Clinical Director, University of Texas Medical Branch School of Medicine
Management History of LMP; normal cycle; number of hours since unprotected intercourse infection under the skin buy 0.5 mg colchidrint mastercard. Give supply of oral contraceptives if day 1 start at next period is planned; if started immediately advise extra precautions as below antibiotic for uti septra ds bactrim order generic colchidrint line. Emergency IUCD More effective than tablet contraception (prevents 99% of expected pregnancies); a copper IUCD can be inserted within 120h of unprotected sex infection vs virus discount colchidrint 0.5mg fast delivery. If exposure was >5 days previously it can be inserted up to 5 days after likely ovulation antibiotics for dogs purchase colchidrint 0.5 mg with mastercard, so is useful in women who present later. Insert under antibiotic cover, eg azithromycin 1g PO if screening results unavailable. It is thought to inhibit fertilization by toxic effects and to inhibit implantation. If for long-term use, coils with 380mm2 Cu have the lowest failure rates so should be used. Unaffected by enzyme inducers (p300), it is the method of choice for those taking them (but see below). A progesterone receptor moderator, it is unsuitable for use if on, or within 28 days of taking, an enzyme inducer (p300), if on antacids or drugs raising gastric pH, for those with severe asthma uncontrolled by oral corticosteroids. Use with caution if liver dysfunction, hereditary galactose intolerance, Lapp lactase deficiency, glucose-galactose malabsorption. Advise extra contraceptive precautions for 14 days for combined pills, 16 days for Qlaira, 9 days for progesterone only pills, if started or continued. Suitable for those with focal migraine and past thromboembolism, there are no medical contraindications to its use. If on, or within 28 days of, taking an enzyme inducer (p300), or with post-sexual exposure HIV prophylaxis, the dose is 3mg. It can be used more than once in 1 cycle; and can be used (but may be less effective) in same cycle after ullipristal acetate. Warn that effective contraception should be used until the next period; and that she should return if she suffers any lower abdominal pain or the next period is abnormal. Gynaecology 300 Combined hormonal contraceptives 1 Combined hormonal contraception (CHC) as vaginal ring, transdermal patch (p304), or pills (COCP) contain oestrogen with a progestogen, either in fixed ratio or varying through the month (phased). COCP Oestrogen content: Most contain ethinylestradiol, but alternatives are estradiol valerate (Qlaira) or mestranol (Norinyl-1). Low-strength preparations contain 20mcg ethinylestradiol and are used if there are risk factors for circulatory disease, or oestrogenic side effects from a higher dose. Use phased preparations for women who have bleeding problems with monophasic products. Consider using pills containing desogestrel, norgestimate, drosperidone or gestodene if symptoms such as acne, headache, breakthrough bleeding. Cyproterone acetate is licensed for the treatment of acne and does provide contraception. Contraceptive patch (eg Evra) Transdermal patch containing 20mcg ethinylestradiol and norelgestromin. Contraceptive vaginal ring (eg NuvaRing) Flexible ring which releases 15mcg/24h ethinylestradiol and etonogestrel. The woman inserts the ring into the vagina on day 1 of cycle, and leaves it in for 3 weeks. Reasons to avoid combined hormonal contraception9, Venous disease: Avoid if current/past VTE or sclerosing treatment to varicose veins. Use with caution if 1 risk factor, avoid if >1 of: age >35y, smoker (avoid if >35y and smokes >15/day), BMI >30kg/m2 (avoid if BMI >35kg/m2), family history of VTE in 1st-degree relative <45y (avoid if known thrombophilia), immobility (avoid if bed-bound or in plaster), superficial thrombophlebitis. Risk factors for CVD (use with caution if 1, avoid if >1: age >35y, smoker (avoid if smokes >40/ day), family history of arterial disease in first-degree relative <45y (avoid if atherogenic lipid profile), diabetes mellitus (avoid if vascular, renal, neurological, or eye complications), hypertension with BP >140/90mmHg (avoid if >160/95mmHg), migraine without aura (avoid if migraine with aura, migraine treated with ergot derivatives and those lasting >72h). If no alternative and breast cancer >5y ago with no known gene mutation, seek specialist advice. Avoid if postpartum and breastfeeding (can be used from 6 weeks if other methods unacceptable). For others, increase the dose to 50mcg ethinylestradiol and shorten pill/patch/ ring-free interval to 4d. There is no evidence that broad-spectrum antibiotics decrease efficacy of combined contraceptives. The background annual incidence is 2 per 100,000 women aged 20, and 20 per 100,000 for those aged 40. For those with migraine and CHC use, incidence of ischaemic stroke becomes 8:100,000 if aged 20; and 80:100,000 in those aged 40. Those with migraine with aura are known to be at special risk precluding use of combined Pills in these women (however, there is no problem with them using progesterone only or non-hormonal contraception). Other risk factors for ischaemic stroke include smoking, age >35yrs, BP, obesity (BMI >30), diabetes mellitus, dyslipidaemia, and family history of arterial disease <45yrs. Women known to have migraine should be warned to stop CHC immediately if they develop aura or worsening of migraine. If a woman has 1st migraine attack on CHC, stop it, observe closely: restart cautiously only if there are no sequelae and if migraine attack was without aura and there are no other risk factors (above).
UTI denotes symptomatic bacteriuria that may involve different GU sites (loin/suprapubic tenderness; fever; dysuria) virus and fever buy colchidrint with paypal. It is a cause of hypertension and can result in renal failure antibiotics for acne from dermatologist order 0.5 mg colchidrint visa, eg if the kidneys are congenitally dysplastic infection after wisdom teeth removal discount colchidrint american express. During micturition antibiotic 3rd generation order colchidrint 0.5 mg amex, urine may reflux up ureters, seen on a micturating cystogram (requires catheterization) or MAG3 scan (catheterization not needed)-grades: I Incomplete filling of upper urinary tract, without dilatation. Get a clean catch sample; bag urines have many false negatives and positives from vulvitis or balanitis. US: US is cheap, non-invasive, getting more accurate, and is worthwhile in 1st UTIs (a good prenatal scan may suffice); 351 sensitivity, specificity, positive predictive value, and negative predictive value for detecting reflux are 18%, 88%, 23%, and 83%, respectively. Treatment and prevention of urinary infections Antibiotic treatment Age <3 months: IV amoxicillin + gentamicin (below) or IV cephalosporin and ampicillin (to cover Listeria) (p106). Resistance to trimethoprim and ampicillin renders monotherapy insufficient in some places. In one study, children and infants were randomly assigned to once-daily gentamicin 5mg/kg/day28 or 2. Treating ureteric reflux If prophylactic antibiotics fail, ureteric reimplantation can reduce reflux, but scarring remains. Prevention Just one episode of reflux of infected urine may initiate renal scarring, so screening for bacteriuria is useless: damage is too quick. But once a UTI is suggested (eg by stix) treat it at once, before you know culture sensitivities, as renal damage may be about to happen. Example: trimethoprim prophylaxis (2mg/kg at night, max 100mg), eg while awaiting imaging-and sometimes indefinitely (optimum duration is unknown, but may be after 2 negative cystograms, if the indication is reflux). Prophylaxis can be stopped after reflux has been ruled out if there is no scarring. Avoid predisposing factors: Treat and prevent constipation Clean the perineum from front to back Avoid nylon underwear and bubble baths Encourage fluid intake and double micturition. If no RBCs seen but Labstix +ve for RBCs, consider haemo/myoglobinuria (OHCM p307). Tall T-waves and QRS slurring prompt urgent lowering of K+, with IV salbutamol 4mcg/kg or 5mg nebulized (2. Essence: Acute microangiopathic haemolytic anaemia (schistocytes, burr cells, OHCM fig 2 p327 & fig 3 p323), thrombocytopenia, renal failure + endothelial damage to glomerular capillaries. Treatment: Liaise early with paediatric nephrology unit as early dialysis may be required. The Child: Weakness, tiredness, vomiting, headache, restlessness, twitches, BP, hypertensive retinopathy, anaemia, failure to thrive, seizures, and coma. If glomerular filtration falls to 25% of normal, compensatory mechanisms to enhance phosphate excretion fail; resulting hyperphosphataemia promotes hypocalcaemia, so PTH rises, which enhances bone resorption to release Ca2+ in an attempt to correct hypocalcaemia. Also, the failing kidneys cannot convert enough 25-hydroxycholecalciferol to active 1,25-dihydroxycholecalciferol, so GI calcium absorption falls, so worsening hypocalcaemia. Avoid aggressive use of calcium-based phosphate binders and vit D derivates to prevent PTH oversuppression and development of adynamic bone disease. NB: there is little paediatric experience with calcimimetics, eg cinacalcet, that directly stimulate Ca2+-sensing receptors and potently suppress PTH secretion without increasing Ca2+. This combines with dietary phosphate to form calcium phosphate, which is expelled in faeces. If there are episodes of Ca2+, sevelamer may have a role (a synthetic calcium- and aluminium-free phosphate binder). Because normal bone requires adequate levels of PTH to promote bone modelling, oversuppression of PTH must be avoided to avoid adynamic osteodystrophy. Erythropoietin is indicated (sc in pre-dialysis and peritoneal dialysis patients, and IV if on haemodialysis). Blood tests: FBC, U&E (creatinine, K, bicarbonate, calcium, phosphate and albumin), complement (low C3, normal c4), ASOT/antiDNAaseB. Antinuclear factor (ANA), anti-DNA antibodies (if SLE suspected), anti-neutrophil cytoplasmic (ANCA) antibodies (if vasculitis suspected), syphilis serology, blood cultures, virology. MSU: Count RBCs, WBCs, hyaline, granular casts; red cell casts mean glomerular bleeding.
Nonimmune pregnant women exposed to rubella who will not consider therapeutic abortion virus with rash purchase colchidrint 0.5 mg with amex. For severe wounds or when there has been a delay in administration bacteria 1 urinalysis buy colchidrint without a prescription, 500 units is recommended antibiotics ending with mycin discount colchidrint on line. Snake bite (pit vipers) Antivenom (Crotalidae) polyvalent immune Fab infection control risk assessment colchidrint 0.5 mg with amex, ovine Tetanus Tetanus immune globulin Treatment of tetanus and postexposure prophylaxis of nonclean, nonminor wounds in inadequately immunized persons (less than two doses of tetanus toxoid or less than three doses if wound is > 24 hours old). Treatment of severe reactions to vaccinia vaccination, including eczema vaccinatum, vaccinia necrosum, and ocular 3 vaccinia. Prior to the administration of animal sera, patients should be questioned and tested for hypersensitivity. See the following references for an analysis of additional uses of intravenously administered immune globulin: Ratko TA et al: Recommendations for off-label use of intravenously administered immunoglobulin preparations. Manufacturers should be held legally accountable for failure to adhere to existing standards for production of biologicals. However, in the present litigious atmosphere of the USA, the filing of large liability claims by the statistically inevitable victims of good public health practice has caused many manufacturers to abandon efforts to develop and produce low-profit but medically valuable therapeutic agents such as vaccines. By 16 weeks, its fundus lies half way between the symphysis pubis and the umbilicus. At term the uterus lies a bit lower than at 36 weeks, as the head descends into the pelvis. NB: more false positives will occur with the simpler rule of weeks of gestation = cm from pubic symphysis to fundus. SFH Obstetrics Other reasons for discrepancy between fundal height and dates: Inaccurate menstrual history Multiple gestation Fibroids Polyhydramnios Adnexal mass Maternal size Hydatidiform mole. Signs consistent with pregnancy include a line of pigmentation, the linea nigra, extending in the midline from pubic hair to umbilicus. Striae gravidarum (stretch marks) can either be purple (new) or silvery-white (old). Note surgical scars, particularly from previous caesarean, laparotomy, and laparoscopy. Then assess fetal lie (longitudinal, oblique, transverse) in relation to the uterus. Presentation is the part of the fetus overlying the pelvic brim and is most commonly cephalic or breech. Midwives are skilled at palpation, and under 32 weeks of pregnancy it is often difficult, so ask them if you need help. Auscultation the fetal heart may be heard by Doppler US (eg SonicaidTM) from ~12 weeks and with a Pinard stethoscope from ~24 weeks. Engagement the level of the head is assessed in 2 ways: engagement, or fifths palpable abdominally. Engagement entails passage of the biggest diameter of the presenting part through the pelvic inlet. Fifths palpable abdominally states what you can feel, and makes no degree of judgement on degree of engagement of the head. In primigravida, the head usually enters the pelvis by 37 weeks, otherwise causes must be excluded (eg placenta praevia or fetal abnormality). Anatomia uteri humani gravidi tabulis illustrata (The anatomy of the human gravid uterus exhibited in figures). Obstetrics 6 Physiological changes in pregnancy Hormonal changes Progesterone, synthesized by the corpus luteum until 35 post-conception days and by the placenta mainly thereafter, decreases smooth muscle excitability (uterus, gut, ureters) and raises body temperature. Oestrogens (90% oestriol) increase breast and nipple growth, water retention, and protein synthesis. Vaginal discharge increases due to cervical ectopy, cell desquamation, and mucus production from a vasocongested vagina. Haemodynamic changes Blood: From 10 weeks the plasma volume rises until 32 weeks when it is 3. With increased venous dispensability, and raised venous pressure (as occurs with any pelvic mass), varicose veins may form. Vasodilatation and hypotension stimulate renin and angiotensin release-an important feature of BP regulation in pregnancy. Aorto-caval compression From 20 weeks the gravid uterus compresses the inferior vena cava (and to a lesser extent the aorta) in supine women, reducing venous return. Other changes Ventilation increases 40% (tidal volume rises from 500 to 700mL), the increased depth of breath being a progesterone effect. Breathlessness is common as maternal PaCO2 is set lower to allow the fetus to off-load CO2. Gut motility is reduced, resulting in constipation, delayed gastric emptying, and, with a lax lower oesophageal sphincter, heartburn.
Chemical carcinogens (particularly those in tobacco smoke) as well as azo dyes virus 4 year old dies order colchidrint 0.5mg free shipping, aflatoxins antimicrobial prophylaxis buy colchidrint 0.5mg low cost, asbestos bacteria prokaryotes purchase cheap colchidrint, benzene virus for mac buy generic colchidrint 0.5mg line, and radon have all been well documented as leading to a wide range of human cancers. Expression of virus-induced neoplasia may also depend on additional host and environmental factors that modulate the transformation process. These mammalian cellular genes, known as oncogenes, have been shown to code for specific growth factors and their corresponding receptors. These genes may be amplified (increased number of gene copies) or mutated, both of which can lead to constitutive overexpression in malignant cells. The bcl-2 family of genes represents a series of pro-survival genes that promotes survival by directly inhibiting apoptosis, a key pathway of programmed cell death. Another class of genes, known as tumor suppressor genes, may be deleted or mutated, which gives rise to the neoplastic phenotype. The p53 gene is the best-established tumor suppressor gene identified to date, and the normal wild-type gene appears to play an important role in suppressing neoplastic transformation. Of note, p53 is mutated in up to 50% of all human solid tumors, including liver, breast, colon, lung, cervix, bladder, prostate, and skin. In the remaining cases, however, early micrometastasis is a characteristic feature, indicating that a systemic approach with chemotherapy is required for effective cancer management. In patients with locally advanced disease, chemotherapy is often combined with radiotherapy to allow for surgical resection to take place, and such a combined modality approach has led to improved clinical outcomes. At present, about 50% of patients who are initially diagnosed with cancer can be cured. In contrast, chemotherapy alone is able to cure less than 10% of all cancer patients when the tumor is diagnosed at an advanced stage. Chemotherapy is presently used in three main clinical settings: (1) primary induction treatment for advanced disease or for cancers for which there are no other effective treatment approaches, (2) neoadjuvant treatment for patients who present with localized disease, for whom local forms of therapy such as surgery or radiation, or both, are inadequate by themselves, (3) adjuvant treatment to local methods of treatment, including surgery, radiation therapy, or both. Primary induction chemotherapy refers to chemotherapy administered as the primary treatment in patients who present with advanced cancer for which no alternative treatment exists. This has been the main approach in treating patients with advanced metastatic disease, and in most cases, the goals of therapy are to relieve tumor-related symptoms, improve overall quality of life, and prolong time to tumor progression. Studies in a wide range of solid tumors have shown that chemotherapy in patients with advanced disease confers survival benefit when compared with supportive care, providing sound rationale for the early initiation of drug treatment. However, cancer chemotherapy can be curative in only a small subset of patients who present with advanced disease. Neoadjuvant chemotherapy refers to the use of chemotherapy in patients who present with localized cancer for which alternative local therapies, such as surgery, exist but which are less than completely effective. At present, neoadjuvant therapy is most often administered in the treatment of anal cancer, bladder cancer, breast cancer, esophageal cancer, laryngeal cancer, locally advanced non-small cell lung cancer, and osteogenic sarcoma. For some of these diseases, such as anal cancer, gastroesophageal cancer, laryngeal cancer, and non-small cell lung cancer, optimal clinical benefit is derived when chemotherapy is administered with radiation therapy either concurrently or sequentially. One of the most important roles for cancer chemotherapy is as an adjuvant to local treatment modalities such as surgery or radiation therapy, and this has been termed adjuvant chemotherapy. The goal of chemotherapy in this setting is to reduce the incidence of both local and systemic recurrence and to improve the overall survival of patients. In general, chemotherapy regimens with clinical activity against advanced disease may have curative potential following surgical resection of the primary tumor, provided the appropriate dose and schedule are administered. However, drug treatment of human cancers requires a clear understanding of the differences between the characteristics of this rodent leukemia and of human cancers, as well as an understanding of the differences in growth rates of normal target tissues between mice and humans. For example, L1210 is a rapidly growing leukemia with a high percentage of cells synthesizing DNA, as measured by the uptake of tritiated thymidine (the labeling index). Because L1210 leukemia has a growth fraction of 100% (ie, all its cells are actively progressing through the cell cycle), its life cycle is consistent and predictable. Based on the murine L1210 model, the cytotoxic effects of anticancer drugs follow log cell-kill kinetics. As such, a given agent would be predicted to kill a constant fraction of cells as opposed to a constant number. Thus, if a particular dose of an individual drug leads to a 3 log 10 7 kill of cancer cells and reduces the tumor burden from 10 to 10 5 cells, the same dose used at a tumor burden of 10 cells reduces 2 the tumor mass to 10 cells. The cardinal rule of chemotherapy- the invariable inverse relation between cell number and curability-was established with this model, and this relationship is applicable to other hematologic malignancies. Although growth of murine leukemias simulates exponential cell kinetics, mathematical modeling data suggest that most human solid tumors do not grow in such an exponential manner. Taken together, the experimental data in human solid cancers support a Gompertzian model of tumor growth and regression. The critical distinction between Gompertzian and exponential growth is that the growth fraction of the tumor is not constant with Gompertzian kinetics but instead decreases exponentially with time (exponential growth is matched by exponential retardation of growth, due to blood supply limitations and other factors). The growth fraction peaks when the tumor is approximately one third its maximum size. Under the Gompertzian model, when a patient with advanced cancer is treated, the tumor mass is larger, its growth fraction is low, and the fraction of cells killed is, therefore, small. An important feature of Gompertzian growth is that response to chemotherapy in drug-sensitive tumors depends, in large measure, on where the tumor is in its particular growth curve. Finally, the antihormonal agents tamoxifen, anastrozole, and letrozole are effective in the adjuvant therapy of postmenopausal women with early-stage breast cancer whose breast tumors express the estrogen receptor (see Chapter 40 for additional detail). Relationship of tumor cell number to time of diagnosis, symptoms, treatment, and survival.
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