Bilateral Parotid Swelling

Bilateral Parotid Swelling
By:Alice Lee

Case presentation - HPI
Case presentation - ROS
Case presentation
Differential Diagnosis – bilateral parotid swelling
Salivary unit
Saliva content and production
Salivary Function
Complications of salivary hypofunction
Autonomic innervation
Masseteric hypertrophy
Sialadenosis
Sialadenosis - Mechanism
Sialadenosis - Diagnosis
Bulimia
Mumps
HIV
Recurrent parotitis of adulthood
Sjogren’s syndrome
Wegener’s granulomatosis
Sarcoidosis
Heerfordt syndrome
Kimura Disease
Polycystic Parotid Disease
Pneumoparotid
Anesthesia “mumps”
Iodine “mumps”
Radioactive I131 sialadenitis

Bilateral Parotid Swelling.ppt

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DYSPHAGIA

DYSPHAGIA

Case study
* A 51 yr.old female presented with a hx of dysphagia that has been progressively worsening for months. Initially dysphagia was for solids only but more recently it is for both solids and liquids.
* Which of the following studies will most likely establish the diagnosis
* EGD
* Barium swallow
* CT
* manometry
Case study
* A 52 year-old male executive c/o intermittent dysphagia which began 2 years ago. When he is eating, he has episodes of the sudden sensation of food sticking in his throat after he swallows, lower chest discomfortand hypersalivation. On two occassions the discomfort has caused him to regurgitate undigested food. There is now wt loss.Physical exam is normal
* The most likely diagnosis is
* Achalasia
* Diffuse esophageal spasm
* Esophageal ring
* Peptic stricture
* Adenocarcinoma

INTRODUCTION
* Dysphagia—difficulty with swallowing—is a common condition, reported by 5–8% of the general population aged over 50 years, and by 16% of the elderly.
* Dysphagia, particularly oropharyngeal dysphagia, is even more common in the chronic-care setting; up to 60% of nursing-home occupants have feeding difficulties that include dysphagia.

Esophageal Anatomy
SWALLOWING
REVIEW
Swallowing Stages
* Oral
* Pharyngeal
* Esophageal
HISTORY
Where is the site of bolus hold-up?
OROPHARYNGEAL VS ESOPHAGEAL
Etiology of oropharyngeal dysphagia.
ESOPHAGEAL
* Differntiation mechanical vs motility disorder?
Is the dysphagia for solids or liquids
Motility- features
How long has dysphagia been present? Is it intermittent? Is it progressive?
Examination of the patient with dysphagia
Investigation of esophageal dysphagia
NO DYSPHAGIA
INTERMITTENT DYSPHAGIA FOR SOLIDS
DYSPHAGIA WITH LONG HX OF GERD
Bulge in the left side of the neck while eating
DYSPHAGIA FOR SOLIDS AND LIQUIDS WITH WT LOSS
DYSPHAGIA FOR SOLIDS AND LIQUIDS
INTERMITTENT DYSPHAGIA FOR SOLIDS AND LIQUIDS
IRON DEFIIENCY ANEMIA

DYSPHAGIA.ppt

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Conditions of the Vulva and Vagina

Conditions of the Vulva and Vagina
By:Marjorie Greenfield MD
Department of Reproductive Biology
a.k.a
Obstetrics and Gynecology

Learning Objectives
* Know surface anatomy of vulva and vagina
* Name and describe common vulvar conditions—skin, subcut, glandular
* Understand the concept of the vagina as an ecosystem influenced by hormones
* Use the ecosystem model to describe four types of vaginitis

Vaginal structure
The vaginal wall
Vaginal function: sexual
Vaginal function: reproductive
Benign conditions of the vagina
The vagina as ecosystem
Where are the bacteria?
Lactobacilli are the good guys because they make acids
The vaginal ecosystem: estrogen present
The vaginal ecosystem
Vaginitis: Why do you need to know?
Common causes of vaginal symptoms
Bacterial vaginosis: a synergistic bacterial infection
Amsel’s criteria for BV:
Repercussions of BV
Bacterial vaginosis:
Is BV a sexually transmitted infection?
Candida vulvovaginitis
Candida likes an estrogenized environment
Asymptomatic yeast carriage
What determines symptomatic candida vulvovaginitis?
Microscopic diagnosis
Wet prep
KOH prep
Role of culture in the diagnosis
Trichomonas vaginitis
Comparative exudates
Atrophic vaginitis
Approach to the Evaluation of Vaginitis
Evaluation of Vaginitis Symptoms
The Vulva
Vulvar function
Vulvar Tissue Types
Vulvar conditions
Skin processes Vulvar dermatoses
Vulvar dystrophies:
Non-neoplastic epithelial disorders
Lichen sclerosis
child
Squamous cell hyperplasia
Other skin processes
* Infections—mostly STDs
* Neoplasms
Subcutaneous processes
* Inclusion cysts
* Fibroma, lipoma, hernia, female hydrocele
* Breast tissue
endometriosis
lipoma
Gland processes
* Skenitis
* Bartholin gland cyst or abscess
Summary
Pathology correlation
Lichen sclerosus
Normal skin
Squamous cell hyperplasia
Normal skin

Conditions of the Vulva and Vagina.ppt

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Sexually Related Diseases/Problems in Women

Sexually Related Diseases/Problems in Women: Vaginitis, PID, Unintended Pregnancy
By:Sarah Guerry, MD
Medical Director, LAC STDP
UCLA

Vaginitis:
What is it?
* Clinical syndrome caused by inflammation/infection of the vagina
* Characterized by abnormal vaginal discharge
* Sometimes caused by an STD

Vaginitis: Who Cares?
Vaginitis Etiologies
Differential diagnosis:
* Irritant Dermatitis
* Foreign body
* HSV
* MCP from GC or CT
* Atrophic vaginitis
* UTI
* Desquamative vaginitis

Vaginitis Epidemiology
* Most common reason for doctors visit

Microbiology of the Vagina
Normal Vaginal Physiology
Factors Adversely Affecting Normal Vaginal Flora
* Douching
* Antibiotic and antifungal therapy
* Hormonal changes: pregnancy, OCs
* Spermicides, lubricant
* Foreign bodies: tampons, IUD, diaphragm
* Intercourse, semen
* Menses


Effects of Estrogen Status on Vaginal Microflora
Infection as a Cause of Vulvovaginitis Across the Lifespan
Vaginitis: Clinical Presentation
* Abnormal vaginal discharge
* Vulvar itch
* Odor
* Discomfort
* Burning with urination
* Painful intercourse

Clinical Evaluation of Vaginitis Physical Exam
* Characteristics of vaginal discharge
* Appearance of the vulva
* Appearance of vaginal mucosa
* Appearance of cervix
* Abdominal/bimanual exam

Diagnostic Evaluation of Vaginitis
* Vaginal pH
* Whiff test (amine test)
* Microscopy
* Chlamydia and GC tests

Vaginal pH Measurement
Bacterial Vaginosis A sexually-associated disease
Bacterial Vaginosis
Clinical Presentation of BV
BV: Diagnostic Criteria
BV: Treatment
BV: Complications
BV: Complications in Pregnancy
BV: Screening in Pregnancy
BV: Treatment Criteria
BV: Recurrent Infection
What’s Wrong with Douching?
Vulvovaginal Candidiasis (VVC)
VVC: Risk Factors
VVC: Clinical Manifestations
Yeast Colonization Study
Most Common Misdiagnoses among Women Reported to Have Recurrent VVC
Diagnosis of VVC
VVC: Diagnosis
Uncomplicated VVC: OTC Treatment
Topical Therapies:
Oral Therapy:
Trichomoniasis
Trichomonas: A Pathogen Over Lifetime
Trichomoniasis Clinical Presentation
Trichomoniasis: Diagnosis in Women
Trichomoniasis: Diagnosis in Men
Trichomonas vaginalis
Seattle STD/HIV Prevention Training Center
Trichomoniasis: Treatment
PID Clinical Presentation
Reproductive Anatomy & Spread of Infections
Pelvic Inflammatory Disease (PID):Magnitude of the Problem
PID Diagnostic Considerations
CDC Diagnostic Criteria for PID and much more

Sexually Related Diseases/Problems in Women.ppt

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Vaginitis

Vaginitis
* pathophysiology
* etiology
* diagnosis
* treatment

The dynamic vagina
* vaginal secretions, exfoliated cells, cervical mucosa
* lactobacillus acidophilus
* estrogen
* glycogen
* vaginal pH
* metabolic byproducts of flora and pathogens

Causes of vaginitis
* antibiotics
* contraceptives
* sexual intercourse
* douching
* stress
* hormones
* allergies and chemical irritation

Bacterial vaginosis
* proliferation of Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis, Peptostreptococcus species
* most common cause
* 1/3 to 2/3 asymptomatic
* 15 to 19% of all women
* 10 to 30% pregnant women

BV misc.
* role of sexual transmission unclear
* risk for preterm labor and PROM
* increased frequency of abnl PAPs, PID, endometritis
* Sxs: profuse malodorous discharge
* Exam: thin grayish discharge, seldom vaginal or vulvar irritation

Risks associated with BV
* Early sexual ‘debut’
* new or multiple sex partners
* IUD (50% contract it over 2y)
* OCP
* Lesbians/receptive oral sex
* no RCT’s but association with douche, c-section and around time of menses

Amsel’s criteria
* thin, homogenous discharge
* positive “whiff” test
* “clue cells” present on microscopy
* vaginal pH > 4.5

BV treatment
* metronidazole 500 mg BID x 7 days
* clindamycin 2% cream qhs x 7 days
* metrogel 0.75% BID x 5 day (vs. QD)
* metronidazole 250 mg TID x 7 days
* metronidazole 2 g po single dose
* metrogel (no previous PTL)

Vulvovaginal Candidiasis
* second most common in U.S.
* Candida albicans predominates
* increasing frequency of non-albicans species (C. glabrata)
* Risks: OCPs, diaphragm, IUD, early intercourse, >4X/month, receptive oral sex, diabetes, recent antibiotics.
* endogenous vaginal flora in 50% women
* not sexually transmitted nor related to number of sexual partners
* treatment of male partner of no benefit
* c/o pruritis, vaginal irritation, dysuria
* vulvovaginal itching not normal in healthy women (lichen sclerosis, vulvar cancer)
* exam: thick white discharge, no odor, normal pH
* vulvar and vaginal erythema

diagnostics
vulvovaginal candidiasis Rx
Trichomoniasis
Evaluation
Trich treatment
Atrophic Vaginitis
Other considerations

Vaginitis.ppt

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VASCULITIS SYNDROMES

VASCULITIS SYNDROMES
By:Emily B. Martin, MD
Rheumatology Board Review

KAWASAKI SYNDROME
Mucocutaneous lymph node syndrome
KAWASAKI DISEASE
* Diagnostic criteria:
CLINICAL MANIFESTIONS
* Arthritis and arthralgia
* Urethritis
* CNS involvement
* GI symptoms

DIFFERENTIAL DIAGNOSIS
* Viral infections
* Toxin mediated illnesses
* Rickettsial or spirochete infections
* Drug reactions
* JRA
* Mercury hypersensitivity reaction

LABORATORY EVALUATION
* Markers of systemic inflammation
* Anemia (normocytic, normochromic)
* Sterile pyuria (urethral origin, don’t do a cath)
* Transaminase elevation (mild to moderate)
* CSF findings
* Synovial fluid inflammation
* Hyponatremia (increased risk for coronary aneurysms)

TREATMENT
* Mainstay of treatment is IVIG 2 gram/kg over 8-12 hours.
* IVIG may need to be repeated in refractory cases.
* Several studies have shown that IVIG + aspirin decreases the risk of coronary aneurysms compared to aspirin alone.
* High dose aspirin during acute illness then low dose for about 2 months.

FOR THE BOARDS…
* Know the clinical manifestations of Kawasaki syndrome.
* Know the differential diagnosis of KD.
* Know the laboratory abnormalities seen in KD.
* Recognize the value of high-dose IVIG in treatment of KD.

QUESTIONS
HENOCH-SCHONLEIN PURPURA

* Most common systemic vasculitis in children.
* Immune mediated
* Often a self-limited disease.
* Occurs more often in fall, winter, and spring.
* About 50% of cases are preceded by URI’s.

CLINICAL PRESENTATION
* Classic tetrad
GI SYMPTOMS
* HSP can cause edema and submucosal hemorrhage of GI tract.
* May be the presenting symptom of HSP.
* Symptoms typically develop within 8 days of the rash.
* Intussusception is the most common GI complication.

RENAL DISEASE
* Occurs in up to 50% of patients.
* Ranges from hematuria to end-stage renal disease (<1% of patients).
* Usually presents within four weeks of onset of HSP.
* Overall prognosis is very good, but there is some long-term risk of progressive renal impairment.

LABORATORY FINDINGS
* There is NO definitive diagnostic test.
* IgA levels may be elevated in 50-70% of patients.
* Platelet counts and coag studies should be normal.
* Inflammatory markers may be elevated.
* Urinalysis
* Negative RF and ANA.
* Recognize the typical presentation of HSP.
* Recognize that HSP may present initially with ABDOMINAL PAIN OR JOINT COMPLAINTS.
* Know the typical laboratory findings in HSP.

MOST likely diagnosis is
* Henoch-Schonlein purpura
* Immune thrombocytopenic purpura
* Juvenile rheumatoid arthritis
* Parvoviral infection
* Post-streptococcal arthritis

VASCULITIS SYNDROMES.ppt

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Pharmacology Review of Everything

Pharmacology Review of Everything 2003-2004

Abacavir
Antiretroviral
Nucleoside reverse transcriptase inhibitor (NRTI)

Abciximab
Antiplatelet
Anti-GPIIb/IIIa receptor antibody

Acarbose
Oral hypoglycemic
Alpha-glucosidase inhibitor
Inhibitor of intestinal glucose absorption

Acebutolol
Sympatholytic
1 adrenergic antagonist
Class II antiarrhytmic

Antihypertensive
Antianginal
Bronchoconstrictor

Acetaminophen
Analgesic, Antipyretic

Acetazolamide
Diuretic
Carbonic anhydrase inhibitor


Acetylcholine
Cholinomimetic
Antigluacoma
Muscle contraction (nicotinic receptor)

Activated charcoal
Antidote

Acyclovir
Antiherpes
Purine analog
Phosphorylated to inhibitor of viral DNA polymerase

Adenosine
Antiarrhythmic
Miscellaneous
(does not fit class I-IV organization)

Adrenocorticotropin
(ACTH)
Anterior pituitary hormone
Anticonvulsant

Stimulates synthesis
and release of cortisol


Albendazole
Antihelminthic
Treatment of intestinal roundworms

Albuterol
Sympathomimetic
2 adrenergic agonist
Short acting bronchodilator
Used in asthma

Aldosterone
Adrenocorticosteroid
Mineralocorticoid

Alemtuzumab
Antineoplastic
Anti-CD52 antibody

Alendronate
Anti-osteoporesis

Bisphosphonate
Inhibitor of osteoclast-mediated bone resorption

Alfentanil
Opioid
General anaesthetic
Intravenous anaesthetic

Allopurinol
Antigout
Antineoplastic (supporting agent)

Folic acid analogue
Xanthine oxidase inhibitor


Alteplase
Thrombolytic
Tissue plasminogen activator (tPA)

Aluminum hydroxide
Antiulcer
Antacid

Amantadine
Antiviral
Antiparkinson

Treatment of Influenza A
Inhibits replication
at the stage of uncoating

List goes A-Z. This is very exhaustive presentation.

Pharmacology Review of Everything 2003-2004

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Designing Anti-Tumor Drugs Using Natural and Synthetic Agents

Designing Anti-Tumor Drugs Using Natural and Synthetic Agents
By:Herman L. Holt, Jr.
University of North Carolina, Asheville

Medicinal Chemistry Folklore
Famous for Synthesis and Discovery of the Mechanism of Action of:
Indomethacin
Sulindac
Diflunisal
Other anti-inflammatory-analgesic (NSAIDS) and immunoregulators
More than 210 U.S. Patents and scientific publications


* Medicinal Chemistry is defined as an interdisciplinary science situated at the interface of organic chemistry and life sciences (such as biochemistry, pharmacology, molecular biology, immunology, pharmacokinetics and toxicology) on one side and chemistry-based disciplines (such as physical chemistry, crystallography, spectroscopy and computer-based information technologies) on the other.

Chemistry based disciplines
Organic Chemistry
Life Sciences
Medicinal Chemistry
Definition and Objectives
Challenges for Medicinal Chemistry
TUBULIN
* Globular Protein
* Taxoid Site
* Vanca Alkaloid
Domain
* Colchicine Site
MICROTUBULES
* Tubulin Polymers
MITOTIC SPINDLE
* Composed of Microtubules and associated proteins
* Needed for cellular division
* Tubulin Polymers

What is the MTT assay?
CISPLATIN
* Anti-cancer agent
* Ovarian
* Testicular
* Lung
* Breast
* Cleaves DNA

TAXOL
* Anti-cancer agent
* Pacific Yew Tree
* Ovarian
* Testicular
* Lung
* Breast

VANCOMYCIN
COLCHICINE
COMBRETASTATIN
HETEROCYCLE ANALOGS OF COMBRETASTATIN
COMBRETASTATIN AND TRIAZOLE SYNTHESIS
AZIRIDINE ANALOGS OF COMBRETASTATINS
AZIRIDINE TYPE ANALOGS OF COMBRETASTATINS
MITOMYCINS
REFERENCES

Designing Anti-Tumor Drugs Using Natural and Synthetic Agents.ppt

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Pharmacology of Drugs Used to Treat Respiratory Disorders

The Pharmacology of Drugs Used to Treat Respiratory Disorders

Stuff about inverse-agonist beta-blockers (nadolol) and asthma
Asthma
COPD
Rhinitis & rhinorrhea
Cough

Asthma

“Obstruction of the airways (3rd to 7th generation of the bronchi) that is reversible with time or in response to treatment.”
Causes

* Allergens
* Cold air
* Exercise
* Upper respiratory infections
* Genetics

Features of asthma
Breathlessness
Cough
Wheezing
Chest tightness
Hyper-responsive lower airway
Hyperinflated lungs
Treatment

Remodeled airway
Poor distensibility of airway lumen on inspiration
Submucosal swelling internal to rigid zone with edema
Limited response to bronchodilator or anti-inflammatory therapy

Cells Recruited During Asthmatic Inflammation
Modulators of BSM contraction Contraction
Smooth muscle cell
Inflammatory mediators (e.g., histamine)
Goals of Therapy

Pharmacologic Therapy of Asthma
Anti-inflammatory
Bronchodilation
Prophylaxis
Anti-inflammatory Glucocorticoids
* Corticosteroids: the most effective anti-inflammatory agents.
* Primary action is to regulate gene expression.
Pharmacologic Actions
Anti-inflammatory Glucocorticoids
Inhalation of corticosteroids minimizes side effects
Disposition of Inhaled Drugs
Glucocorticoids Pharmacologic Actions
Inflammation Bronchonstriction
Mechanism of Action
Glucocorticoid Toxicity Administration by Inhalation
Toxicity: Inhalation
Glucocorticoid Toxicity: Systemic administration
Toxicity: Chronic systemic
Precautions/Contraindications
Therapy of Asthma
Long-acting(prophylaxis)
Short-acting(symptomatic)
and more topics are covered

The Pharmacology of Drugs Used to Treat Respiratory Disorders.ppt

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CANCER CHEMOTHERAPY

CANCER CHEMOTHERAPY
By:Dr. Debra Laskin
Rutgers.edu

Cancer (Neoplastic Disease)
Types of Cancers
Hematologic Malignancies
Leukemias
Lymphomas
Hodgkin’s Disease
Non-Hodgkin’s Lymphoma
Solid Tumors
Carcinomas
Sarcomas
Hematologic Malignancies
Tumors of blood forming organs and cells
* Leukemias: Proliferation of immature progenitors which circulate in blood
o Acute lymphocytic leukemia (ALL, BM lymphblasts)
o Chronic lymphocytic leukemia (CLL- immature B cells)
o Acute myelocytic leukemia (AML, BM myeloid cells)
o Chronic myelocytic leukemia (CML, myeloid cells; Philadelphia chromosome)
* Lymphomas: Lymph System
o Hodgkin’s Disease: lymph nodes
o Non-Hodgkin’s lymphoma: lymphocytes (CLL)
Solid Tumors
Can occur in any organ or tissue; malignant (metastatic and invasive)
* Carcinomas: Arises from epithelial cells; malignant by definition
* Sarcomas: Cancer of connective or supportive tissue (bone, cartilage, fat, muscle, blood vessels) and soft tissue

Cancer Chemotherapy Versus Antimicrobial Chemotherapy
I. Goal
II. Selective Toxicity
III. Immune System
IV. Kinetics of killing

Goal
* ACT: Get rid of invading organisms, restore health
* CCT: Kill as many tumors cells as possible without killing too many normal cells; tumor regression, increased patient survival time, alleviation of symptoms

Selective Toxicity
* ACT: Exploit biochemical differences between pathogenic organism and host; selective toxicity
* CCT: Only quantitative differences between normal and neoplastic cells; differences in growth rate, treatment is nonselective

Immune System
Kinetics
Tumor Cell Killing: First Order Kinetics
Tumor burden
Time
Stationary phase
New steady state
Determinants of Responsiveness to Cancer Chemotherapy
Tumor Determinants of Responsiveness
Total Tumor Burden (Size)
Cell Cycle
Cell Cycle Phase
Phases of Cell Cycle
Cancer Chemotherapy
Cell Cycle Specific Agents (self limiting)
Cell Cycle Nonspecific Agents
Drug Resistance
Mechanisms vary with drug
Host Determinants
General health status of patients
Immune status
General Considerations Cancer Chemotherapy
Adjuvant Therapy
Drug Toxicity
Most CCT agents:
Cytotoxic agents- kill all rapidly growing cells, nonselective
Side Effects of Anticancer Drugs
Cancer Chemotherapeutic Agents
Alkylating Agents
Mechanism of Action
Evidence in mammalian cells
Bi-functional: more toxic can cross link DNA
Resistance: excision/DNA repair enzymes; get rid of alkylated DNA
Cell cycle nonspecific
Classes of Alkylating Agents
Nitrogen Mustards
Classes of Alkylating Agents
Nitrosoureas
Classes of Alkylating Agents
Methane sulfonate esters (Alkyl sulfonates)
Folic Acid Analogs-Antifolates
Mechanism of Action
Cytotoxic Effects of Inhibiting DHFR
Leucovorin Rescue
Combination chemotherapy
Adjuvant to surgery
Antimetabolites
DNA Synthesis
Salvage Pathways
Purine Analogs
Mechanisms of Cytotoxicity
Resistance
Lethal Synthesis
Irreversible Ic
5-Fluorouracil
Mechanism of Action
Microtuble Inhibitors: Taxanes
Chromatin Function Inhibitors
Chromatin Function Inhibitors
Antibiotics
Steroid Hormones
Estrogens and Androgens
Immunotherapy: Monoclonal Antibodies
Monoclonal Antibodies
Targeted Therapy
Traditional CCT
Drugs inhibit proliferation

CANCER CHEMOTHERAPY

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Clinical Pharmacology of Anti-cancer Chemotherapeutic Agents

Clinical Pharmacology of Anti-cancer Chemotherapeutic Agents
By:Dr. Jeff R. Wilcke

Therapeutic Principles Diagnosis & Drug Selection
Absorption
Distribution
Metabolism
Elimination
Toxicity &/OR
Efficacy
Pharmacokinetics
Pharmacodynamics
Therapeutic Endpoints
* Efficacy without toxicity
o Human medicine: palliative therapy only
o Veterinary medicine: palliative therapy probably?
* Efficacy AND toxicity
o Human and veterinary medicine: aggressive, curative therapy
* Toxicity without efficacy
o Tentative administration
+ You may affect bone marrow ONLY rather than bone marrow AND tumor
o Drug Resistance
+ Reduces tumor response, bone marrow still sensitive
* Neither toxicity nor efficacy

Dosing v. P’kinetic End Points
Dose vs AUC Target
Peak Concentration
AUC
Intensity / Time Above
Absorption
* Oral
* Intramuscular
Activation
* Hepatic
* Intracellular phosphorylation
* Tissue metabolism with free radical production
Distribution
Elimination
Dosing Chemotherapeutics
Body Surface Area
Oral Chemotherapy
IM Chemotherapy
Intravenous Chemotherapy
Gemcitabine
Dose Form Manipulation

Clinical Pharmacology of Anti-cancer Chemotherapeutic Agents.ppt

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Tumors and Vascular diseases of the Brain

Tumors and Vascular diseases of the Brain
By:Jennifer Villa Frabizzio, M.D.
* Abington Memorial Hospital
* Radiology Group of Abington, PC
* Board Certified in Diagnostic Imaging with Added Qualifications in Neuroradiology

Topics for Discussion
Neuroimaging Then and Now
Neuroanatomy
Vascular and Nonvascular
Diagnosis and Treatment
Tumors
Primary and Metastatic Disease
Neuroimaging- Then
Standard Radiograph
Pneumoencephalography
Direct Cerebral Angiography
Direct Cerebral Arteriography
Neuroimaging-Now
Computed Tomography
* Advanced techniques
CT angiography and venography
* CT perfusion
Magnetic Resonance Imaging (MRI)
Neuroimaging Nonvascular
Vascular diseases Stroke
Trauma/Intracranial Hemorrhage
Aneurysm
Arteriovenous Malformations
Stroke
case study
Anoxic brain injury
Intracranial Hemorrhage
Aneurysms
Arteriovenous Malformations (AVM)
Brain Tumors

Tumors and Vascular diseases of the Brain.ppt

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U.S. Public Health Service Perinatal Guidelines

U.S. Public Health Service Perinatal Guidelines

Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and to Reduce Perinatal HIV-1 Transmission in the United States.

Perinatal Guidelines

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Obstetrical Ultrasound Cases

Obstetrical Ultrasound Cases
By:Douglas Richards, M.D.
Maternal Fetal Medicine
University of Florida

40 case studies were discussed in this presentation.

http://www.obgyn.ufl.edu/ultrasound/RichardsFinalHotSeatsAnswers2009.ppt
http://obgyn.ufl.edu/ultrasound/RichardsFinalHotSeatsPodium2009.ppt

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VENTRICLES AND BRAIN DISORDERS

VENTRICLES AND BRAIN DISORDERS

Hydrocephalus Enlarged ventricles
By: Arnold Chiari

Syringomyelia/syringobulbia
Hydrocephalus
Communicative hydrocephalus:
Obstructive hydrocephalus:
Hydrocephalus
Traumatic brain injury:
Hydrocephalus in Children
Aqueductal stenosis/compression
Arnold Chiari
Communicative hydrocephalus: increased production or impaired absorption
Postmeningitis or posthemorrhagic – decreased absorption
Signs and Tests
Signs:
Tapping the skull: abnormal sound indicates thinning
Enlarged head
Eyes have sunken in look, setting sun appearance
Abnormal reflexes

Tests:
Head CT scan
Angiogram
Ultrasound
Treatment:
VP (ventriculo-peritoneal) shunt: brain to abdomen
Ventriculostomy: 3rd ventricle to subarachnoid space
Remove the blockage
Arnold Chiari Malformation
Blockage of CSF and formation of syringomyelia
Types of Arnold Chiari
* Type I: may not be symptomatic
* Type II: usually accompanied by myelomeningocele
* Type III: most serious form with severe neurological defects
* Hydrodynamic: hydrocephalus applies pressure to brain
* Traction: tethered cord pulls the brain downward
* Small posterior fossa: Normal brain size pushed brain downward

Theories on etiology
Surgical Treatment of Arnold Chiari Malformation

* Suboccipital decompression
* Cerebellar tonsils are shrunk
* Cranial nerves are decompressed
* Dural patch is applied
Neural elements monitored during surgery
Somatosensory evoked potentials
Motor evoked potentials
Cranial nerves 10, 11, and 12

Syringomyelia
CSF filled cavity in the spinal cord (syrinx)
Arnold Chiari
Spinal cord injury
Tumors
Treatment
Remove the cause
Shunt
Laminectomy
Open dura
Midline myelotomy
Insert tube into syrinx
Midline myelotomy
Baseline
Closing
Shunt placement
Right Tibial N. SEP
Right Abd. Halluc. MEP
Enlarged Ventricles
Parkinson’s Disease

VENTRICLES AND BRAIN DISORDERS.ppt

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Dermal and Subcutaneous Tumors

Dermal and Subcutaneous Tumors
By:Erik Austin, D.O., M.P.H.

Cutaneous Vascular Anomalies
* Hamartomas
* Malformations
* Dilation of preexisting vessels
* Hyperplasias
* Benign neoplasms
* Malignant neoplasms
Hamartomas
Phakomatosis Pigmentovascularis
* Type I: nevus flammeus + epidermal nevus
* Type II: nevus flammeus + aberrant mongolian spots
* Type III: nevus flammeus + nevus spilus
* Type IV: nevus flammeus + nevus spilus + ectopic mongolian spots
* Typically, affects Asians
* Systemic findings may include: intracranial and visceral anomalies, visceral vascular anomalies, ocular abnormalities, and hemi-hypertrophy of the limbs.
* Type II = most common

Eccrine Angiomatous Hamartoma
* Benign, slow growing, solitary, bluish nodule on the palms, soles or extremities
* Presents at birth or in early childhood
* Often painful – when touched may develop beads of perspiration (hyperhidrosis)
* Histo: lobules of mature eccrine glands and ducts with thin-walled blood vessels
Malformations
* Definition: abnormal structures that result from an aberration in embryonic development.
* Functional: Nevus Anemicus
* Anatomic: capillary, venous, arterial, lymphatic, or combined
Nevus Anemicus
* Congenital pale macules
* Cannot be made red by trauma, cold or heat
* Normal amount of melanin
* Occur due to increased sensitivity of the blood vessels to catecholamines
* Associations: neurofibromatosis, tubercular sclerosis, phakomatosis pigmentovascularis
Cutis Marmorata Telangiectatica Congenita
* Presents as a purplish, reticulated vascular network pattern (referred to as livedo reticularis) – extremities, trunk, face, scalp
* Telangiectasis and superficial ulcerations occur, but improve with age
* Associations: varicosities, nevus flammeus, hypoplasia and hypertrophy of soft tissue and bone
* Tx: none; regress with time
Cutis Marmorata Telangectatica Congenita
Nevus Flammeus (Port Wine Stain)
* Pink, red, or wine colored macules or patches
* Congenital malformation of skin
* Histo: dilated capillaries in dermis
* “stork bite” = Nevus flammeus nuchae
* “salmon patch” = glabellar region or upper eyelid
* Rarely involutes
Nevus Flammeus “Salmon Patch”
Sturge-Weber Syndrome
Klippel-Trenaunay Syndrome
Beckwith-Wiedemann Syndrome
Cobb Syndrome

* Proteus Syndrome:
* Robert’s Syndrome
* Wyburn-Mason Syndrome:
* Tar Syndrome
* Tx: Flashlamp pumped pulsed dye laser
* Localizes heat within ectatic vessels
* 450microsecond pulse
* 577 or 585nm
Venous Malformation
* Aka: cavernous hemangioma
* Congenital malformation of veins
* Round, bright red or purple, spongy nodules
* Often on head and neck, mucous membranes
* Usually a deep component
* Associated with recurrent thrombophlebitis and calcified phleboliths
* Pressure on surrounding structures (nerves)
* Tx: U/S, MRI studies; vascular sx consult
* Bannayan-Riley-Ruvalcaba Syndrome: cutaneous and visceral venous, capillary, and lymphatic malformations, macrocephaly, pseudopapilledema, systemic lipoangiomatosis, spotted pigmentation of the penis, hamartomatous intestinal polyps, and rarely trichilemmomas
* Autosomal dominant
* Maffucci’s syndrome: (dyschondroplasia with hemangiomata) uneven bone growth, frequent fractures, nodules on small bones in puberty and later on long bones
* Degeneration of the sacrum in 50%
* Nonhereditary

Maffucci’s syndrome

* Blue rubber bleb nevus syndrome: cutaneous and gastrointestinal venous malformations
* Skin lesions have a cyanotic, bluish appearance with a soft, elevated, nipplelike center
* Emptied by firm pressure
* Affects trunk and arms; associated w/nocturnal pain
* GI hemangiomas in small bowel may rupture

Blue rubber bleb nevus syndrome
* Gorham’s disease: cutaneous and osseus venous and lymphatic malformations
* Massive Osteolysis ~ “Disappearing Bones”
Arteriovenous Fistulas
* Route from artery to vein that bypasses the capillary bed. Congenital or aquired.
* Osler-Weber-Rendu: (hereditary hemorrhagic telangectasia) internal AV fistulas
* Acquired or secondary to trauma (HD access)
Osler-Weber-Rendu
Arteriovenous Fistulas
Superficial Lymphatic Malformation
Cystic Lymphatic Malformation
Dilation of Preexisting Vessels
Spider Angioma
Venous Lakes
Capillary Aneurysms
Telangiectasia
* Radiodermatitis
* Xeroderma pigmentosum
* Lupus erythematosus
* Dermatomyositis
* Scleroderma
* CREST
* rosacea
* Liver disease
* Poikiloderma
* BCC
* Sarcoid
* SLE
* Pregenacy
* Osler-Weber-Rendu
* Etc.

Generalized Essential Telangiectasia
Angiokeratomas
Angiokeratoma of Mibeli
Angiokeratoma of the Scrotum (Fordyce)
Solitary Angiokeratoma
Lymphangiectasis
Hyperplasias
Angiolymphoid Hyperplasia with Eosinophilia (AHLE)
Pyogenic Granuloma
Intravascular Papillary Endothelial Hyperplasia
Benign Neoplasms
Angioma Serpiginosum
Infantile Hemangioma (Strawberry Hemangioma)
Infantile Hemangiomas Treatment
Cherry Angiomas (Senile Angiomas, DeMorgan Spots)
Targetoid Hemosiderotic Hemangioma
Microvenular Hemangioma
Tufted Angioma (Angioblastoma)
Glomeruloid Hemangioma
Kaposiform Hemangioendothelioma
Kasabach-Merritt Syndrome (Hemangioma with Thrombocytopenia)
Glomus Tumor
Hemangiopericytoma
Proliferating Angioendotheliomatosis

Dermal and Subcutaneous Tumors.ppt

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Pediatric Neurology

Pediatric Neurology
Topics
* Lecture 1
o Clinical duties of neurologists and pediatric neurologists
o Neonatal and developmental neurobiology (normal development and congenital malformations of the CNS)
* Lecture 2
o Developmental disorders (cerebral palsy, mental retardation)
o The Floppy Infant: Hypotonia

Developmental Milestones
CATEGORY EXAMPLE
Gross motor sitting, walking
Fine motor manipulate toys, utensils
Personal-social play, imitate housework
Language speech acquisition
Normal Motor Function
Abnormal Motor Function
Developmental Case #1
Physical Findings
CT Scan
Pathology and Pathophysiology
Diagnosis
* Obstructive hydrocephalus, due to stenosis of the cerebral aqueduct
* Other congenital causes
o Chiari malformation
o Dandy-Walker malformation
* Acquired causes
o Post-meningitis
o Post-traumatic
o Tumor
Hydrocephalus Treatment
Prognosis
* Cognitive and motor handicaps
* Complications of shunt system
o Shunt failure
o Shunt infection
* Epilepsy
Developmental Case #2
Fetal Ultrasound
Fetal Autopsy
Diagnosis
Developmental Pathology
Prognosis
Related Conditions
Encephalocele
Anencephaly
Prevention:
Folic Acid

Pediatric Neurology.ppt

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CNS Malformations

CNS Malformations
By:SCOTT KULICH, M.D., Ph.D.
RAFAEL MEDINA-FLORES, M.D.
RONALD L. HAMILTON, M.D.
Division of Neuropathology

Neural tube defects
Anencephaly
Failure of closure of the anterior neuropore
Common malformation
Frog-like facies
Area cerebrovasculosa
Underdeveloped hypothalamus
Adrenal cortical hyperplasia
Multifactorial-Folic acid supplementation
Anencephaly
SPINA BIFIDA
* myelomenigocele occulta meningocele
* Sacral dimple: dermal sinus track with spina bifida
Myelomeningocele
* Herniation of malformed cord + meninges through vertebral defect
* Usually associated with Arnold-Chiari and hydrocephalus
* Lumbosacral level most common
Chiari II (Arnold Chiari)
* Cerebellar tonsillar herniation
* Small posterior fossa
* Extension of medulla below foramen magnum
* Kinking of medulla (Z-formation)
* Beaking of the quadrigeminal plate
* Hydrocephalus
* Myelomeningocele
* Cerebellar tonsillar herniation
* Small posterior fossa
* Extension of medulla below foramen magnum
* Kinking of medulla (Z-formation)
* Beaking of the quadrigeminal plate
* Hydrocephalus
* Myelomeningocele
Chiari I Malformation
Dandy-Walker Malformation
* Dandy-Walker syndrome
o Agenesis of cerebellar vermis
o cystic dilatation of 4th venticle
o enlargement of posterior fossa
o Variable clinical manifestations
o Hypothesized to result from arrest of cerebellar development prior to the 3rd month

CEREBELLAR MALFORMATIONS: VERMIAN (PALEOCEREBELLUM)
* Joubert syndrome
Holoprosencephaly
Encephalocele
AGENESIS OF CORPUS CALLOSUM
MICROENCEPHALY
MEGALENCEPHALY
CORTICAL DYSPLASIA
Polymicrogyria
TUBEROUS SCLEROSIS
Sturge-Weber Disease
Port-wine stain or nevus
Flammeus tuypical of Sturge-Weber, occurring in V1 distribution.

CNS Malformations.ppt

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Sexual Development

Sexual Development

UROGENITAL SINUS & TUBERCLE
VULVA
UTERUS
OVARY
VAGINA
UTERINE TUBE
MULLERIAN DUCT
SEXUAL DEVELOPMENT
PROSTATE
PENIS
SEMINAL VESICLE
RETE TESTIS
TUBULUS RECTUS
EFFERENT DUCT
EPIDIDYMIS
DUCTUS DEFERNS
BULBOURETHRAL GLAND
urethra
INTERSTITIAL CELLS
SEMINIFEROUS TUBULE
TESTIS
WOLFFIAN DUCT
MESONEPHRIC DUCT
PARAMESONEPHRIC DUCT
GONAD on hold
OVARY
TESTIS
INTERSTITIAL CELLS
SEMINIFEROUS TUBULE
TUBULUS RECTUS
OVARY
GONAD on hold
Sex-determining Factor
Default pathways
Testosterone
Mullerian-inhibiting Factor
MULLERIAN DUCT
WOLFFIAN DUCT
UROGENITAL SINUS & TUBERCLE
Driven pathways
SERTOLI CELL
OVARY
GONAD on hold
Default pathway
and much more topics are covered

Sexual Development.ppt

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Male Hypogonadism

Male Hypogonadism
By: Michael Jakoby, MD/MA
Clinical Associate Professor of Medicine
Chief, Division of Endocrinology

Case study:
Definition

Decrease in one or both of the two major functions of the testes.
Gonadotrope failure
Secondary
Elevated
Testicular failure
Primary
Sperm count
Testosterone
Gonadotropins
Pathology
Hypogonadism
Gonadal Axis
Male Gonadal Function
Male Puberty
Clinical Features
Postpuberty
* Incomplete puberty
* Eunichoidal body habitus*
Prepuberty
Micropenis
3rd trimester
Incomplete virilization
1st trimester
Effects
Age
Screening for Androgen Deficiency
* Infertility
* Sellar mass, radiation, or surgery
* Osteoporosis or low trauma fracture
* HIV-associated weight loss
* ESRD
* COPD (moderate to severe)
* Type 2 diabetes mellitus
* Medications that effect testosterone production
o Glucocorticoids
o Opiates
o Ketoconazle

The Endocrine Society recommends against screening for androgen deficiency in the general population
History
* Symptoms onset
* Testicular size
* Breast enlargement
* Behavioral abnormalities
* Chemotherapy or radiation therapy
* Alcoholism
* Visual field defects
* Medications
Examination
* Testicular size
* Pubic hair
* Gynecomastia
* Muscle mass
* Body proportions
* Fundoscopy & visual fields screening

Laboratory Testing
Secondary hypogonadism
Primary hypogonadism
Elevated
Diagnosis
Gonadotropins (LH/FSH)
Semen analysis
Testosterone

Testosterone Measurements
* Total testosterone (free + protein bound) is almost always an accurate measure of testosterone secretion
* Free testosterone should be measured by equilibrium dialysis; analog methods commonly available give results proportionate to SHBG levels (Vermeulin A JCEM 84:3666)
* Testosterone should be measured in the morning (~ 8 AM) due to diurnal variations in testosterone levels, especially in young men
* Conditions that predispose to low SHBG levels:
o Obesity (BMI > 40)
o Senescence
o Nephrotic syndrome
o Cirrhosis
o Anticonvulsants

Testosterone in Obese Men
Testosterone Secretion: Comparison of Young and Elderly Men
Standard Semen Analysis
* Typically ordered for infertility w/u only
* Normal specimen:
o > 40 million sperm/ejaculate
o > 50% motile; > 25% rapidly motile
o > 50% normal morphology
DDx: Primary Hypogonadism
* Klinefelter’s syndrome
* Gonadotropin receptor mutations
* Cryptorchidism
* Androgen biosynthesis disorders
* Varicocele
* Congenital anorchia
* Mumps orchitis
* Radiation
* Antineoplastic drugs
* Ketoconazole
* Glucocorticoid excess
* Trauma
* Testicular torsion
* Autoimmune orchitis
* Cirrhosis
* Chronic renal failure
* HIV infection
* Idiopathic

Congenital
Acquired

DDx: Secondary Hypogonadism
* Isolated hypogonadotropic hypogonadism
* Kallman’s syndrome
* DAX1 mutation
* GPR 54 mutation
* Leptin or leptin receptor mutations
* Gonadotrope receptor mutations
* Hypopituitarism
* Hyperprolactinemia
* Androgen therapy
* GnRH analog therapy
* Glucocorticoid therapy
* Critical illness
* Chronic illness
* Diabetes mellitus
* Opiates
* Pituitary mass lesions
* Infiltrative diseases
* Sellar surgery
* Sellar radiation

DDx: Primary Hypogonadism
* Klinefelter’s syndrome
* Gonadotropin receptor mutations
* Cryptorchidism
* Androgen biosynthesis disorders
* Varicocele
* Congenital anorchia
* Mumps orchitis
* Radiation
* Antineoplastic drugs
* Ketoconazole
* Glucocorticoid excess
* Trauma
* Testicular torsion
* Autoimmune orchitis
* Cirrhosis
* Chronic renal failure
* HIV infection
* Idiopathic

Evaluation of Men with Androgen Deficiency
Confirmed low testosterone
Check LH+FSH (SA if infertility)
High gonadotropins – 1o
Low/low nl gonadotropins – 2o
Karyotype
Prolactin, other pituitary hormones, iron studies, sella MRI
What is the initial diagnosis?
Primary hypogonadism
What is the next step in work up?
Karyotype: 47 XXY
Klinefelter’s Syndrome
Gonadal Manifestations of Klinefelter’s Syndrome
Decreased penis length
Decreased axillary hair
Gynecomastia
Decreased sexual function
Increased gonadotropins
Decreased facial hair
Low testosterone
Azoospermia
Decreased testicular length
Abnormal testicular histology
Frequency (%)
Abnormality
Testosterone Replacement
* Primary goal is to restore testosterone levels to the laboratory reference range
* Prescribe only for patients with confirmed hypogonadism
* Role in “treating” decline in testosterone levels with aging uncertain
* Multiple preparations
o Oral
o Intramuscular
o Transdermal
o Buccal
Oral Testosterone Preparations
* Alkylated testosterone more slowly metabolized by liver than native testosterone
* May not induce virilization in adolescents
* Untoward effects
+ Cholestatic jaundice
+ Peliosis hepatis
+ Hepatocellular carcinoma
Intramuscular Testosterone
* Enanthate and cypionat
Serum testosterone levels after a single 200 mg IM dose of testosterone enanthate.
Transdermal Testosterone
* Patch (Androderm)
* Gels (Androgel, Testim)
Desirable Effects of Testosterone Therapy
Untoward Effects of Testosterone Therapy
* Pain at injection site (IM preparations)
* Contact dermatitis (patch >> gel)
* Acne or oily skin
* Gynecomastia
* Aggressive behavior (adolescents)
* Short stature (adolescents)
* Increased prostate volume/PSA
* Urinary retention (BPH exacerbation)
* Sleep apnea
* Erythrocytosis

Contraindications to Testosterone Therapy
* Very high risk of adverse outcomes
o Prostate cancer
o Breast cancer
* High risk of adverse outcomes
o Undiagnosed prostate nodule
o Unexplained PSA elevation
o BPH with severe urinary retention
o Erythrocytosis
o NYHA Class III or IV heart failure

Pre-treatment Screening
* Digital rectal exam
* History of urinary retention (urodynamic studies, bladder US PRN)
* History of sleep apnea symptoms (polysomnography PRN)
* PSA (urology referral if > 4 ng/mL)
* CBC

Treatment Monitoring
* Serum testosterone
* Prostate
* Red cell mass
Summary

* Signs and symptoms of hypogonadism depend on when the condition occurs in development
* Initial evaluation focuses on distinguishing between primary and secondary hypogonadism
o Primary: LH elevated, testosterone low
o Secondary: LH low, testosterone low
* Goal of testosterone replacement is physiological testosterone levels and preservation of testosterone-dependent physiological functions

Male Hypogonadism.ppt

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Fertility Facts

Fertility Facts
Definition:unprotected sex for one year, not pregnant
What can cause infertility?
* Ovulation disorders
* Tube/uterus blockage
* Cervix
* Endometriosis
* Other
* Sperm count and defects
* Erectile or ejaculation deficiency

Intrinsic vs. Extrinsic, Environmental
More detail on female infertility
* Ovulatory failure-polycystic ovarian syndrome (high androgen/estrogenlevels), resistant ovarian syndrome, gonadal dysgenesis
* Impaired gamete/zygote transport-pelvic inflammatory disease, endometriosis
* Implantation defects-progesterone low
* Spontaneous abortion-chromosome abnormality

More detail on male infertility
* Cryptorchidism-Why?
* Chromosome disorders-gonadal dysgenesis
* Obstructions
* Gonadotropin deficiency
Result in:Low sperm count, sperm of poor quality

Female Infertility Tests
* For ovulation
* Post ovulatory block
Laparoscopy
Hysterosalpingogram
Blocked tubes
Male Infertility Tests
* Sperm count/motility
* If low check LH and androgen levels
* Testicular biopsy
Sperm Count
Older, low tech treatments
* Drug treatment for ovulation block
* Intrauterine insemination
* Tubal surgery

High tech Assisted Reproduction Technologies
* IVF-in vitro fert and embryo transfer
* GIFT-gamete intrafallopian tube transfer
* ZIFT-zygote intrafallopian tube transfer
* Intracytoplasmic sperm injection

frozen eggs/ ovary transplant; cloned human embryo
First test-tube baby

Assisted Reproductive Technology
* Estimate 1/100 births now
* Around 40,000/year
* Costs between $7,000 to 15,000 per attempt

IVF
In Vitro Fertilization and Embryo Transfer
Basic Steps in IVF
* Ovary stimulation
* Egg retrieval
* Sperm retrieval-wash sperm
* Fertilization
* Embryo transfer
* Progesterone
Drugs used for ovary stimulation
* Clomiphene (clomid)-anti-estrogen
* hMG (pergonal)-menopausal gonadotropin (FSH and LH)
* FSH-(metrodin)
* GnRH
* GnRH agonists (lupron)-FSH/LH first promoted, then inhibited
* hCG-acts like LH

Why transfer more than one embryo?
* Increase the pregnancy rate
* Leads to increased risk of multiple pregnancies
* In future- Test embryos before transfer
sHLA-G measure of embryo health
Egg retrieval, vaginal, with ultrasound
Gametes mixed for GIFT
Modifications if tube not blocked
If fertilization needs help-transfer zygote
ZIFT
Intracytoplasmic sperm injection
ICSI
Additional twists
* Surrogacy
o Gestational
o Egg donor plus gestational
o Egg donor plus sperm donor plus gestational
* Frozen embryos
* Egg donors
* Frozen eggs
* Cloning
From CDC
IVF Success Rates
Stage Number of Women

Fertility Facts.ppt

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Male Sexual Anatomy & Physiology

Male Sexual Anatomy & Physiology

The Penis
* Nerves, blood vessels, fibrous tissue, and three parallel cylinders of spongy tissue.
* There is no bone and little muscular tissue (although there are muscles at the base of the penis)
* Terms:
* Penis: consists of internal root, external shaft, & glans.
* Root: the portion of the penis that extends internally into the pelvic cavity.
* Shaft: the length of the penis between the glans and the body.
* Glans: the head of the penis; has many nerve endings.
* Cavernous bodies: the structures in the shaft of the penis that engorge with blood during sexual arousal.
* Spongy body: a cylinder that forms a bulb at the base of the penis, extends up into the penile shaft, and forms the penile glans. Also engorge with blood during arousal.
* Foreskin: a covering of skin over the penile glans.

Fig 5.1a Interior structure of the penis:
External penile structures
Scrotum and testes
* Scrotum (or scrotal sac):
* Testis
o Male gonad inside scrotum that produces sperm and sex hormones
* Spermatic cord
o A cord attached to the testis inside the scrotum that contains the vas deferens, blood vessels, nerves, and muscle fibers
Structures inside the testis
Cross-section of seminiferous tubule
Interstitial cells: secrete androgens
Spermatogenic cells: produce sperm
Immature sperm
Vas deferens
Overview: male sexual anatomy
Seminal vesicles
Prostate gland
Cowper’s glands
Semen
Analagous structures in male and female sexual anatomy
Male
Glans
Foreskin
Shaft
Scrotal sac
Testes
Female
Clitoris
Clitoral hood
Labia minora
Labia majora
Ovaries
Group activity: male A & P flashcards
One side: name of term
Other side: definition, function, location
Group activity:
Male reproductive anatomy & physiology
Male sexual function: Erection
How blood inflow helps maintain erection
Ejaculation
Emission phase of ejaculation (phase 1)
Penis size
Penile Augmentation (phalloplasty)
Circumcision
Circumcision: medical perspective
Circumcision and sexual functioning
Discussion question:
Penile cancer
Testicular cancer
Prostate Health Care Issues
Prostate Cancer
Prostate Cancer: Symptoms & diagnosis

Male Sexual Anatomy & Physiology.ppt

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Reproductive Ethics

Reproductive Ethics

Schedule
* Papers
* Understanding the Technology
* Ethical Issues

Reproductive Technology
* Artificial Insemination
* In Vitro Fertilization
* Surrogacy
* Freezing Sperm
* Freezing Embryos
* Freezing Eggs
* (Cloning)

Artificial Insemination
* Essentially, sperm (either from the husband or some other donor) is injected into the reproductive tract of the intended mother.
* Used most commonly when there are concerns about male infertility.
* The sperm can be “washed” first to ensure that there is a high concentration of sperm.
* Actually a general term, not a specific procedure.
* The most common procedure is intrauterine insemination (IUI), where the sperm is inserted directly into the uterus, so as to avoid possible problems with the cervix.
* IUI has a success rate of about 15-20%, and is fairly quick.
* A major disadvantage is that the doctor cannot tell if insemination has been successful because it occurs in the body.
* Another procedure, intracytoplasmic sperm injection (ICSI) involves injecting a single sperm by pipette into an egg.
* ICSI allows men with very low sperm counts to reproduce.
* Can be done in utero, but is becoming more common in vitro.

In Vitro Fertilization
* In these processes, sperm and eggs are combined outside the body, and reinserted after it is clear that insemination has occurred.
* The most common sign that insemination is successful is when the egg has divided into an eight-celled organism. This is the point that the egg(s) are reinserted.
* Depending on the procedure used, can cost between $5,000 and $12,000 an attempt.
* The rate of success for IVF varies from clinic to clinic, and procedure to procedure, but the national average is about 34% (measured in terms of babies per egg retrieval.)

GIFT
* Gamete Intrafallopian Transfer (GIFT) is a hybrid of IVF and AI.
* Eggs and sperm are both retrieved from the potential parents, and screened for problems.
* The sperm and eggs are then placed in a catheter together and inserted directly into one the woman’s fallopian tubes.
* Since the eggs are withdrawn from the body first, GIFT is similar to in vitro, but since the fertilization occurs in the body it is like AI.
* Some find this preferable to traditional IVF, because there is no question about what to do with “excess” embryos.

Surrogacy
* Surrogacy is when the potential parents have someone other than the eventual mother carry the child to term.
* This can be done with AI, or IVF, and can utilize either the eventual mother’s eggs, the surrogate's eggs, or eggs from a donor.
* Surrogates generally fall into two camps: Close relatives or hired surrogates.
* In either case it is routine to sign a contract stating what compensation (if any) will be done, concerns about how the surrogate will handle health issues during pregnancy, and a waiver of the surrogate’s parental rights.

Freezing Sperm
* A.K.A. “Sperm Banks”
* Sperm is collected via masturbation and is stored in a frozen manner. The sperm can be later “thawed,” and used in various reproductive technologies.
* While people who “sell” their sperm gets the most media attention, many men have some sperm frozen if they are going to be undergoing various procedures that could affect future fertility.

Freezing Embryos
* After fertilization, embryos can be frozen for later implantation via IVF.
* Most common with the “excess” embryos from IVF attempts and women who will be undergoing procedures that could effect future fertility.
* A problem with this approach is that embryos require both the egg and the sperm.
* Women who do not know for sure if they want to have children with Father “X,” but wish to save embryos cannot use this procedure.

Freezing Eggs
* Problematic for a long time because in the freezing process ice crystals could form, harming the eggs.
* Involves removing ovarian tissue, and freezing it. After the tissue is “thawed” it is transplanted into a host. Mature eggs are removed, inseminated, and implanted into the birth mother.
* The technology is still evolving, and many caution that there may be lingering side-effects from the freezing of the eggs.
* Allows women who want to preserve fertility, but not commit to having a child with any particular person to do so.

Cloning Technologies
* We will be looking into these next week, but many of the same ethical issues that rise with these technologies are also raised. (But as a bonus, additional ethical issues are raised.)

Ethical Questions
* What concerns do you have about these technologies?
* Has technology outpaced law?

More Questions
* Who has access to these technologies?
* Given problems with overpopulation, should we continue to look into advanced in reproductive technology?
* Is reproduction without sex moral?
* What should happen to eggs/sperm/embryos that have been stored when the donors have died?
* Do you own your genetic material? Can you bequeath it?
The Big Question
* What is to be done with “excess” embryos?

Reproductive Ethics.ppt

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Assisted Reproductive Technologies (ART)

Assisted Reproductive Technologies (ART)
* Artificial Inseminations
* In vitro fertilization (IVF)
* Embryo transfers
* “Cloning”

Some Common Reasons for ART
* Infertility
o Male
o Female
* Absence of one or the other partner
o Lesbian, gay, transgendered parent
o Death of spouse
* Genetic Engineering
o Hereditary disorders
o Sex selection

Artificial Insemination
* Method other than intercourse to facilitate fertilization
* Introduction of semen or washed sperm into the vagina, the uterus or the Fallopian tubes
* Can be from legally recognized partner (husband) = AIH, or from another donor = AID
* Fresh or frozen semen samples (e.g., Select Sires, Inc.)

Long History of AI
* Agricultural uses
o 14th Century breeding of Arabian horses
o 1780 Spallanzani used sperm in dog breeding
o By 1940 many breeders Coops
* Human experience
o John Hunter (1780s) patient with hypospadias
o Marion Sims (mid 1800s) one success out of 55 tries
o By 1941 over 10,000 births in the US by AI
o By 1955 over 50,000
o Now, approx 1 percent of all births in US

The Famous Turkey Baster
Sorting sperm according to sex
* Sperm are sexually dimorphic: half have an X-chromosome, half have a Y-chromosome
* The X-chromosome is much bigger, so “female determining” sperm have more DNA, and are (hypothetically) slightly heavier
* Try to physically separate sperm based on size or DNA content
* Mark either the X or Y chromosome in some way and sort on the basis of the marking.
More than one X chromosome: Sex chromatin (
Flow sorting of marked sperm
IVF: In vitro fertilization
* Surgically remove “ripe” egg from follicle in ovary
* Obtain sperm sample
* Mix egg and sperm in glass (in vitro) dish
* Allow fertilized egg to develop for several days (in nutrient solution at body temp)
* Put embryo(s) (blastocyst) into “prepared” uterus (or Fallopian tube)
* Variation: sperm and egg are put into Fallopian tube
Fertilized egg or “zygote” [note the two nuclei, egg and sperm]
Direct injection of sperm into egg
3 day old human embryo
Embryo Transfers
* One kind of ART
* First Step: IVF
* Transfer Embryo into Recipient
* Combinations of:
o Egg Donor
o Sperm Donor
o Recipient
Outcomes of ART Pregnancies
One-third of ART deliveries are multiple births
Multiple Embryo Transfer
Success rate goes down with age
Births depend on age of eggs not mom
Three Thawed Embryos
Bring on the Clones

Clones in Context
* A clone is any organism whose genetic information is identical to that of a "mother organism" from which it was created.
* A clone is an exact replica of all or part of a macromolecule (e.g. DNA).
* A clone is a computer system based on another company's system and designed to be compatible with it.
* A clone is a butch or masculine gay man, a term mostly associated with the 70s and 80s. The "clone uniform" is mustache, jeans, and white t-shirt. E.g., a “Chelsea Clone” etc….
Reproductive vs Non-reproductive Cloning
Gestational Cloning
* New technology: becoming widely used in animal reproduction
* Allows unlimited reproduction of genetically identical individuals (clones)
* Potential for a sort of “genetic immortality”
* Many possible “good” and “bad” applications
* Societal vs Individual Rights: very unclear

Clones in Context
* Any group of cells that descends from a single cell….
o Includes such groups of cells as freckles, colonies of mold on bread, antibody producing lymphocytes, tumor cells…
* Any organism grown up from a single cell…
o Includes some plants, identical twins, some animals such as “Dolly” the Sheep…

Assisted Reproductive Technologies (ART).ppt

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Sperm Terms

Sperm Terms

Sperm Count – # of sperm
Sperm Mobility- ability of sperm to move
Forward Progression- quality of movement
Sperm Morphology- size and shape of sperm

Factors in Decreased Spermatogenesis
* Exposure to Heat
* Lifestyle Factors
* Age
* Endocrine Problems
* Immunological Problems

Anatomical Problems
Retrograde Ejaculation
Variocele
* Varicose vein around testicle.
* Decrease in sperm production due to increased scrotal temperature.
Cryptochordism
* Failure of one testis or both to descend into the scrotum.
* Decrease in sperm production due to temperature increase associated with being inside the body cavity
Erectile Dysfunction
-Inability to maintain an erection during sexual intercourse
* Many causes including: diabetes, alcohol and antidepressant use, anxiety, low testosterone, and arteriosclerosis
* Treatment includes medications such as Viagra, testosterone therapy, and counseling.

References

Sperm Terms.ppt

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Semen quality in relation to pesticides

Semen quality in relation to exposure to currently used pesticides
By:Shanna H. Swan, PhD
University of Missouri-Columbia
6th International Symposium on Environmental Endocrine Disrupters
Sendai, Japan

Background
Normal morphology
Motile sperm
Concentration

The Study for Future Families (SFF)
SFF Recruitment:
Summary of Semen Parameters
We considered these factors
o Age
o Smoking
o History of infertility
o Body mass index (BMI)
o History of STDS

* Ethnicity
* Recent fever
* Abstinence time
* Analysis time
Differences in semen quality were unchanged by adjustment for these factors
How does mid-Missouri differ from Minneapolis ?
% Acres in farms and use of pesticides
Herbicides
Insecticides
Fertilizer
Pesticides applied (acres)
Study hypothesis
Pesticides found more often in MN
Remaining analyses
Pesticides detected more often in cases than controls Percent of men with pesticide > LOD
Two pesticides were weakly associated with sperm count
Dose response for alachlor in MO men
Drinking water is a likely source of exposure
Examining pesticides and semen quality in a second agricultural center
Use of pesticides in IA is greater than MO
Semen quality in Iowa City and other SFF centers
What is needed?
* Urinary pesticide levels in IA men
* Serum levels of pesticides to examine total exposure
* Tap water pesticide levels
* Replication of study in other areas and countries
The Study for Future Families

Semen quality.ppt

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Evidence-based Treatment of Psychotic Depression

Evidence-based Treatment of Psychotic Depression
By:Gregory W. Dalack, MD

The Practice of EBM

Step 1: Asking an answerable question
Step 2: Tracking down the best evidence to answer that question
Step 3: Critically appraise the evidence for validity, size of the effect, and utility of the findings
Step 4: Incorporate the clinical appraisal into our clinical expertise and patient’s individual issues
Step 5: Evaluate and improve steps 1-4 with each new opportunity to apply these principles


Brief case history
Asking answerable clinical questions (CEBM- Oxford)
An answerable clinical question

For patients with psychotic depression...
...is antidepressant treatment alone...
...when compared to antidepressant plus antipsychotic treatment…
...result in greater improvement of depressive/psychotic symptoms?

Search Treatment of Psychotic Depression

Electronic Books
Classic Study
The pharmacological treatment of delusional depression
Search Treatment of Psychotic Depression
Relative Risk: the ratio in the treated group to the risk in the control group (TG/CG)
Conclusions

Evidence-based Treatment of Psychotic Depression.ppt

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Combined Pharmacotherapy and Psychotherapy for Anxiety Disorders

Combined Pharmacotherapy and Psychotherapy for Anxiety Disorders: Is Efficacy Enhanced?
An Evidenced-Based Approach
By: Heide Klumpp, Ph.D.


Components of Evidence-Based Treatment include:
Chambless and Hollon (1998)
Comparison with a no-treatment control group, alternative treatment group, or placebo in a randomized control trial or equivalent time-samples design


Study must have been conducted with:

a) Treatment manual
b) Population, treated for specified problems
c) Reliable/valid outcome assessment measures
d) Appropriate data analysis

Clinical scenario

Family hx
Clinical questions:
Does she meet DSM-IV criteria for Social Phobia?
What’s your Evidenced-Based Treatment plan?
2) Psychotherapy (e.g., cognitive-behavioral treatment)?
3) Combined therapy?

Rationale for combined therapy:

Sources for evidence regarding combined therapy
Results consisted of:
Articles comparing treatment approaches
+ Provides details of research methods and analysis
- Difficult to compare results across different studies

Meta-analytic studies
Literature reviews
Efficacy of combined pharmacotherapy and psychotherapy for Social Phobia
Primary outcome measure:
Clinician rated: Clinic Global Impression Inventory-Social Phobia Scale (CGII-SPS)
Patient rated: CGII-SPS

Response defined as:

1) Overall severity score at final visit in the “no menta
Pharmacotherapy:
Exposure therapy:
Outcome after 24 weeks of treatment
Conclusions:
Points to consider:
Recruitment: two outpatient programs at medical centers
Response primarily via Clinical Global Impressions Improvement (CGII):
Pharmacotherapy: Double-blind administration
Cognitive-behavioral treatment:
Points to consider:
Recruitment: 133 participants from Cognitive behavioral treatment program at an Anxiety Disorders Clinic at a hospital
Pre Post Pre Post
Conclusion:
Points to consider:
Summary
Questions regarding clinical scenario

Combined Pharmacotherapy and Psychotherapy for Anxiety Disorders.ppt

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Delirium, Dementias, and Related Disorders

Delirium, Dementias, and Related Disorders

Key Concepts
* Cognition
o System of interrelated abilities, such as perception, reasoning, judgment, intuition and memory
o Allows one to be aware of oneself
* Memory
o Facet of cognition, retaining and recalling past experiences
* Delirium
o Acute cognitive impairment caused by medical condition
* Dementia
o Chronic, cognitive impairment
o Differentiated by cause, not symptoms

Delirium Clinical Course
* Disturbance in consciousness and a change in cognition
* Develops over a short period of time
* Usually reversible if underlying cause identified
* Serious, should be treated as an emergency

Delirium Diagnostic Criteria
* Impairment in consciousness - key diagnostic criteria
* Children - can be related to medications or fever
* Elderly - most common in this group, often mistaken as dementia

Delirium Epidemiology & Risk Factors
* Prevalence rates from 10-30% of patients
* In nursing homes, prevalence reaching 60% of those older than the age of 75 years
* Occurs in 30% of hospitalized cancer patients
* 30-40% of those hospitalized with AIDS
* Higher for women than men
* Common in elderly, post-surgical patients

Delirium Etiology
Variety of brain alterations
o Imbalance of neurotransmitter
o Raised plasma cortisol level
o Involvement of white matter
Types

* Due to General Medical Condition
* Substance-Induced
* Substance-Intoxication
* Substance-Withdrawal
* Multiple Etiologies

Medications
Physiological
* Fluid/kidney
o Dehydration, Hypocalcemia, Hypokalemia, Abnormal sodium, Low serum albumin, Elevated BUN, Elevated creatinine, Azotemia, Proteinuria, CRD
* Cardiac/Respiratory
o Hypotension, CVD, CHF, AA, Elevated PT, Low hematocrit, Respiratory insufficiency, Noncardiac thoracic surgery
LABS

* BUN
* Creatinine Clearance
* Serum Albumin
* Hyponatremia
* Hypocalcemia
* Hypokalemia
* Elevated PT

Physiological
* Metabolism/Temperature
* Age, gender

PhysiologicalInfection and Trauma
o Symptomatic infection
o Urinary tract infection
o Respiratory infection
o Elevated WBC
o Emergency Admission
o Fracture
o Falls
o Orthopedic surgery
o Combination illnesses
Physiological
* More than 4 medications
* Drugs with anticholinergic or CNS effects
* Hypoxia/Ischemia
Interdisciplinary Treatment & Priorities
Nursing Management Biologic Domain Assessment
Nursing Management Pharmacologic Assessment
Delirium: Biologic Domain Nursing Diagnosis
Delirium Biologic Nursing Interventions
Delirium Psychological Domain Assessment
Delirium: Psychologic Domain Nursing Diagnosis
Delirium Psychological Nursing Interventions
Delirium Social Domain Assessment
Delirium: Social Domain Nursing Diagnosis
Delirium Social Nursing Interventions
Evaluation Delirium Dementia
Dementia Alzheimer’s Type
Personality changes
Language difficulties
Dementia/Alzheimers Progression
Diagnosis of AD
Epidemiology
Risk Factors
Etiology
Interdisciplinary Treatment
Priority Care Issues
Family Response to AD
Nursing Management Biologic Domain Assessment
Dementia: Biologic Domain Nursing Diagnosis
Dementia Biologic Nursing Interventions
Pharmacologic Interventions
Dementia Psychological Domain Assessment
Dementia: Psychological Domain Nursing Diagnosis
Dementia Psychological Nursing Interventions
Dementia Psychological Nursing Interventions
Dementia Psychological Nursing Interventions
Dementia Social Domain Assessment & Nursing Diagnosis
Dementia Social Nursing Interventions
Family Interventions
Other Dementias
Amnestic Disorder

Delirium, Dementias, and Related Disorders.ppt

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Geropsychiatry: Delirium and Dementia

Geropsychiatry: Delirium and Dementia
By:Robert Averbuch, MD
Assistant Professor, Department of Psychiatry

Disorders of Cognition
* DSM-IV devotes an entire section to a subset of “organic” disorders that primarily affect cognition: “Delirium, Dementia, and Amnestic and other Cognitive Disorders”
What is “organic”?
* Previous differentiation between mental disorders with a clear “physical or biological” etiology (Organic) and those without (“Functional” or “Primary”)
* Falsely implied that Functional (or primary) disorders have no underlying pathophysiological basis
* Primary mental disorder- not due to a GMC or substance
Disorders of Cognition
* Delirium-disturbance in consciousness and cognition that develops rapidly
* Dementia- multiple cognitive deficits that include memory disturbance
* Amnestic Disorder- primarily memory impairment
Delirium: defined

* Disturbance of consciousness (awareness of the environment) and attention,
* PLUS…
o Changes in cognition (ie, “thinking”-memory, orientation, language, etc) OR
o Perceptual disturbances
The Course of Delirium
Delirium: Associated Features
* Disturbance in sleep-wake cycle
* Easily distracted by irrelevant stimuli
* Changes in activity level
o Restlessness, hyperactivity
o Picking at clothes, getting out of bed
o OR hypoactivity (lethargy)
* Emotional disturbances- mood lability, anger, irritability, euphoria, apathy
* Speech or language disturbances
* Perceptual abnormalities- common:
o Illusions, hallucinations, delusions
* Neurological deficits/dysfunction

What Are the Causes?
* DIRECT: Brain pathology: head injury, seizures (during and after), strokes, infections
* INDIRECT: Systemic Illness: electrolyte abnormalities, dehydration, uremia, hepatic encephalopathy, cardiovascular compromise
* Sensory deprivation
* After surgery (post-operative state)- ie. “ICU Psychosis”
* Side effects of medications or toxins or with abused recreational drugs:
Treating Delirium
* Considered a Medical Emergency
* Supportive care in an ICU setting
* Safety- close monitoring
* Remove offending agent, treat underlying cause
Dementia
Hallmark is Memory Impairment
Dementia- defined
Details: Aphasia
Disturbances in Executive Functioning
Associated Features
More associated features
Course of Dementia
What causes Dementia?
More causes:
Alzheimer’s Dementia of the Alzheimer’s Type (DAT)
Vascular Dementia
Aka Multi-Infarct Dementia
Treatment of Dementia
Medications

Geropsychiatry: Delirium and Dementia.ppt

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Delirium in the Elderly: Evaluation and Management

Delirium in the Elderly: Evaluation and Management
By:M. Andrew Greganti, MD

Outline of Discussion
* Case Presentation
* Characteristics of Delirium
* Etiology/Pathogenesis
* Risk Factors
* Prevalence
* Clinical Presentation
* Diagnosis
* Evaluation
* Prevention and Treatment
Case Presentation
Hospital Course
Post Hospital Course
Characteristics of Delirium
Other Characteristics
Etiology
Pathogenesis
How common is delirium?
Risk Factors
Other Risk Factors
Prodrome
Clinical Presentation
Diagnosis
Differential Diagnosis
Prognosis
Evaluation
Preventive Measures Perioperatively
Treatment
Treatment of “Yelling Out”
Summary of Key Points

Delirium in the Elderly: Evaluation and Management.ppt

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Delirium in the Elderly

Delirium in the Elderly
By:Bree Johnston MD MPH
UCSF Division of Geriatrics

Case Study
Atypical Presentations
Learning Objectives
* Recognize that delirium is a common presentation of disease in the elderly
* Recognize that delirium is associated with adverse outcomes
* Know how to distinguish between delirium and other diagnoses (dementia, depression)
* Identify risk factors for delirium and strategies for risk reduction
* Discuss management strategies, recognizing the limitations of current data
Definition
* “an acute disorder of attention and cognition” (de lira “off the path”)
* Standard definition not use until 1980 with publication of DSM III
* Other terms used include organic brain syndrome, metabolic encephelopathy, toxic psychosis, acute mental status change, exogenous psychosis, sundowning
Pathophysiology
Delirium Risk Factors
* Age
* Cognitive impairment
* Male gender
* Severe illness
* Hip fracture
* Fever or hypothermia
* Hypotension
* Malnutrition
* High number of meds
* Sensory impairment
* Psychoactive medications
* Use of lines and restraints
* Metabolic disorders:
* Depression
* Alcoholism
* Pain

Delirium Risk Model
Baseline Risk Group
Precipitating Factor Group
Surgical Prediction Rule
Clinical Prediction Rule for Post-surgical Delirium
Differential Diagnosis
* CNS pathology
* Dementia, particularly frontal lobe
* Other Psychiatric disorders
o Psychosis
* Depression: 41% misdiagnosed as depression Farrell Arch Intern Med 1995
o Bipolar disorder
* Aconvulsive status epilepticus
* Akathisia
* Overall, 32-67% missed or misdiagnosed

Diagnosis
Diagnostic Tools
Delirium versus Dementia
Medications and Delirium
Searching for the cause
103 treatment and 111 controls
Intervention: Surgery as soon as possible & geriatric evaluation pre and post op vs usual care
Outcomes Treatment Control
Possible Benefit From:
* Preoperative psychiatric assessment followed by nursing reorienation (33% vs 14%)
* Postoperative reorienation (87% vs 6%)
* Preoperative education about delirium (78% vs. 59%)
* Pre and post operative psychiatric intervention (13% vs 0)
Can Interventions Prevent Delirium?
Intervention Protocol
* Cognition Orientation, activities
* Sleep Bedtime drink, massage, music, noise reduction
* Immobility Ambulation, exercises
* Vision Visual aids and adaptive equipment
* Hearing Portable amplifiers, cerumen disimpaction
* Dehydration BUN, volume repletion
Preventing Delirium post Hip fracture
* Protocols for:
o Fluid/electrolytes
o Pain treatment
o Eliminating unnecessary medications
o Bowel/bladder function
o Nutrition
o Mobilization
o CNS oxygenation
o Prevention of complications (MI, PE, UTI, pneumonia)
o Environmental stimuli
o Treatment of agitated delirium
Delirium in Hip fracture
Severe delirium, cumulative incidence
Delirium, cumulative incidence
Delirium at discharge
Interventions that May Help
Drug therapy
Drug Therapy of Delirium
Neuroleptics
Use of Haloperidol
Atypical neuroleptics
Benzodiazepines
Other agents
Delirium in the ICU
Sedation in the ICU
Prevention is the Best Medicine

Delirium in the Elderly.ppt

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Alcoholic Hepatitis and Delirium Tremens

Alcoholic Hepatitis and Delirium Tremens

Normal liver
Fatty Liver
Alcoholic Hepatitis
Cirrhosis
Acute Alcoholic Hepatitis
Symptoms include
How to assess severe acute alcoholic hepatitis
Management of Alcoholic Hepatitis
TNF and Alcoholic Hepatitis
Management of Alcoholic Hepatits
Delirium Tremens
Treatment
Selecting patients for alcohol withdrawal outpaitent treatment
* Indications: Alchohol dependence with evidence of tolerance and withdrawal
* Contraindications:
o Coexisting acute or chronic illness requiring inpatient treatment
o Current severe withdrawal with DTs
o No possibility for follow up
o Pregnancy
o Seizure disorder or risk of withdrawal seizure
o Suicide risk
* Relative contraindications
o Benzo dependance
o h/o unsuccessful outpatient detozification
o Age>40 years
o Drinking >100g ethanol daily
o Elevated MCV
o Elevated BUN
o Cirrhosis
o Random blood alcohol >200mg/dl
References
Alcoholic Hepatitis and Delirium Tremens.ppt

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Management of Sedation and Delirium in Ventilated ICU Patients

Management of Sedation and Delirium in Ventilated ICU Patients
By:Gabriel Tsao
Stanford University, School of Medicine

Introduction
Presentation Outline
* Sedation in the ICU
o Drug overview
o Sedation assessment
o Drug selection
* Delirium in the ICU
o Incidence and mortality
o Delirium assessment
o Management of delirium

Sedation in Ventilated Patients
* Mechanical ventilation is uncomfortable and anxiety provoking
* Sedation is often necessary for comfort and airway, line, foley, nursing protection
* >85% of ventilated patients receive sedation

Commonly Used Sedatives
Central alpha-agonists
Dexmedetomidine
Fentanyl
Assessing Sedation
Selection of sedative agent
Sedation Use Recommendations
Sedation Interruption
Sedative Dependence
Presentation Outline
* Sedation in the ICU
o Drug overview
o Sedation assessment
o Drug selection
* Delirium in the ICU
o Incidence and mortality
o Delirium assessment
o Management of delirium
Delirium highly prevalent in ICU
Delirium in ventilated patients
Overview of Delirium
Subtypes of Delirium
Assessing Delirium
Pathophysiology Poorly Understood
Treatment of Hyperactive and Mixed Delirium
Other Treatments for Hyperactive/Mixed Delirium
Treatment of Hypoactive Delirium

Management of Sedation and Delirium in Ventilated ICU Patients.ppt

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