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By: I. Delazar, M.B.A., M.B.B.S., M.H.S.
Professor, Louisiana State University School of Medicine in Shreveport
Skin and superficial soft tissue infections Skin and subcutaneous tissues Infections involving the skin hypertension 2 cheap 2.5 mg plendil fast delivery, nails and subcutaneous tissues are very common heart attack vs heart failure discount plendil 2.5mg mastercard, and the skin and subcutaneous tissues are frequent targets of infection in diabetes blood pressure medication benefits order plendil 10 mg without prescription, particularly in association with poor glycemic control blood pressure 55 years age discount 10mg plendil amex. Candidal infections, bacterial infections such as furunculosis, dermatophycoses and onychophycoses are all commonly seen and may be the reason for diabetes being identified. Cutaneous forms of mucormycosis or other fungal infections may occur and be diagnosed following skin biopsy. More detailed consideration is given to these disorders in Chapter 47 and are not repeated here. Sensory neuropathy, atherosclerotic vascular disease and hyperglycemia predispose patients with diabetes to skin and soft tissue infections. Additional risk factors for the development of cellulitis include a past history of cellulitis, edema, peripheral vascular disease, tinea infection and dryness of the skin. Nasal colonization may also contribute to increased risk of staphylococcal pneumonia, for example in association with influenza. The underlying conditions identified included smoking (35%), previous skin infection (21%) and diabetes (19%). Colonization may predispose to cutaneous or incisional staphylococcal (or other bacterial) infections as well as transient bacteremia. In two relatively early Diabetes and Infections Chapter 50 studies (each from the 1960s) older patients with diabetes were shown both to be at greater risk of staphylococcal septicemia and also to suffer a substantially higher mortality (69% in the diabetic patients compared to 42% overall) [101,102]. Early disease may be characterized by severe local pain, which is either disproportionate to or precedes other clinical features such as local inflammation and cellulitis, fever and systemic toxicity. Violaceous discoloration of the skin may be noticed and may progress into blistering and bullae. Thrombosis and vasculitis each contribute to necrosis of the superficial fascia and suppuration from liquefactive necrosis. Aerobic and anaerobic cultures should be taken from within the lesion, as should blood cultures. The antibiotic cover can subsequently be tailored according to culture and sensitivity results. Additional supportive therapy in an intensive care environment should be provided where possible and as necessary. Deeper soft tissue infections Deeper soft tissue infections also occur with increased frequency in people with diabetes. Necrotizing fasciitis Necrotizing fasciitis is a deep-seated life-threatening infection of subcutaneous tissue. Although relatively uncommon, necrotizing fasciitis is a life-threatening condition. Necrotising fasciitis and Fournier gangrene (a form of necrotizing fasciitis involving the perineum), as well as other necrotizing soft tissue infections resulting from a variety of organisms, all have reported associations with diabetes. Diabetes is the most common of a number of conditions predisposing to necrotizing fasciitis, all of which are associated with compromise to the immune system. As its name indicates, necrotizing fasciitis spreads initially along fascial planes; however, as infection and inflammation progress, necrosis of muscle, subcutaneous tissues and overlying skin occurs. Necrotizing fasciitis usually follows identifiable episodes of trauma such as burns, insect bites or abrasions, or can result from exposure of non-intact skin to a source of infection. Involvement of the vulva in women with diabetes may begin as a Bartholin gland ductal abscess, usually associated with obesity [103]. Polymicrobial infection is most commonly observed, with streptococci and Enterobacteriaceae being the most common isolates. An interesting example is infection by halophilic marine Vibrios either following exposure of non-intact skin to seawater [105] or following bites by marine organisms, such as crabs, and this should be considered when a history of appropriate exposure is present. Necrotizing fasciitis carries a high mortality, particularly when affecting the lower extremities or perineum, and is rapidly fatal unless diagnosed promptly and treated aggressively.
Diseases
- Diabetes insipidus, nephrogenic, dominant type
- Kousseff syndrome
- Macrodactyly of the foot
- Graham Boyle Troxell syndrome
- Pulmonary veins stenosis
- Sutton disease II
- Radiation related neoplasm /cancer
- Congenital nephrotic syndrome
- Garcia Torres Guarner syndrome
- Doxorubicin-induced cardiomyopathy
For random urine samples blood pressure juice generic 2.5 mg plendil mastercard, the ratio of protein or albumin to creatinine in mg/dL approximates the 24-h urine protein excretion blood pressure medication infertility generic plendil 2.5 mg amex, since creatinine excretion is only slightly greater than 1000 mg/d per 1 hypertension 2 discount 5mg plendil otc. Quantification of urine protein excretion on spot urines has largely supplanted formal 24-h urine collections artaria string quartet discount 5mg plendil free shipping, due to the greater ease and the need to verify a complete 24-h collection. The total protein:creatinine ratio does not detect microalbuminuria, a level of albumin excretion that is below the level of detection by tests for total protein; urine albumin: creatinine measurement is therefore preferred as a screening tool for lesser proteinuria. Recent upper respiratory infection, allergies, or immunizations are present in some cases; nonsteroidal anti-inflammatory drugs can cause minimal change disease with interstitial nephritis. Remission of proteinuria with glucocorticoids carries a good prognosis; cytotoxic therapy may be required for relapse. Hypertension, mild renal insufficiency, and abnormal urine sediment develop later. Male gender, older age, hypertension, and persistence of significant proteinuria (>6 g/d) are associated with a higher risk of progressive disease. Cytotoxic agents may promote complete or partial remission in some pts, as may cyclosporine. Cyclosporine is an alternative therapy for maintenance of remission and for steroid-resistant pts. Clinical history, kidney size, biopsy findings, and associated conditions usually allow differentiation of primary versus secondary causes. Small amounts of Ig (usually IgM) are present, but early components of complement are absent. Glucocorticoids, cytotoxic agents, antiplatelet agents, and plasmapheresis have been used with limited success; rituximab is a newer therapy with greater evident efficacy. Retinopathy is nearly universal in type 1 diabetics with nephropathy, so much so that the absence of retinopathy should prompt consideration of another glomerular lesion. In contrast, only ~60% of type 2 diabetics with diabetic nephropathy have retinopathy. Clinical features include proteinuria, progressive hypertension, and progressive renal insufficiency. Pathologic changes include mesangial sclerosis, diffuse, and/or nodular (Kimmelstiel-Wilson) glomerulosclerosis. However, pts rarely undergo renal biopsy; to the extent that yearly measurement of microalbuminuria is routine management for all diabetics, the natural history is an important component of the diagnosis. However, proteinuria can be quite variable in diabetic nephropathy, with as much as 25 g/24 h in the absence of profound renal insufficiency or alternatively with progressive renal insufficiency and stable, modest proteinuria. Other primary glomerular hematurias accompanied by "pure" mesangial proliferation, focal and segmental proliferative glomerulonephritis, or other lesions 4. Thin Basement Membrane Nephropathy Also known as benign familial hematuria, may cause up to 25% of isolated, sustained hematuria without proteinuria. Diffuse thinning of the glomerular basement membrane on renal biopsy, with minimal other changes. IgA Nephropathy Another very common cause of recurrent hematuria of glomerular origin; is most frequent in young men. Episodes of macroscopic hematuria are present with flulike symptoms, without skin rash, abdominal pain, or arthritis. Renal biopsy shows diffuse mesangial deposition of IgA, often with lesser amounts of IgG, nearly always by C3 and properdin but not by C1q or C4. A randomized clinical trial of fish oil supplementation suggested a modest therapeutic benefit. In uncontrolled studies, glucocorticoids have been shown to promote earlier recovery of renal function and reduce fibrosis; this therapy is generally reserved to avoid or reduce the duration of dialytic therapy in pts who fail to respond to medication withdrawal. Interstitial nephritis characterized by a dense infiltrate of IgG4-expressing plasma cells can occur as part of IgG4-related systemic disease; pancreatitis, retroperitoneal fibrosis, and a chronic sclerosing sialadenitis may variably be present. The renal disease is typically self-limited; those with progressive disease are often treated with prednisone.
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Patient-centeredness implies a more collaborative approach and holistic understanding of the patient that elicits hypertension kidney stones order plendil 5mg mastercard, acknowledges and addresses relevant beliefs hypertension zyrtec order 10 mg plendil, concerns pulse pressure 60 mmhg order 5 mg plendil mastercard, ideas and fears [14] hypertension young male buy plendil 5mg. Patient-centeredness is in part a paradigm shift in the mind of the health worker from a bio-medical, technical and sometimes authoritarian model to a biopsychosocial, holistic and participatory model [14]. Nevertheless, a range of specific communication skills can be learnt such as the ability to ask open as well as closed questions, to make reflective listening statements, exchange information or invite mutual decision-making [29]. While training of doctors has begun to include these communication skills, even in low resource settings, the training of nurses and mid-level health workers often has not. Motivational interviewing builds on a patient-centered approach and can best be described as a guiding style. Diabetes, which involves multiple changes in behavior (diet, exercise, smoking, alcohol, medication), particularly lends itself to adaptations of motivational interviewing. A challenge in low resource settings is to see how a range of health workers can incorporate a guiding style into their consultations. In a model of care that emphasizes patient empowerment and self-care as key components [2], every consultation needs to be seen as an opportunity for this. Health providers need to have the necessary expertise in the relevant topics, useful communication skills and a range of educational materials appropriate to the literacy level of the community. A family and community orientation Beyond the individual patient is their family and community context. Clearly, family beliefs and customs and degree of social support will have an impact on the ability of an individual within that family to make lifestyle changes and cope with their diabetes. Involving family members in the consultation or educational program can strengthen the overall response to diabetes [31]. In low resource settings, where facilities are overwhelmed with large numbers of patients it may make sense to extend care into the community [2]. For example community-based support groups can be run by health promoters or local non-government organizations to offer some aspects of routine chronic care. Patients can then return to the local clinic for periodic or annual review and help with complications. Expert patients, an increasingly developed resource in both low and high income situations, may also be useful to enhance self-care, although further evaluation is required [32]. Community health workers have the potential to promote healthy lifestyle, provide home-based care and link selected patients with the local facilities [33]. Patient-centered care In low resource settings the need to be patient-centered is often dismissed as a luxury in the face of high workloads and sometimes broad differences in education, language and culture between health providers and patients. Primary care workers usually have a responsibility not just for individual patients but for people living within specific communities or health districts [14]. Concern for the growing number of people with diabetes should lead to interventions that address the underlying determinants of obesity and reduced physical activity: for example, school-based healthy lifestyle programs, provision of green spaces in inner cities, marketing of food to children, sale of junk food on public premises and labeling of food. Many of these require health workers to contribute to interventions in other sectors [34]. Making use of evidence the evidence base for diabetes is constantly expanding and all the above areas need to be informed by the latest evidence base that is relevant to the resource setting in which it is to be applied. Ideally, a systematic process for reviewing the evidence and updating guidance accordingly should be in place in all countries. The availability of evidence does not guarantee that it will be used, and there is a strong and growing literature on how to build local ownership and influence local practice, such as through the development of local treatment guidelines. Quality of care may be enhanced by access to the latest evidence or decision-support tools; auditing may be supported by software that automates the analysis of raw data and integrates it with district health information systems. Innovative strategies for clinical management, especially those which address monitoring of patients by technology-mediated communication with the diabetes care team, are being introduced in high resource settings. Even when a large health center or hospital has computers and Internet access, these are likely to be available to the managers or possibly large clinical areas, certainly not in individual consulting rooms, while such access in primary care settings is simply not to be had for the most part. Furthermore, patients coming from poor backgrounds are very unlikely to have access to the Internet. Mobile phone-based telecommunication system to enhance patient self-care Mobile phones, of all the currently available technologies directed at the patient, are likely to have the greatest potential use in low resource settings. Mobile phones are even to be found in remote villages, indicating the extent of their penetration in contrast to the lack of access to land lines in many rural areas; however, unlike the situation in well-resourced countries where the majority of mobile phone owners have a contract for a year or so, the usual practice in low income countries is one using prepaid phone cards and sharing of phones. In countries with better resources, mobile phones have been put to additional uses in diabetes care.
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