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| Zinc deficiency |
A collection of growth retardation, hypogonadism, cell mediated immune dysfunction, and skin changes related to decreased zinc
SIGNS AND SYMPTOMS:
•Mild deficiency
•Hypogeusia
•Decreased dark adaptation
•Decreased lean body mass
•Moderate deficiency
•All of the above
•Diarrhea
•Growth retardation
•Hypogonadism (especially male)
•Mental lethargy
•Anergy
•Rough skin
•Delayed wound healing
•Glucose intolerance
•Impaired cell mediated immunity
•Severe deficiency
•All of the above
•Bullous pustular dermatitis
•Weight loss
•Dwarfism
•Emotional instability
•Tremors
•Ataxia
•Alopecia
•Death
CAUSES:
•Increased requirements
•Pregnancy
•Lactation
•Rapid growth phase of childhood
•Burns
•Major trauma
•Increased losses
•Diabetes
•Cirrhosis
•Renal disease
•Malabsorption states, e.g., inflammatory bowel diseases
•Sickle cell anemia
•Decreased absorption
•Acrodermatitis enteropathica, an autosomal recessive deficiency in the enzyme required for
intestinal absorption
•Geophagia
•Chelating agents
•Parasitism
•Diet high in phytates
•Insufficient dietary intake
•Vegetarianism
•Parenteral hyperalimentation without supplementation
•Breast feeding
•Suboptimal zinc conditions in diet (rare)
•Alcoholism
RISK FACTORS:
•High milk consumption
•Low socioeconomic status
LABORATORY:
•Plasma zinc levels decreased (in moderate to severe zinc deficiency)
•Erythrocyte or leukocyte zinc levels more adequately assess tissue stores, but these are more
costly and not widely available
•Hair or fingernail zinc levels not useful
DIET:
•Balanced omnivorous diet
•Avoid excessive intake of foods with high phytate content, (e.g., cereals)
DRUG(S) OF CHOICE:
•Zinc gluconate or zinc sulfate for 6-9 months
•Elemental zinc added to hyperalimentation in adult patient.
•In pediatric patients, 0.02-0.04 mg zinc/kg/day in hyperalimentation
•Prenatal vitamins with minerals during pregnancy and lactation to prevent deficiency
PREVENTION/AVOIDANCE:
•Adequate diet
•Supplementation when indicatedLabels: zinc deficiency |
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| Zollinger-Ellison syndrome |
A triad of (Marked elevated gastric acid secretion, Peptic ulcer disease, A gastrinoma or non-beta islet cell tumor of the pancreas or duodenal wall which produces gastrin). Gastrinomas (at time of diagnosis) may be single or multiple (1/2-2/3), large or small, benign or malignant (2/3), sporadic (70-75%) or associated with multiple endocrine neoplasia (MEN 1)(25-30%)
SIGNS AND SYMPTOMS:
- Abdominal pain >80%
- Epigastric pain
- Reflux esophagitis
- Vomiting unresponsive to standard therapy
- Diarrhea including while fasting 40-70%
- Peptic ulcer disease
- Weight loss
- Hepatomegaly with metastasis
- Steatorrhea
- Endoscopic findings including esophagitis, duodenal ulceration with multiple ulcers and prominent gastric and duodenal folds
- Complications of severe peptic ulcer disease including hemorrhage, perforation and obstruction
- Signs of MEN 1 including those of hypercalcemia hyperparathyroidism and Cushing's syndrome.
CAUSES:
Gastrinoma equally distributed between the head of the pancreas and the first or second portion of the duodenum. May also be found rarely in the mesentery, peritoneum, spleen, skin or mediastinum (possibly metastasis with primary not identified).
LABORATORY:
- Elevated serum gastrin-fasting (>1000 pg/mL with ulcers diagnostic, >200 pg/mL with ulcers suggestive)
- Elevated basal gastric acid output >15 mEq/hr (>15 mmol/hr)
- Gastric pH <2.0>
- Check serum calcium, phosphorous, cortisol and prolactin (to R/O MEN 1)
APPROPRIATE HEALTH CARE:
- Advise daily care based on symptoms
- Appropriate surveillance of basal gastric acid output to monitor anti-acid secretory therapy
- Appropriate surveillance postoperatively to look for metastasis
GENERAL MEASURES:
- Advanced imaging initially to assess for possible resection
- Surgical removal when primary can be identified and as an adjunct for symptom control
- Medical treatment for symptom control when primary not found or metastasis present on diagnosis
SURGICAL MEASURES:
- Laparotomy to search for resectable tumors unless have liver metastasis on presentation or MEN 1
- Definitive therapy-removal of gastrinomas when found (surgery finds 95% of tumors, 5 year cure 30% when all can be removed)
- Total gastrectomy was formerly used to stop acid production before pharmacologic therapy available, now seldom done
- Vagotomy in some patients will reduce acid secretion and improve therapeutic effect of medication. May allow decrease dose of medication.
- In MEN 1 parathyroidectomy by lowering calcium may decrease acid production and decrease antisecretory drug use. Gastrinomas generally benign but multiple and not usually cured by surgery.
DIET:
Restrict foods which aggravate symptoms
Contraindications:
- Known hypersensitivity to the drug
- H2-blockers-androgen effects, drug interactions due to Cytochrome P-450 stimulation
- Omeprazole-none
- Lansoprazole-none
Precautions:
- Adjust doses for renal and geriatric patients depending on drug
- Gynecomastia reported with high dose cimetidine (>2.4 gm/d)
- Proton pump inhibitors may induce a profound and long lasting effect on gastric acid secretion, thereby affecting the bioavailability of drugs dependent on low gastric pH (eg, ketoconazole, ampicillin, iron)
ALTERNATIVE DRUGS:
- Octreotide appears helpful in slowing growth of liver metastasis. May produce regression in some cases.
- Chemotherapy regimens of streptozocin, 5-fluorouracil and doxorubicin show only limited response
- Interferon and shows more limited response; may be useful in combination with octreotide
Labels: Gastric acid secretion, Gastrinoma, Peptic ulcer disease |
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| Zygomycosis |
Fungal infection typically seen in immunocompromised or debilitated patients. In healthy individuals, the organisms seldom cause infection. Several forms exist - gastrointestinal, rhinocerebral, disseminated mucormycosis, pulmonary, cutaneous, central nervous system. Prognosis is guarded.
Patients with hematologic malignancies are currently at higher risk of invasive fungal infections (IFI) caused by molds than by yeasts, and the incidence of IFI is highest among patients with acute myeloid leukemia. Aspergillus spp are still the most common pathogens, followed by Candida spp. Other agents are rare. The attributable mortality rate for aspergillosis has dropped from 60-70% to approximately 40%. Candidemia-related mortality remains within the 30-40% range reported in literature although the incidence has decreased.
CAUSES:
fungi of the class Zygomycetes
TREATMENT
Amphotericin B´
surgical removal of necrotic tissueLabels: Zygomycosis |
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| Altitude Illness |
Altitude illness is a medical problem ranging from mild discomfort to fatal illness that may occur on ascent to higher altitude. It can affect anyone, including those who are experienced and fit, and who ascend to more than about 8,000 feet (2438 m). Several factors appear to be important in adaptation to altitude, including how long the ascent takes, how high, and length of stay. Much variation exists between people; in addition, an individual's response may vary from ascent to ascent.Sign and symptoms are Mild to moderately severe symptoms: (Headache, Lack of energy and appetite, Mild nausea, Dizziness, Weakness and Insomnia), Severe symptoms: (Increased headache, Irritability, Marked fatigue, Shortness of breath with exercise, Nausea and vomiting, Irregular or periodic breathing at night and Difficulty or cessation of breathing), High altitude pulmonary edema (NAPE) symptoms: ( Excessive shortness of breath on exertion, Severe respiratory distress, Shortness of breath at rest, Dry cough and/or wheezing, Increased heart rate and breathing rate, Marked irregular breathing present at night, Gurgling breathing, Frothy cough, Wet crackling sounds in the lungs, Confusion and Coma), High altitude cerebral edema (HACE) symptoms: ( Progressive headache that is unrelieved by mild pain relievers, Lack of coordination, Confusion and bizarre behavior followed by unconsciousness, Other symptoms of moderate altitude sickness, such as dizziness, vomiting, and irritability, are usually present)
CAUSES:
The physiology of altitude illness is still not completely understood. The fundamental problem is a decrease in air pressure, resulting in less oxygen delivery to the body.
MOST OFTEN AFFECTED:
Altitude sickness can affect any age individual, men and women in equal proportion. Young, well-conditioned climbers have a higher incidence of altitude illness, probably because they push themselves more.
RISK FACTORS:
•In general, the faster and higher the ascent, the more likely a person will experience symptoms of altitude illness.
•Chronic illness
•Lack of conditioning
WHAT THE DOCTOR LOOKS FOR:
The doctor will consider other respiratory problems, such as pneumonia, respiratory infection, or heart failure.
TESTS AND PROCEDURES:
•A variety of blood tests may be performed.
•Arterial blood may be obtained to measure blood gasses.
•A chest X-ray may be done to evaluate the respiratory system.
•An electrocardiogram (EKG) may be done to monitor heart function.
GENERAL MEASURES:
•Severe cases of altitude sickness may require hospitalization.
•Treatment is tailored to fit the severity of disease and may be limited by the environment.
•Definitive treatment is to descend to a lower altitude. Dramatic improvement accompanies even modest reductions in altitude (as little as 1,000 feet).
•Giving oxygen helps relieve symptoms.
•Descent is rarely needed for mild cases. Drink fluids, eat a light diet, and curtail activity.
•For severe symptoms, the victim should be immediately evacuated to a lower altitude and given continuous oxygen.
•A portable hyperbaric chamber is another effective and practical alternative for severe symptoms when descent is not possible.
ACTIVITY:
Rest until symptoms clear.
DIET:
Increased intake of fluids, a light diet, and avoidance of alcohol
COMMONLY PRESCRIBED DRUGS:
•Aspirin or codeine to relieve headache
•Antibiotics, if infection is present
•Dexamethasone or acetazolamide
•Corticosteroids
PREVENTION/AVOIDANCE:
•Staged ascent with appropriate acclimatization
•Sleeping elevation: "Climb high and sleep low" is a prudent practice for anyone going above 12,000 feet (3656 m).
•Adequate hydration: Dehydration makes altitude sickness worse.
•Good physical conditioning
•Consider carrying a supply of oxygen.
•Some drugs can prevent or lessen the symptoms of altitude sickness.
COMPLICATIONS:
•Aspirin or codeine to relieve headache
•Antibiotics, if infection is present
•Dexamethasone or acetazolamide
•Corticosteroids
WHAT TO EXPECT:
•Mild to moderate altitude sickness resolves over 1 to 3 days. Climbers may resume ascent once symptoms subside.
•People with severe symptoms can expect complete recovery if there is no underlying disease. They should not resume ascent.
•Problems are more likely among people who have had one or more attacks.Labels: higher altitude |
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