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By H. Frillock. Metropolitan State College of Denver.

No tolerance develops to anxiolytic effects order generic ivermectin pills, and tolerance to hypnotic effects is generally low buy ivermectin 3mg with visa. Physical Dependence Benzodiazepines can cause physical dependence—but the incidence of substantial dependence is low order ivermectin once a day. When benzodiazepines are discontinued after short-term use at therapeutic doses, the resulting withdrawal syndrome is generally mild and often goes unrecognized. Withdrawal from long-term, high- dose therapy can cause more serious reactions, such as panic, paranoia, delirium, hypertension, muscle twitches, and seizures. Symptoms of withdrawal are usually more intense with benzodiazepines that have a short duration of action. Because the benzodiazepine withdrawal syndrome can resemble an anxiety disorder, it is important to differentiate withdrawal symptoms from the return of the original symptoms of anxiety. The intensity of withdrawal symptoms can be minimized by discontinuing treatment gradually. Substituting a benzodiazepine with a long half-life for one with a short half-life is also helpful. After discontinuation of treatment, patients should be monitored for 3 weeks for indications of withdrawal or recurrence of original symptoms. Acute Toxicity Oral Overdose When administered in excessive dosage by mouth, benzodiazepines rarely cause serious toxicity. If an individual known to have taken an overdose of benzodiazepines does exhibit signs of serious toxicity, it is probable that another drug was taken, too. Preparations, Dosage, and Administration Preparations and dosages for insomnia are presented later in the chapter. Preparations and dosages of benzodiazepines used for other disorders are presented in Chapters 19, 20, and 28. When used for sedation or induction of sleep, benzodiazepines are almost always administered by mouth. Oral Patients should be advised to take oral benzodiazepines with food if gastric upset occurs. Also, they should be instructed to swallow sustained-release formulations intact, without crushing or chewing. Patients should be warned not to increase the dosage or discontinue therapy without consulting the prescriber. For treatment of insomnia, benzodiazepines should be given on an intermittent schedule (e. P ro t o t y p e D r u g s Sedative-Hypnotic Drugs Benzodiazepine Triazolam Benzodiazepine-Like Drugs Zolpidem Zaleplon Barbiturate Secobarbital Melatonin Receptor Agonist Ramelteon Benzodiazepine-Like Drugs Three benzodiazepine-like drugs are available: zolpidem, zaleplon, and eszopiclone. However, although approval is limited to short-term use, many patients have taken the drug long term with no apparent tolerance or increase in adverse effects. All zolpidem formulations have a rapid onset and hence can help people who have difficulty falling asleep. Like the benzodiazepines, zolpidem can reduce sleep latency and awakenings and can prolong sleep duration. Rather, binding is limited to the benzodiazepine-1 subtype of benzodiazepine receptors. Zolpidem is extensively metabolized to inactive compounds that are excreted in the bile, urine, and feces. Daytime drowsiness and dizziness are most common, and these occur in only 1% to 2% of patients. Like the benzodiazepines, zolpidem has been associated with sleep driving and other sleep-related complex behaviors. Short-term treatment is not associated with significant tolerance or physical dependence. Zaleplon Zaleplon [Sonata] is the first representative of a new class of hypnotics, the pyrazolopyrimidines. The drug is approved only for short-term management of insomnia, but prolonged use does not appear to cause tolerance. In contrast to zolpidem, zaleplon has a very rapid onset and short duration of action and hence is good for helping patients fall asleep, but not for maintaining sleep. Plasma levels peak about 1 hour after administration and then rapidly decline, returning to baseline in 4 to 5 hours. Zaleplon is metabolized by hepatic aldehyde oxidase before excretion in the urine. The most common side effects are headache, nausea, drowsiness, dizziness, myalgia, and abdominal pain. Like the benzodiazepines, zaleplon has been associated with rare cases of sleep driving and other complex sleep-related behaviors. Physical dependence is minimum, the only sign being mild rebound insomnia the first night after drug withdrawal. Eszopiclone is approved for treating insomnia, with no limitation on how long it can be used. This contrasts with zaleplon and zolpidem, which are approved for short-term use only. Does this mean that eszopiclone is safer than the other two drugs, or less likely to promote tolerance? It only means that the manufacturer of eszopiclone conducted a prolonged (6-month) study, whereas the manufacturers of the other two drugs did not. In that prolonged study, eszopiclone reduced sleep latency and nighttime awakening, increased total sleep time and sleep quality, had no significant effect on sleep architecture, and showed no indication of tolerance. Eszopiclone is rapidly absorbed after oral dosing, reaching peak blood levels in 1 to 2 hours. The most common adverse effect is a bitter aftertaste, reported by 17% of patients dosed with 2 mg and 34% of those dosed with 3 mg. Like the benzodiazepines and the other benzodiazepine- like drugs, eszopiclone has been associated with cases of sleep driving and other sleep-related complex behaviors. Ramelteon: A Melatonin Agonist Ramelteon [Rozerem] is a relatively new hypnotic with a unique mechanism of action: activation of receptors for melatonin. The drug is approved for treating chronic insomnia characterized by difficulty with sleep onset, but not with sleep maintenance. Of the major drugs for insomnia, ramelteon is the only one not regulated as a controlled substance. Therapeutic Use Ramelteon has a rapid onset (about 30 minutes) and short duration and hence is good for inducing sleep but not maintaining sleep. Nor is there any rebound insomnia when treatment is stopped after 35 consecutive nights of use. Pharmacokinetics Absorption is rapid and nearly complete, although food can reduce both the rate and extent of absorption. Despite generally good absorption, the absolute bioavailability of ramelteon is very low—only 1. In patients with hepatic impairment, elimination is delayed and drug levels can rise. In clinical trials, the incidence of adverse effects was nearly identical to that of placebo.

Because of concerns about tendon injury (see later) ivermectin 3 mg free shipping, systemic ciprofloxacin is generally avoided in children younger than 18 years generic ivermectin 3mg on-line. Nonetheless generic 3 mg ivermectin with amex, the drug does have two approved pediatric uses: (1) treatment of complicated urinary tract and kidney infections caused by E. In older adults, ciprofloxacin poses a significant risk for confusion, somnolence, psychosis, and visual disturbances. Because of concerns regarding tendon injury, fluoroquinolones are generally avoided in this population. Pregnant women Although data reveal little potential for fluoroquinolone toxicity in the fetus, these data are limited. Breast-feeding Effects of fluoroquinolones on the nursing infant are largely unknown. B l a c k B o x Wa r n i n g : F l u ro q u i n a l o n e s a n d The n d o n R u p t u re Rarely, ciprofloxacin and other fluoroquinolones have caused tendon rupture, usually of the Achilles tendon. People at highest risk are those 60 years and older, those taking glucocorticoids, and those who have undergone heart, lung, or kidney transplantation. Fluoroquinolones damage tendons by disrupting the extracellular matrix of cartilage in immature animals. Because tendon injury is reversible if diagnosed early, fluoroquinolones should be discontinued at the first sign of tendon pain, swelling, or inflammation. In addition, patients should refrain from exercise until tendinitis has been ruled out. Although there are no controlled studies on the use of ciprofloxacin during pregnancy or lactation, limited data indicate that such use poses little or no risk for tendon damage to either the fetus or nursing infant. Because of the relative lack of data, alternative drugs should be given if possible. Ciprofloxacin and other fluoroquinolones pose a risk for phototoxicity (severe sunburn), characterized by burning, erythema, exudation, vesicles, blistering, and edema. These can occur after exposure to direct sunlight, indirect sunlight, and sunlamps—even if a sunscreen has been applied. Patients should be warned about phototoxicity and advised to avoid sunlight and sunlamps. People who must go outdoors should wear protective clothing and apply a sunscreen. B l a c k B o x Wa r n i n g : C i p ro f l o x a c i n a n d M y a s t h e n i a G r a v i s Ciprofloxacin and other fluoroquinolones can exacerbate muscle weakness in patients with myasthenia gravis. Accordingly, patients with a history of myasthenia gravis should not receive these drugs. Drug and Food Interactions Cationic Compounds Absorption of ciprofloxacin can be reduced by compounds that contain cations. Among these are (1) aluminum- or magnesium-containing antacids, (2) iron salts, (3) zinc salts, (4) sucralfate, (5) calcium supplements, and (6) milk and other dairy products, all of which contain calcium ions. These cationic agents should be administered at least 6 hours before ciprofloxacin or 2 hours after. Elevation of Drug Levels Ciprofloxacin can increase plasma levels of several drugs, including theophylline (used for asthma), warfarin (an anticoagulant), and tinidazole (an antifungal drug). For patients taking theophylline, drug levels should be monitored and the dosage adjusted accordingly. For patients taking warfarin, prothrombin time should be monitored and the dosage of warfarin reduced as appropriate. Ciprofloxacin is used to reduce the incidence of anthrax or prevent anthrax progression in people who have inhaled B. Other Systemic Fluoroquinolones Ofloxacin Basic Pharmacology Ofloxacin is similar to ciprofloxacin in mechanism of action, antimicrobial spectrum, therapeutic applications, and adverse effects. Bioavailability is high (90%) in the absence of food and is greatly reduced in the presence of food. Like ciprofloxacin, ofloxacin can cause a variety of mild adverse effects, including nausea, vomiting, headache, and dizziness. In addition, ofloxacin may intensify sensitivity to sunlight, thereby increasing the risk for severe sunburn. Ofloxacin elevates plasma levels of warfarin, but, in contrast to ciprofloxacin, has little effect on levels of theophylline. Absorption of oral ofloxacin is reduced by cationic substances: milk, milk products, sucralfate, iron and zinc salts, and magnesium- and aluminum-containing antacids. Preparations, Dosage, and Administration Ofloxacin is available in tablets (200, 300, and 400 mg) for dosing with or without food. Side effects are generally mild, the most common being nausea, vomiting, diarrhea, stomach pain, dizziness, and altered sense of taste. Preparations, Dosage, and Administration For systemic therapy, moxifloxacin [Avelox, Avelox I. The usual dosage for sinusitis and pneumonia is 400 mg once a day for 10 days; the usual dosage for bronchitis is 400 mg once a day for 5 days. Levofloxacin Levofloxacin [Levaquin] is active against Streptococcus pneumoniae (also known as pneumococcus), H. Gemifloxacin causes a high incidence of rash and, compared with older fluoroquinolones used for respiratory infections, has no significant advantages and costs more. The most common reactions are diarrhea, rash, nausea, headache, abdominal pain, vomiting, dizziness, and altered sense of taste. The incidence of rash with gemifloxacin is much higher than with other fluoroquinolones. Symptoms are severe in about 10% of patients who develop a rash; in the rest, symptoms are mild to moderate. As a rule, gemifloxacin-induced rash resolves spontaneously in 1 to 2 weeks, although some patients require treatment with systemic glucocorticoids. Drug Interactions As with ciprofloxacin, absorption of gemifloxacin can be reduced by compounds that contain cations. Among these are iron salts, zinc salts, sucralfate, aluminum- or magnesium-containing antacids, and milk and other dairy products, which contain calcium ions. To ensure adequate absorption, these cationic agents should be administered at least 6 hours before gemifloxacin or 2 hours after. Preparations, Dosage, and Administration Gemifloxacin [Factive] is available in 320-mg tablets for oral dosing, with or without food. To prevent high concentrations in the urine, all patients should consume liberal amounts of fluid. Additional Antibacterial Drugs Metronidazole Metronidazole [Flagyl] is used for protozoal infections and infections caused by obligate anaerobic bacteria. Mechanism of Antibacterial Action Metronidazole is lethal to anaerobic organisms only. To exert bactericidal effects, metronidazole must first be taken up by cells and then converted into its active form; only anaerobes can perform the conversion. Because aerobic bacteria are unable to activate metronidazole, they are insensitive to the drug.

This recently identified and described deformity of Depending on the severity of the condition purchase line ivermectin, ptosis of the tip the nasal tip is quite often found in the Mediterranean nose cheap 3mg ivermectin otc, should be addressed on the basis of common strategies with the either in isolation or combined with defects of rotation and pro- gradual introduction of more complex techniques such as lateral jection cheap ivermectin 3 mg amex. Though cephalic malposition of the lateral crura can crural overlay, which makes it possible to obtain the highest sometimes be masked by a markedly bulbous nasal tip with degree of rotation. Regardless of the degree of ptosis, it very thick skin, careful analysis is sufficient to detect its presence. Palpation can also serve to reveal an greater importance attaches to the eclectic sensibility of a sur- area devoid of cartilage corresponding with the caudal portion geon capable of harmonizing nasal modifications to the ethnic of the nasal wing. This malposition can be completely resolved proportions of the face than to technical analysis based solely with no need for cartilage grafts by making a step incision, on millimetric parameters. In other words, it is very often pref- detaching the anterior segment of the lateral crura from the erable to leave a nose that is large but well suited to the overall skin beneath, and securing it in a caudal position. The values provided by the latter for pro- tip in the Mediterranean nose, bearing in mind the height of jection, rotation, and nasal angles should in fact be regarded the nasal dorsum and its relationship with the supratip region. The common methods of anal- Efforts to enhance projection should also begin with proce- ysis provide useful guidelines for some defects but should not dures involving cartilage sutures and go on to the use of be taken in an absolute sense, and the modifications should be grafts only if these prove insufficient. The balancing of the adapted to the situation case by case to avoid impairment of the projection of the tip and the line of the dorsum is the most patient’s physiognomy. Respect for the ethnic group of origin is delicate phase of rhinoplasty on the Mediterranean nose. If therefore more important than the abstract pursuit of an excellent results are to be obtained, crucial importance unnatural aesthetic ideal. Arch Facial Plast Surg 1999; 1: 246–256, scope 1988; 98: 202–208 discussion 257–258 [5] Friedman O, Akcam T, Cook T. Arch Facial Plast Surg 2006; 8: 195–201 deprojection techniques and introduction of medial crural overlay. Lateral crural strut graft: technique and clinical Facial Plast Surg 2005; 7: 374–380 applications in rhinoplasty. The lateral crural stairstep technique: a modification sion 953–955 of the kridel lateral crural overlay technique. Controlled nasal tip rotation via the lateral crural over- 1975; 56: 35–40 lay technique. Facial Plast Surg 2003; 19: 279–294 524–529 556 Rhinoplasty for the East Asian Nose 70 Rhinoplasty for the East Asian Nose Yong Ju Jang and Myeong Sang Yu Asians include people living in Eastern Asia, Southeast Asia, Autologous Tissue India, and the Middle East who have different ethnic origins The advantage of autologous material for the dorsal augmenta- and different aesthetic features. As a result of the diverse eth- tion of the nose cannot be questioned as these implants are nicities in these populations, the anatomic characteristics of well tolerated and carry the least risk of infection. Although there are substantial variations, in any autologous tissue other than septal cartilage is selected, the the typical Asian nose, the nasal skin tends to be thicker than additional operative time required to harvest the graft and the that of Caucasian noses, with abundant subcutaneous soft tis- donor-site morbidity become limiting factors. The tip of the nose is usually low, and the lower lateral car- gous tissues used for dorsal augmentation include septal carti- tilages are small and weak. The nasal bones are poorly devel- lage, conchal cartilage, costal cartilage, and fascia. The septal cartilage is to harvest and shape the septal cartilage, it can be used to mod- thin and small. Altogether, when compared with Caucasian erately elevate the nasal dorsum, to camouflage a partial con- noses, the typical Asian nose appears to be relatively small and cavity on the dorsum, and for nasal tip surgery. In an aesthetic analysis of the patients have relatively small noses, it is practically difficult to nasal profile, the nasolabial angles of Asians are typically more harvest enough amount of septal cartilage, leaving at least 1-cm acute than those of Caucasians, but the nasofrontal angles do 1 width of the L-strut, suitable for a full-length dorsal graft. Unlike septal cartilage, conchal cartilage has an intrinsic curva- ture that hampers its routine use in a dorsal augmentation in its original shape. In addition, the conchal cartilage Dorsal augmentation is the most commonly addressed issue in is frequently too small to yield a cartilage piece suitable for one- Asian rhinoplasty and also the most common reason for revi- piece dorsal augmentation. When performing augmentation rhinoplasty on tion of the septal cartilages and to overcome the limitation in Asians, it is preferable or mandatory to first perform tip surgery size, the author (Y. The thickness of the patient’s Also, when using conchal cartilage, it may be necessary to over- skin must be taken into consideration. If excessive dorsal aug- lap pieces of cartilage in opposite directions of their curvature mentation is performed on a patient whose skin is too thin, to neutralize their intrinsic curvature. Although costal cartilage there is a risk of implant visibility through the skin or an extru- is difficult to harvest and is associated with more serious sion of the implant. Conversely, too thick skin can decrease the donor-site morbidity such as pneumothorax, as well as the effect of nasal augmentation. Therefore, with patients who have problem of warping, it is the most useful autologous cartilage thin skin, it is preferable to use soft implants such as Gore-Tex for substantial augmentation or for patients who have experi- (W. In patients Although strongly advocated by some surgeons for routine use with thick skin, a relatively solid material such as silicone, rein- in Asian rhinoplasty,5 during the primary rhinoplasty, it is very forced Gore-Tex, or costal cartilage can be used without signifi- difficult to persuade Asian women to use costal cartilage cant problems. One other critically important limitation of autologous tissue is that except for only a few highly experienced surgeons, most rhino- 70. Materials used in rhinoplasty can be divided largely Warping, graft visibility, and unnatural-looking noses are com- between biologic tissues (autologous and homologous tissue) mon complications of augmentation using costal cartilage. Alloplastic implants generally need to more difficult cases, and use of these implants is associated be biocompatible, nontoxic, chemically safe, and nonimmuno- with unpredictable scarring, warping, and at times visible graft genic. At present, Autologous fascia, including temporalis fascia, can be used in the most commonly used alloplastic implants that meet these rhinoplasty as radix graft or dorsal onlay grafts. Furthermore, it shown conflicting results regarding the degree of resorption is not always possible to harvest sufficient fascia of reasonable and warping. The high complica- tion rate associated with homologous cartilage may limit its Homologous Tissue or Tissue Allograft 10 utility for dorsal augmentation. For example, homologous costal used for smoothening grafts for dorsal irregularity after correc- cartilage harvested from cadaveric donors and processed in var- tion of a deviated nose, as additional graft material when an ious ways has been shown to be useful in rhinoplasty. Due to its stable chemical structure, silicone has several advantages, including its low degree of tissue reaction and ease of handling. More- over, the availability of ready-made products makes application convenient, and the relative hardness of silicone makes it suit- able for fashioning the desired nasal shape for Asians with a thick skin. Some surgeons favor an L-shaped or a variation of I-shaped silicone (covering the nasal tip) capable of coverage from the radix all the way down to the nasal tip. However, because the nasal tip is an area that is always exposed to exterior stimulation, use of L-shaped silicone carries a higher risk of extrusion regardless of the thickness of nasal subcutaneous tissue in Asians. Thus, placement of an I-shaped implant at the nasal dorsum area and tip plasty using an autologous material (septal cartilage, conchal cartilage) at the nasal tip area is the more preferred surgical method. In addition to using prefabricated silicone implants, the author has used silicone sheeting for nasal dorsal augmentation, which is more versatile and carries no increased risk of complica- tions. Revision rhinoplasty after silicone implants may be needed for implant deviation, floating, displacement, extrusion, impending extrusion, and infection. Gore-Tex implants are porous, inducing the surrounding tissue to grow inward through the pore, and have the advan- tages of increased stability and lower risk of capsule formation. The soft texture of Gore-Tex reduces patient dis- and extrusion, an unpredictable degree of resorption could be a comfort and the occurrence of unnatural visible implant problem. Reports of delayed inflammation are increas- The typical endonasal approach for Caucasian noses involves ing, thus one must be cautious when using Gore-Tex in the cephalic resection through a delivery or nondelivery approach presence of inflammation within the nasal cavity (sinusitis, ves- and placement of transdomal and interdomal sutures and col- tibulitis, and active acne). This approach can also be used for the placement tions that may create microcommunication with the nasal cav- of shield or onlay graft.

In such case buy ivermectin 3mg, disease modifying drugs discount ivermectin 3mg on-line, such as sulphasalazine or methotrexate or azathioprine may be given purchase ivermectin 3mg visa. Involvement of joints Mainly of upper and lower extremities Mainly lower extremity 2. A: Wrist, elbow, scalp, hairline, back of ear, natal cleft, around umbilicus, shin, knee, extensor surfaces of limbs, scrotum. Onycholysis Subungual hyperkeratosis Nails pitting Ridging in nail Q:What are the types of arthritis in psoriasis? More in males, psoriatic lesion before arthritis, nail changes are usually present. Extensive bone resorption results in ‘opera glass hand’ (one bone enters into its neighbouring bone like a telescope, giving rise to this appearance). Treatment of psoriasis: General measures, local therapy and systemic therapy (for details see in chapter Dermatology). Sometimes helpful in arthritis when synchronous skin lesion and arthritis are present. A: Avoid the following drugs (which may aggravate psoriatic skin lesion, even may cause exfoliative lesion): • Chloroquine. A: Methotrexate, sulphasalazine, cyclosporine, azathioprine and biological agents. The patient may complain of pain on the affected side, which indicates root pressure due to disc prolapse). Now, ask the patient to stand up and perform the following points: • Observe whether there is fxed thoracic kyphosis, loss of lumbar lordosis and compensatory hyperextension of neck. A: Low back pain with morning stiffness, any skin lesion (indicates psoriatic arthritis) and history of frequent loose motion or bloody diarrhoea (indicates infammatory bowel disease). Juvenile ankylosing spondylitis Protruded abdomen, thoracic Stooping forward posture kyphosis, lumbar lordosis mebooksfree. Q:How to differentiate aortic regurgitations of rheumatic heart disease and of ankylosing spondylitis? A: From history and echocardiogram: • In rheumatic fever: echocardiogram shows involvement of valve cusps (there is shortening, thickening and fusion). Typical overlapping extra-articular features: • Mucosal infammation (such as conjunctivitis, buccal ulceration, urethritis, prostatitis, bowel ulceration). Healing of such lesion at the junction of intervertebral disc and vertebral bodies causes new bone formation, called syn- desmophyte (hallmark of ankylosing spondylitis). A: It is a chronic infammatory sero-negative spondyloarthritis characterized by progressive stiffening and fusion of axial skeleton. The patient usually presents with low back pain with morning stiffness, worse in the morning and with inactivity, the pain improves after exercise. Eyes: Uveitis (iritis) 25%, conjunctivitis 20% (the patient may present with painful red eye and photophobia). Chest and lungs: • Chest pain (pleuritic) and reduced chest expansion (due to costo-vertebral joint involvement). Neurological: Cauda equina syndrome (weakness of lower limbs, loss of sphincter and rectal control, saddle sensory loss). There may be ossifcation of anterior longitudi- nal ligament or interspinous ligament and facet joint fusion. Calcifcation gives the appearance of fowing wax on the anterior body of vertebrae. It grows longitudinally (above or below) causing bridging of adjacent It grows horizontally outwards vertebra 3. Due to endochondralcalcifcation of annulus fbrosus New bone at the corners of vertebra 4. It is the hallmark of ankylosing spondylitis It is the hallmark of osteoarthrosis Q:What is the natural history of ankylosing spondylitis? A: Up to 40% may develop severe spinal restriction, 20% may have signifcant disability. Early periph- eral joint disease, especially hip joint involvement indicates poor prognosis. A: With treatment, prognosis is better with minimum disability unless hip joints are involved. In the face, see the following points: • Skin rash (macular, maculopapular, scaly, erythematous) over the cheeks and forehead. A: I want to see skin lesion in other parts of the body, proximal myopathy and joints. Also, I want to exclude other primary causes, especially malignancy (such as bronchial carcinoma). Also, rashes with fat topped macules over the knuckles (Gottron’s sign) are present. Gottron’s sign Skin rash in dermatomyositis Dermatomyositis (contracture) (body) mebooksfree. A: Polymyositis is the non-suppurative, non-infective infammation of skeletal muscle characterized by necrosis, fbrosis and regeneration of muscles. Probable factors are: • Autoimmune mechanism (due to the presence of anti-Jo-1 antibody and lymphocyte infltration in muscle). Flat, red rash on face and upper trunk, erythematous rash of knuckles with raised violaceous scaly eruption (Gottron’s sign). Erythematous rash also may occur in knee, elbow, malleoli, neck and anterior chest (often a V sign) or back and shoulder (shawl’s sign). A: It is a violaceous, purple or lilac coloured rash, present usually over the eyelids. It is derived from the name of a shrub Heliotropium, which has fragmented, purple fowers. A: It is scaly, purple-red, raised, fat-topped and vasculitic patches over the extensor surface of joints and knuckles of hands. Muscle biopsy shows the following fndings: • Necrosis, swelling, vacuolation, disruption and fragmentation of muscles. Positive in 30% in dermatomyositis and 50% in polymyositis (if anti-Jo-1 antibody is present, respiratory muscles involvement may occur). In the upper limbs: • Ask the patient to raise the arms above head (patient is unable to do so). In the lower limbs: • While the patient is lying fat, ask him to raise the lower limbs (patient may be unable to do so). Presentation of a Case: • This patient has diffculty in raising both the arms above the head and weakness of both arms as well. A: The patient may complain of diffculty in combing, climbing upstairs and raising from the chair or squatting (also features of primary diseases may be present). Unable to raise both arms Proximal myopathy (wasting Proximal myopathy (wasting shown, severe) shown, early stage) mebooksfree.

Koebner’s phenomenon Auspitz sign Psoriasis in surgical scar Scalp psoriasis Q:What are the factors that aggravate psoriasis? A: It is a chronic infammatory disease of skin characterized by well defned erythematous plaque with silvery white scales generic ivermectin 3mg without prescription, involving commonly the extensor surface ivermectin 3mg sale, elbows purchase ivermectin australia, knees and sacral regions associated with recurrence and remission. It commonly involves elbow, knee and lower back, but may also involve scalp, nails, fexures, palms). An explosive eruption of very small circular or oval plaques appears over the trunk about 2 weeks after a streptococcal sore throat. A: There is rapid proliferation and abnormal differentiation of epidermis due to hyperproliferation of keratinocyte and infltration of infammatory cells (polymorph, T-lymphocyte and other infammatory cells). To establish the diagnosis, the following procedures may be performed: • Skin biopsy for histopathology (defnitive). Psoriasis (sub-mammary fold) Exfoliative dermatitis (body) Exfoliative dermatitis (body) Q:What are the complications of psoriasis? Local therapy (topical therapy on the lesion): • Emollient: petrolatum, paraffn, urea (up to 10%), olive oil. It inhibits epidermal proliferation and restores normal horny layer, very effective in the treatment of plaque and scalp psoriasis. It acts by modulating keratinocyte differentiation and hyperproliferation, also by suppressing infammation. If mouth ulcer is present with skin lesion, the diagnosis is Stevens– Johnson syndrome. In this lesion, there is central pallor or dusky purpura with oedema and peripheral redness. Erythema multiforme Erythema multiforme Stevens–Johnson Stevens–Johnson (target lesion on hands) (target lesion on thigh) syndrome (face) syndrome (body) Q:What are the differential diagnoses? A: As follows: • Erythema multiforme is an acute infammatory reaction in the skin and mucous membrane, characterized by multiple erythematous skin lesions, such as macules, papules, vesicles, bullae and target lesions involving the extensor surfaces of limbs. It is due to circulating immune- complex that follows 7 to 14 days after precipitating factors (such as infections and drugs). However, it can be used and should be tapered rapidly because once skin loss occurs, it may aggravate morbidity and mortality due to immunosuppression. A: Bullae is a circumscribed, fuid-flled elevation of skin more than 1 cm in diameter. Presentation of a Case: • There are multiple grouped, symmetrical, erythematous, polymorphous, papular, papulo-vesicular, vesiculo-bullous or bullous, urticarial and excoriated skin lesion on the extensor surface of knee, elbow, buttock, scalp, upper back and sacrum. A: Group lesions, symmetrical and characteristic distribution in extensor surface. A: Diarrhoea or malabsorption after taking gluten containing diet (oat, rye, wheat, barley). Dermatitis herpetiformis (knee) Dermatitis herpetiformis Dermatitis herpetiformis (elbow) (bullous lesion) mebooksfree. Remember the following points: • Dermatitis herpetiformis is common in male and male to female ratio is 2:1. A: It is an autoimmune bullous lesion of skin that is associated with gluten sensitive enteropathy. It is caused by IgA deposition at dermoepidermal junction leading to neutrophil chemotaxis, cytokine and complement activation, which results in vesicle formation at the dermoepidermal junction. Skin biopsy shows: • Infltration of neutrophils, eosinophils, fbrin at dermal papilla and sub-epidermal vesicle. A: As follows: • Dapsone: 100 to 150 mg daily (start with 100 mg, increase the dose gradually). Dramatic clinical response occurs in 72 hours (a therapeutic test) and itching reduces quickly. A: As follows: • Blood dyscrasia (such as haemolytic anaemia, agranulocytosis, methaemoglobinaemia). A:It is due to reactivation of varicella zoster virus that lies dormant in dorsal root ganglion of sensory nerves, following chicken pox in childhood. Herpes zoster Herpes zoster (healed) Herpes Zoster (shoulder) Herpes zoster (thigh) Q:What are the sites of lesion? A: As follows: • Dorsal root ganglia (when thoracic or lumbar dermatome is involved). A: As follows: • Initially, burning discomfort or pain along the involvement of dermatome and dysaesthesia is present (when thoracic dermatome is involved on right side, it confuses with acute cholecysti- tis. Local treatment: • Antiseptic powder (povidone-iodine), drying solution, calamine lotion and local aciclovir cream. A: It is the herpes zoster of geniculate ganglia characterized by: • Rash in the external auditory meatus and palate. Pain, tingling and numbness, redness around the eye followed by vesicular or pustular lesions up to the scalp, don’t cross the mid line (other 2 branches of trigeminal nerve, maxillary and mandibular nerves are rarely involved). Local care of the eye: • Local 3% aciclovir ointment (fve times daily) and idoxuridine 0. Presentation of a Case: • There are brown (or black), velvety plaques of skin (thick and rugose-like warts) in axilla and neck. A: Limb fexures, also may be found around the umbilicus, nipple and groins which are symmetrically distributed. Acanthosis nigricans Acanthosis nigricans Acanthosis nigricans Acanthosis nigricans (axilla) (front of neck) (back of neck) (flexure of knee) Q:What is acanthosis nigricans? A: Acanthosis nigricans is a disorder of skin characterized by dark, thick, velvety skin in body folds and creases. A: Acanthosis nigricans may occur before the development of malignancy in 18% or may parallel with malignancy in 60% and may follow malignancy in 22% cases. A:Ichthyosis is the dry and rough skin with persistent visible scaling, which may resemble fsh scale. Ichthyosis is not a single disease, but a group of diseases in which homeostatic mecha- nism of epidermal cell kinetics or differentiation is altered, resulting in the clinical appearance of scale. Detailed history including any familial history and physical examination should be done. Major: • Autosomal dominant: Ichthyosis vulgaris and bullous ichthyosiform erythroderma. Presentation of a Case: • There are multiple thin-walled blisters or bullae flled with clear fuid in the trunk, axilla and face. A: It is an autoimmune blistering disease characterized by thin-walled, faccid, easily ruptured bullae that appear in apparently normal skin and mucous membrane or on erythematous base (associated with mouth ulcer). Probable factors are: • Autoimmunity, as suggested by the intercellular deposition of IgG and C3 complement in epidermis.

As more was discovered about the high community prevalence buy cheapest ivermectin and ivermectin, it became clear that the case fatality rate was lower than for other forms of seasonal influenza purchase ivermectin online now. H1N1 was common between 1918 and 1957 cost of ivermectin, which may explain why those over 60 were less severely affected. The antiviral neuraminidase inhibitor drugs Oseltamivir and Zanamivir have been recommended for the treatment of patients with suspected influenza during a flu pandemic. This is based on evidence that these drugs shorten the duration of illness (by around a day) and reduce transmission and the likelihood of secondary complications. A recent Cochrane review has raised concerns about the quality of this evidence and as a result their use in healthy adults has been questioned. There remains, however, a consensus that these agents should be used in patients with more severe illness and patients at higher risk of complications. They should ideally be started within 48h of the illness for maximum benefit, but in critically ill patients starting them after this period may still confer some benefit. The intravenous antiviral peramivir may be used in patients where the oral or inhaled route is not practicable. Primary viral pneumonia is a common finding in severe cases of H1N1 influenza and a relatively frequent cause of death. In hospitalized patients who have developed viral pneumonia the most common finding is patchy change on chest radiograph. During the initial viral pneumonia, single-organ failure is the most common disorder. Follow-up Most patients with a good clinical response to treatment do not need routine follow-up, particularly non-smokers and age <50years. Age, severity of pneumonia, co-morbidities, and the nature of the infectious agent can all affect the rate of resolution. Overall, 6–15% of hospitalized patients do not respond to initial antibiotic treatment. It is important to recognize non-responders so they can be reassessed and appropriate therapeutic changes made. Patients may fail to respond to treatment for a number of reasons: • Resistant bacterial pathogen—rates vary from area to area and close liaison with a local microbiologist is important. Patients may be infected with bacteria such as Pseudomonas aeuriginosa, with innate resistance to some first-line antibiotics. Neoplasms Neoplasms may be mistaken for pneumonic change (most typically broncho-alveolar cell lung cancers) and may also coexist with it if they cause endobronchial obstruction leading to pneumonia. Inflammatory disorders Inflammatory disorders can cause symptoms similar to pneumonia. Eosinophilic lung disease There is a spectrum of eosinophilic lung disease, including eosinophilic pneumonia, where the lung infiltrate is due to eosinophils. Globally, para- sites are the major aetiological factor and these diseases are rare in the developed world. Eosinophilic pneumonia can also occur due to drug hypersensitivity and inhaled antigens. Pulmonary infiltrates are also seen in Churg Strauss syndrome, which may occur in the context of an established diagnosis of asthma and is characterized by peripheral blood eosinophilia and systemic vasculitis. Diagnosis rests on a combination of the clinical picture, chest radiograph findings, laboratory tests, and, in some cases, bronchiolar lavage and lung biopsy. Most eosinophilic lung disease responds to steroids, but it is important to look for and treat specific parasitic infections and drug reactions. It is a recognized complication of a large number of agents, including amiodarone, disease-modifying agents used in rheumatoid arthritis such as leflunomide, and biological agents such as rituximab. A careful drug history is important, although symptoms may lag behind the start of a new drug regime. It has a rapid onset with fever, cough, and shortness of breath being the most common symptoms. There is an equal gender distribution with most patients being over the age of 40. Mortality is over 60%, with only a minority of patients surviving more than 6 months. An approach to the non-responding patient Review history In patients failing to respond history and presentation should be reviewed. Review microbiology Initial microbiological studies should be pursued, if they were collected. Further evaluation is aimed at detecting complications and obtaining microbiological information. Ensure the patient is receiving appropriate treatment at the appropriate doses for organisms identified or suspected. Bronchoscopy may reveal evidence of non-infectious aetiologies such as diffuse alveolar haemorrhage, acute eosinophilic pneumonia, or neoplasm. Low pH or turbid appearance of pleural fluid are immediately suggestive of an empyema. All empyemas need draining as well as prolonged antibiotic treatment, including cover for anaerobes. The quoted mortality of surgical lung biopsy is around 6%, and a careful risk–benefit analysis needs to be made. Aspiration pneumonia Microaspiration is a phenomenon that occurs in many healthy individuals, often without clinical sequelae. Aspiration refers to the aspiration of large volumes of exogenous or endogenous substances into the lower airway. Predisposing factors include: • Reduced conscious level • Neurological disease, particularly with dysphagia • Gastrointestinal conditions, reflux, motility disorders • Medical procedures—endotracheal intubation, occasionally bronchoscopy, upper gastrointestinal endoscopy • Protracted vomiting, large volume nasogastric feeding • Prolonged periods in the recumbent position. Aspiration can cause airway obstruction, chemical pneumonitis, and bacterial infection. It is essen- tial to remove the obstruction using suction for fluids and a rigid or fibre optic bronchoscope for particles. Chemical pneumonitis Chemical pneumonitis occurs following the aspiration or inhalation of substances toxic to the lungs, normally acid stomach contents. Steroid treatment has been shown not to be of value and may increase the incidence of Gram-negative infection. Bacterial infection Bacterial pneumonia following aspiration may be a secondary infection following airway obstruction or chemical pneumonitis, or it may be a primary event following aspiration of fluid-containing bacteria (especially anaerobes) that are resident in the stomach and upper airways. Metronidazole should not be used alone as it is associated with a significant rate of treatment failure as a sole agent. Pneumonia in the immunocompromised host The immunocompromised host presents a number of challenges. Particularly in patients who have undergone chemotherapy or radiation treatment for malignancy, a number of non-infectious disease processes may also occur: • Radiation-induced pneumonitis • Drug reactions • Progression of the primary disease. These patients are also at increased risk of non-infectious disease, including Kaposi’s, lung cancer, lymphoma, and emphysema. In immunocompromised patients chest radiograph changes may be subtle or even non-existent due to immune suppression.

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