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Measurements which included pocket depth and attachment levels were taken at the initial exam, after the hygienic phase and 1 and 2 years after treatment. In the 1 to 3 mm crevices there was a slight loss of attachment after all types of treatments. In the > 7 mm pockets there was a significant reduction after all modalities with the greatest reduction after pocket elimination, and no significant differences in attachment results among the 4 methods. None of the surgical modalities had any better effect than scaling and root planing alone in maintenance of periodontal support which was not directly related to reduction in pocket depth. The following 2 studies were part of the Michigan surgery studies but point out the effects of patient-performed oral hygiene measures. The scores were used to test the hypothesis of equal effect of plaque scores above and below the median for the 3 severity groups of the initial disease based on probing depth. The 25% of patients with the highest plaque scores in 1 group and the 25% with the lowest scores in another group were also compared. These scores were then related to variations in probing depth and attachment levels. The results showed no more return of probing depth with poorer than average oral hygiene than with better than average. A comparison of the 25% of patients having the lowest plaque scores with the 25% having the highest score showed no significant differences in pocket depth responses over the 8 years. After 1 year, there was no indication that poorer oral hygiene leads to a greater loss of attachment than better oral hygiene. Similar results were seen in the 4 to 6 and the > 7 mm group after 4 years of study. For pockets 1 to 3 mm and 4 to 6 mm there was no difference in pocket reduction maintenance. For attachment there was no difference in 1 to 3 mm probing depths and in 4 to 6 mm pockets, lower gingivitis scores had better gain the first 2 years but thereafter no difference was recorded. For 7 to 12 mm pockets, the lower gingivitis scores seemed to result in better probing levels and attachment gain for the first 3 years but this was not maintained throughout the experiment. The severity of gingivitis did not affect the maintenance of pocket depth reduction or clinical attachment levels. Patients with advanced periodontal disease were entered into a split mouth design to compare the results of subgingival debridement performed in conjunction with a modified Widman flap or scaling and root planing alone. Attachment levels improved following non-surgical therapy at 6 and 12 months, but at 24 months returned to baseline values. When comparing single-rooted to multi-rooted teeth, there was a trend for slightly better results for single-rooted teeth. These similar results can be maintained over time in patients with proper oral hygiene levels. Probing depths shallower than the critical probing depth tend to lose attachment following the procedure. The results also showed that the level of oral hygiene established during healing and maintenance is more critical for the resulting probing depths and attachment levels than the mode of treatment used. Sites with initial probing depth exceeding 3 mm responded equally well to non-surgical and surgical treatment. One side of both the maxilla and the mandible were treated with modified Widman flap. Patients were recalled every 2 weeks, and examination was performed at 3 and 6 months after the completion of treatment. Lateral incisors, canines, and premolars in the maxilla and mandible in 16 patients diagnosed with advanced periodontitis were used for study. The plaque index and bleeding on probing were assessed prior to and 3, 6, and 12 months after treatment. Probing depths and clinical attachment levels were assessed prior to and 1 year after treatment. Radiographs were taken using the bisecting angle technique before and 1 year after treatment, and the bone level was expressed as a percentage of the distance from the apex of the tooth to the normal bone level. Angular bony defects corresponding to 15% or more of the distance between the normal level of the bone and the apex of the involved tooth were located.
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Facial twitch and spasm can be identified in patients with tumors compressing the facial nerve and have been reported in patients with geniculate hemangiomas. Hearing loss is typically conductive owing to impingement of the tumor on the ossicular mass in the middle ear. Patients may complain of symptoms related to compression of the greater superficial nerve, including either epiphora or dry eye. On physical exam, the patient may present with a red mass behind the eardrum and the Weber and Rinne tuning fork tests suggest a conductive hearing loss in that ear. If surgical excision is required, routine eye care is needed until facial nerve function returns. This may require the use of artificial tears and Lacri-Lube (a nighttime eye lubricant), a protective eye shield, or the placement of a gold weight in the upper eyelid. Patients may also have conductive or sensorineural hearing loss that needs to be managed accordingly. The best surgical strategy is via a middle cranial fossa approach, with care to identify the interface between the tumor and the dura during the initial elevation of the dura off the floor of the middle cranial fossa. The tumor can usually be delicately microdissected from the geniculate ganglion with facial nerve preservation. Classically, there may be intratumoral calcifications or bone spicules within the tumor, which are diagnostic for a hemangioma. On T1weighted images without contrast, the tumor has the same density as brain tissue; on T2-weighted images, the tumor is bright. Leukemia Leukemia is the production of an abnormally high number of white blood cells that become deposited in various organs and sites within the body. The temporal bone is one site that occasionally becomes infiltrated, typically within the marrow of the petrous apex. Involvement of the middle ear cleft and mastoid can also occur; however, it is unusual for leukemic infiltrates to involve the inner ear or the facial nerve. Patients with leukemia are immunosuppressed and are highly prone to developing acute otitis media. Up to 32% of patients with leukemia have otologic symptoms, usually due to eustachian tube dysfunction with resultant middle ear effusion and conductive hearing loss. Obstruction of the eustachian tube can occur along its length or at its opening to the nasopharynx at the adenoid bed. A solid tumor known as a granulocytic sarcoma or chloroma is occasionally noted with myelogenous leukemia. This is a localized concentration of neoplastic granulocytic cells that begins within the marrow of the petrous apex. The treatment for leukemic infiltrates, granulocytic sarcoma, or both is based on systemic chemotherapy; there is no need for surgical treatment of this disease. Occasionally, a myringotomy is useful to drain fluid out of the middle ear cleft and for culture of the middle ear effusion if infection is suspected. Very rarely, a mastoidectomy is required if coalescent mastoiditis has developed or for biopsy purposes. Differential Diagnosis the differential diagnosis of a geniculate lesion includes facial nerve schwannomas, meningioma, metastases, cholesteatomas, cholesterol granulomas, and mucoceles. Observation can be considered in an older or debilitated patient in whom surgical risks are felt to be too great. Although they are next to the facial nerve, they usually do not infiltrate the nerve nor do they extend intradurally. Surgery often permits complete tumor resection with minimal impact on the facial nerve function. Lymphoma Lymphoma can infiltrate the marrow spaces of the temporal bone, typically within the petrous apex. Like patients with leukemia, these patients can have eustachian tube dysfunction or hemorrhage into the middle ear with resultant middle ear effusion and conductive hearing loss. It is unusual to see destruction of the inner ear or facial nerve in this group of patients. General Considerations Langerhans cell histiocytosis is a proliferation of cells that arise from the bone marrow and are found circulating within the blood and lymph nodes and at junctional areas between the body and the outside environment (eg, along epithelial and endothelial surfaces).
- Paget disease juvenile type
- Bilateral renal agenesis dominant type
- Staphylococcal infection
- Interstitial lung disease
- Enolase deficiency
- Peripheral neuroectodermal tumor
- Myxoma-spotty pigmentation-endocrine overactivity
- Mental retardation X linked severe Gustavson type
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Metrical Rasdyana cribed) his Text;- After one should reside his having in a drunk the (Elixir) windless (presover his in 6. He the (in body of a cow his and after sit down the same manner Vomitings mark the digestion of the Soma-juice and vomiting the blood -streaked worm-infested matter, the *Patanjali, propounder of as ihe enumerates the Yamis follows: - "=? The muscles become withered by seventh day the patient is time and on the found to be a mere skeleton left covered with a skin only and the vital spark being retained with bare animation, the body should be washed with tepid milk by the potency of Soma. On the morning of the eighth day, the body should with sandal paste, of be washed with milk, and plastered and potions of dust and milk should be prescribed for him after his which the patient should be advised to leave bed of down on one covered with a Kshauma cloth. From now the muscles of lie piece begin to the skin the body show signs of fresh and vigorous growth, teeth, becomes cracked, and the fall off. From the thirteenth till the sixteenth day (both the days inclusive) the body should be washed with the decoction formed, of Soma-valka. New and teeth well- symmetrical, strong, hard as clear as a diamond or crystal or ruby would appear on the seventeenth and eighteenth days. Fixed, glossy and coral coloured fingerrising resembling the new possessed of auspicious marks sun in lusture and would be found to be growing lotus after the lapse of that period soft and hair begin hue of a blue a to grow, the skin (Nilotpala), would assume the Atasi flower or of ruby stone. Chandana and black sesamum applied to the and the patient should take a this would lead to the growth of deep course of a week. Thenceforth Vala^ taila (described before) should be used in anointing (Abhyanga); his body in; pasted barley in rubbing (Udvartana) it; tepid milk in washing (Parisheka) and a decoction of Aja-karna of. Then he should be quiet made to come out and enter the third ^outmost) chamber (veranda) and to remain there for ten days with a control over the mind and should be allowed to take a short exposure to the sun and wind during this period (of ten days). The patient should not contemplate himself in a mirror during this time owing to his enhanced personal respect of beauty and renounce period of ten days. The expressed juice a Soma * t plant belonging to any other species is should be A Mushti measure equal to eight Tolas. Such a person bears a charmed life against fire, water, poison and weapon and develops a muscular energy in his limbs which would be in no strength of a thousand way are inferior to the ele- combined cious excited (rutted) phants, of the Bhadrd class (which the most fero- and irresistible) in their sixtieth year. He is invested with a beauty of frame which belongs to Kandarpa (the god of love) and his complexion (lustre) vies with the the presence of such a beams of the full moon. Plants the Distinctive features of the Soma - A Soma plant of whatever species is fur: nished with fifteen leaves which wax and wane with leaf waxing and the waning of the moon. Thus one grows every day in the lighted fortnight attaining the greatest number (fifteen) in the night of the full moon and then the leaves begin to decrease in number dropping one by one every day till the bare stem of the creeper is left on the night of the new moon. The Munjavdn puts forth leaves like those of a garlic while the Chandramdh species is possessed of a golden the Garuddhrita colour and is aquatic in its habitat. Possession of fifteen leaves of variegated colours, a bulb, a creeper-like appearance, of milky juice are the general characteristics of all the Soma plants. The Soma plants the ungrateful as virtues are invisible to the impious or to to the unbeliever in the curative well of medicine 12. The first group comprises hunting, dice-playing, day-sleep, censuring, addiciion to woman, intoxication, singing, dancing, playing on musical instruments and idle wanderings. In order to use them a man should enter the (prescribed) chamber (Ag2ira) and perform the (prescribed) Homa ceremonies. A Kudava measure of the milky juice of the secreting species of the plants should be taken once for all after entering the chamber. Three twigs or branches, however, to the length of a span of those of the non-secreting species having roots should be taken for a its single dose. A quantity of the severed pieces of either of the Gonasi, Ajagari (Suvarchala) or Krishna-kdpoti species including their thorns, and weighing a Musti (Sanakha-mushtika;* should be boiled with (an adequate quantity thus cooked of; milk (and water). The milk and prepared should be passed through a piece of cloth and taken the milk cooked and only once duly consecrated. Chahrakd species also prepared with one of the should be taken with milk only once, whereas (that of one of) the Brahnia-suvarchald species should be taken in succession. Memorable Verses;- the the aforesaid use of any of fills drugs rejuvenates lion, invests the it system^ it with the strength of a with a beautiful shape, blesses the user with such powerful memory that he can commit to memory anything once heard, and ultimately years. Persons whose systems have herbs (Oshadhis), not by the roads on earth but been with these medicinal like the users of Soma go scale those inaccessible heights of heaven from whence the pendent rain-clouds look the soil below and where the feathered wingers of the ethereal blue frequently soar up to. The Gonasi two bulbous is plant possessed of two leaflets, red-coloured and marked with height and black rings.
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Also, it is nonspecific because many patients without a fistula experience disequilibrium during the test. Facial Nerve Injury the rate of facial nerve paralysis with penetrating trauma to the temporal bone is 36%. Essentially all of these injuries are of immediate onset and occur because of nerve transection. Facial nerve electrophysiologic testing with a Hilger stimulator can be used to identify facial nerve trauma in a comatose patient. Facial nerve repair needs to be undertaken as soon as the patient is medically stable. The only definitive way to make the diagnosis of a perilymphatic fistula is surgical exploration with visualization of the leak. Even this evaluation is not necessarily definitive since it is difficult to verify that small amounts of clear fluid within the middle ear cavity represent a perilymphatic leak and not serous transudate from the middle ear mucosa. Although the test result is not immediately available, it may be useful when following up these patients postoperatively. Patients are placed on stool softeners and serial audiograms should be obtained to follow up for evidence of disease progression. If symptoms persist or the sensorineural hearing loss worsens, surgical treatment may be considered. This is done by a transcanal approach with elevation of the tympanomeatal flap and careful examination of the oval and round windows. Many surgeons place fascia around both the oval and the round windows, even if a fistula is not definitively seen, since defects are considered to be difficult to detect. Case records of the Massachusetts General Hospital: weekly clinicopathological exercises. Case 40-2001: an eight-year-old boy with fever, headache, and vertigo two days after aural trauma. First clinical experience with beta-trace protein (prostaglandin D synthase) as a marker for perilymphatic fistula. Outcome of hearing and vertigo after surgery for congenital perilymphatic fistula in children. Nystagmus elicited by straining can be documented using electronystagmography monitoring and then evaluated. Differential Diagnosis the differential diagnosis includes all causes of dysequilibrium, most notably Meniere disease, cervical vertigo, psychogenic vertigo, disequilibrium related to aging (presbyastasis), vestibular neuritis, and labyrinthitis. Complications Fluctuating, but progressive, sensorineural or mixed hearing loss can occur. Most of the problems the surgical team encounters in anterior skull base surgery are either malignant tumors of the paranasal sinuses that extend superiorly to involve the anterior skull base, or benign or malignant processes such as meningiomas, which extend inferiorly from above. In addition, benign lesions of the paranasal sinuses, such as extensive inverted papillomas, extensive mucoceles, and selected benign fibro-osseous lesions, occasionally require these approaches to skull base surgery. It includes the posterior wall of the frontal sinus, the ethmoid roof and cribriform plate, and the orbital roof. More posteriorly, it includes parts of the sphenoid bone, including the lesser wing of the sphenoid, the planum sphenoidale, and the roof of the sphenoid sinus. The significance of this layer is that the orbit is generally able to be preserved if the extraocular muscles, which are inside this fascial plane, are uninvolved. This is generally true when the patient has full extraocular motility preoperatively, and it may be true at times even when there is some diplopia secondary to mass effect. The actual invasion of orbit fat deep to this fascial plane usually suggests the need for orbital exenteration. The significance of this anatomy is that dissection of the medial surface of the optic nerves to the optic chiasm is generally safe with respect to its blood supply. Although 30% of the 66 reviewed cases recurred locally, this was at the site of the initial orbit involvement in only 8% of these cases.
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The submucosa is made of elastic and fibrous tissue and is the strongest layer of the esophageal wall. The esophageal muscle is composed of an inner circular and an outer longitudinal layer. The upper third of the esophageal musculature consists of skeletal muscle and the lower two thirds consist of smooth muscle. The upper esophageal sphincter is formed by the cricopharyngeus muscle along with the inferior constrictors of the pharynx and fibers of the esophageal wall. The sphincter prevents both the passage of air from the pharynx into the esophagus and the reflux of esophageal contents into the pharynx. These periodic relaxations are called transient lower esophageal sphincter relaxations to distinguish them from relaxations triggered by swallows. The cause of these transient relaxations is not known, but gastric distention probably plays a role. The pinchcock action of the diaphragm is particularly important because it protects against reflux caused by sudden increases of intraabdominal pressure, such as with coughing or bending. Heartburn is present in about 40% of patients, and it is caused by stasis and fermentation of undigested food in the distal esophagus. In evaluating a patient with dysphagia, a barium swallow should be the first test performed. An endoscopy should be performed to rule out a tumor of the esophagogastric junction and gastroduodenal pathology. Esophageal manometry-Esophageal manometry is the key test for establishing the diagnosis of esophageal achalasia. Ambulatory pH monitoring-In patients who have undergone pneumatic dilatation or a myotomy, ambulatory pH monitoring should always be performed to rule out abnormal gastroesophageal reflux; if present, it should be treated with acid-reducing medications. Differential Diagnosis Benign strictures caused by gastroesophageal reflux and esophageal carcinoma may mimic the clinical presentation of achalasia. Sometimes an infiltrating tumor of the cardia can mimic not only the clinical and radiologic presentation of achalasia, but also the manometric profile. This condition is known as secondary achalasia or pseudoachalasia and should be suspected in patients older than 60 years of age who present with a recent onset of dysphagia and excessive weight loss. A degeneration of the myenteric plexus of Auerbach has been documented, with loss of the postganglionic inhibitory neurons. Complications the aspiration of retained and undigested food can cause repeated episodes of pneumonia. Squamous cell carcinoma is probably due to the continuous irritation of the mucosa by the retained and fermenting food. However, adenocarcinoma can occur in patients who develop gastroesophageal reflux after either pneumatic dilatation or myotomy. Most patients adapt to this symptom by changing their diet and are able to maintain a stable weight, whereas others experience a progressive increase in dysphagia that eventually leads to weight loss. Regurgitation is the second most common symptom and it is present in about 60% of patients. Because peristalsis is absent, gravity becomes the key factor that allows the emptying of food from the esophagus into the stomach. It should be used primarily in elderly patients who have contraindications to either pneumatic dilatation or surgery. This treatment, however, is of limited value since only 30% of treated patients still experience a relief of dysphagia 2. It should be used primarily in elderly patients who are poor candidates for dilatation or surgery. Pneumatic dilatation-Pneumatic dilatation has been the main form of treatment for many years.
- Anti-mitochondrial antibodies (results are positive in about 95% of cases)
- U.S. Centers for Disease Control and Prevention - www.cdc.gov/hepatitis
- Do not drink anything after midnight, including water. Your doctor may even tell you not to drink anything for up to 12 hours before surgery.
- Nerve conduction velocity study
- Get more protein, complex carbohydrates, and dietary fiber
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Active rewarming is contraindicated, because it may induce vasodilation and vascular collapse. The patient should be screened for concomitant adrenal insufficiency by a cosyntropin stimulation test. Elderly patients or patients with coronary artery disease should be started on much smaller doses of 12. T4 has a half-life of about 7 days and therefore needs to be given only once daily. Desiccated thyroid is unsatisfactory because of its variable hormone content and should not be used. The current preparation is rapidly absorbed, has a short half-life, and a rapid biological effect. Patients who experience malabsorption or who ingest drugs such as calcium and iron, which impair T4 absorption, may require an increase in T4 dosing. Thyroid cancer, moreover, makes up 92% of endocrine gland cancers and accounts for approximately 12,000 new cases in the United States annually. However, only 1200 people succumb to thyroid cancer each year in the United States, making it one of the more survivable cancers. Poorly differentiated thyroid cancers are seen in equal proportions in men and women. The spectrum of malignant thyroid disorders ranges from very indolent tumors, such as most papillary carcinomas, to highly aggressive tumors, such as anaplastic or undifferentiated carcinoma. Papillary carcinoma typically is seen in young adults and often metastasizes regionally to the lymphatics of the neck. Even in the presence of regional metastasis, however, patients with papillary carcinoma have very low mortality rates. Conversely, patients are typically in their sixth or seventh decade when a diagnosis of anaplastic thyroid cancer is made. Only 10% of patients with anaplastic thyroid cancer will survive one year after the diagnosis, with a median survival of approximately 6 months. The cause of most malignant thyroid growths is unknown; however, patients whose thyroid glands have been exposed to low-dose therapeutic radiation therapy are at an increased risk of developing thyroid cancer. In general, there is a long latency period (> 20 years) between the exposure to radiation and the onset of carcinoma. Children who receive ionizing radiation (as little as 10 cGy) are more likely to develop thyroid carcinoma later in life than adults who receive equal amounts of ionizing radiation. Also, medical personnel and others exposed to radiation have a significantly higher prevalence of thyroid carcinoma than do control groups. The sporadic form of medullary thyroid cancer tends to be unilateral, and the familial form is almost always bilateral and multifocal. Papillary carcinoma can also be familial, by itself or in association with familial adenomatous polyposis, Gardner syndrome, and Cowden syndrome. Occasionally, patients present with more problematic symptoms and signs, which alert the physician to the possibility of a malignant condition. These symptoms and signs include hoarseness, localized or referred pain, dysphagia, shortness of breath, hemoptysis, and a hard, fixed thyroid nodule or neck mass. Although these symptoms may also occur with benign disease, their presence increases the suspicion of a malignant growth. The physical examination of patients with possible thyroid cancer should include a thorough examination of the head and neck. Laryngoscopy is essential to evaluate vocal cord function because invasive cancers can invade the recurrent laryngeal nerve and cause vocal cord paralysis. Also, it is important to document any preexisting functional abnormalities of the vocal cords prior to thyroidectomy.
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Syndromes of Possible Viral Etiology Several diseases either produce symptoms or have epidemiologic or other characteristics that resemble those of viral infections or may be the sequelae of viral infections. They include multiple sclerosis, Kawasaki disease, arthritis, diabetes, and chronic fatigue syndrome. Also, the strong cytokine response to many virus infections may trigger a loss of tolerance to self-antigens to initiate autoimmune diseases. This type of passive immunity can remain effective for 6 months to a year after birth. Maternal antibodies can (1) protect against spread of virus to the fetus during a viremia. Nevertheless, because the cell-mediated immune system is not mature at birth, newborns are susceptible to viruses that spread by cell-to-cell contact. These include better antibody reagents and more sensitive assays for direct analysis of samples, molecular genetics techniques and genomic sequencing for direct identification of the virus, and assays that can identify multiple viruses (multiplex) and be automated. Often, isolation of the organism is unnecessary and avoided to minimize the risk to laboratory and other personnel. The quicker turnaround allows a more rapid choice of the appropriate antiviral therapy. Viral laboratory studies are performed to (1) confirm the diagnosis by identifying the viral agent of infection, (2) determine appropriate antimicrobial therapy, (3) check on the compliance of the patient taking antiviral drugs, (4) define the course of the disease, (5) monitor the disease epidemiologically, and (6) educate physicians and patients. Specimens should be collected early in the acute phase of infection, before the virus ceases to be shed. For example, respiratory viruses may be shed for only 3 to 7 days, and shedding may lapse before the symptoms cease. In addition, antibody produced in response to the infection may block the detection of virus. The shorter the interval between the collection of a specimen and its delivery to the laboratory, the greater the potential for isolating a virus. The reasons are that many viruses are labile, and the samples are susceptible to bacterial and fungal overgrowth. Viruses are best transported and stored on ice and in special media that contain antibiotics and proteins, such as serum albumin or gelatin. Syncytia are multinucleated giant cells formed by viral fusion of individual cells. Inclusion bodies are either histologic changes in the cells caused by viral components or virus-induced changes in cell structures. Rabies may be detected through the finding of cytoplasmic Negri bodies (rabies virus inclusions) in brain tissue (Figure 39-3). Selection of the appropriate specimen for analysis is often complicated because several viruses may cause the same clinical disease. These tests are specific for individual viruses and must be chosen based on the differential diagnosis. The addition of virus-specific antibody to a sample can cause viral particles to clump, thereby facilitating the detection and simultaneous identification of the virus (immunoelectron microscopy). Appropriately processed tissue from a biopsy or clinical specimen can also be examined for the presence of viral structures. A virus can be grown in tissue culture, embryonated eggs, and experimental animals (Box 39-2). Although embryonated eggs are still used for the growth of virus for some vaccines. Experimental animals are rarely used in clinical laboratories for the purpose of isolating viruses. Primary cell cultures are obtained by dissociating specific animal organs with trypsin or collagenase. The cells obtained by this method are then grown as monolayers (fibroblast or epithelial) or in suspension (lymphocyte) in artificial media supplemented with bovine serum or another source of growth factors. Primary cells can be dissociated with trypsin, diluted, and allowed to grow into new monolayers (passed) to become secondary cell cultures.
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This approach is also useful in examining material from sputum, urine, vaginal swabs, duodenal aspirates, sigmoidoscopy, abscesses, and tissue biopsies. Concentration All fecal specimens should be placed in 10% formalin to preserve parasite morphology and should be concentrated using a procedure such as formalin ethyl acetate (or formalin ether) sedimentation or zinc sulfate flotation. These methods separate protozoan cysts and helminth eggs from the bulk of fecal material and thus enhance the ability to detect small numbers of organisms usually missed by the use of only a direct smear. After concentration, the material is stained with iodine and examined microscopically. Permanently Stained Slides Detection and correct identification of intestinal protozoa often depend on examination of the permanently stained smear. The cytologic detail revealed by one of the permanent staining methods is essential for accurate identification, and most identification should be considered tentative until confirmed by the permanently stained slide. It should be noted that an order for a routine microscopic examination of stool for O&P does not necessarily include special stains required to detect organisms such as Cryptosporidium or Cyclospora. It has become apparent that in the United States, submission of stool for parasitologic examination from patients with hospital-acquired diarrhea (onset > 3 days after admission) is usually inappropriate. This is because the frequency of acquisition of protozoan or helminthic parasites in a hospital is vanishingly rare. A request for stool examination for O&P in a hospitalized patient should be accompanied by a clear statement of clinical indications and only after the more common causes of hospital-acquired diarrhea. Collection and Examination of Specimens Other Than Stool Frequently, specimens other than fecal material must be collected and examined to diagnose infections caused by intestinal pathogens. These specimens include perianal samples, sigmoidoscopic material, aspirates of duodenal contents, and liver abscess, sputum, urine, and urogenital specimens. Techniques of Stool Examination Specimens should be examined systematically by a competent microscopist for helminth eggs and larvae as well as intestinal protozoa. For optimal detection of these various Perianal Specimens Collection of perianal specimens is frequently necessary to diagnose pinworm (E. Cellulose tape slide preparation is the method of choice for detection of pinworm eggs. Specimens collected by either method should be obtained in the morning before the patient bathes or goes to the bathroom. The tape method requires that the adhesive surface of the tape be pressed firmly against the right and left perianal folds and then spread onto the surface of a microscope slide. Likewise, the anal swab should be rubbed gently over the perianal area and transported to the laboratory for microscopic examination. Microscopic examination should include saline wet-mount and permanently stained preparations. Urine Examination of urine specimens may be useful in diagnosing infections caused by Schistosoma haematobium (occasionally other species as well) and Trichomonas vaginalis. Detection of eggs in urine can be accomplished using direct detection or concentration using the sedimentation centrifugation technique. Eggs may be trapped in mucus or pus and are more frequently present in the last few drops of the specimen rather than the first portion. The production of Schistosoma eggs fluctuates; therefore examinations should be performed over several days. Sigmoidoscopic Material Material from sigmoidoscopy can be helpful in the diagnosis of E. Identification is based on wet-mount preparation examinations of vaginal and urethral discharges, prostatic secretions, or urine sediment. Duodenal Aspirates Sampling and examination of duodenal contents is a means of recovering Strongyloides larvae; the eggs of Clonorchis, Opisthorchis, and Fasciola species; and other small bowel parasites such as Giardia, Cystoisospora, and Cryptosporidium organisms. Specimens may be obtained by endoscopic intubation or by use of the enteric capsule or string test (Entero-Test).
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In general, people at risk for tick exposure are involved in outdoor activities in wooded areas. Tick exposure may also occur during stays in rural cabins inhabited by small rodents, which commonly serve as hosts for ticks and other ectoparasites. Ticks Physiology and Structure Ticks are bloodsucking ectoparasites of a number of vertebrates, including humans. Ticks are opportunistic rather than host specific and tend to suck blood from a number of large and small animals. Although the larva, nymph, and adult are all bloodsuckers, it is the adult tick that usually bites humans. Ticks comprise two large families, the Ixodidae, or hard ticks, and the Argasidae, or soft ticks. Soft ticks have a leathery body that lacks a hard dorsal scutum, and the mouthparts are located ventrally and not visible from above (Figure 78-6). Hard ticks have a hard dorsal plate or scutum, and the mouthparts are clearly visible from above (Figure 78-7). Soft ticks complete engorgement in a matter of Clinical Syndromes Tick bites are generally of minor consequence and are limited to small erythematous papules. More serious consequences of tick bite include the development of a type of paralysis resulting from substances released by ticks during feeding and transmission of a number of rickettsial, bacterial, viral, spirochetal, and protozoan diseases of humans and other animals. Ticks may attach at any point on the body but typically favor the scalp, hairline, ears, axillae, and groin. The initial bite is usually painless, and the presence of the tick may not be detected for several hours after contact. After the tick has dropped off or has been removed manually, the area may become reddened, painful, and pruritic. Biopsy of the cutaneous lesion revealed a histopathologic pattern consistent with an infectious pathogenesis. African tick bite fever is an illness caused by Rickettsia africae that has recently emerged as a significant disease among international travelers. Because ticks may harbor highly infectious agents, the clinician should use appropriate infection-control precautions. Unless the tick is removed, quadriplegia and respiratory paralysis may ensue; the case fatality rate without tick removal approaches 10%. Preventive measures used in tick-infested areas include wearing protective clothing that fits snugly about the ankles, wrists, waist, and neck so that ticks cannot gain access to the skin. People and pets should be inspected for ticks after visits to tick-infested areas. It should be noted that upon removal of the tick, the mouthparts often remain imbedded in the skin. Removal of the mouthparts is not critical; they will either be walled off as a foreign body or be worked out in the process of scratching. This is characterized by an ascending flaccid paralysis, fever, and general intoxication, which may lead to respiratory compromise and death. The paralysis is due to toxic substances released in the saliva of the tick and may be reversed by tick removal. Tick paralysis is observed more commonly in young children and when tick attachment is in opposition to the central nervous system. Ticks are also involved in the transmission of infections such as Lyme disease, Rocky Mountain spotted fever, ehrlichiosis, Colorado tick fever, relapsing fever, tularemia, Q fever, and babesiosis (Clinical Case 78-2; see also Table 78-2). The reader is referred to the appropriate sections of this book for discussion of the clinical and microbiological aspects of these infections. Insects include mosquitoes, flies, fleas, lice, roaches, bees, wasps, beetles, and moths, to name just a few. The insect body is divided into three parts-head, thorax, and abdomen-and is equipped with one pair of antennae, three pairs of appendages, and one or two pairs of wings or no wings at all. The medical significance of any insect is related to its way of life, particularly its mouthparts and feeding habits. Insects may serve as vectors for a number of bacterial, viral, protozoan, and metazoan pathogens. Certain insects may serve merely as mechanical vectors for the transmission of pathogens, whereas in other insects, the pathogens undergo multiplication or cyclic development within the insect host.
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In vitro assays are safe, specific, cost-effective, and reproducible, and do not require the patient to be free of antihistamines and other medications that may interfere with skin testing. They are also easy and quick and are therefore preferred, especially in children and in anxious patients. The newer assays tend to be faster, more reliable, and more efficient than previous tests. Typical findings in the nose in patients with seasonal allergic rhinitis include bluish, pale, boggy turbinates; wet, swollen mucosa; and nasal congestion with nasal obstruction. With perennial allergies, nasal congestion is the predominant sign, but the nasal examination may appear normal. Anatomic abnormalities, such as a deviated nasal septum, concha bullosa, and nasal polyps, may be present. Other possible physical findings include conjunctivitis, eczema, and, possibly, asthmatic wheezing. If the screening battery is positive and if no immunotherapy is considered, additional allergy testing can be performed. Methods of minimizing exposure to pollen are to avoid outdoor activities during relevant pollen seasons (eg, mowing the lawn and gardening), to keep home and car windows closed, and to use air conditioning when possible. Differential Diagnosis the differential diagnoses of allergic rhinitis include the following: (1) infectious rhinitis (acute or chronic); (2) perennial nonallergic rhinitis (eg, vasomotor rhinitis); (3) pollutants and irritants; (4) hormonal rhinitis (eg, pregnancy or hypothyroidism); (5) medication-induced topical rhinitis (rhinitis medicamentosa); (6) anatomic deformity (eg, a deviated septum, nasal polyps, or a concha bullosa); and (7) tumors or foreign bodies. Antihistamines-Antihistamines are frequently used as a first-line therapy; many are available without a prescription. They block H1 receptor sites and prevent histamine-induced reactions, including inhibiting increased vascular permeability, smooth muscle contraction, increased mucus production, and pruritus. Antihistamines also inhibit the "wheal and flare" response of the skin and therefore they affect skin test- Treatment the appropriate management of these common respiratory diseases differs substantially, particularly when allergy is a contributing component. In general, three options are available for the management of allergic rhinitis: (1) avoidance and environmental controls, (2) pharmacotherapy, and (3) immunotherapy. Antihistamines are effective in early-phase reaction and therefore reduce sneezing, rhinorrhea, and itching. Nonprescription, first-generation antihistamines can cause sedation and impair performance and have been associated with a higher risk of both automobile and work-related accidents, decreased work performance and productivity, and impaired learning and academic performance. These side effects can be significantly exacerbated by alcohol, sedatives, antidepressants, and hypnotics. These include diphenhydramine (eg, Benadryl), hydroxyzine (eg, Atarax), chlorpheniramine, and brompheniramine. Second-generation antihistamines have an antihistamine activity comparable to that of first-generation antihistamines but have a better safety profile with little, if any, sedation as they have little affinity for central H1 receptors. They have no anticholinergic activity and are well absorbed, with a rapid onset of action and symptom relief usually within 1 hour. Second-generation antihistamines are typically dosed once daily and are rarely associated with drug tolerance with prolonged use. Those available orally in the United States are fexofenadine (eg, Allegra), loratadine (eg, Claritin), desloratadine (eg, Clarinex), and cetirizine (eg, Zyrtec). A second-generation intranasal antihistamine, azelastine (eg, Astelin), is also available. Intranasal corticosteroids-Intranasal corticosteroids may be the most effective medications for the overall control of allergic rhinitis symptoms. They act on the late-phase reaction and therefore prevent a significant influx of inflammatory cells. The newer formulations (mentioned below) have minimal systemic absorption with no systemic side effects, and they have been approved for use in children. In young adults and children, they are considered the drugs of choice in the treatment of allergic rhinitis.