Saturday 14 February 2009

BRONCHOSCOPY

The therapeutic indications for bronchoscopy include:


removal of secretions and mucus plugs:
often used in ITU
pneumonic lobar collapse
allergic bronchopulmonary aspergillosis

removal of foreign bodies

stent insertion in benign airways disease:
for example in relapsing polychondritis

BRONCHOSCOPY

Diagnostic role of flexible bronchoscopy






lung cancer:
the type and operability of lung tumours can be assessed

pneumonia:
good for identifying infecting organism

interstitial lung disease:
permits histoloy and analysis of bronchoalveolar lavage

causes of haemoptysis, cough and recurrent pneumonia

BROCHODILATORS

bronchodilators






Bronchodilation is a phenomenon of sympathetic stimulation. Thus drugs which attempt to achieve it include:

1.sympathomimetics

salbutamol } beta-2 adrenoceptor
terbutaline } agonists
fenoterol }
rimiterol }
salmeterol }
adrenaline
isoprenaline


2.antimuscarinics

Anticholinergics are drugs which antagonise cholinergic receptors.





3.xanthinesTypes of sympathomimetic include:
Xanthines are compounds which inhibit phosphodiesterase and thus are able to produce bronchodilatation.




theophylline
aminophylline
caffeine, theophylline and tannin

Wednesday 11 February 2009

LONG TERM SIDE EFFECTS OF TREATMENT OF BREAST CANCER

Lymphoedema after axillary dissection and/or
radiotherapy. It can arise at any time, even many
years after treatment.
● Cardiovascular toxicity after radiotherapy, and
increased cardiovascular risk after premature
menopause. Treat with appropriate medical and
risk-reduction strategies.
● Congestive heart failure associated with anthracyclines
and trastuzumab. Monitor (mandatory with
trastuzumab) and manage medically if present.
● DVT, stroke (tamoxifen). Treat as usual if present.
● Hot flushes after premature menopause, tamoxifen
or aromatase inhibitors (less so). SSRIs, SNRIs and
gabapentin may be useful. Alternatives such as
black cohosh have also been suggested.
● Vaginal dryness and dyspareunia. Non-hormonal
moisturisers and lubricants; use local oestrogen
with caution as there may be systemic absorption.
● Loss of libido resulting from altered body image,
radiotherapy, chemotherapy, depression or
dyspareunia. Counselling may be helpful, as well as
appropriate medical treatment.
● Arthralgia and musculoskeletal symptoms, from
aromatase inhibitors and sometimes tamoxifen.
Conservative treatment such as paracetamol or
NSAIDs if needed.
● Depression and anxiety following the diagnosis,
loss of body image, concern about morbidity and
mortality, and the direct effects of some
treatment. Treat as usual, including supportive
counselling and antidepressants if needed.
● Fatigue, associated with the diagnosis and
treatment. Provide support, encourage activity,
and rule out psychiatric or biological causes
(depression, anaemia, hypothyroidism).
● Weight gain, which can occur with chemotherapy
and possibly with tamoxifen and aromatase
inhibitors. Manage as usual with diet and
exercise.
● Osteopenia or osteoporosis, associated with
treatment-induced menopause and aromatase
inhibitors. Monitor bone mineral density and treat
as usual, including bisphosphonates if needed.
NEJM 2007; 356:2505-13.
Drug class
Anthracycline
Alkylating agent
Anti-metabolite - Folic acid analogue
- Uracil analogue
- Taxane
Selective oestrogen receptor modulator
Nonsteroidal aromatase inhibitors
Steroidal aromatase inactivator
Luteinising hormone releasing hormone agonist
Monoclonal antibody

RISK FACTORS FOR BREAST CANCER

Relative risk

Advanced age >10
Genes, family history, personal history
BRCA1/2 mutation 5-10
Breast cancer in first-degree relative 2
Previous atypical hyperplasia 4-5
Previous breast cancer >4
Breastfeeding for 12 months 0.96
One birth 0.93
Two births 0.84

Menstrual/reproductive history

Menarche before 11 years 3
Menopause after 54 years 2
First child after 30 1.2-1.4
First child after age 40 3
Current use of HRT 1.3-1.6
Current use of oral contraceptive 1.2

OtherLiving in a developed country (?oestrogen exposure) 5
High breast density on mammogram (?oestrogen exposure) >5
Abnormal exposure to ionising radiation 3
‘Lifestyle’
High socioeconomic status 2
High postmenopausal BMI 2
High premenopausal BMI <1
One alcoholic drink daily 1.07
Lancet 2005; 265: 1727-1741. Cancer 2004; 101:353-62.

Sunday 1 February 2009

THE MANAGEMENT OF VARIZELLA ZOSTER VIRUS EXPOSURE AND INFECTION IN PREGNANCY AND NEW BORN PERIOD

GOOD DAY

1.Zoster immunoglobulin (ZIG) should be offered to pregnant, varicella-seronegative women with significant exposure to varicella-zoster virus (VZV) (chickenpox) infection.

2.Oral aciclovir prophylaxis should be considered for susceptible pregnant women exposed to VZV who did not receive ZIG or have risk factors for severe disease.

3.Intravenous aciclovir should be given to pregnant women who develop complicated varicella at any stage of pregnancy.

4.Counselling on the risk of congenital varicella syndrome is recommended for pregnant women who develop chickenpox.

5.ZIG should be given to a baby whose mother develops chickenpox up to 7 days before delivery or up to 28 days after delivery.

6.Intravenous aciclovir should be given to babies presenting unwell with chickenpox, whether or not they received ZIG.

7.Breastfeeding of babies infected with or exposed to VZV is encouraged.

8.A mother with chickenpox or zoster does not need to be isolated from her own baby.

9.If siblings at home have chickenpox, a newborn baby should be given ZIG if its mother is seronegative.

10.The newborn baby does not need to be isolated from its siblings with chickenpox, whether or not the baby was given ZIG.

11.After significant nursery exposure to VZV, ZIG should be given to seronegative babies and to all babies born before 28 weeks' gestation.

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