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For example women's health clinic yuma arizona discount femcare american express, in a large randomized trial menopause 1800s femcare 100mg on-line, raloxifene (Evista) failed to menstruation nausea and vomiting discount 100 mg femcare free shipping reduce coronary artery disease and signifcantly doms was assessed during pressurized air inincreased the incidence of fatal stroke and venous thromboembolism menstruation kit for girls cheap femcare 100 mg amex. Oil-based lubricants also have been Another question: Is it realistic to expect the patient to take a drug shown to increase the slippage rate, with a every day when her chief complaint is postmenopausal dyspareunia and 10 she is likely to have intercourse only once or twice a weekfi These questions probably won’t be addressed until the drug enters Water-based lubricants may slightly inthe market—and physicians and their patients will be the ones providing crease slippage, but they reduce breakage. Lubricants may afect recommended to hold moisture within the the integrity and function of sperm, even if tissues and provide a protective barrier. NoncomAdequate lubrication is also recommended mercial products, such as glycerin, olive oil, during intercourse. FemGlide causes less of a such products should be avoided in this decrease—but still a signifcant one. Pre-Seed, which has a more physioCareful examination reveals urogenital atrologic pH level and isotonic quality, was found phy with absence of any fungal or bacterial to cause minimal harm to sperm motility and infection of the vulva or vagina. Symptoms who have vulvodynia of dyspareunia disappear almost immediVaginal lubricants and moisturizers are ately, and vaginal burning improves after 6 also used in the treatment of vulvodynia or weeks. Urogeniof women’s sexual dysfunctions: an epibricants on sperm motility and chromatin spermicide tal atrophy: prevention and treatment. Ophena is a me-too drug with an imulation-based study of menopausal sympversus dienoestrol cream in the symppractical mode of administration. Clinical issues regarding et al; Women’s Health Initiative Steering nal intercourse. Vaginal dilation is used to lengthen and widen a vagina in women that have: • Extra tissue dividing the vagina (vaginal septum) • A small or not fully formed vagina (vaginal agenesis) • Surgery to make a vagina – you need to use dilation after surgery to keep the area open • After pelvic radiation for cancer treatment • Tight vaginal muscles (vaginismus) How do the dilators workfi Most women and teens without a fully formed vagina have a vaginal dimple, where the tissue puckers in a bit, or a small vaginal opening. Unless you have had surgery to make a vagina, it is your decision if and when you want to dilate. Using the dilators at the same time each day, such as first thing in the morning or before you go to sleep, will help you get into a routine. You will have time to practice placing the dilator in the right spot before you start using it at home. Set aside about 20 minutes, 2 times each day when you will have privacy in your bedroom or place of your choice. To let others in your household know you do not want to be disturbed, you may want to: • Hang a “Do not disturb” sign on your door 1 of 3 How to Use Vaginal Dilators • Put a lock on your door • Have a code word with your mom or dad Getting ready Before you dilate: 1. If you have time, take a warm bath for at least 10 minutes – the warm water helps to soften the tissue where you will be using the dilators. Use a small amount of water-based lubricant – put a small amount of lubricant, such as K-Y Jelly or coconut oil on the tip of your dilator. Place the lubricated dilator against your skin, right in your vaginal dimple (this is entrance of your vagina). You can find this spot by slowly and gently sliding the tip of the dilator along the spot below your urethra (where your urine leaves your body). Clitoris Labia Minora (inner lips) Vaginal Entrance Urethra (dimple) Anus the Vulva Using pressure, push the dilator at an angle toward your lower back or tail bone. Using the Vaginal Dilators Urethra Urethra Uterus Dilator Dilator Vagina Vagina Anus Anus With the Uterus Without the Uterus 2 of 3 How to Use Vaginal Dilators You should feel pressure but not pain. You will see your doctor often while you are dilating to make sure it is going well for you. As your vagina stretches, your doctor will have you start using Free Interpreter the next size dilator. If you toll-free Family have any questions about how to use the dilators, ask your doctor or nurse. If Interpreting Line you have been using the dilators regularly and you don’t get good results, 1-866-583-1527. We encourage you to talk with your healthcare provider, family member or friend before you make this decision. It is very important to talk to your doctor before you have sex to make sure it will be comfortable for you. Your doctor will also want to talk to you about how to prevent sexually transmitted infections. Talk to your doctor if you are having pain during sex or you are worried about sex. Seattle Children’s offers interpreter services for Deaf, hard of hearing or non-English speaking patients, family members and legal representatives free of charge. Seattle Children’s will make this information available in alternate formats upon request. Policy analysis helps decision makers achieve the greatest value from limited available resources. One way that health systems expand intervention coverage is through selected platforms that deliver interventions that require similar logistics but deliver interventions from different packages of conceptually related interventions, for example, against cardiovascular disease. Platforms often provide a more natural unit for investment than do individual interventions. Analysis of the costs of packages and platforms—and of the health improvements they can generate in given epidemiological environments—can help to guide health system investments and development. In populations lacking access to health insurance or prepaid care, medical expenses that are high relative to income can be impoverishing. Where incomes are low, seemingly inexpensive medical procedures can have catastrophic financial effects. Each individual volume will provide valuable, specific policy analyses on the full range of interventions, packages, and policies relevant to its health topic. Here we express our particular gratitude to the Bill & Melinda Gates Foundation for its sustained financial support, to the InterAcademy Medical Panel (and its U. Jamison Rachel Nugent Hellen Gelband Susan Horton Prabhat Jha Ramanan Laxminarayan Charles N. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Nothing herein shall constitute or be considered to be a limitation upon or waiver of the privileges and immunities of the World Bank, all of which are specifically reserved. Rights and Permissions this work is available under the Creative Commons Attribution 3. Under the Creative Commons Attribution license, you are free to copy, distribute, transmit, and adapt this work, including for commercial purposes, under the following conditions: Attribution—Please cite the work as follows: Black, R. Adaptations—If you create an adaptation of this work, please add the following disclaimer along with the attribution: this is an adaptation of an original work by the World Bank. Views and opinions expressed in the adaptation are the sole responsibility of the author or authors of the adaptation and are not endorsed by the World Bank. Third-party content—The World Bank does not necessarily own each component of the content contained within the work. The World Bank therefore does not warrant that the use of any third-party-owned individual component or part contained in the work will not infringe on the rights of those third parties. If you wish to re-use a component of the work, it is your responsibility to determine whether permission is needed for that re-use and to obtain permission from the copyright owner. Examples of components can include, but are not limited to, tables, figures, or images. Title: Reproductive, maternal, newborn, and child health / volume editors, Robert Black, Ramanan Laxminarayan, Marleen Temmerman, Neff Walker. Reproductive, Maternal, Newborn, and Child Health: Key Messages of this Volume 1 Robert E. Burden of Reproductive Ill Health 25 Alex Ezeh, Akinrinola Bankole, John Cleland, Claudia Garcia-Moreno, Marleen Temmerman, and Abdhalah Kasiira Ziraba 3. Levels and Causes of Maternal Mortality and Morbidity 51 Veronique Filippi, Doris Chou, Carine Ronsmans, Wendy Graham, and Lale Say 4.
Diseases
- Herpes virus antenatal infection
- Galactosamine-6-sulfatase deficiency
- Immunodeficiency, secondary
- Arthrogryposis like hand anomaly sensorineural
- Acute lymphoblastic leukemia
- Hyperkeratosis palmoplantar localized acanthokeratolytic
- Spina bifida
Back to menopause natural remedies purchase cheapest femcare and femcare Top Date Sent: 8/25/20 238 these criteria do not imply or guarantee approval womens health 97045 buy discount femcare 100 mg. Acute manifestations of atherosclerosis such as acute myocardial infarction menstruation age 9 purchase femcare with a visa, stroke menstrual goddess buy 100mg femcare otc, or sudden cardiac death are due to thrombosis following rupture of an unstable plaque. It is thus valuable to detect coronary atherosclerosis early in its course and try to alter its progression by modifying certain identifiable risk factors. Atherosclerosis predominantly affects the intima of the vessel wall; however, ultrasound imaging cannot discriminate between the intima and media, and is thus applied to the intima-media complex. Criteria | Codes | Revision History measured at several areas along the vessel wall; at the posterior aspect of the common carotid artery, the anterior wall of the internal carotid artery or at the common carotid artery bifurcation. It is believed however that imaging from different segments will most likely increase the likelihood of providing more relevant information, based on the fact that atherosclerosis tends to develop in an asymmetric manner. The inter-reader variability is fairly high, and there is no clear cut-off point above which atherosclerosis can be defined. The cut-off points to determine the presence of an atherosclerotic plaque were arbitrarily chosen. It was suggested that an average thickness of the combined intima and media ranging between 0. The Rotterdam study was a cohort study of 8,000 patients aged 55 years or older, followed up for 4. Different sites of the carotid artery were imaged, and different methods of measurements were used, as well as different standards or cutoff values for the threshold thickness. A change in carotid intima-media thickness does not necessarily indicate a change in cardiovascular risk. The majority were review articles, opinion pieces, or dealt with specific subgroups of patients. Is Carotid Intima-media thickness useful in cardiovascular diseases risk assessment. Back to Top Date Sent: 8/25/20 241 these criteria do not imply or guarantee approval. Effective April 1 – November 1, 2020, Kaiser Permanente is changing the utilization management requirement for Non-invasive prenatal Fetal testing. The approximate risk of a trisomy 21 (T21; Down syndrome) fiaffected birth is 1 in 1100 at age 25 to 29. The risk of a fetus with T21 (at 16 weeks of gestation) is about 1 in 250 at age 35 and 1 in 75 at age 40. Other trisomy syndromes include T18 (Edwards syndrome) and T13 (Patau syndrome), which are the next most common forms of fetal aneuploidy, although the percentage of cases surviving to birth is low and survival beyond birth is limited. The prevalence of these other aneuploidies is much lower than the prevalence of T21 and identifying them is not currently the main intent of prenatal screening programs. Also, the clinical implications of identifying T18 and 1T3 are unclear because survival beyond birth is limited for both conditions. Standard aneuploidy screening involves combinations of maternal serum markers and fetal ultrasound done at various stages of pregnancy. The detection rate for various combinations of noninvasive testing ranges from 60% to 96% when the false-positive rate is set at 5%. Commercial, noninvasive, sequencing-based testing of maternal serum for fetal trisomy syndromes is now available. The tests are unable to provide a result if the fetal fraction is too low (ie, <4%). For example, fetal fraction was found to be lower at higher maternal weights and higher with increasing fetal crown-rump length. After adjusting for guanine cytosine content and removing repetitive regions, the test had a sensitivity of 99. Back to Top Date Sent: 8/25/20 243 these criteria do not imply or guarantee approval. After adjustment for guanine cytosine content the test had a sensitivity of 100% and a false positive rate of 0. Based on this evidence Kaiser concluded that despite a promising diagnostic performance, MaterniT21 suffers from an extremely sparse, vendor-involved body of evidence specific to a high-risk population, and lacks studies examining the prospective impact of MaterniT21 on patients’ decisions of whether to purse chorionic villus sampling or amniocentesis (Kaiser 2012). Articles: In March 2012, Kaiser review MaterniT21 for the detection of trisomy 21. The use of MaterniT21 does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Criteria For Medicare Members this service is covered, and no medical necessity review required. Second-generation metal-on-metal implants, believed to have lower wear rates, were introduced in the 1990s. The ceramic material has undergone modifications, and a third-generation ceramic, released in the mid-1990s, is believed to have better wear properties. The cause of squeaking remains unknown; possible sources include suboptimal anteversion and inclination of the cup, focally increased surface roughness, and lack of lubrication fluid between the articulating surfaces (Keurentjes et al. Back to Top Date Sent: 8/25/20 246 these criteria do not imply or guarantee approval. D’Antonio did not present statistical comparisons among groups, but scores on the outcome variables appear to be similar. No ceramic fractures were reported during a mean of 35 months’ follow-up; there was a 2-3% rate of intraoperative insert chips. The D’Antonio study, conducted by the team with substantial financial links to Stryker, found a significantly lower rate of revision in the group receiving ceramic-on-ceramic implants compared to metal-on-polyethylene systems after a mean follow-up of 5 years. The study finding the higher rate required objective verification of the squeaking noise. In conclusion, there is insufficient evidence on the safety and efficacy of ceramic hip implant systems compared to other types of systems. Studies tended to be small, assess different safety variables, and be underpowered to measure differences in pain and function. Although this is largely a nuisance side effect, it is a reason for revision surgeries. The largest studies have been conducted by investigators associated with Stryker, which may lead to bias. Articles: Three randomized controlled trials evaluating ceramic-on-ceramic hip implants were identified and critically appraised. In addition, the findings of the two series that specifically addressed squeaking are included (Keurentjes et al. Back to Top Date Sent: 8/25/20 247 these criteria do not imply or guarantee approval. The use of ceramic on ceramic hips in total hip replacement surgery does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 8/25/20 248 these criteria do not imply or guarantee approval. Background Multiple sclerosis is an autoimmune inflammatory disease of the central nervous system that affects approximately 250,000 to 500,000 people in the United States. After the endovascular treatment, disease severity significantly © 2011 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 8/25/20 249 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History improved for patients with relapse remitting multiple sclerosis, but not for patients with primary progressive or secondary progressive multiple sclerosis. In patients with relapse remitting multiple sclerosis, significantly more patients were relapse free during the 18 months posttreatment compared to the year proceeding endovascular treatment; however, there was no significant difference in annualized relapse rate. Quality of life improved significantly for subjects with relapse remitting and primary progressive multiple sclerosis, but not for subjects with secondary progressive multiple sclerosis. For Non-Medicare Members There is insufficient evidence in the published medical literature to show that this service/therapy is as safe as standard services/therapies and/or provides better long-term outcomes than current standard services/therapies. People aged 50 to 54 years are the most affected and C7 is the most frequently involved (Radhakrishnan et al. Clinical manifestations include neck, shoulder, scapula, and hand pain, as well as neurologic symptoms. Initial treatment consists of conservative therapy including analgesics, corticosteroids, physical therapy, cervical traction (Carette & Fehlings, 2005).
These women should have an endometrial biopsy every 3 months to pregnancy 0-9 months buy cheap femcare 100mg on-line check for recurrence breast cancer gear femcare 100mg with amex, with recurrence risks approaching 50% (185) womens health nurse practitioner program online buy femcare 100 mg lowest price. Ovarian volume is related to breast cancer under arm order femcare 100mg online age, menopausal status, weight, height, and use of exogenous hormones (260). A large body habitus and uterine size make it more difficult to palpate and assess ovarian size, particularly among postmenopausal women, and transvaginal ultrasonography is significantly more accurate than clinical examination. Transvaginal ultrasonography is suggested in addition to annual pelvic examination among overweight postmenopausal women (261). Although ovarian cancer is notoriously difficult to diagnose at any early stage, the concept that it is frequently asymptomatic is challenged. Symptoms may include back pain, fatigue, bloating, constipation, abdominal pain, and urinary symptoms; these symptoms are of greater severity and more recent onset in women with ovarian malignancy (262). Thus it is argued that among primary clinicians, the possibility of an ovarian mass (either benign or malignant) in women with these symptoms warrants further diagnostic investigation. However, the positive predictive value of these symptoms is not high for the prediction of early-stage disease, and the use of symptoms to trigger an evaluation for ovarian cancer is noted to result in diagnosis of the disease in only 1 in 100 women in the general population with such symptoms (263). Ovarian cancer is predominantly a disease of postmenopausal women; the incidence increases with age, and the average patient age is about 56 to 60 years (see Chapter 37). With increased use of pelvic ultrasonographic evaluation, a new problem arose in postmenopausal women: the discovery of a small ovarian cyst. This is particularly troublesome in a woman who is entirely asymptomatic and whose ultrasonographic examination was performed for indications unrelated to pelvic pathology. Surgery may be indicated in some women with a strong family history of ovarian, breast, endometrial, or colon cancer, or with a mass that appears to be enlarging (see Chapter 37). The addition of color flow Doppler examination and other ultrasonographic characteristics may be helpful in distinguishing benign from malignant masses, although the role of Doppler ultrasonography remains somewhat controversial (Tables 14. Uterine and Other Masses Many postmenopausal women have not had regular gynecologic care, and the discovery of a pelvic mass may reflect the persistence of a uterine leiomyoma that previously was not discovered. The possibility of transient ovarian cysts is noted above, and it may be difficult to distinguish an ovarian from a uterine mass. Thus, a review of medical records may be helpful in determining the preexistence of a benign pelvic mass. Uterine leiomyomas are hormonally responsive and typically decrease in size or resolve after menopause (see Chapter 15). Diagnosis A personal and family medical history is helpful in detecting individuals at increased risk for the development of ovarian cancer. Several hereditary family cancer syndromes involve ovarian neoplasms (see Chapter 37). However, patients with hereditary forms of epithelial ovarian cancer account for only a small percentage of all cases; 90% to 95% of cases of ovarian cancer are sporadic and without identifiable heritable risk. A high index of suspicion by both women and their clinicians represents the best way to detect early ovarian cancer. Persistent symptoms such as an increase in abdominal size, bloating, fatigue, abdominal pain, indigestion, inability to eat normally, urinary frequency, pelvic pain, constipation, back pain, new onset of urinary incontinence, or unexplained weight loss require evaluation and consideration of the possibility of ovarian cancer. Management the use of improved imaging techniques may allow the nonoperative management of ovarian masses that are probably benign (Table 14. A physician trained to appropriately stage and debulk ovarian cancer, such as a gynecologic oncologist, should perform the surgery in a hospital with the necessary support and consultative services to optimize the patient’s outcome (266). When a malignant ovarian mass is discovered and the appropriate surgical staging and debulking procedure cannot be performed by the generalist obstetriciangynecologist, a gynecologic oncologist should be consulted. Comprehensive surgical staging facilitates appropriate therapy and optimizes prognosis. Postmenopausal Vulvar Conditions Anatomic changes that occur in postmenopausal women include atrophy of the labia majora and increasing prominence of the labia minora. The epithelium of the hymen and vestibule become thin; there is a shift in vaginal cellular maturation in response to estrogen deprivation, with resultant thinning. Although these changes lead to minimal symptoms in most women, external dysuria, pruritus, tenderness, dyspareunia, and bleeding can result from fissuring and excoriations. Vulvar Dermatoses Several vulvar conditions occur most commonly in postmenopausal women. In the past, numerous terms were used to describe disorders of vulvar epithelial growth that produce a number of nonspecific gross changes. These terms included leukoplakia, lichen sclerosus and atrophicus, atrophic and hyperplastic vulvitis, and kraurosis vulvae. Vulvar conditions that are described in this classification system include atopic, allergic, and irritant contact dermatitis, psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, pemphigoid, aphthous ulcers, Behcet’s disease, and Crohn’s disease. Lichen sclerosus can occur at any age, although it is most common among postmenopausal women and prepubertal girls (Fig. Lichen sclerosus characteristically is associated with decreased subcutaneous fat to the extent that the vulva is atrophic, with small or absent labia minora, obliteration of the anatomic landmarks, thin labia majora, and sometimes phimosis of the prepuce. The surface is pale with a shiny, crinkled pattern (described as having characteristics like “cigarette paper”), often with fissures and excoriation. The lesion tends to be symmetric and often extends to the perineal and perianal areas. Invasive cancer is associated with lichen sclerosus, although the significance of this association is unclear in terms of causation (289). Maintenance therapy is frequently required, and a graduated reduction from ultrapotent to mediumand lowpotency topical steroids can help to maintain remission of symptoms (269–271). Premalignant Vulvar Lesions Squamous vulvar intraepithelial neoplasia is seen most often in postmenopausal women but may occur during the reproductive years. Pruritus is the most common symptom, although “lumps” may be described and are sometimes confused with condyloma (268). Urethral Lesions the urethra and vagina have a common embryonic origin and are steroid-dependent tissues. Urethral caruncles and prolapse of the urethral mucosa are examples of vulvar lesions that may be seen in other age groups but that occur more commonly among older women. Various vulvar skin lesions, including seborrheic keratoses and cherry hemangiomas (senile hemangiomas), occur more commonly on aging skin. Postmenopausal Vaginal Conditions Up to 50% of postmenopausal women have symptoms of atrophic vaginitis (257). Symptoms include an external dysuria, pruritus, tenderness, dyspareunia, and bleeding from fissuring or ulcerations. In addition to the clinical findings of a shiny, flat, thin-appearing vaginal mucosa without rugae, microscopic examination of vaginal secretions reveals an increased number of white blood cells. Treatment with local or systemic estrogens effectively manages the symptoms and restores normal pH levels with ongoing therapy (274,275). Systemic absorption does occur with topical estrogen therapy, and rates of absorption differ depending on the degree of atrophy. Topical emollients may be helpful if estrogens are not desired or are contraindicated. Vaginal lubricants are universally useful in minimizing symptoms of dyspareunia for postmenopausal women (275). Pubertal maturation in girls and the relationship to anthropometric changes: pathways through puberty. Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings network. Childhood vulval lichen sclerosus and sexual abuse are not mutually exclusive diagnoses. Premenarchal vaginal discharge: findings of procedures to rule out foreign bodies. Drug and Therapeutics and Executive Committees of the Lawson Wilkins Pediatric Endocrine Society. American Medical Association Diagnostic and Treatment Guidelines on Child Sexual Abuse. Patterns of accidental genital trauma in young girls and indications for operative management. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Pubertal maturation of the internal genitalia: an ultrasound evaluation of 166 healthy girls. Occurrence of ovarian malignancy in childhood and adolescence: a community-wide evaluation.
Pus alone or a cursory surface swab is gram-positive cocci women's health center riverside hospital 100 mg femcare otc, specifically staphylococci ehealthforum.com › womens health › birth control forum buy genuine femcare online, are the most inadequate and does not represent the disease process pregnancy 40 weeks buy cheap femcare 100mg. Pseudomonas aeruginosa is involved • Do not ask the laboratory to pregnancy 4 months cheap generic femcare canada report everything that grows. Burn Wound Infections including decubitus ulcers, are not valuable, as they usually Reliance on clinical signs and symptoms alone in the diagrepresent colonizing microbes, which cannot be differentiated nosis of burn wound infections is challenging and unreliable. Tissue biopsies after thorSampling of the burn wound by either surface swab or tissue ough debridement, or bone biopsies through a debrided site, are biopsy for culture is recommended for monitoring the presence most valuable. Necrotizing cutaneous infections, such as necroand extent of infection (Table 41). The surface swabs requires twice-weekly sampling of the same site to infection usually occurs following a penetrating wound to the accurately monitor the trend of bacterial colonization. A major extremities, is often life-threatening, and requires immediate limitation of surface swab quantitative culture is that microbial recognition and intervention. On rare occasions, necrotizing growth reflects the microbial flora on the surface of the wound fasciitis occurs in the absence of identifiable trauma. Quantitative bacterial culture of for uncomplicated infections (cellulitis, subcutaneous abscesses) tissue biopsy should be supplemented with histopathological treated in the outpatient setting. Whether cultures are benefcial examination to better ascertain the extent of microbial invain managing cellulitis in the hospitalized patient is uncertain and sion. Be advised that quantitative bacterial cultures may not be the sensitivity of blood cultures in this setting is low. Cultures offered in all laboratories; quantitative biopsy cultures should are indicated for the patient who requires operative incision and be considered for patients in whom grafting is necessary. For drainage because of risk for deep structure and underlying tissue laboratories that provide quantitative wound culture services involvement and cases of therapeutic failure [223]. It is important that the clinician be familiar with the to insufficient quantity of specimen, especially when cultures extent or limitation of services provided by the supporting lab(fungal, mycobacterial) other than bacteriology are requested. For example, not all laboratories provide quantitative Prior to any sampling or biopsy, the wound should be thorcultures for the assessment of wounds, especially burn wounds. Blood cultures should be collected microbiology laboratory, consult with the laboratory so that for detection of systemic disease secondary to the wound. It is advisable that the around times are likely to be longer, thus extending the time to clinician determine if the local supporting laboratory has validated receipt of results. Human Bite Wound Infections the human oral cavity contains many potential aerobic and C. Animal Bite Wound Infections anaerobic pathogens and is the primary source of pathogens that As with human bite wounds, the oral cavity of animals is the cause infections following human bites. The most common of primary source of potential pathogens and thus the anticipated these are Staphylococcus spp, Streptococcus spp, Clostridium spp, etiological agent(s) is highly dependent upon the type of anipigmented anaerobic gram-negative rods, and Fusobacterium mal that inflicted the bite (Table 43). Such infections are common in the pediatric age group and for the majority of animal-inflicted bite wounds, the 2 most are often inflicted during play or by abusive adults. Bite wounds prominent groups of microorganisms initially considered in the can vary from superficial abrasions to more severe manifestaevaluation of patients are Pasteurella spp, namely P. Other common aerobes include endocarditis, meningitis, brain abscess, and sepsis with accomstreptococci, staphylococci, Moraxella spp, and saprophytic panying disseminated intravascular coagulation, especially in Neisseria spp. Due to the complexIn addition to the challenge of acquiring a representative ity of the microbial flora in animals, examination of cultures for wound specimen for aerobic and anaerobic culture, a major organisms other than those listed in Table 43 is of little benelimitation of culture is the potential for misleading informafit since these organisms are not included in most of the comtion as a result of the polymicrobial nature of the wound. It is mercial identification systems (conventional and automated) important that a Gram stain be performed on the specimen to databases [229–238]. Matrix-assisted laser desorption–ionassess the presence of indicators of infammation (eg, neutroization mass spectrometry has proven valuable in identifying phils), superfcial contamination (squamous epithelial cells), organisms when conventional phenotypic systems have failed. Swabs are not the specimen of choice If rabies or herpes B infection is suspected, contact the local or in many cases (Table 42). Major limitations of swabs vs tissue state public health laboratory for assistance and advice on how biopsy or aspirates include (1) greater risk of contamination to proceed. Laboratory Diagnosis of Human Bite Wound Infections Transport Issues and Etiologic Agents Diagnostic Proceduresa Optimum Specimens Optimal Transport Time Bacterial Aerobes Aerobic/anaerobic culture Tissue Anaerobic transport conditions/vials Mixed aerobic and anaerobic oral fora Gram stain Biopsy/aspirate aThere is no utility in collecting a specimen at the time of the bite; collect samples only if infection occurs. It is strongly providers, the environment, or materials manipulated during recommended that specimens not be submitted for culture an “incisional” or “organ/space” surgical procedure. Incisional within the first 48 hours posttrauma as growth from speciinfections are further divided into superficial (skin and submens collected within this time frame most likely represents cutaneous tissue) and deep (tissue, muscle, fascia). The optimal time to acquire cultures is immediately after guidelines for prevention of surgical site infections, 2014, for debridement of the trauma site [239–242]. Of the microbial agents listed with additional testing being reserved for uncommon or rare below (Table 45), S. Although enterococcal species chronic manifestations of infection or who do not respond to are commonly isolated from superficial cultures, they are selan initial course of therapy. To optinal trauma, intravenous drug users inject themselves with exogmize clinically relevant laboratory results, resist the use of swabs enous substances that may include spores from soil and other during surgical procedures, and instead submit tissue, fluids, or contaminants that cause skin and sof tissue infections, rangaspirates. Agents are similar to those in Table 44, with the addition of Clostridium sordelF. Tubing may also be tailored accordinserted gastrostomy, dialysis access and related intervention, ing to the aforementioned specifcations. Some types of tubtransjugular intrahepatic portosystemic shunt, biliary intervening include round or fat silicone, rubber, Blake/channel, and tion, and endovenous laser ablation of varicose veins) performed triple-lumen sump. Procedures are regarded as either diagon gravity or bulb suction, or it may require hospital wall sucnostic (eg, angiogram) or performed for treatment purposes (eg, tion or a portable suction device. Images are used to direct procedures that are perfrom 1 day to weeks, but should be removed if an infection formed with needles or other tiny instruments (eg, catheters). The infectious organisms that may colonize a Infections as a result of such procedures are rare but should be drain or its tubing typically depend on the anatomical locaconsidered when evaluating a patient who has undergone intertion and position of the drain (superfcial, intraperitoneal, or ventional radiology, which constitutes a risk factor for infection within an organ, duct or fstula) and the indication for its use. Interpretation of culture results from drains that have been in A variety of drainage devices are used to remove blood, place for >3 days may be difcult due to the presence of coloserum, lymph, urine, pus, and other fuids that accumulate in nizing bacteria and yeast. They are commonly used following abdominal, from drains are optimal specimens for collection and subcardiothoracic, neurosurgery, orthopedic, and breast surgery. The routine use of postoperaile, leak-proof container (ie, urine cup), or a citrate-containing tive surgical drains is diminishing, although their use in certain blood collection tube to prevent clotting in the event that blood situations is quite necessary. A series of sternal wound infections due to Legionella spp were traced to contamination of the hospital water supply. A post–hip surgery Legionella infection occurred after skin cleansing with tap water. To help diferentiate the dematiaceous species, a Fontana-Masson stain (histopathology) should be perG. Cutaneous Fungal Infections formed to detect small quantities of melanin produced by these the presence of fungi (molds or yeasts) on the skin poses a chalfungi. It is not uncommon for this group of fungi to be mislenge to the clinician in determining if this represents contaminatakenly misidentifed by histology as a hyaline mold such as tion, saprophytic colonization, or is a true clinical infection. This highlights the importance of correlating convenience, the fungi have been listed by the type of mycosis culture results with histological observations in determining they produce (Table 46): for example, dermatophytes typically the clinical relevance since the observation of fungal elements produce tinea (ringworm)–type infections; dematiaceous (darkly in histopathology specimens is most likely indicative of active pigmented molds and yeast-like fungi) cause both cutaneous and fungal invasion [244, 245]. In Those transmitted by ticks are most likely to require clinical addition to the recommended optimal specimens and associated laboratory support (Table 47). Borreliosis includes relapsing cultures, fungal serology testing (complement fixation and immufever, Borrelia miyamotoi infection, and Lyme borreliosis; these nodiffusion performed in parallel, not independent of the other) diseases are transmitted by ticks to humans. Lyme borreliosis or is often beneficial in diagnosing agents of systemic mycosis, speLyme disease (primarily due to infection with Borrelia burgdorcifically those caused by Histoplasma and Coccidioides. In cases of feri or Borrelia mayonii in the United States), a multisystem disactive histoplasmosis and blastomycosis, the urine antigen test may ease that can affect the skin, nervous system, joints, and heart, is be of value in identifying disseminated disease. Because travel between North America and Europe is common, Lyme borreliosis caused by Borrelia garinii and Borrelia afzelii have been included in the table. With subsequent febrile episodes, the number of circulating spirochetes decreases. A centrifugation-based enrichment method followed by Giemsa staining is a rapid and viable approach [256]. An acute serum (obtained within 7 days of the onset of symptoms) and convalescent serum (obtained at least 21 days after the onset of symptoms) should be submitted for testing. Of signifcance, early antibiotic treatment can blunt the antibody response and antibody levels may fall quickly during the months after exposure. If skin is biopsied, >1 biopsy sample should be taken for culture due to uneven distribution of spirochetes; disinfect the skin prior to collection and submit tissues in sterile saline.
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