West Nile Virus

West Nile Virus

In the summer of 1999, West Nile virus infection of epidemic proportions was a concern solely for New York City and surrounding counties. However, by the end of the year 2000, West Nile virus activity had been identified in 12 states from as far north as Vermont and New Hampshire to as far south as North Carolina. What is this potentially dangerous, vector-borne disease, and what course could it take in the future?

A definitive diagnosis can be made only through laboratory testing of cerebrospinal fluid and acute and convalescent serum specimens to detect immunoglobin M antibody by enzyme-linked immunosorbent assay.Treatment for WNV is supportive; in more severe cases, it may include hospitalization with airway management and administration of intravenous fluids.

Surveillance and prevention

According to the Centers for Disease Control and Prevention, surveillance strategies should be implemented in areas where no system exists, or strengthened in regions where a system does exist. These strategies include active surveillance (ie, local health department solicitation of dead bird and mosquito population reports from health care providers) and enhanced passive surveillance (health department-issued general alerts to encourage key health care personnel to report cases of human viral encephalitis and neurologic disease in other mammals).
Measures for disease prevention should include eliminating mosquito-breeding habitats and controlling the adult mosquito population and mosquito larvae with the systematic use of insecticides.


Recommended Regional Surveillance Strategies

Northeastern United States. Active surveillance and enhanced passive surveillance of human cases, with an emphasis on urban and surrounding areas, should begin in early spring and continue through the fall until mosquito activity ceases because of cold weather.

Southeastern United States. Because of the year-round warm weather here, this region should implement continual active surveillance and enhanced passive surveillance.

Western and Central United States. WNV infection could conceivably spread to this region of the United States through birds migrating from Central and South America. The medical community should maintain active dead bird surveillance and enhanced passive human surveillance starting in early spring.

Other Areas of the Western Hemisphere. Canada, the Caribbean, and Central and South America should be encouraged to develop surveillance systems in their respective locations

The American Cancer Society recommends that men age 50 and over have prostate-specific antigen determination annually; however, the United States Preventative Services Task Force recommends against such studies. Each of the following statements represents a valid argument against annual prostate-specific antigen measurement EXCEPT

A Randomized studies have not yet shown a survival benefit for patients who are screened compared to those who are unscreened
B Early unimportant tumors may be detected in the screening group
C Screening may lead to net harm
D Most tumors are surgically incurable at the time of detection
E PSA screening may not lead to a change in the natural history of prostate cancer, but rather make it appear that life is prolonged after screening due to lead time bias

The answer is D
In order to definitively prove that a screening test is worthwhile, a randomized controlled trial comparing screened and unscreened patients with cause-specific mortality as the endpoint is required. Any other endpoint, such as a reduction in the incidence of advanced stage disease, improved survival, or a stage shift, provides less clear-cut support of benefit. No such trials have been completed with regard to prostate-specific antigen screening. Moreover, screening for prostate-specific antigen is fraught with many potential biases. For example, the test may not lead to any change in the natural history of prostate-cancer (lead-time bias); the patient may be diagnosed at an earlier date and appear to survive longer, but life is not really prolonged. Second, length bias, which refers to the detection of slow-growing less aggressive cancers, is certainly a problem with prostate-specific antigen screening. It is highly likely that prostate-specific antigen screening will lead to overdiagnosis with many patients will be found to have prostate cancer in whom this disease never would have been a problem. It is not clear whether the most effective treatment for low-stage prostate cancer is radical prostatectomy, radiation therapy, observation, or possibly even early hormonal therapy. As such, treating low-stage prostate cancers will certainly cause excess morbidity, including impotence or urinary incontinence.

Two years ago a 69-year-old man was found to have a prostate nodule on routine examination. Biopsy revealed poorly differentiated prostatic adenocarcinoma; staging studies failed to reveal any evidence of extraprostatic spread. Because of a desire to maintain potency, the patient opted for radiation therapy as primary treatment. Except for requiring lower extremity revascularization for intractable claudication, he did well until recently, when he developed pain in his right hip. Prostate specific antigen was elevated. Bone scan revealed areas of positive uptake in the pelvis and ribs (not present on the original staging study). The patient expresses a desire not to have a bilateral orchiectomy, 'unless it would significantly improve my quality of life or survival compared with other therapies.'
The most appropriate strategy at this point is to

A biopsy one of the bony lesions
B administer cisplatin and 5-fluorouracil
C administer leuprolide and flutamide
D administer diethylstilbestrol (DES) at low dose
E perform an orchiectomy

The answer is C
Given the poorly differentiated histology at presentation with the associated high risk of recurrence and the characteristic indicators of metastatic prostate cancer, biopsy is unnecessary. Since the patient has symptomatic disease, he should be started on androgen deprivation therapy, which is likely to cause a decrease in his pain. An equivalent response rate has been demonstrated with bilateral orchiectomy, diethylstilbestrol, and luteinizing hormone releasing hormone (LHRH) analogues such as leuprolide. Given his desire not to have an orchiectomy and his vascular disease, LHRH analogues would be the best approach.Prostatic carcinoma is poorly responsive to chemotherapy.

Management of DUB

Mild:
reassurance
Menstral calendar
Oral OCP

Severe or recurrent DUB without anemia:
Medroxyprogesterol 10 mg for 10 days
OCP if the patient is sexal active

Acute bleeding in a stable patient:
OCP one pill/6 hr untill bleeding stop
After bleeding stop,tape the OCP to routine dose and continue for 3-6 month

Acute bleeding associated with anemia and hypotension
Admission
Transfusion
Lab:CBC Pt/Ptt Blood T/C
IV estrogen 23 mg/4-6 hr
Cyclic progesterol dominant OCP
One pill/6Hr/3 day-one pill/8 hr/3days-one pill/12 hr/2wks-continue OCP for two months

A 25-year-old man visits his primary care physician because of a 1-month history of pain and swelling in his right testicle. The patient has no history of cryptorchidism or recent trauma. Physical examination reveals a normal left testis and a tense right hydrocele that precludes examination of the right testicle. Which of the following is the most appropriate next step in the treatment of this patient?

Antibiotic therapy for epididymoorchitis
Needle aspiration of the right hydrocele
Scrotal ultrasonography
Surgical repair of right hydrocele

C

Differentiating between a hydrocele and an acute scrotum (eg, testicular torsion, strangulated hernia) is important.
As many as 50% of acute scrotum cases are initially misdiagnosed.
Transillumination is not diagnostic and cannot rule out an acute scrotum.
Ultrasound anatomic imaging with Doppler evaluation of testicular blood flow is indicated when an acute scrotum is suspected, as follows:
A traumatic hemorrhage into a hydrocele or testes
A testicular torsion with or without a secondary hydrocele
An ischemic testicle

A general surgery evaluation is indicated for patients with a tense hydrocele that threatens to embarrass the scrotal circulation. Surgical evaluation is also indicated for hydrocele producing a large and bulky mass that is unsightly or uncomfortable
Immediately consult a urologist if testicular torsion is found or suspected.

A 30-year-old man sees his primary care physician for advice regarding prostate cancer screening. He states that his father was recently diagnosed with prostate cancer at age 69 years. His father also has a history of noninsulin-dependent diabetes mellitus and hypertension. At what age should this patient be advised to obtain prostate-specific antigen screening?

30 years
40 years
50 years
60 years

The U.S. Food and Drug Administration (FDA) has approved the PSA test for use in conjunction with a digital rectal exam (DRE) to help detect prostate cancer in men age 50 and older
The FDA has also approved the PSA test to monitor patients with a history of prostate cancer to see if the cancer has come back (recurred).
Several risk factors increase a mans chances of developing prostate cancer. These factors may be taken into consideration when a doctor recommends screening. Age is the most common risk factor, with more than 96 percent of prostate cancer cases occurring in men age 55 and older. Other risk factors for prostate cancer include family history and race. Men who have a father or brother with prostate cancer have a greater chance of developing prostate cancer. African American men have the highest rate of prostate cancer, while Native American men have the lowest.
Recommendations for screening vary. Some encourage yearly screening for men over age 50; others recommend against routine screening.
The PSA level that is considered normal for an average man ranges from 0 to 4 nanograms per milliliter (ng/ml). A PSA level of 4 to 10 ng/ml is considered slightly elevated; levels between 10 and 20 ng/ml are considered moderately elevated; and anything above that is considered highly elevated. The higher a mans PSA level, the more likely it is that cancer is present.

an asymptomatic 24yo woman is seen at 10weeks gestation. a urine culture shows a positive growth e.coli 100,000 CFU/mL. which of the following statement is NOT true?
1) if the patient is not treated, she has a 30% chance of developing pyelonephritis
2)if the patient is treated, her chance for recurrence will be approximately 30% during this pregnancy
3) patients with recurrent bacteriuria should be placed on suppressive therapy
4) the incidence of asymptomatic bacteriuria is higher in pregnant women

i am confused,
correct answer is 2 as kaplan said
but asx. bacteriuria is similar to the nonpregnant population even APN,cystitis is higher in preg.group
so4 is right?

Asymptomatic Bacteriuria


2 or B

A. Diagnosis requires >100,000 CFU/ml of urine of same organism in two clean-catch specimens or >100 organisms on a single catheterized specimen.
B. Must be distinguished from contamination from vaginal or urethral organisms attributable to poor technique in specimen collection. Treat based on C&S, not empirically.
C. The only patients who should be treated for asymptomatic bacteriuria include those who (1) are pregnant, (2) have had a past urologic pro-cedure, (3) have recently had the removal of an indwelling catheter, (4) have diabetes mellitus, or (5) are children. Asymptomatic bacteriuria is not an indication for treatment with antibiotics in the elderly, because treatment does not affect the outcome in these patients.
D. Between 2 and 10 percent of pregnancies are complicated by UTIs; if left untreated, 25 to 30 percent of these women develop pyelonephritis. Pregnancies that are complicated by pyelonephritis have been associated with low-birth-weight infants and prematurity. Thus, pregnant women should be screened for bacteriuria by urine culture at 12 to 16 weeks of gestation.
E. Pregnant women with asymptomatic bacteriuria should be treated with a three- to seven-day course of antibiotics, and the urine should subsequently be cultured to ensure cure and the avoidance of relapse. Although amoxicillin is frequently suggested as the agent of choice, E. coli is now commonly resistant to ampicillin, amoxicillin and cephalexin. Thus, treatment should be based on the results of susceptibility tests.

A 24-year-old woman presents with a sudden onset of diplopia. On examination she is unable to adduct the left eye past the midline. Nystagmus is noted in the right eye on abduction. Otherwise, extraocular movements are normal. The most likely location of the lesion is the

A right frontal lobe
B left labyrinth
C midbrain, affecting the rostral interstitial nucleus of the medial longitudinal fasciculus
D left occipital cortex
E left upper pons, affecting the medial longitudinal fasciculus

The answer is E
A lesion of the right frontal lobe involving the cortical gaze center would result in a gaze preference to the right. A left labyrinthine lesion would cause bilateral nystagmus and vertigo. The rostral interstitial nucleus of the medial longitudinal fasciculus (MLF) controls vertical gaze, which is not affected in this case. A lesion of the left occipital cortex would result in a right homonymous hemianopia. The MLF connects the horizontal gaze center in the pons with the oculomotor nuclei. Lesions of the MLF, which are common in multiple sclerosis, result in an internuclear ophthalmoplegia, or failure of adduction of the eye on the side of the lesion, accompanied by contralateral nystagmus.

A 38-year-old man presents with acute low back pain radiating into the posterior aspect of the right thigh and continuing down to the lateral aspect of the foot. On examination, the right patellar reflex is normal but the right Achilles tendon reflex is depressed compared with the left. Muscle power in the right lower extremity is full when the patient is examined in the supine position. The patient can stand on his heels and on the toes of the left foot, but the right toes are weak. Magnetic resonance imaging of the lumbosacral spine reveals a right-sided disk protrusion. The most likely site of disk pro- trusion is the

A L2-L3 interspace
B L3-L4 interspace
C L4-L5 interspace
D L5-S1 interspace
E S1-S2 interspace

The answer is E
A disk at the L2-L3 interspace would compress the L2 root. There may be weakness of hip flexion and sensory loss along the upper border of the thigh below the inguinal ligament. No tendon reflex is mediated by this root. A lesion of the L3 root would cause weakness of hip flexion and knee extension and sensory loss over the midportion of the anterior thigh. No tendon reflex is mediated by this root. A lesion of the L4 root would result in a depressed or absent patellar reflex, weakness of knee extension and foot dorsiflexion, and sensory loss over the anterior knee and the medial portion of the foreleg. A lesion of the L5 root would result in weakness of knee flexion, dorsiflexion of the ankle and great toe, and weakness of inversion and eversion of the foot. Sensory loss would be noted over the lateral aspect of the foreleg and the dorsal surface of the foot. A lateral disk protrusion at the S1-S2 interspace would compress the S1 nerve root. The S1 root mediates the Achilles tendon reflex, innervates part of the gastrocnemius, and provides sensation to the lateral aspect and sole of the foot.

A 66-year-old woman who has previously been healthy undergoes emergency surgery for a ruptured abdominal aortic aneurysm. Intraoperatively she requires 8 units of packed red blood cells to maintain her blood pressure and hematocrit. After surgery she is hemodynamically stable. On the third postoperative day she appears jaundiced, but abdominal examination is unremarkable and she is afebrile. Total serum bilirubin concentration at this time is 141 mol/L (8.3 mg/dL) [direct, 107 mol/L (6.3 mg/dL)]. Serum alkaline phosphatase level is 6 kat/L (360 U/L), and serum AST level is 0.85 kat/L (51 Karmen units/mL). The most likely explanation for the woman's jaundice is

A: a stone in the common bile duct
B: halothane hepatitis
C: posttransfusion hepatitis
D: acute hepatic infarct
E: benign intrahepatic cholestasis

The answer is E
Benign postoperative intrahepatic cholestasis can develop as a consequence of major surgery for a catastrophic event in which hypotension, extensive blood loss into tissues, and massive blood replacement are notable. Factors contributing to jaundice include the pigment load from transfusions, decreased liver function resulting from hypotension, and decreased renal bilirubin excretion caused by tubular necrosis. Jaundice becomes evident on the second or third postoperative day, with bilirubin levels (mainly levels of conjugated bilirubin) peaking by the tenth day. Serum alkaline phosphatase concentration may be elevated up to tenfold, but aspartate aminotransferase (AST) levels are only mildly elevated. Hepatitis, choledocholithiasis, and hepatic infarct are unlikely diagnoses in the absence of abdominal tenderness, fever, or a significant rise in AST levels. The incubation period of posttransfusion hepatitis is 7 weeks, making this diagnosis unlikely.

A 3-week-old white female who is being fed a formula with a cow's milk base is brought to your office with a 4-day history of dark blood flecks in otherwise normal appearing stools. Other history is unremarkable. A physical examination reveals yellow, curdy, guaiac-positive stool. Anal and rectal examinations are normal, as is the rest of the examination.

The best course of action would be to


a.draw blood for CBC, BUN, and electrolytes, and start intravenous fluids
b.culture the stool for rotavirus
c.obtain upper and lower GI barium fluoroscopy studies
d.perform an alkali denaturation test on the stool to rule out a maternal source for the blood
e.suggest a change to a soy-based formula

E? or A?

infants who have cow milk allergy will have soy milk allergy also

A 15-year-old white male is seen in the emergency department because he took approximately 17 grams of acetaminophen about 6 hours ago. A plasma acetaminophen level indicates a high risk for hepatic toxicity.

Which one of the following is the most beneficial management at this time?

a.Gastric lavage to clear stomach contents
b.Observation only, with AST and plasma acetaminophen levels checked every 4 hours
c.Therapy with N-acetylcysteine (Mucomyst, Mucosil)
d.Peritoneal dialysis
e.Oral activated charcoal

C

In all cases of suspected acetaminophen toxicity, a plasma acetaminophen level should be obtained at least 4 hours post ingestion. Serum levels drawn before this time may not represent peak values. The value of this level should be plotted on a standard nomogram to determine whether antidotal treatment is indicated. N-acetylcysteine is widely accepted as the antidote of choice for prevention of hepatotoxicity associated with acetaminophen overdose. It should be administered until up to 24 hours after ingestion; however, it is most effective when administered prior to 16 hours post ingestion. Gastric lavage alone is inadequate therapy in the case described. Peritoneal dialysis and oral activated charcoal are acceptable therapeutic approaches to some acute overdoses, but N-acetylcysteine is the specific and preferred antidote for acetaminophen poisoning.