they can be classified many ways. Professionals often group them according to the way they gather information or the type of technology they employ. These tests can also be classified according to how they are used and the purpose they serve in the health care delivery system. For example, some tests are general chemistry tests that provide measures of base compounds in the body, like cholesterol tests and urinalysis tests. Others are microbiology tests that are used to detect disease-causing agents, like viruses. Molecular tests may indicate the presence of disease or ones susceptibility to disease. Table 2 provides a number of these test categories, along with test examples for each category. The information provided by diagnostic tests informs decisions that are made throughout the health care continuum. For example, a blood glucose test can be used to screen for and to diagnose diabetes. It can also be used to monitor a diabetic patients condition and evaluate the results of treatment.

Fever and severe constitutional symptoms differentiate influenza from the common cold The leukocyte count is normal in uncomplicated cases buy genuine indinavir online symptoms joint pain fatigue. Prophylaxis: Vaccines that include the prevalent strains of influenza viruses effectively reduce the incidence of infection order indinavir master card medications equivalent to asmanex inhaler. Amantadine 100mg orally bid (for adults) can be used prophylactically against influenza A order generic indinavir line medicine 93 7338. Treatment: Amantadine has a beneficial effect on fever and respiratory symptoms if given early in uncomplicated influenza. It may develop after a common cold or other viral infection of the nasopharynx, 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.