By R. Cruz. University of North Dakota--Lake Region. 2018.
Systemic antibiotics should be administered during a Acne is a disorder of the pilosebaceous units located on period of 8–12 weeks 160 mg super avana for sale. In severe papulopustular and in the face discount super avana 160mg, chest and back super avana 160 mg with visa. It is an almost universal disease purchase 160mg super avana free shipping, nodulocystic/conglobate acne, oral isotretinoin is the occurring in all races, predominantly among adolescents treatment of choice. Epidemiological studies have shown that about 70– alternative regimen in female acne, whereas it is manda- 87% of the adolescents experience acne lesions [5, 6]. The tory in resistant, severe pubertal or post-adolescent disease exhibits a peak incidence at 15–18 years of age. Compounds with anti-androgenic Spontaneous regression occurs in the majority of the properties include estrogens combined with progestins, patients after puberty, but in 10% of them acne persists such as ethinyl estradiol with cyproterone acetate, chlor- over the age of 25 years and can last up to the 4th decade of madinone acetate, desogestrel, drospirenone, levono- life, and even up to the 6th decade of life in some cases. In the years 1996–1998, more than 6 million els, corticosteroids, spironolactone, cimetidine, and ke- visits per year to office-based physicians with acne as the toconazole. After 3 months of treatment control of principal reason have been registered in the USA; the © 2003 S. Simplified acne severity grading for the therapeutic decision Severity Comedones Papules/ Small nodules, Nodules Inflammation Scar grade pustules cysts, fistules formation Mild few n or few Moderate numerous few to many n or few n marked n Severe numerous very numerous many n or few strong present Very severe fistule-comedones very numerous many few to many, very strong present deeply located patients received 6. The compliance of the different age ranges and the varying clinical pictures patient is an additional important parameter for the ther- require better knowledge of the pathogenesis of the dis- apeutic strategy to be considered and its success. Skin type ease and clinical experience for its treatment [1–5, 8], (dark skin tends to postinflammatory hyperpigmentation) especially since misconceptions regarding factors that ex- and, especially, the tendency for scar formation play a role acerbate acne vulgaris not only exist in the community in the selection of treatment. Two to 7% of the but have also been registered in last year medical students patients with acne experience a severe course associated in an Australian study. Several factors contribute to with considerable scarring. A severe course associated the pathogenesis of acne, among them increased seba- with the presence of potential generators of physical and ceous gland activity with hyperseborrhea, abnormal psychotic scars may require a therapeutic regimen based follicular differentiation and increased cornification, on systemic drugs [3, 18] (table 1). Each of these factors provides a potential Therapeutic Targets and Acne Drugs target for treatment. Genetic investigations have pro- vided ambiguous proof for hereditary factors; irregu- Several clinical observations point to the importance larities of the menstrual cycle, pregnancy, etc. Androgens play an essential influence on the acne course in females, and nutritional role in stimulating sebum production; androgen-insensi- factors are accused to modify acne in some patients. Moreover, mental factors may occasionally play a role. Several drugs systemic administration of testosterone and dehydro- can induce acne or acneiform lesions. Psychological epiandrosterone increases the size and secretion of seba- factors and stress have still no proven influence on the ceous glands [24–27]. Abnormal keratinization of the infundibulum and the distal part of the sebaceous duct can be directly influenced through topical and systemic retinoids as well as through Treatment of Acne: General Considerations topical application of azelaic acid. A number of fur- ther drugs can also secondarily induce keratolysis over The exact classification and grading of acne is a funda- their influence on other pathogenic factors. Benzoyl mental requirement for the decision of the therapeutic peroxide and topical and systemic antibiotics primarily regimen [1–4, 17–19]. In addition, acne at puberty needs exhibit antimicrobial, but also anti-inflammatory activi- subsequent prophylactic medication and care over several ties [32, 33]. Various agents administered in acne treat- years after clinical healing. Infantile and pediatric acne, ment exhibit direct or indirect anti-inflammatory activi- 38 Dermatology 2003;206:37–53 Zouboulis/Piquero-Martin Table 2. Different action profile of systemic anti-acne drugs on the four major Follicular Seborrhea Bacterial Inflammation pathogenic factors of acne hyperkeratosis hypercolonization Antiandrogens(s) – ++ – – Isotretinoin(s) ++ +++ (+) ++ Tetracyclines(s) – – ++ + +++ = Very strong, ++ = strong, + = moderate, + = indirect/weak.
In most cases of Mt cytopathy buy 160 mg super avana with amex, there is a dysfunction of Mt oxidative phospho- Pathogenesis rylation buy discount super avana 160mg. Oxidative phosphorylation is dependent on four enzyme complexes (Complexes I to IV) that comprise the electron transport chain order super avana 160 mg mastercard, and are neces- sary for generation of ATP cheap super avana 160 mg with mastercard. Both the nuclear and Mt genomes are necessary for generation of the oxidative phosphorylation complexes. Proteins for the eighty structural subunits are encoded in the Mt-DNA, and the remainder by genomic DNA. Thus the disorders can exhibit any mode of inheritance, including maternal, autosomal dominant, recessive, or sporadic. Laboratory: Diagnosis CK values may be mildly elevated, and there may be elevation in serum lactic acid levels. Electromyography: The nerve conduction studies are usually normal unless there is an associated neuropathy. In most cases of mitochondrial myopathy, the needle EMG is normal. In some cases there may be minimal evidence of increased spontane- ous activity, coupled with small motor unit action potentials. Muscle biopsy: The muscle biopsy may show increased lipid accumulations, glycogen accu- mulations, or excessive bundles of enlarged Mt. In general most muscle fibers show evidence of typical ragged-red fibers (Fig. Succinate Dehydrogenase (SDH) is the most sensitive and specific stain for Mt proliferation in muscle fibers. Trichrome stains are much less specific and sensitive for Mt proliferation than SDH. Cytochrome Oxidase (COX) stain identifies additional patients with Mt disorders. Scattered COX-fibers with ragged red fibers is consistent with a mtDNA mutation affecting Mt protein synthesis. Genetic testing: Genetic testing on serum, or more appropriately on muscle biopsy samples is extremely helpful in differentiating the specific Mt disorder. Aerobic training improves exercise tolerance, cardiovascular func- tion, and muscle metabolism in some patients. A variety of mitochondrial enzyme supplements have been tried with variable success. These include coenzyme Q, creatine, carnitine, thia- mine, nicotinamide, riboflavin, succinate, and menadione. Until the specific enzyme defects within a particular Mt myopathy are better defined, enzyme supplements will have a limited role in treatment of this disorder. Where there is isolated myopathy, pro- gression is usually slow and prognosis is good. References Barrientos A, Barros MH, Valnot I, et al (2002) Cytochrome oxidase in health and disease. Gene 286: 53–63 DiMauro S (2001) Lessons from mitochondrial DNA mutations. Seminars in Cell and Developmental Biology 12: 397–405 Nardin RA, Johns DR (2001) Mitochondrial dysfunction and neuromuscular disease. Muscle Nerve 24: 170–191 Schoffner JM (2000) Mitochondrial myopathy diagnosis. Neurologic Clinics 18: 105–123 413 Glycogen storage diseases Genetic testing NCV/EMG Laboratory Imaging Biopsy – ++ + – +++ Fig. The muscle contains vacu- oles filled with glycoprotein (ar- row) Fig.
Penicillin resistance is usually mediated by a plasmid-encoded β-lactamase B discount super avana 160 mg online. The frequency of penicillin resistance is significantly higher among HIV-infected patients than among others C generic 160 mg super avana with mastercard. Penicillin resistance is usually mediated by a chromosomally mediated β-lactamase D cheap 160mg super avana mastercard. Most penicillin-resistant pneumococci are also vancomycin-resistant E cheap super avana 160mg visa. Penicillin resistance is mediated by altered penicillin-binding proteins Key Concept/Objective: To understand the mechanism of penicillin resistance in Streptococcus pneumoniae Penicillin resistance among pneumococci is becoming increasingly common. The usual mechanism of resistance is alteration of penicillin-binding proteins, not production of either plasmid or chromosomal β-lactamase. Penicillin resistance is commonly associ- ated with resistance to other classes of antibiotics, further complicating treatment of such infections. The prevalence of penicillin-resistant pneumococci appears to be high- er in patients taking antibiotics, children younger than 6 years, and adults older than 65 years. A young woman presents to your office and states that her roommate has just been diagnosed with active tuberculosis. She recently had a fever, a nonproductive cough, and pleuritic chest pain. A chest x-ray shows no infiltrate, but there is a moderate-sized left pleu- ral effusion. Which of the following statements is true regarding this patient? If this patient has become infected, the most likely initial site of infec- tion is the lung apices 7 INFECTIOUS DISEASE 9 B. A test with purified protein derivative (PPD) should have 10 mm of induration to be considered positive D. If this patient does have tuberculous pleuritis, the diagnosis can be reli- ably made on the basis of an acid-fast smear of pleural fluid E. Tuberculosis is transmitted by inhalation of a tubercle bacillus into the pulmonary alveoli. Initial infection usually occurs in the lower lung fields, not the apices, because of gravity and the greater venti- lation of the lung bases. Reactivation (in an immunocompetent host) tends to occur in the apices because the bacillus has a propensity to disseminate to areas of higher Po2. About 90% of patients with primary tuberculosis infection are asymptomatic. Thus, pleuritis is fairly uncommon, as are the three other potential manifestations of symp- tomatic primary infection (atypical pneumonia, extrapulmonary tuberculosis, and direct progression to upper lobe disease). Patients who are HIV positive, who are immunologically suppressed, or who are in some way debilitated are at increased risk for symptomatic primary infection. Patients with tuberculous pleuritis present with a high fever, cough, and pleuritic chest pain. Only one third of patients will have a positive result on acid-fast smear of the pleural fluid; for two thirds of patients, noncaseating granulomas will be found on pleural biopsy. A 27-year-old man known to have HIV presents to the emergency department with fever, mild short- ness of breath, and a productive cough with streaky hemoptysis. Recent records show his CD4+ T cell count to be 150 cells/µl. A chest x-ray shows bilateral lower lobe consolidation. Results of acid-fast staining of the first sputum sample obtained are positive. Because this patient is immunocompromised and has lower lobe dis- ease, he most likely has a primary tuberculosis infection B. The infection should quickly improve if antiretroviral therapy is initiated C. Plans to initiate highly active antiretroviral therapy (HAART) do not affect the choice of antituberculous chemotherapy regimen D. Because the patient has HIV, he should receive an empirical four- drug regimen regardless of the rate of isoniazid resistance in his community E.
His appetite is still fairly good generic super avana 160mg with visa, but he has lost 10 lb over the past 2 months and is somewhat fatigued buy super avana 160 mg on line. His medical history is notable for hypertension buy super avana 160 mg without prescription, hyperlipi- 20 BOARD REVIEW demia order super avana 160mg free shipping, type 2 diabetes with retinopathy and mild neuropathy, and gastroesophageal reflux disease. His medications include metformin, insulin, atenolol, simvastatin, aspirin, and omeprazole. The neurologic examination is notable only for mild stocking-glove neuropathy, and an S4 is heard on cardiac exami- nation. Laboratory tests reveal macrocytic anemia and mild hypoalbuminemia. Which of the following is the most likely diagnosis for this patient? Chronic pancreatitis Key Concept/Objective: To understand the precipitants for the bacterial overgrowth syndrome This patient has a subacute to chronic presentation with steatorrhea and likely folate defi- ciency, vitamin B12 deficiency, or both. He has diabetes mellitus, which can cause stasis through autonomic neuropathy, which is not uncommon in a patient with other diabetic complications. Anything that causes intestinal stasis allows a proliferation of bacteria, which leads to changes in bile salt metabolism and impaired absorption, primarily of vita- min B12. In addition, this patient is taking a proton pump inhibitor, which can both reduce motility and change the acid milieu of the proximal small bowel, often precipitat- ing symptoms in a predisposed patient. Therapy usually entails repeated courses of antibi- otics active against anaerobes. There is no convincing evidence for the effectiveness of any of the other choices presented. A 38-year-old man with debilitating Crohn disease who is status post a 40 cm ileal resection presents for evaluation. He recounts progressive nonbloody diarrhea since his surgery 9 months ago, which is worse in the evening. He denies having abdominal pain, nausea or vomiting, fevers, chills, or sweats. He reports no recent travel, camping, or use of antibiotics. Chemistries show mod- est hypokalemia and a mild non–anion gap acidosis. Fecal fat quantitative analysis reveals minimal steatorrhea. Safflower oil before meals Key Concept/Objective: To understand the effects of ileal resection on absorption, and recognize the appropriate therapy to minimize these effects Ileal involvement is a common component of Crohn disease (regional enteritis) and may result in a poorly functioning ileum or even require resection. With moderate resections (30 to 100 cm), as in this case, malabsorption of bile salts is significant and results in bile salts entering the colon. This can lead to a secretory diarrhea known as choleretic enteropathy, the causal mechanism of which is bile salt-induced chloride secretion. Cholestyramine reduces the distal delivery of bile salts, thus lessening the diarrhea, and would be the most appropriate therapy in this patient. With larger ileal resections (> 100 cm), steatorrhea predominates, and cholestyramine may actually exacerbate the diarrhea. Therapy for patients undergoing larger resections is similar to that for patients with short bowel syndrome and includes antimotility agents such as loperamide and steps to increase the proportion of medium-chain fatty acids, which do not require bile salts for absorption. Safflower oil may also be used preprandially to act via peptide YY to slow gastric empty- ing, but it would be less useful in bile salt-induced diarrhea. Tetracycline is used to treat the bacterial overgrowth syndrome. A 54-year-old man presents with a 3-day history of left lower quadrant pain. He reports that his appetite has decreased and that he has been experiencing mild nausea.