Ralph Catalano PhD, MRP

• Professor of the Graduate School, Public Health

https://publichealth.berkeley.edu/people/ralph-catalano/

Amiodarone Chemotherapy agents Methotrexate Naproxen Nitrofurantoin Sulphonamides the pulmonary side effects of some of these commonly used drugs are discussed in Chapter 3 gastritis and diet pills purchase nexium with visa. A histological diagnosis will be required in many cases to make a definite diagnosis which will determine the management and prognosis gastritis diet ������ purchase 40 mg nexium amex. In advanced disease gastritis diet ��������� buy nexium 20mg on line, histology may be unhelpful as it will only show nonspecific lung fibrosis without any clues as to the aetiology gastritis with chest pain order nexium 40mg with amex. The differential diagnosis gastritis alcohol purchase nexium 20 mg fast delivery, therefore chronic gastritis forum 40 mg nexium, always includes infection, malignancy, and heart failure. The classification used is that adopted by the American Thoracic Society/ European Respiratory Society International Multidisciplinary Consensus and the British Thoracic Society and is listed in Box 7. It is rare in patients younger than 50 years old and is twice as common in men as in women. Crackles are usually first audible at the lung bases in the posterior axillary line. In advanced disease, patients may develop clinical signs of cor pulmonale, which includes a raised jugular venous pressure, a parasternal heave, a loud P2, peripheral oedema, and low oxygen saturation. Blood tests should be sent for full blood count, urea and electrolytes and autoimmune profile. Compliance can also be checked by looking at a urine sample which will turn an orange/red color if the patient is taking rifampicin. The recommended regime should be continued even if the culture results are subsequently negative. Approximately 9% of patients on these drugs develop significant sideeffects requiring all medication to be stopped and then reintroduced carefully, one at a time, to see which one has caused the problem. Patients with liver disease are at increased risk of hepatotoxicity, so should be monitored more closely. Hepatitis is the commonest sideeffect, resulting in the medications having to be stopped. Rifampicin blocks the excretion of bilirubin and results in an isolated increase in bilirubin which is not of concern. It is only of concern if the levels rise to greater than four times the baseline and if the patient becomes symptomatic. Tuberculin testing will be negative because they are unable to mount an immunological reaction as their T lymphocytes are not functioning. The side effects of the medication should be explained, and they should be advised to stop the medication if they develop symptoms, such as fever, vomiting, or severe rash. If they are on medication that may interact with rifampicin, for example, anticoagulants, anticonvulsants, steroids, or oestrogens, including the oral contraceptive pill, they need to understand the consequences. These patients are usually admitted to a negative pressure isolation room on the ward, commenced on anti tuberculous treatment and kept in isolation for two weeks. After this time, in most cases, they will no longer be considered infectious, although when the bacterial load is large, a longer period of isolation may be required. If there is any doubt about multidrug resistance, then the individual should be kept in isolation until the sensitivities are confirmed. Healthcare workers should wear a proper protective mask as should the patient if he or she were to go outside the room for any reason. It is important, therefore, to assess the close contacts of the index case to see if they might have contracted tuberculosis. This is important because contacts who might have been infected may not show any clinical symptoms which may later become activated. The Public 196 / Chapter 8: Respiratory infections Health consultant will be involved in any case of outbreak in the community. The Occupational Health Department will be involved in identifying and managing healthcare workers in any setting, for example, hospital or nursing home. Latent tuberculosis Individuals who are exposed to the organism but do not develop active disease are considered to have latent tuberculosis. These individuals are at risk of reactivation of tuberculosis at a later stage, for example, when they are older or become immunocompromised. As discussed earlier, there is a risk of a rise in liver enzymes, therefore liver function tests should be checked prior to starting treatment and one week later. Older children need Heaf testing to demonstrate a negative response before immunisation. The diagnosis is confirmed by observing the acidfast bacilli and culturing the organism from the samples. Histopathology will show granuloma containing epithelioid macrophages, Langerhans giant cells and lymphocytes, with caseation in the centre. The lymph nodes will start to shrink two to three months after treatment is started. Miliary tuberculosis results from the haematogenous dissemination of mycobacterium tuberculosis to many organs. In patients who present with miliary tuberculosis, evidence of involvement of other Table 8. Histology of peritoneum, ascitic fluid or biopsy of appendix mass will show caseating granuloma. Mycobacterium abscessus Opportunistic (atypical) mycobacterium Opportunistic mycobacteria, often called atypical mycobacteria, are saprophytes that are found in the environment; in soil and water. These organisms only cause disease in those who are immunocompromised or those with chronic lung disease. These organisms are not infectious and therefore cannot be caught by close contacts. Surgery in the form of lobectomy or pneumonectomy may be an option in those with heterogeneous disease, who are fit for major surgery. Viral infections of the upper respiratory tract are responsible for the common cold, laryngitis, and tracheobronchitis; these can be troublesome in infants and young children. Community acquired pneumonia is a common presentation to general practice and to hospitals and is caused by a vari ety of bacteria. It is essential for individuals to complete treatment as oth erwise there is a risk of multidrug resist ance and poorer outcomes. Antituberculous medications have side effects, including hepatitis, so monitoring is required. Antituberculous medications interact with many other drugs through the cytochrome P450 enzyme system. Atypical mycobacteria are only pathogenic in immunocompromised individuals and those with chronic lung diseases. Elderly and immunocompromised patients may not present with cough and fever as they are unable to mount an immune response. Patients who are immunocompromised do not always present with the classic symptoms of an infection. Patients with sickle cell disease are at risk of developing Streptococcus pneumonia infection so should have the vaccine against this organism and take prophylactic penicillin V. E Fast acetylators are more likely to develop hepatitis than slow acetylators Answer: C Chapter 8: Respiratory infections / 203 Isoniazid is the drug most likely to cause hepatitis but adding in rifampicin increases the risk. Liver enzymes should be measured before starting the drugs and again two weeks after starting treatment. Genetic polymorphism means that low acetylators are more likely to develop liver failure than fast acetylators. Although there is little evidence that it offers protection to adults, it is often offered to healthcare workers. Diagnosis is made on silver staining or florescent staining but it cannot be cultured. Guidelines for the management of adults with hospital acquired, ventilatorassociated, and healthcare associated pneumonia. Prognosis and outcomes of patients with communityacquired pneumonia: a metaanalysis. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Guidelines for the treatment of community acquired pneumonia: predictors of adherence and outcome. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. Adeno carcinoma in situ, previously known as bronchoal veolar cell carcinoma (5%), arises from the alveolar cells. Metastases to the lungs from other primary tumours, such as breast, colon, prostate, kidneys, ovary, and thyroid can also occur. Lung cancer has a poor prognosis because many types are rapidly growing, aggressive, and have usually metastasized at the time of presentation. In addi tion, lung cancer often presents late because many of the symptoms, such as cough and breathlessness, are nonspecific and common in smokers. Current studies are evaluating whether screen ing is feasible, costeffective, and likely to reduce mortality. Lung cancer has overtaken breast cancer as the leading cause of cancer deaths in women. There is a higher prevalence of lung cancer in the North of England and Scotland compared to the South of England reflecting the higher prevalence of smoking in those areas. Lung can cer is also commoner in the lower socioeco nomic groups: this may be due to smoking habits as well as poor nutrition. Survival: the overall 1year survival for lung cancer is still only 30% in men and 35% in women with a 5year survival of only 9. There has been no convincing reduction in mortality despite some advances in diagnosis and treatment and the introduction of guidelines, pathways, and multidisciplinary working. The probability of developing lung cancer correlates to the number and duration of cigarettes smoked, quantified as the number of pack years. The earlier the onset of smoking, the higher the risk of developing lung cancer, as there is a 30year latent period. The risk of developing lung cancer is halved every 5 years after smoking cessation but remains higher than for a nonsmoker. However, rates of smoking and lung cancer are increasing in China, India, and other developing countries. In the past decade, evidence has accumulated that passive smoking, caused by exposure to the cigarette smoke from others, increases the risk of lung cancer 1. Children are particularly vulnerable to the effects Chapter 9: Lung cancer / 209 of smoking, especially in places with little ventila tion, such as cars. Chapter 15 discusses the carcinogenic proper ties of cigarette smoke and the seminal studies by Hill and Doll establishing the link between lung cancer and smoking. Asbestos exposure and smoking act synergistically and increase the risk of lung cancer 100 times compared to a nonsmoker. Asbestos exposure is also a risk factor for mesothelioma, a malignant tumour of the pleura, which is discussed in Chapter 10. Basic investigations, such as a chest Xray, should be conducted without delay and the Box 9. Areas of dysplasia can be visualised at bronchos copy using fluoroscopy, but this is still largely a research tool. The cancer initially invades local tissues, spread ing to the parenchyma, pleura, pericardium, oesophagus, ribs, and muscle. This can result in cough, pain, breathlessness, dysphagia and pleural and pericardial effusions. Invasion of local nerves can cause vocal cord palsy (left recurrent laryngeal nerve), raised hemidiaphragm (phrenic nerve), and brachial plexus symptoms. The tumour can also spread to lymph nodes via the lymphatics and metastases to distant sites occurs haematogenously. Clinical presentation of lung cancer Lung cancer is a common condition, so all health care professionals should be alert to the possibility that patients with risk factors for lung cancer or a family history of malignancy, and who present with certain symptoms, may have lung cancer. Lung can cer can present with local or systemic symptoms, some of which are nonspecific. If this fails, then pharmacological agents, such as demeclocycline, a vasopressin inhibitor or tolvaptan, a selective V2 receptor antagonist can be used. Hypercalcaemia secondary to malignancy responds well to intravenous fluids, intravenous diuretics, steroids 212 / Chapter 9: Lung cancer (prednisolone or dexamathasone), and intravenous bisphosphonate, such as pamidronate. Invasive contrast venography and Doppler scanning may be helpful in assessing the extent of the obstruction. Manage ment depends on the patient and the imaging, but includes commencing dexamethasone (up to 8 mg twice a day), after tissue biopsy if possible. Inser tion of a metallic stent by an interventional radiol ogist can be considered in an emergency, and anticoagulation must be considered if there is thrombus present. Management of a patient suspected of having a lung malignancy Lung cancer has a poor prognosis because patients often present late with evidence of local or distant metastases.

Side effects include N/V gastritis and esophagitis buy cheap nexium 20mg, diarrhea gastritis remedy food generic 40mg nexium free shipping, anorexia gastritis symptoms belching purchase nexium 20mg fast delivery, dryness of mouth gastritis healing time buy nexium 20 mg low cost, hypersecretion gastritis symptoms hemorrhage discount nexium 40 mg with amex, arrhythmias gastritis zinc purchase nexium 20 mg line, syncope, angina-like symptoms, bradycardia, edema, dyspnea, epistaxis, nasal congestion, dizziness, headache, paradoxical anxiety, depression, nervousness, nightmares, drowsiness, myalgias, weight gain, deafness, and pruritus. It can increase neonatal respiratory tract secretions and cause nasal congestion, cyanosis, and anorexia. Although it is unclear whether reserpine is a human teratogen, rodent studies reveal evidence of teratogenicity and embryotoxicity. Increased respiratory tract secretions, nasal congestion, cyanosis, and anorexia can occur in breastfed infants. Should be used cautiously with digitalis and quinidine, because cardiac arrhythmias have occurred with rauwolfia preparations. Use with other antihypertensive agents necessitates careful titration of dosage with each agent. There are no adequate reports or well-controlled studies of reteplase in pregnant women. The published experience is limited to two case reports associated with life-threatening thrombosis. Rodent studies showed no evidence of teratogenicity, but there was an increased risk of genital hemorrhage and abortion. However, considering the indication and dosing, one-time reteplase use is unlikely to pose a clinically significant risk to the breastfeeding neonate. R Mechanism Dosage With Qualifiers Maternal Considerations Fetal Considerations Breastfeeding Safety 768 Drug Interactions Interaction with other cardioactive drugs has not been studied. In addition to bleeding associated with heparin and vitamin K antagonists, drugs that alter platelet function. Its assessment is based more on experience than on well-designed comparative trials, but it is estimated to have reduced perinatal mortality by about 10,000 cases/y in the United States alone. A meta-analysis of six trials involving more than 10,000 women demonstrated the efficacy of prophylaxis after delivery of an Rho(D)-positive infant to an Rho(D)-negative woman, reducing sensitization from 10% to 1. The addition of antenatal prophylaxis reduces the rate of sensitization further, down to <0. Criteria for an Rh-incompatible pregnancy requiring treatment includes mother Rho(D)-negative, not previously sensitized to the Rho(D) factor; neonate Rho(D)positive and direct antiglobulin negative. It is generally recommended that Rho(D) immune globulin should be administered to all nonsensitized Rh- women after spontaneous or induced abortion, ruptured tubal pregnancy, chorionic villus sampling, amniocentesis, abdominal trauma, or any occurrence of transplacental hemorrhage unless the fetus is known to be Rho(D)-negative. However, there is minimal evidence that administering Rh immune globulin for first-trimester vaginal bleeding prevents maternal sensitization or the development of hemolytic disease of the newborn. If Rho(D) immune globulin is given antenatally, it is essential the mother receive another dose after delivery of an Rho(D)-positive infant. If the father is known and Rho(D)-negative, Rho(D) immune globulin is unnecessary. Rho(D) immune globulin should be given within 72 h of delivery or abortion (spontaneous or iatrogenic). Passively acquired anti-Rho(D) may be detected after delivery following antenatal treatment; however, the woman should be treated again postpartum if the neonate is Rho(D)-positive. Fetal Considerations There is no evidence of fetal harm after extensive clinical experience. Babies born of women given Rho(D) immune globulin antepartum may have a weakly positive antiglobulin test at birth. There is no credible evidence that the risk of autism is increased by antenatal exposure. Rho(D) immune globulin is excreted into human breast milk, but the amount of intact antibody detectable in the neonate is too low to cause clinically relevant hemolysis. Other antibodies contained in Rho(D) immune globulin may interfere with the response to live virus vaccines such as measles, mumps, polio, or rubella. Breastfeeding Safety Drug Interactions References R Summary Ribavirin Drug Class Indications Mechanism 770 - (Rebetol; Viramid; Virazid; Virazole) International Brand Names Log on to ExpertConsult. The application of blood product screening has virtually eliminated transfusion-related viral transmission. As a result, maternal-fetal transmission is now one of the most important modes of transmission. The published experience with ribavirin during pregnancy is limited to case reports. Patients with chronic hepatitis whose therapy can be delayed should not be treated until controlled studies are available. However, women exposed to ribavirin inadvertently during pregnancy may be encouraged to continue pregnancy. In patients with acute hepatitis C during pregnancy, the use of ribavirin therapy should be considered with close monitoring. Initial evidence from the Ribavirin Pregnancy Registry does not suggest human teratogenicity for ribavirin. However, the current sample size is small and insufficient to draw reliable conclusions. The major mode of acquisition has shifted from parenteral to maternal-infant transmission. There are reports of fatal hepatic failure, as well as peripheral neuropathy, pancreatitis, and symptomatic hyperlactatemia/lactic acidosis. The maternal concentration of riboflavin does not decline during normal, unsupplemented pregnancy. Riboflavin is actively transported across the human placenta with a transfer index (clearance riboflavin:clearance L-glucose) in the isolated cotyledon of 3. Observational studies note a positive relationship between maternal riboflavin levels and fetal size. There is no substantive evidence riboflavin is a teratogen, though epidemiologic study suggests low intake may be associated with congenital heart disease. Riboflavin is excreted into human breast milk, and the concentration is proportional to the maternal concentration. Women who do not drink milk are more likely to have low concentrations of riboflavin in their breast milk. Summary Rifabutin Drug Class Indications Mechanism - (Ansamycin; Mycobutin) International Brand Names Log on to ExpertConsult. In healthy nonpregnant women, rifabutin and rifampin significantly increase the clearance of ethinyl estradiol, suggesting women who use low-dose oral contraceptives should either switch to a higher dose or use a backup contraceptive method while taking rifabutin. Side effects include thrombocytopenia, neutropenia, leukopenia, uveitis, rash, N/V, abdominal pain, headache, dyspepsia, diarrhea, belching, discolored urine, taste changes, fever, anorexia, myalgias, asthenia, flatus, chest pain, and insomnia. The related drug rifampin is known to reduce the activity of a number of other drugs, including analgesics, anticoagulants, cardiac glycoside preparations, corticosteroids, cyclosporine, dapsone, narcotics (including methadone), oral contraceptives, oral hypoglycemic agents (sulfonylureas), and quinidine. Rifampin has also been reported to decrease the effects of anticonvulsants, barbiturates, -adrenergic blockers, chloramphenicol, clofibrate, diazepam, disopyramide, ketoconazole, mexiletine, progestins, theophylline, and verapamil. However, unlike rifampin, rifabutin appears not to affect the acetylation of isoniazid. Patients using oral contraceptives should consider changing to nonhormonal methods of birth control. References Summary Rifampin - (Abrifam; Aptecin; Corifam; Fenampicin; Rifadin; Rifamate; Rifamed; Rifampicin; Rifamycin; Rifarad; Rifocina; Rifumycin; Rimactane; Rimpacin; Syntaxil; Syntoren; Tibirim; Visedan) International Brand Names Drug Class Log on to ExpertConsult. A threedrug regimen of rifampin, isoniazid, and pyrazinamide is recommended for the initial 2-mo treatment phase. All pregnant women taking isoniazid should also take pyridoxine to reduce the chance of a "chemical" hepatitis. There are no adequate reports or well-controlled studies of rifampin in pregnant women. A long clinical experience suggests pregnancy does not increase the risk of an adverse effect. R Indications Mechanism Dosage With Qualifiers Maternal Considerations 774 Rifampin may cause hemorrhage in the mother and neonate when administered during the third trimester. Due to its interaction with various metabolic enzymes and transporters, rifampin is known to alter the plasma level of a large number of drugs. Women using oral or other systemic hormonal contraceptives should be advised to change to nonhormonal methods of birth control. Enalapril decreases concentrations of enalaprilat, the active metabolite of enalapril. The potential for hepatotoxicity increases when used with either halothane or isoniazid. Breastfeeding Safety Drug Interactions R References Summary 775 Rifapentine International Brand Names None identified. It must be taken in tandem with at least one other antituberculosis drug to which the isolate is susceptible. There are no adequate reports or well-controlled studies of rifapentine in pregnant women. Rifapentine is teratogenic in rodents when given at doses similar to those given to humans, affecting bone, heart, spine, and palate (species dependent). The clearance of indinavir increased by threefold in the presence of rifapentine, whereas t/2 did not change. Rifapentine should be used with extreme caution, if at all, in patients who are also taking protease inhibitors. Patients using oral or other systemic hormonal contraceptives should be advised to change to nonhormonal methods of birth control. Enzyme induction occurs within 4 d, and return to baseline occurs 14 d after discontinuing rifapentine. The magnitude of enzyme induction by rifapentine is dose and dosing frequency dependent. Maternal Considerations Fetal Considerations Breastfeeding Safety Drug Interactions R References Summary 776 Riluzole None identified. Side effects include hepatotoxicity, asthenia, N/V, diarrhea, rhinitis, headache, abdominal pain, weight loss, tachycardia, worsening of spasticity, insomnia, cough, paresthesias, edema, and depression. Fetal Considerations Breastfeeding Safety Drug Interactions References Summary R Rimantadine International Brand Names Drug Class Indications Mechanism - (Flumadine) Log on to ExpertConsult. Prophylaxis is not a substitute for vaccination, although it is an important adjunct. When used for prophylaxis, antiviral agents can prevent illness while permitting subclinical infection and the genesis of protective antibodies. Rimantadine reduces the duration of the illness if administered within 2 d of symptom onset should an unprotected woman contract influenza A. It does cross the rodent placenta and is initially concentrated in the fetal liver. Until further study, breastfeeding women who choose to take rimantadine should probably stop feeding and pump until 48 h after discontinuing the drug. Maternal Considerations Fetal Considerations Breastfeeding Safety Drug Interactions References Summary R Risedronate International Brand Names Drug Class Indications Mechanism - (Actonel) Log on to ExpertConsult. Side effects include headache, irritability, nervousness, menstrual irregularities, sweating, increased bowel motility, shock, insomnia, tremor, tachycardia, arrhythmia, weight loss, heat intolerance, and diaphoresis. The available published data are reassuring, revealing no evidence of skeletal abnormalities or other congenital malformations. Use with calcium, antacids, or oral medications containing divalent cations will interfere with the absorption of risedronate. Maternal Considerations Fetal Considerations Breastfeeding Safety Drug Interactions References Summary Risperidone International Brand Names Drug Class Indications Mechanism Dosage With Qualifiers - (Risperdal) R Log on to ExpertConsult. Risperidone and its metabolite cross the placenta, though the kinetics remain to be determined. The observed increased neonatal mortality may relate to either the drug or maternal toxicity. A study in rats suggested that maternal exposure to clinically relevant doses of risperidone may induce neurostructural changes in developing hippocampus and striatum and cognitive sequelae in young offspring. There are case reports of its use in breastfeeding women without apparent adverse effect. Chronic administration of clozapine with risperidone may decrease the clearance of risperidone.

Increased markers of neutrophilic inflammation were found in the sputum of those with bronchiectasis and vitamin D deficiency gastritis morning nausea buy nexium 40 mg with visa. Recurrent aspiration pneumonia is a common cause of bronchiectasis in the elderly bile gastritis diet purchase nexium 20 mg online. The risk of aspiration pneumonia is increased in patients with reduced consciousness chronic gastritis raw vegetables cheap 40 mg nexium mastercard, for example gastritis dietitian discount 20mg nexium overnight delivery, after a stroke gastritis diet recommendations buy discount nexium line, after a seizure gastritis diet 9 month buy generic nexium 20 mg on-line, or when intoxicated with alcohol or other drugs. Foreign body aspiration is more likely to occur in small children and the elderly. Common items aspirated include small toys, nut and seeds in children, and bones and a bolus of food in the elderly. There is usually a history of choking and coughing preceding the development of chronic symptoms, often weeks earlier. The foreign body is more likely to enter the right lung and lodge in the middle lobe. In some cases, if the foreign body Chapter 12: Suppurative lung disease / 297 Table 12. Tracheobronchomalacia (WilliamsCampbell syndrome) and tracheobronchomegaly (Mounier Kuhn syndrome) are diffuse or segmental weaknesses of the trachea or main stem bronchi due to anatomic defects of the airways arising from a deficiency of cartilage in the fourth to sixth order bronchi. This results in inefficient clearance of respiratory secretions and predisposes to the development of bronchiectasis. The diameter of the trachea (measured 2 cm above the main carina) will be greater than 3 cm, the right main bronchus greater than 2. Symptoms of bronchiectasis occur years after the diagnosis of the underlying condition is made. It is assumed that optimal treatment of the underlying systemic disease will prevent the deterioration of bronchiectasis, although there are no studies supporting this assumption. Congenital hypogammaglobulinaemia and selective immunoglobulin deficiencies present with recurrent upper and lower respiratory tract infections in childhood and, if undetected, will result in bronchiectasis. It is not clear whether an isolated IgG subclass deficiency, for example, IgG2 deficiency, can result in bronchiectasis as the levels of these vary greatly in normal adults. Investigation for bronchiectasis includes measurement of IgG, IgA, and IgM with serum electrophoresis and other specialist immunology assessments as indicated. Immunoglobulin deficiencies can be managed with intravenous or subcutaneous immunoglobulin replacement therapy, vaccination as well as prompt treatment of infections. If baseline levels are low, the adequacy of the humoral response should be assessed by immunisation with the appropriate vaccines and re measurement of antibody levels after four weeks. Immunoglobulin deficiency can occur because of haematological malignancies, such as lymphoma and myeloma. Diagnosis of bronchiectasis A careful history of presenting complaints, childhood infections, past medical history and family history should be taken. Information about hearing loss, sinusitis, gastrointestinal symptoms, and infertility should be ascertained. Only 2% of patients with bronchiectasis will have finger clubbing, although the majority will have coarse crackles on auscultation. The diagnosis of bronchiectasis is made on clinical history and radiological appearance. Airway dilatation results in the appearance of parallel lines, referred to as tram lines, and ring shadows when the airway is seen in crosssection. With severe bronchiectasis there is the formation of cysts, and this is termed cystic bronchiectasis. A tree in bud appearance is often seen with nontuberculous mycobacterial infection. Individuals with severe bronchiectasis may develop type 1 respiratory failure, with hypoxia and normocapnia on arterial blood gas measurement. The result of the shuttle walking test correlates well with the severity of bronchiectasis and may be of prognostic value. Shuttle walking test can be used to monitor the response to treatment and is used as an endpoint in many trials. Differential diagnoses of bronchiectasis the differential diagnosis of bronchiectasis includes other conditions which cause bronchial wall dilatation. Traction bronchiectasis describes stretching and distortion of bronchi due to pulmonary fibrosis, and is discussed in Chapter 7. Management of bronchiectasis the management of bronchiectasis depends on the underlying cause. For example, bronchiectasis that occurs due to immunodeficiency will respond to intravenous or subcutaneous immunoglobulin therapy. However, there are several evidencebased treatments that improve symptoms, reduce the frequency of infections, thus preventing further bronchial wall damage. The aim of the management of bronchiectasis is to improve the symptoms of breathlessness and productive cough, and to prevent recurrent chest infections. Longacting bronchodilators, in combination with inhaled corticosteroids, should be Chapter 12: Suppurative lung disease / 301 Box 12. Short acting bronchodilators will improve the symptoms of breathlessness and wheeze. There is no evidence for the routine use of oral corticosteroids in the management of chronic bronchiectasis. Pulmonary rehabilitation is effective in bronchiectasis, as it is in all chronic respiratory diseases, and will result in improvement in exercise tolerance and quality of life measures. Pulmonary rehabilitation has been shown to improve endurance capacity, breathlessness, the distance walked in the shuttle walk test, and the sixminute walk test. Nutritional supplementation with a high protein diet may benefit those with bronchiectasis which is often associated with a poor appetite and weight loss. The recurrent infection and raised inflammation drive a catabolic process, therefore extra calories are required. Supplementation with hydroxylbetamethylbutyrate, which has anti inflammatory and anticatabolic effects, may help. If the bronchiectasis is confined to one lobe of the lung, wedge resection or lobectomy can be very effective and potentially curative. Single or double lung transplantation could be considered in those with severe diffuse bronchiectasis. Infective exacerbations of bronchiectasis An infective exacerbation should be suspected when the patient reports an increase in the volume of sputum, a change in the colour of sputum to yellow or green, sputum that is purulent, worsening breathlessness, chest pain, haemoptysis, and systemic symptoms, such as fever and decreased appetite. Bacterial pathogens, including opportunistic organisms, are the main cause of exacerbations, although viruses, such as coronavirus, rhinovirus, and influenza can also cause infections. Bacteria often associated with exacerbations in bronchiectasis include Haemophilus influenza, Staphylococcus aureus, Moraxella catarrhalis, and the mucoid type of Pseudomonas aeruginosa. Many of these organisms will be resistant to the usual oral antibiotics; therefore, it is important to culture sputum to determine antibiotic sensitivities. The exact length of the treatment and the route of antibiotic therapy will depend on the clinical condition of the patient and the antibiotic sensitivities. Patients who become clinically unwell with hypotension, tachypnoea, and respiratory failure will need to be admitted for intravenous antibiotics, intravenous fluids, oxygen therapy, and chest physiotherapy to clear retained secretions, thus improving oxygenation. Blood cultures should be taken in patients who are febrile or show other signs of sepsis. If information is available about the antibiotic sensitivities of the bacterial pathogen colonising the lungs of the patient, this should guide the choice of antibiotics given. If no sputum culture result is available, then a fluoroquinolone, amoxicillin, or a macrolide would be a suitable initial choice. The initial antibiotic therapy may need to be modified when sputum culture results become available. If there is a betalactamasepositive organism, then a second or third generation cephalosporin or macrolide should be used. Pseudomonas aeruginosa colonises the lungs of patients with bronchiectasis and its presence in the sputum of a patient with bronchiectasis signifies a worse prognosis. The usual choice of antibiotics for Pseudomonas is oral ciprofloxacin, 500 or 750 mg twice a day for 14 days. Resistance to ciprofloxacin can develop rapidly, so further sputum samples should be sent if there is no clinical improvement. An antipseudomonal penicillin, such as ceftazidime, together with an aminoglycoside or fluoroquinolone, is the usual combination given. Aminoglycosides should not be given alone, and the level should be monitored carefully to avoid renal toxicity and ototoxicity. If the sputum grows Aspergillus fumigatus, then a course of Itraconazole or Voriconazole should be given, with careful monitoring of liver function tests. Other treatments during an exacerbation include nebulised bronchodilators, controlled oxygen therapy, regular chest physiotherapy, intravenous fluids, and systemic corticosteroids in some cases. Corticosteroids must be used with care as they are immunosuppressive drugs and therefore can worsen infection. Prevention of exacerbations There is evidence that meticulous attention to sputum clearance techniques will reduce the bacterial load in the lungs and reduce the frequency of Chapter 12: Suppurative lung disease / 303 exacerbations. Regular sputum clearance improves symptoms, improves lung function, and reduces infective exacerbations. There are various mucolytic drugs that have been shown in in vitro studies to aid the clearance of mucus from the lungs, although trial evidence is limited. Carbocysteine, a commonly used mucolytic drug, reduces the viscosity of mucus and the number of exacerbations. Although clinical trials have not shown a benefit, oncedaily nebulised mannitol, which is a hyperosmolar agent, hydrates airway secretions and aids sputum clearance. Care must be taken not to use mannitol in patients with coexisting asthma as this can result in mast cell mediator release and bronchoconstriction. Chest physiotherapy, an essential part of the management of bronchiectasis, involves techniques of chest percussion, active cycle of breathing, and the use of various devices which break up the mucus into smaller particles, making it easier to expectorate. Standard physiotherapy applied by trained experts is timeconsuming and not possible for patients who are at home. Devices which aid sputum clearance include positive expiratory pressure devices, high frequency chest wall oscillation devices, oral high frequency oscillation devices, intrapulmonary percussive ventilation, incentive spirometry, the flutter valve, the Acapella device, and the cornet. These devices are less time consuming, easier for the patient to use after training, and a good alternative to standard chest physiotherapy. These devices can be used by children, for example, those with cystic fibrosis, under the supervision of their parents. The physiotherapist will recommend the most appropriate device for the individual. There is trial evidence that patients who have more than two infective exacerbations every year benefit from lowdose prophylactic Azithromycin, 250 mg two or three times a week. Lowdose azithromycin appears to work by a mechanism other than the antimicrobial one, although the exact way it works is unclear. Side effects of macrolides include gastrointestinal discomfort, hepatotoxicity, ototoxicity, and bacterial resistance. Patients should be informed of the potential side effects and asked to report any adverse effects, such as change in hearing. It is recommended that liver function tests are monitored and the drug discontinued if there is any evidence of hepatotoxicity. It is important to give a break after this period to reduce the risk of developing resistance to macrolide antibiotics. If macrolide prophylaxis is contraindicated, amoxicillin 500 mg twice a day or doxycycline 100 mg twice a day should be considered. Inhaled tobramycin, ciprofloxacin and colistin have been shown to reduce the volume of sputum and reduce the bacterial load but are associated with bronchoconstriction. In patients with three or more exacerbations a year with Pseudomonas aeruginosa, a therapeutic trial of inhaled antibiotics could be considered. Administering inhaled 2agonist prior to giving the inhaled antibiotic will reduce the risk of bronchoconstriction. There is less evidence for the use of inhaled Aztreonam and inhaled gentamicin, so their use in this way is not recommended. In one small, singlecentre, pilot study, atorvastatin 80 mg daily for six months resulted in improvement in cough compared to the placebo group but there were significant side effects. A larger, randomised, doubleblind controlled study is required before the routine use of a statin is recommended in bronchiectasis. It is essential to reiterate the importance of compliance with all these treatments to the patient. Annual influenza vaccination and regular pneumonia vaccination should be offered to the patient. It is inherited as an autosomal recessive disorder, which means that the individual has inherited a defective gene from each parent. One in 25 of the Caucasian population is an asymptomatic carrier of the defective gene. The severity of the disease and the clinical presentation depend on the nature of the mutation. The most common mutation is a deletion of phenylalanine at position 508 of the protein, described as Delta F508, which is a Class 1 defect. Defects belonging to Classes 4 and 5 will result in some active protein being produced so that the patient presents with less severe clinical disease than mutations in Classes 1, 2, and 3.

Syndromes

• Special education, to address learning disabilities and attention deficit problems the child may have 
• Pneumonia, recurrent
• When Dinosaurs Die: A Guide to Understanding Death by Laurene Krasny Brown and Marc Brown (ages 4 - 8)
• Shallow breathing
• If you have bleeding problems
• Gas or bloating
• Feeling faint or dizzy
• Careful follow-up with a physical exam and ultrasound
• Diarrhea

Side effects include abdominal or precordial pain diet with gastritis cheap nexium 20 mg on-line, dizziness distal gastritis definition purchase nexium 20mg visa, headache gastritis oatmeal buy nexium 40 mg visa, methemoglobin chronic gastritis message boards cheap nexium 40 mg fast delivery, necrotic abscess gastritis kiwi order nexium once a day, fecal discoloration gastritis diet ������������� discount 20mg nexium free shipping, urine discoloration, hypertension, chest pain, N/V, fever, skin coloration, bladder irritation, diaphoresis, and mental confusion. Methylene blue crosses the human placenta after intraamniotic injection and is excreted in the maternal urine. A specific syndrome is described that includes hemolytic anemia, hyperbilirubinemia, and methemoglobinemia. Photosensitization is reported in very-low-birth-weight neonates exposed prenatally. Methylene blue use for second-trimester amniocentesis in twin gestation is associated with a dose-dependent increased risk of fetal intestinal atresia and/or death. Summary Methylergonovine International Brand Names Drug Class Indications Mechanism Dosage With Qualifiers - (Methergine) Log on to ExpertConsult. Oxytocin, methylergonovine, and several prostaglandin agents are the pharmacologic agents most frequently used to prevent or treat postpartum hemorrhage. Unfortunately, it is contraindicated in women with either hypertension or a history of hypertension, as it may trigger a hypertensive crisis leading to a cerebrovascular event. Further, its shelf life is compromised in tropical climates, where misoprostol may be preferable. Methylergonovine is typically administered in the immediate postpartum period when oxytocin alone fails to control myometrial atony. However, it is not effective prophylaxis for atony after delivery, and its administration with delivery of the anterior shoulder may actually increase the risk of a retained placenta. There are potential interactions of methylergonovine and vasoactive agents, which perhaps have been administered to treat hemorrhagic hypotension. Therefore there must be communication between the obstetrician and anesthesiologist at an operative delivery with unexpected blood loss before the methylergonovine is given. The combination of oxytocin and methylergonovine is more effective than oxytocin and misoprostol with fewer side effects. Given late postpartum, methylergonovine accelerates involution but enhances maternal cramping. A combination of misoprostol and methylergonovine is an extremely efficient abortifacient in the second trimester. Inadvertent administration during pregnancy is followed by tetanic contractions and fetal bradycardia. The concentrations of methylergonovine in human breast milk are clinically insignificant. There are rare reports of serious adverse events associated with the use of certain ergot alkaloids. The clinical experience consists of limited case reports of narcolepsy and substance abuse. It is unknown whether methylphenidate crosses the human placenta, but limited human data do not indicate a significant risk of structural abnormalities. In one large registry study, 382 methylphenidate-exposed pregnancies (90% in the first trimester) were followed. The overall rate of major congenital anomalies was similar between exposed and unexposed groups (3. There was a higher rate of miscarriage and elective termination of pregnancy in the methylphenidate group. As a caution, it would be wise to observe for signs of jitteriness or poor weight gain. It may be necessary to adjust the dosage and monitor plasma drug concentrations (or, in the case of coumarin, coagulation times). Summary Methylprednisolone International Brand Names Drug Class Corticosteroids - (Medlone; Medrol; Metrocort Summicort) Log on to ExpertConsult. It has been suggested that first-trimester hyperemesis gravidarium refractory to conventional treatments can also be treated with methylprednisolone. Methylprednisolone reduces the risk of ovarian hyperstimulation during ovulation induction for in vitro fertilization. The use of a maternal stress-dose corticosteroid in labor should trigger consideration of a screening neonatal blood culture. Rodent teratogenicity studies have not been performed, but there is no clinical evidence it is teratogenic. Methylprednisolone enters human breast milk; the relative infant dose is approximately 0. The quantity of corticosteroid excreted into breast milk is not likely clinically relevant for the newborn. Mutual inhibition of metabolism occurs with concurrent use of cyclosporine and methylprednisolone. Hepatic enzymes such as phenobarbital, phenytoin, and rifampin may increase the clearance of methylprednisolone and may require increases in methylprednisolone dose to achieve the desired response. Troleandomycin and ketoconazole may inhibit the metabolism of methylprednisolone and thus decrease its clearance. May increase the clearance of chronic high-dose aspirin leading to decreased salicylate levels or increase the risk of toxicity when the methylprednisolone is withdrawn. There are reports of enhanced as well as diminished effects of anticoagulant when given concurrently with corticosteroids. Therefore coagulation indices should be monitored to maintain the desired anticoagulant effect. Breastfeeding Safety Drug Interactions M References Summary 543 Methyltestosterone International Brand Names Drug Class Indications Mechanism Dosage With Qualifiers - (Android; Androral; Fopou; Forton; Madiol; Metandren; Metestone; Oreton Methyl; Primotest; Testo-B; Testred; Vigorex; Virilon; Virormone) Log on to ExpertConsult. It is used for palliation with advancing inoperable breast cancer known or believed to be estrogen sensitive. Methyltestosterone is also used in combination with estrogen to enhance libido in women. There are no adequate reports or well-controlled studies of methyltestosterone in pregnant women, nor are there indications for its use. Side effects include amenorrhea, breast tenderness, edema, virilism, hypertension, hepatic dysfunction, N/V, hirsutism, cholestatic jaundice, decreased/increased libido, hypercholesterolemia, clitoral enlargement, acne, leukopenia, hypercalcemia, and polycythemia. Animal studies (rodents, dog) reveal pseudohermaphroditism in female fetuses exposed to methyltestosterone. The metabolic effects of androgens may decrease blood glucose levels and insulin requirements. Maternal Considerations M Fetal Considerations Breastfeeding Safety Drug Interactions References Summary 544 Methysergide International Brand Names None identified. There are no adequate reports or well-controlled studies of methysergide in pregnant women. Despite limited clinical data to provide guidance, methysergide is generally considered contraindicated during pregnancy because of its vasoconstrictive effects. Side effects include retroperitoneal, pleural, pulmonary, or cardiac fibrosis; thickening of the aortic root; aortic and mitral valve fibrosis; N/V; diarrhea; heartburn; abdominal pain; insomnia; drowsiness; mild euphoria; dizziness; ataxia; light-headedness; hyperesthesia; facial flush; telangiectasia; increased hair loss; peripheral edema; neutropenia; eosinophilia; arthralgia; and myalgia. Rodent studies reveal evidence of embryotoxicity and bradycardia when administered at high doses. It is suspected that the toxic effects are vascularly mediated and not a direct myocardial effect. Maternal Considerations M Fetal Considerations Breastfeeding Safety Drug Interactions References Summary 545 Metoclopramide International Brand Names Drug Class Indications Mechanism Dosage With Qualifiers - (Reglan) Log on to ExpertConsult. It is a reasonable selection for the treatment of mild to moderate nausea/vomiting of pregnancy. Metoclopramide is highly effective controlling N/V during surgery in women undergoing cesarean section. It reduces gastric secretions but does not decrease the quantity of narcotics used to control pain postoperatively. To reduce the risk of dystonia, patients may be premedicated with diphenhydramine. Metoclopramide is also helpful for the treatment of migraine and enhances erythropoiesis in women with Diamond-Blackfan anemia. Metoclopramide crosses the human placenta, though the kinetics remain to be elucidated. In a population-based study, 28,486 women ingested metoclopramide in the first trimester; 2. There were no significant associations between metoclopramide use and malformations overall or in any of the 20 individual malformation categories sought. Metoclopramide was not associated with increased risk of spontaneous abortion or stillbirth. These quantities are considerably less than the therapeutic dose of 500 mcg/kg/d recommended for children. Metoclopramide is believed to augment milk production without altering prolactin or sodium concentrations. Additive sedative effects may occur if given with alcohol, sedatives, hypnotics, narcotics, or tranquilizers. The clearance of metoprolol is increased during pregnancy, and the dose may require upward revision. There are many case reports of its use during pregnancy without apparent adverse effects. In principle, the management of an arrhythmia is similar whether or not the patient is pregnant. It may also reduce the frequency of migraine headache during pregnancy when given prophylactically. Metoprolol is as effective as propranolol in controlling symptoms of hyperthyroidism. Fetal Considerations There are no adequate reports or well-controlled studies in human fetuses. The risks of neonatal hypoglycemia and bradycardia associated with maternal exposure to -blockers at delivery were assessed in a cohort of 2,292,116 completed pregnancies. Metoprolol is excreted into human breast milk; the relative infant dose approximates 1. The neonatal plasma level is typically either very low or undetectable between breastfeeding periods. Patients should be observed closely for hypotension or marked bradycardia, which may in turn produce vertigo, syncope, or postural hypotension. Patients with a history of severe anaphylaxis to a variety of allergens may be more reactive to repeated challenge while taking -blockers. The -blocker should be withdrawn several days before the gradual withdrawal of clonidine. If replacing clonidine by -blocker therapy, the introduction should be delayed until several days after the clonidine was stopped. Breastfeeding Safety M Drug Interactions References Summary 548 Metronidazole International Brand Names Drug Class Indications - (Flagyl) Log on to ExpertConsult. Antibiotics; Antiprotozoals; Dermatologics Bacterial infections (anaerobic gram-negative bacilli: B. Small trials suggest that the combination of ampicillin and metronidazole successfully prolongs pregnancy in women with threatened idiopathic preterm labor. Metronidazole also decreases the risk of upper genital tract infection after first-trimester suction curettage. Trichomoniasis is associated with an increased incidence of adverse outcomes of pregnancy. Unfortunately, the treatment of pregnant women with asymptomatic trichomoniasis does not prevent preterm delivery. Though achieving an F:M ratio near unity, it does not pose a major teratogenic risk when used in the recommended doses. The safety of drug therapy for inflammatory bowel disease during pregnancy is an important clinical concern. The possible fetal adverse effects related with long-term exposure as required by this condition remain unknown.

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