By Z. Eusebio. Metropolitan State College of Denver.
It contains numerous 1-mm granulomas (arrows) in a miliary pattern involving both cortex and medulla order genuine promethazine on line. This sample purchase promethazine overnight, stained by Fite’s method buy promethazine 25mg without prescription, shows a cluster of acid-fast organisms associated with tubular epithelium. Patients present with signs of infection, such as fever and leukocytosis, and have urinary ﬁndings such as ﬂank pain, pyuria, and white blood cell casts. The organisms responsible most often are enteric in origin because the most common avenue for infection is via an ascending route fol- lowing a lower urinary tract infection. However, almost any infective agent may involve the kidney, especially with blood-borne infections, which encompass many possible organisms. Some would use the phrase pyelonephritis with fungal infections, that is, fungal pyelonephritis. Complications of acute pyelonephritis include urosepsis, abscess, pyonephrosis, and, rarely, emphysematous pyelone- phritis. If acute pyelonephritis is protracted or recurrent, it may evolve into chronic pyelonephritis. This bivalved kid- Chronic pyelonephritis often is separated into two major ney shows two compound pyramids, each representing distal fusion of forms—chronic obstructive pyelonephritis and reﬂux neph- two papillae tips. These would be susceptible to intrarenal reﬂux with increased intrapel- ropathy—because these types have distinctive gross features vic pressure and differ in pathogenesis. In chronic obstructive pyelone- phritis, the entire kidney usually is affected because it is uni- formly exposed to a lower urinary tract obstructive injury. Exceptions occur if the obstruction is segmental—for instance, in a duplex kidney with two ureters, only one of which is obstructed (see also the segmental example of xanthogranulomatous pyelonephritis in Fig. The obstruction may be extrinsic (the result of ureteral or urethral obstruction, secondary to neoplasms, radiation injury, retro- peritoneal ﬁbrosis, and so on) or intrinsic (secondary to ure- teral and ureteral pelvic junction developmental abnormalities, nephrolithiasis, and so on). Reﬂuxing renal pyramids are usually compound renal pyramids in which two or more renal papillae are fused. Compound renal pyramids usually are polar in location; thus, the scars of reﬂux nephropathy usually are polar. Implication of an ascend- largely unaffected, so reﬂux-related scars often are sharply ing source of acute pyelonephritis is supported by the presence of neu- delineated. This image shows collecting ducts in the inner medulla ﬁlled with neutro- Acute and chronic pyelonephritis is classiﬁed as follows: phils. The neutrophils and necrotic cell debris would be destined to • Acute pyelonephritis enter the urine as white blood cell casts. Bacterial usually are not – Ascending acute pyelonephritis visible – Hematogenous acute pyelonephritis – Emphysematous pyelonephritis 3. The cortex in this case of acute pyelonephritis shows a neutrophilic intratubular inﬁltrate. The adjacent interstitium contains a lymphocytic and plasmacytic inﬁltrate and ﬁbrosis, indicating more advanced evolution into chronic pyelone- Fig. Many tubules are ﬁlled with neutrophils that have not appreciably spilled over into the intersti- tium, implicating an ascending source of infection Fig. This is a case of hematogenous acute pyelonephritis secondary to infective endocarditis. Multifocal rounded cortical microabcesses are present, a typical feature of the hematogenous route of infection. The cortex in this case of pyelonephritis, no pelvicalyceal abnormalities or medullary abscesses ascending acute pyelonephritis shows a neutrophilic intratubular are present. This is the typical pattern seen in infections from an embo- lic hematogenous source Fig. This image from a patient with acute bacterial endocarditis shows large collections of bac- Fig. This image shows a teria within the glomerular capillary loops, representing embolization microabscess. In the center is a large collection of neutrophils that have of a microvegetation to a glomerulus. There is a surrounding suppura- produced liquefactive necrosis, destroying the native tissue. The neutro- tive response, soon to result in liquefactive necrosis and microabscess phils are rimmed by a histiocytic reaction formation. In acute pyelonephri- tis, several complications may develop, the most serious of which is emphysematous pyelonephritis. The renal parenchyma is completely necrotic and permeated with tiny gas bubbles obscuring its architecture. This image shows visible in the center (arrow ) chronic pyelonephritis secondary to lower urinary tract obstruction. Most of the renal pyramids are ablated, and there is severe cortical thinning Fig. The clear spaces pyelonephritis secondary to lower urinary tract obstruction shows represent gas formation, and the blue granular foci are large colonies of hydronephrosis with caliectasis most severe in the lower pole. Recurrent intractable nephrolithiasis was the cally occurs in diabetics, and the organisms responsible typically are underlying cause of obstruction in this case enteric in origin. This is an example of severe obstructive pyelonephritis with massive hydronephrosis second- ary to a very unusual abnormality of the collecting system and proximal ureter that is difﬁcult to classify. To the left (just outside the image area), a ureteropelvic junction obstruction was present. Also notice the triﬁd extrarenal calyces with infundibulum stenosis and only a thin rim of atrophic kidney at the top Fig. This example of re ﬂ ux nephropathy shows several scarred regions, the largest of which involves the upper pole; however, there are two small scars involving the mid- and lower poles. The gross features are the most important clues to the underlying etiology of chronic pyelone- phritis. Including portions of the renal pyramids is important in the his- tologic diagnosis of pyelonephritis because it will demonstrate damage in both forms of pyelonephritis, implicating a lower urinary tract prob- lem. In this image, the renal pyramid is concave and effaced, rather than convex, a ﬁnding that would not be seen if the cortical damage were a result of glomerular, vascular, or another type of chronic tubulointersti- tial disease.
The nucleus tractus solitarius generic 25mg promethazine otc, located within the medulla order promethazine 25mg free shipping, is the primary area for relay of afferent chemoreceptor and baroreceptor information from the glossopharyngeal and vagus nerves buy promethazine 25 mg low cost. Studies of patients with high spinal cord lesions show that a number of reflex changes are mediated at the spinal or segmental level. In general, activities of the two systems produce opposite but complementary effects (Table 14-1). The efferent somatic motor system, like somatic afferents, is composed of a single (unipolar) neuron with its cell body in the ventral gray matter of the spinal cord. Parasympathetic preganglionic fibers pass directly to the organ that is innervated. Their postganglionic cell bodies are situated near or within the innervated viscera. This limited distribution of parasympathetic postganglionic fibers is consistent with the discrete and limited effect of parasympathetic function. The postganglionic sympathetic neurons originate in either the paired sympathetic ganglia or one of the unpaired collateral plexuses. Preganglionic fibers of both subdivisions are myelinated with diameters of less than 3 mm. The1 postganglionic fibers are unmyelinated and conduct impulses at slower speeds of less than 2 m/s. They are similar to unmyelinated visceral and somatic afferent C fibers (Table 14-2). Efferent impulses are integrated centrally and sent reflexly to the adrenergic and cholinergic receptors. The myelinated axons of these nerve cells leave the spinal cord with the motor fibers to form the white (myelinated) communicating rami (Fig. The rami enter one of the paired 22 sympathetic ganglia at their respective segmental levels. Preganglionic fibers pass directly into the adrenal medulla without 881 synapsing in a ganglion (Fig. The cells of the medulla are derived from neuronal tissue and are analogous to postganglionic neurons. Table 14-2 Classification of Nerve Fibers Figure 14-3 The spinal reflex arc of the somatic nerves is shown on the left. The different arrangements of neurons in the sympathetic system are shown on the right. Preganglionic fibers coming out through white rami may make synaptic connections following one of three courses: (1) synapse in ganglia at the level of exit, (2) course up or down the sympathetic chain to synapse at another level, or (3) exit the chain without synapsing to an outlying collateral ganglion. Collateral ganglia, such as the celiac and inferior mesenteric ganglia (plexus), are formed by the convergence of preganglionic fibers with many postganglionic neuronal bodies. The unmyelinated postganglionic fibers then proceed from the ganglia to terminate within the organs they innervate. They are distributed distally to sweat glands, pilomotor muscle, and blood vessels of the skin and muscle. These nerves are unmyelinated C type fibers (Table 14-2) and are carried within the somatic nerves. The first four or five thoracic spinal segments generate preganglionic fibers that ascend in the neck to form three special paired ganglia. These ganglia provide sympathetic innervation of the head, neck, upper extremities, heart, and lungs. Afferent pain fibers also travel with these nerves, accounting for chest, neck, or upper extremity pain with myocardial ischemia. One preganglionic2 fiber influences a larger number of postganglionic neurons, which are dispersed to many organs. The preganglionic cell bodies originate in the brainstem and sacral segments of the spinal cord. The sacral outflow originates in the intermediolateral gray horns of the second, third, and fourth sacral nerves. These nerves supply the remainder of the viscera that are not innervated by the vagus. They supply the descending colon, rectum, uterus, bladder, and lower portions of the ureters and are primarily concerned with 883 emptying. The postganglionic cell bodies are situated near or within the innervated viscera and generally are not visible. The Auerbach plexus in the distal colon is the exception, with a ratio of 8,000:1. For example, vagal bradycardia can occur without a concomitant change in intestinal motility or salivation. These nerves affect cardiac pump function in three ways: (1) by changing the rate (chronotropism), (2) by changing the strength of contraction (inotropism), and (3) by modulating coronary blood flow. Therefore, the main effect of vagal cardiac stimulation to the heart is chronotropic. A strong vagal discharge can completely arrest sinoatrial node firing and block impulse conduction to the ventricles. Vagal stimulation of the heart can reduce left ventricular maximum rate of tension development (dP/dT) and decrease contractile force by as much as 10% to 20%. The right stellate ganglion distributes primarily to the anterior epicardial surface and the interventricular septum. The left stellate ganglion supplies the posterior and lateral surfaces of both ventricles. Future research interests concern the modification of the autonomic cardiac innervation through pharmacology or using alternative approaches. Different segments of the coronary arterial tree react differently to various stimuli and drugs. Normally, the large conductance vessels contribute little to overall coronary vascular resistance (see Chapter 12). Fluctuations in resistance reflect changes in lumen size of the small, precapillary vessels. Blood flow through the resistance vessels is regulated primarily by the local metabolic requirements of the myocardium. The larger conductance vessels, however, can constrict markedly due to neurogenic stimulation. Neurogenic influence also assumes a greater role in the resistance vessels when they become hypoxic and lose autoregulation.
Clinical signs of dehydration include a sunken fontanel buy promethazine 25 mg visa, poor skin turgor cheap promethazine online, dry mucous membranes discount promethazine 25mg mastercard, sunken eyes, poor skin perfusion, delayed capillary refill, hypothermia, tachycardia, or absent urine output. If there are clinical signs of dehydration, efforts should be made to correct the deficits before surgery, except in extreme, life- threatening situations. Physical examination also focuses on the respiratory 2962 and cardiovascular systems. The presence of any cardiovascular abnormalities should be noted, including poor perfusion or pulses, abnormal rhythm or rate, a murmur or gallop, hepatomegaly, or other signs of either heart failure or poor perfusion. The presence of a murmur is of concern in the neonatal period and warrants further evaluation, which is best done by a pediatric cardiologist. An electrocardiogram and echocardiogram will help define whether there is significant cardiovascular disease present that will affect the anesthetic management. Although this evaluation may take some effort and time, it is worthwhile to ensure that the anesthesiologist can plan the child’s care with full knowledge of the limitations cardiovascular disease can impose. Table 42-3 Abnormalities Associated with the Preterm Infant: Common Anesthetic Concerns The respiratory system also must be examined in some detail. The presence of stridor or other evidence of airway obstruction, such as sternal or chest wall retractions, should be identified and investigated. Although upper airway obstruction is relatively rare in the newborn, laryngeal webs, cysts of 2963 the tongue or supraglottic region, vocal cord paralysis after a traumatic delivery, and hemangiomas of the airway can cause obstruction and need to be identified. In addition, newborns that have been previously intubated may have some degree of subglottic edema related to previous intubation. More likely are signs of lower airway disease such as tachypnea, grunting, rhonchi, retractions, and cyanosis. The cause of any respiratory distress needs to be evaluated expeditiously prior to anesthesia to identify treatable causes and begin therapy. Preanesthetic Evaluation—Laboratory Most laboratory investigations are related to the underlying surgical condition such as radiography, computed tomography, magnetic resonance imaging, and echocardiography. However, most newborns will have, at a minimum, a blood count and glucose level drawn. The hemoglobin in a newborn is primarily fetal hemoglobin, which has a higher affinity for oxygen than adult hemoglobin. Because of this higher affinity, the hemoglobin dissociation curve is shifted to the left, releasing less oxygen to the tissues than adult hemoglobin. Newborns have a higher hemoglobin than the infant or child, often in the 15 to 18 g/dL range. Rarely, a newborn will have significant94 polycythemia, with hemoglobin levels above 20 g/dL. If symptomatic, these patients may benefit from therapeutic phlebotomy and volume replacement. The stressed newborn, especially the stressed preterm or small-for- gestational age newborn, are at particular risk for hypoglycemia. A glucose95 level between 60 and 80 mg/dL is expected in a full-term newborn, with a preterm often 10 mg/dL below that. Although there is some controversy about what actually constitutes hypoglycemia in these populations, most agree that levels less than 45 mg/dL warrant therapy with additional dextrose. Other laboratory studies, such as electrolyte determinations and coagulation profiles, are indicated in specific patients. Hypocalcemia, in particular, can be troubling because signs of hypocalcemia are nonspecific. Hypocalcemia is a problem with preterm newborns, but can also be seen in full-term newborns who have a delay in starting enteral feedings. Hyponatremia is not uncommon in newborns who have been receiving 2964 solutions with little or no salt in the first days of life, although hypernatremia may occur if there is inadequate resuscitation of the dehydrated patient when water loss is greater than salt loss. The longer a newborn has received parenteral fluids, the greater the chance of electrolyte abnormalities because of the difficulty in matching ongoing losses with replacement in the presence of an immature kidney. Unexplained thrombocytopenia can be an early sign of sepsis, and a falling count should be an impetus to look for other signs of sepsis. The prothrombin time and partial thromboplastin time levels are about 10% longer in the newborn, but prothrombin time values approach adult levels in the first week of life and partial thromboplastin time levels within the first month of life. Major factors that should be considered in planning the anesthetic include (1) anticipated blood loss and necessity for blood products to be available before beginning the case, (2) monitoring requirements, including invasive monitoring techniques, (3) additional equipment needs for airway and vascular access, (4) transport requirements, (5) postoperative recovery location risk of postoperative ventilation requirements, and (6) plan for postoperative pain relief. Both the medical status of the patient and the planned surgical procedure will impact this planning. The anesthesiologist has the responsibility of clarifying any medical issues with the neonatologist before finalizing the plan, as well as clarifying any issues related to the planned procedure with the surgeon. Occasionally, as planning progresses, it becomes obvious that the patient needs further medical resuscitation or evaluation before it is prudent to proceed with the procedure. Once the anesthetic plan is clear, it should be discussed with the available parent or caregiver who has legal custody of the child. Informed consent is a process by which the anesthesiologist explains his/her understanding of the patient’s status, the planned procedure, the plan for anesthetic management, alternatives to the plan, and some discussion of risks and benefits. Although 2965 there may be rare circumstances in which the legal guardian is not available to provide consent, efforts should be made in all except the most emergent of situations to have this discussion. The goal of informed consent is to help the parent understand what care is being proposed, the risks and benefits involved, and reasonable alternatives. It is the discussion, in terms understandable to the parent, that is the basis of true informed consent. Sedation is not usually necessary and analgesics are rarely indicated before taking the patient to the operating room. Because of the dominance of the parasympathetic nervous system, bradycardia on induction or in response to inhalation agents is of concern. Manipulation of the airway or administration of succinylcholine may cause bradycardia in neonates without administration of atropine or glycopyrrolate. Although it is not requisite to administer a vagolytic, it should be among the drugs immediately available and additional vigilance from the anesthesiologist is necessary to quickly respond to bradycardia. Although a dose of 20 μg/kg of atropine is most frequently used to prevent bradycardia, the question of a minimum dose of 100 to 200 μg has been a source of controversy.
Grundmann H buy promethazine 25 mg low price, Barwolff S purchase promethazine 25mg overnight delivery, Tami A et al (2005) How many infections are caused by patient- to-patient transmission in intensive care units? Chaix C 25 mg promethazine with amex, Durand-Zaleski I, Alberti C, Brun-Buisson C (1999) Control of endemic methicil- lin-resistant Staphylococcus aureus: a cost-beneﬁt analysis in an intensive care unit. Rubinovitch B, Pittet D (2001) Screening for methicillin-resistant Staphylococcus aureus in the endemic hospital: what have we learned? Harbarth S, Fankhauser C, Schrenzel J et al (2008) Universal screening for methicillin-resis- tant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. Katayama Y, Takeuchi F, Ito T et al (2003) Identiﬁcation in methicillin-susceptible Staphylococcus hominis of an active primordial mobile genetic element for the staphylococ- cal cassette chromosome mec of methicillin-resistant Staphylococcus aureus. 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Rohrer S, Tschierske M, Zbinden R, Berger-Bachi B (2001) Improved methods for detection of methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother 36(1):25–31 31 Rapid Screening and Identiﬁcation of Methicillin-Resistant Staphylococcus aureus 601 83. Murakami K, Minamide W, Wada K, Nakamura E, Teraoka H, Watanabe S (1991) Identiﬁcation of methicillin-resistant strains of staphylococci by polymerase chain reaction. Gieseler S, Konig B, Konig W, Backert S (2005) Strain-speciﬁc expression proﬁles of virulence genes in Helicobacter pylori during infection of gastric epithelial cells and granulocytes. Francois P, Pittet D, Bento M et al (2003) Rapid detection of methicillin-resistant Staphylococcus aureus directly from sterile or nonsterile clinical samples by a new molecular assay. Harbarth S, Masuet-Aumatell C, Schrenzel J et al (2006) Evaluation of rapid screening and pre-emptive contact isolation for detecting and controlling methicillin-resistantStaphylococcus aureus in critical care: an interventional cohort study. Francois P, Bento M, Vaudaux P, Schrenzel J (2003) Comparison of ﬂuorescence and resonance light scattering for highly sensitive microarray detection of bacterial pathogens. J Med Microbiol 49(3):295–300 31 Rapid Screening and Identiﬁcation of Methicillin-Resistant Staphylococcus aureus 603 118. Int J Med Microbiol 301(1):64–68 Chapter 32 Advanced Methods for Detection of Foodborne Pathogens Heather Harbottle and Michael Pendrak Traditional Methods The detection of bacterial and viral foodborne pathogens has been in practice for many decades to assure the safety and cleanliness of human food. During this long and storied history of food safety, the most traditional methods for detection have been employed with great success, consisting of bacterial and viral culture of the food sample using microbiological media and biochemical identiﬁcation of bacte- rial genera or cell culture techniques. These fundamental microbiologi- cal assays remain the cornerstone of most pathogen detection schemes, in spite of the fact that traditional culture methods are slow and labor intensive. In a bacterial foodborne disease outbreak, a minimum of 5–7 days are required to obtain an identiﬁed isolated colony, which delays the proper diagnosis and treatment regime, resulting in longer hospital stays. Therefore, a signiﬁcant demand for the rapid detection of pathogens in minutes, rather than days, has arisen. Alternate molecular methods have been developed to attempt reduce or eliminate this rate limiting step and provide identiﬁcation and characterization information to public health ofﬁcials in the event of a foodborne disease outbreak. Harbottle (*) Microbial Food Safety, Ofﬁce of New Animal Drug Evaluation, Center for Veterinary Medicine, U. The leading cause of foodborne illness-related hospitalization and deaths was attributed to Salmonella enterica serotypes, and therefore, a major focus of this chapter is on detection and characterization of S. Antibody Mediated After identiﬁcation of a bacterial foodborne pathogen utilizing selective media and biochemical testing, a common and successful method for further characterizing strains involves the use of antibodies. Serotyping is based on antibody recog- nition of the O and the H antigens present on S. Typhimurium , which are the main focus of surveillance and outbreak identiﬁcation. Molecular serotyping methods are much faster and orders of magnitude less labor intensive, but are not 100 % accurate and have not been established for all 2,500 serotypes of S. Additionally, very limited information can be gleaned from establishing a serotype, and this method of detec- tion is considered a ﬁrst step in the broad characterization of a S. These researchers tested the antibody-based microarray for simultaneous detection of each pathogen as well as cross-reactivity to other similar bacteria and common foodborne pathogens such as Listeria, Staphylococcus, Klebsiella, and Corynebacterium spp. Microbead assays are capable of detecting a multiplex of 40–100 or more different targets including foodborne pathogens and associated virulence genes, are faster, more reproducible, and more sensitive . In addition to Luminex technology, immunoassays to detect foodborne bacteria such as Salmonella are being developed whereby polyclonal antibodies ﬁxed to gold nano- particles capture the bacterial antigens and the signal is enhanced using a silver- based chemiluminescent detection system. Bacteriophage Typing Bacteriophage are naturally occurring viruses that target and infect speciﬁc strains of bacteria. Due to the speciﬁcity of bacteriophage, typing schemes have been developed to further classify very speciﬁc strains of bacteria. This speci ﬁ c strain was differ- entiated by the phage type from all other Salmonella Typhimurium strains, demon- strating the ability of phage typing to characterize very similar strains within the same serotype. Therefore, phage typing systems have been employed to detect and characterize foodborne bacteria such as Salmonella serotypes, E. Phage typing systems can demonstrate positive detection of speciﬁc strains via simple plaque assays, or be coupled with ﬂuorophores, antibodies, or other signal ampliﬁcation schemes, or used as part of a biosensor system [17, 18]. Whole chromosomes are ﬁxed, immobilized and digested with a restriction enzyme on the glass surface for each bacterial strain.