By S. Snorre. Saint Petersburg College.

If pleural or peritoneal fluid collections are present buy discount zudena 100 mg on-line drugs for erectile dysfunction philippines, these may be aspirated and cultured cheap zudena 100mg with visa erectile dysfunction lab tests. If meningitis is suspected, lumbar puncture should be performed; however, if there is any delay in performing invasive procedures, antibiotics should be commenced without delay. Chest radiography is very useful in demonstrating new infiltrates suggestive of pneumonia. Intravenous antibiotics are nearly always required, and should be given in adequate doses. The choice of antibiotic will most of the time be empiric initially, and will be based on the suspected site of infection and the expected common organisms, as Severe infection 51 Handbook of Critical Care Medicine detailed above. If a source or site cannot be identified, broad spectrum antibiotics are usually commenced, aimed at providing adequate gram negative and gram positive cover. Once antibiotics are chosen based on a rational approach, they should be reviewed every 3 days, unless there is justification in changing therapy based on culture results. Vancomycin has poor alveolar penetration and hence has poor efficacy in pneumonia. Certain antibiotics have time dependent killing, and others have peak concentration dependent killing. Antibiotics with time-dependent killing: Glycopeptides and beta lactams have time dependent effects. This is achieved by x administering the antibiotic by continuous infusion or more frequent dosing x using a drug with a long half life x co-administration of another drug which blocks the elimination of the antibiotic Severe infection 53 Handbook of Critical Care Medicine Antibiotics with peak concentration dependent killing: Aminoglycosides and fluoroquinoloes have this property. The drug should be administered at high doses to achieve high peak concentrations, with longer intervals between doses to prevent toxicity. In general, it is defined as systolic blood pressure less than 90 mmHg or mean blood pressure below 60 mmHg. Also, patients who are hypertensive may have symptoms of hypotension when their pressure falls. Because of this, a drop in systolic blood pressure more than 40-50 mmHg from baseline is also considered hypotension. Ask the patient, relatives; check previous records, physician’s notes x Is the patient on antihypertensive medications? Sometimes, features of organ hypoperfusion may present, such as anginal chest pain, hypoxia, or altered level of consciousness. Always think of unusual but obvious causes of hypotension: consider the following case-vignette: A 60 year old man presented to an outpatient clinic with a history of feeling faintish for a few hours. He was resuscitated with fluids and blood, and was later found to have a hepatoma, with haematobilia. Hypotension 55 Handbook of Critical Care Medicine Differentiate between hypotension and shock Hypotension can occur without shock. Shock is a serious condition, with ongoing tissue hypoperfusion and tissue dysfunction and, most of the time, metabolic acidosis caused by anaerobic tissue metabolism with lactic acid production. Can also be caused by certain antihypertensives x Idiopathic low blood pressure can be seen in some healthy individuals. Patients with dengue infection can manifest with low blood pressures without tissue hypoperfusion, although such patients could develop shock and should be watched carefully. Organ dysfunction has not set in yet, and at this point fluid resuscitation alone will normalise the blood pressure and prevent the development of septic shock. Hypotension 56 Handbook of Critical Care Medicine Conversely, shock may be present with an apparently normal blood pressure.

Almost a century later buy zudena 100 mg lowest price effexor xr impotence, in 1935 purchase zudena 100mg visa erectile dysfunction pumps side effects, by clomiphene, may improve the prognosis pean guideline for the management of ano- Stein and Leventhal14 described the classical Figure 14 Patient aged 26. J Obstet Gynecol 1999;19:298–9 New York: Taylor and Francis, 2005:62–3 368 26 Pregnancy and fertility counseling in breast cancer survivors Christobel Saunders, Angela Ives and Toni Musiello Breast cancer is the commonest malignancy in second, once chemotherapy treatment is com- females, with nearly 1. In devel- conception for 2 years, thus further reducing oped countries, it affects up to 1 in 8 women potential ovarian function; and third, when in their lifetime. Whilst breast cancer is rela- endocrine therapy is recommended for up to 5 tively uncommon in younger women, with years, ovarian function declines even further4. The recent and of a breast cancer diagnosis may color the deci- growing trend in developed countries to delay sion a couple may make about future children. Under these circumstances, of premenopausal women remain fertile5–8 and younger women who are diagnosed with only 3–4% become pregnant following a diag- breast cancer have important but complex nosis of breast cancer9–11. Previous cancer could result from under-reporting of research has shown that young women diag- pregnancy terminations and missed abortions nosed with breast cancer want the opportunity in this population, as is the case in the gen- to discuss and understand the consequences eral population. According to Barthelmes and of the options open to them; however, studies Gateley, 14–44% of pregnancies conceived fnd that fertility issues are not fully discussed after a diagnosis of breast cancer are termi- or that information is lacking1–3. These numbers suggest the actual per- information is available, women often do not centage of women who conceive after a diag- feel adequately supported in making decisions. Many women success- include lymph node status, tumor size, tumor years) with a pathologically confrmed diagno- younger at the time of their breast cancer diag- fully deliver a healthy child following a diag- grade and hormone receptor status. Various sis of breast cancer, 1421 (56%) had naturally nosis compared to other women aged less than nosis of breast cancer, but still may fear the algorithms can be constructed which then conceived at least one full-term pregnancy 45 years diagnosed with breast cancer, but effects of the breast cancer on the child and/ give a likely prognosis. Further prospective studies are Studies have examined subsequent preg- sive ductal carcinoma, ranging in size from 1 needed, however, to explore how pregnancy nancies in women previously diagnosed with to 90mm, with half less than 20mm in diam- and fertility affect a diagnosis of breast cancer breast cancer. Tables 1 or better survival than similar aged women and 2 show recurrence-free and overall survival who do not conceive after a diagnosis of breast 9,13,18–24 in women who had a subsequent pregnancy Pregnancy is not usually recommended in the cancer. As seen frst 2 years following the treatment of breast a subsequent pregnancy may provide a posi- in the tables, the 5-year overall survival was cancer, as most early recurrences develop tive survival beneft to women. This recommendation is tant, however, to interpret these studies with Recurrence and survival rates were similar not made because the pregnancy will affect caution due to the bias known as the ‘healthy whether survival was measured from time of breast cancer outcome. Moreover, some pregnancy, with four women experiencing vant therapy, available evidence suggests that hormonal agents (including tamoxifen and the more than three subsequent live births. The median time from breast cancer able research examining outcomes and sur- sis of breast cancer, the evidence concerning diagnosis to frst subsequent pregnancy was vival in those who become pregnant and those harms and benefts of this type of contracep- 23 months (interquartile range 11–42). Two research will be necessary to corroborate these Figure 2 Fetal ultrasound tial stimulating effects of progestin is pres- births occurred before 36 weeks: a set of twins fndings. Compared to other women diagnosed with Treatments for early breast cancer in premeno- reasons to explain why women conceive fol- The decision to terminate the pregnancy or breast cancer when they were less than 45 pausal women may include local treatments, lowing a diagnosis of breast cancer. Radiotherapy is it is important that the woman avoids preg- One of the most important issues facing but this result suggests that those women who contraindicated during pregnancy25. Tamoxi- women who have not yet started or completed nancy, and personalized instruction regard- have completed treatment, have good progno- fen has potential fetal toxicity, including Gold- ing the use of adequate mechanical forms of their families when diagnosed with breast sis tumors and are unlikely to have disease enhar’s syndrome12,26. Chemotherapy is likely cancer is fertility preservation and/or options contraception, including condoms or the ft- recurrence during this time can safely consider to be teratogenic in the frst trimester of preg- ting of a diaphragm, becomes a priority. For some women, the opportunity Forty-two (34%) women underwent preg- early stages of development and potential fetal to all pre- and perimenopausal women follow- (rather than the reality) to have a child is more nancy termination. Of the women who ter- damage later on; this is possibly related to the ing their diagnosis of breast cancer for two important than their own long-term survival. Data on the use of Herceptin and Health professionals need to sensitively assess reasons: frst, mechanical contraception is pre- had at least one subsequent live birth.