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The availability of a transdermal clonidine patch applied once weekly may offer an alternative to hypertensive patients with adherence problems. Of particular importance is the issue of severe rebound hypertension when clonidine is abruptly discontinued. The dose of this agent should be gradually reduced when being discontinued. In patients concurrently taking a β-blocker, the β-blocker should be tapered to discontinuation first, ideally several days before initiating the clonidine taper. Because clonidine withdrawal results in an increase in sns activity, patients withdrawing from clonidine while on a β-blocker could experience unbalanced α-mediated vasoconstriction. 11 other agents direct vasodilators such as hydralazine and minoxidil represent alternative agents used for patients with resistant hypertension. They primarily act to relax smooth muscles in arterioles and activate baroreceptors. Because of the reflex tachycardia and fluid retention they cause, their use in the absence of concurrently administered β-blockers and diuretics is uncommon. Rare adverse effects include hydralazine-induced lupus-like syndrome and hypertrichosis from minoxidil. References describing the appropriate use and monitoring of these infrequently used agents should be consulted before use. 11 finally, reserpine, although slow to act, reduces sympathetic tone and thus pr by depleting norepinephrine from sympathetic nerve endings.

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Infants present with nonspecific signs and symptoms, including excessive irritability or crying, vomiting or diarrhea, tachypnea, altered buy viagra bahrain sleep pattern, and poor eating. Depending on involved pathogens and disease severity, patients may also present with altered mental status, stupor, and seizures. Treatment goals of therapy prior to antibiotic therapy and vaccination bacterial meningitis was almost universally fatal, with survivors suffering from debilitating residual neurologic deficits, such as permanent hearing loss. 1,2 although significant improvements have been made, the fatality rate of meningitis remains above 15% in adults, likely due to its occurrence in debilitated patient populations. 2 the treatment goals for cns infections are to prevent death and residual neurologic deficits, eradicate or control causative micro-organisms, ameliorate clinical signs and symptoms, and implement vaccination and suppressive measures to prevent future infections. Surgical debridement should be employed, if appropriate (as in postneurosurgical infections and brain abscess). Supportive care, consisting of hydration, electrolyte replacement, antipyretics, antiemetics, analgesics, antiepileptic drugs, and wound care (for surgical wounds), is an important adjunct to antimicrobial therapy, particularly early in the treatment course. Treatment principles prompt initiation of iv high-dose bactericidal antimicrobial therapy directed at the most likely pathogen(s) is essential due to the high morbidity and mortality associated with cns infections. Although there are no prospective studies that relate timing of antibiotic administration to clinical outcome in bacterial meningitis, a longer duration of symptoms and more advanced disease before treatment initiation increase the risk of a poor outcome. 2,11 initiation of antibiotic therapy as soon as possible after bacterial meningitis is suspected or proven (even before hospitalization) reduces mortality and neurologic sequelae. 11–13 high-dose parenteral bactericidal antibiotic therapy is required to achieve csf antibiotic concentrations adequate to rapidly sterilize the csf and reduce the risk of complications. Data from animal studies and patients demonstrate better outcomes when bactericidal antibiotic therapy (vs bacteriostatic therapy) is used to sterilize the csf. 14 however, successful treatment of meningitis has been reported with bacteriostatic agents. The presence of infection in the csf reduces the activity of some classes of antibiotics. For example, the decreased ph of csf associated with meningitis significantly reduces the activity of aminoglycoside antibiotics. 15 antimicrobial pharmacokinetics and pharmacodynamics must be considered when designing treatment regimens for cns infections. Ability of antibiotics to reach and achieve effective concentrations at the infection site is the key to treatment success. In experimental models of meningitis, maximum bactericidal activity is achieved when csf concentrations exceed the minimum bactericidal concentration (mbc) of the infecting pathogen by 10- to 30-fold. 16 in general, low-molecular-weight lipophilic antibiotics that are unionized at physiologic ph and not highly chapter 70  |  central nervous system infections  1051 clinical presentation and diagnosis of cns infections general •• evaluate patient risk factors and recent exposures •• evaluate other possible causes. Space-occupying lesion (which may or may not be malignant), drug-induced cns pathology autoimmune disease, and trauma12,13 signs and symptoms2 •• 95% of patients with bacterial meningitis have two of the following. Headache, fever, neck stiffness, and altered mental status •• headache (87%) •• nuchal rigidity (stiff neck) (83%) •• fever (77%) •• nausea (74%) •• altered mental status (ie, confusion, lethargy, and obtundation) (69%) •• focal neurologic defects (including positive brudzinski sign and kernig sign) (33%) •• seizures •• malaise, restlessness •• photophobia •• skin lesions (diffuse petechial rash observed in 50% of patients with meningococcal meningitis) •• signs and symptoms in neonates, infants, and young children. Nonspecific findings, such as altered feeding and sleep patterns, vomiting, irritability, lethargy, bulging fontanel, seizures, respiratory distress, and petechial/purpuric rash17 •• predictors of an unfavorable outcome. Seizures, focal neurologic findings, altered mental status, papilledema, hypotension, septic shock, and pneumococcal meningitis4 laboratory tests5,18,44 •• csf examination via lumbar puncture (lp, spinal tap). Contraindicated in patients with cardiorespiratory compromise, increased intracranial pressure and papilledema, focal neurologic signs, seizures, bleeding disorders, abnormal level of consciousness, and possible brain herniation (a ct scan should be performed before lp if there is a question of a cns mass to avoid potential for brain herniation) (see table 70–2 for specific csf findings) •• elevated opening pressure (may be decreased in neonates, infants, and children) •• cloudy csf •• decreased glucose •• elevated protein •• elevated wbc (differential provides clues to offending pathogen) •• gram stain (adequate for diagnosis in 60%–90% of patients with bacterial meningitis) •• culture and sensitivity (positive in 70%–85% without prior antibiotic therapy, positive in less than 20% who have had prior therapy) •• if csf gram stain and/or culture is negative, rapid diagnostic tests (such as latex agglutination) may be useful. These tests are positive even if bacteria are dead •• polymerase chain reaction (pcr. Dna amplification of the most common bacterial meningitis pathogens) may be useful to help exclude bacterial meningitis •• elevated csf lactate and c-reactive protein •• blood cultures (at least two cultures, one “set”. Positive in 66%) •• scraping of skin lesions (eg, rash) for direct microscopic examination and culture •• other cultures should be obtained as clinically indicated (eg, sputum) •• wbc with differential •• fungal meningitis. Csf culture, csf and serum cryptococcal antigen titers, microscopic examination of csf specimens •• tuberculous meningitis. Csf culture, pcr evaluation (preferred), and acid-fast stain patient encounter 1, part 2 the 67-year-old patient with signs and symptoms of meningitis underwent lumbar puncture. Initial results from csf studies are wbc 1.

8 × 103/mm3 (1.

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Warfarin is associated with fetal malformations when used between 6 and 12 weeks of pregnancy and with fetal and maternal bleeding when used during the third trimester and delivery (see patient encounter, part 2 at 28 weeks of pregnancy, the patient is admitted for acute pyelonephritis and back pain. Blood glucose levels are between 100 and 160 mg/dl (5. 6 and 8. 9 mmol/l). Urine culture reports the presence of e. Coli and group b streptococcus. Meds. Lithium 600 mg orally in the morning and at bedtime. Quetiapine 100 mg orally at bedtime. Levothyroxine 75 mcg orally daily. Insulin nph 10 units subcutaneously at bedtime. Insulin aspart 10 units subcutaneously before breakfast what treatment do you recommend at this time?. Patient encounter, part 3 at 35 weeks’ gestation, the patient is admitted for preterm labor. Meds. Lithium 600 mg orally in the morning and at bedtime. Quetiapine 100 mg orally at bedtime. Levothyroxine 75 mcg orally in the morning. Insulin nph 16 units subcutaneously at bedtime. Insulin aspart 20 units subcutaneously before breakfast will you recommend a tocolytic agent?. If labor progresses, what special care should be provided?. Table 47–3). 7,10 however, it could be used by some women with prosthetic heart valves in the second trimester and early third trimester, as valve thrombosis has been reported with heparin therapy. 10 warfarin and heparins are safe for use during lactation. 20 bacterial vaginosis bacterial vaginosis is associated with pprom, chorioamnionitis, preterm birth, and postpartum endometritis.