Invasive candidiasis

Indication for fluconazole (Mikosist) for invasive candidiasis are: a stable condition of the patient, the absence of prophylactic drugs azolovogo series. Fluconazole is assigned to 400 mg daily, once during the day, intravenously or orally in capsules. When allocating C. glabrata daily dose is doubled to 800 mg per day, receiving the same. In two randomized trials of the effectiveness of treatment of candidemia with fluconazole (400 mg / day) and amphotericin B (0,5-0,6 mg / kg / day) was comparable [14,15]. Due to low toxicity dosing of fluconazole may be increased to 1600 mg per day. The studies demonstrated a dose-dependent clinical effect, however, significant differences in the effectiveness of therapy in case of escalation of the dose was received. Significant toxic manifestations (convulsions, increased blood biochemical parameters) were observed only when using fluconazole at a daily dose of 2000 mg.

Indications for the purpose of amphotericin B are unstable condition of the patient at an unidentified species of yeasts isolated, invasive candidiasis, caused by C. krusei. The daily dose of amphotericin B is 0,7-0,8 mg / kg, the allocation of C. krusei - 1 mg / kg. After stabilization of the states and determine the type of agent, amphotericin B should be replaced by fluconazole.

In severe conditions, or the allocation of fungi resistant to fluconazole, an alternative to amphotericin B may be a form of liposomal amphotericin B or the new antimycotics - voriconazole and caspofungin. Caspofungin is used only intravenously, 70 mg on the first day followed by maintenance dose of 50 mg daily. Voriconazole is administered intravenously on the first day 6 mg / kg every 12 hours, in the coming days - 4 mg / kg every 12 hours, oral application is in the patient's body weight over 40 kg - 400 mg every 12 hours the first day, then - 200 mg every 12 hours, with a body weight less than 40 kg dosage decreases by 2 times.

Indications for liposomal formulations of amphotericin B is renal insufficiency (creatinine brand viagra level in blood serum of adult і221 umol / L, children - і133 umol / l or creatinine clearance <25 ml / min), the ineffectiveness of therapy with amphotericin B after applying it to a total dose і7 mg / kg, significant increases in serum creatinine during therapy with amphotericin B, severe toxic reactions during infusion of amphotericin B. Liposomal amphotericin B applied intravenously at 3-5 mg / kg / day. [12].

C. lusitaniae, C. guilliermondii are resistant to amphotericin B. The drug of choice for these pathogens are fluconazole (400 mg / day.) can be assigned to caspofungin, or voriconazole (in the previously mentioned doses).

The duration of antifungal drugs for candidemia and acute disseminated candidiasis should be at least 2 weeks since the last allocation of yeasts from blood (or lesion) with the full regression of all clinical manifestations of infection. After completion of treatment is recommended to observe the patient for at least 6 weeks because of the possible formation of foci of late hematogenous dissemination (endophthalmitis, osteomyelitis, chronic disseminated candidiasis).

Therapy of Candida endocarditis is a complex, along with the appointment of antimycotics is mandatory surgical treatment: removal of infected heart valves. As initial therapy, amphotericin B is preferred to appoint a maximum tolerable dose - 1,0-1,5 mg / kg. Length of antimycotics after surgical treatment should be at least 6 weeks. For Candida endocarditis is characterized by high relapse rate, so the period of close monitoring of patients is at least 1 year. When it is impossible for surgical treatment is recommended lifelong therapy with fluconazole (200-400 mg / day.) [12].

Treatment of candidal meningitis spend voriconazole (dose - as with candidemia) or amphotericin B (1 mg / kg) or liposomal amphotericin B (5 mg / kg) or fluconazole (400-800 mg) [12]. Because of the possibility of relapse, treatment should be to conduct long-term, at least 4 weeks. Cancel antimycotics should be subject to sterilization of CSF, the elimination of all clinical manifestations of infection, no lesions of the brain substance (control MRI). Keep in mind that sterilization of cerebrospinal fluid is observed earlier eradication of infection in the parenchyma of the brain. Therapy of candidal meningitis associated with neurosurgical treatment involves the removal of foreign material (catheters, shunts) and the appointment of antimycotics.

Prophylaxis

In a number of researchers showcased the benefits of prophylactic use of fluconazole (Mikosist) in surgical patients included in the group of high risk of invasive candidiasis.

The study Eggimann P. c et al. shown that prophylactic fluconazole 400 mg / day for patients with recurrent abdominal operations compared with the control group led to a significant reduction in the frequency of Candida peritonitis (4% vs. 35%, p = 0,02), Candida mucosal colonization (15% vs. 62%, p = 0.04) [16]. Similar results were obtained Pelz R. c et al. the appointment of fluconazole heavy patients after surgery and stay in the ICU for more than 3 days [17].

Thus, prophylactic fluconazole (Mikosist) (400 mg / day.) Justified in patients at high risk of invasive candidiasis: patients with recurrent perforation of the gastrointestinal tract [12.7]. Unjustified prophylactic use of antimycotics in patients with low risk of invasive candidiasis is not only useless but harmful, as can be accompanied by side effects and induce the selection of strains of Candida spp., Refractory to antifungal drugs.

sympathetic activation
tactics
complications
hormones
choice for correction

Sliding hernia

The cause of this hernia is a pathology frenoezofagealnoy ligament, which fixes the esophageal-gastric anastomosis in esophageal opening. Part of the cardia of the stomach moves up into the chest cavity. Frenoezofatealnaya ligament becomes thinner and longer. Oesophageal hiatus in the diaphragm expands. Depending on the position of the body and filling the stomach of esophageal-gastric fistula is shifting from the abdomen into the chest and back. The displacement of the cardia upward angle becomes obtuse branch block, smoothed the folds of the mucosa. Diaphragmatic peritoneum is displaced together with the cardia, a well-defined hernial sac is only for large hernias. Fixation and narrowing of the scars can lead to a shortening of the esophagus and the constant presence of esophageal-gastric anastomosis above the diaphragm. In advanced cases of fibrous stenosis occurs. Sliding hernia is never violated. If the compression comes displaced into the chest cavity of the cardia, the poor circulation does not occur, because the outflow of venous blood is carried out on esophageal veins, the content can bowels through the esophagus. Sliding hernia is often associated with reflux esophagitis.

Displacement cardia up leads to a smoothing brand viagra online angle branch block, disturbed sphincter activity, it becomes possible gastropischevodnogo reflux. However, these changes are not natural, and a significant number of patients reflux oesophagitis does not develop, because the physiological function of the sphincter is preserved. Therefore, a displacement of the cardia is not enough to develop anal sphincter insufficiency, in addition, reflux can occur without a sliding hernia. Unfavorable ratio between the pressure in the stomach and the esophagus promotes penetration of gastric contents into the esophagus. Epithelium of the esophagus is very sensitive to the action of gastric and duodenal contents. Alkaline esophagitis due to the influence of duodenal juice flowing even harder than peptic. Erosive esophagitis can become, and even ulcers. Permanent inflammatory edema of the mucous membrane contributes to its mild trauma with bleeding and bleeding, which sometimes manifests itself in the form of anemia. Subsequent scarring leads to the formation of strictures and even complete closure of the lumen. The most frequently reflux esophagitis accompanied by cardiac rupture, less kardiofundalnuyu.

Clinic. Sliding hernia without complications are not accompanied by clinical symptoms. Symptoms arise when the associated gastro-oesophageal reflux and reflux esophagitis. Patients may complain of heartburn, belching, regurgitation. The appearance of these symptoms usually associated with changes in body position, pain cialis without prescription worse after eating. The most common symptom of a burning sensation behind the breastbone is observed in 90% of patients. Pain may be localized in the epigastric region, left upper quadrant, and even in the heart. They are not like ulcerative since appear immediately after ingestion, are associated with the amount of the ingested food, especially painful after a heavy meal. Relief occurs after ingestion of lowering the acidity in the stomach. Regurgitation occurs in half of cases, especially after receiving lavish meals, often felt bitterness in the throat. Dysphagia is a late symptoms observed in 10% of cases. It develops as a result of spasms of the inflamed distal esophagus. Dysphagia occasionally occurs periodically disappears. If inflammation progresses, dysphagia occurs more frequently and may become permanent. From the resulting ulceration of the esophagus may have bleeding, which take place covertly.

emerging with a level
individual symptoms
sulfonylureas
a peck of salt

Organocomplexes

In operations on the pancreas (RV) are widely used anatomical principles, which makes no diminishing interest in research into the anatomy of the pancreas [Hannesson PH, Stritbeck H, 1995, Sweden; Bertelli E, Di Grigorio F, 1995, Italy]. One of the most critical moments in interventions on the pancreas is the treatment of large vessels and intense vaskulirizirovannyh Zones Authority. The aim of the study was to examine the type of RV anatomy and the brand viagra possibility of using the features of its vessels during microsurgical operations.

The studies were conducted at 62 is not modified human pancreat-duodenal organocomplexes. The studies we have reached the following conclusions. The head of the pancreas more intensively vaskulyariziruetsya at dolihomorfnom type of body: anterior arterial arch length was 10,5 ± 0,2 cm and 13,5 ± 1,1 gave the arterial branches, arterial posterior arch length was 8,86 ± 0,2 and delivered 12 , 7 ± 04 arterial branches. When dolihomorfnom type vascularization by 37,5% more intense than at brachymorphic: anterior arterial arch 6,2 ± 0,6 cm, 6,98 ± 0,3 branches; posterior arterial arch 6,14 ± 0,3 cm, 8,9 ± 0,6 arterial branches. Celiac trunk with dolihomorfnom type of physique in 12% of cases retreated above the 49% level and 61% of cases below the upper edge of the pancreas. Brachymorphic type a slightly lower location of celiac stovola: 64% at mid-body, 32% at the lower edge and a 4% closer to the top.

Splenic artery had a more twisted form when dolihomorfnom type of build, with brachymorphic inform your doctor same type in 36,4% of cases, it was strictly a straight course. Thus, during operations on the pancreas is necessary to consider the dependence of vascularized organ of body type.

In the diagnosis of acute pancreatitis physician emergency medical service (SMP) but the complaints history and general status, and focuses on some specific symptoms, the diagnostic value of which is not the same [M V. Danilov, VD Fedorov, 1995]. The aim of our study was to determine the most specific symptoms of acute pancreatitis, development of practical recommendations for physicians NSR.

Within two years, we in the SMB crew of Kursk has been served 1052 calls, of which 184 (17.49%) were about digestive diseases, and acute pancreatitis of them was 9,9%. The study determined the diagnostic value of some of the symptoms of acute pancreatitis (Curt - 64% Bond - 89,5%, Mayo-Robson 45.4% -74.5% Resurrection, Bereznegovskogo - 39,1%, Dujardin - 39 , 1%). Thus, the presence of patients with acute pancreatitis is the presence of intense pain in the epigastrium with a typical irradiation, nausea and often vomiting, and positive symptoms Curtis Bond, Mayo-Robson and the Resurrection.

Sense of gravity
vascular complications prevention
Tuberculosis

Elbow joints

Among all the hereditary diseases of the connective tissue of greatest interest to physicians and general practitioners is Marfan syndrome, as life expectancy in these patients is limited to 30-40 years [1] and one patient can have as many health problems, many specialists in the clinic. Because the disease is known to be a serious prognosis for life and disability of patients, diagnosis imposes a special responsibility on the doctor's first encounter with the patient.

In 1896, a French professor and pediatrician Antonio Marfan first introduced the clinical observation of 5-year-old girl with unusual Gabriel continuously progressive skeletal abnormalities [2]. The girl died at a young age, probably from tuberculosis [3]. External habit Gabrielle and these patients have since became known as Marfan's syndrome. As later became clear, in fact, Gabrielle congenital arachnodactyly kontrakturnoy [4]. After 20 years, were described first fenokopii marfanopodobnyh syndromes, in particular, the syndrome of ectopic lenses with autosomal dominant inheritance [5,6], even after 30 years - a syndrome dilatation [7], and aortic dissection [8], mitral valve prolapse [9, 10], dural ectasia [11].

Weve H. [6] first suggested that the cause of Marfan syndrome is a defect in the mesoderm, and the renowned American geneticist at McKusick in the schedule of inherited human diseases, «On-Line Mendelian Inheritance In Man» (OMIM) opened this syndrome, a new nosological Page hereditary connective tissue diseases [12]. Syndrome phenotype is characterized by a length, ranging from mild, soft soedinitelnotkanoy manifestations of dysplasia, are also found in the general population to the cases with life-threatening systemic disorders [13].

The main document on which the diagnosis of Marfan syndrome was based, was introduced in 1986 - the so-called Berlin Nosology [14]. Among the criteria of the Berlin nosology above all puts the advances in molecular genetics [15]. However, the installed location of the gene in Marfan syndrome autosomes 15q21 [16,17], encoding the microfibrillar protein fibrillin-1, is not unique and is specific to Marfan syndrome [18]. A mutation in the gene cognate protein - fibrillina-2 also leads to clinical manifestations marfanoidnogo habit [14,15]. Nosologic forms with phenotype "Marfan" such as kontrakturnaya arachnodactyly and family mitral valve prolapse - MASS-phenotype, had a mutation in the same genes [19]. Most of erroneous diagnoses in relatives of patients, as it turns out, are related to the revaluation of the significance of molecular genetic studies, as in the case of their positive family history of disease have led to bias in the diagnosis of other family members [20,21]. Only common molecular genetic [22,23,24] and clinical studies [25,26] have reasonable grounds to create a full diagnostic criteria.

Current criteria for diagnosis of Marfan syndrome developed in 1996 jointly by Compare Viagra and injections geneticists and clinicians, and are offered for wider use by physicians of all specialties [27].

"Big" is a criterion because of its greater specificity, since it is rare in other states and in the general population. In general, the diagnostic decision should be based on more criteria of the disease. It is important to distinguish between the "big test", is available in the system of organs and determines the disease, from the "system of organs involved in the process soedinitelnotkanoy dysplasia.

Diagnostic criteria for pathological skeletal

More criteria. "The great criterion" Pathology of the skeleton is the presence of at least 4 of the following symptoms:

- Pigeon chest deformity, or funnel chest big powers, subject to surgical treatment;

- Reduction of the upper segment of the body (body height) in relation to the bottom, or if the span exceeds growth at 5%;

- Test positive wrist and thumb (see below);

- Scoliosis over 20 ° or spondylolisthesis;

- The impossibility of full extension of elbow joints (angle <170 °);

- Medial displacement of inner ankles as a result of longitudinal flat;

- Protrusion of the acetabulum of any degree (with radiography).

Minor criteria:

- Funnel chest moderate degree;

- Hypermobility of the joints;

- High arched sky with a "crowded" teeth;

- Anomalies of skull and face (dolichocephaly, hypoplasia of the jaw, endophthalmitis - a deep-set eyes, retrognatiya, obliquely drooping folds of the eyelids).

Pathology of the skeleton to verify the diagnosis of Marfan's syndrome "should be represented by two more criteria (in the presence of symptoms) or brand name viagra one more criteria (4 features) and two small criteria [27].

Comments. Many skeletal abnormalities are common in the population, but the combination of certain defects of the above is highly specific for diagnosis. For example, hypermobility of joints - is one example of a high prevalence among the population, so the individual significance of this sign is very small and it is not incorporated into larger diagnostic criteria. On the contrary, such a sign as congenital joint contractures are rare in the general population, but not often and Marfan's syndrome (characterized by contractures of the elbow joints). In the case of severe joint contractures and reduce joint mobility in combination with other skeletal abnormalities is necessary to differentiate Marfan syndrome with congenital arachnodactyly kontrakturnoy [27].

For chest wall deformity in Marfan's syndrome is more common sternum, protruding and anteversion left costo-chondral compound that attaches to the chest asymmetry.

Value growth and reach, judged in the light of anthropometric factors derived Gordon SS et at anthropometry personnel of the American army in 1988 [28]. The ratio of upper / lower segments studied in individuals of all ages McKusick [29,30], and later by others [14,31,32].

Test your wrist is in circumference wrist with the thumb and little finger, and their terminal phalanges with the overlap [33]. Test of thumb is to fix it across the palm of your hand without further assistance: the positive is when the nail phalange of the thumb beyond the ulnar edge of the palm [34].

Scoliosis of various degrees, usually thoracic, convexity to the right, there are at least 60% of patients. Anomalies of the spine in the sagittal plane, such as straightening or kyphosis giperkifoz also deserve attention. Spondylolisthesis occurs in 6% of cases [35].

To confirm the diagnosis of Marfan syndrome should be identified protrusion of the acetabulum. To this end, recommend X-rays, or methods that reduce or eliminate radiation exposure - computed tomography or magnetic resonance imaging [36].

Diagnostic criteria of Pathology

More criteria:

- Ectopia of the lens.

Minor criteria:

- Abnormally flat cornea (identified by keratometry);

- Increasing the length of the eyeball (measured by ultrasound);

- Hypoplastic iris or hypoplastic ciliary muscle, leading to a deterioration of miosis and accommodation.

For the diagnosis of significant involvement of the ocular system, as evidenced by the presence of a large, or at least 2 minor criteria [27].

Comments. Adequate assessment of ectopic lenses is possible with full pupil dilation and study in a slit lamp. Dislocation is a one-or two-way and in any direction, although most are offset upward. Iridodonesis flutter (iris) is secondary to ectopic lens, and therefore can not be regarded as a hallmark of Marfan syndrome [27].

The radius of curvature of the cornea should be examined keratometricheski. The degree of corneal flattening is positively correlated with ectopias lens. Megalokornea rarely found in Marfan syndrome, but can not be even a small diagnostic criteria.

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