SkullRing.org Medical Weblog

CLINICAL MANIFESTATIONS OF ANTHRAXThere are three main types of anthrax infection:Cutaneous anthraxCutaneous anthrax results from direct contact with the microbe on the skin or mucous membranes. More than 95% of naturally occurring anthrax is the cutaneous form. Approximately 1 to 7 days after anthrax endospores are introduced into the skin at a site of a previous cut or abrasion, a painless, pruritic macule or papule appears. Within 24 to 36 hours, the lesion forms a vesicle filled with clear or serosanguinous fluid containing numerous organisms that can be seen with Gram stain. The lesion undergoes necrosis, forming a painless ulcer covered by a characteristic central black eschar. There is accompanying non-pitting edema, which may be extensive, and multiple bullae may occasionally develop. Low-grade fever and malaise may be present, and painful regional lymphadenopathy can occur. Incision and debridement of early lesions should be avoided, since this may increase the chance of bacteremia. The eschar dries and falls off in 1 to 2 weeks, often with no residual scarring. The administration of antibiotics does not change the course of eschar formation but does decrease the likelihood of systemic disease. Although bacteremia is rare, the mortality rate has been reported to be as high as 20% without antibiotics but is less than 1 % with them.
Inhalational anthraxInhalational anthrax follows deposition of endospores into the alveolar spaces and may be a biphasic illness. The minimum infectious inhaled dose has not been precisely determined. Symptoms can develop 2 to 60 days after the inhalation of spores but usually develop after 6 days of incubation. The early phase is characterized by the insidious onset of fever, malaise, nonproductive cough, and dyspnea. Nausea, vomiting, and abdominal pain may also be present. Pleuritic chest pain and drenching sweats were prominent features in the 2001 U.S. anthrax outbreak. This stage of illness lasts from hours to a few days. Some patients may experience a brief period of apparent recovery. However, a second phase begins abruptly with spiking fevers, worsening dyspnea, and hypotension. A widened mediastinum due to massive mediastinal lymphadenopathy may be identified on chest radiograph. Pleural effusions may also be evident. These enlarged nodes can lead to partial tracheal compression and stridor. Up to one half of patients develop hemorrhagic meningitis with subsequent coma. Death can occur within hours. The mortality rate was previously reported to approach 90%, but in the recent U.S. anthrax bioterrorist cases, lower mortality rates (approximately 40%) were observed.
Gastrointestinal anthraxGastrointestinal anthrax can occur following the deposition of endospores in the upper or lower gastrointestinal tract. It is presumed that endospores inoculate areas of mucosal breakdown. This form of anthrax has never been reported in the United States. Symptoms can appear 2 to 5 days after the ingestion of endospore-contaminated meat. If spores are deposited in the oropharyngeal region, clinical findings typically include oral or esophageal ulceration accompanied by cervical edema and lymphadenopathy. Patients may complain of dysphagia, nausea, vomiting, fever, and even respiratory difficulty. Lesions have the appearance of pseudomembranous ulceration. If endospores are deposited in the lower gastrointestinal tract, patients may present with nausea, abdominal pain, fever, and bloody diarrhea. Hemorrhagic mesenteric lymphadenitis and massive ascites can also occur. Death occurs from intestinal perforation and anthrax toxemia. The case-fatality rate of gastrointestinal anthrax ranges from 12% to 50%.*207/348/5*

COGNITIVE-BEHAVIORAL THERAPY FOR BDD: COGNITIVE RESTRUCTURING (COGNITIVE THERAPY)  - IT CAN ALSO HELP TO DO COGNITIVE RESTRUCTURING BEFORE, DURING, AND AFTER THE EXPOSURE  This can help you get your thinking straight before you go into the anxiety-provoking situation. You can also do cognitive restructuring during the exposure, while you’re actually in the situation, by identifying your cognitive errors and thinking alternative, more realistic thoughts. Filling out a thought record after the exposure may also be helpful, especially if the situation made you very nervous. This can help you reappraise what happened in a more accurate way.If exposure therapy is too anxiety provoking, move back down to a lower-rated activity on your hierarchy. If this, too, is too anxiety provoking, you may need to modify the hierarchy, so less anxiety-provoking situations are included. Sometimes the SUDS levels need to be reevaluated and modified because you may underestimate the actual anxiety level you’ll experience in the situation. The important thing is not to give up! If you do it right, exposure will make you somewhat anxious, but the more you do it, the easier it will get. And the rewards can be enormous: you’ll be able to live a much freer and more enjoyable life.*322\204\8*

THE EVOLUTION OF INSOMNIA DRUG THERAPYFor the first half of this century, barbiturates were the only pharmacological option available for insomnia. Veronal, the first barbiturate, was introduced in 1903. In the years following, about fifty drugs of this class reached the market (out of nearly twenty-five hundred barbiturate compounds developed in the lab). However, barbiturates were found to have two dangerous drawbacks: a high potential for addiction and a great risk of lethal overdose. Today only a dozen or so are still available; those used primarily for sleep are secobarbital (Seconal), amobarbital (combined with secobarbital in a product called Tuinal), and pentobarbital (Nembutal). Other uses for barbiturates are as antianxiety agents, anesthetics, and anticonvulsants.In the late 1950s tricyclic antidepressants came on the market. In addition to their effect on serious depression, some of these drugs also possess sedative effects, although just how they work is not completely understood. Antidepressants offered an alternative to the potential dangers of barbiturates, but they too have undesirable side effects. While not considered the drug of first choice today, antidepressants may be used to alleviate insomnia—especially if the insomnia is associated with depression.A major breakthrough in the drug treatment of insomnia was achieved with the arrival of benzodiazepines in the early 1960s. Compared to their prescription drug predecessors, benzodiazepines—primarily flurazepam, temazepam, and triazolam—have a greatly improved safety profile and are much more effective, particularly in disorders of initiating and maintaining sleep in individuals whose insomnia lacks an identifiable physical cause. Their improved ratio of therapeutic dose to lethal dose means a much lower risk of abuse or dangerous adverse effects. Some research does indicate, however, that there is a potential for addiction in patients taking the drugs over long periods of time. Benzodiazepines fall into several subcategories, usually depending on how quickly and for how long the drug works.Of course, there are also several nonprescription sleeping aids available (brand names include Nytol, Sominex, and Sleep-Eze).In all of these the active ingredient is the same: diphenhydramine, a form of antihistamine. As you may know, antihistamines are used to dry up secretions in the eyes, nose, and throat, thus relieving some symptoms of colds and allergies. The drowsiness caused by antihistamines is really only a side effect; makers of over-the-counter sleeping aids have thus taken a drug liability and marketed it as an asset. Antihistamines may prove especially useful in the treatment of insomnia complicated by a history of drug or alcohol abuse, since they do not have the potential for abuse that is associated with other drug therapies (such as benzodiazepines and barbiturates).*270\226\8*

HIV: ON LIVING-TAKING CONTROL: CONFRONT THE POSSIBILITIES A LITTLE AT A TIMEOnce, when Dean Lombard was in the hospital, he “roomed for a while with a man who was in the advanced stages of AIDS. “I was glad to get out of that room,” Dean said. “As long as I was there, I needed to confront the possibility that what happened to him would happen to me. But confronting that possibility seemed necessary, to deal with this disease as positively as I am.”     Confronting the possibilities means, for Dean and others like him, understanding and admitting that the fact of HIV infection cannot be annulled. Steven said, “I have to deal with this whether I want to or not.” It is now a part of life. So are the possibilities of fatigue, disability, dependency, illness, clinic appointments, and hospitalizations. And so are the emotional reactions to all this. “HIV makes me face things I didn’t think I’d have to face,” Helen said. Confronting the facts and possibilities and reactions is often the only way through them.     Confronting everything all at once, however, is overwhelming and unnecessary. Face what you are ready to face, and only when you are ready. When you are tired of thinking or feeling, stop and rest. Do not push yourself because you or someone else thinks you ought to be facing things. Face a little at a time.     In fact, confronting the facts means facing not only sickness but also health. If, within some amount of time, fatigue, death, or dependency are possibilities, so are strength, life, and confidence. People remind themselves that no one knows with certainty how the disease progresses in every individual.*244\191\2*