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Specific infectious causes Bacterial meningitis – Mycobacterium tuberculosis – Treponema pallidum (neurosyphilis) – Borrelia burgdorferi (Lyme disease) – Brucella melitensis – Listeria monocytogenes – Nocardia asteroides Fungal meningitis – Cryptococcus neoformans – Coccidiodes immitis – Histoplasma capsulatum – Blastomyces dermatitides – Candida species – Sporothrix schenckii Parasitic meningitis – Cysticercus cellulosae discount 4mg amaryl overnight delivery, C order amaryl 1mg mastercard. Recurrent Meningitis 301 Chronic meningitis as- – Primary brain tumors (astrocytoma discount amaryl 2 mg on line, glioblas- sociated with malignancies toma, ependymoma, PNET tumors) – Metastatic tumors (breast, lung, thyroid, renal, melanoma) – Meningeal carcinomatosis – Chronic benign lymphocytic meningitis Chemical meningitis Due to intrathecal injection of: – Contrast agents for radiological studies – Chemotherapeutic agents – Antibiotics (penicillin, trimethoprim, isoniazid, ibuprofen) – Local anesthetics Immunocompromised patients AIDS (HIV infection) The main infectious complications that present as chronic meningitis are: – Toxoplasmosis – Cryptococcosis – Syphilis – Aspergillosis – Non-Hodgkin’s systemic lymphoma Hypoimmunoglobulinemia AIDS: acquired immune deficiency syndrome; CNS: central nervous system; HIV: human im- munodeficiency virus; PNET: primitive neuroectodermal tumor. Recurrent Meningitis Recurrent meningitis is defined as repetitive episodes of meningitis as- sociated with an abnormal cerebrospinal fluid followed by symptom- free periods during which the cerebrospinal fluid is normal. Traumatic: basal skull fractures involving the paranasal sinuses, cribriform plate, petrous bone; postoperative Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Congenital: myelomeningocele; dermoid sinus with midline cranial or spinal dermal sinus; petrous fistula; neurenteric cysts – Parameningeal infec-! Cranial or spinal epidural abscess – Idiopathic recurrent bacterial meningitis – Defective immune! Postsplenectomy susceptibility in children Special bacterial meningitis – Organisms! Leptospira species Fungal meningitis – Cryptococcus neoformans – Coccidiodes immitis – Histoplasma capsulatum – Blastomyces dermatitides – Candida species – Sporothrix schenckii Parasitic meningitis – Cysticercus cellulosae, C. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Spinal Epidural Bacterial Abscess 303 Conditions Predisposing to Recurrent Bacterial Meningitis – Anatomical communication with the nasopharynx, middle ear, paranasal sinuses, skin (e. This is most likely to be produced by synergistic effects between the infecting organism or bacterial products, the host inflammatory response, and alterations of normal brain physiology that result in brain injury. The pathophysiologi- cal changes that accompany acute meningitis are: a) brain edema, b) in- tracranial hypertension, and c) abnormalities of cerebral blood flow, loss of cerebrovascular autoregulation and decreased cerebral perfusion pressure. Herpes simplex virus thrombosis tative effects of infection), or focal due to increased ICP or venous or arterial infarcts Syndrome of inappropriate re-! Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Neurological Complications of Meningitis 305 Intermediate Complications These complications become manifest during hospitalization, and may persist after discharge. In some cases, the problems are present earlier in the course of the meningitis but are not recognized until the patient has been in the hospital for a few days, or they do not develop until the dis- ease process has gone on for several days. Type of complication Associated organisms Hydrocephalus Haemophilus influenzae – Two types: a) obstructive, due to obstruction of Mycobacterium tuber- CSF resorption from postinflammatory adhesions culosis of arachnoid granulations; and b) ex vacuo, due to Group B streptococci diffuse brain injury and loss and resultant brain atrophy Subdural effusions H. Almost all sterile Streptococcus pneu- effusions resolve spontaneously, except for a small moniae minority, which may cause pressure phenomena, requiring serial subdural taps Fever – In cases of purulent meningitis, fever resolves within 3–4 days of drug therapy. After a week of therapy, drug fever may occur, although this is most typical after 10–14 days Brain abscess Citrobacter species – Unusual complication of common bacterial menin- Listeria monocytogenes gitis, except with disease attributable to Citrobacter species, where abscesses develop in approx. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Streptococcus pneumoniae – Range from isolated paresis to global in- jury, leading to tetra- plegia. Only 20% of motor handicaps present at discharge persist at one-year follow-up Deafness, hearing loss! Diagnostic Clinical Criteria Major criteria – Regional pain complaint – Pain complaint or altered sensation in the expected distribution of referred pain from a myofascial trigger point – Taut band palpable in an accessible muscle – Exquisite spot tenderness at one point along the length of the taut band – Some degree of restricted range of motion, when measurable Minor criteria – Reproduction of clinical pain complaint, or altered sensation, when pressure is applied at the tender spot – Elicitation of a local twitch response by transverse snapping – Palpation at the tender spot or by needle insertion into the tender spot in the taut band – Pain alleviated by stretching the muscle or by injecting the tender spot From: Simons DG. Associated Neurological Disorders Neuropathies – Radiculopathy – Entrapment neuropathies – Peripheral neuropathy – Plexopathy Multiple sclerosis Rheumatological disorders – Osteoarthritis – Rheumatoid arthritis – Systemic lupus erythematosus Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. The incidence of postherpetic neuralgia (PHN) after herpes zoster varies between 9% and 15%, with 35–55% of patients continuing to have pain three months later, and 30% having intractable pain for one year. Thoracic dermatome 55% Trigeminal distribution 20% Cervical dermatomes 10% Lumbar dermatomes 10% Sacral dermatomes 5% Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Atypical Facial Pain 309 Atypical Facial Pain The pain usually starts in the upper jaw. Postherpetic neuralgia This occurs mainly with first-division herpes; although the whole zone hurts, pain in the eyebrow and around the eye is especially severe. Pain is continual and burn- ing, with severe pain added by touching the eyebrow or brushing the hair. The condition shows a tendency to spontaneous remission Temporal arteritis Swelling, redness and tenderness of the temporal artery and a headache in the distribution of the artery are the classic hallmarks of the disease.

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The network of concepts about positive "stuffs" such as vital fluid generic amaryl 1 mg on-line, includes "breath" as the "stuff" of spirit purchase 1 mg amaryl free shipping, "protein" as the "stuff" of strength amaryl 1 mg with mastercard, "mother’s milk" as the epitome of nourishment and, in many cultures, "fat" as the embodiment of well being. Even though no quantifiable, commensurable "stuff" has been found sprinkled around the body as a cause of good health, we persist in hoping for elixirs, vitamins, mineral supplements and nutritional additives which will add to our general level of vitality. Similarly, we attempt to draw "virtue" from medicinal plants as a source of power. Once found, fluid is held on to, and holding on and retaining typify the activities involved in preserving health. Changes in health status described metaphorically (and as noted, occasionally literally) as gains and losses of fluids exemplify the Object Event-Structure Metaphor outlined in Chapter One. A target domain, the experience of changes in health status, is imaginatively structured like a change in the possession of an object, in this case the vital fluid. If, on the level of folk culture, we still often think of health and disease in such humoral terms, we naturally do not expect that small defects, such as single cell mutations and aberrant cardiac conduction pathways, or incidents like the bites of fleas or the lodging of a cherry pit in the appendix can spell the beginning of the end for us. Whereas non-specific measures addressed toward "filling us up" with global health are often efficacious in building resistance, it is manifestly imprudent to stop there. A shift from the global view of illness to the crucial particulars may often be necessary. Even the average ninety five year old with congestive heart failure, who statistically has a very short time to live and colloquially has little vitality remaining, will die after thousands of robust people in the world who are shortly to be felled by specific insults, often seemingly innocuous like the unexpected ones above. So, along with the other health constructs, looking at health in terms of quantity of vitality has its limitations as well as its uses. Cannon and used by Hans Selye, is synonymous with proper balance or stability of an organism and with maintaining that stability. Anciently, this balance consisted of the proper mixture of the Four Humors, and balance is integral to temperance according to Aristotle. Following the Greeks, we still speak of "well roundedness" as important to health, thus relating health both to wholeness and balance of parts. Bodily balance, as with stable gait and bilateral symmetry is the literal source of cognitive structuring for steady states, regular rhythmic cycling, law-like predictability, and proper proportion in HEALTH AND DISEASE 53 art, ecosystems, climates, societies, organizations, machines and servomechanisms, to name only a few domains. The following are a few samples of how we talk about health as balance and illness as imbalance: Mentally ill people are said to be "unstable," "unhinged," and "unbalanced" whereas the mentally healthy are "stable," "emotionally steady," and "well balanced. Inconstancy, discontinuity, disproportion, loss or mutual antagonism of parts is generally deleterious. But philosophically, at least, we should inquire as to what is proper proportion and mutual harmony in the service of particular and perhaps different ends. Some ends may be served by one mix of mutuality in the body parts and some by another, although I will claim that certain ends have near universality. Generally, these common ends are the prevention or elimination of symptoms, about which more will be said later. The balance metaphor cannot be the whole story simply because there are better ways to describe some medical problems. When cancer develops, or tuberculosis, or rheumatoid arthritis, or when a baby cannot eat because the esophagus connects to its lungs, we are not enlightened by conceptualizing the problem as a "lack of balance. Treatments———————————-Offensive Weapons (typically for cutting, poisoning, burning and in general, killing. Accordingly, "The fluoroquinolones (a category of antibiotics) are new weapons in the therapeutic armamentarium for our fight against bacteria. This makes them natural sources of inference structure for the domain of dealing with illness. Both attacks and illness typically supersede all else, become the principal business of life, and are emergencies during which normal customs and rules are often suspended and drastic and unusual acts allowed. Furthermore, wars are so vast in scope, prolonged, complicated and rich with detail that they present nearly endless resources for the imagination to use in structuring the rapidly ramifying domain of health and illness. The logic of being attacked has to do both with modeling disease and our response to it.

The rate of redness with the 25 mm needle was manufacturing process is now required cheap amaryl 4mg. Any factor that initially two thirds the rate with the 16 mm needle can reduce the rates of adverse reactions in childhood (relative risk 0 2 mg amaryl mastercard. Waddesdon; Lyn Murphy amaryl 1mg low cost, Whitehill; Carol Gill, Aston Clinton; These differences were statistically significant. Tender- Judith Brown, Meadowcroft; Cesca Carter, Wendover; Nicky Oliver,Oakfield;Chris Mildred,Wing;ClareStroud,TringRoad. Contributors: LD conceived and planned the study, recruited and trained practice nurses, managed data collection, Discussion wrote the first draft of the paper, and is guarantor for the study. JD advised on design,produced the randomisation scheme,and This study showed that both redness and swelling were undertook all analyses. Both authors had input into the final significantly reduced when the 23 gauge, 25 mm, blue manuscript. Funding: This study was funded by the Smith and Nephew hub needle was used instead of the 25 gauge, 16 mm, Foundation through the award of a nursing research orange hub needle to administer the third dose of scholarship. The differences suggest that, for every three to five infants vaccinated 1 Department of Health. During a case of redness and one of swelling would be session:givingimmunisations. Arandomisedcontrolledtrialofdifferentneedlelengthsonthe incidence of local reactions when administering the combined injection both length (16 v 25 mm) and bore (25 v 23 gauge), we ofdiphtheria/pertussis/tetanus(DPT)andHaemophilusinfluenzaetype cannot know which of these factors determined the b (Hib) to infants at 4-months of age [dissertation]. However, previous studies comparing injections injection for booster DT vaccination of adolescents. Localadverseeffectsofmeningo- intramuscular) with the same gauge needle have coccalvaccine. Formulate an answerable question, either from a Cochrane systematic review, another high quality review question. Track down the best the results of the search apply to your individual patient using your own clinical evidence of outcomes expertise and the values and preferences of the patient. Critically appraise the Te questions that you should ask before you decide to apply the results of the evidence (ie find out how study to your patient are: good it is). Apply the evidence (integrate the results with • Is my patient so different to those in the study that the results cannot clinical expertise and apply? Evaluate the effectiveness and efficiency of the • Will the potential benefits of treatment outweigh the potential harms of process (to improve next treatment for my patient? Tis is sometimes called the ‘external validity’, or ‘generalisability’ of the research results. Although this step is usually given as Step 4, which implies that it is done after Step 3 (Critical appraisal), it is entirely up to you which order you approach these two steps. For example, you will not want to waste time doing a critical appraisal of a study if it obviously will not apply in your clinical setting. On the other hand, you equally will not want to waste time working out the applicability of a study, only to find that it is a poor study. Tere is no easy answer to this — you will probably need to work it out on a case-by-case basis. As your patients were not in the studies you have researched, you need to use your clinical expertise to decide whether they are sufficiently similar to the subjects in the studies for the results to be applicable to them. Factors that may affect your decision include: • age (the clinical trial subjects may be older or younger than your patient) • comorbidity (your patient may have another condition and be taking drugs that could interact with the one tested in the trial) • compliance (you may feel that your patient is unlikely to comply with the regimen because of other factors) • any other relevant factors. Tese factors will tell you if your patient is at higher risk than the trial subjects (and likely to benefit more than seen in the trial), or at lower risk than the trial subjects (and therefore likely to benefit less). You also need to assess whether the treatment, diagnostic test or other factor described in the study would be comparable in your setting.

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This will involve all systems purchase amaryl 2mg with amex, but should par- bleeding from the electrode site amaryl 2 mg sale, patients should ticularly include: always contact the department prior to their arrival to – Neurological system – motor generic amaryl 2mg fast delivery, sensory and auto- check any necessary alterations in drug therapy. Despite this, the technique is finding increased plex regional pain syndrome (CRPS). This rests upon the premise that increased abnormal muscle activity may itself result in pain. By using Special tests visual cues of muscle activity, patients may be actively taught to relax muscles. Quantitative sensory testing This is the quantification of responses to specific Nerve conduction studies stimuli of known type and degree (Chapter 10). Most commonly used in the research setting, but may help- Objective studies to determine the speed of neuronal fully document status in complex patients. Two skin surface electrodes are utilized; one placed over the nerve under test (stimulating) and Behavioural testing the other over the muscle it supplies (recording). The The most commonly used example of this is the facial time taken from nerve stimulation to muscle contrac- action coding system (FACS). This is most likely to tion can then be recorded and compared to nomo- be useful where there are difficulties with achieving grams. Physiological and neurological measures Positron emission tomography (PET) Vital signs This technique can provide information regarding Vital signs (e. Labelled chemicals and itionally been used to confirm or exclude the presence drugs highlight areas where synaptic or cellular activ- of pain. As regards the brain, this is not necessarily (falsely fail to identify real pain) and specificity (iden- analogous to neuronal activity, since non-neuronal tify many causative conditions in addition to pain). Particular compounds will localize to particular areas (hydrogen ions label water and demonstrate blood flow) and provide information Electromyography related to that area. A further problem with the cur- This can provide objective documentation and assess- rent generation of scanners is the relatively poor spa- ment of neuromuscular function in the clinical set- tial and temporal resolution possible (when compared ting. A fine needle electrode is placed in the muscle to functional magnetic resonance imaging (fMRI)). Under tively charged electrons (positrons) that can be normal conditions this results in no activity with the detected by a specialized scanner. Numerous func- muscle at rest and smooth waves during contraction tionally distinct areas have been shown to exhibit 84 PAIN ASSESSMENT activation in association with painful stimuli (including Key points the thalamus, anterior cingulate and primary and sec- ondary somatosensory cortical areas). Some groups • Pain evaluation allows measurement and monitor- have demonstrated that such activation occurs bilat- ing over time. It documents responses to treatment erally when the perceived pain intensity is high. Currently the meaning of such findings is under • Patient self-report is the most important feature of debate and the technique remains in the research pain evaluation. The tion of tissue damage – both neuronal and other radiation is detected during its passage in the blood tissue. References Functional magnetic resonance imaging(fMRI) This technique detects blood flow in an organ under Davis, K. Event-related fMRI of pain: entering a new era in depends upon the tissue magnetic susceptibility of imaging pain. Thus alter- through measurement and action (available through ations in cerebral blood flow will be clearly visualized. Intracranial vessels in trigeminal single high-resolution scan provides anatomical infor- neuralgia transmitted pain: a PET study. The McGill Pain Questionnaire: major in the presence and absence of painful stimuli. Holdcroft The key elements of a pain evaluation include a struc- relationship should be noted. Where possible the his- tured record of the: tory should be taken directly from the patient, but responses of the other person/people (verbal, etc. The triggering event The pain complaint Questions to explore this event are as follows: A pain history is often time consuming, but can be • How did it happen?

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