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By W. Dargoth. Empire State College.
Andre Maurois – Lancet : () French writer While there are several chronic diseases more Growing old is a bad habit which a busy man has destructive to life than cancer cheap quibron-t 400mg line, none is more no time to form discount 400 mg quibron-t with amex. The Aging American Annals of Surgery : () Yet had Fleming not possessed immense knowledge and an unremitting gift of observation There are two objects of medical education: To he might not have observed the effect of the heal the sick, and to advance the science. Collected Papers of the Mayo Clinic and Mayo Foundation : () Life of Alexander Fleming I knew a man who had been virtually drowned The scientist is not content to stop at the and then revived. Collected Papers of the Mayo Clinic and Mayo Foundation : () Attributed I have never known a man who died from Gavin Maxwell – overwork, but many who died from doubt. British writer and naturalist Bartlett’s Unfamiliar Quotations Then it came again, thunderous, earthshaking, The safest thing for a patient is to be in the hands the longest, loudest and most superbly of a man engaged in teaching medicine. In order stupendous fart that I have ever heard in to be a teacher of medicine the doctor must my life, a sound of such magnificent and always be a student. Longmans, Harlow () Medicine is a profession for social service and it developed organisation in response to social Tom G. The The object of health education is to change the musculature involved in spinal movement and conduct of individual men, women and children control is in turn the largest complex of skeletal by teaching them to care for their bodies well, and muscles in the body. Journal of the American Medical Association : () The custom of giving patients appointments weeks in advance, during which time their illness Experience is the great teacher; unfortunately, may become seriously aggravated, seems to me to experience leaves mental scars, and scar tissue fall short of the ideal doctor–patient relationship. Daedalus : () Journal of the American Medical Association : () The most conspicuous change in the behaviour of Medical science aims at the truth and nothing but the doctor is that nowadays he is usually in such the truth. Daedalus : () The aim of medicine is to prevent disease and prolong life, the ideal of medicine is to eliminate So much of the diagnostic process is now done the need of a physician. Cannon) The surgeon is often intolerant and the internist Sir Peter Medawar – self sufficient. British scientist and Nobel laureate Surgery, Gynecology and Obstetrics : () Science without the underpinning of hypotheses The glory of medicine is that it is constantly is just kitchen arts. He does not realise that, instead of conceiving National Education Association: Addresses and Proceedings : () him, his parents might have conceived any one of a hundred thousand other children, all unlike Truth is a constant variable. Medieval maxim Annals of Surgery : () In the presence of the patient, Latin is the The church and the law deal with the yesterdays language. An expert is someone who is more than fifty miles Collected Papers of the Mayo Clinic and Mayo Foundation from home, has no responsibility for implementing : () the advice he gives, and shows slides. I think all of us who have worked years in the Penguin Dictionary of Modern Humorous Quotations p. Penguin Books, London () profession understand that many very skilful operators are not good surgeons. Quoted in The Doctors Mayo (Helen Clapesattle) Attributed · Giles Ménage – C. British comedian and writer Dis Exapaton Contraceptives should be used on every H. PrejudicesTypes of Men Attributed George Meredith – But pain is perfect misery, the worst of evils, and English novelist and poet excessive, overturns all patience. Attributed In Physic, things of melancholic hue and quality are used against melancholy, sour against sour, Ilya Metchnikoff – salt to remove salt humours. Russian biologist Samson Agonistes Preface Already it is complained that the burden of The fever is to the physicians, the eternal supporting old people is too heavy, and statesmen reproach. Chalmers Mitchell) ‘Minerva’ Contemporary British medical columnist Alan Milburn – British Secretary of State for Health ‒ A good physician appreciates the difference between postponing death and prolonging the act Medicine is not a perfect science. Bartholomew’s Hospital, Association London Practically the only opposition to effective medical legislation in the country comes from the If there is any doubt as to whether a person is or is profession itself. Weir Mitchell – Since dim antiquity the people have believed American neurophysician and author surgeons to be thieves, murderers and the worst kind of tricksters. Flammarion, Paris () Bulletin of the New York Academy of Medicine : () Surgery cures diseases that cannot be cured by Do not think of the dignity of your profession or any other means, not by themselves, not by what it is beneath you to do. Garrison, Bulletin of the New York cures a disease so evidently that one could say Academy of Medicine October: – () that the cure is due to medicine. Treatise on Surgery Ever since the Crimean War, nurses have been getting into novels. Garrison, Bulletin of the New York Academy of Medicine October: – () – English writer and traveller and importer of smallpox I can remember when older physicians refused to inoculation from the Middle East recognise socially a man who devoted himself to the eye alone. Garrison, Bulletin of the New York here rendered entirely harmless by the invention of Academy of Medicine October: – () ingrafting. They take the smallpox here by way of diversion, as they take the waters in other countries. The true rate of advance in medicine is not to be Letter from Adrianople 1 April (1717) tested by the work of single men, but by the practical capacity of the mass.
Adverse effects (1) Chloramphenicol causes dose-related bone marrow suppression buy discount quibron-t 400mg online, resulting in pancyto- penia that may lead to irreversible aplastic anemia buy discount quibron-t 400mg line. Also, chloramphenicol causes hemolytic anemia in patients with low levels of glucose 6-phosphate dehydrogenase. This syn- drome results from the inadequacy of both cytochrome P-450 and glucuronic acid con- jugation systems to detoxify the drug. Elevated plasma chloramphenicol levels cause a shocklike syndrome and a reduction in peripheral circulation; the incidence of fatalities is high (40%). Erythromycin, clarithromycin (Biaxin), azithromycin (Zithromax), telithromycin (Ketek) a. It is due primarily to increased active efflux or ribosomal protection by increased methylase production. Pharmacologic properties (1) Erythromycin is inactivated by stomach acid and is therefore administered as an enteric-coated tablet. Use of clindamycin is limited to alternative therapy for abscesses associated with infections caused by anaerobes, such as B. It is used in dental patients with valvular heart dis- ease for prophylaxis of endocarditis. Potential severe pseudomembranous colitis occurs as a result of superinfection by resistant clostridia. Sulfonamides: sulfadoxine/pyrimethamine (Fansidar), sulfisoxazole, sulfadiazine, silver sulfa- diazine (Silvadene), sulfasalazine (Azaline, Azulfidine), trimethoprim (Proloprim), and trime- thoprim/sulfamethoxazole (Bactrim, Septra) a. Spectrum and therapeutic uses (1) Sulfonamides inhibit both gram-negative and gram-positive organisms. The combination is used in the treatment of malaria caused by chloroquine-resistant Plasmodium falciparum. Adverse effects (1) Sulfonamides produce hypersensitivity reactions (rashes, fever, eosinophilia) in approx- imately 3% of individuals receiving oral doses. It is used in combination with other drugs for the treatment of most atypical mycobacteria, including M. Adverse effects of rifampin include nausea and vomiting, dermatitis, and red-orange discol- oration of feces, urine, tears, and sweat. Rifampin induces liver microsomal enzymes and enhances the metabolism of other drugs such as anticoagulants, contraceptives, and corticosteroids. Fluoroquinolones (1) These agents, ciprofloxacin (Cipro), norfloxacin (Noroxin), ofloxacin (Floxin), levoflox- acin (Levaquin), moxifloxacin (Avelox), lomefloxacin (Maxaquin), and gemifloxacin (Factive), are fluorinated analogs of nalidixic acid (NegGram), which is now used infrequently. Moxifloxacin and gemifloxacin have even greater activity against gram-positive organisms. These agents are useful against urinary tract infections and against infections caused by Chapter 11 Drugs Used in Treatment of Infectious Diseases 265 N. Cartilage toxic- ity has been reported, and thus these agents should not be used in children and young adults. Polymyxin is a cationic basic polypeptide that acts as a detergent to disrupt the cell membrane functions of gram-negative bacteria (bactericidal). Polymyxin has substantial nephrotoxicity and neurotoxicity and is therefore only for ophthal- mic, otic, or topical use. Polymyxin B often is applied as a topical ointment in mixture with bacitracin or neomycin, or both (Neosporin). Metronidazole, a prodrug, is bactericidal against most anaerobic bacteria, as well as other organisms, including anaerobic protozoal parasites. Daptomycin (Cubicin) is a very powerful cyclic lipopeptide bactericidal agent that has a spec- trum of activity similar to vancomycin. Myelosuppression and pseudomembranous colitis can occur with the use of this agent. The streptogranins bind the 50S ribosomal subunit and are bactericidal for most organisms. Trimethoprim/sulfamethoxazole, ampicillin, or third-generation cephalosporin Erythromycin Legionella spp. Hepa- totoxicity with jaundice is observed in up to 3% of individuals over age 35. High serum concentrations of this agent may result in peripheral neuropathy; slow acetylators are more susceptible. Structure and mechanism of action (1) Rifampin is a semisynthetic derivative of the antibiotic rifamycin. Resistance, a change in affinity of the polymerase, develops rapidly when the drug is used alone. It enters enterohepatic circulation and induces hepatic mi- crosomes to decrease the half-lives of other drugs, such as anticonvulsants. Structure and mechanism of action (1) Ethambutol inhibits arabinosyl transferases involved in cell wall biosynthesis. Ethambutol is administered orally in combination with isoniazid to avoid development of resistance.
Certain categories of patients justify specific m ention: • O bese patients m ay be especially resistant to cardioversion from the external route but not necessarily using electrodes positioned w ithin the heart order quibron-t 400mg with amex. If cardioverted their propensity to atrial fibrillation rem ains and they are likely to relapse 400mg quibron-t. A long-term follow -up study of patients w ith post-thyrotoxic atrial fibrillation. Prediction of uneventful cardioversion and m aintenance of sinus rhythm from direct current electrical cardioversion of chronic atrial fibrillation and flutter. The risks include those relating to an, albeit brief, general anaesthetic w hich w ill reflect the overall health of the patient, and those relating to the application of synchronised direct current shock. The latter include the developm ent of bradyarrhythm ias (m ore likely in the presence of heavy beta blockade and especially w here there is concom itant use of calcium channel antagonists) and tachyarrhythm ias (m ore likely in the presence of deranged biochem istry including low serum K+ or M g++, and high levels of serum digoxin). These dysrhythm ias m ay necessitate em ergency pacing or further cardioversion and full resuscitation. Elective cardioversion of adequately assessed patients should only be undertaken by appropriately trained staff in an area w here full resuscitation facilities are available. Failure to observe these guidelines w ill likely result in higher com plication rates w hich on occasion includes death. There have been no random ised trials of anticoagulation but there is convincing circum stantial evidence that anti- coagulation reduces the risk of cardioversion-related throm bo- em bolism from figures in the order of 7% to less than 1% : anticoagulation does not appear to abolish the risk and this should be m ade explicit w hen inform ed consent is obtained from a patient. Suzanna Hardman and Martin Cowie Although com m on clinical practice and guidelines do not advocate routine anticoagulation of patients w ith atrial flutter undergoing cardioversion, there are no data to support this practice. Rather, recent studies suggest the prevalence of intra- atrial throm bus in unselected patients w ith atrial flutter is significant and of the order of 30–35% (com pared w ith 3% preva- lence in a control population in sinus rhythm ). The atrial stand- still (or stunning) that has been described post-cardioversion of atrial fibrillation and is thought to be a factor in the associated throm boem bolic risk has also now been described im m ediately post-cardioversion of patients w ith atrial flutter. Although som e authors argue that the stunning post-cardioversion of atrial flutter is “attenuated” com pared w ith the response in atrial fibrillation, the throm boem bolic rate associated w ith cardioversion of atrial flutter in the absence of anticoagulation argues against this. Indeed, the throm boem bolic rate appears to be com parable w ith the early experience of cardioverting atrial fibrillation. Furtherm ore, atrial flutter is an intrinsically unstable rhythm w hich m ay degenerate into atrial fibrillation and certain patients alternate betw een atrial fibrillation and atrial flutter. Like atrial fibrillation, atrial flutter m ay be the first m anifestation of underlying heart disease and it is likely, though not yet proven, that the throm boem bolic risks associated w ith both chronic atrial flutter and w ith cardioversion of atrial flutter vary w ith the extent of underlying cardiovascular pathology. Although existing data are lim ited, on current evidence w e advise that patients w ith atrial flutter should be anticoagulated prior to, during and post- cardioversion, in the sam e w ay as patients w ith atrial fibrillation. Prevalence of throm bus, spontaneous echo contrast, and atrial stunning in patients undergoing cardioversion 148 100 Questions in Cardiology of atrial flutter. Delayed restoration of atrial function after cardioversion of atrial flutter by pacing or electrical cardioversion. If the patient is aged less than 60 years, and has no evidence of other cardiac disease (such as coronary artery disease, valve disease or heart failure) the risk of throm bo- em bolism is low (of the order of 0. This risk is low er than the risk of a serious bleed if the patient is anticoagulated w ith w arfarin (1. If the patient is older than the 60 years, or has evidence of other cardiovascular disease, the risk of throm boem bolism increases. In the Stroke Prevention in Atrial Fibrillation Study clinical features indicating a higher risk of throm boem bolism w ere: age over 60 years; history of congestive heart failure w ithin the previous 3 m onths; hypertension (treated or untreated); and previous throm boem bolism. The m ore of these features present in a patient the higher the risk of throm boem bolism. Paroxysm al (as opposed to chronic) atrial fibrillation covers a w ide spectrum of disease severity w ith the duration and frequency of attacks varying m arkedly betw een and w ithin patients. Although the clinical trials of anticoagulation in patients w ith atrial fibrillation w ere inconsistent in including patients w ith paroxysm al atrial fibrillation, there w as no evidence that such patients had a low er risk of throm boem bolism than those w ith chronic atrial fibrillation. It is likely that as the episodes becom e m ore frequent and of longer duration that the risk approaches those in patients w ith chronic atrial fibrillation. Suzanna Hardman and Martin Cowie The ability of echocardiography to detect left atrial clot is determ ined by the sophistication of the equipm ent, the ease w ith w hich the left atrium and left atrial appendage can be scanned and the skill and experience of the operator. Historically, at best, the sensitivity of tw o dim ensional transthoracic echo- cardiography for detecting left atrial throm bus has been of the order of 40–65% , w ith the left atrial appendage visualised in under 20% of patients even in experienced hands. This com pared w ith a reported sensitivity of 75–95% for visualising left ventricular throm bi from the transthoracic approach. M ore recent data, from a tertiary referral centre using the new gener- ation transthoracic echocardiography, suggest the left atrial appendage can be adequately im aged in 75% of patients and that w ithin this group 91% of throm bi identified by trans- oesophageal echocardiography w ill also be visualised from the transthoracic approach. Although encouraging, the extent to w hich these figures can be reproduced using sim ilar equipm ent by the generality of units rem ains to be established. Available data for the sensitivity of transoesophageal echo- cardiography in detecting left atrial and left atrial appendage throm bus consistently report a high positive predictive value.
The presence of a hemorrhagic rash is somewhat helpful in narrowing the differential to arboviral generic 400 mg quibron-t with amex, rickettsial generic 400mg quibron-t visa, and meningococcal etiologies but even this is not completely reliable. Rickettsial diseases are usually in the differential for critically ill patients with fever and rash. There has been increasing recognition of rickettsial infections as etiologies of serious travel-associated infections (144,145). Scrub typhus has reported case fatality rates in indigenous populations of 15% and rarely has caused life- threatening disease in returning travelers (150). These reports highlight the importance of including rickettsial agents in the differential diagnosis and consideration of empiric therapy with doxycycline. Rapid responses to doxycycline therapy within 24 hours support the diagnosis and the lack of response should prompt alternative diagnoses. Sexually transmitted diseases such as secondary syphilis, disseminated gonococcal infection, or acute retroviral syndrome may rarely present in this manner and need consideration. Measles has significant morbidity with the most common complication, pneumonitis, resulting in mortality rates of 2% to 15% in children and <1% in adults (151,152). A study of hospitalized adults with complications of typical measles revealed pneumonitis rates of approximately 50% with respiratory failure and mechanical ventilation in 18% (153). Dengue fever is, by far, the most common arboviral etiology of nonspecific febrile illness in returning travelers (126,154,155). In West Africa, Lassa fever is endemic, causing 100,000–300,000 human infections and approximately 5000 deaths each year (158). To date, approximately 20 cases of imported Lassa fever have been reported worldwide with one death in the United States in 2004 after travel to West Africa (158). These viruses have distinct geographic distributions, variable case fatality rates, and potential therapeutic options as detailed on Table 3. Nosocomial transmission has been documented for each of these agents and is primarily transmitted through direct contact or aerosolization of blood or body fluids from often terminally ill infected patients (157,162). Consideration should also be given to postexposure Tropical Infections in Critical Care 333 334 Wood-Morris et al. The practice of travel medicine: guidelines by the Infectious Disease Society of America. Spectrum of disease and relation to place of exposure among ill returned travelers. Mortality from Plasmodium falciparum malaria in travelers from the United States, 1959 to 1987. Conquering the intolerable burden of malaria: what’s new, what’s needed: a summary. Treatment of severe malaria in the United States with a continuous infusion of quinidine gluconate and exchange transfusion. Artesunate versus quinine for treatment of severe falciparum malaria: a randomized trial. New medication for severe malaria available under an investigational new drug protocol. Exchange transfusion as an adjunct to the treatment of severe falciparum malaria: case report and review. Exchange transfusion as an adjunct therapy in severe Plasmodium falciparum malaria: a meta-analysis. Hemofiltration and peritoneal dialysis in infection-associated acute renal failure in Vietnam. The clinical spectrum of severe imported falciparum malaria in the intensive care unit: report of 188 cases in adults. Respiratory tract infections in travelers: a review of the GeoSentinel Surveillance Network. Risk of infection with Mycobacterium tuberculosis in travelers to areas of high tuberculosis endemicity. Miliary tuberculosis: epidemiology, clinical manifestations, diagnosis, and outcome. Miliary tuberculosis: rapid diagnosis, hematologic abnormalities, and outcome in 109 treated adults. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities. Retreatment tuberculosis cases* factors associated with drug resistance and adverse outcomes. Outbreak of Legionnaires’ disease among cruise ship passengers exposed to a contaminated whirlpool spa. Prevalence and diagnosis of Legionella pneumonia: a 3-year prospective study with emphasis on application of urinary antigen detection. Clinical features that differentiate hantavirus pulmonary syndrome from three other acute respiratory illnesses. Discriminators between hantavirus-infected and -uninfected persons enrolled in a trial of intravenous ribavirin for presumptive hantavirus pulmonary syndrome.