Mark Corson

By I. Innostian. Concord College.

Older children and adolescents are more likely to have chest pain buy 150 mg clindamycin with mastercard, easy fatigue and general malaise order clindamycin 150 mg online, exercise intolerance and abdominal pain buy cheap clindamycin 150mg, or even arrhythmias and syncope. On physical examination, infants might have pallor and appear dusky in addition to the findings of congestive heart failure signs. Respiratory distress is the next most common finding, fol- lowed by hepatomegaly and abnormal heart sounds or a heart murmur of mitral regurgitation. Jugular venous distension is more likely in older children, as this is an unreliable sign in the younger age group. Chest X-Ray Chest X-ray may show the presence of cardiomegaly and increased pulmo- nary vascular markings or frank pulmonary edema in almost half of patients (Fig. Arrhythmias such as ventricular or supraventricular tachycardia or atrio- ventricular block can also be seen. Echocardiography The typical findings include the presence of a dilated left ventricle with decreased systolic function in most patients (Chap. Echocardiography may also reveal the presence of mitral valve regurgitation and pericardial effusion. Pulmonary vasculature is prominent due to congested pulmonary venous circulation secon- dary to poor ventricular function due to myocarditis Laboratory Investigations The gold standard for the diagnosis of myocarditis historically has been endomyo- cardial biopsy. However, this is not routinely done due to the low sensitivity of the procedure (3 63%) and the often patchy involvement of the myocardium. Elevation of the cardiac enzymes especially involving cardiac troponins is posi- tive in about 1/3 of patients. Cardiac Catheterization This is not routinely performed in the workup of patients with myocarditis. The main indication for this procedure is to perform endomyocardial biopsy, which is invasive and has higher complication rate in younger age groups. It is estimated that about one quarter of pediatric patient cases of dilated cardiomyopathy is caused by acute myocarditis. The differential diagnosis of the presenting manifestations in infants include sepsis, metabolic disturbances, inherited metabolic disorders, mito- chondrial myopathies and anomalous origin of the left coronary artery from the pul- monary artery. The differential diagnosis in older children includes idiopathic and inherited cardiomyopathy, chronic tachyarrhythmia, and connective tissue diseases. This includes use of intravenous inotropic support with Dopamine, Dobutamine, and Milrinone. Intravenous after-load reducing agents like sodium nitroprusside are used in the acute intensive care setting. Diuretic therapy is usually used for those patients who present with congestive symptoms and signs. Oral therapy with afterload reducing agents is used in patients with more stable clinical condition who have persistent left ventricular dysfunction. Angiotensin- converting enzyme inhibitors such as captopril and enalapril, b-adrenergic blockers, and anticoagulant or antiplatelet medications are the main treatment modalities. Bed rest in the acute stage with close observation is the mainstay of treatment in mild and asymptomatic cases. Digitalis is avoided during the acute stage of the inflammation due to possible cardiac side effects such as ventricular arrhythmias, although it can be used in the chronic stage of the disease or in those who progress to dilated cardiomyopathy. Other therapies, such as the use of immunosuppressive therapy and immuno- modulating agents like intravenous immunoglobulin is still controversial. So far studies showed no benefit of steroids or other immunosuppressants in the long-term outcome of the disease. Patients who present with fulminant myocarditis or intractable arrhythmias may need mechanical support like extracorporeal membrane oxygenation, ventricular assist devices, or even heart transplantation. Prognosis The long-term outcome of patients with acute myocarditis varies by the initial pre- sentation. Torchen Patients who present with acute fulminant myocarditis have the best recovery outcome if they survive the initial acute stage, with full recovery of ventricular function in >90% of patients in one series. Overall, about 1/2 to 2/3 of pediatric patients with myocarditis show complete recovery, 10% have incomplete recovery and up to 25% either die or require heart transplantation. Case Scenarios Case 1 History: A previously healthy 3-year-old boy is brought to the emergency room because he has been having abdominal pain and vomiting for the last 2 days. Physical examination: The patient s physical examination shows that he has mild dehydration. Other causes such as endocarditis, myocarditis, or pericarditis must be considered. Final diagnosis: An echocardiogram is performed which shows dilatation of the left ventricle with decreased systolic function and moderate mitral regurgitation. It is usually preceded by a viral prodrome of either upper respiratory tract infection or gastro- enteritis. He recovers from the acute phase of the disease and is then discharged home on an oral ace inhibitor, aspirin, and a diuretic. Case 2 History: An 8-month-old infant is brought to the emergency room by ambulance after what is thought to be a brief seizure episode. This infant was previously healthy and was playing at home when she suddenly became limp and unresponsive for a few seconds prior to regaining consciousness. She had a preceding upper respiratory tract infection and low-grade fever 5 days prior to this episode. Physical examination: On physical exam, the patient is fully awake and alert with mild tachypnea. Investigative studies: Laboratory workup shows mildly elevated white cell count, with lymphocytic predominance. Differential diagnosis: The differential diagnosis remains quite broad at this time. However, the anion gap metabolic acidosis is more concerning; causes including hypoperfusion leading to lactic acidosis, diabetic ketoacidosis, and toxic ingestion must be considered.

Ensure that their dietary habits and patterns do not increase dental caries risk 3 discount 150 mg clindamycin amex. Maintain Good Nutriture Despite Oral Impairment Good nutrition is important to assure the consumption of the nutrients known to be essential for good eye and oral health as well as general health generic clindamycin 150 mg with mastercard. Many of the oral conditions listed previously conspire to limit food choices for these individuals cheap 150mg clindamycin overnight delivery. The lack of saliva makes it difficult to chew food and move it easily through the mouth in preparation for swallowing. If the oral tissues are sore, the physical form of the food may make it painful to bite or chew. However, when faced with the inability to eat the usual nutritious diet, people may adapt to a soft diet, which can be low in nutritional value. The therapeutic challenge is to provide food choices that help patients overcome the oral impediments while maintaining optimum nutriture. Table 8 provides food choice suggestions from each of the recommended food groups that will be nutritious and yet will help overcome specific oral impediments. These could include soothing beverages with meals, gravies on foods, soups, and soothing smooth deserts like ice cream and gelatin. Ensure That Dietary Habits and Patterns Do Not Increase Risk for Dental Caries The primary focus of dietary prevention of dental caries is to decrease the caries- promoting properties of the diet and enhance its protective qualities. Impaired oral clearance of food is the major factor contributing to increased caries in the patient with xerostomia. A dry mouth has a slower oral clearance, allowing carbohydrates prolonged contact with plaque bacteria, and increasing acid production. The important dietary factors include the following: frequency of meals and snacks; oral retentiveness of the diet; length of time between meal/snacks; and sequence of food consumption. Each time a carbohydrate is consumed, the salivary pH drops below the critical (49) level for 20 to 30 minutes, and in those with xerostomia, the pH may remain low for an extended period with little saliva available to help buffer the acids. If meals/snacks are frequent, the rate of demineralization will exceed the rate of remineralization and caries will result. Nutrition counseling should stress having fewer simple carbohydrate- containing snacks between meals to reduce caries risk and allow for dental enamel remineralization. Chewing provides a strong mechanical stimulus for saliva production and may help in alleviating dry mouth. When consumed at the end of a meal or snack, some foods help increase saliva, buffer or neutralize the acid challenge from bacteria, and help remineralize the tooth surface. These food sialagogues include cheese, sugar-free gum, and sugar-free artificially sweetened hard candy (50). If only as deserts when sweet snacks are oral hygiene procedures needed, they can follow. Never use slowly dissolving hard candies, lozenges, cough drops, or breath mints as they promote dental caries. Recent research has found a possible association between intake of omega-3 (n-3) fatty acids and dry eye syndrome (53). In a study of 32,470 women in the Women s Health Study, it was found that frequent eaters of fish such as tuna and salmon had a 17% lower risk of developing dry eye syndrome than those who ate little of these fish. Women who ate tuna or salmon at least five times a week had a 68% lower risk of developing dry eye. Although this data does not pertain directly to Sjogren s syndrome, it may be helpful to people suffering from dry eye to recommend that they increase their consumption of foods high in n-3 fatty acids (49). Green tea contains polyphenols that possess anti-inflammatory and anti- apoptotic properties in normal human cells. It may be that these polyphenols could provide protective effects against autoimmune reactions in salivary glands and skin as well. However, caution must be exercised, as too much tea can provide excessively high amounts of caffeine as well (58). The condition is rarely fatal, but its symptoms can severely compromise health and quality of life. Early diagnosis and treatment are extremely important in trying to prevent damage to major organs. Ocular and oral care is particularly important to prevent serious harm to eyes and teeth. Sjogren s syndrome: the diagnostic potential of early oral manifestations preceding hyposalivation/xerostomia. Abundant IgG4-positive plasma cell infiltration characterizes chronic sclerosing sialadenitis (Kuttner s tumor). Immunopathogenesis of primary Sjogren s syndrome: implications for disease management and therapy. Tolerance and short term efficacy of rituximab in 43 patients with systemic autoimmune diseases. Reproduction and gynaecological manifestations in women with primary Sjogren s syndrome: a case control study. Essential fatty acid status in cell membranes and plasma of patients with primary Sjogren s syndrome. Correlations to clinical and immunologic variables using a new model for classification and assessment of disease manifestations. Induction of salivary gland epithelial cell injury in Sjogren s syndrome: in vitro assessment of T cell derived cytokines and Fas protein expression. Xerostomia secondary to Sjogren s syndrome in the elderly: recognition and management.

Antioxidants neutralize free radicals as the natural by-product of normal cell processes order 150 mg clindamycin fast delivery. Free radicals are molecules with incomplete electron shells which make them more chemically re active than those with complete electron shells buy 150mg clindamycin overnight delivery. Exposure to various environmental factors generic clindamycin 150mg amex, including tobacco smoke and radiation, can also lead to free radical formation. Over time, such damage may become irreversible and lead to disease including cancer. Antioxidants are often described as mopping up free radicals, meaning they neutralize the electrical charge and prevent the free radical from tak ing electrons from other molecules. Because of the importance that involves using antioxidants as an alternative in the treatment and prevention of chronic degenerative diseases is useful to express the potential in the use and development of new drugs that include antioxidants. Free radicals are highly reactive chemical species that possess an unpaired electron. These reactions cause changes in the normal functions of these primary metabolites, which cause severe damage that can cause diseases such as can cer and degenerative diseases like Parkinsons disease or Alzheimers disease and athero sclerosis, coronary heart disease and diabetes [1-4]. When any of these afore mentioned diseases, the patient receive the treatment used to treat the particular disease, however, prevention plays a big role. Oxidation in the body tissues caused by free radicals can be prevented with a daily intake of foods that have antioxidants. The implications of modern life cause changes in eating habits of people, these results in a lack of antioxidants in the body to cope with free radicals that are in contact. The role of an tioxidants is to react with free radicals and thus prevent, to react with the primary metabo lites, thus acting as natural shields against diseases like cancer [5, 6]. Breast cancer Currently breast cancer is a disease of high incidence worldwide and causes millions of deaths annually [7]. In the treatment of various cancers have been used drugs that originate from natural products. To get to the application of the drug as a treatment, it requires years of research. The use of treatment leads to the destruction of cancer cells and normal cells in addition, there are numbers side effects resulting from the application of therapies. The simplest method to prevent cancer and other diseases is undoubtedly add to the diet foods that contain high concentrations of antioxidants, this treatment is easy to perform and causes no adverse side effects. Other organisms containing large amounts of secondary metabolites some of which can act as antioxidants and thereby help prevent cancer and pre vent its development (Fruits, vegetables, plants). Suppressing cancer by inhibiting the progressive stages after formation of pre-neoplastic cells [8]. Studies are underway to help better understand the mechanism of action of antioxidants and test its efficacy against cancer and other diseases. Several studies report that the addition to the diet of foods containing antioxidants may increase the effectiveness of cancer treatment, and help strengthen the body against the side effects associated with treatment [9-11]. The antioxidants found in fruits and vegetables can mention vitamins C and E, carotenoids group and the group of polyphenols. The following briefly discuss some results of studies using antioxidants from fruits and veg etables for the treatment of breast cancer. Another recent study [15], focused on the action of terpenes located in the skin of the olives suggests that they may serve as natural potential protective against breast cancer. The triter penes were isolated in significant quantities from the pulp of the olive oil and can act pro phylactically and therapeutically. Moreover, in mice treated with apigenin was observed a decrease of the tumor when compared with the group of mice used as a blank. Yet unknown mechanism of action of apigenin chemical, however, although the study was conducted in mice, is very promis ing for future treatment of breast cancer. Which are still unknown factors that cause this type of cancer, the disease also takes years in some cases to express symptoms, making it necessary for men to undergo regular medical examinations to detect early. One form of treatment of prostate cancer is surgery, whereby the prostate is removed, but this is a procedure which results in urinary incontinence and impotence, which in some cases is permanent. Prevention through diet prostate cancer has increased because it is recognized as a way to combat this disease [18, 19]. Among the foods that are recommended for the prevention of prostate cancer are generally fruits and vegetables due to its high content of antioxidants. Fruits like pomegranate containing metabolites such as polyphenols and delphinidin uroliti na A and B chloride, kaempferol, and punicic acid are considered biologically active against prostate cancer [20, 21]. These studies confirm the effectiveness of the cutter to inhibit growth of cancer cells. The apple is considered the quintessential fruit of health, its daily intake is associated with low risk of chronic diseases and cancer, particularly prostate and colon [24-26]. The block contains a variety of compounds polyphenolic that are responsible for their biological activi ty among these compounds, studies were performed with quercetin which has proven effec tive as an inhibitor in vitro cell growth of prostate cancer [23, 24]. Another study showed that the antioxidant activity of apples is correlated [27] with the total concentration of phe nolic compounds present in it clear that this concentration varies according to growing re gion, and other growth period factors [28-30]. It has been reported that tomato consumption reduces the occurrence of prostate cancer [33-35]. Another study used extracts of potato species Solanum jamesii to test their cytotoxic activity toward antiproliferatva and prostate cancer cells and colon in vitro. Fractions were also tested extract containing anthocyanin and it showed the same activity as the full extract [36]. Cervical cancer It is a type of cancer that has one of the top female deaths worldwide [37].

Findings of otitis media (dull tympanic Responds to verbal command 3 membrane order clindamycin 150 mg without prescription, uid behind the ear drum) may be discov- Response to pain 2 ered in cases of S buy clindamycin 150 mg on-line. The nasal passage and posterior pharynx may also reveal a M:Best motor Obeys commands 6 purulent discharge suggestive of sinusitis generic 150 mg clindamycin otc, an infection response Localizing response to pain 5 that less commonly leads to meningitis. Withdrawal response to pain 4 Flexion to pain 3 Auscultation of the heart may reveal a diastolic mur- Extension to pain 2 mur suggesting aortic insufciency, which would No motor response 1 strongly suggest bacterial endocarditis as the primary a Worst possible score is 3; best possible score is 15. Most cases of endocardi- tis complicated by meningitis are the result of infection category should be scored individually for example, with S. Interpretation: 13 mild brain injury; 9 12 moderate brain injury; 8 severe brain injury. About Clinical Manifestations in A thorough examination of the skin needs to be per- formed looking for purpuric lesions. Petechiae and pur- Bacterial Meningitis pura are most commonly encountered in patients with meningococcemia, but they may also may be found in 1. The ight leg raise) signs are insensitive; head jolt exact level of neurologic function should be docu- maneuver may have higher sensitivity mented by determining a Glasgow score (Table 6. The patient who is unrespon- nasal discharge resulting from a cere- sive to deep pain (Glasgow score 3) has a much higher brospinal uid leak (S. Focal nd- d) Neurologic exam should look for focal nd- ings such as hemiparesis, asymmetric pupillary response ings (suggests a space-occupying lesion) to light, or other unilateral cranial nerve decits are and assess mental status (Glasgow score is uncommon in bacterial meningitis, and they raise the an important prognostic factor). The nding of papilledema on fundo- If no focal neurologic decits are apparent, and if scopic exam is rare in meningitis and usually indicates papilledema is not seen on fundoscopic examination, a the presence of a space-occupying lesion. In very young patients, neonatal and infant Patients with bacterial meningitis who have not meningitis presents simply as fever and irritability. If the clinician has included Because bacterial meningitis causes marked inam- meningitis as part of the differential diagnosis, a lumbar mation of the meninges, glucose transport is impaired, puncture needs to be performed. Because this organism usually remains intracellu- About the Diagnosis lar, Gram stain is positive in only 25% of cases. If meningitis is a consideration, a lumbar punc- patients with a negative Gram stain. If focal neurologic decits and papilledema are absebt, a lumbar puncture can be performed exclude the possibility of bacterial meningitis. Opening pressure of the cerebrospinal fluid remains the most sensitive test for diagnosis. In patients over the age of poor penetration of antibiotics across the blood 60 years, maximal doses of ampicillin are added to the brain barrier. Intermediately resistant stains (penicillin third-generation cephalosporin to cover for L. This organism is not sensitive to cephalosporins, and cillin therapy; however, as the integrity of the blood brain penicillin or ampicillin are the treatment of choice. When intracranial pressure is documented by high-dose ceftriaxone or cefotaxime is recommended for lumbar puncture to be markedly elevated, intravenous intermediately penicillin-resistant S. Oral glycerol may also reduce cerebral edema, and For infections with highly penicillin-resistant S. Vancomycin penetrates the intact blood brain barrier These agents are administered only after the rst seizure. Rifampin combined with vancomycin may also be effective for the treatment of highly resistant S. The antibiotic response should be monitored in About the Treatment patients infected with highly penicillin-resistant pneu- mococci. In these patients, the lumbar puncture should of Bacterial Meningitis be repeated 24 to 36 hours after the initiation of therapy. Antibiotics should be given within 30 minutes if cyclines, and rst-generation cephalosporins should not bacterial meningitis is suspected. Dexamethasone also 3 months to 60 years is ceftriaxone or cefo- signicantly reduces the incidence of deafness. If with pneumococcal meningitis and Glasgow coma scores more than 60 years or immunocompro- of 8 to 11, dexamethasone administration (10 mg q6h mised, use ceftriaxone or cefotaxime, plus 4 days) was also found to reduce morbidity and mortal- ampicillin and vancomycin. Dexamethasone should be given just before or simul- b) nosocomial disease, is vancomycin and taneously with antibiotics, because inammatory media- ceftazidime or cefepime. Other inhibitors of otics in inammation, such as monoclonal antibodies directed a) children (shown to be efcacious in Haemo- against the adherence receptors of leukocytes, are poten- philus inuenzae). Additional therapeutic measures are primarily directed b) adults (efcacious in Streptococcus pneumo- niae with Glasgow coma score of 8 to 11). Mortality is higher in very States), and about half of these deaths could be prevented young and elderly individuals. The young patient at higher risk for developing invasive pneumococcal infec- whose brain is developing often suffers mental retarda- tion including meningitis and should be vaccinated. A single intramuscular or subcutaneous injection is pro- Prevention tective for 5 to 10 years. Permanent sequelae are common: bloodstream reduces the likelihood of seeding the meninges. Chemoprophylaxis use: to be short-lived, with antibody titers decreasing after 3 a) H. The incidence household contacts with unvaccinated child of meningococcal disease remains low in the United under 2 years of age, and for children under States (approximately 1 in 100,000 population), and 2 years of age exposed in a daycare center. Two days mised host and patients over 65 years of age who often later, she developed a sharp, throbbing bi-temporal develop a more rapid decline in protective antibody levels. Her headache Revaccination may considered after at least 5 years have was made worse by sitting up or moving. She also noted some muscle stiff- vaccine that is immunogenic in children under the age of ness in other areas in particular her lower back. She felt 2 years is recommended for routine pediatric immuniza- very tired and lost her appetite.