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Potent topical cortico- mide (100 mg/day reduced to 50 mg twice weekly) over 5 months steroids should generally be favored over topical calcineurin inhibitors generic super cialis 80mg with visa prostaglandin injections erectile dysfunction, without adverse effect super cialis 80mg with visa bradford erectile dysfunction diabetes service. Etretinate E Danazol E Successful therapy of chronic actinic dermatitis with inf- Thalidomide E liximab super cialis 80 mg without a prescription erectile dysfunction drugs india. Exp Dermatol 2009; 18: Interferon E 302 (abstracThat 36th Annual Meeting of Arbeitsgemeinschaft Infiximab E Dermatologische Forschung, Heidelberg, 2009). Infiximab infusions were associated with marked improve- ment in one patient who had not shown useful response to previ- Chronic actinic dermatitis. Antifungal therapy is indicated for severe or chronic pneumonia, progressive or disseminated infection. Keto- conazole (400 mg daily) shows comparable effcacy to the other azoles, but is associated with a higher risk of adverse effects with long-term use. Published reports of its use, however, are still limited to small numbers of patients treated in open-label, non-randomized studies. There have been no clinical trials assessing the effcacy of lipid formulations of amphotericin B. Newly available antifungal agents that may be used for refractory infection include the tri- azoles, posaconazole and voriconazole, in vitro studies having demonstrated their effcacy. However, there have been no com- parative studies as yet evaluating their effcacy against the estab- lished azoles used for treating coccidioidomycosis. There are early reports too of the successful use of caspofungin, an echinocandin, although results of in vitro susceptibility studies have varied widely. In addition to drug therapy, surgery is sometimes indicated for the removal of focal infection such as pulmonary cavities, focal osseous infection, or the debridement of soft tissue. Long-term prophylaxis with azoles is indicated for the immunocompro- mised, and meningeal infection requires lifelong azole therapy in order to prevent recurrence. Recovery from infection confers Coccidioidomycosis is an endemic systemic mycosis caused by lifelong immunity and provides the rationale for the ongoing inhalation of dimorphic fungi of the genus Coccidioides (C. It is endemic in desert regions of south- western United States, Central and South America. The immunocompromised are particularly susceptible to chronic pul- monary disease. One percent progress to disseminated disease, Direct microscopy and again, those with impaired cell-mediated immunity are at Culture greater risk of this. Culture is the defnitive method of establishing the almost any organ but most frequently involves the skin, lymph diagnosis. In the mycelial form, the fungus is highly infectious, so can give rise to ulcerative and verrucous lesions with a predilec- cultures should be handled with care. Subcutaneous abscesses, sinus tracts and can be used to assess response to therapy. Fluconazole A Dermatologists should be aware that the combination of atypi- Itraconazole A cal skin lesions, pulmonary infltrates, and a history of travel to endemic areas of the disease may represent disseminated infec- Fluconazole therapy for coccidioidal meningitis. Uncontrolled clinical trial which included 50 patients with Treatment depends on disease extent and predisposing factors. Response rates were similar in patients who had or azoles to prevent any risk of progression, although there are no had not received previous therapy. Fluconazole in the treatment of chronic pulmonary and Amphotericin B D nonmeningeal disseminated coccidioidomycosis. Of 78 patients This article provides a comprehensive review of the use of enrolled, 22 had soft tissue, 42 had chronic lung, and 14 had amphotericin B in the treatment of coccidioidomycosis. Patients were tericins are only used now for widely disseminated infection, in given fuconazole 200 mg daily. Non-responders were increased cases of azole intolerance, or when there are contraindications to to 400 mg daily. In meningitis, the intrathecal use of 75 evaluable patients, a satisfactory response was observed in 12 amphotericin B is still used frequently by some clinicians alone (86%) of those with bone, 22 (55%) of those with lung, and 16 or with a triazole. The Given that all studies to date of amphotericin use for coccidioidomy- study concluded that fuconazole 200–400 mg daily is well- cosis are limited by small numbers, this review article provides a tolerated but demonstrates only moderate effcacy in the treat- detailed assessment of current indications for its use. Intrathecal amphotericin in the management of coccidioi- Itraconazole treatment of coccidioidomycosis. This review advocates the use of intrathecal amphotericin B as A multicenter study which included 51 patients with non- a way to avoid the toxicity of intra-cerebrospinal fuid amphoteri- meningeal coccidioidomycosis who suffered with either chronic cin treatment. Three patients were not able to tolerate treatment which had to Report of an immunosuppressed patient on long-term steroid be discontinued. Comparison of 400- and 800-mg doses and observations at This was a prospective, non-randomized, multicenter study. Three patients received intrathe- sive pulmonary, skeletal, or soft tissue infections. Success rate was cal amphotericin B in addition, and were able to successfully similar for the two groups (23. Side-effects were signifcantly higher with high- on itraconazole monotherapy responded to treatment. Relapse rates were higher with This small but important study demonstrates the effcacy of itracon- high-dose therapy (52% vs 11%) although it depended also on azole for the treatment of meningeal infection. The study concluded little or no beneft with high-dose ketoconazole for non-meningeal infection. Comparison of oral fuconazole and itraconazole for pro- gressive, nonmeningeal coccidioidomycosis. In this randomized, double-blind, placebo-controlled trial, Posaconazole B 198 patients with pulmonary and non-meningeal infection were Voriconazole C treated with either fuconazole 400 mg daily or itraconazole Caspofungin E 200 mg twice daily. Overall effcacy rates at 12 months were Adjunctive interferon-γ immunotherapy E similar (itraconazole, 63%; fuconazole 50%; p=0. However, the response rate was higher in patients with bone disease treated Safety, tolerance, and effcacy of posaconazole therapy in with itraconazole (52% vs 26%; p=0. The rates of relapse patients with nonmeningeal disseminated or chronic pul- were comparable (itraconazole, 18%; fuconazole, 28%; p>0. Clin Infect Dis This is the frst prospective, randomized trial comparing two different 2007; 45: 562–8. The results dem- In this multicenter trial, 20 patients with chronic pulmonary onstrate that both itraconazole and fuconazole are effective therapies or non-meningeal disseminated coccidioidomycosis were treated for non-meningeal coccidioidomycosis. Paired motherapy has the potential to improve host immune responses and baseline and end-of-treatment culture results for Coccidioides facilitate complete eradication of pathogens. Infectious Diseases Society of Posaconazole therapy for chronic refractory coccidioido- America Guidelines. This was an open-label multinational study which included 15 These guidelines replace the guidelines published in 2000, and patients with pulmonary (n=7) and disseminated (n=8) disease the most notable difference being that itraconazole and fuco- that was refractory to previous therapy, which included ampho- nazole have replaced amphotericin B as frst-line therapy for most tericin B with and without an azole. Treatment was commonly used azoles are fuconazole 400–800 mg daily, itra- very well-tolerated. This was a retrospective study of all cases treated with either Persistent pulmonary infection voriconazole (n=21) or posaconazole (n= 16) in a single center.

Motor vehicle accidents buy genuine super cialis on line erectile dysfunction treatment doctors in hyderabad, reduced mileage driven purchase cheap super cialis on-line erectile dysfunction treatment options, Hyperphosphorylated tau accumulates in neurons and aggression buy super cialis cheap erectile dysfunction depression, and impulsivity also raise concern that 6. Presented at the annual meeting of the American Academy of The patient’s medication can be changed to transdermal Neurology Institute, Philadelphia, 2014. Vascular contributions to Rivastigmine is a pseudo-irreversible cholinesterase cognitive impairment and dementia: A statement for healthcare pro- inhibitor (acetylcholinesterase and butyrylcholinester- fessionals from the American Heart Association/American Stroke Association. Neurology linesterase inhibitor and an allosteric nicotinic receptor 2005;65:1863– 1872. A patient presents with vision impairment, hearing loss, He is found to have a centrocecal scotoma in that eye. Which of the following is least likely to cause reap- 1-phosphate receptor modulator? Which of with cardiac arrhythmias, elevated liver enzymes, the following statements is false? There is a limit for mitoxantrone dosing that should not be exceeded in a patient’s lifetime. Which of the following potential treatments used for logic cause for their transverse myelitis. Acute cerebellar ataxia increased risk for relapse of transverse myelitis accord- B. In children, most cases of acute transverse myelitis are elinating disorders in children is false? Patients with myasthenia gravis with which of these weighted and fuid-attenuated inversion recovery antibodies ofen have a thymoma? Anti−striated muscle antibodies of both hemispheres, in the deep white matter, and in B. Antibodies to the sodium channel of the following conditions is most closely associated with Morvan syndrome? The treatment of choice is that are found incidentally, without any clinical symptoms methylprednisolone followed by prednisone according to consistent with the disease. B • Spinal cord This patient and his family members have Leber hereditary optic neuropathy. In the 2010 Revised McDonald eral symptoms and then progress to bilateral severe vision criteria, this is one of the criteria that can be used to aid in loss. Susac syndrome is a microangiopathy that afects the brain, retina, and cochlea, causing a triad of encepha- lopathy, sensorineural hearing loss, and vision loss. Susac syndrome causes lesions in the middle of the corpus callosum; the periphery of the corpus callosum tends to be spared. Lesions can also be found in the basal ganglia, thalamus, brainstem, and cerebellum. Behçet disease is a type of vasculitis associated with recurrent oral and geni- 5. There is some evidence that vitamin is another disease that afects the brainstem and resembles D defciency plays a role in this diference in prevalence. B also reactive astrocytes and macrophages containing Injection site reactions, fu-like symptoms, elevated myelin debris. Astrocytes become gemistocytes, which liver enzymes, and neutralizing antibodies can occur in are plump cells with abundant fbrillary processes. A Chronic plaques are characterized by astrocytic Dalfampridine (Ampyra) is the extended -release form of fbrillary gliosis and sharp margins on gross specimens. They contain remyelinating axons, which Fingolimod (Gilenya) is a sphingosine-1-phosphate have thin myelination. B pregnancy, but there is a higher risk in the postpartum Fingolimod has been associated with cardiac arrhyth- period. B Glatiramer acetate (Copaxone) is pregnancy category Natalizumab is an antibody to α4 integrin. It consists of a polymer that includes salt forms of feres with the interaction between the integrin very late four amino acids (l- glutamic acid, l- lysine, l- alanine, antigen-4 and vascular endothelial adhesion molecule-1. It is administered by injection, and It prevents entry of lymphocytes into the central nervous some patients have an immediate postinjection reaction. D Dalfampridine, fngolimod, interferon-beta, and natalizumab are pregnancy category C. A maximum cumulative dose of mitoxantrone for a patient’s lifetime has been determined. It potentially xantrone therapy because there can be delayed cardio- could reactivate tuberculosis. Natalizumab should not be combined Interferon-beta 1a (Avonex, Immunomodulation with immunosuppressants. A washout period is recom- Rebif); peginterferon- beta 1a mended before starting natalizumab if the patient has (Plegridy) been taking an immunosuppressant. Alemtuzumab (Lemtrada) Infusion Extensive perivascular cufng and necrosis indi- 4- Aminopyridine/ Dalfampridine Oral cates signifcant infammation, as might be seen in (Ampyra) encephalitis. Alemtuzumab carries a risk for autoimmune complica- Interferon-beta 1a (Avonex, Rebif); Injection tions such as immune thrombocytopenic purpura, auto- peginterferon-beta 1a (Plegridy) immune thyroiditis, and glomerular nephropathy. There is weak evidence that plasma exchange neuritis, acute myelitis, area postrema syndrome, acute can be used in patients if treatment with methylpred- brainstem syndrome, symptomatic narcolepsy or acute nisolone fails. A complete spinal cord syndrome and centrally located lesions also Aquaporin-4 is a water channel protein. B useful in diferentiating patients with acute complete Azathioprine is a purine analog. Children typically have more relapses than adults be involved in the mechanism of action of daclizumab. A myelin on multiple axons, so injury to a few oligoden- drocytes can produce a noticeable area of demyelination. An incomplete rim of enhancement is consistent with Schwann cells produce one internode of myelin and demyelination. This occurs imity to the internode of myelin, whereas the oligoden- in acute hemorrhagic leukoencephalitis. Pathology shows hemorrhagic demyelin- ating lesions with necrosis surrounding blood vessels. Central nervous system Peripheral nervous system There is axonal injury and prominent edema. It is defective in Pelizaeus- Marchiafava-Bignami disease is demyelination of the Merzbacher disease. Morvan syndrome is characterized by limbic encephali- Acetylcholine receptor antibodies may be measured in tis, neuromyotonia, hyperhidrosis, and polyneuropathy.

Semilobar holopros- tal lobe of polymicrogyria (small black arrows) generic super cialis 80mg visa erectile dysfunction self injection, with many very small encephaly is illustrated in the third patient discount 80mg super cialis mastercard erectile dysfunction drug stores, with the interhemispheric gyri producing a cobblestoning appearance super cialis 80mg low price impotence marriage. The term porencephaly has also been used more communicate with the ventricle but is not lined by gray generally to include any non-neoplastic cavity within the matter. Porencephaly is caused by a vascular accident dur- brain, not specifically in utero in etiology, including vascu- ing the third trimester of fetal development, and as such lar insult, trauma, infection, and surgery. As well, there is only a hint of the defect on the right (“closed lip” schizencephaly), with a small ventricular dimple seen (small white arrow). There is an additional small named segment, the The corpus callosum develops in the fetus between the rostrum, which is a continuation of the genu, and proj- 8th and 20th weeks, in an anterior to posterior fashion. Total agen- esis of the corpus callosum is due to an early insult, with partial agenesis due to a later insult during gestation. With total agenesis, axons that normally cross the midline in- stead run along the medial borders of the lateral ventri- cles, parallel to the interhemispheric fissure, forming the bundles of Probst (Fig. The lateral ventricles will be more widely separated than normal, and their orientation parallel. On a coronal image, there will be a crescent shape to the lateral ventricles, in particular the front horns, with the bundles of Probst lying medially. Along the midline, as seen in the sagittal plane, there will be a radial orientation to the gyri adjacent to the body of the lateral ventricles. The term callosal dysgenesis includes both partial and complete absence of the corpus callosum. On the left, a ventricular dimple (black arrow)—the ependymal margin of the con- Holoprosencephaly is a congenital malformation of the tralateral cleft—is demonstrated, together with part of a gray matter brain, characterized by failure of cleavage and differen- lined cleft, in this patient with bilateral “closed lip” schizencephaly. The 1 Brain 15 prosencephalon separates early in development into the diencephalon (which includes the thalamus and hypo- thalamus) and the telencephalon (which includes the ce- rebral hemispheres and basal ganglia). Holoprosencephaly is somewhat artificially divided into three subcategories, which are subsequently discussed in order of decreasing severity. In alobar holoprosencephaly, the thalami are fused, the third ven- tricle is absent, the falx is absent (there is no interhemi- spheric fissure), and there is a single crescent-shaped ventricle connected to a large dorsal cyst. In semilobar holoprosencephaly, the interhemispheric fissure and falx are present posteriorly (Fig. There is partial separation of the thalami by a small third ventricle, with rudimentary temporal horns. In lobar holoprosencephaly, the falx and interhemispheric fissure extend into the frontal region. The frontal horns of the lateral ventricles have an abnormal configuration, and the frontal lobes may be hypoplastic. Septo-optic dysplasia is defined by the presence of an abnormality involving the septum pellucidum and hypo- Fig. This entity is characterized, in its most classic presentation, by absence of the septum pellucidum, which is well plasia of the optic nerves (Fig. There may be mild seen on axial scans, together with a small optic chiasm (white arrow), dysplasia to complete absence of the septum pellucidum. The optic chiasm and nerves will be small, together with a thin pituitary infundibulum. The degree of pituitary dys- function is variable, with growth hormone deficiency most pathognomonic (Fig. These are readily recognized on both T1- and locations in the majority of preteen children. Here the lesions are usually bilateral, but often chymal lesions, which are best visualized on T2-weighted asymmetric in size. Simi- hamartomas (tubers) involve both gray and white mat- lar lesions can also be seen, but are less common, in the ter, with their epicenter in the subcortical white matter. The other common abnormalities seen the subcortical white matter core of an expanded gyrus. Mild ventricular enlargement can have bilateral contiguous optic tract involvement and may be present. Bilateral internal audi- tory canal enhancing lesions are noted (white arrows), each con- sistent with a vestibular schwannoma. The lesion on the right expands the internal auditory canal and has both intra- and extra-canalicular components. An additional, moderate in size, enhancing extra-axial lesion (black arrow) is noted, invading the left transverse sinus, con- sistent with a meningioma. The cutaneous lesion characteristic for Sturge-Weber is a “port wine stain”; however, this le- hydrocephalus due to blockage of the foramen of Monro sion need not be present. Cutaneous lesions seen in tuberous sclerosis in- Cerebellar hemangioblastomas can occur in adults in clude leaf-shaped hypopigmented spots (on the trunk and von Hippel-Lindau disease. The Sturge-Weber syndrome is also known as Lipomas encephalotrigeminal angiomatosis. The two pathognomic findings in this disease entity are illustrated, with the re- spective modalities on which they are best visualized. Abnormal high signal intensity (white arrow) on the (black arrow), intraventricular mass is noted, lying at the foramen T2-weighted scan within the white matter of an expanded gyrus of Monro. There is ventricular enlargement, but without inter- is consistent with a cortical tuber, in this patient with tuberous stitial edema, consistent with chronic compensated obstructive sclerosis. Other characteristic quence, a chemical shift artifact may also be seen (in the but less common locations include the suprasellar cistern, Fig. Subtle cortical/subcortical low sig- seen post-contrast, reflecting the pial angioma, overlying the gyri and nal intensity on both scans (part 1) reflects dense dystrophic calcifica- extending within the sulci in the right occipital lobe in this patient. Serpentine enhancement is ferent patient, classic features for chronic disease in this phakomatosis. A lipoma, with high signal intensity (isointense to subcutane- ous fat), is noted along the midline, immedi- ately superior to the corpus callosum. This section discusses a diverse group of disorders due to inborn errors of metabolism. Imaging is often suggestive of Anomalies of the Skull the general diagnosis, but rarely specific for the individual disease. White matter is usually involved, although this may A cephalocele is a protrusion of cranial contents through be secondarily. There are two main types, a menin- share a similar imaging appearance, with atrophy and usu- gocele (Fig. These have not been discussed in More than 50% are occipital, the most common location, detail below, as they contribute little to image interpretation. A related entity to the latter, from an embryogenesis perspective, is a nasal dermal Diseases Affecting White Matter sinus. Metachromatic Leukodystrophy Craniosynostosis is premature fusion of a skull suture. The cranial sutures normally begin to fuse at age 3 and are The most common form of this disease presents in the completely fused by age 6. The imaging appearance is nonspecific, calvarium is predictable based upon the suture(s) involved. Brachycephaly is used to describe an increase in transverse dimension of the skull, which can be due to Krabbe Disease synostosis of the coronal or lambdoid sutures bilaterally.

Overall cheapest generic super cialis uk erectile dysfunction doterra, anticholinergic drugs Certain patient populations are particularly likely to do not reliably reduce the risk of aspiration pneu- have large volumes of acidic gastric fluid: patients monia and can reverse the protective effects of with an acute abdomen or peptic ulcer disease buy super cialis amex erectile dysfunction cancer, metoclopramide buy generic super cialis 80mg on line impotence organic origin definition. Proton pump inhibitors are gen- children, the elderly, diabetic patients, pregnant erally as effective as H2 antagonists. Furthermore, pain, anxiety, or opioid-agonists may delay gastric empty- What anesthetic techniques are used ing. If the risk factor is not the risk of aspiration pneumonia (increased acidity reversible (eg, large hiatal hernia) or the case is and volume of gastric contents). Aspiration is more emergent, proper anesthetic technique can mini- common in patients undergoing esophageal, upper mize the risk of aspiration pneumonia. If there are signs avoid filling the stomach with gas and thereby suggesting a difficult airway, intubation should increasing the risk of emesis. Otherwise, a rapid-sequence ous efforts have ceased or muscle response induction is indicated. A mod- • The patient is always preoxygenated prior to ification of the classic rapid-sequence induc- induction. Patients with lung disease require tion allows gentle ventilation as long as cricoid 3–5 min of preoxygenation. If intubation This step is often omitted, however, as it can is still unsuccessful, spontaneous ventilation decrease lower esophageal sphincter tone. If should be allowed to return and an awake intu- rocuronium has been selected for relaxation, a bation performed. What are the relative contraindications • An assistant may apply firm pressure over the to rapid-sequence inductions? Because the cricoid cartilage forms ated with increases in intracranial pressure, arterial an uninterrupted and incompressible ring, blood pressure, and heart rate. Contraindications pressure over it is transmitted to underlying to succinylcholine also apply (eg, thermal burns). The esophagus is collapsed, and pas- sively regurgitated gastric fluid cannot reach Describe the pathophysiology and clinical the hypopharynx. Acid solutions has been associated with rupture of the poste- cause atelectasis, alveolar edema, and loss of rior wall of the esophagus. Granulomas may form around food or antacid par- Obviously, this dose must be modified if there ticles. The earliest physiological change following is any indication that the patient’s cardiovas- aspiration is intrapulmonary shunting, resulting in cular system is unstable. Other changes may include pulmonary induction agents can be substituted (eg, edema, pulmonary hypertension, and hypercapnia. Arterial blood gases reveal hypoxemia, Gan T, Apfel C, Kovac A, et al: A randomized double hypercapnia, and respiratory acidosis. The pharynx and, if pos- versus ondansetron plus dexamethasone to prevent sible, the trachea should be thoroughly suctioned. Bronchoscopy of postoperative nausea and vomiting: Past, present and pulmonary lavage are usually indicated when and future. Use of cortico- George E, Hornuss C, Apfel C: Neurokinin 1 and steroids is generally not recommended and anti- novel serotonin antagonists for postoperative and biotics are administered depending upon culture postdischarge nausea and vomiting. Schug S, Joshi G, Camu F, et al: Cardiovascular Practice guidelines for preoperative fasting and the use of safety of the cyclooxygenase 2 selective inhibitors pharmacologic agents to reduce the risk of pulmonary parecoxib and valdecoxib in the postoperative aspiration: Application to healthy patients undergoing setting; an analysis of integrated data. The pre- operative evaluation guides the anesthetic plan: Will sedative-hypnotic premedication be useful? Airway management Induction drugs The preoperative evaluation serves multiple Maintenance drugs purposes. One purpose is to identify those few Regional patients whose outcomes likely will be improved Technique(s) by implementation of a specifc medical treatment Agent(s) Sedation and monitored anesthesia care (which in rare circumstances may require that the Supplemental oxygen planned surgery be rescheduled). For example, a Specific sedative drugs 60-year-old patient scheduled for elective total hip Are there special intraoperative management issues? Another anesthetic drugs Fluid management purpose is to identify patients whose condition is Special techniques so poor that the proposed surgery might only has- Site (anesthetizing location) concerns ten death without improving the quality of life. Finally, the preoperative evalua- tion is an opportunity for the anesthesiologist to 5 Moribund patient who is not expected to describe the proposed anesthetic plan in the context survive without the operation of the overall surgical and postoperative plan, pro- 6 Brain-dead patient whose organs are being vide the patient with psychological support, and removed for donor purposes obtain informed consent for the proposed anesthetic E If the procedure is an emergency, the physical plan from the surgical patient. But, many other complete discussion of cardiovascular assessment is risk assessment tools are available. The focus of preoperative cardiac assessment should be on determining Elements of the whether the patient’s condition can and must be Preoperative History improved prior to the scheduled procedure, and Patients presenting for elective surgery and anesthe- whether the patient meets criteria for further cardiac sia typically require a focused preoperative medical evaluation prior to the scheduled surgery. Clearly history emphasizing cardiac and pulmonary func- the criteria for what must be done before elective tion, kidney disease, endocrine and metabolic dis- arthroplasty will difer from what must be done eases, musculoskeletal and anatomic issues relevant before an operation for resectable pancreatic cancer, to airway management and regional anesthesia, and given the benign results of a delay in the former pro- responses and reactions to previous anesthetics. In general, the 4 guidelines for preoperative assessment (see Guide- indications for cardiovascular investigations lines at end of Chapter). Cardiovascular Issues scheduled to undergo surgery does not change the Guidelines for preoperative cardiac assessment are indications for such measures as noninvasive stress available from the American College of Cardiology/ testing to diagnose coronary artery disease. Pulmonary Issues presenting for elective surgery do not maintain Perioperative pulmonary complications, most blood glucose within the desired range. Other notably postoperative respiratory depression and patients, who may be unaware that they have type 2 respiratory failure, are vexing problems that have diabetes, present with blood glucose measurements become seemingly more common as severe obe- above the normal range. Adequacy of long- 5 sity and obstructive sleep apnea have increased term blood glucose control can be easily and in incidence. A recent guideline developed by the rapidly assessed by measurement of hemoglobin A1c. American College of Physicians takes an aggres- In patients with abnormally elevated hemoglobin sive stance; it identifes patients 60 years of age or A1c, referral to a diabetology service for education older, those with chronic obstructive lung disease, about the disease and adjustment of diet and medi- those with markedly reduced exercise tolerance and cations to improve metabolic control may be benef- functional dependence, and those with heart failure cial. Elective surgery should be delayed in patients as potentially requiring preoperative and postop- presenting with marked hyperglycemia; this delay erative interventions to avoid complications. A more complete dis- markedly increased risk of pulmonary complica- cussion of diabetes mellitus and other perioperative tions relative to class 1 patients), cigarette smok- endocrine concerns is provided in Chapter 34. Coagulation Issues (abdominal, thoracic, aortic aneurysm, head and neck, and emergency surgery), and general anes- T ree important coagulation issues that must be thesia (compared with cases in which general anes- addressed during the preoperative evaluation are thesia was not used). Patients with asthma, particularly those agulation therapy or who will receive anticoagula- receiving suboptimal medical management, have tion perioperatively. In the frst circumstance, most a greater risk for bronchospasm during airway patients who undergoing anything more involved manipulation. Appropriate use of analgesia and than minor surgery will require discontinuation of monitoring are key strategies for avoiding post- warfarin 5 days in advance of surgery to avoid exces- operative respiratory depression in patients with sive blood loss. Further discussion of this whether the patient will require “bridging” therapy topic appears in Chapter 44. Endocrine and Metabolic Issues (eg, those with certain mechanical heart valve Appropriate targets for control of diabetes mellitus implants or with atrial fbrillation and a prior throm- and of blood glucose in critically ill patients have boembolic stroke), warfarin should be replaced by been subjects of great debate over the past decade. In in the normal range, was shown in the Diabetes patients receiving bridging therapy for a high risk of Control and Complications Trial to improve out- thrombosis, the risk of death from excessive bleed- comes in ambulatory patients with type 1 diabetes ing is an order of magnitude lower than the risk of mellitus. It has become the usual practice to obtain a death or disability from stroke if the bridging ther- blood glucose measurement on the morning of elec- apy is omitted. Decisions regarding bridg- Although there is a consensus that pregnant ing therapy ofen require consultation with the phy- women and those who have recently (within 6 h) sician who initiated the warfarin therapy. The 8 intervention and suggest that treatment options truth is that there are no good outcomes data other than a drug-eluting stent (which will require to support restricting fuid intake (of any kind or any prolonged dual antiplatelet therapy) be used in amount) more than 2 h before induction of general patients expected to undergo a surgical procedure anesthesia in healthy patients undergoing elective within 12 months afer the intervention (eg, in a procedures; indeed, there is evidence that nondia- patient with colon cancer who requires treatment betic patients should be encouraged to drink for coronary disease).

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