Еще одна пилюлька Hескучина

[riltsov]

Туберкулез

[Dr.]

Сообщение от riltsov

Туберкулез

Не, не туберкулез .

[riltsov]

аспергиллез!

[Dr.]

Сообщение от riltsov

аспергиллез!

Не аспергиллез . Не могу даже ничего подсказать, получится прямолинейно .

[filbi]

Вегенера?

[yananshs]

Histoplasmosis?

[Dr.]

Сообщение от filbi

Вегенера?

Да, он . Кстати, пользуясь случаем, хочу напомнить, как же я ненавижу мг/дл, фунты, инчи и градусы Фаренгейта. Я это каждый раз повторяю, когда считаю СКФ архимедесом , поэтому если кто-то хочет экеселевский файл, считающий СКФ по MDRD исходя из нормальных единиц измерения креатинина - могу залить

[Gilarov]

К предыдущей задаче... Стимулятор - не противопоказание к МРТ !!! Если очень нужно, то вполне можно, с соблюдением мер предосторожности. Хотя, конечно, делают это нечасто.
Ссылки:
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Что касаемо тромболизиса, то стреляйте меня, но я бы 125 раз подумал делать или нет тромболизис бабуле в 88 лет. И, наверное, делать бы не стал.

[yananshs]

"Guidelines for MRI of Pacemaker/ICD-Patients:

Patients are divided into 3 groups:
Pacemaker or ICD dependent patients:
Absolute contraindication.

ICD patient (non dependent):
The patient must have a documented extremely serious, life threatening or severely quality of life limiting condition.
Due to higher degree of interaction between MRI and ICD, the threshold for imaging is higher than for pacemakers.

Pacemaker patient (non dependent):
The patient must have a documented very serious, life threatening or severely quality of life limiting condition.
The patient must not be pacemaker/ICD dependent.
The clinician needs to document in the chart, that MRI is crucial to the management of the patient.
No other imaging can be expected to provide an alternative or has been unsuccessfully tried.
The patient or family will sign a preprinted consent form explaining potential adverse reactions, invalidation of warranty, heating leads, rapid pacing, alteration of programming, damage of circuitry requiring replacement and movement of the device.
An information sheet will be given to the clinician, explaining risks and restrictions of the procedure.
Arranging the procedure:
Procedure must be approved by attending radiologist
A Cardiology consult must be obtained to determine pacemaker- or ICD-dependency.
Procedure will be scheduled with Radiology and Cardiology in coordinated fashion.
MRI of pacemaker or ICD patients will only be performed in the main Hospital, not at CAMT or Huntsman.
The exam will only be performed on weekdays during regular business hours."
Насколько я поняла из вашей ссылки, решить вопрос о возможности сделать МРТ этой бабушке - дело не одного часа. А большой необходимости в МРТ по-моему нет. А почему вы бы побоялись?

[Dr.Vad]

Сообщение от yananshs

А почему вы бы побоялись?

Neurology. 2005 Dec 13;65(11):1690-1

Editorials

Stroke thrombolysis in the elderly
Risk or benefit?
J. Claude Hemphill, III, MD and Patrick Lyden, MD

From the Department of Neurology (Dr. Hemphill), University of California, San Francisco; and Department of Neurosciences (Dr. Lyden), University of California, San Diego.

As the population ages the proportion of patients with stroke who are elderly is increasing. With the rise of stroke centers, stroke units, and public education regarding acute stroke intervention, we should expect that many of the patients who present for ultra-early treatment of acute ischemic stroke will be elderly. Therefore, it becomes important to know whether advanced age, in and of itself, should influence how a patient is treated and, specifically, whether recombinant tissue plasminogen activator (t-PA) should be administered. While some might wonder whether age influences t-PA efficacy, the central issue is one of safety.

Age is an independent predictor of outcome after ischemic stroke. Older patients, especially those over 80 years old, are more likely to die in the hospital after stroke and less likely to make a favorable long-term recovery.1 The fact that elderly patients are at high risk for stroke-related death and disability makes them an important target group for acute treatment. However, the elderly may also be at increased risk for hemorrhagic complications from t-PA. Older patients have a higher risk of intracranial hemorrhage after thrombolysis for myocardial infarction2 and patients over the ages of 80 or 85 were excluded from many clinical trials of thrombolysis for acute ischemic stroke (although not the National Institute of Neurologic Disorders and Stroke t-PA study).3 Perhaps because of this concern and relative lack of information, the European Medicines Evaluation Agency provisional license for alteplase (recombinant t-PA) indicates that it is not recommended for treatment of acute ischemic stroke in patients over the age of 80.4 Information about t-PA in the elderly patient with stroke is sorely needed.

In this issue of Neurology, Engelter et al. report findings from a nine-center Swiss stroke thrombolysis registry regarding the impact of advanced age (80 years) on outcome after t-PA treatment for ischemic stroke.5 Elderly patients constituted 12% (n = 38) of their t-PA treated patients and were more likely to be women and to have atrial fibrillation and cardioembolic stroke etiology. Older patients were much more likely to die in hospital (32% vs 12%). However, among patients surviving for 3 months, those over age 80 had essentially the same likelihood of a favorable outcome as younger patients (42% vs 43%). While not significantly different, the rate of symptomatic intracranial hemorrhage was higher in the patients 80 years old (13% vs 8%). Of note, in their cohort, age (either dichotomous as age 80 or as a continuous variable) did not independently predict outcome. As this was not a randomized trial, there was no untreated comparison group; treatment bias could not be assessed.

The findings of this study are similar but not identical to those from other studies of stroke thrombolysis in the very old. A US study that included 30 patients age 80 or older found comparable outcomes and no increase in hemorrhage risk vs patients below age 80.6 In a Canadian cohort of 62 patients age 80 or older who received t-PA for ischemic stroke, 9.7% of patients had a symptomatic intracranial hemorrhage with half being fatal.7 In a German study of 1,658 t-PA patients, those over the age of 75 (n = 396) were more than twice as likely to have an intracranial hemorrhage as those younger than 55 years of age (10.3% vs 4.9%); age and disturbed consciousness were independent predictors of in-hospital death.8 Interestingly, in the National Institute of Neurologic Disorders and Stroke t-PA trial (which included 42 patients over the age of 80), outcome was related to an age-by-neurologic deficit interaction which did not effect the likelihood of favorable response to t-PA and age did not independently influence risk of intracranial hemorrhage.9,10 Of the 49 patients in the National Institute of Neurologic Disorders and Stroke trial older than 75 years and who also had an NIH Stroke Scale score of >20, none improved to an NIH Stroke Score of 0 or 1 in either the placebo or t-PA groups; however, the t-PA group had overall lower NIH Stroke Scale scores at 3 months and better scores on the Barthel Index.9

So what are we to do? The results of these studies could be used both by those who support the use of t-PA in elderly stroke patients (on the grounds of similar efficacy) and those who reject it (on the basis of possible increased risk of hemorrhage). While some may call for a randomized trial in elderly patients, the existing regulatory approval and current use of t-PA probably make this unlikely to happen. Elderly patients present a clinical conundrum: those most likely to do poorly as a result of stroke itself are also at highest risk for stroke treatment complications. Current evidence does not indicate that the risk of t-PA outweighs (or even equals) the benefit in elderly patients. In these recent reports, the lack of an untreated comparison group makes the determination of risk/benefit ratio impossible. Case-control studies and systematic reviews or meta-analyses involving elderly patients (and adjusting for other characteristics such as stroke severity and CT findings) could provide more clarity. In the meantime, physicians and patients face a central question in elderly ischemic patients with stroke who meet all other t-PA eligibility criteria: withhold treatment in those least likely to survive and recover or treat knowing that there may be an increased risk of hemorrhagic complications? We usually choose treatment but hope that future randomized trials will include adequate numbers of elderly patients to answer the question.

[audovichenko]

Ссылки на СrСl калькуляторы:
1) для взрослых
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2) для детей
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3) разные Online Clinical Calculators
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4) на [Ссылки доступны только зарегистрированным пользователям ] есть скачиваемые калькуляторы для Exel и для Pocket PC

[yananshs]

A 21-year-old woman comes to the clinic to "discuss contraception options."

The correct answer is C. A patient in a monogamous relationship with a latex allergy should be given oral contraceptive pills as contraception, as long as she does not have any contraindications to them. Contraindications include cardiovascular and cerebrovascular disease, hyperlipidemia, hepatic disease, breast, endometrial, or ovarian cancer, pregnancy, melanoma, pulmonary embolisms or venous thrombosis, and vaginal bleeding from an unknown source. Relative contraindications include uterine fibroids, lactation, smoking and age greater than 35, diabetes, epilepsy, gallbladder disease, galactorrhea, anovulation, obesity, sickle cell disease, severe vascular headaches, varicose veins (severe), and vaginal adenosis. This patient does not have any of these contraindications.

It is inappropriate to advise her to use condoms made out of animal membranes and use petroleum jelly on the condom to decrease the irritation (choice A) because they do not protect against disease as well, and one should never use oil-based lubricants, such as petroleum jelly because they weaken the condoms.

It is inappropriate to fit her for a diaphragm that can be inserted before intercourse and taken out immediately after intercourse (choice B). A diaphragm is a rubber or latex dome shaped device that is placed over the cervix before sex and must be left in for 6-8 hours after intercourse. Taking it out sooner, especially immediately after sex may lead to spillage of the semen and pregnancy may occur.

An IUD (choice D) is contraindicated in this patient with a previous history of pelvic inflammatory disease.
It is completely incorrect to tell her that she does not need contraception because she is probably infertile from pelvic inflammatory disease (choice E). Approximately 15% of patients with a single episode of PID are infertile and about 75% are infertile after 3 or more episodes. You have no idea if she is infertile after 1 episode of PID, but chances are that she is not.

[yananshs]

A 6-year-old girl is brought to the clinic because of a 24-hour history of an " itchy, red rash." Over the past 7 days she has not been feeling well. She had a fever reaching 39.3 C (102.8 F), a headache, and muscle aches. Her mother treated her with acetaminophen and these symptoms resolved. Now she has this rash that appeared over night, as the other symptoms resolved. Her temperature is 37 C (98.6 F). Physical examination shows an erythematous facial rash on the cheeks and a symmetric, maculopapular, lace-like rash on the arms, buttocks, and thighs. The remainder of the examination is unremarkable. Laboratory studies show:

Leukocyte 36.000/mm3
Platelet 350,000/mm3

At this time the most correct statement about her condition is:
A. Droplet precautions should be used to prevent the spread of infection
B. Intravenous immunoglobulin therapy should be given
C. Pregnant women should not have contact with this patient
D. She should return to school after this office visit
E. She should be given a blood transfusion to prevent an aplastic crisis

[Tim Vetrov]

Яна, мне непонятно - лейкоцитов 36 в мм3 или 36 тыс. в мм3?
То же касается тромбоцитов. Не разобрался с разделителем порядков - в данном случае это запятая или точка?

[Dr.Vad]

Лейкоциты 36х10/9/л или 36х10/6/мл или 36 тыс. в мкл (мм3), тромбоциты 350х10/9/л