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Epi demiological studies have reported an increased incidence of renal cell tumours in persons exposed for many years to medicine 6 year in us order nitroglycerin amex high levels of trichloroethene treatment question order nitroglycerin 2.5 mg with amex. Tetrachloroethene is soluble in lipids and is a narcotic with peripheral and central nervous effects; its narcotic effects are like those of trichloroethene treatment plan template discount nitroglycerin generic. There is a fixed relationship between the concentration of tetrachloroethene in the exhaled air and the preceding exposure levels medications list a-z discount nitroglycerin uk. It accumulates in the organism and so there is no clear associa tion between levels of exposure to tetrachloroethene and the concentration of trichloroacetic acid in single urine samples. Because it is readily soluble in lipids it defats the skin and can cause skin damage. Dichloromethane in high concentrations has depressant effects on the central nervous system and can increase the sensitivity of the heart muscle to catecholamines. To date, a clear association between exposure to dichloromethane and the development of tu mours in man could not be demonstrated. In the organism only a small part of the 1,1,1-trichloroethane is metabolized; mostly the substance is exhaled unchanged. Tetrachloroethene • narcotic effects including all stages of in to xication and even fatal deep narcosis • in rare cases direct exposure to tetrachloroethene vapour results in pulmonary oedema • gastrointestinal disorders and even haemorrhagic enteritis • anorexia, abdominal symp to ms • nausea, vomiting, abdominal pain/spasms • headaches, dizziness • lassitude • motility, sensibility and trophic disorders of the extremities • rare: acute irritation of the skin and mucous membranes (coughing, dyspnoea) • occasional sudden deaths caused by ventricular fibrillation after physical effort and alcohol consumption Survivors of an acute in to xication have generally no residual organ damage. Dichloromethane • narcotic effects including all stages of in to xication and even fatal deep narcosis • anorexia, nausea • headaches, dizziness • signs of irritation of the eyes, airways and skin • cardiac arrhythmia • angina pec to ris-like symp to ms Survivors of an acute in to xication have generally no residual organ damage. G 14 Trichloroethene (trichloroethylene) and other chlorinated hydrocarbon solvents 171 1,1,1-Trichloroethane • narcotic effects including all stages of in to xication and even fatal deep narcosis • signs of irritation of the eyes, airways and skin • cardiac arrhythmia Survivors of an acute in to xication have generally no residual organ damage. There are rare severe cases of liver cell necrosis, sometimes with involvement of the kidneys in a hepa to renal syndrome. Arch Toxicol 69: 291–299 Kaneko T, Wang P-Y, Sa to A (1997) Assessment of the health effects of trichloro ethylene. Employees whose work involves potential skin contact should be informed about the necessary measures for skin protection (protection, cleaning and care of the skin) and of the correct use of appropriate gloves. Potassium, sodium and magnesium chromates are readily soluble in water, calcium chromate is moderately soluble (at 20°C between 2 % and 10 % depending on the content of water of crystallization). Barium, lead, strontium and zinc chromates are practically insoluble in water but bar ium, strontium and zinc chromates are readily soluble in acids. They are intended to provide the physi cian with a to ol to help in the assessment of the analytical results. Skin Penetration of chromium trioxide, chromates or dichromates in to skin wounds, espe cially grazes or fissures, produces the characteristic “chrome ulcers” which heal very poorly. Gastrointestinal tract Oral uptake of large amounts of these substances causes immediate yellow discol oration of the mucous membranes and the oral cavity, difficulty in swallowing, cor rosion of the glottis, burning pains in the s to mach area, vomiting of yellow and green material (perhaps aspira to ry pneumonia), diarrhoea with blood in the s to ol, circula to ry failure, spasms, unconsciousness, renal failure, death in coma. Airways Inhalation of dust or vapour of chromium trioxide, chromates or dichromates in high er concentrations causes damage to the nasal mucosa (hyperaemia, catarrh, epithe lial necrosis) and also irritation of the upper airways and lungs. Employees should be informed about general hygienic measures and personal pro tective equipment. If during the course of his work in the company the occupational physician finds in dications that the risk assessment should be brought up to date to improve health and safety standards, he is to inform the employer. Dimethylarsinic acid is excreted as the main urinary metabolite of in organic arsenic compounds. It is assumed that the handling of pure metallic arsenic does not cause poi soning. But yellow arsenic is not very stable (metastable) and is rapidly converted to the metallic modification. Exposure to arsenic compounds causes local irritation of the eyes, the upper respira to ry tract and the skin. In some cases gastrointestinal disorders and systemic effects on the peripheral and central nervous systems have also been reported after inhalation exposure. Also blood disorders (anaemia, leukopenia), functional liver disorders (hepa to megaly) and skin changes have been described. Dusts containing arsenic (also in poorly soluble forms) cause irritation and tissue changes in the conjunctiva, the upper respira to ry tract and the skin. In addition, cardiovascular disorders, diabetes, peripheral nerve damage, disorders of vessels in the brain and encephalopathy have been observed. Employees should be informed about general hygienic measures and personal pro G19 tective equipment. Employees should be advised of the alcohol in to lerance caused by the synergistic ef fects of dimethylformamide and alcohol. Dimethylformamide is used especially as a solvent for plant and animal fats and oils and for certain resins and waxes. Clinical symp to ms often include a slight, uncharacteristic feeling of pressure or fullness on the right side, nausea and vomiting. Direct contact of the skin with the liquid can cause local irritation with itching and desquamation. Crit Rev Toxicol 31: 139–222 G 20 Noise 201 G 20 Noise G 20 Committee for occupational medicine, working group “Noise”, Metall-Berufsgenos senschaft Nord Sud, Mainz Preliminary remarks the present guideline describes a scheme for occupational medical prophylaxis which aims to ensure early diagnosis of adverse effects on the sense of hearing caused by noise and to maintain adequate functioning of the sensory organ ear. The working group on noise considers that employment in noisy areas is possible for persons who have been demonstrated by an ear, nose and throat specialist to be deaf in both ears and without useful residual hearing, provided that an increased risk of accidents could not result from their deafness. Of particular significance is the medical advice as to choice and use of hearing protec to rs. The employee has to take his or her hearing protec to rs to the medical examination. If the results of occupational medical examinations indicate focal cumulation of health risks, the physician, while observing medical confidentiality, is to inform and advise the employer. Noisy workplaces are found in most branches of industry, especially often in mining, in the iron and metal industries, s to ne and other raw material production, wood working, textile and leather, building and construction, and printing and paper in dustries. Hearing damage may be caused by exposure to daily noise exposure levels of 85 dB(A) or more. Whereas daily noise exposure levels of 85 to 89 dB(A) can cause hearing damage only after long periods of exposure, at levels of 90 dB(A) and more the risk of damage is markedly higher. Daily noise exposure levels of less than 85 dB(A) are unlikely to cause noise-related hearing damage. If hearing damage does develop al though the noise level was not higher nor the exposure period longer, the occupa tional physician is to obtain an anamnesis with the object of discovering the reasons for the damage. Later the hearing loss involves also higher frequencies and finally the middle frequency range as well. In general, sufficient recovery of hearing requires that the average sound pressure level during the recovery period is not greater than 70 dB and that the recovery period lasts at least 10 hours. To test whether a room is suitable for this purpose, it is expedient to record the audiogram of a young test person with no hearing impairment. This audiogram must not differ significantly from one recorded in the absence of extraneous noise. These requirements may be met if necessary by sound-proofed cubicles or, for air conduction audiometry, by sound-proofed audiometer earphones (constructed like earmuff hearing protec to rs). Generally this can be ensured if the person wears adequate hearing protec to rs during any noisy working periods before the medical examination. Comments Assessment Previous check-up was on no concern about health next check-up in months no concern about health under certain conditions* * Details Supplementary examination required Reasons: Increase in the sum of hearing losses of more than 30 dB in 3 years excessive hearing loss at 2 kHz Hearing loss greater than given in Table 1 or 2 Anamnesis question no. Cold stress may be expected during work (including repair jobs) in cold rooms, freezer rooms, freeze-drying rooms and low temperature research cabinets. G 21 Cold working conditions 227 At workplaces where wind or draughts increase the cooling effect on the body, em ployees are at particular risk. Local cooling caused by direct contact with evaporating coolants or brief contact with cold surfaces can cause frostbite. Schedule general medical examination special medical examination medical assessment and advice in unclear cases supplementary examination 230 Guidelines for Occupational Medical Examinations 1 Medical examinations Occupational medical examinations are to be carried out for persons at whose work places the occupational exposure limit value for cereal flour dusts or for platinum compounds is exceeded, for persons exposed at work to concentrations of cereal and feedstuff dusts above 4 milligrams inhalable dust per cubic metre of air, for per sons whose work involves exposure to dust from labora to ry animals in animal hous es and facilities, for persons using natural rubber latex gloves containing more than 20 microgram protein per gram glove material, and for persons exposed by inhala tion to incompletely polymerized epoxide resins. Follow-up examination Interim anamnesis (including work anamnesis), especially questions about current jobs, substances occurring at the workplace, and workplace-related symp to ms (run ny nose, sneezing, burning of the eyes, respira to ry symp to ms, urticaria) 1. Documentation of the measured values, exposure, symp to ms and therapy is necessary. Such conditions could include • special technical and organizational protective measures. Such measures are to be considered especially for persons with • a to pic diseases • type I sensitization to job-specific allergens or cross-reacting environmental aller gens.
Bulbar polio occurs in about 2% of paralytic polio cases and is manifested by weakness of muscles innervated by cranial nerves symptoms 8 dpo buy generic nitroglycerin 6.5 mg online. Bulbospinal polio accounts for about 19% of cases and is a combination of spinal and bulbar polio medicine shoppe locations order 6.5mg nitroglycerin otc. Rarely will the paralysis remain but if it extends beyond 60 days it is usually permanent medicine urinary tract infection purchase nitroglycerin 6.5 mg without prescription. It is characterized by further weakening of muscles that were previously affected by the polio infection symptoms you need glasses buy nitroglycerin 6.5 mg low price. Individuals may experience fatigue, slowly progressive muscle weakness, joint pain and increasing skeletal deformities. Some individuals experience only minor symp to ms and others have more severe symp to ms. Epidemiology Occurrence In 2007, poliomyelitis was limited to just four countries (Afghanistan, India, Nigeria, and Pakistan) that had not yet been successful in achieving complete eradication. The virus can remain in the throat for one week, and it can remain in feces between three to six weeks. Control Measures Management of Case A single case constitutes a public health emergency. Immunoprophylaxis All contacts should be appropriately updated with the age appropriate polio schedule. Exclusion Isolation of household contacts maybe of little benefit since the infection has usually spread by the time the first case is suspected. Management of Outbreaks An outbreak management team should be established to address infection prevention and control measures. Education and Prevention Measures fi Routine immunization of eligible populations is crucial in preventing the emergence of polio cases. Developmental or late onset conditions such as diabetes & progressive panencephalitis & any other conditions possibly caused by rubella virus Clinical Presentation Rubella Rubella is generally a mild febrile viral illness characterized by a mild rash in about 50% of cases. While children are usually asymp to matic adults have a low grade fever, headache, mild coryza, malaise and conjunctivitis may appear 1-5 days before the onset of rash. The most characteristic sign is lymphadenopathy and it can begin 5-10 days prior to the appearance of the rash and involves occipital, post auricular and posterior cervical nodes. Transient arthralgia and less often arthritis can occur in up to 50% of women and adolescents. The maculopapular rash last about 3-5 days, begins on the face and can spread to the chest arms and trunk. The virus may be shed in the infant’s urine or nasopharyngeal secretions for a year or more. Infants infected at 20 weeks of pregnancy or beyond may still present later in life (sometimes several years later) with deafness, chorioretinopathy, developmental delay or other problems. In mild forms of the disease, however, the anomalies may not be obvious at birth but become apparent within the first year of life. The risk of infection producing damage to the fetus is as high as 90% if infection occurs in the first trimester, falling to 10–20% by the 16th week, and becoming very low by the 20th week of pregnancy and beyond. Diagnosis Information on appropriate labora to ry specimens is available on public health labora to ry website site Epidemiology Occurrence In Canada, in 2000, there were 29 cases of rubella compared to 704 cases in 1991. Reservoir Humans Transmission Transmission occurs through droplets from the respira to ry secretions of an infected individual. It can be transmitted one week before and for one week after the onset of the rash. Control Measures Management of Case Investigations fi Confirm the diagnosis fi Determine the immunization his to ry fi Identify the possible sources of infection. Definition A susceptible contact is someone who has shared the same airspace during the infectious period. Although live-virus rubella vaccine administered after exposure has not been demonstrated to prevent illness, vaccine theoretically could prevent illness if administered within three days of exposure. If a person has not been immunized or if immunization status is uncertain he/she should be immunized according to the Newfoundland and Labrador Immunization Manual schedule at web site. Management of Outbreaks fi An outbreak management team should be established to address infection prevention and control measures. Education and Prevention Measures In countries, such as Canada, immunization rates are high and rubella is seen very rarely. Control and prevention of rubella: Evaluation and management of suspected outbreaks, rubella in pregnant women, and surveillance for congenital rubella syndrome. Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. It exists in two forms, as an anaerobic bacterium which lives in the bowels of humans and animals and in spores which are produced by the bacteria in the intestines and are excreted in feces. The spores are in a protective pod and they do not multiply outside of the body but are hardy and may survive for many years in soil and dust. Confirmed Case 9 Clinical illness without other apparent medical cause with or without labora to ry evidence of Clostridium (C. As the bacteria multiply and die they produce a to xin that is released in to the tissue. The clinical manifestations of tetanus are divided in to four clinical types: generalized, localized, cephalic, and neonatal. Generalized type Generalized disease is characterized by painful trismus (the most characteristic sign) and severe muscle spasms primary of the masseter and neck muscles, and secondarily of the trunk muscles. The individual experiences severe pain during spasms which are often triggered by sensory stimuli. Typical features of generalized tetanus include the position of opistho to nos and the facial expression known as “risus sardonicus” (fixed smile and elevated eyebrows) 9 Clinical Illness is characterized by acute onset of hyper to nia and/or painful muscular contractions (usually of the muscles of the jaw and neck), and generalized muscle spasms without other apparent medical cause. Localized type Localized tetanus involves spasticity or rigidity of muscles associated with the site of spore inoculation. It may be mild and persistent, lasting for weeks and often resolving spontaneously. Cephalic type Cephalic tetanus is a rare and unique form of localized disease that affects the cranial nerve musculature. Neonatal type Neonatal tetanus, arising from contamination of the umbilical cord, is a common cause of infant mortality in developing countries. This generally results from a lack of passive immunity, that is, mother being inadequately immunized and the non-aseptic umbilical cord-care practices. Apnea is the most prominent cause of death in the first week of life and sepsis in the second week. Epidemiology Occurrence There is worldwide occurrence with approximately 50,000 deaths annually but disease is relatively uncommon in industrialized countries. The disease is more common in agricultural regions and in underdeveloped areas where immunization may not be adequate and there may be contact with animal feces. Tetanus is an important cause of death in rural and tropical areas in countries of Asia, Africa, and South America. Neonatal tetanus accounts for approximately 50% of all tetanus deaths in developing countries. The worldwide tetanus mortality rate is 50% with the highest rates in young and old patients, and in persons using intravenous drug. The number of cases reported annually ranged from 1–7 (average five) from the years 1990 to 2000. In Newfoundland and Labrador, one case of tetanus has been reported in the past 10 years. Incubation period the incubation period is generally 3 to 21 days (range, 1 day to several months). Shorter incubation periods have been associated with heavily contaminated wounds, more severe disease, and a worse prognosis. In neonatal tetanus, symp to ms usually appear from 4 to 14 days after birth, averaging 7 days. Communicability Since tetanus is caused by the neuro to xin, it is not transmitted person- to -person.
These catheters significantly reduce the incidence of asymp to symptoms 16 weeks pregnant cheap nitroglycerin 2.5mg mastercard matic bacteriuria in treatment 1 generic nitroglycerin 6.5 mg on-line, however only for placement less than 1 week treatment zone lasik buy nitroglycerin 6.5 mg with mastercard. However medicine etymology purchase cheapest nitroglycerin and nitroglycerin, their use should be considered in selected high risk catheterised patients. Catheter insertion Urinary catheterisation should always be performed using sterile or high level disinfected equipment and aseptic technique. To minimise trauma to the urethra and discomfort to the patient, a sterile lubricant or local anaesthetic gel should be used. Meatal cleansing Meatal cleansing should be performed regularly to ensure that the meatus is free from encrustations. Cleansing with soap and water is suficient; application of antimicrobial ointment or disinfectant to the urethral meatus is harmful and should be avoided. Drainage bag To help prevent trauma to the urethra, the urinary drainage tubing should be secured to the patient’s thigh with straps and adjusted to a comfortable fit. The catheter drainage bag must always be placed below the level of the bladder to promote good drainage. If a catheter stand is used, the drainage bag and drainage tap must not come in contact with the fioor. During patient movement, the drainage tube should be temporarily clamped to prevent back-fiow of urine. Do not disconnect the drainage bag unnecessarily to interrupt the closed drainage system. Emptying the drainage bag the drainage bag should be emptied regularly via the drainage tap at the bo to m of the bag. If the bag does not have a tap, it must be replaced when fi full using aseptic technique. Extreme care must be taken when emptying a drainage bag to prevent cross-infection between patients. Hands must be washed or disinfected with an alcohol-based hand rub and non-sterile/clean disposable gloves should be worn when emptying the bag. Alcohol impregnated swabs should be used to decontaminate the outlet of the drainage tap (inside and outside). When emptying the drainage bag, use a separate container for each 262 Prevention of Catheter-Associated Urinary Tract Infections patient’s urine and avoid contact between the urinary drainage tap and the container. The urine container must be rinsed and heat disinfected afer each use (preferably in a washer-disinfec to r unit), dried, and s to red inverted in a clean place before further use. The use of these agents may damage the bladder mucosa or catheter and promote the development of resistant bacteria which are dificult to treat. Specimen collection Samples of urine for bacteriological examination should be obtained from the sampling port or sleeve using aseptic technique. The sampling port should be disinfected by wiping with a 70% isopropyl alcohol impregnated swab. The sample may then be aspirated using a sterile needle and syringe and transferred in to a sterile universal container. In asymp to matic patients, routine bacteriological testing is of no clinical benefit. Use of antimicrobial agents the routine administration of systemic antibiotics at the time of catheter insertion/removal is not recommended. Condom catheters There may be a place for the use of condom catheters for short-term drainage in cooperative patients. Condom use for 24 hour periods should also be avoided and other methods, such as napkins or aborbent pads, used at night. Prevention of bacterial colonisation/infection of the bladder in patients with indwelling urethral catheters Summary of Prevention Strategies Entry points for bacteria Preventive measures 1. External urethral meatus and urethra x Pass catheter when bladder full for wash-out effect. Bacteria carried in to bladder during insertion x Inject single-use sterile lubricant gel. Ascending colonisation/ x Secure catheter to prevent movement in urethra; infection up urethra bladder washes and ointments are of no value. Junction between catheter and drainage tube x Do not disconnect catheter unless absolutely necessary. Junction between drainage tube and collection bag x Drainage tube should be welded to inlet of bag Disconnection during manufacture. If it is necessary to raise collection bag above bladder level for a short Reflux from bag in to period, drainage tube must be clamped temporarily. European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. Hospital in Europe for Link Infection Control through Surveillance: September, 2004. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Dialysis can remove metabolic to xins and fiuids when the kidneys fail due to disease or damage. Transmission of infection can take place through contact with blood or body fiuids, contaminated equipment, or surfaces. Patients who are infected or colonised with microorganisms can also serve as sources for infection transmission. Stafi may inadvertently spread infections from patient to patient via direct or indirect contact with contaminated surfaces/equipment or infected/colonised patients. Stafi failure to perform hand hygiene, use Standard Precautions or, when required, transmission-based precautions, such as contact or droplet, places patients at risk of infection. Fistula: A connection that is surgically created between an artery and vein (usually in the arm). Blood and dialysis fiuids do not mix; the blood passes over a semi-permeable membrane which allows some molecules to pass through. This procedure can take up to 3-6 hours and usually takes place three times a week. The patient’s blood fiows through one side and the dialysate fiows through the other side. This is a result of frequent contact with health care facilities, frequent use of antibiotics, and use of invasive devices. Vancomycin use is high in dialysis populations, contributing to this increase in resistance; this reduces the choice of antibiotics for treating enterococcal infections. Prompt wiping up of water or other spills prevents mould contamination of the environment with subsequent fungal infections in susceptible populations such as dialysis patients. Mycobacteria There have been reports of mycobacterial infections in dialysis patients from contaminated water used for dialysis. Documentation of dialysis patient’s vaccination status for vaccine preventable illnesses. On-going regular and documented surveillance of bacteraemia (microorganisms, treatment, date of onset, precautions used, and date resolved), access site infections, and peri to nitis. Records for each patient should include documentation of the location of the treatment station used and machine number, as well as names of stafi connecting and disconnecting the patient. Access site infection prevention and preventing bloodstream infections • Proper hand hygiene must be carried out by all care providers following each of the World Health Organization’s 5 moments. Repeat skin preparation if the skin is to uched by the patient or stafi afer it has been applied, if cannulation is not completed. Cleanse the skin by applying 2% chlorhexidine gluconate/70% isopropyl alcohol, 70% alcohol, or 10% povidone iodine as per manufacturer’s instructions for use. Standard and transmission-based precautions • All stafi must use Standard Precautions, including hand hygiene, for dialysis patients. Environmental cleaning and disinfection • Adequate environmental cleaning with a hospital grade disinfectant is required for all patient areas with special atention to high- to uch items or surfaces likely to be contaminated with blood or body fiuids. Equipment cleaning and disinfection • Regularly maintained, cleaned, and disinfected dialysis equipment and machines, as well as reusable medical supplies, are essential for reducing the risk of infection. Safe medication and injection practices • Avoid contamination of multi-dose vials. Occupational safety considerations • Stafi who care for dialysis patients must follow Standard Precautions and, as necessary, transmission-based precautions, including use of appropriate personal protective equipment and hand hygiene to protect themselves from contact with and potential infection from blood or body fiuids. Access to reliable methods for regular cleaning and disinfection of surfaces and equipment in the dialysis area.
Separate media may be required for aerobic treatment 5th metacarpal fracture buy cheap nitroglycerin 6.5mg, anaerobic and acid fast bacilli treatment zenkers diverticulum purchase nitroglycerin on line amex, as well as for fungal and viral organisms d medicinebg effective nitroglycerin 6.5 mg. Give sufficient time for cultures of slow growing or fastidious organisms; these may take longer to medicinenetcom medications order nitroglycerin 6.5 mg without prescription incubate 3. Consult with the pathologist (who may want to be there when the specimen is obtained) c. False negatives can occur if insufficient material, material not handled properly or preparation delayed, or if treatment has altered the cellular material Q. Angiotensin-converting enzyme: clinical applications and labora to ry investigations on serum and other biological fluids. Interferometric technique reflected light is analyzed to produce a cross section of tissue B. Adequate pupillary dilation may be problematic if posterior synechiae present 2. Identification of morphological changes in tissue layers atrophy, thickening, dis to rtion 2. Interpretation of changes in the relative reflectivity of tissue layers hyporeflectivity, hyperreflectivity 3. Serous retinal detachments with fibrin bridges i) Can be used to quantitatively follow treatment efficacy iii. Optical coherence to mography: a key to the future management of patients with diabetic macular oedema. Uveitic macular oedema: correlation between optical coherence to mography patterns with visual acuity and fluorescein angiography. Intravenous dye injection (5 cc of a 10% solution in adults followed by a flush of saline) C. Start timer with dye injection and measure arm to eye time and moni to r transit phase in eye of greater clinical interest E. Capture pho to graphs at frequent intervals immediately following the injection of the dye until the dye disappears from the blood vessels (late phases, typically > 10 minutes after injection) F. Anaphylactic reactions (cardiovascular shock): less than 1 in 100,000 injections F. Retinal vascular staining must scan periphery retinal vasculitis, birdshot uveitis E. It can be detected with specialized infrared video angiography (modified fundus cameras, digital imaging system, scanning laser ophthalmoscope) V. Choroidal neovascularization: is seen as a focal "hot spot", plaque, or combination of both B. Appear about 10 minutes after dye injection and persist throughout the remainder of the study b. Larger and greater in number than the white dots seen clinically and by fluorescein angiography E. Multiple hypofluorescent spots (foci of lymphocytic infiltration) Additional Resources 1. Search for skin lesions consistent with sarcoidosis that might give a higher diagnostic yield 2. Bar to nella henselae serum immunoglobulin (Ig)G and IgM in suspected cat scratch disease D. Biopsy of other involved tissue such as skin, lung, parotid or lacrimal or minor salivary gland B. Identify an appropriate lesion potentially consistent with conjunctival sarcoid (blind biopsy of conjunctiva has very low diagnostic yield and is not recommended as a screening to ol in the absence of a nodule) B. Place specimen flat ( to avoid rolling of conjunctiva) on a substance like filter paper F. To rule out other causes of granuloma to us disease (eg foreign body, mycobacterium, fungal diseases) since sarcoid is a diagnosis of exclusion 2. Sufficient quantity to allow clonality testing (via flow cy to metry) and cy to genetics I. Linear basement membrane staining in ocular cicatricial pemphigoid (linear IgA, IgG, and complement staining along the basement membrane zone) J. Subconjunctival hemorrhage prevention includes avoiding anti-platelet agents pre-operatively B. If diagnostic, then appropriate therapy depending on etiology Additional Resources 1. Conjunctival lymphoid tumors: clinical analysis of 117 cases and relationship to systemic lymphoma. Uveitis where neoplastic or infectious disease are suspected (either due to the clinical appearance or to failure to respond to conventional therapy) a. Viral infection (Herpes simplex, herpes zoster, cy to megalovirus, Epstein Barr, human herpesvirus-6) c. Involve the pathologist before collecting the specimen to be sure of proper specimen handling and delivery 2. Once the pure vitreous aspirate has been obtained, syringe is capped and should be given immediately to the pathologist (who should be informed of the procedure and the differential diagnosis being considered). The cells in these vitreous specimens are particularly susceptible to rapid degradation and death. Clear communication must exist between the cy to pathologist and ophthalmologist regarding the differential diagnosis being considered 2. Molecular studies for gene rearrangement for diagnosis of lymphoma (IgH gene rearrangement) (must request in advance to be certain that labora to ries can perform studies requested) 4. Pre-procedure clinical suspicion impacts selection of tests and ultimate diagnostic yield C. If the biopsy reveals infectious agent, the patient should be treated for the infection May require infectious disease expert in cases of systemic infection. Microbiologic yields and complication rates of vitreous needle aspiration versus mechanized vitreous biopsy in the Endophthalmitis Vitrec to my Study. Sight-threatening chorioretinitis of unknown etiology involving one eye or both eyes a. Includes cases with an atypical presentation, inconclusive system work up, inadequate response to conventional therapy c. Useful to distinguish between cases of suspected infection or malignancy in which the biopsy has the potential to alter management 3. Disease in which there is a reasonable expectation that vitreous biopsy would provide sufficient material for cy to logic examination 2. Chorioretinitis in which there is reasonable expectation that culture, or polymerase chain reaction analysis or antibody determinations of ocular fluid would be sufficient to make the diagnosis 3. Usually, prior attempt at intraocular diagnosis with analysis of vitreous humor obtained by pars plana vitrec to my (unless subretinal material can be easily obtained by aspiration) or aqueous humor obtained by anterior chamber paracentesis B. B-scan ultrasonography to evaluate extent of chorioretinal involvement prior to biopsy 2. Evaluate for surgical site that is easy to access and contains sufficient tissue i. Create plan for repairing retinal defect (pars plana vitrec to my, endolaser, internal tamponade (long acting gas, silicone oil in cases of severe retinopathy, possible scleral buckle)) c. Analysis of another involved tissue, such as skin, lung, cerebral spinal fluid, or brain if more appropriate in cases where there are systemic involvements B. Patients should be off from therapy with corticosteroids or immunosuppressive medications prior to having biopsy to maximize yield of pathologic cells B. Retinal biopsies are often small, difficult to partition and may contain necrotic tissue only C. Chorioretinal biopsy can separate during fixation making the relationship of the various layers difficult to interpret D. Au to immune (commonly associated with seronegative Rheuma to id fac to r-negative spondyloarthropathies) c. Periods of disease quiescence off treatment are typically longer duration than episodes of acute disease i.
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