June 24th, 2011
Although structural heart diseases are the most studied risk factors for IE, a few other risk factors are worth noting. It is unclear how to quantify the risks from these risk factors, or how their presence may or may not affect the decision to offer antibiotic prophylaxis.Previous endocarditis, with or without current structural abnormalities on echocardiography, should be considered a high-risk condition.Diabetes has been identified as a risk factor for IE in several series. It is not clear whether this increased risk is due to microscopic endocardial damage or the relative immunodeficiency associated with diabetes.Chronic renal disease is common in patients with advanced diabetes but was shown to be an independent risk factor in a large study.Nosocomial endocarditis accounts for 10% to 20% of all endocarditis cases in most published series. Furthermore, patients who acquire endocarditis on the inpatient wards are more likely to contract IE with Staphylococcus aureus or Enterococcus, and thus have a significantly higher overall mortality rate than outpatients who contract IE. Careful attention must be paid to inpatients who are going to undergo invasive procedures or who have longstanding indwelling central venous catheters.Systemic lupus erythematosus and the antiphospholipid antibody syndrome are both likely elevate a patient’s risk of contracting IE. This is most likely due to the 25% to 75% chance of clinically significant valvular disease in patients with these diseases. Especially in the presence of a heart murmur or any history of symptoms potentially related to valve disease, a cardiac work-up should be undertaken in these patients prior to making a determination regarding antibiotic prophylaxis for IE.The true effect of immunodeficiency on the development of IE is unknown. Other immunodeficiencies (human immunodeficiency virus infection, organ transplants) have not been specifically identified as risks for IE, as patients with these conditions have not been included to any significant degree in the older studies that form the basis for current recommendations.*47/348/5*
Categories: Anti-Infectives |
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June 19th, 2011
Peter, a 40-year-old unemployed carpenter who hated his ears, jaw, and eyes, discussed his appearance and questioned his wife so often that she left him. “All I did was complain about how I looked and talk about how I wanted plastic surgery,” he said. “I didn’t accept her reassurances. She considered it mental abuse. She ended up hating me because of my obsession and because I talked about my looks all the time. Once I drove her so crazy talking to her about it that she pulled a knife on me. She threatened me, lIf you think you need surgery, now you’ll really need it!’ “One parent told me something that’s been echoed by many other family members: “The most frustrating part of it is that no matter what I say, it doesn’t really help.” Indeed, responding to requests for reassurance is a no-win situation. Saying the person looks fine doesn’t help, but neither does telling them that something is wrong. If you say they look fine, they usually don’t believe you. They think you’re just trying to be nice or that you didn’t get a good enough look at the problem. Or maybe you need new glasses. A handsome young man told me that he could “just tell” that his parents think he’s ugly, even though they tell him he’s handsome, because it’s “their moral obligation.” Another told me that “reassurance doesn’t really help, because why did everyone laugh at me at camp and in the locker room?” And a very attractive woman said, “When people say I look fine and I get complimented, they overdo it, so I must be really ugly.”*103\204\8*
Categories: Anti Depressants-Sleeping Aid |
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June 8th, 2011
Infantile spasms may occur in the young child who has developmental problems of the brain or with brain damage caused by birth injury, meningitis, or head trauma. Abnormalities of metabolism such as low blood sugar or amino acid problems may also be responsible. All of these are designated as “symptomatic” infantile spasms, since they are caused by the underlying process. A second and smaller group of infantile spasms are called “cryptogenic” since their cause is unknown. Children with cryptogenic infantile spasms appear perfectly normal in development before the seizures begin.Infantile spasms are virtually always accompanied by an abnormality of the EEG known as “hypsarrhythmia,” a wildly chaotic pattern with multiple spikes and slow waves. While it may or may not be true, it is useful to think of this EEG pattern as imposing severe “static” on the brain waves so that the brain functions poorly and the child’s functioning deteriorates.A physician evaluating a child with infantile spasms should search for treatable metabolic causes of the spasms and infectious processes. An EEG and a CT or MRI scan should also be requested. Unless a specific treatable condition is found, and one rarely is, treatment for the spasms should begin promptly.We initially treat all such children with ACTH (adrenocorticotropic hormone), a form of steroid given twice a day by intramuscular injection. However, some physicians use oral steroids, benzodiazepines such as diazepam (Valium) or clonazepam (Klonopin), or valproic acid (Depakote, Depakene). The relative effectiveness of these various forms of treatment has not been tested, nor has the duration of treatment been established. Each treatment has substantial risks or side effects, but, as indicated above, there are also substantial risks in not treating this form of epilepsy. Clearly we do not understand the reason for the related retardation or its optimal treatment. Further research is needed.*94\208\8*
Categories: Epilepsy |
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