By V. Killian. Finch University of Health Sciences/The Chicago Medical School.
Classification is the assignment of organisms (species) into anorganised scheme of naming buy malegra dxt plus 160 mg free shipping. The establishment of criteria for identifying organisms & assignment to groups (what belongs where) 5 2 buy malegra dxt plus with mastercard. At what level of diversity should a single species be split in to two or more species? Species) are more similar to each other than are members of higher level taxa (eg generic malegra dxt plus 160 mg amex. Thus once you know that two individuals are member of the same taxon, you can inter certain similarities between the two organisms. Strain is the level below the species b) Two members of the same strain are more similar to each other than either is to an individual that is a member of a different strain, even if all three organisms are members of the same species Bacterial species - A bacterial species is defined by the similarities found among its members. Properties such as biochemical reactions, chemical composition, cellular structures, genetic characteristics, and immunological features are used in defining a bacterial species. Identifying a species and determining its limits presents the most challenging aspects of biological classification for any type of organism. Monera ( the prokaryotes) Kingdom of Monera Three categories: - Eubacteria Are our common, everyday bacteria, some of which are disease – causing; also the taxon from which mitochondria originated. Distinctively, however, the members of Kingdom Protista are all eukaryotic while the mebers of kingdom Monera are all prokaryotic. Some members of protista are multicellular, however Kingdom protista represents a grab bag, essentially the place where the species are classified when they are not classified as either fungi, animals or plants. Kingdom Fungi Unlike pprotists, the eukaryotic fungi are typically non – aquatic species. They traditionally are nutrients absorbers plus have additional distinctive features. The domain system contains three members 9 ¾ Eukaryotes ( domain Eukarya ) ¾ Eubacteria ( domain Bacteria) ¾ Archaebacteria ( domain Archaea) Viral classification Classification of viruses is not nearly as well developed as the classification of cellular organisms. Today viruses tend to be classified by their chemical, morphological and physiological attributes (e. Binomial nomenclature is not employed to name viruses; instead viruses are named by their common names (e. The distinguishing features between Eukaryotic cell and Prokaryotic cell Features Prokaryotic cell Eukaryotic cell. Cellular element enclosed with in the cell envelope: Mesosomes, ribosomes, nuclear apparatus, polyamies and cytoplasmic granules. Cell wall Multi layered structure and constitutes about 20% of the bacterial dry weight. Young and rapidly growing bacteria has thin cell wall but old and slowly dividing bacteria has thick cell wall. It is composed of N-acetyl Muramic acid and N-acetyl Glucosamine back bones cross linked with peptide chain and pentaglycine bridge. Contains toxic components to host Bacteria with defective cell walls Bacteria with out cell wall can be induced by growth in the presence of antibiotics and a hypertonic environment to prevent lysis. Protoplasts: Derived from Gram-positive bacteria and totally lacking cell walls; unstable and osmotically fragile; produced artificially by lysozyme and hypertonic medium: require hypertonic conditions for maintenance. Spheroplast: Derived from Gram-negative bacteria; retain some residual but non-functional cellwall material; osmotically fragile;produced by growth with penicillin and must be maintained in hypertonic medium. L- forms: Cell wall-deficient forms of bacteria usually produced in the laboratory but sometimes spontaneously formed in the body of patients treated with penicillin; more stable than protoplasts or spheroplasts, they can replicate in ordinary media. Cell membrane Also named as cell membrane or cytoplasmic membrane It is a delicate trilaminar unit membrane. Mesosomes Convoluted invagination of cytoplasmic membrane often at sites of septum formation. Nuclear apparatus Well defined nucleus and nuclear membrane, discrete chromosome and mitotic apparatus are not present in bacteria ; so nuclear region of bacteria is named as nuclear body, nuclear apparatus and nucleoid. Besides nuclear apparatus, bacteria may have extra chromosomal genetic material named as plasmids. Plasmids do not play any role in the normal function of the bacterial cell but may confer certain additional properties(Eg. Virulence, drug resistance) which may facilitate survival and propagation of the micro- organism. Glycocalyx (capsule and slime layer) Capsule is gel firmly adherent to cell envelope. Capsule is composed of polysaccharide and protein(D-Glutamate of Bacillus anthracis) Features of capsule 1. Flagellum It is the organ of locomotion in bacterial cell and consists of thee parts. The basal body The basal body and hook are embedded in the cell surface while the filament is free on the surface of bacterial cell. Pili (fimbriae) It is hair like structure composed of protein (pilin) Two types (Based on function). Sex pili: The structure for transfer of genetic material from the donor to the recipient during the process of conjugation. Spores Resting cells which are capable of surviving under adverse environmental conditions like heat, drying, freezing, action of toxic chemicals and radiation. Classification of bacteria Bacterial classification depends on the following characteristics. Morphology of bacteria When bacteria are visualized under light microscope, the following morphology are seen. Bacilli (singular bacillus): Stick-like bacteria with rounded, tepered, square or swollen ends; with a size measuring 1-10μm in length by 0. Spiral: Spiral shaped bacteria with regular or irregular distance between twisting. Staining of bacteria Bacterial staining is the process of coloring of colorless bacterial structural components using stains (dyes). The principle of staining is to identify microorganisms selectively by using dyes, fluorescence and radioisotope emission. Staining reactions are made possible because of the physical phenomena of capillary osmosis, solubility, adsorption, and absorption of stains or dyes by cells of microorganisms. Individual variation in the cell wall constituents among different groups of bacteria will consequently produce variations in colors during microscopic examination. Whereas, cytoplasm is basic in character and has greater affinity for acidic dyes. Because dyes absorb radiation energy in visible region of electromagnetic spectrum i. Direct staining Is the process by which microorganisms are stained with simple dyes. A mordant is the substance which, when taken up by the microbial cells helps make dye in return, serving as a link or bridge to make the staining recline possible. It combines with a dye to form a colored “lake”, which in turn combines with the microbial cell to form a “ cell-mordant-dye- complex”.
Group of 10 pulmonologists and 10 primary care Implementation: 03/2000 physicians (who recruited 98 and 100 patients with persistent asthma Study Start: 10/1999 respectively) were randomized to intervention and control 160mg malegra dxt plus sale. Costs were calculated from the consumption of resources registration for 12 months and determined the cost effectiveness of intervention by an incremental analysis malegra dxt plus 160 mg on-line. N = 30 patients Study patients received a Bluetooth enable blood glucose meter purchase malegra dxt plus 160mg without prescription, a Implementation: 00/0000 cell phone and WellDoc’s proprietary diabetes management Study Start: 00/0000 software, Diabetes Manager. Average decrease of A1c and physicians change of medication were measured and compared between the groups. The objective of the study was to determine whether N = 9,565 patients, 10,169 computerized alerts were effective at increasing the percentage of dispensing ambulatory patients with laboratory monitoring at initiation of drug Implementation: 00/0000 therapy. The primary outcome measure was the percentage of drug Study Start: 09/2002 dispensing with baseline laboratory monitoring. Alerts were triggered Study End: 12/2003 by a dispensing of one of 15 target drug or drug classes. The alert was sent electronically to the Clinical Pharmacy Call Center daily if lab tests were not completed. This team of pharmacists contacted patients by phone to remind them their test was due or to order the tests if the physician did not do so. The intervention therefore had 2 stages; the alerting of the pharmacist by the computer and the phone follow-up by the pharmacist. An alert generated in the pharmacy system prevented printing of the label until a pharmacist intervened by contacting prescribing clinicians by phone. N = 11,100 women Measured by the proportion of pregnant women dispensed a Implementation: 00/0000 category D or X medication and the total number of first dispensing Study Start: 01/2003 of targeted medications. Alerts were sent to pharmacists who had to Study End: 04/2003 review prescription and contact prescriber before the prescription label would print. During the second N = 484 patients period, the guideline was randomly applied in either paper or Implementation: 04/2001 computerized form. In the third period, the guideline was available Study Start: 00/0000 only in paper form. This window appeared on bedside workstations and at any workstation where the patient’s record was activated. The two guideline-related outcome measures consisted of compliance with: (a) glucose measurement timing recommendations and (b) insulin dose advice. For patients in the physician reminder group a Study Start: 04/1985 computer-generated reminder to ask the patient about tetanus Study End: 03/1986 vaccination was included on the routinely printed encounter form used for billing purposes. Proportion of patients who received tetanus toxoid during the study year or who had a claim of vaccination in the previous 10 years. Providers were Implementation: 00/0000 randomly assigned to receive an e-mail with a Web-based link to the Study Start: 06/2004 7th Report of the Joint National Committee on the Prevention, Study End: 12/2004 Detection, Evaluation and Treatment of High Blood Pressure guidelines (provider education); provider education and a patient- specific hypertension computerized alert (provider education and alert); or provider education, hypertension alert, and patient education, in which patients were sent a letter advocating drug adherence, lifestyle modification, and conversations with providers (patient education). Main Implementation: 00/0000 outcome was time to implementation of clinical alerts with secondary Study Start: 05/1992 review of and improved quality of care. In the 18 month trial, 191 Study End: 09/1993 patients were treated by 70 physicians and nurse practitioners assigned to the intervention group, and 158 patients were treated by 66 physicians and nurse practitioners assigned to the control group. Physicians also used the system to enter patient notes and medication prescriptions. Each time a clinician opened a patient chart within the system, the algorithm for all reminders determined whether the patient had received care in accordance with the recommended practice guidelines. Measures of vancomycin prescribing were the number of Implementation: 00/0000 orders, duration of the therapy and number of days per course of Study Start: 06/1996 treatment. Alerts identified 159 clinically relevant prescribing problems in the elderly, a list established previously by expert consensus. Each alert identified the nature of the problem and possible consequences and suggested alternative therapy in accordance with the expert consensus. The primary outcomes were initiation and discontinuation rates of the 159 prescription-related problems. There Study Start: 04/2006 were 2,293 primary care patients prescribed lipid-lowering or Study End: 00/0000 antihypertensive drugs by 59 physicians who were randomized to the adherence tracking and alert system or active medication list alone to determine if the intervention increased drug profile review, changes in cardiovascular drug treatment, and refill adherence in the first 6 months. The secondary outcome of interest examined was the proportion of all prescribed medications that were potentially inappropriate. This 2 X 2 factorial randomization of practice Implementation: 00/0000 sessions and pharmacists resulted in four groups of patients: Study Start: 01/1994 physician intervention, pharmacist intervention, both interventions, Study End: 05/1996 and controls. This 2 X 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls. Practices wererandomly assigned to 3 arms of the study: Study End: 00/0000 control arm,and 2 intervention arms (an on-demand arm and an alerting arm). Data onpatients requiring treatment and patient treated based onthe two intervention arms were measured and compared. Reports N = 396 patients were printed in the nursing division and placed in patient charts. Pharmacists were not provided information about laboratory monitoring for patients in the usual-care group. Filing an up-to-date children with asthma asthma care plan improved having an up-to-date 14% (p = 0. At follow-up, the rates were statistically different, with lower proportions for intervention residents after adjustment for baseline rates (0. Control group prescribing degraded over time while the intervention group was stable. Alternative logistic regression analysis: significant interaction between group and site, indicating that the efficacy of prompts differed by site. Change in behavior was significantly related to the intervention, although both groups improved (p<0. Overall, for 13 standards including non-medicinal preventive care actions, adherence was significantly improved (53. The alerts also significantly changed the trend in the interacting prescription rate, with a preintervention increasing rate of 1. The absolute increase in the proportion of telephone consults for sore throat was 1. Two of 8 non-medication related preventive care recommendations were significantly improved as well. This pronounced in difference constitutes a higher the intervention rate of drug initiation (2. Hospital emergency physicians found mean effort department visit to use discharge software was within 6 months more difficult than the usual (35. Number of visits to the primary care provider (as recommended) increased significantly more in the intervention group than in the control group (difference of 0. In the recommendation control group, physicians s, there were spontaneously instituted the 19% fewer treatment that would have hospital been recommended in 17% of admissions in the instances in which the intervention recommendation was triggered group compared but not issued. Other prescribing (3 12 to 39 year asthma or drugs or drug classes and 4 group related age groups) did not differ (p = 0. No 40 yr, first choice differences were found for drugs for sore those in the cholesterol throats reminder group.
In general order malegra dxt plus with mastercard, one should start with a noninvasive and relatively inex- pensive test ﬁrst before proceeding to more expensive and invasive studies buy malegra dxt plus discount. For example purchase 160mg malegra dxt plus free shipping, the patient in the case presented at the start of this chapter, based on her presentation, would beneﬁt from an angiogram, provid- ing an emergent operation is not required. Order the test that the patient needs and that gives the information that is needed to take care of the patient optimally. It simply is the ankle systolic pressure taken by Doppler over either the posterior tibial or dorsalis pedis artery (whichever is highest) divided by the brachial systolic pressure, also taken by Doppler. The lower the value, the greater the degree of ischemia, with the important caveat that patients with very calciﬁed lower extremity vessels (e. Rest pain on dorsum of foot, worse at night, with inflow disease improves with dependency 2. These relatively easy-to-perform and inexpensive studies provide very accurate and reproducible information regarding lower extremity ischemia. It also is important to recognize that the above-mentioned studies also can be performed after the patient has exercised. The normal response to exercise is an increase in heart rate, blood pressure, and 28. Other noninvasive studies worth mentioning are arterial duplex ultrasound and transcutaneous O2 measurement. Duplex ultrasound is the combination of B-mode ultrasound with Doppler ultrasound. While it has become the gold standard for noninvasive imaging of the carotid arteries, its usefulness in lower extremity imaging is deﬁned less clearly. It is much more labor intensive than the above-mentioned studies and frequently more time-consuming to perform. Duplex scan- ning has been reported to detect signiﬁcant stenoses, with an average 82% sensitivity and 92% speciﬁcity depending on the vessels studied. The higher the level of O2, the better the arterial perfusion and generally the more likely a wound is to heal at that level. Transcutaneous O2 levels greater than 50mmHg correlate with good perfusion and generally good wound healing. Con- versely, transcutaneous O2 levels below 25mmHg indicate poor arter- ial perfusion and low likelihood of wound healing. Transcutaneous O2 measurements can be helpful in assessing the need to reperfuse an extremity prior to amputation or in assessing the proper level of amputation. While safe and particularly helpful for patients who have absolute contraindications for conventional angiography, there are several limitations. The best results are obtained when a speciﬁc area is being interrogated rather than when a global assessment is being made. Treatment Treatment of the ischemic extremity varies over a wide range of options and degrees of intervention. A large segment of patients who have nondisabling claudication can and should be treated conservatively. The recommendation for such conservatism is borne out by the fact that only 7% of patients with claudication at 5 years and only 12% at 10 years progress to amputation if left alone. This includes a program of exer- cise, smoking cessation, and control of lipids, glucose, and blood pressure. The patient, particularly the diabetic patient, must be educated about how to meticulously care for the lower extremity. Duplex scan- ning for diagnosis of aortoiliac and femoropopliteal disease: a prospective study. Initial assessment: Angiography (embolectomy) -pain -pallor -pulseless Reperfusion injury -paresthesias -paralysis G. Chronic Surgery in-situ technique Suspected (bypass) thrombosis Below knee—vein Acute H. Urokinase Start Thrombolytic therapy (intraarterial) Streptokinase heparinization Plasminogen activator I. If conservative measures are unsuccessful or if the patient presents with advanced disease, then vascular inter- vention is indicated. The guiding principles of vascular reconstruction are inﬂow, outﬂow, and a conduit. In addition, the reconstructions may be performed anatomically, extraanatomically, and, increasingly, endovascularly (within the artery itself). It is important to note that, occasionally, patients are in such a low cardiac output state that good inﬂow cannot be had. These patients generally have a dismal overall prognosis unless their cardiac status can be improved. Outﬂow generally refers to the target vessel below the occlusive disease to which blood will be supplied. Frequent outﬂow vessels in the ischemic lower extremity include the above-knee popliteal artery, the below- knee popliteal artery, tibial arteries, and, increasingly, particularly in diabetic patients, pedal arteries. Conduits may be pros- thetic, and, in fact, prosthetic conduits (particularly Dacron grafts) are the conduit of choice for large-vessel reconstruction such as the aorta and iliac segments. The success of prosthetic conduits for lower extremity conduits gener- ally are inferior to vein conduits. There are various adjunctive proce- dures that may be employed to enhance the success of these bypass procedures (Table 28. Lower extremity reconstructions can be performed safely on prop- erly selected patients with very acceptable morbidity and mortalities. Five-year survival, however, remains low, in the range of 50% to 60%, and this speaks to the advanced age of these patients and to the comor- bidities, particularly coronary artery disease, that afﬂict these patients. We generally speak in terms of primary and secondary patency and limb salvage when describing the success of lower extremity recon- structions. Increasingly, functional outcome data also are being assessed, which helps to provide a more detailed understanding of the beneﬁts of revascularization. In general, anatomic reconstructions have better long-term patency than extraanatomic reconstruction (e. Autologous conduits have better patency than prosthetic bypasses, particularly when the distal anastomosis is to an artery below the knee joint. It is important to remember that veins have valves and that these must be accounted for when a vein is going to be used as an arterial conduit. Endovascular procedures have been around since the early 1960s, but they have been reﬁned over the past decade. Most of these proce- dures can be performed percutaneously and therefore obviate the need for an incision and the associated pain, healing, and recovery. Many endovascular procedures, therefore, readily can be done using only local anesthesia or in combination with mild sedation. Most of the techniques are preformed with a guidewire technique devised originally by Seldinger. These are all in a state of evolution, but there is growing evidence to support their use in properly selected patients (Table 28. Comparative evaluation of prosthetic, reversed, and in situ vein bypass grafts in distal popliteal and tibialperoneal revascularization.
Therefore purchase generic malegra dxt plus on-line, speaking in terms of cerebral hemispheres provides a clearer understanding of the possible source of the problem purchase genuine malegra dxt plus online. The presence of a cervical bruit is an important physical ﬁnding to document in the evaluation of a patient with cerebrovascular disease discount malegra dxt plus online amex. In 20% of patients with bruits, hemodynamically signiﬁcant stenosis can be documented. Conversely, it is estimated that 19% to 27% of patients with notable stenotic lesions of the carotid were reported to have no bruit. It also is important to recognize that internal carotid artery plaques cause the vast majority (75–90%) of cervical bruits. While the presence of a carotid bruit may denote signiﬁcant carotid disease in only a small minority of patients, it is an important marker for increased risk of death from coronary artery disease. Interestingly, a bruit may disappear as the degree of stenosis increases beyond 85% to 90%. In addition to focusing on the patient’s neurologic status and whether or not a cervical bruit is present, one also must focus atten- tion on the overall health and physical ﬁndings of the patient, as these are of equal, if not of more, importance. Attention needs to be paid to the patients other comorbities, and their surgical risk should be assessed. Evaluation of the Doppler waveform and the peak systolic and end diastolic velocities in the internal carotid artery deter- mine the degree of internal artery within several relatively broad ranges. It is a relatively inexpensive exam that is safe and very well tol- erated by the patient. It also is accurate approximately 90% of the time in experienced vascular diagnostic laboratories. In addition, it may be difﬁcult to differentiate between a very high grade stenosis and complete occlusion. Axial images of the brain are obtained noninvasively, and anatomic abnormalities are visualized. These characteristics include the density of hydrogen nuclei, whether the nuclei are moving or stationary (ﬂow), and two magnetic properties of tissue called T1 and T2 relaxation. Scans can be generated that capital- ize on tissue difference of T1, T2, hydrogen density, and ﬂow. Magnetic resonance angiography is used best in conjunction with a high-quality duplex scan. Preoperative assessment of the carotid bifurca- tion: can magnetic resonance angiography and duplex ultrasonography replace contrast arteriography? Radiopaque contrast material then is injected via the catheter, and x-rays are taken. However, contrast angiography is invasive and is associated with a signiﬁcant complication rate. Positron-emitting isotopes are produced for carbon, nitrogen, oxygen, and ﬂuorine; these can be utilized to label a wide variety of metabolic substrates and drug ana- logues. When a positron decays, two photons are emitted 180 degrees apart: these photons are detected electronically by detectors that record only the simultaneously occurring photons 180 degrees apart. Tracer techniques are available for measuring cerebral blood ﬂow, cerebral blood volume, cerebral metabolic rate for oxygen, and cerebral metabolic rate for glucose; in addition, a useful derived function is the fraction of oxygen extracted by tissue (oxygen extraction fraction). Treatment The initial therapy for a patient who presents with a change in neu- rologic status is supportive. It is critical to take an accurate history, with particular attention to the onset of symptoms. There is increas- ing evidence that early intervention in a patient with stroke can affect the outcome positively. A thorough physical examination needs to be performed, and clear and concise documentation of any neurologic deﬁcit needs to be made. Comorbid conditions, such as hypertension, breathing problems, and chest pain, need to be treated aggressively. While the study frequently is interpreted as “normal” or “unchanged” initially in the evaluation of a patient presenting with a stroke, it also is helpful in ruling out other possible causes of a change in neurologic function, particularly an intracranial bleed or mass lesion. Ruling out a bleed particularly is important if the treating physician is contemplating the use of thrombolytic therapy for the treatment of acute stroke. There is increasing interest, growing experience, and accruing evi- dence to suggest that there is a role for thrombolytic therapy in the acute management of stroke. Successful protocols have been developed for the use of both intraarterial and intravenous throm- bolytic therapy. Multicentered trials have demonstrated a signiﬁcant beneﬁt to stroke patients if the therapy can be employed within 3 to 6 hours after the onset of symptoms. Analysis of the safety and efﬁcacy of intra- arterial thrombolytic therapy for ischemic stroke. Ciocca increased rate of signiﬁcant intracranial hemorrhage without a signiﬁ- cant effect on overall mortality. In general, the beneﬁt of thrombolysis decreases and the risks increase with time after the onset of symptoms. It is thought that, with increased awareness of the signs and symptoms of stroke and with more rapid response, employment of thrombolysis will prove to be safe and cost-effective. The evidence does not support the use of systemic anticoagulation for either therapeutic or prophylactic treatment of stroke, the critical exception being for those patients who have cardiogenic sources of cerebral embolization (e. There is level-one evidence to support the use of antiplatelet therapy in the management and prevention of patients with stroke. There is some debate as to the optimal dose, with the range being between 81 and 325mg daily. One of the more controversial issues in the management of stroke has been the role of carotid surgery. Beneﬁcial effect of carotid endarterectomy in symptomatic patients with high-grade carotid steno- sis. Prevention Risk Reduction Risk reduction is the cornerstone of prevention; it means the cessa- tion of smoking, and the control of diabetes, hypertension, and cho- lesterol. Anticoagulation with heparin and Coumadin has been shown to reduce the incidence of stroke in patients with cardiogenic sources of embolization. This beneﬁcial effect of surgery in asymptomatic carotid disease was in large part the result of a low 30-day operative risk (2. Interestingly, only half of the strokes were related to the surgical pro- cedure; the remainder were due to contrast angiography. This ﬁnding has led to a signiﬁcant decrease in the use of routine preoperative con- trast angiography for patients with carotid stenosis. This may be accounted for partly by the fact that the perioperative stroke rate in women was higher (3. The patient’s longevity 10 Executive Committee for the Asymptomatic Carotid Artherosclerosis Study. There is increasing evidence to support a selectively aggressive approach in these patients as well. While this chapter does not cover the surgical technique of carotid endarterectomy in detail, there are, however, several issues regard- ing this operation that do warrant brief consideration here. The operation may be performed either under general anesthesia or via a regional block.