Lawrence Richard Kleinberg, M.D.

• Vice Chair of Clinical Research
• Associate Professor of Radiation Oncology and Molecular Radiation Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0007190/lawrence-kleinberg

Small bronchioles (1 mm or less) are prone to close when lung volume reaches a critical point (closing volume) mood disorder 311 buy amitriptyline 25 mg. The closing volume is higher in older patients and in smokers depression analysis test purchase 50 mg amitriptyline mastercard, owing to the loss of elastic recoil of the lung depression symptoms dementia discount 25 mg amitriptyline overnight delivery, which increases the risk of atelectasis severe depression symptoms yahoo cheap amitriptyline 25 mg otc. The extent of collapse varies from closure of a small segment to collapse of a lobe or jung depression test buy amitriptyline discount, when a main bronchus is obstructed depression diagnosis code purchase generic amitriptyline, the entire lung. Atelectasis is a very common complication of surgery and usually occurs within 24 hours. It is of clinical relevance because it leads to increased work of breathing and impaired gas exchange; if untreated, secondary bacterial infection will supervene, causing lobar or bronchopneumonia. The clinical signs of pulmonary collapse include rapid respiration, tachycardia and mild pyrexia, with diminished breath sounds and dullness to percussion over the affected segment. Postoperatively, pulmonary collapse is prevented by encouraging the patient to breathe deeply, cough and mobilise. Placement of an epidural catheter in patients undergoing major abdominal surgery may help alleviate postoperative wound pain. Hypoxia is treated by giving oxygen by mask or nasal prongs, and bronchospasm is relieved by inhalation of salbutamol. When hypoxia is severe, endotracheal intubation, assisted ventilation and repeated bronchial aspiration may be needed. Posture is important and the patient should initially be placed on the unaffected side to aid expansion of the collapsed lung. The chest signs are those of collapse with absent or diminished breath sounds, often in association with bronchial breathing and coarse crepitations from surrounding areas of partial bronchial occlusion. The patient is encouraged to cough, and antibiotics are prescribed after sputum is sent for bacteriological examination. Most pulmonary infections are caused by the respiratory commensals Streptococcus pneumoniae and Haemophilus influenzae, but many postoperative pulmonary infections are caused by gramnegative bacilli acquired by aspiration of oropharyngeal secretions. Blood gas determinations are the key to its early recognition and should be repeated frequently in patients with previous respiratory problems. In type 1 respiratory failure there is hypoxia and in type 2 there is hypercarbia with hypoxia. They may be secondary to other pulmonary pathology, such as collapse/consolidation, pulmonary infarction or secondary tumour deposits. Small effusions may be left alone to reabsorb if they do not interfere with respiration. It may result from pulmonary or systemic sepsis, following massive blood transfusion, or as a consequence of aspiration of gastric contents. Many minor and transient cases recover spontaneously, whereas in a proportion of cases, progressive respiratory insufficiency occurs. Tachypnoea with increasing ventilatory effort, restlessness and confusion develop. Hypoxia initially responds to an increase in the oxygen content of inspired air, but progressively increasing concentrations are required to prevent the PaO2 from falling. The pathophysiology is unclear, but endotoxin-activated leucocytes may be deposited in the pulmonary capillaries, releasing oxygen-derived free radicals, cytokines and other chemical mediators. Damage to the vascular endothelium results in increased capillary permeability and leakage of fluid, causing widespread interstitial and alveolar oedema. There is also an enhanced risk of pneumothorax in patients on positive-pressure ventilation, presumably owing to rupture of preexisting bullae. The insertion of an underwater seal drain is usually followed by rapid expansion of the lung. Cardiac complications the risks of anaesthesia and surgery are increased in patients suffering from cardiovascular disease. Whenever possible, arrhythmias, unstable angina, heart failure or hypertension should be corrected before surgery. Valvular disease, especially aortic stenosis, impairs the ability of the heart to respond to the increased demand of the postoperative period. The administration of fluids to patients with severe aortic or mitral valve disease should be carefully monitored. Patients with ischaemia may complain of gripping chest pain, but this is not invariable (particularly in the elderly diabetic patient or in the early postoperative period) and hypotension may be the only sign. The absence of symptoms after operation is thought to be due to the residual effects of anaesthesia and to the administration of postoperative analgesia. Postoperative pain, the effects of anaesthesia and drugs, and difficulties in initiating micturition while lying or sitting in bed may all contribute. When its normal capacity of approximately 500 mL is exceeded, the bladder may be unable to contract and empty itself. Frequent dribbling or the passage of small volumes of urine may indicate overflow incontinence, and examination may reveal a distended bladder. Clinical manifestations are progressive dyspnoea, hypoxaemia and diffuse congestion on chest x-ray. Treatment consists of avoiding further fluid overload, and the administration of diuretics and cardiac inotropes. Urinary tract infection Urinary tract infections are most common after urological or gynaecological operations. Preexisting contamination of the urinary tract, urinary retention and instrumentation are the principal factors contributing to postoperative urinary infection. Cystitis is manifested by frequency, dysuria and mild fever, and pyelonephritis by high fever and flank tenderness. Treatment involves adequate hydration, proper drainage of the bladder and appropriate antibiotics. Renal failure Acute renal failure after surgery results from protracted inadequate perfusion of the kidneys. The most common cause of postoperative oliguria is prerenal vascular insufficiency from hypovolaemia, water depletion or extracellular fluid depletion. Hypoperfusion of the kidney may be aggravated by hypoxia, sepsis and nephrotoxic drugs. Patients with preexisting renal disease and jaundice are particularly susceptible to hypoperfusion, and are more likely to develop acute renal failure. The complication can largely be prevented by adequate fluid replacement before, during and after surgery, so that urine output is maintained at 0. The importance of monitoring hourly urine output means that bladder catheterisation is needed in all patients undergoing major surgery, and in those at risk of renal failure. Early recognition and treatment of Arrhythmias Sinus tachycardia is common and may be a physiological response to hypovolaemia or hypotension. Tachycardia increases myocardial oxygen consumption and may decrease coronary artery perfusion. Sinus bradycardia may be due to vagal stimulation by neostigmine, pharyngeal irritation during suction, or the residual effects of anaesthetic agents. Fast atrial fibrillation may result in haemodynamic disturbances and may require pharmacological intervention. Postoperative shock Shock is defined as a failure to maintain adequate tissue perfusion. Hypovolaemic shock may be caused by inadequate replacement of pre- or perioperative fluid losses, or postoperative haemorrhage, whereas cardiogenic shock is usually secondary to acute myocardial ischaemia/infarction or an arrhythmia. Hypovolaemic and cardiogenic shock are characterised by tachycardia, hypotension, sweating, pallor and vasoconstriction. Septic shock is characterised in the early stages by a hyperdynamic circulation with fever, rigors, a warm vasodilated periphery and a bounding pulse. Without appropriate management, shock will result in oliguria and the development of multisystem organ failure, and may lead to death. Management involves the restoration of an adequate circulating intravascular compartment by the administration of intravenous fluids. Diuretics may be administered only if the patient is well hydrated; however, they should not be continually prescribed if the patient remains oliguric. Acute postoperative renal failure occurs when the reversible stage of acute renal insufficiency progresses to acute tubular necrosis. Volume loading becomes potentially dangerous with established renal failure, and the mainstays of treatment at this stage are the replacement of observed fluid loss, plus an allowance of approximately 500 mL/day for insensible loss, and restriction of dietary protein intake to less than 20 g/day. Biochemical status is checked by frequent estimations of serum urea and electrolytes. Hyperkalaemia can be treated by intravenous administration of insulin and glucose, or cation exchange resins. Haemofiltration or haemodialysis may be indicated if conservative measures fail to prevent rapid rises in serum concentrations of urea and potassium. The patient will then enter a polyuric phase, in which fluid and electrolyte balance requires careful monitoring. The fully developed condition is characterised by extreme agitation, visual hallucinations, restlessness, confusion and, rarely, convulsions and hyperthermia. If symptoms are mild, treatment involves the prescription of oral diazepam and vitamin B (thiamine). Control of extreme agitation may require intravenous administration of diazepam, or haloperidol. Venous thrombosis and pulmonary embolism these complications are discussed in detail in Chapter 21, but the essential details are summarised here for convenience. Neuropsychiatric disturbances these occur frequently and cover a wide spectrum of disorders. The most common is mental confusion with agitation, restlessness and disorientation, and is known as delirium. It usually occurs in the elderly and may arise on a background of dementia due to cerebral atrophy, but is often precipitated by the use of sedative or hypnotic drugs. Acute toxic confusion state is a well-recognised acute psychiatric disorder that occurs in some patients during a serious illness or after a major surgical intervention. Many factors can contribute, and it is important to look for a treatable cause, such as hypoxia, sepsis, or a metabolic disturbance such as hypoglycaemia, hepatic encephalopathy, uraemia or electrolyte imbalance. Sleep deprivation, particularly in intensive care units, can also cause severe mental disturbance. The primary cause of postoperative confusion needs to be treated and such patients may need management in an intensive care unit. Fibrinolytic agents, such as streptokinase or urokinase, can be infused intravenously to encourage clot lysis if it is at least 6 days after surgical intervention, or in extreme cases the clot can be removed at open pulmonary embolectomy under cardiopulmonary bypass. In such cases, it is also important to search for the source of the embolus; warfarin therapy is recommended in all patients who have sustained a pulmonary embolus, and therapy is normally continued for 6 months. If the patient cannot be anticoagulated, or sustains Delirium tremens (acute alcohol withdrawal syndrome) Delirium tremens occurs in alcoholics who stop drinking suddenly. If the wound infection is chronic, the presence of a suture sinus or an enterocutaneous fistula must be excluded. Subcutaneous haematoma is a common prelude to a wound infection, and large haematomas may require evacuation. Signs include local erythema, tenderness, swelling, cellulitis, wound discharge or frank abscess formation, as well as an elevated temperature and pulse rate. If a wound becomes infected, it may be necessary to remove one or more sutures or staples prematurely to allow the egress of infected material. The extrusion of abdominal viscera through a complete abdominal wound dehiscence is known as evisceration. Risk factors include obesity, smoking, respiratory disease, obstructive jaundice, nutritional deficiencies, renal failure, malignancy, diabetes and steroid therapy; however, the most important causes are poor surgical technique, persistently increased intraabdominal pressure, and local tissue necrosis due to infection. Postoperative fever Fever in a patient who has had surgery can be due to a variety of causes related to the primary disease or complications related to the surgical intervention or general anaesthesia. Hill Evidence-based practice and professional development Chapter contents Introduction 137 Levels of evidence 137 Care pathways and guidelines 140 Clinical governance 140 Clinical audit 141 Quality improvement 141 Critical appraisal 141 Continuing professional development 141 10 Cochrane review Introduction In the past, clinicians relied solely on their experience and the advice of colleagues when making clinical decisions. Modern practice has evolved beyond this as a result of the vast array of information that is now available to clinicians through modern technology. Data and guidelines have become easily accessible through electronic databases such as PubMed and UpToDate. Evidence-based medicine has become ubiquitous in modernday clinical practice, and so a detailed understanding of what it is, how it is achieved, why it is important, and how it should be interpreted is required of both undergraduates and surgical trainees. Levels of evidence Many different types of research exist, each with their own strengths and weaknesses. The data from the various research methods can be grouped into a qualitative hierarchy of levels of evidence. Although many different grading methods exist, each designed to answer different questions, one commonly used example is that of the Centre of Evidence-Based Medicine (Table 10. The recommendations that develop from these different TheCochraneCollaboration, a global independent networkcomprising more than 37,000 researchers, professionals, patients and carers from over 130 different countries, was created in 1993 with the aim of improving healthcare decisions.

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Hand biting and gaze aversion are characteristic behaviors seen in children with fragile X depression definition dsm amitriptyline 50mg overnight delivery. Attention-deficit/hyperactivity disorder depression test dass generic amitriptyline 25mg on-line, anxiety anxiety 2 days after drinking order on line amitriptyline, perseverative speech bipolar depression famous people buy amitriptyline 25 mg, and hand flapping may also be seen depression severe joint pain purchase genuine amitriptyline online. Classic features such as long face mood disorder nos dsm discount amitriptyline 50 mg overnight delivery, prominent jaw, and macro-orchidism are seen around the time of puberty. Language is a symbolic means of communication, which involves cognitive function through effects on memory and the development of concepts. Language skills, particularly receptive language skills, correlate well with cognitive function. Clinical features such as hypotonia, epicanthal folds, flat nasal bridge, increased neck tissue, clinodactyly, and wide space between first and second toes are present at birth. Prader-Willi syndrome is most commonly caused by a microdeletion on the paternal chromosome 15q11. By 2 years of age, as the hypotonia improves, affected children develop obesity and hyperphagia. Physical features include almond-shaped eyes, thin upper lip and downturned mouth, hypogonadism, short stature, and small hands and feet. Development in early infancy is normal, slows in later infancy, and then regresses between 1 and 4 years of age. Acquired microcephaly and stereotypic hand movements (eg, hand wringing, hand washing, clapping, tapping) are characteristic. The physical features of frontal prominence; hoarse, deep voice; and coarse facial features (eg, heavy brows, synophrys, prognathism) may not manifest until late childhood. Children with Smith-Magenis syndrome exhibit unusual behaviors including self-hugging, pulling out fingernails and toenails, and insertion of foreign objects into their body. Classic features such as long face, prominent jaw, and macro-orchidism are generally seen around the time of puberty. You order fluorescence in situ hybridization analysis that reveals the presence of an extra chromosome 21. A complete blood cell count shows a normal white blood cell count, polycythemia, macrocytosis, and mild thrombocytopenia. Facial characteristics include small head with brachycephaly, epicanthal folds, upslanting palpebral fissures, small posteriorly rotated low-set ears, flat midface, Brushfield spots, and small mouth. In addition, children also commonly have a short neck, single transverse palmar crease, sandal toe, brachydactyly, fifth finger clinodactyly, and short stature. Cognitive impairment typically varies from mild to moderate intellectual disability; only rarely is the cognitive impairment severe. A high resolution chromosome analysis to assess the mechanism of the trisomy 21 is also required. This analysis will reveal if the trisomy 21 is caused by a complete extra chromosome 21 (sporadic trisomy 21) or by an unbalanced translocation; this information allows the family to be informed of recurrence risk. Fluorescence in situ hybridization analysis can indicate that an extra copy of chromosome 21 is present, but it cannot detect a translocation. Physical examination of the newborn with trisomy 21 should include careful evaluation for cataracts by looking for a red reflex. Auscultation for a cardiac murmur and pulse oximetry are important initial evaluations for cardiac disease. The child should be observed for stridor, wheezing, or noisy breathing that could indicate cardiorespiratory anomalies or intestinal atresias. A careful history for feeding problems, gastroesophageal reflux, constipation, apnea, bradycardia, cyanosis, or other respiratory difficulties is also needed. A brainstem auditory evoked response or otoacoustic emission should be performed at birth because of increased risk for hearing loss (and per universal newborn hearing screening guidelines). Newborn screening should include measurement of free thyroxine and thyroid-stimulating hormone because many children with trisomy 21 have mildly elevated thyroid-stimulating hormone and normal free thyroxine levels. Because 50% of children with trisomy 21 have congenital heart defects, an echocardiogram should be obtained and read by a pediatric cardiologist even if a normal fetal echocardiogram was obtained. A complete blood cell count is needed to look for hematologic abnormalities, leukemoid reactions, or transient myeloproliferative disorder, which poses an increased risk for leukemia later in life (10%-30%). Leukemia is more common in individuals with trisomy 21 than in the general population, although it is still rare (1%). Magnetic resonance imaging of the brain and renal ultrasonography are not indicated because brain and kidney anomalies are not common in individuals with trisomy 21. The routine serum laboratory values to be followed over time with a diagnosis of trisomy 21 are a complete blood cell count and thyroid function testing, not liver function testing. Because 50% of children with trisomy 21 have congenital heart defects, an echocardiogram should be obtained and read by a pediatric cardiologist regardless of a normal fetal echocardiogram. Her mother reports that the girl has a history of recurrent kidney infections and small kidneys. Her urinalysis results are shown: Laboratory Test Specific gravity pH Protein Result 1. Symptoms of abnormal voiding patterns (enuresis or polyuria), poor growth, and pallor may be subtle and easily missed. The history of small kidneys and recurrent urinary tract infections in this patient suggests underlying vesicoureteral reflux and associated reflux nephropathy as the cause of her symptoms. In children with vesicoureteral reflux, decreased renal mass and hence small kidneys could be congenital (associated with abnormal renal development) or secondary to renal scars (recurrent urinary tract infections associated with vesicoureteral reflux). However, a history of infections and small kidneys is unlikely with orthostatic proteinuria and acute glomerulonephritis. Orthostatic proteinuria is characterized by increased urinary protein excretion during the day when the patient is active and normal urinary protein excretion when the patient is supine/asleep for at least 2 hours. Therefore, to confirm orthostatic proteinuria, a first-morning urine sample is needed. It is important that the patient collect the first urine sample immediately upon waking because even a small amount of activity can lead to proteinuria. Acute glomerulonephritis is characterized by glomerular hematuria (cola- or tea-colored urine), hypertension, and renal failure. Acute glomerulonephritis may be associated with hypertension and proteinuria; however, in the absence of hematuria, acute nephritis is unlikely in this patient. Urinary tract infection is unlikely in this case because of the absence of fever, dysuria, flank pain, or a burning sensation on micturition. The absence of leukocyte esterase, nitrates, and bacteria in the urinalysis excludes urinary tract infection as the underlying cause of proteinuria in this patient. Proteinuria, a history of infections, and a history of small kidneys suggest an underlying renal etiology, which is the most common cause of secondary hypertension in children. The boy recently moved with his family to the rural area where you practice, where his parents have started a strawberry farm. The entire family eats a variety of fresh fruits and vegetables that are grown on their farm. He is breastfed and eats some solid foods, though his mother states that he is a "picky" eater. He does not attend daycare, and loves playing with his 7-year-old twin sisters and 13-year-old brother (who are all healthy and developing normally according to the parents). His growth parameters are normal for his age, and findings of a complete physical examination are unremarkable. His parents ask you to discuss the potential health consequences of exposure to environmental toxins in this boy and his older siblings and how they can reduce the risk of exposure to environmental toxins for their children. This is because the developmentally normal exploratory behaviors at his age (frequent oral exploratory and hand-tomouth behaviors), his higher respiratory rate, and his closer physical proximity to the ground and contaminated surfaces (eg, window sills) place him at higher risk for exposure to lead dust than older children. Pediatric health care providers should know the age- and developmentally specific effects of exposure to a toxic substance in the environment, as well as how to obtain an appropriate exposure history. Children may be exposed to various environmental toxins on a daily basis in air, food, dust, soil, and on surfaces in their home, school, play, and occupational environments. The field of pediatric environmental health is an emerging and rapidly evolving one, with a growing body of literature that is helping to shed light on the effects of various environmental toxins on human health. According to the World Health Organization, nearly a third of the global burden of disease in children is due to environmental factors. Children have both increased exposure and increased physiologic vulnerability to environmental toxins. Physiologically, children differ from adults in organ system functioning, metabolic capabilities, physical size, and developmental abilities/behaviors. They are particularly susceptible to adverse outcomes from toxic exposures, given their rapid growth and development. In homes where there is a concern for contamination of water from lead pipes or lead pipe joints, families should be advised to discard "first-draw" water that has stood overnight in pipes (or to use it for a purpose other than drinking/cooking). Although certain lipophilic chemicals can be transmitted through breast milk and result in exposure to nursing infants, instances of harm occurring from chemicals transmitted through breast milk are very rare. The many benefits conferred by breastfeeding, such as enhanced immune function and growth factors that enhance brain development, generally outweigh the risks of exposure to environmental toxins through breast milk. Younger children have higher respiratory rates, resulting in higher weight-adjusted exposure to air contaminants. Furthermore, there is evidence that respiratory exposure to air contaminants during the first years of life have a greater influence on the incidence and severity of asthma compared with exposure later in life. Young children have higher metabolic rates and generally consume a greater amount of food, water, and air per kilogram than older children. As a result, they have a greater exposure per kilogram of body weight to foodborne toxins. Furthermore, many young children have limited food preferences and may consume the same foods over relatively long periods. This can result in greater exposure per kilogram of body weight to foodborne and airborne toxins. Environmental health and medical education: principles of pediatric environmental health. Principles for evaluating health risks in children associated with exposure to chemicals. The girl reports localized swelling at the site of pain and denies any feeling of catching, locking, or instability. On physical examination, you note mild swelling and moderate tenderness at the site of the patellar tendon insertion on the tibia, and pain with resisted knee extension. Physical examination findings of the knee and hip are otherwise unremarkable and her gait is normal. A patellar strap may be applied to relieve the tension caused by the patellar tendon pulling on the tibial tuberosity (Item C36). These areas are susceptible to stress with repeated use of the attached muscle groups or with repeated local impact. On physical examination, affected individuals often have a tender and prominent tibial tuberosity. Treatment involves relative rest; young athletes can participate in sports if they have mild pain, but should refrain from physical activities if they have severe pain or limp. Use of a patellar strap may lessen the tension from the patellar tendon on the tubercle, thereby decreasing pain. However, 10% of affected children will have a persistent bony prominence at the site. She can continue to participate in sports as long as she has minimal pain and no change in her gait. Radiography and magnetic resonance imaging are not required to make this diagnosis. Prevalence and associated factors of Osgood-Schlatter syndrome in a population-based sample of Brazilian adolescents. Persistent infection with 1 of the 13 oncogenic (high-risk) types may lead to precancerous or cancerous lesions. The additional coverage provided by the 9-valent vaccine could increase protection against invasive cervical cancer from 70% to 90%. The 4- and 9-valent vaccines are approved for the prevention of anogenital warts, 90% of which are caused by types 6 and 11. The vaccine is not associated with an increased risk of developing central nervous system demyelinating disease. Although it is a concern expressed by some parents, studies indicate that girls who receive the vaccine are not more likely than those who do not to be sexually active or to have an increased number of sexual partners. Although the reasons for this are not fully understood, the lack of a strong provider recommendation is 1 factor. His parents report that he "lights up" when they enter the room, and he laughs, smiles, and coos. He holds his head steady when he is placed in a seated position and recently began to roll from his back to his abdomen. His parents report that he more consistently reaches for toys with his left hand and preferentially brings this hand in front of his face to gaze at his fingers and place them in his mouth. Consistent handedness does not typically develop until between 4 and 6 years of age, although emerging dominance can be seen between 1 and 3 years of age. As with other asymmetrical movements, handedness that is apparent before 18 months of age may indicate a central or peripheral neurologic abnormality of the opposite side, including hemiparesis. The remainder of the developmental milestones described for the boy in this vignette are age appropriate. Although each child progresses slightly differently, typically developing 4-monthold infants have the skills and abilities shown in Item C38. He was seen in an urgent care center 3 days ago and was diagnosed with an upper respiratory infection. You refer him to the emergency department for blood cultures, inflammatory marker measurement, and admission.

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Macrophages depression zaps your energy cheapest generic amitriptyline uk, neutrophils and complement provide innate immunity through phagocytosis and bacterial lysis mood disorder ptsd 25 mg amitriptyline for sale. The complement system (a cascade of bioactive proteins) mood disorder of unknown axis iii etiology order 25mg amitriptyline with amex, which is activated when required anxiety 9 months after baby purchase cheap amitriptyline online, attracts the phagocytic cells anxiety zoning out cheap amitriptyline 50 mg on line, directly lyses pathogens and increases vascular permeability bipolar depression symptoms in women purchase amitriptyline us. The five classes of antibody (immunoglobulin [Ig]A, IgM, IgG, IgD and IgE) are secreted by B-lymphocytes, usually following stimulation via T cells. Antibodies, with or without complement, bind to and opsonise, lyse or kill the pathogen. Cytokines (small peptide molecules) are released by leucocytes and facilitate the interaction between immune cells. Typically, a patient presents with signs of severe infection, but instead of improving with antibiotic treatment develops worsening fever, hypotension, tissue hypoxia, acidosis and multiple organ failure. Screening of emergency surgical admissions may also be performed, although the timing of available results will determine whether this has an impact on management and outcomes. Reduction in the rate of methicillin-resistant Staphylococcus aureus acquisition in surgical wards by rapid screening for colonisation: a prospective, crossover study. Preventing infection in surgical patients All hospitals should have infection prevention programmes that include measures to minimise risks to patients and staff from infections which may be acquired during and after surgery. Most healthcare-associated infections can be prevented by adherence to good hand hygiene. These include patients showering preoperatively, hand washing, surgical scrub, skin preparation of the patient, maintaining a sterile operating field and using safe operating practices. Hand decontamination the operating team should wash their hands prior to each operation on the list using an aqueous antiseptic surgical solution, with a single-use brush for the nails. Where hands are not soiled, alcohol hand gel is a suitable alternative for decontamination on the wards. Rub the thumbs (rotational rubbing of right thumb clasped in the left palm, and then vice versa) 6. Rub palms with fingertips (rotational rubbing of right fingers on left palm, and then vice versa) Rinse the hands under running water, and dry thoroughly Technique based on that of Ayliffe et al. In addition, double gloving and maintaining sharps safety is important for patients known or suspected to be infected with blood-borne viruses. This includes water-repellant coveralls, fulllength disposable apron over the coverall, fluid-repellant footwear, wearing double gloves as a minimum, and power-assisted personal respirator with P3 filter and full hood. Surgical instruments To prevent cross-infection only sterile or disposable, single-use instruments are used. Instruments can then be packed and processed in a steam steriliser or autoclave to destroy any remaining microorganisms and their spores. Pressures above atmospheric are used so that higher temperatures can be achieved. Skin preparation Although it is not possible to sterilise the skin, antiseptics such as chlorhexidine or povidone-iodine applied to the surgical site prior to incision reduce the number of resident organisms and thereby the risks of wound infection. Antiseptics containing alcohol must be allowed to evaporate completely before using diathermy. Maintaining patient homeostasis Maintaining a normal patient temperature (unless active cooling is part of the procedure), optimal oxygenation and adequate perfusion during surgery are important in reducing the risk of postoperative infection. Whether disposable or not, all instruments used on such patients must be subsequently destroyed by incineration. If the surgery is prolonged >4 hours or blood loss is high then a second intraoperative dose may be given. Antibiotic choice the antibiotic chosen must cover the expected pathogens for the type of surgery. Most hospitals have policies that take into account local resistance patterns, and propensity to cause C. Patients with a history of anaphylaxis, urticaria or other signs of allergy to penicillin should not be given -lactam antibiotic prophylaxis. This may be achieved by decontamination of instruments in Sterile Services Departments or by using sterile, disposable instruments. Prophylactic use of antibiotics Antibiotic prophylaxis refers to the prevention of infective complications by the administration of antibiotics (Table 4. Prophylaxis for immunosuppressed patients the choice of agent will depend on individual circumstances, and expert microbiological help should be sought. Travelers to areas with risk of malaria transmission should consider appropriate precautions. Timing and dose the aim is to achieve high concentrations of drug at the surgical site at the time of incision. A single intravenous dose at induction has been shown to be as effective as multiple doses with the Table 4. There is no break in aseptic operating theatre technique Operations in which the respiratory, alimentary or genitourinary tracts are entered but without significant spillage Operations where acute inflammation (without pus) is encountered, or where there is visible contamination of the wound. Diagnosis Infections in the early postoperative period (>48 hours) are most likely to be respiratory or urinary, with wound infections usually becoming evident later. Early diagnosis and treatment is essential but clinical examination is often unreliable, even misleading. An integrated and logical approach to patient management should be followed as described in the surviving sepsis guidelines, which are summarised in Tables 4. Three recent studies of invasive haemodynamic monitoring have shown that protocol-based, early goal-directed therapy confers little survival advantage over standard care. It is not always possible to await these results if the patient is seriously ill, and empirical therapy should be started immediately according to Table 4. Clostridium difficile Piperacillin-Tazobactam Trimethoprimb Amoxicillin Co-amoxiclav Co-amoxiclav Piperacillin-Tazobactam Benzylpenicillinb Metronidazole Stop predisposing antibiotic metronidazole Meropenemb Co-amoxiclav Co-amoxiclav Meropenemb Meropenemb Meropenemb Metronidazoleb Vancomycinb (oral) for either Fidaxomicinb or faecal microbiota transplant relapse First choice Flucloxacillin Vancomycinb Vancomycin Benzylpenicillin Benzylpenicillin Clindamycin Amoxicillin Metronidazole b Alternative Clarithromycinb Linezolidb or daptomycinb Linezolidb or daptomycinb Clarithromycinb Clarithromycinb Vancomycinb Co-amoxiclav these suggestions should be considered in light of local antibiotic resistance patterns. Specific protocols are available from microbiology/ pharmacy departments at individual hospitals. Amendments may be necessary in the light of local epidemiology of hospital-acquired pathogens and antibiotic resistance patterns. Deeper infection may present more insidiously with pyrexia, leucocytosis, and organ dysfunction, such as prolonged postoperative ileus. Treatment Cellulitis can be treated with antibiotics but an abscess will require drainage as antibiotics will not penetrate pus. Drainage may involve simply laying open the wound and healing by secondary intention. The most common organisms are Escherichia coli, Klebsiella species, Enterococcus faecalis and Pseudomonas aeruginosa. Treatment will require the use of specialised antibiotics advised by an expert in infection. A positive sputum culture without clinical symptoms and signs of infection does not automatically merit antimicrobial therapy. Antibiotic treatment should follow the local hospital policy until culture and sensitivity results become available. Physiotherapy, early mobilisation and adequate pain relief in the postoperative period will help prevent respiratory infection. In catheterised patients the urine frequently contains organisms but not white cells. First-line empirical treatment should be guided by local epidemiology; suggestions are included in Table 4. The bacterium produces two cytotoxins, A and B (some strains only produce B), that destroy the colonic mucosal cell cytoskeleton. A spectrum of disease is seen, ranging from abdominal discomfort to profuse watery diarrhoea (one of the most common features), severe abdominal cramps and rarely toxic dilatation of the colon leading to rupture. At colonoscopy characteristic yellow Emergence of multiresistant bacteria -Lactam antibiotics like penicillins and cephalosporins may be rendered ineffective by -lactamase enzymes produced by gram-positive and gram-negative bacteria. Nystatin can be given orally to treat mucocutaneous candidiasis of the oropharynx. Empiric antifungal therapy should be considered in critically ill patients with risk factors for invasive candidiasis and no other known cause of fever. The balls rise on inflation of increasing levels of tidal volume, with all three balls rising on maximum inspiratory effort. The patient is self-motivated to raise the maximum number and keep them afloat for the longest period of time. In many fields of surgery the use of implants has become routine and affords huge clinical benefit. Nevertheless, there is a small risk of device-related infection, which can be catastrophic for the patient. Antibiotics alone are often unsuccessful and removal of the device is frequently necessary to eradicate the sepsis. Such surgery may be difficult and is associated with significant morbidity and mortality. Emergency colectomy in patients with fulminant colitis can be life saving, although mortality is high. Infections primarily treated by surgical management Abscess this is a localised collection of pus containing neutrophils, dead tissue and organisms that can develop anywhere in the body. Abscesses close to the skin are often painful and the overlying skin will be raised, red and hot to the touch. Invasive candidiasis (most commonly due to Candida albicans), in particular, is now recognised as a major cause of morbidity and mortality in the healthcare environment. Antibiotics do not usually penetrate into abscesses but may be required for treatment if the patient is systemically unwell or for prophylaxis if a surgical wound is being made in the course of drainage. Surgical involvement is required for debridement, drainage of abscess and/or amputation in chronic osteomyelitis. The infection usually starts at a site of (often minor) trauma and can spread very quickly, as bacterial exotoxins and enzymes lead to necrosis of fat and fascia and eventually overlying skin. Initially, the overlying skin may appear deceptively normal, but as the infection progresses there is oedema, discoloration and crepitus (due to gas production). Urgent surgical debridement of all necrotic tissue is essential and several visits to theatre may be required. Initial antibiotic choice is usually empirical with a combination of broad-spectrum agents against likely pathogens. Antibiotic therapy can later be tailored according to the results of pus and tissue cultures. Heavily contaminated wounds need thorough cleaning and debridement of all nonviable tissue; failure may lead to severe infections including gas gangrene. A short course of broadspectrum antibiotics has been shown to reduce the incidence of early infection in open limb fractures. Diabetic foot infections Infections involving the lower extremities in diabetic patients range from cellulitis to complex skin and soft tissue infection to osteomyelitis. Clinical diagnosis is based on the presence of cellulitis, purulent discharge, pain, tenderness and gangrene. Microbiological diagnosis is best achieved by culture of tissue and bone biopsy samples, as culturing surface swabs from ulcers merely indicates which microorganisms are colonising the ulcer/wound. Antibiotic therapy is usually Tetanus this is caused by Clostridium tetani, a spore-forming anaerobic organism that enters the body through soil or animal faecal contamination of a wound, injury or burn, and then multiplies anaerobically in tissues if the wound is not adequately cleaned or debrided. Tetanospasmin (a neurotoxin) spreads along nerves from the site of infection and causes generalised rigidity and spasm of skeletal muscles. The muscle stiffness usually involves the jaw (lockjaw) and neck, and then becomes generalised. Antibiotic treatment is with penicillins or, for penicillin-allergic patients, clarithromycin, but is only an adjunct to correct surgical care of wounds and further specialised medical treatment. However, all staff members and students have a duty to take responsibility for this very important aspect of patient care. Systematic collection of infection data (surveillance) can be by nurse follow-up of all patients who have undergone surgery during a given period. Surveillance nurses will inspect surgical wounds for any signs of infection and often also follow-up the patient once discharged home to detect infection.

Diseases

• Dimitri Sturge Weber syndrome
• High-molecular-weight kininogen deficiency, congenital
• 2-hydroxyethyl methacrylate sensitization, rare (NIH)
• VATER association
• Osteoectasia familial
• Diffuse palmoplantar keratoderma, Bothnian type
• GAPO syndrome
• Biliary hypoplasia
• Uveitis, posterior