Micardis

By G. Baldar. Alabama A&M University.

A blood film will demonstrate stitution valine for glutamine at the sixth codon on the the spherocytes generic micardis 40 mg line, but this cell morphology is not diagnos- β globin chain to form haemoglobin (Hb)S discount micardis 80mg visa. Thediagnosiscanbeconfirmedbydemonstratingthe dehydration, hypoxia and cold may precipitate a sickle osmotic fragility of the red blood cells. Patients are given Pathophysiology pneumococcal vaccinations and prophylactic antibiotics HbS molecules, when deoxygenated tend to aggregate post splenectomy. The red blood cells become inflex- ible and sickle shaped and become trapped in the mi- Haemoglobinopathies crocirculation, especially within bones, resulting in mi- Haemoglobinopathies are abnormalities in the nor- crovessel occlusion. Normal haemoglobin is made up of four polypeptide chains Clinical features each containing a haem group. HbA is the main adult Sickle cell trait (the carrier state) is asymptomatic, but form comprising two α chains and two β chains. Sickle cell also have a minor haemoglobin HbA2,which makes up anaemia is a clinical spectrum ranging from asymp- around 2% of the circulating haemoglobin and con- tomatic to severe haemolytic anaemia and recurrent sists of two α chains and two δ chains. Painful vascular occlusive crises typically haemoglobins result from: produce symptoms of bone pain and pleuritic chest pain r Abnormal globin chain production such as thalas- with a low-grade fever. Other patterns of crisis: r Acute sequestration (pooling of blood in liver and Sickle cell anaemia spleen) requires transfusion for apparent hypo- Definition volaemia. Autosomal recessive condition in which there is abnor- r Pulmonary infarction may occur in association with mal structure of the globin chain. Chapter 12: Haemoglobin disorders and anaemia 475 Complications syndrome or cerebral infarction require exchange blood Patients have a susceptibility to infections including transfusionstoremovesicklecells. Transfusionsmayalso streptococcal infections and osteomyelitis often due be indicated in patients with regular severe crises and to salmonella. Prognosis Retinal detachment and proliferative retinopathy may Thereismarkedvariationintheseverityofthecondition, result in blindness. See also complications of haemolytic some patients have a relatively normal life span with few anaemia (page 473). Blood film shows a α-Thalassaemia high reticulocyte count and sickle shaped red blood cells. Definition r Sickle screening tests use a reducing solution, which Inherited haemoglobinopathy with defective synthesis causes HbS to precipitate. Aetiology r X-ray of the tubular bones may show destruction and α-Thalassaemia is caused by gene deletions. There are medullary sclerosis together with periosteal bone for- four copies of the α gene, two on each chromosome 16. Management Clinical features Treatment is largely symptomatic with prophylactic an- r Deletion of all four copies of the α gene (–/–) prevents tibiotics,folicacidandpneumococcalvaccination. This disorder agement of a painful crisis includes oxygenation, ade- is also termed haemoglobin Bart’s (γ4)hydrops syn- quate hydration and analgesia. Acute se- r Deletion of three genes (–/α-) causes HbH disease (a questration requires blood transfusion, as patients be- moderate anaemia with splenomegaly and the pro- comeshocked. Normal Investigations Full blood count shows microcytosis with or without Sickle Trait anaemia. These mutations may result in no β chain production Investigations (β0)orveryreducedproduction (β+). The reticulocyte count is noproductionofβ globinandhavetheclinicalpicture raised and there are nucleated red cells. Management Excess α chains precipitate in the red blood cells r Thalassaemiaminordoesnotrequiretreatment;how- or combine with δ resulting in increased HbA2, and ever, iron supplements should be avoided unless γ resulting in increased levels of fetal haemoglobin co-existent iron deficiency has been demonstrated. The partners of women with thalassaemia minor r If there are defects in both β and δ genes, patients shouldbescreenedtoallowappropriategeneticcoun- have thalassaemia intermedia (homozygous) or tha- selling. Homozygous combined β, γ and δ are in- r Thalassaemia major and symptomatic thalassaemia compatible with life. This Clinical features aims to suppress ineffective erythropoesis and pre- r Thalassaemia minor/trait is asymptomatic with a vent bony deformity, while allowing normal growth mild hypochromic microcytic anaemia. Iron overload is prevented by the r Thalassaemia intermedia causes symptomatic mod- use of the chelating agent desferrioxamine, which is erate anaemia with splenomegaly. Splenectomy should be considered in patients ure to thrive and recurrent infections. Bone the production of fetal haemoglobin ceases and the marrow transplantation has been used successfully patient becomes symptomatic with a severe anae- in young patients with severe β-thalassaemia major. Extramedullary haemopoesis causes hepato- Other treatments under investigation include gene splenomegaly, maxillary overgrowth and trabecula- therapy and drugs to maintain the production of fetal tion on bone X-rays. Random X inacti- vation (Lyonisation) means that some heterozygous fe- Glucose-6-phosphate dehydrogenase males may also have symptoms. Clinical features With such a wide variety of genes and enzymatic activity, Aetiology aspectrum of clinical conditions occur. Investigations Pathophysiology During an attack the blood film may show irregularly IgMorIgG antibodies are produced, which bind to red contracted cells, bite cells (indented membrane), blister cells. Autoimmune haemolytic anaemia Definition Clinical features Acquired disorders resulting in haemolysis due to red The clinical features, specific investigations and manage- cell autoantibodies. IgM anti human globulin Red cells coated in antibodies Agglutination (visible) Figure 12.

Ringworm is a fungal infection of the skin that can affect different parts of the body purchase micardis 40 mg mastercard. On the scalp it often starts as a small bump cheap micardis 40mg with visa, gradually spreading outwards and is associated with hair loss. As ringworm spreads through skin contact or through contact with infectious skin fakes shed into clothes or the environment, it can easily spread within a school. It is important that you check your child’s skin and hair for the presence of any suspicious lesion. However, to prevent the spread of infection to others it is important that the affected child receives appropriate treatment. If, however, your child has not been vaccinated then it is quite possible that he/she might get rubella. In childhood it causes a mild fu like illness with mild swelling of the glands, particularly those at the back of the neck, and a fne pinkish red rash. If a pregnant woman develops rubella in the early stages of pregnancy her unborn baby may also be infected and the consequences can be devastating. Rubella infection in the unborn can cause severe developmental delay, eye defects, hearing problems and a wide variety of congenital abnormalities. Anyone who is not immune to it and who has contact with someone with rubella can get rubella. If you and your child have received rubella vaccine or you have been tested and know that you are immune, there is no need for concern. The vaccine will not protect them if they have been exposed this time, but it will protect them from future exposures. If your child develops a fu-like illness, with a fne red rash and swelling of the glands behind the ears, arrange for your doctor to see the child. He will be able to tell you if it looks like rubella and will advise you what to do. If you suspect rubella, do not bring your child into a crowded surgery waiting room, as this may only spread the infection further. Children with rubella must stay at home until at least seven days after the appearance of the rash. We are bringing this to your attention because scabies can spread rapidly unless all affected children are promptly treated. The rash is caused by the body’s reaction to the mite and the scratching that occurs. The itching may occur anytime from two to eight weeks after catching the mites, so mites can pass to someone else before the rash appears. A variety of special lotions and creams that kill mites are available at the pharmacy. It is important to follow the instructions that come with the lotion carefully, as there are a number of different preparations available. As spread within households is common, it is a good idea to treat all family members at the same time even if there are no symptoms Thank you for giving this your attention. Scarlet fever is a scattered red rash and high temperature caused by bacteria (Group A streptococci). A scattered red rash that is often most marked in the creases of the joints and over the stomach. The skin may feel rough to the touch, sometimes described as feeling like sandpaper. Someone with scarlet fever will have evidence of a streptococcal infection somewhere, usually in the throat or sometimes in the skin. Your child can return to school when he/she is well and has fnished one full day of antibiotic treatment. The bacteria are spread through contact with nose and mouth secretions so: • Wash hands thoroughly after wiping nose. The ill child typically has a ‘slapped-cheek’ rash on the face and a lacy red rash on the trunk and limbs. An ill child may feel unwell and have a low-grade fever or a ‘cold’ a few days before the rash breaks out. An adult who is not immune can be infected with parvovirus B19 and either have no symptoms or develop the typical rash of slapped cheek syndrome, joint pain or swelling, or both. The joint pain and swelling usually resolve in a week or two, but may last longer. However, most adults have previously been infected with parvovirus B19 and have developed life-long immunity to the virus and cannot become infected again. A person infected with parvovirus B19 is infectious during the early part of the illness, before the rash appears.

Nodularity may be generalised or lo- their age at diagnosis) discount micardis 40 mg mastercard, history of oestrogen usage order micardis 80mg without a prescription, in- calised and it may be difficult to differentiate a localised cludingthecombinedoralcontraceptivepillorhormone area of nodularity from a discrete breast lump. It should replacement therapy, pregnancy history and history of however be noted that particularly in younger women, breast feeding. A menstrual history including the date of breast cancer may present as an area of localised nodu- last menstrual period should also be documented. Further assessment is required for any new dis- Inspection of the breasts starts with the woman sitting crete lump, a new lump within pre-existing nodularity upright with her arms to the side and then raised above or asymmetrical nodularity that persists after menstru- her head. The Many women develop one or more breast lumps dur- breasts should be palpated (normal breast first) exam- ing their lifetime. Both axillae should be pal- distressing, the majority are due to benign breast dis- pated for lymph nodes. A lump larger than 1 cm in size in a younger woman is most likely to be a fibroade- is usually palpable, although some are missed until they noma. Skin resolves with rest and nonsteroidal anti-inflammatory changes suggestive of malignancy are given in drugs. Breast pain may also be referred pain Breast pain (mastalgia) fromconditionssuchasangina,pleuralinflammation, pneumonia and oesophageal inflammation. Athoroughhistory Once underlying pathology has been excluded the ma- of the pain (documenting the site, onset and relationship jority of patients can be effectively managed with re- to the menstrual cycle) should be taken. Lifestyle changes have been suggested in- occur premenstrually (cyclical mastalgia) or may be un- cluding the use of a well-fitting sports bra, reduction related to the menstrual cycle. Athoroughbreastexaminationin- including danazol (a synthetic testosterone), tamoxifen cluding examination of the regional lymph nodes may and bromocriptine although all have significant side ef- reveal a cyst, an abscess or localised inflammation sec- fects limiting their clinical use. In non-cyclical mastalgia the chest lisuride (a dopamine agonist with fewer side effects than wall should also be palpated. The symptoms tend to Nipple discharge subside as menstruation starts and generally resolve Nipple discharge may arise from single or multiple ducts within a few days. Causes are given in Table tected imaging is not normally required for cyclical 10. True breast pain may be Clinical features caused by acute mastitis, a breast abscess, fat necrosis There may be a mass palpable, which when pressed pro- or benign breast disorders. Even if no mass is palpable, the dis- be a presentation of breast cancer therefore mammog- charge may come from one duct when one segment of raphy must be considered for women over the age of the breast is pressed. Unilateral blood-stained discharge is sugges- pressure on the costochondral junctions. It usually tive of an intraductal papilloma and also requires a triple Chapter 10: Clinical 411 Table10. However, needle core biopsy false Yellowish, green Perimenopausal negative rates are higher than fine needle aspiration and or brown Multiple/bilateral in duct ectasia fine needle aspiration allows aspiration of cystic lesions. Pus Breast abscess, periductal Fine needle aspiration may also provide cytology results mastitis on the same day (one stop clinic) helping to alleviate anxiety at a particularly stressful time for the patient. Copious bilateral milky discharge (galator- index finger and thumb and a fine needle attached to rhoea) may indicate a prolactinoma (see page 421) hence asyringe (often in a holder) is inserted into the lesion aserum prolactin level should be sent. Aspiration is performed by exerting gentle negative Management pressure through the syringe. A number of passes are If thereisnomass,anon-bloodydischargeandtheinves- made through the lesion at differing angles whilst neg- tigations have proved negative, management is conser- ative pressure is maintained. Surgical intervention is indicated if the discharge is profuse and embarrassing or if malignancy cannot be the area. One or Investigations/procedures two passes are usually sufficient to obtain diagnostic material. Imaging in breast disease Cytology from either procedure is graded into five cate- gories (see Table 10. There are two main modalities of imaging used in as- sessment of breast disease depending on the age of the patient: r Breast reconstruction Ultrasound is the imaging method of choice for estab- lishing the nature of a breast mass in younger women Following a mastectomy breast reconstruction can be (less than 35 years). Mammograms can be difficult to performed at the same time or as a delayed procedure. Mammography alone has C2 B2 Benign a 10% false negative rate, hence it is used as part of C3 B3 Probably benign C4 B4 Probably malignant the triple assessment (clinical examination, imaging, C5 B5 Malignant breast tissue sampling). Breast development Fibroadenoma, juvenile r Previous irradiation does not rule out breast recon- hypertrophy struction but may affect the choice of surgical tech- Cyclical activity Cyclical mastalgia, cyclical niques. The mammary dysplasia) these have now been classified skin may need to be gradually stretched first using as aberrations of normal development and involution atissue expander. A free flap requires its blood vessels to be surgically re- Aetiology anastomosed such as a latissimus dorsi flap. It may be used Some women develop generalised breast nodularity and as a pedicle or free flap. Complications of myocuta- others present with more localised nodularity (see also neous flaps include necrosis of the flap and scarring section Breast Lumps, page 409).

An Image Gently campaign focused on paediatric radiology was launched in 2008 by the Alliance for Radiation Safety in Pediatric Imaging [4] buy micardis 80 mg on-line. This campaign has had a major impact on reducing radiation dose to paediatric patients by ‘right-sizing’ imaging protocols to patient sizes discount micardis 80mg online. Within the Image Gently campaign, the Step Lightly Initiative focuses on the reduction of radiation dose in interventional radiologic procedures [5]. The Image Wisely campaign is modelled, in part, on the Image Gently campaign and is focused on appropriate and safe use of medical imaging for adult patients [6]. This initiative is a cooperative effort of the American College of Radiology, American Association of Physicists in Medicine, American Society of Radiologic Technologists, and the Radiological Society of North America. The Choosing Wisely programme is an effort by the American Board of Internal Medicine Foundation to encourage physicians to be better stewards of finite health care resources, including the use of imaging procedures [7]. Instilling a culture of safety in an organization encompasses several processes and steps, many of which are outlined in this paper. Foremost, it requires leadership from the top of the organization, and recognition by all employees that safety is everyone’s responsibility. The radiation dose to the population of the United States of America from medical radiation is now almost equal to that of background radiation, and increased more than seven times in the 25 years from the early 1980s to 2006. There has been an inexorable rise in the range and numbers of minimally invasive interventional techniques being performed using fluoroscopy, and these techniques have offered enormous benefits to many patients who otherwise may not be candidates for more invasive surgery. The range of radionuclides that can be used in medicine has also increased and the types of specific radiotherapy have become more complex. Despite these huge benefits, health professionals have to accept that some procedures deliver high radiation doses to patients. Radiation injuries, in interventional radiology and cardiology, and accidental exposures in radiotherapy are fortunately not common compared to the number of procedures or treatments performed, but were increasingly reported in the 1990s and 2000s. It is now 11 years since the International Conference on the Radiological Protection of Patients in Diagnostic and Interventional Radiology, Nuclear Medicine and Radiotherapy was held in March 2001, in Malaga, Spain. This landmark conference is now often referred to simply as the ‘Malaga conference’ among radiological protection professionals, which is a reflection of the significance of the event. These included optimization with an emphasis on reducing doses and risks without compromising image quality or treatment effectiveness, recognition of high dose procedures, monitoring doses from multiple examinations, and the development of adequate infrastructures to support the safe use of ionizing radiation in medicine. The subsequent Action Plan addressed issues of education and training of health professionals; appropriate exchange of information, with wider dissemination of that related to protection of patients; and the provision of practice specific guidance documents in collaboration with professional bodies and international organizations. Many national and international organizations have worked on initiatives to improve patient safety. Guidance on the use of appropriate imaging investigations for a wide range of clinical problems have been produced to aid clinicians and to reduce the unnecessary irradiation of patients. A learning, no blame culture has been encouraged by the establishment of databases, e. Two campaigns in the United States of America have been established to raise awareness of radiation and to lower doses where possible. The Image 2 Gently campaign is an initiative of the Alliance for Radiation Safety in Pediatric Imaging aimed at lowering radiation dose in the imaging of children. Several subsequent publications have focused on providing guidance on specific topics, for example, Preventing Accidental Exposures from New External Beam Radiation Therapy Technologies [7], while others have been more general, for example, Radiological Protection in Medicine [8]. This training now needs to extend beyond those traditionally working in radiology departments as the number of non-radiological specialists using ionizing radiation is increasing, and this was addressed in Radiological Protection in Fluoroscopically Guided Procedures Performed outside the Imaging Department [10]. Working parties are reviewing areas of justification and reference levels for both diagnostic and interventional imaging. Technological developments in medicine continue at a great pace and it is a challenge to produce timely recommendations that deal with the associated radiological protection issues. In addition, there is an ongoing need to raise the awareness of radiological protection among the many health professionals who either use or request procedures involving ionizing radiation, often with little or no knowledge. Significant progress has been made in the radiological protection of patients since the Malaga conference. This has been due to the considerable efforts of individuals and many organizations. Despite the achievements, there is no place for complacency and it is the responsibility of all radiological protection and health care professionals to continue to make improvements that enhance patient safety. This forms part of a larger move to improve the system of benefit–risk assessment, which takes in three key steps: awareness, appropriateness and audit (the ‘three As’). Justification of medical exposures at three levels as identified by the International Commission on Radiological Protection (from Ref. Awareness of this assessment is frequently portrayed in the media as a cost issue but health professionals correctly see the bigger picture of good medical practice and radiation safety as the two main criteria for selection of the best test first, before cost effectiveness. The balance of health benefit against radiation risk in a justified medical procedure is almost invariably in favour of the benefit.