Mark Corson

By A. Taklar. State University of New York College at Oneonta.

Tobacco use is the major cause of cancer in India particularly for cancers of lung discount 6.5mg nitroglycerin visa, oral cavity order nitroglycerin 2.5mg on line, esophagus nitroglycerin 2.5 mg free shipping, larynx, pancreas and bladder. The overall prevalence rate of diabetes in urban and rural areas combined was estimated as 62. The pooled estimates of prevalence rates for diabetes mellitus for urban and rural areas were found to be 118. The first documented study on diabetes was a hospital based study from Kolkata in 1938 showing a prevalence of glycosuria as 1. Population based surveys done in the early 1970s in different Indian cities and nearby rural areas reported prevalence of diabetes ranging from 1. From these reports, it is evident that till the 1970s, the prevalence of diabetes was less than 3. The rise in prevalence of type 2 diabetes was reported in 1980s, which accelerated after 1990s, 22 showing rapid rises in the southern parts of the country. Urban residents with abdominal obesity and sedentary activity had the highest prevalence of self-reported diabetes (11. Increase in the prevalence of diabetes has also been reported among the marginalized and the poor. Urban locations have been observing a reversal of socio economic trends with the burden of disease increasing among the 26 poor. Diabetes substantially increases the propensity to macrovascular and microvascular complications, such as cardiovascular disease, cerebrovascular disease, retinopathy, nephropathy, neuropathy and foot problems, all of which account for considerable mortality and 27 morbidity. Assuming 40 million people with diabetes in India, the prevalence of various complications would be: Retinopathy (7 million); Nephropathy (0. In 12 addition, a third of the heart attack patients in India have concurrent diabetes. Fatality rate after myocardial infarction is greater in diabetic patients, and overall prognosis after coronary heart disease is worse. Hence, it has been proposed that diabetes should be considered as a coronary heart disease risk equivalent i. A review of published literature has highlighted several barriers in addressing the growing 28 burden of diabetes. Even in tertiary care centers, poor glucose control was observed in half of the patients highlighting poor management of individuals with diabetes. Hypertension is directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths 29 in India. The meta analysis of eight studies carried out in urban areas gives a pooled prevalence rate of 164. About 16% of ischaemic heart disease in the country is attributable of hypertension. The population attributable 21 risk due to hypertension was found to be 29% for stroke. Pooling of epidemiological studies shows that hypertension is present in 25% urban and 10% rural subjects in India. Subsequent studies report steadily increasing prevalence from 5% in 1960s to 12–15% in 1990s. Hypertension prevalence is lower in the rural Indian population, although there has been a steady increase over time here as well. Among the rural 29 populations, hypertension prevalence is men 24%, women 17% in Rajasthan (1994). Hypertension diagnosed by multiple examinations has been reported in 27% men and 28% 24 women executives in Mumbai (2000) and 4. Over the years, from 1942 to 1997, there has been a significant increase in the mean levels of systolic blood pressure in the Indian population particularly among urban men aged 40–49 years (from 120. According to the estimates of the Indian Council for Medical Research, 24% of acute myocardial infarction, 29% for stroke and 21% of peripheral vascular diseases in the country are attributed to hypertension. Detection and management, though relatively easier, less than half (31-37%) the hypertensive subjects get to identify their hypertensive status. Less than half of the hypertensive subjects undertake any kind of medication and only half of them 31 achieve good control. There is a strong correlation between changing lifestyle factors and increase in hypertension in India. The nature of genetic contribution and gene– environment interaction in accelerating the hypertension epidemic in India needs exploration. The prevalence rates among younger adults and women (in the age group of 40 years and above) are also likely to increase. Of course this also reflects the level of 10 treatment and management facilities available. The pooled estimates of prevalence rates for urban and rural areas were found to be 6. Recent studies showed that the age-adjusted annual incidence rate was 105/100,000 in the urban community of Kolkata and 262/100,000 in a rural community of Bengal. Similarly stroke prevalence is between 136 – 842/ 34 100,000 population in urban areas and 143-165/ 100, 000 population in rural areas. The poorer sections of the society, the less educated and the rural population have high prevalence of smoking and in certain settings such as worksites, high prevalence of diabetes and high blood pressure are seen among less educated groups. A higher prevalence was observed in low income groups as compared to the well-off (5.

Rarely discount 2.5 mg nitroglycerin, other less dramatic types of annular erythema may be signs of an internal malignancy cheap nitroglycerin 6.5mg online. Skin metastases Carcinomas of the breast buy nitroglycerin 6.5mg mastercard, bronchus, stomach, kidney and prostate are the most common visceral neoplasms to metastasize to the skin. Secondary deposits on the skin may be the first sign of the underlying visceral cancer. The lesions themselves are usually smooth nodules, which are pink or skin coloured (Fig. Acquired ichthyosis When generalized scaling without erythema begins in adult life, it is quite likely that there is an underlying neoplasm, particularly a reticulosis. This has to be dis- tinguished from mild dryness of the skin and the slight irritation seen in many chronic disorders, known as xeroderma. Nonetheless, there are a few patients with pemphigoid in whom the skin disorder is provoked by the malignancy and remits after the neoplasm has been removed. Dermatomyositis Women over the age of 40 years with dermatomyositis may have 50 per cent chance of a malignant tumour of the genitourinary tract, but infants with the 284 Endocrine disease, diabetes and the skin Figure 19. Overall, even in adults, the asso- ciation is not common and most cases of dermatomyositis occur without an iden- tifiable cause. There is an impression that dermatomyositis provoked by malignant disease is more severe. Figurate erythemas Rarely, annular erythema and erythema multiforme (see page 75) seem to be caused by underlying malignant disease. Histologically, there is a cellu- lar connective tissue with deposition of mucinous material. The serum from such patients contains substances that stimulate the growth and activity of fibroblasts. The condition is almost always a sign of thyrotoxicosis and is accompanied by exophthalmos. Rarely, there is diffuse infiltration with similar mucinous connective tissue of the hands and feet and finger clubbing in the condition of thyroid acropachy. Patients with thyrotoxicosis have warm, sweaty skin and a proportion complain of pruritus. In myxoedema, the skin often feels dry and rough and may have a yellowish orange tint, as carotenaemia may accompany the disorder. In addition, there may 285 Systemic disease and the skin be coarsening of the scalp hair, hair loss, loss of the outer third of the eyebrows, pinkish cheeks but a yellowish background colour – the so-called peaches and cream complexion. More than 50 per cent of individuals who present with this disorder will already have insulin-dependent diabetes. Many of those who do not have diabetes when they present will develop diabetes or have a first- degree relative with diabetes. Typically, irregular yellowish pink plaques occur on the lower legs and around the ankles (Fig. Uncommonly, lesions may occur elsewhere and there may be areas of atrophy and ulceration. Histologically, there is a central area of altered and damaged collagen in the mid-dermis, surrounded by inflammatory cells, including giant cells. When she was examined, the doctor found an elevated, irregular, yellowish pink patch measuring 2. It was thought that Julie had diabetes and that the leg patches were due to necrobiosis lipoidica diabeticorum. It was explained to her that, unfortunately, there was no certain cure for the disorder. Granuloma annulare This disorder has some superficial resemblance to necrobiosis lipoidica, both clin- ically and histologically, but in its common form has no association with diabetes. However, there is a rare, generalized and ‘diffuse’ form that is strongly related to diabetes. Ulceration of the skin in diabetes The neuropathy of diabetes can result in neuropathic ulceration due to failure of the so-called nociceptive reflex, in which the limb is rapidly withdrawn from a painful stimulus. Deep ‘perforating ulcers’ may develop on the soles and elsewhere around the feet (Fig. Atherosclerotic vascular disease is more common in diabetics and the resulting ischaemia may also contribute substantially to the ulceration of the feet or legs. There is also a depressed ability to cope with infections, and infection of the ulcer- ated area usually complicates such lesions in diabetics. Wounds in diabetics also tend to heal more slowly, turning any minor injury of the foot into a serious health risk. Their clinical appearance and lipid composition depend on the type of lipid abnormality. In diabetes, there is usually a mixed hyperlipidaemia in which both cholesterol and triglycerides are elevated. When the lipid levels are very elevated, eruptive xanthomata may develop in which numerous, small, yellow-pink papules appear anywhere, but especially on extensor surfaces (Fig. Skin infection and pruritus As mentioned above, diabetics appear particularly susceptible to skin infections. Monilial infection is a particular problem and monilial vulvovaginitis and bal- anoposthitis are common. These are ‘itchy disorders’ and it may be that this is how it came to be believed that diabetics can develop generalized itch. In fact, there is little evidence that diabetes is responsible for generalized itch. The underlying veins can be easily seen and the skin has a ‘transparent’ quality (Fig. The thinning is due to the suppressive action of glucocorticoids on the growth and synthetic activity of dermal fibroblasts and the epidermis.

Poliovirus specifically binds receptors on motor neuron terminals purchase 2.5 mg nitroglycerin with mastercard, then migrates centrally within axons (2) order nitroglycerin 6.5 mg otc. Other strains of organisms have developed mechanisms to cross the blood–brain barrier buy nitroglycerin 6.5mg, but lack the ability to bind to neurons or glia; these cause infections limited to the meninges, and not encephalitis. In most instances alterations of consciousness and cognitive function will be a nonspecific response to the febrile state, probably caused by circulating cytokines or other small molecules that cross the blood– brain barrier and are then neuroactive (3). Two key elements are involved in differentiating between such encephalopathies and primary brain processes. From the systemic perspective, identification of a specific underlying medical abnormality is the key. Neurologically, it is essential to establish whether the observed changes are focal or not—brain disorders resulting from localized damage to the brain cause abnormalities of function related to the site of damage. Damage to the cerebral cortex can cause seizures, an altered level of consciousness, and cognitive difficulty. Damage to the deep white matter causes spasticity, ataxia, visual and sensory problems, but not seizures and has a less severe impact on alertness and cognition. Damage to the brainstem can affect level of consciousness, long tracts that pass through the brainstem, but most importantly cranial nerve function. Damage to the temporal lobes can cause memory and olfactory problems, frontal lobe damage affects behavior, occipital lobe damage affects vision, etc. Typically if there is a brain-damaging process, functions that are affected remain affected throughout. In contrast, in patients with an encephalopathy abnormalities fluctuate in space and time. Hence a detailed clinical neurologic assessment can help differentiate between a structural process—i. In assessing patients’ mental status, one of the first steps must be assessing language. Without establishing meaningful communication with the patient, further assessment of brain function can be uninterpretable. Aphasic patients are commonly described as “confused” because what they say makes no sense. If a patient’s language sounds fluent but its content is incomprehensible, it is understandable to interpret this as evidence of confusion. However, several simple steps—asking the patient to follow several simple verbal commands (without helpful gesticulations), asking him/her to name a few objects or repeat a few words—should readily differentiate between a language disorder and a confusional state. Similarly, the behavior of a patient with psychosis may seem inexplicable and may be interpreted as evidence of confusion. Remarkably, although psychotic patients may Encephalitis and Its Mimics in Critical Care 155 demonstrate extraordinarily bizarre behavior, they almost always retain orientation and memory. Many disorders other than infections can produce focal brain damage—strokes and tumors being the most common. Differentiating between these disorders and infections should usually be straightforward, based on the clinical context. Stroke usually has a virtually instantaneous onset and causes abnormalities related to the specific blood vessel involved. Tumors typically cause symptoms that develop insidiously (over weeks or longer) and are not usually accompanied by systemic symptoms of infection. If there is no past history of epilepsy, and if no motor seizure activity was witnessed, these can be particularly perplexing. Post-ictal confusional states usually clarify themselves by resolving over minutes to hours. Although, as in patients with brain tumors, these patients do not typically have systemic symptoms of infection, assuming that this excludes encephalitis can be dangerous—not all patients with encephalitis have systemic signs at the onset, and encephalitis can present as non-convulsive status! All are potentially devastating and much-feared diseases—think of rabies or “sleeping sickness” as just two examples. On the other hand, most of the viruses that can cause encephalitis cause many more asymptomatic infections than symptomatic ones, and typically even among patients with symptomatic infection only a small subset develops neuroinvasive disease (2). The initial presentation of these infections is often unimpressive—typically much less dramatic than that of meningitis, where infection of the brain lining causes severe pain, sensitivity to light and sound, and reflex protective neck stiffness. The meninges and cortical blood vessels have nociceptive receptors, so inflammation is painful; the brain itself has no nociceptors. Fever, often low grade, is common—but less so in the very young, the elderly, and the immunocompromised. Neurologic changes are often initially limited to subtle alterations of consciousness or cognition—easily confused with the mild changes typically seen as a nonspecific result of systemic infection. Enteroviruses and listeria often cause prominent associated gastrointestinal symptoms. Specific Encephalitides A consideration of the specific infections (Table 1) that cause encephalitis should begin with those that are most treatable—spirochetoses, mycobacteria, and herpes viruses—all of which cause meningitis with varying degrees of parenchymal brain involvement. Consideration should next turn to disorders with significant prevalence—the arboviruses and most specifically West Nile Virus. Finally, there is a broad array of other agents that must be identified—if for no other reason than for epidemiologic recognition and prevention of additional victims (e. Although this infection is typically controlled by cell-mediated immunity, some degree of hematogenous dissem- ination occurs frequently. At some point long after initial infection, a tuberculoma may rupture into the subarachnoid space causing meningitis.