What is Medicine – Amenorrhea
The following are the basic descriptions of primary and secondary amenorrhea: Primary amenorrhea: No menses by age 13 years with no secondary sexual characteristics OR Secondary amenorrhea: cessation of menses for 3 months with previously regular cycles or 6 months with a history of irregular cycles Endocrine/metabolic; reproductive system(s) affected pregnant women's issues Secondary amenorrhea is almost always caused by pregnancy. EPIDEMIOLOGY There is no indication that race or ethnicity has any bearing on the prevalence of primary amenorrhea, which affects 1% of females, and secondary amenorrhea, which affects 3-4% of females. PATHOPHYSIOLOGY AND AETIOLOGY Menstrual irregularity caused by malfunction of the hypothalamus, pituitary, uterus, ovaries, or vagina that may be transient, intermittent, or chronic Gonadal dysgenesis (such as Turner syndrome [45,X]) or failure (such as autoimmune, idiopathic) are the two primary causes of amenorrhea. - Anatomic anomalies (e.g., müllerian agenesis, imperforate hymen, transverse vaginal septum) - Abnormalities of the hypothalamus and pituitaryReduced GnRH secretion, such as in cases of anorexia nervosa and functional hypothalamic amenorrhea,Puberty physiologically delayed; central lesions (tumours, hypophysitis, granulomas)Pituitary dysfunction (hyperprolactinemia, aberrant FSH, LH, or GnRH levels, or any combination thereof)) - Polycystic ovarian syndrome (PCOS) - Hypothyroidism) - The syndrome of androgen insensitivitye Amenorrhea secondary to pregnancy - Dysfunction of the hypothalamus (reduced GnRH secretion) Functional hypothalamic amenorrhea (as a result of anxiety, anorexia nervosa, or overexertion) Tumours of the hypothalamus A severe systemic ailment, such as celiac disease or type 1 diabetes Pituitary disorder, such as hyperprolactinemia, Sheehan syndrome, and Cushing syndrome, for example - PCOS - Thyroid illness - Conditions affecting the ovaries, such as ovarian tumours or primary ovarian insufficiency brought on by chemotherapy, radiation, or the fragile X syndrome. - Anatomical anomalies (such as iatrogenic cervical stenosis, obstructive fibroids, polyps, intrauterine adhesions [Asherman syndrome]). Depending on the aetiology, pathophysiology differs. Turner syndrome or testicular feminization may be genetic conditions. RISK FACTORS Include obesity, excessive exercise, and eating disorders (often referred to as the "female athlete triad"). Stress (emotional or illness-induced, such as myocardial infarction or severe burns) Amenorrhea or early menopause in the family history Antipsychotic medication use GENERAL PREVENTION maintaining a healthy body mass index (BMI) and leading a balanced, active lifestyle CONDITIONS OFTEN Associated with Autoimmune disorders like type 1 diabetes and autoimmune thyroiditis may be linked to primary ovarian insufficiency. Obesity and insulin resistance are linked to PCOS. Reduced oestrogen exposure may raise the incidence of osteopenia or osteoporosis. DIAGNOSIS HISTORY Review of systems, including virilizing changes, cyclic pelvic discomfort, galactorrhea, headaches, visual changes, weariness, palpitations, polyuria/polydipsia, weight change, pregnancy or menopausal symptoms, History of growth and pubertal development, including pubertal growth spurt age, adrenarche (early sexual maturation), and chemotherapy or radiation prior to adolescence Obstetric history Psychiatric history Social history, including diet and exercise history, drug abuse history, sexual history, and stress Family history of delayed or absent puberty Physical examination includes a look at general appearance, vital signs, height, weight, growth percentile, and BMI, as well as a look for hypotension, bradycardia, and hypothermia (anorexia nervosa). HEENT exam findings include dental erosions, palate trauma from bulimia, visual field defects, funduscopic changes, cranial nerve findings from prolactinoma, webbed neck from Turner syndrome, and thyromegaly. Skin exam findings include androgen excess (acne, hirsutism), acanthosis nigricans (PCOS), striae, vitiligo, and easily bruised skin. Breast exam findings include the stage of development, galactorrhea (prolactinoma), and shield chest (Turner syndrome). Pelvic exam findings include the presence or absence of pubic hair (if sparse, androgen insensitivity or deficiency), clitoromegaly (androgen excess), distention or bulging of the external vagina (imperforate hymen), thin, pale vaginal mucosa without rugae (oestrogen de) DETECTION & INTERPRETATION OF DIAGNOSIS Initial examinations (lab, imaging) Serum thyroid-stimulating hormone (TSH), prolactin (PRL), hCG, and FSH are indicators of primary amenorrhea. - If there is little or no breast development: Low FSH points to a main hypothalamic-pituitary cause or a genetic delay in puberty. High FSH is a sign of gonadal failure, hence a karyotype study needs to be done. – If breast development is normal, check for anatomic anomalies if FSH levels are low. Analyse the karyotype, the testosterone level, and the dehydroepiandrosterone sulphate (DHEA-S) levels if the uterus is absent or atypical. Serum hCG, PRL, TSH, and FSH are indicators of secondary amenorrhea. PRL >100 ng/mL: indicates pituitary adenoma or empty sella syndrome; nevertheless, levels can momentarily rise with stress. Repeat the test, and if it is elevated, have an MRI done for analysis. If your PRL is raised but under 100 ng/mL, you should check for additional causes, the majority of which are drugs. If FSH is high, think about primary ovarian insufficiency or menopause naturally. – Perform a progestin challenge to test endogenous oestrogen production; if withdrawal bleeding occurs, the condition chronic anovulation (most frequently PCOS) is likely. Perform an oestrogen and progestin challenge if there is no withdrawal bleeding: Consider outflow tract obstruction or hypoestrogenism if there is no bleeding. If bleeding occurs, check FSH/LH levels, which are increased in premature ovarian failure and decreased in eating disorders, chronic illnesses, and pituitary tumours. Measure the levels of total testosterone, DHEA-S, and 17-OH progesterone if hyperandrogenism is present. If testosterone is greater than 200 ng/dL, begin the assessment for an androgen-secreting tumour. Imaging is typically not recommended as a first line of treatment. The US can detect ovarian cysts (PCOS), the presence or absence of a uterus, and endometrial thickness; if the patient is unable to tolerate the US probe, MRI should be considered. Tests in the Future & Special Considerations Women under 30 with ovarian failure should have a karyotype analysis, as well as have their adrenal antibodies and fragile X syndrome premutation status checked. Karyotype analysis should also be carried out if there is no uterus or a foreshortened vagina. Laparoscopic diagnosis of polycystic or streak ovaries (Turner syndrome) Hysterosalpingogram: Distinguish different causes of outflow obstruction, such as Asherman syndrome. Other/Diagnostic Procedures If hypothalamic amenorrhea from functional suppression is suspected, take a dual energy x-ray absorptiometry (DEXA) scan to measure bone loss. If constitutional delay is indicated, get bone age. GENERAL TREATMENT MEASURES Identify and, if feasible, treat any underlying pathology. MEDICATION Medroxyprogesterone (Provera): 10 mg/day for 10 days will result in withdrawal bleeding within 7 days of last dose if hypothalamic-pituitary-gonadal axis is intact (i.e., amenorrhea is a result of anovulation and a lack of progesterone), although experts disagree. Oestrogen replacement: If the uterus and lower genital tract are normal (hypothalamic-pituitary axis pathologic), cycling with a combination oral contraceptive (containing 35 or 50 g of oestrogen) or conjugated oestrogen (Premarin) 0.625 mg for 25 days with progesterone added as above for the last 10 days will result in a withdrawal bleed. Hormone replacement therapy won't solve the fundamental issue. For example, bromocriptine is used to treat hyperprolactinemia when other medications are needed. For the long-term treatment of amenorrhea in elderly women, hormone replacement therapy is not advised. - Might be safe for treating symptoms in young women - Give to young girls and women to retain secondary sex characteristics and avoid osteoporosis. Oral contraceptive pills (OCPs), patches, and rings are examples of contraceptives that replace oestrogen while preventing conception. - Improve bone mineral density in women who are oligo-/amenorrheic but not in those who have functional hypothalamic amenorrheaCalcium supplementation: 1,500 mg/day if the cause is hypoestrogenism - Can reduce hirsutism in PCOS Metformin (Glucophage) has been used (starting at 500 mg BID) to address metabolic irregularities, promote ovulation, and restore regular menstrual cycles because PCOS and insulin resistance are connected. It is noteworthy that metformin therapy has increased clinical pregnancy rates but not live birth rates. Exogenous leptin injection appears to help functional hypothalamic amenorrhea; however, this is currently under investigation. Pregnancy, thromboembolic illness, past myocardial infarction or cerebrovascular accident, an estrogen-dependent cancer, and significant hepatic disease or impairment are all contraindications to the administration of oestrogen. Precautions: Women with amenorrhea who want to get pregnant shouldn't use HRT; instead, they should get treatment for infertility based on the cause. QUESTIONS FOR REFERENCE Referrals to ob/gyn, endocrine, surgical, and/or psychiatric experts are necessary for many reasons of amenorrhea. SURGICAL AND OTHER PROCEDURE If an imperforate hymen is the cause of the primary amenorrhea, hymenectomy In cases of Asherman syndrome, lysis of adhesions is frequently successful in reestablishing regular menstruation and fertility. Patients with congenitally short vagina can undergo surgery to create a functional vagina; treatment of prolactinomas may entail surgical resection; if the karyotype is XY, the gonads must be removed due to an elevated risk of tumours. CONTINUING CARE AFTERCARE RECOMMENDATIONS Activity level should be decreased by 25–50% if excessive exercise is indicated. Patient Monitoring Depending on the underlying cause and selected treatment If hormonal replacement therapy is utilised, stop using it after 6 months to monitor the reappearance of menstruation on its own. Diet: If PCOS is the underlying cause, a weight-loss diet will aid in resuming ovulation. Diet: Correct overweight or underweight by dietary management and behaviour change. EDUCATION OF PATIENTS Inform them about the specifics and side effects of her ailment as well as its underlying cause. Particular educational resources, such as prenatal classes and menopausal support groups, are beneficial. Talk about the projected amenorrhea duration (temporary or permanent), impact on fertility, and long-term effects of untreated amenorrhea (such as osteoporosis, vaginal dryness). Because fertility returns before menses, appropriate contraceptive counselling should be offered. If the amenorrhea is linked to a decline in fertility or sterility, more support might be required. PROGNOSIS shows the underlying reason. One study found that 83% of functional hypothalamic amenorrhea cases reversed when a clear contributing factor was present. COMPLICATIONS Increased risk of endometrial cancer in patients whose amenorrhea is caused by anovulation with oestrogen excess (obesity, PCOS) Premature ovarian failure may increase cardiovascular risk. Estrogen-deficiency symptoms (e.g., hot flashes, vaginal dryness) and osteoporosis in prolonged hypoestrogenic amenorrhea.
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What is Medicine – Alzheimer Disease
ESSENTIAL DESCRIPTION Alzheimer disease (AD) is a degenerative, progressive, and irreversible neurologic condition that kills neurons. AD accounts for 60–80% of dementia. In the US, AD is the sixth most common cause of death. Alzheimer's disease (AD) is underdiagnosed (50%) and >50% of those with AD are ignorant of their diagnosis. The economic cost in 2018 was $305 billion, and by 2050, it is expected to reach $1.1 trillion. Dementia should be separated from: - Age-related cognitive decline: permanent modifications to mental capacity and memory; a result of natural ageing Greater impairment than cognitive decline is mild cognitive impairment (MCI). MCI: From a cognitive standpoint, most people are able to live independently. MCI: affects 15–20% of people under 65, and 32–38% of those people will develop dementia within 5 years. AD diagnostic classification: Preclinical AD has no cognitive symptoms, but has AD biomarkers. MCI from AD typically has memory issues. - AD-related dementia Early stage: memory impairment >MCI; Middle stage: communication and environment response impairment; Late stage: loss of ability to recognise and respond to environment properly; Affected System(s): Nervous Synonym(s): Alzheimer-type senile dementia; presenile dementia EPIDEMIOLOGY Females outnumber males in incidence and prevalence and are more prevalent in people over the age of 65. Incidence 484,000 new cases of AD are reported annually in the US . 2 new instances for every 1,000 adults aged 65 to 75. From the ages of 75 to 84: 11 new cases per 1,000 individuals 85 years: 37 new instances for every 1,000 individuals There are 5.8 million cases in the US; 44 million cases worldwide; 13.8 million cases in the US by 2050; and 1 in 10 of people 65 years and older have AD dementia. 32% of people over 85 have AD dementia. There are 200,000 Americans under 65 who have early-onset AD. AETIOLOGY AND PATHOPHYSIOLOGY Age, genetics, systemic diseases, and lifestyle choices may all affect the progression of AD. -Amyloid plaques outside of neurons and protein tangles inside of neurons, resulting in loss of connections and neuron death. Genetics: Autosomal dominant: 5% of AD, typically appearing before age 65. Nonautosomal dominant AD (familial inheritance): 15–25% of AD Non-modifiable risk variables include age, gender (owing to women's longer lifespans), family history, and genetic mutations. - APOE-e4 gene variant: e4 homozygous risk is 8 times higher than e4 heterozygous risk. – There are racial and ethnic variations in AD. Risk factors for cardiovascular disease include: - Hyperlipidemia and hypertension (HTN), particularly in midlife - Diabetes, obesity, and a decreased ability to metabolise glucose - Smoking, a poor diet, and a lack of exercise - Stroke risks and harm from cerebrovascular disease Additional risk elements that may be altered include: - Fewer years of formal schooling (8th grade) - Insufficient ongoing learning - Mild, moderate, and severe recurrent traumatic brain injuries - Social isolation - Late-life depression - Insufficient and poor-quality sleep - Deficits in hearing and vision - Heavy alcohol use - Potential environmental variables (such as pollution). DURATIONAL PREVENTION People under the age of 50 are most concerned about cognitive decline and impairment. HTN control, more exercise, and cognitive training may slow or stop cognitive ageing, MCI, and AD. NSAIDs, oestrogen, and vitamin E do not postpone the beginning of AD; statins and proton pump inhibitors have inadequate data to support their use. Healthy habits could stop or delay the onset of AD. Manage psychiatric disorders and prevent delirium while patients are in the hospital. COMMONLY ASSOCIATED CONDITIONS Depression Down syndrome The "Welcome to Medicare" preventive visit and the Medicare Annual Wellness Visit both call for a cognitive function assessment. Excluding delirium is necessary for the diagnosis of dementia. A comprehensive H&P, cognitive exam, and other diagnostic procedures are required to identify a specific dementia type. - DSM-IV-TR criteria from 2000: The ability to operate at work, at home, or in social situations is significantly hampered by a progressive deterioration in at least two areas of memory, executive function, attention, language, or visuospatial abilities. - As of 2013, the DSM-5 refers to "neurocognitive disorder" rather than "dementia," and lists the following cognitive impairments as neurocognitive disorders: complex attention, executive function, learning and memory, language, perceptual motor, and social cognition. Include an informant from your history, such as a family member, friend, or carer. - Memory loss that interferes with daily activities - Difficulty finishing routine tasks - Challenges in planning and problem solving - New word problems in speaking or writing - Difficulty with spatial relationships or visual images - Changes in mood or personality - Loss of the ability to remember where things are or how to get there - Reduced or poor judgement - Withdrawal from social or professional activity - Time and location confusion. Exam should rule out other dementia or delirium causes. Noncognitive parts of physical exam frequently normal for age, with the exception of late stage AD. ● Neuro: speech, language, vision, hearing, gait, balance, reflexes, muscle strength and tone, tremor, abnormal movements (akathisia, bradykinesia/dyskinesia) ● Late stage: skin lesions, nutrition-hydration status ● Brief cognitive testing, such as: Mini-Cog, Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE, under copyright, fee for use) ● Assess depression: Patient Health Questionnaire-9, Geriatric Depression Scale (GDS). Functional evaluation methods include the Functional Activities Questionnaire (FAQ) and instrumental activities of daily living (IADLs). DIFFERENTIAL DIAGNOSIS Additional dementias (most prevalent): - Vascular; mixed type (with AD); big and microvessels - Parkinson's disease; normal pressure hydrocephalus; dementia with Lewy bodies; frontotemporal lobar degeneration - Wernicke-Korsakoff, Huntington, and Creutzfeldt-Jakob Depression; primary or metastatic brain tumours; subdural hematoma (usually acute presentation); hyper-/hypothyroidism; vitamin-nutrient deficiency; uremia/renal; hepatic; hyponatremia; autoimmune: vasculitis; end-stage multiple sclerosis; infectious: HIV; syphilis; Lyme disease; varicella-zoster virus; prion Drug-alcohol interactions, medications, and addiction DETECTION & INTERPRETATION OF DIAGNOSIS Neuropsychological testing to establish independent decision-making in cases of unusual symptoms, youth, hazy presentation, or other factors Initial examinations (lab, imaging) To help rule out alternative dementia-causing factors Homocysteine level, a complete blood count with differential, thyroid function, syphilis tests, lipid panel, and vitamin B12 are all included in a chemistry panel. ESR, HIV, folate, C-reactive protein, and HbA1c are special factors to take into account. Biomarkers used in imaging There are various professional standards; they could reveal dementia's root cause. If MRI is not an option, think about a computed tomography (CT) scan instead. Initial AD examination; recent or rapid decline; age 65; stroke history; unusual presentation; worry for malignancy; high bleeding risk - Positron emission tomography (PET) and single-photon emission CT (SPECT): rarely indicated; inadequate data to utilise alone Tests in the Future & Special Considerations Consider genetic testing if you're worried about familial and autosomal dominant AD. Cerebrospinal fluid biomarker testing is not yet recommended. GENERAL TREATMENT MEASURES Optimise the management of comorbid illnesses (such hearing disorders) and risk factors. Planning for advanced care before a person loses the capacity to make independent decisions Evaluate carer exhaustion and support. ALERT In its Choosing Wisely statement, the American Geriatrics Society advises "Don't prescribe cholinesterase inhibitors (ChEIs) for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects". First Line: MEDICATION Acetylcholinesterase inhibitors (ChEIs) are most beneficial in mild to moderate disease; they may also be effective in Lewy body dementia. GI issues as well as additional adverse effects like bradycardia and syncope Try a different ChEI if there is no benefit. - When administered for at least 6 months, may produce a mild benefit in cognition and behaviour. Start with 5 mg/day PO of donepezil (Aricept), and if necessary, increase to 10 mg/day after a month and 23 mg/day after three months. - Orally dissolving pills; available in generic - Digoxin and -blockers should be used cautiously (donepezil may lengthen the PR interval). - Capsule, solution, or patch (reduced side effects) for rivastigmine (Exelon): Start at 1.5 mg PO BID, increase by 1.5 mg BID every two weeks, and maintain at 6 to 12 mg/day overall. - Galantamine (Razadyne) tablets, solution, extended-release (ER) capsules, and transdermal formulations: Start at 4 mg BID for 4 weeks, then increase by 4 mg BID every month to reach a dose of 16 to 24 mg/day. Vitamin E: 2,000 IU per day, inconsistent results, potential negative effects Memantine, an NMDA receptor antagonist, is used to treat moderate to severe Alzheimer's disease (AD). - Acetylcholinesterase inhibitors alone or in conjunction with other therapies (2)[A] - Memantine instant release: 5 mg daily; titrate to 10 mg BID, increasing 5 mg per day per week as needed. Memantine ER: 7 mg/day to 28 mg/day with an additional 7 mg/day qwk PRN A monoclonal antibody treatment called Aducanumab (Aduhelm) that targets beta-amyloid. limited benefit and some adverse effects. advise against frequent use; have doctors who specialise in AD evaluate aducanumab Consider second-line treatment for moderate to severe neuropsychiatric symptoms; check for delirium and treatable reasons (sleep hygiene, hearing, environment alterations). Next Line Selective serotonin reuptake inhibitors (SSRIs) are chosen for treating moderate to severe depression. Drugs for insomnia in AD are not very effective at getting people to sleep. - Seniors should not take antihistamines. Risperidone, trazodone, and sleep aids (such as zolpidem) should be used with caution and at the lowest effective doses. If you are experiencing moderate agitation, anxiety, or restlessness, you may want to investigate SSRIs (citalopram) or low-dose risperidone. Careful low-dose risperidone administration for severe psychosis Safety measures - When feasible, stay away from anticholinergic medication. – The use of benzos may result in paradoxical excitement or afternoon sleepiness. - Halcion, a brand name for triazolam, can cause confusion, memory loss, and psychotic behaviour. - Donepezil: use with caution if you have a history of peptic ulcers, sick sinus syndrome, or anticholinergics QUESTIONS FOR REFERENCE If an AD patient has behavioural problems and needs to take psychotropic drugs, think about referring them to geriatric psychiatry. Exercise to relieve restlessness; cognitive stimulation therapy; consider occupational, music, scent, and pet therapy as additional modalities. CONTINUING CARE AFTERCARE RECOMMENDATIONS patient observation Each visit's medication reconciliation, including OTCs Encourage a healthy lifestyle, including physical activity, a balanced diet, enough sleep, social interaction, and mental stimulation. Warn consumers against unproven items that claim to enhance brain function, such as some drugs, dietary supplements, and brain games. Continually evaluate the effectiveness and negative effects of medications (ChEIs/memantine). Late AD might call for placement in skilled care. Medicare will pay for advanced care planning. Assessment of safe driving by the National Highway Traffic Safety Administration: https://www.nhtsa.gov/older-drivers/driving-safely-while-aging-gracefully EDUCATION OF PATIENTS Alzheimer's Association website: www.alz.org Early advanced care planning, including financial preparation, carer assistance, and advanced directives PROGNOSIS Initial diagnosis is frequently delayed, and the average survival time after diagnosis is 4 to 8 years. COMPLICATIONS Include anger, agitation, stumbling, falls, "sundowning," depression, and suicide. Infections, insufficient water or nutrition, and medication toxicity What is Medicine – Altitude Illness
ESSENTIAL DESCRIPTION Ascent to greater elevations can cause a variety of brain and pulmonary symptoms, some of which can be fatal, as a direct result of insufficient acclimatisation. The following height ranges are classified as intermediate: 1,520 to 2,440 metres; high: 2,440 to 4,270 metres; very high: 4,270 to 5,490 metres; and extreme: >5,490 metres. Everyone, even seasoned travellers and physically strong people, can develop altitude sickness. The majority of people experience it as an unpleasant (self-limited) syndrome that doesn't need treatment. Acute mountain sickness (AMS) is a set of symptoms brought on by the body's reaction to a hypobaric, hypoxic environment. Onset often happens 6 to 12 hours after climbing more than 2,500 metres. The majority of the symptoms are neurological, ranging from mild to serious headache, malaise, and severe impairment. High-altitude pulmonary edoema (HAPE): noncardiogenic pulmonary edoema that occurs at elevations of 3,000 m or higher and is uncommon between 2,500 and 3,000 m. High-altitude cerebral edoema (HACE) is a potentially fatal neurologic disease that develops after at least two days at altitudes greater than 4,000 metres. System(s) impacted: pulmonary and nervous Mountain sickness is a possible synonym. Aspects of Geriatrics Age alone should not prevent travel to high altitude; provide extra time to acclimatise. Risk does not increase with age. Exacerbation of pre-existing medical disorders known as altitude-exacerbated conditions Child Safety Considerations Altitude sickness seems to affect children at the same rate as it does adults, however younger children may take longer to get diagnosed. Any youngster who exhibits behavioural signs following a recent ascent should be assumed to have an illness associated with high altitude. No data suggests that exposure to high altitudes (1,500 to 3,500 m) poses a harm to a pregnancy, hence the risk during pregnancy is uncertain. EPIDEMIOLOGY The majority of epidemiologic studies are only conducted on male groups that are comparatively homogeneous. Incidence AMS: 10–25% of unacclimatized climbers who reach 2,500 m; 50–85% at 4,500–5,500 m; and HAPE/HACE: 0.5%–1.0% of climbers who spend two or more days at elevations above 3,000 m. Above 2,500 m (8,200 feet), for every 1,000 m rise in altitude, the risk of acute mountain sickness (AMS) increases by 13%. PATHOPHYSIOLOGY AND AETIOLOGY People who have experienced AMS, HACE, or HAPE in the past are more likely to experience it again. Altitude illness's pathophysiologic predecessors include hypobaric hypoxia and hypoxemia. Other mechanisms include impaired cerebral autoregulation, release of vasogenic mediators, and alteration of the blood-brain barrier. HAPE is a noncardiogenic pulmonary edoema characterised by exaggerated pulmonary hypertension leading to vascular leakage through overperfusion, stress failure, or both. Symptoms of AMS may be caused by cerebral swelling, either through vasodilatation induced by hypoxia or through cerebral edoema. Genetics It is unclear what genetic factors contribute to AMS predisposition. RISK FACTORS include: inadequate acclimatisation at a lower altitude; ascent rates greater than 300 to 500 metres per day; extreme altitude; increased time spent at high altitude; higher altitude at night; previous history of altitude illness; cardiac congenital abnormalities; female gender; migraine history; younger age (46 years); and history of anxiety. GENERAL PREVENTION Fundamental principles - Preacclimatization, or being exposed to hypoxia before climbing, guards against altitude sickness. – Altitude sickness can also be avoided by making a staged ascent over six to seven days at 2,200 to 3,000 metres. - >2,500 m, don't climb more quickly than 500 m/day, and take breaks every 3 to 4 days (2). - Lower sleeping altitude: "Climb high and sleep low" is advised for everyone travelling above 3,500 m. - For the first 1 to 3 days at altitude, refrain from strenuous activity. - Steer clear of sedatives and alcohol, which inhibit breathing. – Physical conditioning before an event is not preventative. Acetazolamide, dexamethasone, and ibuprofen are examples of pharmacologic prophylaxis. Only if at risk, consider nifedipine, -agonists, and tadalafil for the prevention of HAPE. DIAGNOSIS HISTORY Symptoms of AMS include headache, anorexia, irritability, extreme exhaustion, nausea, vomiting, lightheadedness, dizziness, and insomnia. – The Lake Louise diagnostic criteria, which range from 0 (none) to 3 (severe), has been used to study severity. Headache, GI symptoms, weakness or exhaustion, lightheadedness or dizziness, and AMS Clinical Functional Score (symptom impact on activities) A headache score of at least 1 point and a total score of at least 3 points are required to diagnose AMS. Reduced capacity for activity, coughing after exertion followed by dyspnea at rest, cyanosis, and a productive cough that may produce pink frothy sputum are all indications of HAPE. HACE symptoms include altered mental status, which may lead to ataxia and disorientation. Other symptoms include illogical behaviour, lethargy, obtundation, and coma. Physical examination findings include HAPE, lupus-like symptoms, central cyanosis, tachycardia, and tachypnea. HACE - Abnormal mental status examination (coma, coma-like behaviour, lethargy, obtundation) Truncal ataxia, papilledema, retinal haemorrhage, and cranial nerve palsies are some of the less common symptoms. DIFFERENTIAL DIAGNOSIS AMS/HACE - Dehydration - Ingestion of toxins, drugs, or alcohol - Subarachnoid haemorrhage, CNS mass, cerebrovascular accident - Migraine headache - Carbon monoxide exposure - CNS infection - Acute psychosis - HAPE - Pneumonia - Cardiogenic pulmonary edoema - Spontaneous pneumothorax - Pulmon The absence of a headache, the onset of symptoms after more than three days at a certain altitude, or a slow reaction to oxygen or descent point to a different diagnosis. Initial tests (lab, imaging) Diagnostic tests and interpretation AMS: Diagnostic laboratory tests are infrequent and nonspecific. HAPE: Extremely low oxygen levels as shown by oximetry or blood gas analyses. Patchy infiltrates are frequently visible on chest radiographs. A different diagnosis is suggested by clear lung areas. ECG results could indicate right-sided cardiac strain or sinus tachycardia. UNSPECIFED MEASURES People who have never been exposed to high altitudes should follow the acclimatisation instructions. If symptoms do not go away within 24 hours, discontinue your ascent, acclimatise at the same altitude, and/or descend. Moving to a lower altitude is the only effective treatment. Even slight drops in altitude result in dramatic improvements. Oxygen aids in symptom relief. Give continuously using a cannula or mask and titrate until your SaO2 is above 90%. AMS symptoms are lessened to a slight to moderate extent by acetazolamide. - Dexamethasone may be useful in the management of mild AMS. Keep the patient warm and minimise effort with oxygen treatment (HAPE). Immediate descent or evacuation to a lower altitude. When a descent is impossible, portable hyperbaric therapy (2 to 15 psi using a Gamow bag or Chamberlite) is a useful and effective option. - Nifedidipine Immediate descent HACE - Extra oxygen (maximum flow possible; keep SaO2 over 90%) - Dexamethasone - If available and impractical, portable hyperbaric therapy. First Line: MEDICATION Oxygen: Maintain SaO2 >90% at 2 to 15 L/min until symptoms subside Acetazolamide: Take into account therapy for primary prevention if the patient has a history of issues at altitude and/or expects to ascend more than 500 m per day above 2,500 m. In those who have a sulfonamide allergy, avoid. Adults should take 125 mg PO BID commencing 24 hours prior to ascension and continuing for 2 to 4 days at a steady altitude. Children should take 2.5 mg/kg (up to 125 mg) every 12 hours. - For the treatment of AMS, take 250 mg PO BID till the symptoms go away; for children, take 2.5 mg/kg q12h. Dexamethasone may considerably lessen both the frequency and severity of AMS. Negative side effects are uncommon. - To prevent AMS, take 2 mg or 4 mg orally every six hours (PO), beginning the day before climb and phasing it out gradually after two days at the highest altitude. Use not advised for prevention in children. Treatment for AMS: 4 mg PO/IV/IM every six hours; for children, 0.15 mg/kg every six hours. - To treat HACE, provide 8 mg PO/IV/IM at first, followed by 4 mg every six hours. The drug nifedipine lowers pulmonary arterial pressure.- To prevent HAPE, provide 30 mg extended-release PO BID beginning the day before climb and continuing for two days at the highest altitude. - If oxygen is available, treating HAPE with 30 mg extended-release PO every 12 hours is probably unnecessary. Tadalafil: Take into account for HAPE prevention (1). - In HAPE-susceptible individuals, use 10 mg PO BID 1 day before to ascent. Adjunct therapy with salmeterol may be used to treat HAPE (unproven): 125 mg breathed BID beginning the day before climb and continuing for two days at the highest altitude. - NSAIDs may help prevent and relieve headaches associated with AMS. Aspirin: 325 mg PO every four hours for a total of three doses Prochlorperazine: 10 mg PO/IM q6-8h; Promethazine: 25 to 50 mg PO/IM/PR q6h; Antiemetics (Ibuprofen: 400 to 600 mg PO every eight hours); Other tested treatments - Gingko balboa does not reduce the risk of AMs any more than a placebo does. Coca-containing items have been consumed in the Andes, although little research has been done on them. - There is insufficient evidence to support the use of simulated altitude or remote ischemic preconditioning (RIPC), antioxidant supplements, medroxyprogesterone, iron, or Rhodiola crenulata. - Furosemide: 20 to 80 mg PO/IV q12h for a total of 2 doses; previously evaluated for the treatment of AMS or HACE. presently unpopular, not advised for prophylaxis, and not approved for usage in HAPE. CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING minor patients receive outpatient care. RECOMMENDATIONS OR CONTINUING CARE patient observation There is no requirement for follow-up in moderate cases. For more severe cases, keep an eye on the patient until the symptoms go away. EDUCATION OF PATIENTS Talk to patients about the dangers of travelling at high altitudes and how to spot high-altitude disease signs. PROGNOSIS The majority of mild to moderate AMS cases resolve on their own and don't need treatment. Ascent may be resumed by the patient after the symptoms pass. If detected early, HAPE and HACE respond favourably to descent, evacuation, and/or medication. COMPLICATIONS Although high-altitude retinal haemorrhage typically has no symptoms, it can alter vision What is Medicine – Alopecia
Alopecia is the absence of hair from areas where it normally grows. It can be classified as scarring (cicatricial), nonscarring (noncicatricial), or structural. Hair that is brittle or fragile due to aberrant hair growth or external trauma is referred to as structural hair problems. EPIDEMIOLOGY Prevalence Androgenic alopecia: - In men, 30% Caucasian by age 30, 50% by age 50, and 80% by age 70 - In women, 70% of women over 65 - AA: 1/1,000 with lifetime risk of 1-2%, men and women affected equally - Scarring alopecia: rare, 3-7% of all hair disorder patients. Scarring (cicatricial) alopecia is an inflammatory condition that results in the follicle's permanent destruction. Lymphocytic, neutrophilic, and mixed inflammation are the three main kinds. Primary scarring includes discoid lupus, lichen planopilaris, dissecting cellulitis of the scalp, primary fibrosing, among other conditions. - Secondary scarring brought on by physical damage, such as tinea capitis, surgery, radiation, and neoplasm - The most prevalent type of scarring hair loss in African American women is central centrifugal cicatricial alopecia; its cause is unknown but is probably related to hair care habits. Noncicatricial (nonscarring) alopecia, Focal alopecia, and AA Patchy hair loss, typically due to an inflammatory condition, T cell-mediated inflammation, and an early transition into the catagen and telogen phases. Alopecia universalis, which causes a rapid loss of all body hair, and alopecia totalis, which affects only the scalp, are possible co-occurring conditions. High psychiatric comorbidity (1) - Frequent nail illness - Alopecia syphilitica: "moth-eaten" appearance, secondary syphilis - Postoperative, pressure-induced alopecia: caused by sustained pressure on a single scalp region Traction alopecia: patchy hair loss brought on by physical tension from braids, ponytails, and hair weaves. Temporal triangular alopecia: congenital patch of hair loss in the temporal area, unilateral or bilateral Hair changes from terminal to vellus hairs in those with androgenic alopecia, a kind of pattern hair loss. - Male pattern hair loss: androgen-mediated hair loss in a specific pattern; bitemporal and vertex hairs on the scalp are androgen sensitive. This disorder is primarily inherited. Increased 5-reductase and androgen receptors increase the rate at which testosterone is converted to dihydrotestosterone (DHT) in the follicle. As a result, follicle size is reduced and vellus hair is produced (2). Types I to VII of the Norwood Hamilton categorization Female pattern hair loss is characterised by vertex and frontal thinning (Ludwig classification, grades I to III). More testosterone is available for the conversion of to DHT in females with low levels of aromatase (3). This has an illegible pattern of inheritance (2). Adrenal hyperplasia, pituitary hyperplasia, and polycystic ovarian disease all cause androgen alterations that can cause alopecia. - Drugs (testosterone, progesterone, danazol, adrenocorticosteroids, anabolic steroids), medications (hormone replacement therapy, oral contraceptive pills), and oral contraceptive pills. Trichotillomania is the deliberate pulling out of hair from the scalp, and it can take many different forms. The abrupt transition of many follicles from the anagen to the telogen phase, which results in reduced hair density but no bald spots, is known as diffuse alopecia-telogen effluvium. Can be chronic with continuous illness, such as SLE, renal failure, IBS, HIV, thyroid disease, pituitary dysfunction, and occur 2 to 3 months after event. May occur after substantial stressors, such as delivery, accident, or illness; occurs 2 to 3 months after event Malnutrition from malabsorption, eating disorders, and a poor diet can all contribute. Adding or altering drugs (oral contraceptives, anticoagulants, anticonvulsants, SSRIs, retinoids, -blockers, ACE inhibitors, colchicine, cholesterol-lowering meds, etc.) is another factor. - A. effluvium Days to weeks following the triggering event; interruption of the anagen phase without a transition to the telogen phase The most frequent trigger is chemotherapy, although additional causes include radiation, toxicity, and medicines. Structural hair diseases include Menkes disease, monilethrix, and other inherited hair conditions. These cause the development of weaker, aberrant hairs. may also be caused by heat or chemical damage from hair-processing procedures. Genetics Androgenic alopecia, like AA, is frequently accompanied with a family history of early patterned hair loss. RISK FACTORS include: genetic susceptibility; chronic illnesses such as autoimmune disorders, infections, and cancer; physiological stress such as childbirth; inadequate nutrition; medication, chemotherapy, and radiation; and hair chemical treatments, braids, and weaves/extensions. GENERAL PREVENTION Reduce risk factors as much as you can. COMMONLY ASSOCIATED CONDITIONS Vitiligo—a condition that affects 4.1% of people with AA and may be caused by the same autoimmune mechanisms DIAGNOSIS The history and examination are used to make a clinical diagnosis. HISTORY Description of the hair loss issue, including the amount of hair lost, where it is occurring, how much hair has been lost, and accompanying symptoms like itching and infection. Hair styling practises such as using prolonged heat, colouring, bleaching, chemical relaxers, and hair styling (braids and ponytails) are associated with pruritus, pain, or burning. Medications are also used to treat medical conditions such as chronic illness, recent illness, surgeries, pregnancy, thyroid disorder, iron deficiency, poisonings, and exposures Stress on the mind, dietary history, and changes in weight family history of autoimmune diseases or hair loss Physical examination: Generalised, patterned, and focused hair loss - Examine broken hair, vellus versus terminal hairs, and hair density. scaling, inflammation, papules, and pustules on the scalp Follicular ostia are used to categorise different types of alopecia. Test for hair pulling involves pinching 25–50 hairs between the thumb and forefinger and pulling slowly and gently while sliding the fingers up. Normal: 1 to 2 displacement Unusual: six dislodged hairs Hair that is broken (structural abnormality) Border patch with easily removeable broken-off hairs (in AA) Other-site hair loss, nail problems, and skin changes Clinical indicators of virilization include acne, hirsutism, acanthosis nigricans, and truncal obesity. Clinical signs of thyroid illness, lupus, or other conditions DETECTION & INTERPRETATION OF DIAGNOSIS Initial examinations (lab, imaging) Depending on the clinical presentation, testing might not be necessary. Nonandrogenic alopecia - TSH, CBC, ferritin - Take into account LFT, BMP, zinc, VDRL, ANA, and prolactin depending on the clinical history and exam Androgenic alopecia: Free testosterone and dehydroepiandrosterone sulphate should be taken into consideration, especially in females. Other/Diagnostic Procedures Light hair-pull test: Pull on 25 to 50 hairs; 6 or more hairs coming loose is indicative of shedding (effluvium, AA). Direct microscopic examination of the hair shaft - Exclamation point hairs: club-shaped root with thinner proximal shaft (AA) - Broken and distorted hairs may be related to various hair dystrophies. Anagen hairs have elongated, distorted bulbs with attached root sheaths. Telogen hairs have rounded bulbs without root sheaths. Biopsy: scarring (cicatricial) alopecia or, if the cause is still uncertain, two 4-mm punch biopsies are advised. Take the biopsy at the margin of inflammation in scarring alopecia. Take the biopsy in a region with thinning hair but not full hair loss if you have non-scarring alopecia. Lymphocytic inflammation with perifollicular fibrosis. Androgenic alopecia: fluctuating hair shaft size, follicular miniaturisation, and a 2:1 terminal: vellus hair follicle ratio Telogen effluvium: increased catagen:telogen ratio, unchanged number of hair follicles, and no follicle miniaturisation Increased catagen:telogen ratio, no change in the number of hair follicles, and follicular miniaturisation are all signs of AA. To rule out tinea capitis, potassium hydroxide preparation and ultraviolet light fluorescence GENERAL TREATMENT MEASURES Prior to starting treatment, weigh the advantages and disadvantages for the patient. A better quality of life will benefit many people. If you can, stop taking any medications that might be the source of your telogen effluvium. Address underlying medical issues (such as syphilis or a thyroid condition). Traction alopecia: Alter hair-care routines and provide instruction Trichotillomania: psychological treatment is frequently needed to change behaviour NON-SCARING MEDICATION Androgenic alopecia: Treatment must be continued continuously; it may be used in conjunction with Minoxidil (Rogaine), which is effective in 60% of cases and comes as 2% and 5% topical solutions (1 mL BID) for women and foam (daily) for men. Skin irritation, hypertrichosis of the hands/face, and tachycardia are side effects that are Category C in pregnancy; the drug's mechanism of action is unclear and it seems to prolong the anagen phase. Finasteride (Propecia): 1 mg/day for men and women (off-label); 30-50% improvement in men; poor data in women; 5-reductase inhibitor; reduces DHT in system; increases total and anagen hairs; slows transition of terminal to vellus hairs; adverse effects: loss of libido, gynecomastia, depression. Category X, dependable contraception is required for female usage, with caution in the presence of liver disease, and absolutely no use or contact during pregnancy.- 100 to 200 mg/day (off-label) of spirolactone (Aldactone)Ketoconazole reduces DHT levels at follicles and works best when combined with minoxidil to treat female androgenic alopecia. It is an aldosterone antagonist and antiandrogen that blocks the effect of androgens, reducing testosterone production. - Combination: Compared to monotherapy, finasteride with minoxidil is more effective. AA: high rate of spontaneous remission in patchy AA; no FDA-approved treatment Intralesional steroids (triamcinolone: 2.5 to 5.0 mg/mL) are injected every 4 to 6 weeks into the deep dermal layer at intervals of 0.5 to 1.0 cm using a 1/2 inch 30-gauge needle. Adverse effects include local burning, itching, and skin atrophy. - Systemic glucocorticoids: Used in severe, multifocal AA; may stimulate regrowth; long-term monthly treatment is necessary to sustain growth Negative effects include obesity, cataracts, osteoporosis, hyperglycemia, and adrenal insufficiency. - Prednisone and PUVA light therapy: modest effectiveness in diffuse AA Tinea (Capitis, Corporis, Cruris): See "Tinea (Capitis, Corporis, Cruris)." SURGICAL/OTHER PROCEDURES Extensions, hairpieces, and wigs Surgery is sometimes performed to treat scarring alopecia and involves graft transplantation, flap transplantation, or removal of the scarred area. Platelet-rich plasma has been demonstrated to revive dormant hair follicles and promote new hair development. ALTERNATIVE & COMPLEMENTARY MEDICINE Volumizing shampoos can make the remaining hair appear fuller; there are many herbal treatments available. CONTINUING CARE Supplementation may be required if a nutritional shortfall is found. EDUCATION OF PATIENTS Website of the National Alopecia Areata Foundation Androgenic alopecia prognosis is based on how well the patient responds to treatment. AA: Even without therapy, it frequently grows back within a year. Recurrence is frequent. 10% of cases are severe and chronic, and the likelihood of a poor prognosis increases with time, substantial hair loss, autoimmune disease, nail involvement, and young age. Telogen effluvium: maximal shedding occurs three months after the trigger event, and recovery occurs after the cause is addressed. usually goes away in 3 to 6 months, but it takes 12 to 18 months for cosmetically significant hair growth to resume; rare cases of permanent hair loss, which are typically associated with long-term sickness. Anagen effluvium: Shedding starts days to a few weeks after the triggering event, recovering if the cause is corrected; in rare cases, permanent hair loss occurs. Excellent prognosis for traction alopecia with behaviour adjustment Cicatricial alopecia: irreversible damage to hair follicles; prognosis depends on alopecia type and available therapies. Excellent prognosis for tinea capitis with therapy What is Medicine – Alcohol Withdrawal Syndrome
ESSENTIAL DESCRIPTION Alcohol withdrawal syndrome (AWS) is a range of symptoms brought on by a sudden reduction in alcohol consumption after a protracted time of use. It can cause everything from modest side effects like tremors and sleepiness to serious ones like seizures and delirious tremors. The majority of the time, symptoms appear within a few hours of the last drink and peak 24 to 48 hours later. EPIDEMIOLOGY Incidence As of 2019, 14.5 million Americans meet the diagnostic criteria for alcohol consumption disorder (AUD), according to the National Survey on Drug consumption and Health. AWS has been experienced by about 50% of people with AUD at some point in their lives. 4% of patients were given access to FDA-approved drugs to treat AUD. AWS risk increases for 2-7% of hospitalised patients who use alcohol heavily, and alcohol use accounts for 32% of ER visits. AUD are among the most common mental illnesses, with lifetime and 12-month prevalence rates of 13.9% and 29.1%, respectively. A higher prevalence is seen in men, younger, single persons, and people from poorer socioeconomic backgrounds. PATHOPHYSIOLOGY AND AETIOLOGY With chronic alcohol use, this recurrent activation downregulates the inhibitory effects of the neurotransmitter gamma-aminobutyric acid (GABA), which is stimulated by alcohol consumption. At the same time that alcohol use suppresses glutamate on the central nervous system (CNS), excitatory N-methyl-D-aspartate glutamate receptors are upregulated by long-term alcohol usage. When alcohol use is suddenly halted, the combined effects of a downregulated inhibitory system (GABA modulated) and an upregulated excitatory system (glutamate modulated) lead to brain hyperexcitability that is no longer inhibited by alcohol; this condition is known clinically as AWS. Genetics The aetiology of AUD is multifaceted, and research indicates that 50% of those who have AUD have a hereditary susceptibility. Long-term heavy alcohol use, a history of alcohol withdrawal episodes, seizures, and delirium tremens (DTs), elevated blood pressure at presentation, comorbid medical conditions, or a surgical illness, and physiological dependence on benzodiazepines (BZDs) or barbiturates are risk factors. Aspects of Geriatrics Elderly people with AUD are more vulnerable to withdrawal, and they are more likely to experience consequences from withdrawal due to chronic comorbid illnesses. pregnant women's issues For the management of acute alcohol withdrawal, inpatient hospitalisation is advised during pregnancy. GENERAL PREVENTION To decrease unhealthy alcohol use, the U.S. Preventive Services Task Force advises universal screening for all people. The most sensitive and precise screening question for identifying unhealthy alcohol use is "How many times in the past year have you had 5 or more (men) or 4 or more (women) drinks in one day." CAGE, AUDIT, or AUDIT-C are quick, common assessment screening techniques that can be used to identify unhealthy alcohol usage. CONDITIONS OFTEN Associated with Dehydration, poor nutrition, and weight loss are general symptoms. Renal symptoms include electrolyte abnormalities (hyponatremia, hypokalemia, hypomagnesemia, and hypophosphatemia). GI symptoms include hepatitis, cirrhosis, esophageal varices, pancreatitis, and portal hypertension. Haematological symptoms include thrombocytopenia and macrocytic anaemia. Cardiovascular symptoms include hypertension, atrial fibrillation, CNS symptoms include seizures, hallucinations, memory loss, atrophy, and Wernicke-Korsakoff syndrome. Peripheral nervous system symptoms include neuropathy. Psychiatric symptoms include depression, post-traumatic stress disorder, bipolar disorder, and polysubstance use disorder. Reproductive symptoms include amenorrhea and sexual dysfunction. Diagnostic criteria for AWS according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: - Two (or more) of the symptoms listed below appear within a few hours of stopping or cutting back on strong and extended alcohol consumption: Hyperactive autonomic function Hand tremor, generalised seizures, anxiety, insomnia, psychomotor agitation, nausea, and vomiting Transient hallucinations or illusions of the visual, auditory, or tactile types - Signs or symptoms seriously hinder a person's social, professional, or occupational functioning. – The presence of signs and symptoms does not imply an underlying physical or mental illness. Clinical signs of AWS can be categorised into three groups of symptoms. - Autonomic hyperactivity: peak 24 to 48 hours after peak commencement a few hours after cessation. - Neural excitation: Seizures linked to alcohol withdrawal are frequently transient and typically start 12 to 48 hours after the last drink. Alcohol withdrawal delirium appears 48 to 72 hours after ceasing to consume alcohol. HISTORY The following key historical details should be included: The amount and duration of alcohol consumed, as well as the time since the last drink Prior seizure activity, preexisting medical and psychiatric disorders, prior alcohol withdrawal symptoms, concurrent substance use, and social history including living circumstances, social support, stresses, and triggers Physical examinations must evaluate any conditions that are made worse by AWS. Heart failure, arrhythmias, and coronary artery disease are cardiovascular conditions. General: hand tremor (six to eight cycles per second), infections, GI bleeding, liver disease, and pancreatitis. Neuro: oculomotor dysfunction, gait ataxia, and neuropathy. Psych: orientation and memory. Hepatic encephalopathy may make these conditions worse. DIFFERENTIAL DIAGNOSIS Intoxication with cocaine and amphetamines; Withdrawal from opioids, marijuana, and other sedatives; Toxicity from anticholinergic medications; Neuroleptic Malignant Syndrome Mania, psychosis, anxiety, or panic disorder; ICU delirium; sepsis; CNS infection; or haemorrhage; and thyroid crisis DETECTION & INTERPRETATION OF DIAGNOSIS Initial examinations (lab, imaging) Blood alcohol content and a urine drug test Full metabolic panel; complete blood count Lipase, GGT, and amylase Head CT for individuals who report with symptoms that are not typical of withdrawal or who have unusually stable mental states for withdrawal If this is your first seizure, get a complete neurological examination including a lumbar puncture, EEG, and other tests. Tests in the Future & Special Considerations Consider abdominal ultrasonography or CT in patients who report unusual pain, elevated lipase or amylase levels. Electrocardiograms are advised for people older than 50 or those who have a history of cardiac issues. Interpretation of Tests Patients who have used alcohol for a long time metabolise it at a quicker rate of 20 to 30 mg/dL/hr. The average rate of alcohol metabolism is 10 to 15 mg/dL/hr. These equations can be used to estimate when withdrawal symptoms might get worse. Blood alcohol content (BAC): A blood alcohol level of 100% may result in loss of coordination and mood disturbances. In the US, a blood alcohol content of 80 is regarded as legally intoxicated. BAC: 100 to 199 neurological dysfunction, sluggish reflexes, or ataxia Unless the person has a clear tolerance, a BAC of 200 to 299 indicates evident intoxication. BAC levels of 300 or above have been linked to death, forgetfulness, slurred speech, and coma. GENERAL TREATMENT MEASURES - "Provide a safe withdrawal from the drug(s) of dependence." is one of the therapy's objectives. "Provide a humane withdrawal and uphold the dignity of the patient." "Get the patient ready for ongoing treatment for alcohol dependence." The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), can be used to determine the frequency and dosage of AWS medication. Except for orientation and sensorium clouding, which are scored on a scale from 0 to 4, the severity of symptoms are graded on a scale from 0 to 7, with 0 representing no symptoms and 7 representing the highest score. - Vomiting and nausea - Tactile disturbances - Tremor - Disturbances in hearing - Paroxysmal sweating - Disturbances in vision - Anxiety - Headache or feeling of heaviness in the head - Agitation - Orientation and sensorium clouding The highest possible CIWA-Ar score is 67. - Mild withdrawal = score of 8 or less: typically resolves without medication - Moderate withdrawal = 8 to 14: frequently needs medication management - Seizures and the emergence of DTs are most likely in patients with severe withdrawal (>15), according to research. It is essential to frequently reevaluate using the CIWA-Ar score. First Line: MEDICATION For CIWA scores more than 10, BZD monotherapy is still the preferred course of action. Based on the following factors, BZD should be chosen: - Agitation is more immediately controlled by substances with a rapid onset, such as IV diazepam. - Long-acting BZDs (diazepam, chlordiazepoxide) lessen breakthrough or rebound symptoms and are more effective at preventing seizures. - When persistent sedation is a problem (such as with elderly patients or those who have other major concurrent medical conditions), short-acting BZDs (such as lorazepam and oxazepam) are preferable. They are also preferable when there is severe hepatic impairment. The patient's BZD dosages will differ. can adopt regimens that are symptom-triggered or fixed in time. - Symptom-triggered regimens are favoured, are linked to lower BZD levels, and shorten hospital stays. - Fixed-schedule regimens are acceptable for patients with severe coronary artery disease, those who have a history of withdrawal seizures, or nursing staff who have not received training for symptom-triggered regimens. Symptom-triggered regimen: Give one of the drugs listed below every 4 to 6 hours, with additional doses as needed (PRN) when CIWA-Ar is below 8. One hour after each dose, evaluate the need for additional medicine. - 50–100 mg of chlordiazepoxide orally - Diazepam: 10–20 mg orally 30 to 60 mg orally of oxycodone.- 2 to 4 mg PO of lorazepam Administer one of the drugs listed below every 6 hours according to a fixed schedule: - Chlordiazepoxide: 50 mg PO for 4 doses, followed by 8 doses of 25 mg PO. - Diazepam: 4 doses of 10 mg PO followed by 8 doses of 5 mg PO - Lorazepam: 2 mg PO for four doses, followed by 1 mg PO for eight doses. - Vital to keep a tight eye on things and give out more BZDs if CIWA-Ar is above 8. Folic acid dosage: daily 1 mg Thiamine: 50 to 100 mg per day - Don't give IV glucose before providing thiamine as this could hasten Korsakoff psychosis and Wernicke encephalopathy. As soon as electrolyte imbalances or irregularities arise, correct them. -Blockers (such as atenolol or propranolol) and 2-agonists (such as clonidine) help to control hypertension and tachycardia but do not prevent severe symptoms like DT or seizures; not used as monotherapy Carbamazepine: associated with reduced seizures and effective at mild withdrawal; should not be used as a monotherapy If the patient exhibits significant withdrawal symptoms, such as DT or seizures, discontinu ADVANCED THERAPIES Physical therapy should be evaluated for peripheral neuropathy and cerebellar impairment. CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING Conditions for admittance as a patient: Poor ability to follow up or no reliable social support Pregnancy History of severe withdrawal symptoms History of seizure disorder, withdrawal seizures, or DTs Presence of cardiovascular disease Concurrent psychiatric illness, associated medical or surgical illness Concurrent nystagmus, confusion, which may indicate Werniecke encephalopathy Severe nausea or vomiting that prevents ingestion of medications CONTINUING CARE AFTERCARE RECOMMENDATIONS Treating the patient's underlying AUD is only the first step after managing alcohol withdrawal. Discharge plans should incorporate the following: - Creation of a strategy to involve the patient in additional therapy - Transition to outpatient substance use counselling, peer support groups, and/or a residential treatment centre. - Prescription of any FDA-approved medication-assisted therapy that is available. Glutamate and GABA modulator acamprosate (666 mg PO TID) is said to lessen cravings - Renal impairment (CrCl 30 mL/min) is a contraindication. Due to daily multidosing, compliance may be a problem; recent research cast doubt on the benefits. Naltrexone: an opiate receptor antagonist that lessens desire (50 mg/day PO; 380 mg IM every 4 weeks). After the patient has been without opioids for at least 7 days, start the therapy. Acute hepatitis/liver failure and concurrent opioid medication are contraindications, and the treatment is only effective for three to six months. Disulfiram (250 mg/day PO) causes an adverse reaction to alcohol by interfering with aldehyde dehydrogenase, blocking alcohol metabolism, and causing an accumulation of acetaldehyde. It is a second-line option due to limited evidence of its effectiveness for preventing relapse. However, it is contraindicated in cases of psychosis, severe myocardial disease, diabetes, seizures, emphysema, severe liver and renal patient observation Continual follow-up to check for relapse Advance your diet as tolerated EDUCATION OF PATIENTS www.aa.org is the website for Alcoholics Anonymous. Self-Management and Recovery Training (SMART Recovery): www.smartrecovery.org (not based on religion) http://www.niaaa.nih.gov/guide/ is the website of the National Institute on Alcohol Abuse and Alcoholism. Alcohol withdrawal syndrome on FamilyDoctor.Org (Spanish resources available) PROGNOSIS 1-5% of people die from severe withdrawal syndrome (DTs). COMPLICATIONS occurs more commonly in people with concurrent diseases or previous instances of withdrawal What is Medicine – Alcohol User Disorder
Any pattern of alcohol use that significantly impairs one's physical, mental, or social functioning. Tolerance, withdrawal, and continued usage despite issues are important characteristics. Based on the number of symptoms, AUD severity is categorised as mild, moderate, or severe on a spectrum. A minor condition is one that meets 2 to 3 of the DSM-5 criteria for substance use disorders. Severe AUD is defined as 6 or greater. - Persistence in usage despite associated interpersonal or societal issues, as well as physical or mental health issues - Repeated usage in risky circumstances - Not meeting commitments at home, school, or job - Cravings, tolerance, and withdrawal - Using more alcohol than intended or for longer than expected periods of time - Constant attempts to cut back or stop - Giving up social, professional, or recreational activities in favour of alcohol usage "Risky drinking" or "unhealthy use" refers to those who drink at amounts that put them at an elevated risk of bad effects even though they do not fulfil the formal criteria for AUD or have not been diagnosed as experiencing AUD. Women: >3 drinks daily, >7 drinks weekly Men: >4 drinks day, >14 drinks weekly The National Institute on Alcohol Abuse and Alcoholism defines "at-risk" drinking as men who consume >14 drinks per week or >4 drinks per occasion; women who consume >7 drinks per week or >3 drinks per occasion. The 2015-2020 Dietary Guidelines for Americans define moderate drinking as up to 1 drink per day for women and up to 2 drinks per day for men. Aspects of Geriatrics accelerated ageing from frequent alcohol use combined with higher consumption in middle-aged and older persons increases risk of cognitive decline and dementia (1). signs and symptoms may differ or be attributed to chronic medical problems or dementia. Child Safety Considerations Early-onset drinkers (those who start drinking before age 21) are 4 times more likely to develop a problem than those who start drinking after age 21. 2.5% of adolescents have AUD. 13.4% of young people aged 12 to 20 report binge drinking in the past month. Males are more likely to develop epidemiology (3:1) than females, with a predominance in the 18 to 25 age range. Weekend heavy to binge drinking (>15 drinks in one session) is typical among young drinkers through college age (4 drinks for women and 5 drinks for males in 2 hours). According to recent studies, binge drinking, particularly among women and middle-aged to older persons, raises the risk of dementia and cognitive impairment. ● Over the past 20 years, the AUD has increased globally. Increases in alcohol consumption have been linked to the COVID-19 pandemic on a worldwide level. In the US, recent rises in AUD are primarily attributable to a sharp increase in AUD among women (84%) compared to men (35%). – stems from a surge in excessive and binge drinking among women and adolescent girls. – Additionally, women are more likely than men to suffer from alcohol-related health problems. Prevalence In the last month, 27% of Americans under the age of 18 reported binge drinking; 7% reported excessive alcohol use; and 15% of individuals over the age of 18 have alcohol use disorder (AUD). In the United States, hazardous alcohol use is the third greatest cause of premature death and has become a serious public health concern, costing $249 billion in 2010 and killing 88,000 Americans annually, or about 1 in 10 working-age individuals. Alcohol is a CNS depressant that facilitates -aminobutyric acid (GABA) inhibition and blocks N-methyl-D-aspartate receptors. Its aetiology and pathophysiology are multifactorial and include genetic, environmental, and psychosocial factors. Genetics accounts for 50–60% of risk. RISK FACTORS: Eating disorders, bipolar disorder, anxiety disorders, and family history of depression. Male gender; lower socioeconomic position; unemployment; low self-esteem; posttraumatic stress disorder; antisocial personality disorder; criminal activity. Tobacco usage and other substance misuse. GENERAL PREVENTION Counsel patients who have risk indicators and family histories. In 2018, the USPSTF suggested screening people for alcohol consumption and offering brief counselling to those who have risky drinking patterns. Brief intervention (SBI) and screening. COMMONLY ASSOCIATED CONDITIONS Diabetes mellitus; malnutrition; upper GI malignancies Cardiomyopathy; atrial fibrillation; hypertension Peptic ulcer disease; cirrhosis; fatty liver; cholelithiasis; hepatitis; pancreatitis Peripheral neuropathy, seizures, violence and abuse, and behavioural problems (depression, bipolar disorder, and schizophrenia): more than 50% of patients also struggle with substance usage. DISEASE HISTORY A thorough behavioural history Domestic violence, anxiety, depression, and/or insomnia; psychological and/or social disorders; marriage or relationship issues; Complaints about alcohol-related behaviour; frequent trauma, MVAs, ED visits; loss of interest in non-drinking activities; blackouts; repeated attempts to stop/reduce drinking; physical symptoms like anorexia, nausea, vomiting, abdominal pain, palpitations, and headaches; employment issues (tardiness, absenteeism, decreased productivity, interpersonal problems, frequent job loss). Physical examination could be entirely normal. Fever, agitation, and diaphoresis in general Cardiovascular: tachycardia, arrhythmias, dilated cardiomyopathy, and hypertension Aspiration pneumonia is a respiratory issue. gastrointestinal (GI): Symptoms of pancreatitis, esophageal cancer, esophageal varices, and chronic liver disease Musculoskeletal: bone marrow suppression, myopathy, osteopenia, osteoporosis, and fractures that have not fully healed Neurologic symptoms include tremors, cognitive abnormalities (such as memory loss), peripheral neuropathy, and Wernicke-Korsakoff syndrome (caused by a severe acute thiamine deficiency; Korsakoff psychosis is a long-term neurologic complication of Wernick encephalopathy). The classic trinity of disorientation, ataxia, and ophthalmoplegia is present in Wernicke encephalopathy. Dermatologic conditions include burns (from smoking, for example), bruising, poor hygiene, palmar erythema, and spider telangiectasias. Other substance use disorders, depression, dementia, cerebellar ataxia, cerebrovascular accident (CVA), benign essential tremor, seizure disorder, diabetic ketoacidosis, and viral hepatitis are among the differential diagnoses. Screening Diagnostic tests and interpretation CAGE (Cut down, Annoyed, Guilty, and Eye opener) questionnaire: >2 "yes" answers is 74–89% sensitive, 79–95% specific for AUD; less sensitive for white women, college students, and the elderly; not an appropriate tool for less severe types of alcohol misuse A single question that should not be used: "How many times in the last year have you had X or more drinks in 1 day?" (X = 5 for men and 4 for women), AUDs are 81.8% sensitive and 79% specific. Alcohol Use Disorders Identification Test (AUDIT): 10 items, better in populations with low rates of alcoholism if >4: 70-92% sensitive Alcohol self-assessment tools are available at https://www.nams.sg/helpseekers/default.aspx. The three-item screening technique called AUDIT-C. Scores of >4 for men and >3 for women indicate alcohol abuse, which is worrisome. - Question #1: In the last year, how frequently did you consume alcoholic beverages? - Question #2: In the last year, how many alcoholic beverages did you typically consume on a day while you were drinking? - Question #3: How frequently in the previous year did you consume six or more drinks at once? Initial examinations (lab, imaging) Hepatitis A, B, and C serology; CBC; liver function tests (LFTs); electrolytes; BUN/creatinine; lipid panel; thiamine; folate; If GI symptoms are present, amylase and lipase Serum concentrations rose in chronic abusers: - Elevated mean corpuscular volume (MCV); - AST/ALT ratio >2.0; - -glutamyl transferase (GGT); - carbohydrate-deficient transferrin; - uric acid Total cholesterol, triglycerides, and prothrombin time Calcium, magnesium, potassium, phosphorus, BUN, haemoglobin, hematocrit, and platelet count are frequently decreased, as are serum protein, albumin, thiamine, and folate. Cortical atrophy, thalamic nucleus lesions, and basal forebrain lesions can be seen on a CT or MRI of the brain. Ascites, periportal fibrosis, lipid infiltration, and inflammation can be seen on an abdominal ultrasound (US). Interpretation of Tests Inflammation or fatty infiltration of the liver (alcoholic hepatitis), periportal fibrosis (only 10–20% of alcoholics develop cirrhosis), ulceration of the gastric mucosa, inflammation of the pancreas, liquefaction necrosis, dilated cardiomyopathy, decreased granulocytes, elevated cortisol levels, testicular atrophy, decreased female hormones, and cortical atrophy and enlarged Treatment UNSPECIFED MEASURES Clinicians' brief treatments and counselling have been shown to be successful for problem drinking. Treat coexisting conditions (such as insomnia, anxiety, etc.), but exercise extreme caution when giving drugs like benzodiazepines that have a cross-tolerance to alcohol. Patients who participate in 12-step or group programmes are more likely to accept treatment and gain understanding. First Line: MEDICATION After the initial withdrawal has subsided, long-term treatment for AUD is started: FDA-approved Naltrexone: 50 to 100 mg/day PO or 380 mg IM once every four weeks; the FDA-approved treatment for AUD with the most evidence. Opiate antagonist decreases the number of heavy drinking days and the chance of relapse in AUD patients (IM route may improve compliance and efficacy). (3)[B]; if the patient is on opioids, it will speed up withdrawal. - Acamprosate (Campral): 666 mg PO TID when withdrawal is finished; take into account if naltrexone is contraindicated. lowers the likelihood of relapse. Use for a year if beneficial; use cautiously if your creatinine clearance is low. Supplements for everyone: 100 mg/day of thiamine (initial dose given intravenously before glucose to prevent Wernicke encephalopathy). Folic acid: 1 mg/day; daily multivitamin Naltrexone is contraindicated during pregnancy, acute hepatitis, and hepatic failure. Acamprosate: GFR less than 30. Next Line Non-FDA-approved drugs for the protracted management of AUD (Start once acute withdrawal has subsided.) Topiramate (Topamax): 25 to 300 mg daily, orally or divided into two doses every two hours; may help with abstinence (off-label FDA use) Baclofen's starting dose is 5 mg TID; it can be increased to 10 mg TID with a maximum dose of 60 mg/day in three separate doses. well tolerated in cirrhotic patients. Beyond 60 mg per day, there is no discernible benefit. Gabapentin: 300 to 600 mg QHS for sleeplessness and/or alcohol-related cravings; may be increased to 600 mg TID Disulfiram: 250–500 mg/day PO; FDA approved but not considered first line due to unproven efficacy and serious risks; may provide psychological deterrent; most effective if used under close supervision; use with extreme caution given potential for severe emesis in population at risk of esophageal varices. Myocardial infarction, upper GI bleeding, seizures, and death are examples of severe reactions. If concomitant depression present, selective serotonin reuptake medications may be helpful. Patients with AUD who also smoke may benefit from varenicline. QUESTIONS FOR REFERENCE Behavioural health specialist, 12-step or long-term programme, and addiction specialist CONTINUING CARE AFTERCARE RECOMMENDATIONS patient observation Daily visits for outpatient detoxification (not advised for people who abuse alcohol heavily) Early outpatient rehabilitation involves weekly appointments; alone detoxification is not enough. EDUCATION OF PATIENTS The Centre for Substance Abuse Treatment can be reached at (800) 662-HELP or online at www.samhsa.gov/find-help. www.aa.org is the website for Alcoholics Anonymous. Secular Organisations for Sobriety can be found online at www.sossobriety.org. PROGNOSIS: Abstinence benefits include survival, mental health, family, and employment. 12-step programmes, cognitive behaviour therapy, and motivational therapies are frequently effective in the first year after treatment. Chronic relapsing disease; mortality rate more than twice general population; death 10 to 15 years earlier. What is Medicine – Air Travel Emergencies
DESCRIPTION OF AIR TRAVEL EMERGENCIES IN GENERAL When there are in-flight medical incidents (IME), doctors frequently assist. Numerous IME are outside of a practitioner's typical area of expertise. There are few medical resources available in the confined space of the aircraft. Despite these challenges, healthcare professionals should be ready to offer aid when necessary. EPIDEMIOLOGY Incidence throughout 4 billion people travel throughout the world each year. The precise frequency of IMEs is unknown. Airlines estimate that an IME happens on 1 in every 40 flights; the flight crew usually deals with minor incidents. Other datasets that only cover IMEs that are more significant estimate the incidence at 1 in 600 flights (2). According to airline estimates, there are 250 to 1,500 IME occurrences every day around the world for every 7,500 to 40,000 aircraft passengers (3). Larger planes, longer flights, and an ageing population all increase the probability of running into an IME. Syncope/near syncope (32.7%), gastrointestinal (14.8%), respiratory (10.1%), and cardiovascular symptoms (7%) are the most frequent IMEs (3). Up to 90% of IMEs in otherwise healthy travellers are caused by vasovagal syncope. Five percent of passengers (5%), who account for two-thirds of IMEs, have a chronic disease. 15% of ground-based doctor calls are for children travelling with you (1). 3% of IMEs result in death; however, because it is frequently not stated in flight, deaths can go unreported. PATHOPHYSIOLOGY AND AETIOLOGY When travelling at cruising altitude in a pressurised cabin, the atmospheric pressure of oxygen falls from 160 mm Hg at sea level to 120 mm Hg. In healthy individuals, the arterial oxygen tension falls from 100 to approximately 60 mm Hg, resulting in mean inflight oxygen saturations of 93% (85–98%). As a result of their lower baseline PaO2, passengers with chronic obstructive pulmonary disease (COPD) or other respiratory illnesses may experience a drop in oxygen tension that occurs on the steep portion of the haemoglobin dissociation curve and causes more severe hypoxemia. It may be impossible for passengers with unstable angina or heart failure to compensate for hypoxia. Gas expansion: In flight, gases expand by around 30%. In children with ear infections, this can result in a pneumothorax, wound dehiscence or perforation from bowel gas expansion, sinus pressure, and tympanic membrane rupture. Venous thromboembolism: Prolonged sitting, low oxygen levels, and dehydration all raise the risk of blood clotting. Deep vein thromboses (DVTs) are more likely to occur on longer flights and in travellers with preexisting medical issues. Travelling is physically and mentally taxing, which increases the risk of psychiatric problems or acute coronary syndrome (ACS). Passengers' altered circadian rhythms, which could lead to seizures and medication non-adherence, cause insomnia. Turbulence: Passengers frequently experience motion sickness, and fallen bags can cause serious injuries. Non-adherence to medication: Forgotten or checked medications may result in glycemic control issues, seizures, blood pressure instability, and inability to access drugs when needed. Limited access to food and liquids: Dehydration may be the cause of vasovagal syncope. Hypoglycemia can occur in diabetics. Low relative humidity in the cabin contributes to dehydration, epistaxis, and asthma or COPD flare-ups. Cabin air is less than 20% relative humidity. Virus infections: Influenza and parainfluenza are the most often transmitted viruses through close contact. The filtered, non-infectious cabin air. Travel by air may result in SARS-CoV2 viral transmission. Similar to other viruses, cabin air flow is less of a risk than proximity to sick, perhaps asymptomatic passengers. By adhering to the relevant rules for mask use, social isolation, and quarantining, risk can be reduced. RISK ELEMENTS Recent surgery: Due to gas expansion, passengers are at risk for wound dehiscence, intestinal perforation, and compartment syndrome. Passengers who have COPD, asthma, CHF, or coronary artery disease may experience hypoxemia and be unable to compensate correctly. Recent cast placement: Tissue edoema puts passengers at risk for compartment syndrome. Hypercoagulability: Individuals who have inherited or acquired hypercoagulable disorders, are pregnant, on medication, have heart disease, or have recently undergone surgery are more likely to develop DVTs. Passengers who have recently dived are at risk of developing decompression symptoms. Long flights: Hypoxia has accumulative and time-dependent effects. GENERAL PREVENTION General recommendations: Consult your doctor before taking any drugs, and bring any essential supplies with you. Patients with a baseline PaO2 70 mm Hg or who are unable to walk 150 feet without getting out of breath or suffering angina must use additional in-flight oxygen. pregnant women's issues It is normally safe for women to fly up until 36 weeks of pregnancy. Child Safety Considerations Children's travellers should bring liquid medication in the permitted quantity on the aircraft. A rescue inhaler with spacer and facemask should be available for children with asthma. Flying should be avoided 10 to 14 days after surgery (depending on the procedure). - If casts are applied 24 to 48 hours before a flight, they might need to be bivalved. - Do not dive 24 hours before taking off. - Preventing DVT (5)[C]: Drink enough water. Passengers with risk characteristics may require compression stockings, aspirin, or anticoagulants. Prevent venous stasis by standing, stretching, and exercising legs throughout flight. DISEASE HISTORY Depending on the situation, the symptoms can vary; if the patient is awake, get as much background information as you can. Inquire about any prior surgeries or medical conditions, the use of drugs, and allergies. Enquire about the use of illegal drugs or alcohol. Create a safe copy of your findings and recommendations and save a copy for your records. PHYSICAL EXAM – Wear all PPE accessible. On board, there are safety gloves available. Due to noise, it could be necessary to take blood pressure by palpitation. Examine the vital signs. Skin perfusion is one sign of dehydration General appearance and mental state; and, if a stethoscope is included in the in-flight package, the optimum auscultation technique By keeping an ear out for contralateral tracheal deviation and diminished lung sounds, check for tension pneumothorax. Needle decompression is required for a tension pneumothorax. Syncope or near-syncope: vasovagal syncope, dehydration, hypoglycemia, intoxication, adverse drug reaction or toxicity, acute coronary syndrome (ACS), arrhythmia, cerebrovascular accident, pulmonary thrombosis/air embolism, and hypoxia Chest pain, shortness of breath, and anxiety are all symptoms of the following conditions: acute coronary syndrome (ACS), pulmonary embolism, pneumothorax, bronchospasm, aortic dissection, gastric reflux, and musculoskeletal aetiology. Stroke-like symptoms include cerebrovascular accident, transient ischemic attack, hypoglycemia, seizure, syncope, intracranial mass, and complex migraine. Seizure symptoms include syncope, hypoglycemia, eclampsia, and cardiac arrest. Gastrointestinal illnesses include motion sickness, food poisoning, gastritis, enteritis, gastroesophageal reflux disease, pancreatitis, and drug withdrawal. Obste Trauma: caused by falling luggage or turbulence. DETECTION & INTERPRETATION OF DIAGNOSIS It is possible to use the automated external defibrillator (AED) as a cardiac monitor. ● Request equipment from other passengers, such as a glucometer, MDI spacer, or pulse oximeter. GENERAL TREATMENT MEASURES First aid and CPR: Begin CPR, BLS, ALS, and PALS if necessary if there is no pulse or breathing. First aid and CPR instruction is provided to airline crew members. Ask for aid: Request equipment, medications, knowledge, and lifting assistance from the flight crew and other passengers. Oxygen is provided on every trip at a rate of 2 to 5 L per minute through facemask. At cruising altitude, the oxygen delivery resembles the atmosphere at ground level. In all instances of respiratory distress, chest discomfort, convulsions, and altered mental status, oxygen should be administered. Support from ground-based doctors: Many airlines have agreements with businesses that provide in-flight medical advice, interpreter services, suggestions for diversions, and occasionally telemedicine technology. Requesting a flight at a lower attitude will allow you to experience the oxygen pressure at sea level while flying below 22,500 feet. Flying slower and lower may not be the best option to get to a hospital quickly because it requires more fuel. Request a diversion: The pilot may ask for a quicker landing, arrival-time medical assistance, or a closer location. Consideration should be given to diverting medical crises including resuscitation, prolonged abnormal vital signs, chest pain, stroke symptoms, respiratory distress, unconsciousness, obstetrics, or psychiatric emergencies. MEDICATION All commercial aeroplanes operated by the United States are equipped with emergency medical kits (EMKs) and standard first aid supplies. Different nations, airlines, and aircraft have different contents. All aeroplanes are outfitted with an AED, and many airlines have adopted a more thorough EMK. Child Safety Considerations Medication in EMKs does not come in liquid or suppository form. Think about breaking tablets or requesting supplies from other passengers. To create a spacer, tape a toilet paper roll or a cut soda bottle to an albuterol pump. ADVANCED THERAPIES Cardiac arrest: CPR, early defibrillation, epinephrine (1 mg IV for adults, 0.01 mg/kg IV for children), lidocaine, or atropine if needed. Recommend diversion. Aspirin (325 mg PO) and nitroglycerin (0.4 mg sublingually every 5–10 minutes if systolic blood pressure is greater than 100 mm Hg) are recommended for acute coronary syndrome. Apply AED. Encourage distraction. Oxygen, albuterol 2.5 mg inhaled (as needed), steroid (if available), and epinephrine 1:1,000 (autoinjector: adult: 0.3 mg, paediatric [25 kg]: 0.15 mg IM; ampule: adult: 0.3 mg, paediatric: 0.01 mg/kg) if there is considerable respiratory distress are the treatments for asthma and COPD exacerbations. Think about a diversion. ● Allergic reaction: diphenhydramine (PO or IV, adult: 25 to 50 mg, paediatric: 1 mg/kg); if anaphylaxis, epinephrine 1:1,000 (autoinjector: adult: 0.3 mg, paediatric [<25 kg]: 0.15 mg IM; ampule: adult: 0.3 mg, paediatric: 0.01 mg/kg); NS (IV, adults: 1 L, paediatric: 20 mL/kg) steroid (if available); divert if anaphylaxis. Vasovagal syncope: Lift your legs. If you're oriented and alert, offer oral drinks. Think about an IV fluid bolus. Give oral glucose and take into account hypoglycemia. Observe your blood pressure. If the patient still exhibits symptoms or continues to show abnormal vital signs, consider diversion. Digestive: The EMK or other passengers may have oral antiemetic and antacid supplies. Consider diversion if you are experiencing stomach pain. Tension pneumothorax: anterior axillary line needle thoracostomy in the fourth or fifth intercostal space Psychological crisis: Think about hypoxia, hypo/hyperglycemia, and intoxication. Try to defuse the situation verbally. Prior to using chemical restraint, established airline practise should be followed if there is hostility. Ask the patient and other travellers if they are taking any oral sedatives. If restraint is required, four passengers should do so, one on each limb. If the patient is constrained, keep an eye out for symptoms of ACS or respiratory distress. Consider diversion. Ingestion of opioids: Use rescue breathing as necessary. Naloxone 0.4 to 0.8 mg IV, 2 mg intranasally, or IM, if accessible in the EMK or from other passengers. CONTINUING CARE/DIAGNOSIS Volunteer in-flight medical professionals are shielded from negligence by the Aviation Medical Assistance Act of 1998. In the US, no doctor has ever been successfully sued for providing free care during an IME. Medical professionals reacted to overhead pages for assistance 76% of the time, with doctors responding in 48% of the cases. About 80% of in-flight diagnoses and hospital diagnoses agree. With assistance from a healthcare professional, 60% of IMEs get better. What is Medicine – Adenomyosis
Basic description: Benign invasion of the endometrium into the myometrium, resulting in a diffusely enlarged uterus; considered a specific entity in the PALM-COEIN FIGO classification of causes of abnormal uterine bleeding (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified; International Usually connected with the uterus, however the term "adenomyosis" can also be used to describe benign hyperplastic alterations in the bile ducts, gallbladder, and ampulla of Vater. It most frequently affects the posterior wall of the uterus. EPIDEMIOLOGY Adenomyosis was previously thought to manifest more frequently in the fourth and fifth decades. However, imaging techniques like transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) are now being used to identify it in younger women who have pain, unusual uterine bleeding, infertility, or no symptoms at all. Significant variance across racial and ethnic groups as well as between various geographic regions (3) Incidence Usually thought to be a uterine condition of multiparous women, women who have had prior caesarean sections, or women who have had prior uterine surgery; however, a growing body of evidence suggests that there may also be an association with infertility and reproductive failure. Variability in the diagnostic criteria makes it difficult to accurately estimate the true incidence. The incidence has been calculated to range between 10% and 80%, depending on the diagnostic criteria utilised. Women who come with endometriosis have a higher incidence, according to reports. Prevalence Depending on the criteria used for diagnosis, the prevalence has been reported to vary from 5% to 70%, with the mean frequency of adenomyosis at hysterectomy given as approximately 20-30%. PATHOPHYSIOLOGY AND AETIOLOGY An abnormal ingrowth and invagination of the basal endometrium into the inner layer of the myometrium (junctional zone [JZ]) is known as adenomyosis. The precise method by which this happens and is sustained is unclear and probably complicated. There are two primary hypotheses that describe the pathophysiology and development of adenomyosis: - Dysregulated tissue injury and repair that encourages cell migration and invagination of the endometrial basalis into the myometrium - De novo epithelial-mesenchymal transformation among displaced embryonic müllerian remnants or adult stem cellThe survival and migration of ectopic endometrial implants outside the myometrial interface appear to be influenced by molecular changes in eutopic endometrium.The primary pathogenic pathways of pain, bleeding, and infertility in adenomyosis presumably involve abnormalities of the sex steroid hormones, inflammation, aberrant cell proliferation, and neuroangiogenesis.. The JZ may be an area of structural weakness and morphologic malfunction in women with adenomyosis, with varied susceptibilities to endometrial stromal cell invagination. Increased uterine pressure brought on by pregnancy, leiomyomas, or other pathologies may alter the JZ environment and make endometrial stromal cell invasion more likely. Specific genes that are differentially expressed in adenomyosis and matching eutopic endometrium have been discovered using genetics, DNA microarray, and proteomics investigation. According to data, anomalies in genetic and epigenetic regulation are involved in the aetiology of adenomyosis. RISK FACTORS Age >40 years; nevertheless, the disease has been found in more young women, including teenagers, as of late. According to reports, early-stage adenomyosis may exhibit a distinct clinical pattern from late-stage disease. Other potential risk factors include: - Infertility and reproductive failure (increasing body of research); - Multiparity; - Tamoxifen medication. - Smoking (studies have shown mixed results) - Previous uterus surgery. CONDITIONS OFTEN Associated with Endometriosis, Leiomyomas (uterine fibroids), Endometrial polyps Urinary tract disease Pelvic pain, dysmenorrhea, and an enlarged uterus are the typical cues that prompt imaging by ultrasound or MRI; endometrial or uterine biopsies may be necessary in some cases. DIAGNOSIS The diagnosis is made through physical examination, radiographic imaging, biopsy, and subsequent histopathologic evaluation. HISTORY One-third of people with adenomyosis are asymptomatic, and the symptoms that do present are nonspecific. The following symptoms are frequently present: Menorrhagia, dysmenorrhea, chronic pelvic discomfort, abnormal uterine bleeding, and urinary tract symptoms (such as urge incontinence, stress incontinence, urgency, and daytime frequency) have all been linked to an elevated risk of adenomyosis, albeit the evidence is sparse. MEDICAL ANALYSIS The uterus may be painful and swollen. Pregnancy, benign uterine tumours, malignant uterine tumours, and metastatic illness are all different diagnoses. Initial tests (lab, imaging) Diagnostic tests and interpretation There hasn't been a unified histologic and radiologic classification system created to specify the kind and degree of adenomyosis. Additionally, there hasn't been a systematic radiologic classification system created to specify the kind and degree of adenomyosis. The Morphological Uterus Sonographic Assessment (MUSA) criteria have recently been used to produce a universal, standardised reporting method for ultrasound findings of adenomyosis. The preferred imaging technique for the initial assessment of suspected adenomyosis is TVUS. Two-dimensional TVUS cannot offer JZ thickness, whereas three-dimensional TVUS can. Two-dimensional TVUS is slightly less sensitive and slightly more specific than three-dimensional TVUS, which has a sensitivity of 65-81% and a specificity of 65- 100%. As compared to MRI, TVUS is less sensitive and has more interobserver variability in identifying adenomyosis from leiomyoma. The results of MRI are superior to those of TVUS, with a pooled sensitivity of 77%, specificity of 89%, positive likelihood ratio of 6.5, and negative likelihood ratio of 0.2 for all subtypes. MRI is the best imaging technique for leiomyomas because, in 36–50% of cases, adenomyosis is present. If cost is not a factor, MRI might be the ideal imaging technique when it is accessible. MRI should unquestionably be taken into account when TVUS cannot make a conclusive diagnosis. Diagnostic Procedures/Other Hysterectomy with histologic interpretation Uterine biopsy with histologic interpretation Uterine-sparing operative treatment (USOT) with histologic interpretation Test Interpretation The following are some examples of the two-dimensional sonographic signs of adenomyosis: - Expansion of the uterus (without a visible leiomyoma) - Cysts - Islands with high echoes - Asymmetrical thickening of the uterine wall Subendometrial linear echogenic striations - Vascularity in translesions - Shadows in the form of fans - A JZ that is irregular, thicker, or interrupted Although many criteria have been put forth, adenomyosis appears to be strongly predicted by a JZ thickness more than 12 mm. On T2-weighted images, the JZ widens with low intensity, which is a sign of adenomyosis and corresponds to thickening of the JZ and smooth muscle hyperplasia. Three distinct criteria have been established to diagnose adenomyosis using an MRI: - Increased JZ thickness of 8 to 12 mm or more; JZ maximum/total myometrium >40% (2)[B] JZ maximum-JZ minimum >5 mm Histologic analysis has historically been regarded as the most practical method of making a conclusive diagnosis of adenomyosis. Uterine biopsy pathologic interpretation: Due to sampling bias and/or biopsy artefact, it is frequently difficult to conclusively diagnose adenomyosis on smaller samples. - Presence of endometrial glands and stromal elements within the myometrium Pathologic interpretation of hysterectomy and USOT: – Diagnostic challenges exist with morcellated specimens because the tissue's spatial organisation has been altered, making it challenging to reference the surface. Sampling bias can also be a problem; even when the surface is correctly referred, pathologists may have different standards for what "definitively" characterises adenomyosis based on the depth of invasion. TREATMENT The cornerstone of treatment for adenomyosis has been surgical therapy, however medicinal therapy has shown success in some patients; there are no universal standards to follow. MEDICATION Consistent use of oral contraceptives, high-dose progestins, and selective progesterone receptor modulators can alleviate symptoms momentarily. The best first-line treatment for adenomyosis is the use of a levonorgestrel-releasing intrauterine device, which is also a successful, long-term, reversible method of treatment. Second-line options include gonadotropin-releasing hormone (GnRH) agonists, which are used to treat menstrual discomfort and bleeding, and GnRH antagonists, which are used to treat leiomyomas and endometriosis. ADVANCED THERAPIES Adenomyosis is being treated with selective progesterone receptor modulators, aromatase inhibitors, valproic acid, and anti-platelet medication. SURGICAL AND OTHER PROCEDURE USOT may be an option for women who want to protect their fertility or do not want to have a hysterectomy because hysterectomy is curative. USOT excisional procedures - Total removal (adenomyomectomy) • Cytoreduction (partial adenomyomectomy); • Resection of the uterine wedge Nonexcisional USOT methods - Laparoscopic procedures such as uterine artery ligation and electrocoagulation - Hysteroscopic procedures such as endomyometrial excision and endometrial ablation - An ultrasound or MRIHigh-intensity focused ultrasound (HIFU)-guided high-frequency ultrasound ablation - The embolisation of the uterine artery (EAU) – The following other reported methods are among them: Radiofrequency ablation (focal adenomyosis) and alcohol instillation (cystic adenomyosis) Ablation by microwave Diffuse adenomyosis (thermoablation) ● The most hopeful outcomes appear to be provided by HIFU and UAE among the non-excisional methods. Excisional USOT, which includes uterine wedge resection, adenomyomectomy, and hysteroscopic excision, may possibly improve fertility, however the optimum surgical approach is still to be determined. This is according to a systemic review of USOT for adenomyosis in reproductive-aged women. Hysterectomy, UAE, and endometrial ablation are only alternatives if future fertility is not sought; nonexcisional USOT may increase fertility with HIFU and radiofrequency ablation. PROGNOSIS Adenomyosis is a benign growth of endometrial tissue; hysterectomy is the recommended treatment; symptoms typically go away during menopause. To ascertain the effect of untreated adenomyosis and USOT on fertility and reproductive outcomes, more research is still required. A consensus on the criteria for diagnosing adenomyosis needs to be developed, and more research is also required to understand the function of medical treatment in women with the condition. COMPLICATIONS Anaemia brought on by blood loss brought on by heavy periods Although it has been suggested that people with adenomyosis are more likely to develop malignancies, there is currently little morphologic, genetic, or epigenetic evidence to support this claim. What is Medicine - Acute Kidney Injury
A sudden decline in kidney function is characterised by one of the following (1): Serum creatinine (SCr) increases by 0.3 mg/dL within 48 hours, by 50% within 7 days, and by 0.5 mL/kg/hr for >6 hours. This causes anomalies in volume, acid-base, and electrolyte balance as well as retention of nitrogenous waste. EPIDEMIOLOGY Incidence Acute kidney damage (AKI) accounts for 5% of hospital admissions and 30% of ICU admissions. AKI occurs in 25% of hospitalised patients; 50% of these cases are iatrogenic. A >4-fold greater risk of death is linked to developing AKI while an inpatient. PATHOPHYSIOLOGY AND AETIOLOGY Prerenal, intrarenal, and postrenal are the three groups. Reduced renal perfusion caused by prerenal (usually reversible): - Glomerular filtration rate (GFR) decreases as a result of decreased renal perfusion, which is frequently brought on by hypovolemia. caused by renal artery stenosis/embolism, hypotension, volume depletion (GI losses, excessive sweating, diuretics, haemorrhage), burns, and heart/liver failure - If the reduced perfusion persists or becomes severe, ischemic acute tubular necrosis (ATN) may result. Intrarenal (intrinsic kidney damage, frequently caused by protracted or severe renal hypoperfusion) - Acute tubular necrosis (ATN), which can be brought on by radiographic contrast material, aminoglycosides, nonsteroidal anti-inflammatory medications (NSAIDs), or other nephrotoxic chemicals. Glomerulonephritis (GN), acute interstitial nephritis (AIN; drug-induced), arteriolar insults, vasculitis, accelerated hypertension, cholesterol embolisation (after an intra-arterial operation), intrarenal deposition/sludging (uric acid nephropathy, multiple myeloma [Bence Jones proteins]), and Postrenal obstruction of the collecting system can be caused by extrinsic compression (such as benign prostatic hypertrophy [BPH], carcinoma, pregnancy), intrinsic obstruction (such as calculi, tumours, clots, strictures, and sloughed papillae), and decreased function (such as neurogenic bladder). Genetics No genetic pattern is known. RISK FACTORS Include diabetes mellitus, hypertension, heart failure, liver failure, and chronic kidney disease (CKD). Age and intravascular radiocontrast substance exposure NSAIDs, ACEIs, ARBs, and cyclosporine/tacrolimus are examples of drugs that interfere with the autoregulation of GFR. Nephrotoxic drugs include antibiotics called aminoglycosides and platinum-based chemotherapy. Hypovolemia (due to, for example, diuretics, bleeding, and GI losses) BPH; cancer (such as multiple myeloma); sepsis; surgery; rhabdomyolysis; solitary kidney (risk in nephrolithiasis); GENERAL PREVENTION Maintain adequate renal perfusion with isotonic fluids and, if required, vasopressor assistance. Avoid nephrotoxic substances, such as IV contrast, herbal supplements, and recognised nephrotoxic drugs. CONDITIONS OFTEN ASSOCIATED WITH : Drug reactions, sepsis, severe trauma, burns, transfusion reactions, recent chemotherapy, rhabdomyolysis, internal bleeding, dehydration, hyperkalemia, hyperphosphatemia, hypercalcemia, hyperuricemia, hydronephrosis, BPH, nephrolithiasis, uremic pericarditis, cirrhosis, CKD, malignant hypertension, and vasculitis. AKI typically causes no symptoms until the patient has suffered a severe loss of function. Oliguria is a potential symptom, however it is neither sensitive nor specific. HISTORY Track changes in body weight, urine output, and oral intake. A complete drug history Prerenal: symptoms of orthostasis and thirst Nephrotoxic medicines, radiocontrast material, and other poisons intrarenally Postrenal: colicky flank pain radiating to the groyne suggests ureteric obstruction, such as a stone; nocturia, frequency, and hesitancy suggest prostatic disease; suprapubic and flank pain are typically secondary to collecting system and bladder distension; anticholinergic medications prevent bladder emptying. Lethargy, nausea/vomiting, anorexia, pruritus, restless legs, disturbed sleep, and hiccups are uremic symptoms. Despite having adequate pulses, ischemic fingers, SC nodules, and livedo reticularis point to atheroembolization. An occluded renal artery or vein may be the cause of flank pain. Prerenal signs include tachycardia, decreased jugular venous pressure (JVP), orthostatic hypotension, dry mucous membranes, and decreased skin turgor. Uremic signs include altered sensorium, seizures, asterixis, myoclonus, pericardial friction rub, and peripheral neuropathies. A pruritic rash, livedo reticularis, SC nodules, and ischemia fingers despite normal pulses are examples of intrinsic renal symptoms. Postrenal signs include suprapubic distension, flank pain, and an enlarged prostate. DETECTION & INTERPRETATION OF DIAGNOSIS Initial examinations (lab, imaging) Contrast renal function (creatinine [Cr]/GFR) to the starting point. Urinalysis: microscope for cells, casts, and crystals; dipstick for blood and protein Sterile pyuria (particularly WBC casts) implies AIN; 10% of individuals had the triad of fever, rash, and eosinophilia. Proteinuria, hematuria, and edoema imply GN or vasculitis and are frequently accompanied with nephritic urine sediment (RBCs and RBC casts). Casts: pigmented granular/muddy brown casts—ATN; transparent hyaline casts—prerenal aetiology; WBC casts—AIN; RBC casts—GN Eosinophils in the urine: 1% or less suggest AIN (low sensitivity). If the patient is taking diuretics, use FEurea instead of FENa: FEurea = [(Uurea PCr) / (PBUN UCr)] 100; FEurea 35% suggests prerenal aetiology. Urine electrolytes in an oliguric condition. FENa = [(UNa PCr) / (PNa UCr)] 100. Consider arterial or venous blood gas (ABG/VBG), electrolytes (including Ca/Mg/P), CBC, BUN, SCr, and electrolytes. BUN/Cr ratio is not a good indicator of prerenal azotemia versus AKI. Increased potassium, phosphate, magnesium, and uric acid are common lab abnormalities in AKI. Haemoglobin, sodium, and calcium levels fell. For accurate drug administration, determine the creatinine clearance (CrCl). Picture this: - Renal ultrasound (US): first line test that determines kidney size, hydronephrosis, and nephrolithiasis while ruling out postrenal causes. - Renal Doppler-flow US: depends on the operator; checks for renal artery stenosis/thrombosis - Kidney, ureter, bladder (KUB) abdominal x-ray: detects calcification, renal calculi, and kidney size; novel biomarkers being studied include urinary IL-18, neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), plasma cystatin C, TIMP-2, and IGFBP7 (4).[C] Tests in the Future & Special Considerations Take into account immunologic testing (if GN or vasculitis are suspected) as well as CK (rhabdomyolysis). Prerenal blockage treated with ultrasound is just as successful as CT in the event that first tests are negative. Noncontrast helical CT is the most accurate test for nephrolithiasis, and radionuclide renal scan assesses renal perfusion, function, and the presence of extravasation and obstructive uropathy. - MRI: T2-weighted signal with enhanced acute tubulointerstitial nephritis. Due to the danger of nephrogenic systemic fibrosis, gadolinium contrast is not recommended if GFR is less than 30 mL/min. Other/Diagnostic Procedures In order to detect bladder tumours, hydronephrosis, obstructions, and upper tract abnormalities without running the risk of contrast nephropathy, cystoscopy with retrograde pyelogram is used. Interpretation of Tests Kidney biopsy is a last choice if the patient does not react to treatment or if the diagnosis is still unclear; it is particularly helpful for evaluating intrinsic AKI with a cause that is unknown (AIN, GN, vasculitis, or rejection of a renal transplant). TREATMENT The cornerstone of treating AKI, both in prerenal and intrinsic kidney disease, is fluid resuscitation. Dialysis may be necessary in cases of severe kidney damage, particularly when the patient is oliguric. Finding the underlying cause is the most crucial step in treating AKI. UNSPECIFED MEASURES Determine and address the reasons that are pre- and postrenal. Stop using nephrotoxic medications and administer others renally. Carefully track your intake, output, and weight each day. Optimise cardiac output to keep the kidneys perfused. Improve your diet and take care of any infections. Volume overload, severe or increasing hyperkalemia, severe metabolic acidosis that is resistant to medical treatment, advanced uremic consequences (pericarditis, encephalopathy, bleeding diathesis), and pulmonary edoema are all indications for renal replacement therapy (RRT). First Line: MEDICATION Prevent fluid overload and repair electrolyte abnormalities, especially hyperkalemia, and find and treat the underlying cause. A monitored fluid challenge might be beneficial if the patient is oliguric and not volume-loaded. Furosemide can be used (judiciously) to treat hyperkalemia and/or volume overload but is ineffective for preventing and treating AKI. Furosemide stress testing may be used to predict mortality, the requirement for RRT, and the likelihood of AKI progression. Dopamine, natriuretic peptides, insulin-like growth factor, and thyroxine do not help treat AKI, and the dopamine agonist fenoldopam has mixed results in terms of reducing the risk of RRT and death in AKI; it is not now advised. Give IV calcium gluconate, isotonic sodium bicarbonate (only if acidemic; avoid using hypertonic "amps" of NaHCO3), glucose with insulin, and/or high-dose nebulized albuterol (to drive K+ into cells); Kayexalate and/or furosemide (to increase K+ excretion); hemodialysis if severe or resistant For oliguric patients, fluid restriction may be necessary to prevent hyponatremia from getting worse. Effective strategies for AKI prevention include isotonic IVF, once-daily aminoglycosides, use of lipid formulations of amphotericin B, and use of iso-osmolar nonionic contrast media. Metabolic acidosis (particularly pH 7.2): Sodium bicarbonate can be given (judiciously); be aware of volume overload, hypocalcemia, and hypokalemia. Avoiding hypovolemia reduces the risk of contrast-induced AKI. Isotonic saline at 1 mL/kg/hr the morning of the procedure and continuing until the next morning, or isotonic NaHCO3 at 3 ml/kg/hr before and 1 ml/kg/hr after contrast delivery, are also effective first-line treatments. Dihydropyridine calcium channel blockers may be protective in posttransplant ATN. Tamsulosin or other selective beta-blockers for bladder outlet obstruction secondary to BPH. QUESTIONS FOR REFERENCE Consider consulting a nephrologist for the following: - The possible beginning of renal replacement treatment (RRT) Consider seeking a urology consultation for obstructive nephropathy in renal transplant patients who have persistent and protracted anuria or oliguria, as well as refractory elevations in BUN and/or creatinine despite adequate fluid and/or electrolyte replacement, as well as underlying structural or functional renal disease (e.g., glomerulonephritis, SLE nephritis, cryoglobulinemia). SURGICAL AND OTHER PROCEDURE Hemodialysis catheter insertion to relieve blockage caused by retrograde ureteral catheters or percutaneous nephrostomy. ALTERNATIVE & COMPLEMENTARY MEDICINE Numerous herbal and nutritional supplements, such as aristolochic acid, ochratoxin A, Djenkol bean, impila, orellanine, and cat's claw, have the potential to be nephrotoxic. Ask the patient for a detailed history of their medications. CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING Treatment of hyperkalemia, metabolic acidosis, volume overload, and advanced uremia, which are life-threatening consequences. Give isotonic IV fluids if the patient is hypovolemic. Keep track of daily weights and fluid balance. Consider placing a urinary catheter to measure urine flow while assessing the risks of CAUTI (catheter-associated urinary tract infection). As soon as you can, remove. Prior to release, stabilise renal function and confirm treatment strategy. Dialysis, if required SUCCESSIVE RECOMMENDATIONS If there is ongoing proteinuria or renal impairment, see a nephrologist. DIET 20 to 30 kcal/kg/day in total caloric intake (1) Limit Na+ to 2 g per day (unless you're hypovolemic). If you are hyperkalemic, think about K+ restriction (2 to 3 g/day). Although there is no proof that phosphate binders are beneficial in AKI, they should be used if you are hyperphosphatemic. Avoid substances containing magnesium and aluminium. EDUCATION OF PATIENTS Keep yourself hydrated. Steer clear of nephrotoxic medications including NSAIDs and aminoglycosides. NCF (National Kidney Foundation). AKI, or acute kidney damage. Acute Kidney Injury: https://www.kidney.org/ atoz/ content PROGNOSIS Mortality rates range from 5% to 80%, depending on the underlying cause, other illnesses, and patient age. Short AKI durations are associated with high rates of recovery in both prerenal and postrenal AKI cases. Even after fully recovering from AKI, affected patients are more likely to go on to develop CKD and ESRD. Among patients who require RRT for AKI, recovery is more likely with higher baseline eGFR, AKI from ATN due to sepsis or surgery, and recovery is less likely with preexisting heart failure. Death, infection, convulsions, paralysis, peripheral edoema, heart failure (CHF), arrhythmias, uremic pericarditis, haemorrhage, hypotension, anaemia, hyperkalemia, and uremia are among the complications. What is Medicine – Acute Coronary Syndrome (STEMI)
BASICS DESCRIPTION The quick onset of myocardial necrosis brought on by a sustained lack of blood flow to a section of the myocardium is known as acute myocardial infarction (AMI). A major coronary artery is completely blocked by atherothrombosis, causing transmural ischemia, and this results in ST-segment elevation myocardial infarction (STEMI). Release of serum cardiac biomarkers and ST-segment elevation on an ECG occur concurrently with this. EPIDEMIOLOGY Incidence Annually, more than 650,000 cases of AMI are reported in the US. With a 95% 30-day survival rate, early revascularization and AMI therapy have reduced death. Prevalence Atherosclerotic heart disease, which affects 7.5 million individuals in the country and has a larger prevalence in males (5.5%) than in women (2.9%), is the main cause of morbidity and mortality in the country. PATHOPHYSIOLOGY AND AETIOLOGY Coronary artery disease (CAD) due to atherosclerosis: Lesions from atherosclerosis can be fibrotic, calcified, or lipid-rich. Atherothrombotic occlusion can more easily result from thin-capped atheromas rupturing. Non-atherogenic causes: - Embolism from infected vegetations, or thrombi coming from the right atrium across the foramen ovale ("paradoxical"), the left atrium, or the left ventricle - Spontaneous coronary artery dissection is common in young women and people with fibromuscular dysplasia (FMD). Chest injury, aortic and/or coronary artery dissection, mechanical or iatrogenic obstruction, coronary artery spasm due to elevated vasomotor tone, anginal variant - Hematologic causes (disseminated intravascular coagulation [DIC], severe anaemia), aortic stenosis, cocaine, IV drug usage, severe burns, and protracted hypotension are some of the aetiologies for arthritis. RISK FACTORS Growing older, high blood pressure, smoking, diabetes, dyslipidemia, a family history of early start of CAD, and a sedentary lifestyle GENERAL PREVENTION Smoking cessation and abstinence; a balanced diet; weight loss and control; regular exercise; and management of diabetes, hypertension, and hyperlipidemia CONDITIONS OFTEN Associated with Cerebrovascular disease, an abdominal aortic aneurysm, and atherosclerotic peripheral vascular disease DISEASE HISTORY Inferior MI patients may primarily experience stomach pain. Symptoms: - Classically, rapid onset of chest heaviness/tightness, with or without exercise, lasting minutes to hours. - Pain/discomfort radiating to neck, mouth, interscapular area, upper extremities, and/or epigastrium. Previous myocardial ischemia history, including stable or unstable angina, AMI, coronary bypass surgery, or percutaneous coronary intervention (PCI) Examine CAD risk factors, such as bleeding history, noncardiac surgery, and a family history of early CAD. Ask if you've recently taken phosphodiesterase type 5 inhibitors (if so, avoid taking nitrates at the same time). Abuse of tobacco, alcohol, and/or drugs, particularly cocaine Physical examination results include: General: restlessness, agitation, hypothermia, fever; Neurologic: dizziness, syncope, weariness, asthenia, and disorientation (particularly in the elderly); Cardiovascular (CV) symptoms include dysrhythmia, hypotension, expanded pulse pressure, S3 and S4, and jugular venous distention (JVD). Respiratory symptoms include dyspnea, tachypnea, crackles, and rales. GI symptoms include nausea, vomiting, and hiccups. Skin: pallor, diaphoresis, and chilly skin gender and geriatrics Considerations: Older patients may present in an unusual way, including with silent or undiagnosed MI. Syncope, weakness, shortness of breath, unexplained nausea, epigastric discomfort, changed mental status, or delirium may frequently be present. Symptoms of diabetes mellitus, such as weariness, dyspnea, and malaise, may be normal or "atypical" in women or individuals. DIFFERENTIAL DIAGNOSIS pericarditis, dysrhythmias, gastroesophageal reflux disease (GERD), esophageal spasm, biliary/pancreatic discomfort, hyperventilation syndrome, unstable angina, aortic dissection, perforating gastric ulcer, anxiety/panic DETECTION & INTERPRETATION OF DIAGNOSIS Initial examinations (lab, imaging) 12-lead ECG: - 1 mm ST elevation in a localised pattern encompassing at least two adjacent leads, with or without aberrant Q waves - STEMI of the posterior wall: tall R waves in V1-V2 with ST depression - The absence of Q waves indicates an early infarction or partial or temporary blockage. – If there is an inferior MI pattern, take into account the right-sided and posterior chest leads (look at V3R, V4R, and V7-V9). The Sgarbossa criterion or BARCELONA method (1) may be useful in the presence of ventricular pacing or a previous left bundle branch block (LBBB). 2-Dimensional transthoracic echocardiography is helpful in assessing mural thrombus, left ventricular function, regional wall motion in MI, and mechanical consequences. Emergent coronary angiography with PCI is preferred whenever a diagnosis is suspected. Tests in the Future & Special Considerations Blood biomarkers Three to six hours after the onset of ischemia symptoms, troponin I and T (cTnI, cTnT) levels increase. cTnI elevations last 7 to 10 days after MI, whereas cTnT elevations last 10 to 14 days. Creatine kinase-MB (CK-MB) myoglobin fraction adds little diagnostic utility to troponin tests in the evaluation of potential AMI. pregnant women's issues Discussions about the advantages and disadvantages of invasive coronary angiography, which exposes the foetus to radiation, are necessary for pregnant patients who present with STEMI. Otherwise, treatment should be the same as for people who are not pregnant. Other/Diagnostic Procedures In some ambiguous presentations, a portable chest x-ray, transthoracic echocardiography, and chest computed tomography angiography (CTA) scan may be useful immediately to assess for alternative diagnosis (aortic dissection, PE, ventricular aneurysm). Coronary angiography is the conclusive examination. The amount of contrast medium used needs to be carefully monitored in patients with chronic renal disease. GENERAL MEASURES/TREATMENT Admit the patient to the coronary care unit (CCU) or a telemetry unit with continuous ECG monitoring and bed rest after emergency revascularization. Use: - Antiarrhythmics when necessary for dysrhythmia that is unstable Aspirin 81 mg/day continued along with clopidogrel 75 mg/day, prasugrel 10 mg/day, or ticagrelor 90 mg twice day as part of dual antiplatelet treatment (DAPT). MEDICATION The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guideline and the 2017 European Society of Cardiology (ESC) guideline (3)[C] are the foundations for the medication recommendations. Initial Line Nitroglycerin (NTG) sublingual 0.4 mg q5min for a total of 3 doses, followed by NTG IV if ongoing pain and/or hypertension and/or management of pulmonary congestion are present and there are no contraindications such as right ventricle (RV) infarction, use of sildenafil or vardenafil within 24 hours of tadalafil, or use of morphine within 48 hours of tadal Antiplatelet medications: - Non-enteric-coated aspirin (ASA), first dose: 162 to 325 mg chewed – For patients with STEMI for whom PCI is intended, a loading dose of a P2Y12 inhibitor is advised. It is advised to use ticagrelor or prasugrel. Prasugrel loading dosage of 60 mg. Patients who have had a past stroke or transient ischemic attack should not use prasugrel. Not advised for patients older than 75 years or who weigh less than 60 kg. 180 mg of ticagrelor as a loading dosage. Transient dyspnea could be brought on by ticagrelor. If neither prasugrel nor ticagrelor are available, clopidogrel 600 mg loading dosage should be administered. Cangrelor may be taken into consideration in patients who were not receiving oral P2Y12 receptor inhibitors prior to PCI or who were unable to take oral medications. The typical advice for the length of DAPT is 6 to 12 months following PCI, depending on the risk of ischemia and bleeding. Unfractionated heparin (UFH) 70- to 100-U/kg IV bolus OR Enoxaparin 0.5-mg IV bolus OR Bivalirudin 0.75-mg IV bolus and then 1.75-mg/kg/hr infusion for up to 4 hours following operation are all examples of anticoagulation therapy. The aim is to keep the entire ischemia time within 120 minutes, whether PCI is used or fibrinolysis. Door to needle or door to balloon should be reached in less than 30 or 90 minutes, respectively. - Primary PCI (balloon angioplasty, coronary stents) in the following situations: A 12-hour symptom onset period The emergence of symptoms within 12 hours and the rejection of fibrinolytic therapy regardless of the elapsed time Regardless of the length of time since the start of a MI, cardiogenic shock or acute severe heart failure (HF) Signs of persistent ischemia 12 to 24 hours following the onset of symptoms: Considerations for the procedure It is advised to use radial access rather than femoral access. It is advised to perform PCI on infarct-related arteries (IRA). - Fiberylysis If a patient arrives to a hospital that cannot do PCI and cannot be moved to a facility that can within 120 minutes of the initial medical contact If there is evidence of continued ischemia and there are no contraindications, administer within 12 to 24 hours of the onset of symptoms. Alteplase (tPA) is administered as a 15-mg IV bolus, 0.75 mg/kg (up to 50 mg) IV over 30 minutes, and then 0.5 mg/kg (up to 35 mg) IV over 60 minutes. The maximum dosage is 100 mg over 90 minutes. Reteplase (rPA): 10 units IV bolus; administer second bolus after a 30-minute interval. Tenecteplase (TNK-tPA): 30- to 50-mg IV bolus, depending on weight. Recommend cutting the dose in half for those under 75. Adjunctive fibrinolysis with antiplatelet treatment Aspirin (loading dose of 162 to 325 mg, then 81 mg every day forever) and Clopidogrel (loading dose of 300 mg for patients under 75 years old, 75 mg dose for patients over 75 years old). Continue taking 75 mg of clopidogrel every day for at least 14 days and maybe up to a year. Fibrinolysis as an adjunct to anticoagulation therapy Use anticoagulants (UFH, enoxaparin, or fondaparinux) in conjunction with reperfusion therapy for at least 48 hours and ideally the entire admission period (up to 8 days), or until revascularization, if necessary. Glycoprotein IIb/IIIa receptor antagonists (abciximab, eptifibatide, or tirofiban) at the time of initial PCI in certain patients if there is no reflow or thrombotic problems In patients with anterior infarction, HF, diabetes, or ejection fraction (EF) 0.40, ACE inhibitors should be started orally within 24 hours of STEMI, unless contraindicated. Starting high-intensity statin medication as soon as feasible is advised. If there is no renal failure or hyperkalemia, a mineralocorticoid receptor antagonist (spironolactone, eplerenone) is advised for patients with EF 40%, HF, or diabetes who are already taking an ACE inhibitor and a beta-blocker (BB). When BB is ineffective or contraindicated and EF is normal, a second-line long-acting non-dihydropyridine calcium channel blocker (CCB) should be used; immediate-release nifedipine should not be used. QUESTIONS FOR REFERENCE As soon as possible, move high-risk patients who are receiving fibrinolytic therapy as their main form of reperfusion therapy to a facility that can perform PCI. SURGICAL AND OTHER PROCEDURE Patients with STEMI with coronary anatomy not susceptible to PCI who have continuing or recurrent oischemia, cardiogenic shock, severe HF, or other high-risk characteristics should undergo urgent coronary artery bypass graft (CABG) surgery. CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING For assessment and treatment, all STEMI patients should be hospitalised to a CCU or an intense cardiac care unit. CONTINUING CARE AFTERCARE RECOMMENDATIONS Following discharge, individuals with STEMI should see a cardiologist every three months for the first year, and subsequently once a year. Stress medication compliance and promote quitting smoking. Take into account a heart rehabilitation programme focused on exercise. Low-fat/healthy-fat diet: trans fatty acids are eliminated, and saturated fat intake is restricted to 7% of total calories. A healthy Mediterranean diet. EDUCATION OF PATIENTS Sexual activity can be resumed 1 to 2 weeks after an uncomplicated MI or 6 to 8 weeks after CABG; smoking cessation and a low-fat diet are also recommended. COMPLICATIONS Advanced age, diabetes, delayed or failed revascularization, decreased left ventricular systolic function, and indications of congestive HF are all linked to poor prognosis. HF, acute mitral regurgitation, myocardial wall rupture, left ventricular aneurysm, pericarditis, dysrhythmias, and depression (common) |
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