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Massage and non-migrainous headache Hypertension Quinn et al (2002) investigated the effect of massage Hypertension is one of the most pervasive disease therapy on chronic non-migraine headache cheap 200 mg suprax visa infection preventionist job description. It can lead to target Chronic tension headache sufferers received struc- organ damage order generic suprax on line infection control training, and although there is no one cause of tured massage therapy treatment directed toward primary hypertension purchase 200mg suprax with amex antibiotics yellow teeth, the theory of an unchecked neck and shoulder muscles. Headache frequency, long-term stress response continues to be a valid argu- duration and intensity were recorded and compared ment. It seems to run in The reduction of headache frequency continued for families and is more common in people of African– the remainder of the study (p = 0. Risk factors for the condition of headaches tended to decrease during the massage include stress, a high alcohol intake, a diet high in salt treatment period (p = 0. Chiropractic and hypertension Exercise and headache There have been both negative and positive studies: Evidence suggests that deficits in muscle performance of the deep neck flexor muscles may be linked to cer- • A randomized clinical trial (Goertz et al 2002) vicogenic headache, and that specific exercise pre- compared the effects of chiropractic spinal scription utilizing a pressure biofeedback device may manipulation and diet with diet alone for play an important treatment role, in conjunction with lowering blood pressure in participants with manipulation treatment (Eldridge & Russell 2005). Results showed that for patients health problem in many countries, even in sedentary with high-normal blood pressure or stage I occupations, and that therapeutic exercise can decrease hypertension, chiropractic spinal manipulation the intensity of pain in the neck area (Ylinen et al in conjunction with a dietary modification 2003), Sjögren et al (2005) designed a study to examine program offered no advantage in lowering the effects of a workplace physical exercise program, either diastolic or systolic blood pressure, consisting of light resistance training and guidance, compared to diet alone. The train- hypertensive patients, but no large-scale ing consisted of six dynamic symmetrical movements: controlled studies have been carried out. The training move- from where the nerve supply to the kidneys ments were carried out 20 times with a 30-second emerges, may be of benefit in reducing pause between the training movements. Physical hypertension (Johnston & Kelso 1995, Johnston exercise intervention resulted in a slight, but statisti- et al 1995). Adults who had been diagnosed as aerobic exercise program drop out within 3–6 hypertensive received ten 30-minute massage months and fewer than 20% continue sessions over 5 weeks, or were given exercising after 24 months (Dishman 1994). Sitting diastolic blood pressure There is a major variation in different ethnic decreased after the first and last massage groups, relative to high blood pressure. In the therapy sessions, and reclining diastolic blood first place, black (non-Hispanic) people appear pressure decreased from the first to the last day to have a greater tendency to hypertension of the study. Although both groups reported than whites or Hispanics, although in all less anxiety, only the massage therapy group groups those with ‘higher rates of physical reported less depression and hostility and inactivity’ have higher blood pressure (Bassett showed decreased urinary and salivary stress 2002). The results suggest significantly lower blood pressure after aerobic that massage therapy may be effective in exercise in white women differs markedly from reducing diastolic blood pressure and the response in black women, where it rises, or symptoms associated with hypertension stays the same. In this experimental, known as ‘white coat hypertension’ – pretest/post-test study, a 10-minute back their blood pressure rises when it is tested massage was given to the experimental group by a physician or nurse. The that this tendency improves markedly when control group (n = 6) relaxed in the same regular exercise is taken: ‘12 weeks of exercise environment for 10 minutes, three times a training can result in successful reduction of week for 10 sessions. This • Vigorous exercise and short-term reduction in has now been partially answered by Japanese hypertension: Research has shown that after research. The researchers conclude that their women with mild levels of hypertension results demonstrate that aerobic exercise is exercised vigorously (i. The researchers • Multiple benefits of modified diet, exercise and conclude that: ‘The magnitude and duration of education: A randomized trial (Aldana et al post-exercise hypotension may be sufficient to 2005) has clearly demonstrated improvements normalise the blood pressure of certain in resting heart rate, total cholesterol, low- hypertensive women throughout most of the density lipoprotein cholesterol, and systolic day’ (Pescatello et al 1999). Yoga and hypertension • Hypertensives benefit more from exercise: It is also • Yoga breathing and hypertension: When different known that blood pressure falls more in methods of stress reduction were compared, it hypertensive than in normotensive people. In was found that the fastest and most effective fact, regular exercise lowers blood pressure in way of lowering blood pressure after a stressful 75% of hypertensive people, with average episode was to use simple yoga-type breathing systolic and diastolic reductions of 11 and methods (Sung et al 2000). Exercise can reduce 10- breathing has been shown to be effectual in year cardiovascular risk by at least 25% in the lowering blood pressure in people with mild average hypertensive patient, because of the hypertension, where it can be as effective as effect on blood pressure and other the use of medication (Sydorchuk & Tryniak cardiovascular risk factors (Hagberg et al 2000). Additionally, low-to- measures for hypertension moderate intensities of exercise are as effective • There is limited evidence suggesting manipulation at lowering blood pressure, if not more to be valuable in reducing hypertension. Osteopathic treatment mechanics in a critically ill patient with acute respira- involved 10–20 minutes daily of a standardized pro- tory failure. High-velocity mobilization of cervical tocol, with attending physicians blinded as to group and thoracic dysfunctions has been shown to result in assignment. It may be used on patients with fractures, surgery is accomplished via a median sternotomy as well as on post-surgical patients who have pain at incision, an approach that has been gaining wide- the site of incision. Results are claimed to be lasting and repetitive treat- ment is needed (in hospital settings) only if there is • The soft tissues below the skin are treated with ongoing neurosensory reflex activity or if the condi- diathermy to stem bleeding and the sternum is tion which produced the dysfunction in the first place divided by an electric bone saw, the exposed is repeated or ongoing. Patients were recruited • There are often drainage tubes exiting from and randomly placed into two groups: 28 in the treat- below the xiphoid following surgery. There was no statistical difference sequelae to this trauma are many and varied, and may between groups for age, gender or simplified acute include ‘dehiscence, substernal and pericardial infec- physiology scores. The treatment group had a signifi- tion, non-union of the sternum, pericardial constric- cantly shorter duration of intravenous antibiotic treat- tion, phrenic nerve injuries, rib fractures and brachial ment and a shorter hospital stay. The treatment diately postoperatively, many problems do not emerge group received osteopathic manipulative treatment until later, and these might include structural and on postoperative days 2–5. The main outcome showed functional changes in chest mechanics that do not that, compared to control subjects, the intervention become evident for weeks or months, particularly group negotiated stairs 20% earlier (mean = 4. The intervention group the importance of structural evaluation and treatment, also required less analgesia, had shorter hospital stays both before and after surgery, involving manual thera- and ambulated farther on postoperative days 1, 2 and peutic methods of various types. The conclusion is that patients receiving osteopathic cifically the positional release approaches (Chaitow manipulative treatment in the early postoperative 2007) that are advocated for treating this type of post- period negotiated stairs earlier and ambulated greater surgical trauma (see Chapter 7 for detail of positional distances than did control group patients. In addition, there was extension of muscu- by median sternotomy, and to improve respiratory lar tension from the injured left knee and ankle into function. A prospective, match-controlled postoperative This example highlights the adaptive changes in outcome study spine and thorax that evolved following lower limb As noted above, osteopathic manipulative treatment injury, and how the opportunity to normalize these has been reported to relieve a variety of conditions, changes arose when the knee damage was repaired. Chiropractic treatment seems to • Immune function markers and physical methods: achieve its effect via mediation of the nervous Research evidence suggests that both system. German research showed that the massage therapy (45 minutes of massage five regular (daily) use of a cold shower had a progres- times weekly for 1 month). For with feelings of anxiety, but natural killer cells, 6 months one group took a graduated cold shower and their activity were significantly increased (i. After 6 months those taking the cold shower were Susceptible and healthy children of the same found to be having half the number of colds compared age were used as controls. The cold shower effect of the treatment group was shown to be group’s colds lasted for approximately half as long as significantly better (p <0. Cold were re-examined 3 and 6 months after the showers were avoided during, and for 1 week after, massage intervention. This intervention Otitis media and was performed concurrently with traditional medical chiropractic manipulation management. Of the three remaining subjects in this juveniles with otitis media have demonstrated prom- cohort, one had a bulging tympanic membrane, ising outcomes (Sawyer et al 1999). Spinal manipula- another had four episodes of otitis media, and the last tion and manual lymphatic drainage massage are underwent surgery after recurrence at 6 weeks post- reported to be the preferred forms of treatment treatment. Closer analysis of the post-treatment course (together with nutritional strategies) used by approxi- of the last two subjects indicates that there may have mately 75% of a group of 33 chiropractors when treat- been a clinically significant decrease in morbidity for ing pediatric otitis media patients (Vallone & Fallon a period of time after intervention. This makes it difficult to be previous 6 months or four in the previous year, who sure whether treatment, such as massage or chiroprac- were not already surgical candidates, were placed tic, helps or not, despite many parents (Spigelblatt et randomly into two groups: one receiving routine al 1994) and practitioners (Sawyer et al 1999) claiming pediatric care, the other receiving routine care plus that these methods have improved the children’s glue osteopathic manipulative treatment. Clinical Tonsillitis and manual methods status was monitored with review of pediatric records. Czech study (Lewit & Abrahamovic 1975) A total of 57 patients (25 intervention patients and offers some support for the use of mobilization 32 control patients) met criteria and completed the and manipulation of neck structures, associated study. Adjusting for the baseline frequency before (via the nerve supply) to the tonsils, in cases of study entry, intervention patients had fewer episodes chronic tonsillitis. Baseline and final tympano- spine, between the first vertebra (the atlas) and grams showed an increased frequency of more normal the occiput.

Studies in the early 1990s in Kenya and other African countries have shown that the epidemic has had little impact on attitudes and subsequent child- bearing (Ryder et al discount 200 mg suprax free shipping antibiotic induced diarrhea treatment. In addition buy suprax online pills antibiotics kidney infection, some countries effective suprax 200mg antibiotics for uti in horses, such as Uganda and Senegal, have managed to reduce transmission by vigorous public health education programmes (Anonymous, 2000b). Pregnant women are considered an ‘epi- demiological useful’ group because they represent a stable sub-group of the heterosexually active population at ‘normal risk’. I shall now consider the potential implications of a positive result, the nature of the relationship between the health professional and the pregnant woman, and the process of consent, as these are all relevant to a discussion about the ethics of anonymized and named testing. The implications of a positive result A pregnant woman is likely to experience considerable distress on discovery of her positive status (Manuel, 1999), particularly as she may feel more vulnerable and dependent on others, and she has the added responsibility of motherhood ahead of her. Once born, however, the interests of the child are paramount, and parental views may be overridden if they are seen to conXict with the child’s welfare. Babies can still gain protection from infection if given antiviral treatment within 48 hours of birth, even if the mother has refused to take medication or have a Caesarean section (Wade et al. It is beyond the scope of this discussion to consider the poignant dilemma for parents of whether or not to disclose to their child his or her incurable infection and uncertain life expectancy, or to explore the burden of imposing life-long unpleasant treatment on a child, and of protect- ing him or her from stigma. It is evident from the case above, however, that women may Wnd that breast-feeding causes disapprobation, and may even result in their infants being considered ‘at risk’. Abstention from breast-feeding creates particular diYculties in countries and cultures where breast-feeding is the norm, and bottle-feeding stigmatizes a woman (Graham and Newell, 1999). The relationship between the health professional and the patient As I have discussed elsewhere (de Zulueta, 2000a), the relationship between a health professional and a patient can be characterized as a Wduciary one. The health professional is therefore entrusted to put the patient’s interests Wrst, and to hold certain things (such as conWdential information) ‘in trust’. As Brazier succinctly expresses this: ‘It is trite to describe the health profes- sional’s relationship with his or her patient as a relationship of trust, yet the description encapsulates the very heart of the relationship’ (Brazier and Lobjoit, 1999: p. The health professional has a duty to promote the well-being of both the mother and the unborn child, but should only provide care that the mother agrees to. Failure to seek the patient’s consent is not only a moral failure, but, in English law, also leaves the doctor liable to the tort or crime of battery or to the tort of negligence. The information required is such that the patient understands in broad terms the nature and purpose of the procedure, and the principal risks, beneWts and alternatives (Chatterton v Gerson, 1981). Consent is a process, not an event, and involves a continuing dialogue between the health care professional and the patient, such that there is genuine shared decision-making. I submit that in the case of anonymized testing, and in the case of ‘routine’ voluntary named testing, consent is often vitiated by a lack of understanding and information, and sometimes by coercion. This may be justiWed in countries where the resources are not available to oVer counselling or treatment, and where the data may be used to galvanize the developed world into providing aid. These Wgures, it is argued, can then be used to provide the justiWcation for allocating more resources to the treatment and prevention of the disease, particularly in areas of high prevalence. But I would counter-argue that it is unprofessional and unethical to encourage individuals to relinquish beneWts that may aVect third parties (human fetuses), even if these are not ‘legal persons’. Finally, it could be argued that if an informed mother agrees to anony- mized testing, she does not intend to deprive the fetus of beneWt, as she does not know if she harbours the virus. This argument is also used to justify the health professional’s behaviour – no harm is intended, and there is no responsibility to act upon the result since it is unobtainable. A woman attending an antenatal clinic carries the reasonable expecta- tion that all tests and procedures are done either directly to beneWt her or her unborn child (de Zulueta, 2000a). The case for abuse of trust is even stronger than with anonymized testing of pregnant women, as the mothers are even more likely to assume that all tests are for the baby’s beneWt. Since the baby relies entirely on others to protect his interests, it is arguably even more unethical to use the baby ‘merely as a means, rather than as an end in himself’, to paraphrase Kant. In order to make an informed choice, the woman needs to understand the nature of the test itself, as well as the advantages and disadvantages of not receiving the result should it be positive. They cite a case when a doctor was found in breach of duty for failing to inform a woman of the potential consequences of not agreeing to a cervical smear. In addition, the leaXet issued by the Department of Health, in circulation after 1994, does not refer to treatments available for reducing vertical transmission. In any case, the notion of passive consent, that is to say that consent is implied unless there is a verbal refusal, is ethically unsound and ‘a concept quite alien in English law’ (Brazier and Lobjoit, 1999: p. In clinics that pro- vide universal testing (see later), the women should have received the relevant information from a pre-test discussion with the midwife, and the 70 P. In one study only Wve per cent fully understood the nature of the testing, and a signiWcant proportion believed that they would be informed should the result be positive (Chrystie et al. The principle of autonomy is frequently infringed by the process of anonymized testing, and, as Brazier says, ‘Consent truly is a myth’ (Brazier and Lobjoit, 1999: p. The ethics of named testing The Department of Health’s Unlinked Anonymous Surveys Steering Group in 1989 rejected mass voluntary testing as an alternative to anonymized testing. As argued above, the beneWts of named testing, and the arguments in favour of truth-telling are further strengthened, particularly as third parties are placed at risk by non-disclosure. The majority of industrialized countries adopted a universal testing policy (whereby all women were oVered the test), and developed their own guide- lines. Women at high risk in ‘low-prevalence areas’ may well miss out; this resource allocation dilemma is one well known to all screening programmes, and diYcult to resolve. This merits further discussion, but suYce to say that if resources are available, there is a strong argument for recommending a universal policy for all pregnant women (Hudson et al. The American Medical Association recently voted in favour of mandatory testing of pregnant women, although mandatory testing is a legal requirement in only a few states such as Texas and New York (Phillips et al. The reasons for this include the following: ∑ ‘high status coercion’ by professionals (see below); ∑ imposed targets, placing health professionals under duress to maximize uptake; ∑ multiple tests, creating confusion; ∑ lack of time and resources to allow a discussion suYciently detailed for women to understand the nature and purpose of the test. A health professional occupies a position of authority, and if he or she recommends a test, many women would feel that it is not within their rights to refuse. The strongest factor inXuencing uptake, excluding the direct oVer of a test, has generally been the individual midwife interviewing the woman (Jones et al. These Wndings reinforce the hypothesis that consent is driven by the health professional’s agenda, and that routine testing may not always be fully voluntary. Women most at risk (aside from intravenous drug users) are from high-prevalence areas, particularly from sub-Saharan Africa, and their Wrst language is not English or any other Western language. Schott and Henley (1996) quote studies that show that women who speak little or no English are given fewer choices and less information, and that health professionals tend to be paternalistic and insensitive towards them, concluding that: ‘They cannot give genuinely informed consent’ (Schott and Henley, 1996: p. The individual is seen as an integral part of the family or community and a woman has to consult her spouse, or other members of the family, and even elders, before consenting to medical or surgical procedures (Schott and Henley, 1996; NuYeld Council on Bioethics, 1999; de Zulueta, 2001). There are no clear guidelines for how long pre-test discussion should take, but it seems unlikely that all the issues referred to can be discussed in such a short time span. They point out the conXicts for the health professionals in providing an ‘ideal’ pre-test counselling practice with ‘the time and cost constraints of busy practices and managed care plans’.

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The protein mdm2 binds to p53 purchase suprax 200 mg with mastercard antibiotic and milk, preventing its action and transporting it from the nucleus to the cytosol cheap suprax 200 mg free shipping antibiotics klebsiella. Also buy discount suprax 100mg on line virus 69, mdm2 acts as a ubiquitin ligase and covalently attaches ubiquitin to p53, thus marking it for degradation by the proteosome. Increasing the amount of p53, which may initially seem a good way to treat tumours or prevent them from spreading, is in actuality not a usable method of treatment, since it can cause premature aging. Persistent infection causes irreversible changes, leading to carcinoma in situ and eventually invasive cervical cancer. Activating mutations in ras are found in 20–25% of all human tumours, and in up to 90% of specific tumour types. This cascade transmits signals downstream and results in the transcription of genes involved in cell growth and division. Ras is attached to the cell membrane by prenylation; prenylation is the addition of hydrophobic prenyl groups (3-methyl-2-buten-1-yl) to the protein to facilitate its attachment to the cell membrane (forming a ‘lipid anchor’). Mutations in the ras family of proto-oncogenes (comprising H-ras,N-ras and K-ras)are very common. Inappropriate activation of the gene has been shown to play a key role in signal trans- duction, proliferation and malignant transformation. Mutations in a number of different genes, as well as ras itself, can have this effect. Horizontal gene transfer (or lateral gene transfer) is any process in which an organism incorporates genetic material from another organism without being its offspring. Vertical transfer occurs when an organism receives genetic material from its ancestor. Amongst single-celled organisms, horizontal gene transfer may be the dominant form of genetic transfer. The bacterial protein LexA has been identified as playing a key role in the acquisition of bacterial mutations. While such mutations are often lethal to the cell, they can also improve the bacteria’s survival. If the bacterium produces the enzyme β-lactamase (penicillinase), the β-lactam ring of the antibiotic will be enzymatically ‘opened’ and rendered ineffective. Genes encoding these enzymes may be inherently present on the bacterial chromosome, or may be acquired via plasmid transfer (horizontal gene transfer); β-lactamase gene expression may also be induced by exposure to β-lactams. The production of a β-lactamase by a bacterium does not necessarily rule out all treatment options with β-lactam antibiotics. In some instances β-lactam antibiotics may be co-administered with a β-lactamase inhibitor. The peptidoglycan layer is important for cell-wall structural integrity, especially in Gram-positive organisms (Figure 20. The cross-linking (transpeptidation) of the peptidoglycan chains is facilitated by transpeptidases known as penicillin-binding proteins. Once the new peptidoglycan monomers are inserted, glycosidic bonds link these monomers into the growing chains of peptidoglycan. In the absence of antibiotic, peptidoglycan precursors signal a reorganisation of the bacterial cell wall, triggering the activation of autolytic cell-wall hydrolases. In the presence of antibiotic, a build-up of peptidoglycan precursors also triggers the digestion of existing peptidoglycan by autolytic hydrolases, but without the production of new peptidoglycan. They have been shown to catalyse a number of reactions involved in the process of synthesising cross-linked peptidoglycan from lipid intermediates and mediating the removal of D-alanine from the precursor of peptidoglycan; the enzyme has a penicillin-insensitive transglycosylase N-terminal domain (involved in the formation of linear glycan strands) and a penicillin-sensitive transpeptidase C-terminal domain (involved in the cross-linking of the peptide subunits). Trimetho- prim inhibits dihydrofolate reductase, the next step in the folic acid biosynthetic pathway (Figure 20. Sulphonamides and trimethoprim have been used for many decades as efficient and inex- pensive antibacterial agents, but resistance to both has spread extensively and rapidly, due to horizontal spread of resistance genes. Two genes, sul1 and sul2, mediated by transposons and plasmids, express dihydropteroate synthases that are highly resistant to sulphonamide. For trimethoprim, almost 20 phylogenetically different resistance genes, expressing drug-insensitive dihydrofolate reductases, have been characterised. They are efficiently spread as cassettes in integrons, and on transposons and plasmids. These same pumps can expel antibiotics and other drugs used in the therapy of infections. A complex formed by an inner- membrane transporter and a periplasmic adaptor protein contacts an outer-membrane channel tunnel. Interaction with the adaptor protein leads to an opening of the periplasmic entrance of channel tunnel prerequisite for a successful export. Interaction with the adaptor protein opens the entrance of the channel tunnel, allowing export of proteins or drugs. In contrast to the channel tunnel, the structure of the adaptor protein is unknown. It also easily develops acquired resistance, either by mutation in chromosomally encoded genes, or by the horizontal gene transfer of antibiotic resistance determinants. Hypermutation favours the selection of mutation-driven antibiotic resistance in P. Vancomycin has increasingly become a first- line therapy in resistant Staphylococcus aureus infections. Found on the mucous membranes and the skin of around a third of the population, it is extremely adaptable to antibiotic pressure. In the past 10 years, several infections caused by this organism have emerged in the community. In more serious cases, oral administration of metronidazole or vancomycin is the treatment of choice. The bacterium produces several known toxins, including enterotoxin (toxin A) and cytotoxin (toxin B), both of which are responsible for the diarrhoea and inflammation seen in infected patients; another toxin, binary toxin, has also been described. No part of this book may be reproduced in any form by any means,including photocopying,or utilized by any information storage and retrieval system without written permission from the copyright owner,except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U. Printed in China Library of Congress Cataloging-in-Publication Data Pocket medicine / edited by Marc S. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommenda- tions and practice at the time of publication. However,in view of ongoing research,changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions,the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particu- larly important when the recommended agent is a new or infrequently employed drug. To purchase additional copies of this book,call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. In an era of information glut, it will logically be asked,“Why another manual for medical house officers?

Any patient with a saturation <90% should be considered severely hypoxic and treated accordingly buy 200mg suprax amex antibiotic 825. It is best used serially to monitor the ef- fects of therapy on patients with mild to moderate disease buy genuine suprax line virustotalcom. Measurements can also be com- pared to predicted levels using nomograms that consider age generic suprax 200mg mastercard virus 58, sex, and height. The decision to obtain laboratory screening should be based upon the patient’s age, medication use, and other comorbid conditions. A directed history and physical examination, along with proper use of diagnostic testing, will help to differentiate these entities. The amount and route primarily depend upon the patient’s symptoms and degree of hypoxia. Patients with severe refractory hypoxia, altered mental status, severely increased work of breathing, and/or ineffective respi- rations are candidates for immediate intubation. Ketamine, in addition to its analgesic and anesthetic properties, is a bronchodilator and therefore should be considered the induction agent of choice in young asthmatics. In older patients with coronary artery disease, the cardiovascular risks of ketamine may outweigh the benefits. Suggested initial adult ventilator settings include FiO2 of 100%, tidal volume of 6-8 ml/kg, ventila- tory rate of 10, and inspiratory time/expiratory time (I/E) ratio of 1:3 or 1:4. In severe cases, pH can be further decreased and a sodium bicarbonate infu- sion initiated. If the former is suspected, the patient should be disconnected from the ventilator and manually ventilated at a slower rate (6 to 8 breaths per minute). Medications • Beta2 Agonists • Inhaled β2 agonists are the mainstay of therapy for acute asthma exacerbation. Albuterol is the most commonly used agent and is generally delivered by nebulizer. Onset of action is <5 min, and repetitive administration produces incremental effect. Administration is usually limited only by symptoms (tremor, tachycar- dia, nausea). It is thought to have similar efficacy to racemic albuterol but fewer nonrespiratory side effects. In these severe circumstances, terbutaline or epinephrine may be administered subcutaneously. Epinephrine should be used with caution in elderly patients and those with cardiovascular disease. It is not to be used as single agent therapy but has been shown to be effective for the treatment of severe asthma when added to albuterol. Inhaled ipratropium does not appear to result in signifi- cant systemic side effects unlike other anticholinergic agents such as atropine. Thus, it is possible that the same benefit may be obtained by simply using higher doses of albuterol without ipratropium. There is little immedi- 3 ate benefit because of the delayed onset of these agents (about 6 h). Corticosteroids are probably unnecessary in mild asthma, but should be given in moderate to severe cases and in any patient who does not respond promptly to inhaled β2agonists. There is no difference between these two medications in terms of effi- cacy or onset of action. Prednisone is less expensive and more easily administered and should be given to the majority of patients. Methylprednisolone is preferred in patients who are unable to take oral medications due to vomiting or respiratory distress. For patients already taking theophylline, a baseline level is mandatory before beginning acute therapy. The most recent data suggests that Mg benefits only the most severe asthmatic patients and should not be given routinely. Heli-ox is thought to improve laminar gas flow through airways, resulting in improved gas exchange and decreased work of breathing. Although early case reports were positive, subsequent clinical studies have shown little benefit and use of heli-ox remains controversial. Patients who don’t meet discharge criteria who have mild to moderate symptoms can be admitted to a ward bed. Patients with more severe symptoms should be admitted to a monitored bed where timely respiratory assessment and therapy is available. The majority of patients have components of both, although one of these entities will frequently domi- nate the clinical picture. Clinically 3 defined as productive cough lasting for at least 3 mo over 2 consecutive years. Etiology and Risk Factors • Cigarette smoking, including passive exposure to cigarette smoke, is by far the leading cause. Diagnosis • Clinical diagnosis is based on the presence of dyspnea, wheezing, and/or cough in a patient with a history of causative exposure and chronic, progressive symptoms. Patients may also have other signs such as a barrel chest and stigmata of chronic pulmonary disease such as clubbing. Respiratory infections, allergen exposure, contin- ued cigarette smoking, air pollution, and patient noncompliance are common causes. Treatment • To a large degree, this mirrors therapy for asthma (see “Asthma”) with some variations as discussed below. The most important aspect of therapy is to initiate rapid interven- tion for those patients with acute or impending respiratory failure. A safe approach in the nonintubated patient is to titrate oxygen to achieve satu- ration between 90-92%. As a result, administration of β2 agonists is more likely to be limited by adverse side effects. Trimethoprim-sulfmethoxazole, Pulmonary Emergencies 63 doxycycline, amoxicillin-clavulanate, azithromycin, or clarithromycin are ap- propriate choices for both acute bronchitis and outpatient pneumonia therapy. If pos- sible, sputum cultures should be obtained for all admitted patients to guide future antibiotic therapy. Part D: Pneumonia Pneumonia is an infection of the gas exchange segments of the lung parenchyma. It can cause a profound inflammatory response leading to airspace accumulation of puru- lent debris. Pneumonia costs are $8 billion annually, accounts for nearly one-tenth of all hospital admissions, and remains a leading cause of mortality in the United States. Etiology and Risk Factors • There are numerous risk factors as discussed in (Table 3D. Depending upon the etiol- ogy, they may also have night sweats, weight loss, myalgias, and localized extrapulmonary symptoms. History should focus on acuity symptom onset, presence of associated symptoms, recent travel history, immunization history, and comorbidities.

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