By R. Angir. Ripon College.
Out-of-home caregivers and household contacts of children aged 0-23 months South Africa has the following guidelines (summarised from Schoub 2005) cheap finast 5 mg fast delivery, divid- ing the population into 4 groups who may receive the vaccine –! Recommendation for Use 135 o Children with chronic pulmonary or cardiac diseases as well as immunosuppressed children order finast without a prescription. Category 2 – Contacts of high-risk persons - healthcare workers order finast 5 mg with amex, caregiv- ers of the elderly and high-risk patients generic finast 5 mg with amex, and persons living with high risk persons. People six months of age and older with chronic illnesses requiring regular medical follow-up or hospitalisation in the previous year! People six months of age and older with chronic illnesses of the pulmonary or circulatory systems (except asthma)! Children and teenagers aged six months to 18 years on long-term aspirin therapy (because aspirin treatment puts them at risk of Reye’s syndrome if they develop a fever)! Canada, al- though having similar recommendations for priority groups, actively encourages vaccination of everyone above the age of 6 months (Orr 2004). However, frontline workers such as healthcare personnel, as well as police forces and military personnel, might be high priority targets. Minor illnesses such as mild upper respiratory tract infections or allergic rhinitis are not con- traindications. Caution should be used when giving the vaccine to those who may come into con- tact with immunocompromised patients, as this caused controversy in 2004 when vaccine supplies were limited (Manion 2005). Both studies conclude that inadvertent vaccination or exposure to the at- tenuated virus is unlikely to result in significant adverse effects. However, it should be noted that small numbers of patients were involved, and until sufficient data are obtained, extreme caution should be exercised. In addition, o safety in asthma sufferers and patients with underlying medical conditions that put them at risk for wild type influenza infections has not been established. Strategies for Use of a Limited Influenza Vaccine Supply Antigen sparing methods Several methods of reducing the amount of antigen in vaccine preparations have been investigated. Most importantly are the use of adjuvants and the exploitation of a part of the immune system designed to elicit an immune response – dendritic cells. Adjuvants are used in a number of vaccines in current use, such as those for Diph- theria/Tetanus/Pertussis (DtaP) and Hemophilus influenzae (Hib). They enhance the immune response to a vaccine, allowing a lower dose to be given, while maintaining sufficient protective response (Couch 1997, Langley 2005, Potter 2004). Dendritic cells can be exploited by giving vaccines intradermally, as they induce T cell responses, as well as T cell dependent antibody formation (La Montagne 2004, Steinman 2002). Intradermal vaccination is well established with hepatitis B and rabies vaccines, and has recently been investigated with considerable success for influenza vaccines (and in a study from 1948 (Weller 2005). While the antibody titre is protective, the levels may not be as durable as those induced by intramuscular vaccination. Subjects over the age Pandemic Vaccine 139 of 60 years seem to have a weaker immune response with the intradermal vaccina- tion, and it is likely that the intramuscular injection will be preferable in this group (Belshe 2004). Also not clear yet, is the dose-response relationship between intra- muscular and intradermal routes (Kilbourne 2005). One drawback is that the local reactions can be more intense, with in- creased pain, swelling, and redness; however, these are still mild. Rationing methods and controversies In the event of a shortage of vaccine, as happened in the 2004/5 influenza season, as well as in the event of a pandemic situation, certain individuals, such as those working in the healthcare sector and in the poultry industry, and those exposed on the front lines, will need to be given priority over other groups for access to vac- cines. As has happened in the past, leaders may have identify groups for urgent vaccination in order to allow for maximum functioning of essential services, while other groups may have to wait until a greater supply is available (MacReady 2005, Treanor 2004). In the event of a pandemic, this could become problematic, but re- cent experience in the 2004/5 shortage showed that it was managed well by most (Lee 2004), with some instances of companies buying up vaccine, leaving private practices and public health services without supply (MacReady 2005). Pandemic Vaccine The purpose of this section is not to be an exhaustive reference on avian influenza vaccine development. That is a rapidly advancing field, and the achievements of those involved will likely change the face of influenza vaccinology, and vaccinol- ogy in general. In 10 years from now, it is likely that we will look back on our cur- rent influenza vaccines and think of them as primitive. This section will provide an outline of the current direction, the problems we face at the moment, and where we can hope to be in the near future. Development As we have seen, vaccination against influenza is a crucial weapon, not only in our fight against seasonal influenza, but against a pandemic that may come tomorrow, next year, or in the next decade. Although it is an ongoing process, initial strains of H5 avian influenza, such as A/Duck/Singapore/97 (H5N3), have been identified for use in vaccine development (Stephenson 2005). However, it should be noted that the focus is not solely on H5 strains – H2, H6, H7, and H9 are not being ignored, although only H1, H2, H3, N1 and N2 have been found in human influenza viruses (Kilbourne 1997). Our most urgent needs are a) a stockpile of anti-influenza drugs, b) a vaccine that matches the pandemic strain, c) expedited testing and approval of this vaccine, and 140 Vaccines d) the capacity to mass-produce enough vaccine to provide the world with a good defense. A matching vaccine will require knowledge of the pandemic strain, and until the next pandemic begins, we will not know for certain what that strain will be. Current efforts are working with a number of strains, mostly H5 strains, as this seems to be the most likely origin at the present time. The cells could be grown on microcarri- ers – glass beads – to enable high volume culture (Osterholm 2005). Attenuating the virulence of the virus is important, considering the increased mortality rate of the current highly pathogenic H5N1 avian influenza when it does enter hu- man hosts. While the H5N1 mortality rate in humans at present doesn’t neces- sarily reflect the mortality rate in an eventual pandemic, serious attention must be paid to the pathogenicity of the current H5N1 strain before it can be used in a vaccine. This may open even more doors for potential reassortment, however, and it may take considerable time to demonstrate safety in certain populations, such as the elderly and chil- dren. These vaccines will likely never be used, and are being developed to demonstrate that when the actual pandemic vaccine is needed, the principle is sound, and the technology is in place and proven on previous vaccines – hence the term “mock vaccine”. The important Pandemic Vaccine 141 aspect is the development of established vaccines that do not need lengthy studies before they can enter the market. They need to contain viral antigens humans have not had previous exposure to, such as the H5N1 antigens, and companies need to take them through clinical trials to determine immunogenicity, dose, and safety, and ultimately be licensed for use in the same stringent procedures used for other vac- cines. Currently, an expedited system is in place for the inactivated influenza vaccines against seasonal human influenza – the whole process, from the identification of the strains to be used, to the injection in the consultation room, takes about 6-8 months, because the vaccine is an established one, and only certain aspects need to be con- firmed prior to release. Production capacity In an ideal world, 12 billion doses of monovalent vaccine would be available in order to administer two doses of vaccine to every living human being. Currently, the world’s vaccine production capacity is for 300 million doses of tri- valent vaccine per year. This amounts to 900 million doses of monovalent vaccine, if all production were shifted to make a pandemic vaccine. Considering that at least two doses will be needed, the current capacity serves to provide for only 450 million people. This is further complicated by the fact that the dose of antigen that will be required is not yet known, but studies indicate that it may be higher than current human influenza vaccines (Fedson 2005). The world has suffered from vaccine shortages before – recently in the 2004/5 winter season, and closer to the threatening situation, in the pandemic of 1968. Furthermore, many countries do not have their own production facilities, and will rely on those countries that do. Transition Osterholm asks (Osterholm 2005), “What if the pandemic were to start …” – tonight – within a year – in ten years? The New England Journal of Medicine had an interview with Dr Osterholm, which is available online for listening to or for downloading: http://content. Vaccine and drug production would have to be escalated – for much later in the pandemic, as this will not make a difference in the short term. The world’s healthcare system would have to plan well in order to cope with distribu- tion when they become available – at present, it is doubted that it could handle the distribution and administration of the vaccines, never mind trying to handle that 142 Vaccines under the pressure placed on it by a pandemic. Vaccines may only be available for the second wave of the pandemic, which tends to have a higher mortality than the initial wave. If the pandemic starts in a year’s time, it is likely that we will then have some expe- rience in developing mock vaccines, so that a vaccine could be produced relatively quickly using a variety of the technologies currently under investigation. There would still be a significant delay, and it is likely that there would still be insufficient quantities, with rationing required. If the pandemic is delayed by a few years, we may well have the required vaccine production capacity to minimise the disastrous consequences. Strategies for expediting the development of a pandemic vaccine Shorten the time between emergence of a pandemic virus and the start of commer- cial production. This will require adopting a centralized evaluation team to examine the find- ings of the studies and give clearance for the use of the vaccine.
Satisfactory quality implies the presence of mucoid or mucopurulent material and a volume of 3-5 ml buy finast in india, although smaller volumes are acceptable if the consistency is adequate order finast 5mg. If a relatively high percentage of the specimens received are saliva buy cheap finast, the laboratory should report this to the medical staff buy finast 5mg online, and instructions should be given to nurses and physicians on how to improve the quality of sputum sampling. The minimum number of bacilli needed to detect their presence in stained smears has been esti- mated to be 5,000-10,000 per mL of sputum. Several studies have been published on improving smear microscopy per- formance using methods that concentrate the bacilli present in the sputum speci- men. The methods consist of submitting the specimen to a liquefaction step prior to concentrating it by sedimentation or centrifugation. The chemical method used for the liquefaction depends on the next step following concentration; smear staining only or smear staining followed by culturing. Other methods involving sputum liquefaction with different substances, and concentration either by sedi- mentation or centrifugation, have been proposed. The methods using dithiothreitol (Murray 2003), chitin (Farnia 2004) and C(18)-carboxypropylbetaine (Scott 2002) have been evaluated favorably for the preparation of concentrated smears. Its presence is needed for the breakdown of adenosine from food and for the turnover of nucleic acids in tissues. The routine use of this method is justified in exudates of pleu- ral, peritoneal and pericardial fluids. The specificity is very high in fluids with a 410 Conventional Diagnostic Methods lymphocyte-to-neutrophil ratio higher than 0. A 25 µL speci- men is incubated for 60 min at 37°C with 500 µL of 21 mM adenosine in 50 mM phosphate buffer pH 7. To control for the ammonium present in the patient’s specimen before addition of exogenous adenosine, specimens without substrate are run in parallel (specimen blank). Culture techniques have been estimated to detect as many as 10–1,000 viable mycobacteria per mL of specimen. For culturing of mycobacteria, two types of clinical specimens are considered: contaminated specimens and specimens collected aseptically from normally sterile sites. Speci- mens from non-sterile bodily sites are considered contaminated and therefore re- quire processing before culturing in order to eliminate the associated flora. Culture 411 properly eliminated, this flora will overgrow the culture medium long before my- cobacteria have the chance to develop visible colonies. Most of these methods include the digestion of mucus or organic debris and treatment to eliminate micro-organisms from the normal flora. No single decontamination method is applicable to all circumstances, laboratories and clinical specimens; therefore, a laboratory should use the best suited method that keeps the contamination rate between 3 % and 5 %. A contamination rate lower than 3 % may indicate that the procedure used is too harsh and may be killing the mycobacteria (Della Latta 2004). This method uses sodium hydroxide at concentrations ranging between 2 % and 4 % to digest and, at the same time, decontami- nate the specimen. Each laboratory should determine the lowest concentra- tion for optimal digestion and decontamination (Della Latta 2004). This method, one of the most used worldwide, uses N- acetylcysteine for mucus digestion and sodium hydroxide as the decon- taminant (Della Latta 2004). This method is recommended for decontamination of clinical specimens that may have Pseudomonas aeruginosa as a contaminant, usu- ally urine specimens and pulmonary specimens from cystic fibrosis patients (Della Latta 2004, Cooper 1930). This is a very simple and practical decontamination method that obviates the use of specimen centrifugation prior to culturing. The procedure was described by Kudoh using sodium hydroxide as the di- gestant-decontaminant and inoculation in a modified Ogawa media (Kudoh 1974). This method is useful to pre- serve specimens from contaminant flora overgrowth while in transit to the laboratory and also fulfills the decontamination step required prior to cul- ture. Concentration of mycobacteria With the exception of the Ogawa-Kudoh method, specimens are inoculated after a concentration step, which is done by spontaneous sedimentation or, more fre- quently, by centrifugation. The sediment of the concentration step will be inoculated directly onto the culture medium, or after decontamination in the case of non-sterile specimens that did not undergo decon- tamination before the concentration step. The most common are based on egg and also contain high concentrations of malachite green to overcome contamination with other bacteria. In gen- eral, after the centrifugation step, sediments are inoculated onto two Löwenstein- Jensen slants. Thus, these organisms will often fail to grow on Löwenstein-Jensen medium, which contains glycerol as the only available carbon source (Keating 2005, see Chapter 3). Stonebrink medium has the same composition as Löwenstein-Jensen, with the exception that glycerol is re- placed by 0. Many diagnostic laboratories that employ egg- based medium for the isolation of mycobacteria, omit the use of Stonebrink me- dium. The Ogawa medium is another egg-based medium, which is comparable in its composition with Löwenstein-Jensen. It is more economic because it replaces as- paragine by sodium glutamate, an amino acid more readily available and much cheaper. Liquid culture media has been proven to be significantly more sensitive than egg-based solid media for the isola- tion of mycobacteria from clinical specimens (Hines 2006). Histori- cally, microbiologists and medical students have been taught for decades that iso- lation of mycobacteria requires a defined, egg-based medium such as Löwenstein- Jensen. In fact, the tubercle bacillus does not have special growth requirements (see Chapter 3), and blood agar is at least as efficient as the widely recommended egg- based media. Preliminary studies suggested that blood agar can also be used as an alternative medium for susceptibility testing of M. Reportedly, re- sults are obtained much earlier with blood agar (2 weeks) than with 7H10 agar (3 weeks) (Coban 2005, Coban 2006). Blood agar plates are readily available in most laboratories dedicated to general bacteriology, and thus, in the absence of more specific media, they could be used for the culture of mycobacteria, especially in resource-limited countries. Reading of results Conventional culture media such as those based on egg and agar should be exam- ined for growth twice a week for the first four weeks starting on day 3 to 5 post- inoculation, and thereafter, once a week until the eighth week. All cultures reported positive for mycobacteria should be identi- fied to the level of species using either biochemical or molecular methods. This means that, in primary isolation, they hardly show any visible growth during the first week of culture. On egg-based media they produce characteristic non-pigmented colonies, with a gen- eral rough and dry appearance simulating breadcrumbs (Figure 12-2). In a recent review, false-positive cul- tures were identified in 13 of the 14 studies that evaluated 100 or more patients; the median false-positive rate was 3. Patients having only one positive culture when two tubes were inoculated and patients with only a few colonies in the culture should be further evaluated for the possibility of a false-positive result (Burman 2000). However, depending on geographical and epidemiological circumstances, it may be necessary to differentiate species within the M. The excreted niacin accumulates in the culture medium and is evidenced in the presence of cyanogen halide with a primary amine (Figure 12-3). These strains give a negative pyrazimidase test (unable to transform pyra- zinamide to pyrazinoic acid, the active form of the drug) (Vincent 2003). At least three respiratory specimens should be evaluated from each patient to establish the clinical significance of the infection. Wound infections, prosthetic valve endocarditis, infections complicating mammary augmentation surgery, and other cutaneous/subcutaneous infections have been attributed to rapidly growing mycobacteria. Rapidly growing mycobacteria often grow on classical bacterial culture media, especially on blood agar plates. However, due to their delay in forming visible colonies (up to 10 days), they are usually not detected in the routine bacteriology laboratory. Although the optimum temperature for most species is 30-32°C, they also grow at 36°C to 37°C, the standard temperature for isolation of the tubercle bacillus. Mycobacteria should be identified at the species level before starting treatment, because different species display different antibiotic resistance patterns. If disease by one of these 420 Conventional Diagnostic Methods mycobacteria is suspected, the bacteriologist must be notified so that appropriate cultivation conditions can be implemented. Mycobacterium marinum causes local- ized cutaneous lesions in patients with a history of a penetrating cutaneous injury and prolonged or repeated aquatic exposure. Two other mycobacterial pathogens require special conditions for laboratory culture: Mycobacterium haemophilum, which causes cutaneous, joint, or pulmonary infection in immunocompromised patients and lymphadenitis in children, grows preferentially at 30°C to 32°C, and requires iron-supplemented media i. Comparison of sodium carbonate, cetyl-pyridinium chloride, and sodium borate for preservation of sputa for culture of Mycobacterium tuberculosis.
Atención y vigilancia de las lesiones de los pacientes portadores de enfermedad arterial periférica: ateroesclerosis obliterante discount finast 5 mg without prescription, tromboangitis obliterante y otras patologías arteriales cheap finast 5mg online. Atención preferencial y cuidadosa de las lesiones de los miembros inferiores de los diabéticos generic finast 5mg with visa. Particular vigilancia estrecha son los pinchazos en la planta del pie del diabético discount finast 5mg visa. Vigilancia sostenida en los muñones de amputación por enfermedades isquémicas, esto es, arteriales, aunque hayan sido operados en las mejores condiciones. Prohibición de las inyecciones extrainstitucionales con jeringuillas y agujas reutilizables, dado el peligro de enfermedades por esporas no destruidas. No hay sepsis peores que las de los clostridios y sus aspectos médicos deben tratarse en este medio como escalón inmediatamente anterior a al cirugía. Se evitará la cristalina potásica, pues cada bulbo suministra 1,5 meq de potasio, que ya el paciente tiene aumentado en sangre por hemólisis e insuficiencia renal. Metronidazol: Infusión endovenosa de 500 mg en 100 cc, a durar entre 20 y 30 minutos, cada 8 horas, de 7 a 10 días. Tinidazol: disponible por vía oral solamente, con dosis inicial de 2 g, seguida de 1 g diario, en una o en varias tomas. La vía parenteral es exclusivamente endovenosa lenta, previa dilución en igual volumen de dextrosa al 5% o cloruro de sodio al 0,9%. Su indicación fundamental es la sepsis a estafilococos, o en pacientes alérgicos a la penicilina, pero también se ha utilizado con éxito en las sepsis por clostridios de tejidos blandos, al ser estos microorganismos grampositivos. Las polivalentes tienen 30 000 unidades en cada ámpula de 10ml: 10 000 U de cada uno de los 3 clostridios más frecuentes. Potencialmente pueden producir anafilaxia y deben realizarse pruebas de sensibilidad, mediante las diluciones recomendadas por el fabricante, al menos 2 veces, antes de ser inyectada la dosis total. La ingestión previa, por parte del enfermo, de carne de caballo es particularmente alergénica, por cuanto se obtienen de este animal. Oxígeno por catéter, máscara nasal, intubación, o hiperbárico en cámara de atención intensiva. Mantener bajo estricto control las enfermedades de base del paciente que pudiesen estar condicionando la sepsis: diabetes mellitus, enfermedades hematológicas, inmunodeficiencias y otras. Oxigenación hiperbárica Su fundamento no es tanto lograr la completa saturación de la hemoglobina al 100 %, sino especialmente lograr la disolución del oxígeno en el plasma, al suministrarlo a 2 ó 3 atmósferas. Los líquidos corporales, por extensión, tendrán O2 que podrá llegar hasta el último rincón del organismo. Es fácil comprender que las dos indicaciones inobjetables de la oxigenación hiperbárica son: 1. El oxígeno hiperbárico además, neutraliza las toxinas de los clostridios, de ahí que se aconseje realizar una sesión de inmediato, antes del acto quirúrgico. Si la disponibilidad de este tratamiento estuviese sujeta a demora, por muy poca que fuese, es mejor entonces operar de inmediato. Tratamiento quirúrgico El tratamiento de las sepsis por clostridios de tejidos blandos, ya establecidas, es eminentemente quirúrgico. El primer médico que haga el diagnóstico debe hacerlo, ya sea en la casa del enfermo, en el policlínico o en una sala hospitalaria. De igual manera, permite la visualización de los planos más profundos y la realización de la coloración de Gram. Dejar la herida cerrada hasta el momento de la cirugía es un olvido inadmisible y mortal. Los minutos cuentan y el paciente además de la toxemia, está "desangrándose" hacia él mismo, por la hemólisis que presenta. Esto puede ser desde el propio inicio de la operación o como consecuencia de grandes resecciones musculares. Esto es una irrigación continua, por goteo, de la zona cruenta, con agua oxigenada, solución Dakin, o permanganato de potasio al 1 x 8000, que permitirá el lavado de los diferentes espacios musculares, con un líquido oxidante. Las sepsis viscerales enfisematosas están más asociadas a las formas espontáneas de sepsis por clostridios, que a las antecedidas por traumatismos u operaciones. Sin embargo, debe enfatizarse que no todas las formas espontáneas de sepsis por clostridios, son viscerales. La causa común de estas formas espontáneas es la irrupción de clostridios desde su hábitat normal, en el órgano en cuestión, o su entrada en el torrente sanguíneo para mostrar sus manifestaciones sépticas en la nidación que pudiesen hacer en tejidos anóxicos a distancia. Se produce invasión del clostridio por contigüidad o diseminación hemática con nidación a distancia. Leucosis 137 Con tendencia a la desaparición, pero particularmente grave, es la afectación del útero, en ocasión del muy séptico traumatismo que significa, un aborto criminal realizado por manos inescrupulosas en condiciones higiénicas deplorables. Un cuadro real de metritis enfisematosa que generalmente lleva a la muerte de la enferma. Estas sepsis viscerales enfisematosas se presentan generalmente en pacientes portadores de las enfermedades previas enunciadas, cuyo cuadro clínico y los estudios complementarios realizados, evidencian una grave sepsis con afectación de determinada víscera, en la que se demuestra la presencia de gases en los estudios imagenológicos, en las inmediaciones del órgano y la zona afectada. Verdaderas colecciones de gas, en forma de burbujas aisladas, apelotonadas o en sartas de perlas, que deben sugerirnos la presencia de clostridios. Las vísceras más frecuentemente involucradas son cuatro: vesícula biliar, riñón, colon y útero. También pudieran denominarse gaseosas, para heredar el término de las originales de las extremidades, así tendríamos colecistitis enfisematosa o colecistitis gaseosa, pielonefritis enfisematosa o pielonefritis gaseosa. Ahora bien, no deberían denominarse gangrena gaseosa de la vesícula o gangrena gaseosa del riñón. El término gangrena gaseosa debería reservarse exclusivamente para la mionecrosis clostridiana, generalmente de las extremidades. La filosofía del tratamiento de las sepsis viscerales enfisematosas es idéntica a la enunciada en los párrafos precedentes, unida a la exéresis de extrema urgencia del órgano enfermo. Las secreciones y fluidos provenientes del edema perivisceral mostrarán los bacilos grampositivos esporulados al hacer una tinción de urgencia mientras se concluye la intervención quirúrgica. Mencione las medidas que toma con un lesionado que busca atención en el dispensario por una herida en su antebrazo con magulladuras y atriciones musculares, así como evidente contaminación con tierra. Ampliamente difundidos en los suelos, la mayoría son saprofitos, inofensivos y valiosos. Muchos producen enzimas, productos químicos y fermentaciones industriales de gran valor. Se encuentran normalmente en piel, tubo digestivo, en particular en intestino grueso, vesícula biliar y vagina. Toxinas Agente Adquisición Enfermedad Datos importantes - Exotoxinas: A, B, C, D, E, F. Clostridium Vía oral Botulismo - Termolábiles, en las conservas Botulinum no esterilizadas. Espora ovalada Alimentos en No es una infección - No crece en sal ni pH de 4,5 Grande, conserva mal Es una intoxicación ó + subterminal procesados - Parálisis de pares craneales y Bacilo en raqueta Botulus = salchicha nervios motores: cara, ojos, nervios motores: cara, garganta, respiratoria. Contaminación accidentales de partes blandas - Inyecciones simple - Este concepto significa una Otras toxinas - Pinchazos conducta de tratamiento Espora oval - Accidentes - Preferencia por los diabéticos Lecitinasas: Subterminal - Cirugía 2. Celulitis - Por encima de la fascia Hemolisinas No hacen relieve - Quemaduras anaeróbica - El estado general está Necrosis hística Muy - Fracturas abiertas conservado termorresistentes Colagenasas: (1210C durante 3 Úlceras de los - Formas clínicas: edematosa, Hialuronidasa minutos) miembros 3. Conocer las precauciones del torniquete y las marcas e identificaciones obligadas. Concepto de hemostasia Son aquellos mecanismos espontáneos o provocados que ayudan a controlar la hemorragia de un vaso o una víscera lesionados. Provocada - Provisional - Definitiva Hemostasia espontánea Son los mecanismos que tiene el propio organismo para detener la hemorragia. Este mecanismo redistribuye la sangre restante y garantiza el transporte de oxígeno a esos órganos vitales. La frecuencia cardíaca se acelera y se mantiene de ese modo la oxigenación de los tejidos con menos sangre, el bazo se contrae con lo cual inyecta en la red vascular un volumen adicional de sangre, una verdadera autotransfusión. El riñón que sufre de isquemia, por la hemorragia y la vasoconstricción, disminuye la producción de orina y economiza líquido, necesario para sustituir el volumen perdido; por tanto, la hipotensión arterial, resultado de la pérdida de sangre, es un mecanismo de defensa que tiene el objetivo de disminuir el escape y concentrar plaquetas y otros factores de la coagulación para que sellen el orificio. Si la hemorragia no está controlada, debe mantenerse la presión arterial máxima entre 80 y 90, lo que asegura la perfusión renal, lo cual protege el riñón y evita la reiteración del sangramiento. Solamente si la hemorragia está controlada, puede llevarse la presión arterial a la normalidad. En un vaso herido, si la sección es completa, sus extremos se separan y se retraen, debido a su elasticidad y a la presencia de fibras musculares lisas en su capa media, el endotelio se enrolla y todo esto tapona los orificios sangrantes.
Frequently buy cheapest finast, the disease presents as a urinary infection that does not respond to routine broad spectrum antimicrobial treatment generic 5mg finast with amex. Excretory urography can either be normal or present a wide variety of alterations that include parenchymatous cavities order cheapest finast, dilatation of the pyelocalicial system order finast 5 mg with visa, renal calcifications of irregular contours, decreased capacity of the urinary bladder, and multiple ureter stenoses (Figure 15-15). In the cystoscopy, edema and diffuse hyperemia are observed, which are more intense around the orifice (golf hole sign), often accompanied by irregular ulcerations and/or infiltrates and vege- tations. Figure 15-15: Infertility patient hysterosalpingogram, revealing proximal dilatations of the fallopian tubes (“rigid pipe stem" appearance ) and distal enlargments/constrictions (“beaded" appearance). Culture of three to six specimens of first morning urine are together as reliable as the culture of a single 24-hour urine sample. Tuberculosis of the central nervous system The compromise of the central nervous system occurs in two basic forms: menin- goencephalitis and intracranial tuberculoma. The clinical manifestations are due to the inflammatory process induced by the mycobacterial infection, and the symptoms depend on the site and intensity of 15. Meningoencephalitis generally has an insidious onset and a slowly progressive course, with symptoms including apathy, lethargy, fever, and mental disturbances such as irritability, understanding difficulties, personality alterations, disorienta- tion, and progressive mental confusion. Findings on physical examination are related to the stage of the disease and the nd rd affected area, such as cranial nerve involvement (the most affected are the 2 , 3 , th th 4 , and 8 nerve pairs), focal neurological deficits, and signs of meningeal and cerebellar irritation. The cerebrospinal fluid is generally clear, with a predominance of lymphocytes, an increase in proteins and a decrease in glucose levels. In the differential diagnosis the following conditions should be considered: other infectious meningitis, vascular pathologies, the collagen vascular disease sarcoido- sis, metastatic carcinoma, acute hemorrhagic leucoencephalopathy, and lymphoma. In the case of intracranial tuberculoma, the clinical manifestations depend on the location of the lesion, which generally grows slowly. When there is no compromise of the sub-arachnoid space, the cerebrospinal fluid is normal and the computerized tomography exhibits a mass, which is generally difficult to differentiate from neo- plasia (Azambuja 1993, Kasik 1994, Norris 1995). Bone involvement consists of osteomyelitis, and arthritis can occur either by extension of the osseous lesion to the joint or by direct hematogenic inoculation. The most frequent sites of bone involvement are the vertebrae (Pott’s disease) and the proximal extremities of the long bones. With evolution, it presents a wedged flattening and gibbus formation that can be associated with a paravertebral cold abscess (Figure 15-17). Image on X-ray is characterized by erosion of the anterior vertebral body margins with no preservation of the intervertebral space. The definitive diagnosis should be obtained by biopsy for culture and histopathological analysis (Ridley 1998, Schle- singer 2005). The diagnosis is established by puncture, biopsy, histo- pathological examination, and culture (Zylbersztejn 1993, Davidson 1994, Ridley 1998, Schlesinger 2005). Other extrapulmonary localizations Tuberculous involvement of other tissues, such the eye, skin (lupus vulgaris), genital, and digestive tract, may also be the result of hematogenous dissemination, but there are other possible routes of infection. Tuberculosis disease 507 and appropriate invasive and non-invasive procedures should be employed to en- sure an early diagnosis (Moore 2002, John 2002, Erkoc 2004). Fever and sweating It is believed that bacillary multiplication increases in the afternoon, with the daily circadian rhythm cortisol peak, which is followed by the evening fever characteris- tic of the disease. However, when there is massive hema- togenous or endobronchial dissemination, peaks of high fever can occur at any time of the day and are accompanied by chills. Weight loss is proportional to the duration and extent of the disease and is frequently accompanied by adynamia. Cough results from the stimulus caused by the alveolar inflammatory process or from the granuloma- tous impingement into the respiratory airways. At the onset of the disease, the cough is dry; but with progression, it becomes productive with mucous or mucopu- rulent expectoration, generally in small amounts, and sometimes with blood. Diagnostic approaches 509 smear microscopy in all respiratory symptomatic persons, defined as those with a productive cough of at least three weeks duration. Hemoptysis When hemoptysis occurs, the blood volume is variable, from bloody streaks mixed in the sputum (hemoptoic sputum) to massive hemoptysis (more than 400 mL/day), which is rare. A higher volume of hemoptysis is generally caused by erosion of Rasmussen’s aneurysms, which are free terminations of arteries within lung cavi- ties. Bleeding can also occur in small lesions during the formation of the cavities, when hemoptysis can be the first manifestation of the disease, which was known by the old phthysiologists as alert hemoptysis or bark. Therefore, dyspnea is not a common symp- tom, but can be caused by pleural effusions, pneumothorax or restriction caused by fibrosis in advanced disease. Dyspnea may be more frequent in the miliary form, due to diffuse interstitial disease and consequent hypoxemia. Generally of low intensity, it disappears within two or three weeks after effective treatment has begun. When cough and other symptoms are overlooked by the patient, hoarseness may be the sole reason for seeking medical assistance. The longer the duration of the disease, the more evident are the classic signs of consumption, such as pallor and weight loss. The extent and the form of the disease in the lung parenchyma determine the pres- ence of specific pulmonary signs. The most common auscultation findings are: coarse crackles in the area corresponding to the lesion (generally apical and poste- rior); wheezing and ronchi in the area of compromised bronchi; clinical signs of lung condensation in the forms with caseous pneumonia; decreased vesicular mur- mur and broncophony or tubular blow when pleural effusion is present; as well as the classic amphoric breath sounds near cavities. Some findings are caused by delayed-type hypersensitivity to tubercle bacilli com- ponents, although the lesions themselves do not contain M. Cultures are most commonly performed on solid media (Löwenstein-Jensen or Ogawa Kudoh), giving results on an average of 30 days. Induced sputum When the patient does not produce expectorant, it is advisable to induce sputum by nebulization with hypertonic (3 % to 5 %) saline solution. Recent studies showed that induced sputum has a diagnostic yield equal to or higher than that of material 512 Tuberculosis in Adults collected by fiberoptic bronchoscopy. Radiological examination The chest X-ray examination may help to make the diagnosis in respiratory symp- tomatic patients that are repeatedly negative on direct microscopy sputum exami- nation. Lor- dotic and oblique views may be helpful for further evaluation of the extent of lung involvement, especially in patients with apical lesions or extensive hilar adenopa- thy (Figure 15-6). If pleural effusion is present, lateral decubitus views may aid determination of the nature of effusion (i. Also, when the presence of an associated lung cancer is suspected, high-resolution computerized tomography with the analysis of the secondary lung lobule becomes an important diagnostic aid (Sinan 2002, Busi-Rizzi 2003). When kept at a temperature between 4°C and 8ºC, tuberculin remains active for six months, but it should not be frozen or exposed to direct sunlight. They have been used in developed nations, but data about the evaluation of its usefulness in high burden countries are scarce (Oxlade-2007, see Chapter 13). They have specificities of > 95 % for smear- positive specimens, but sensitivities are variable, especially in smear-negative dis- ease, where a rapid diagnostic test is most needed. Few series have estimated the potential clinical utility of these tests in relation to different levels of clinical suspicion and pretest probability (Cantazaro 2000). Moreover, appropriate follow-up of the patient is necessary to ensure a regular drug supply and at least 70 % adherence to the preventive treat- ment regimen. Contact tracing and control Even for developed nations, competing demands restrict the resources that can be allocated to contact tracing. Therefore, public health officials must decide which contact investigations should be assigned a higher priority (Guidelines for contact investigation 2005). A decision to investigate an index patient depends on the presence of factors used to predict the likelihood of transmission. When exposure is related to households, congregate living settings, or cough-inducing medical procedures, contacts are designated as high priority. This classification is useful for control strategies in areas of low prevalence of infection and low inci- dence of new cases. This strategy is not feasible in low resource countries where health attention systems have scarce economic, operational and human resources. Yield of smear, culture and amplification tests from repeated sputum induction for the diagnosis of pulmonary tuber- culosis. The role of clinical suspicion in evaluating a new diagnostic test for active tuberculosis: results of a multicenter prospective trial. 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