By E. Mufassa. College of Saint Joseph.
Bleeding after or during Secondary dysmenorrhea intercourse can hint at STI but also at cervical cancer discount rumalaya liniment 60 ml without prescription. Possible causes of secondary dysmenorrhea are: • Parity order 60 ml rumalaya liniment otc, pelvic operations: subfertility can be a sign • Endometriosis (endometrial cells growing out- for endometriosis, PID and fibroids; recurrent side the uterus, leading to cysts and adhesions) abortion can hint at the existence of uterine (see Chapter 6). Pelvic operations can cause adhesions • Adenomyosis (endometrial cells growing within or lead to infections which in turn can cause the uterine wall in the muscle layer called PID. D&Cs carried out under unsterile condi- myometrium). In most of these conditions, menstrual pain is re- • Stress or a family history of dysmenorrhea: primary lated to pressure of the impaired tissue (fibroids, dysmenorrhea can be psychosomatic. The way 80 Painful Menstrual Period: Dysmenorrhea older female relatives deal with their menstrual Speculum examination period can influence the perception of girls During a speculum examination you can find signs about womanhood and menstruation and the of cervical cancer (bleeding, ulcers, erosions, way they deal with painful periods. Stress in masses) or for STI (abnormal vaginal discharge, a school or around issues of adolescence and reddish cervical surface, discharge from the cervical growing up can lead to a change in pain percep- os) and for vaginal endometriosis (dark-red or tion and primary dysmenorrhea as well. The cervix can be distorted Please bear in mind that a menstrual period is to one side by fibroids, tubo-ovarian masses or the inevitable sign that a pregnancy did not endometriosis, or shortened by cervical or intra- work out. So, for women with difficulties in cavitary fibroid growth. Wet mount The wet mount can show signs of vaginal or cervi- cal infections including STI (pus cells, clue cells, PHYSICAL EXAMINATION Trichomonas). Most of the time you can make the diagnosis with- out many investigations in your facility. Primary Vaginal examination dysmenorrhea is a diagnosis of exclusion, but your During bimanual palpation you can find signs of history with onset of symptoms and menarche can adenomyosis (enlarged, soft, often tender uterus) or already help you to establish the diagnosis. In pri- fibroids (enlarged, firm uterus, bulky uterus with mary dysmenorrhea your examination outside humps, mobile or immobile) and ovarian masses menstruation will be normal as there is no under- such as benign or malignant ovarian tumors and lying cause for it. Most women come when they tubo-ovarian abscesses as a sign of PID (masses are having pain, so it might be wise to re-examine right, left or behind the uterus, mobile or im- them once their period is over to see the difference. Cervical tenderness can be a sign of acute Be aware of possible congenital malformations like or chronic infection (STI, PID) but also for endo- a rudimentary uterine horn that can cause the pain. A painful palpation Keep in mind: a woman can start with primary of the posterior fornix can be a sign of endometrio- dysmenorrhea and with time experience additional sis of Douglas’ space or infiltration of the tissue secondary symptoms due to new underlying causes. So ask every woman if the pain changed with time, especially concerning onset and duration. You Rectal examination must do a full gynecological examination on all patients with dysmenorrhea to establish or rule A rectal examination can reveal blood or anal pain out underlying causes. Special considerations for which can be signs of endometriosis and sometimes examination of young girls or virgins are given in endometriosis in recto-vaginal septum can be pal- Chapter 1 on gynecological examination and pated by recto-vaginal examination. You can find a description on each examination method or Further investigations investigation in Chapter 1. Vaginal/abdominal ultrasound Abdominal palpation If your clinical diagnosis is secondary dysmenor- rhea look for the following pathology: By doing an abdominal examination you can assess abdominal masses (fibroids, cancer) or points of Uterine fibroids Their echogenicity in ultrasound is a pain-related resistance (PID, adhesions). They usually should look for scars and assess their healing. An have well-defined borders to the myometrium and ugly broad scar might be a sign of secondary heal- a capsule. Don’t forget to do abdominal ultrasound ing with the likelihood of infection or adhesions. This is due to Adenomyosis Adenomyosis is difficult to see with their mode of action: NSAIDs stop prosta- ultrasound and the diagnosis is often one of exclu- glandin production, something which paraceta- sion. The posterior wall of the uterus might be mol or Buscopan cannot do. They do not reduce the effect of pros- ten enlarged. Patients with adenomyosis often taglandin on the uterus. Once prostaglandins are suffer from menstrual disorders together with in the circulation they will cause pain and dysmenorrhea. Endometrioma Endometrioma often appear as tumors Usually women with primary dysmenorrhea know in the ovaries. If they are big enough you may see when pain starts and how long it usually stays and them on ultrasound. They are usually cystic with there are only few cycles where they won’t experi- decreased or absent echogenicity and can resemble ence pain. Thus, for a successful treatment and ovarian cysts or hydrosalpinx. See • Always have your NSAIDs in stock and in reach Chapter 17 on STI for description of ultrasound when you are near your period. Don’t wait until the pain is Urine pregnancy test/urinalysis very strong because this is too late. Every patient with new pelvic pain should have a • Always take your NSAIDs as long as the pain urine pregnancy test (UPT) to exclude ectopic usually stays.
With ART cheap rumalaya liniment 60 ml overnight delivery, PCP and TB have become less frequent and pulmonary mortality has decreased (Grubb 2006 discount rumalaya liniment 60 ml, Morris 2011). HIV influences toll-like receptors and other factors of immune function that increase the risk of pneumonia (Morris 2011). Particularly in patients with respiratory pro- blems and advanced immune deficiency, it is essential to take all differential diag- noses into consideration, of which this chapter presents an outline. PCP, myco- bacterial infections and pulmonary hypertension are covered in detail in other chapters. Table 1: Pulmonary complications in HIV+ patients Infections Neoplasia Other Pneumocystis jiroveci Kaposi sarcoma (KS) Lymphocytic interstitial pneumonia (LIP) Non-Hodgkin lymphoma Non-specific interstitial pneumonia (NSIP) Bacterial pneumonia Hodgkin lymphoma Cryptogenic organizing pneumonia (COP) S. Cryptococcus neoformans Histoplasma capsulatum Toxoplasma gondii Talking with the patient The most important question: What is the immune status? The number of CD4 T cells is an excellent marker of the patient’s individual risk of opportunistic infec- tions. More important than the trough level (nadir) is the current CD4 T cell count. Above 200 cells/µl, typical opportunistic infections are unlikely. In these patients, generally “usual” problems such as acute bronchitis and bacterial pneumonia can be expected. Although the risk increases with immunodeficiency, more than half of HIV+ TB patients have more than 200 cells/µl (Wood 2000, Lange 2004). HIV and Respiratory Diseases 601 In patients with less than 200 CD4 T cells/µl the most common pulmonary disease is bacterial pneumonia, and PCP is also typical. Pulmonary Kaposi sarcoma and pulmonary Toxoplasma gondii infection tend to appear at less than 100 cells/µl but are rarely seen. Below 50 cells/µl, pulmonary infections with CMV (mostly in combination with PCP), invasive pulmonary aspergillosis (IPA), endemic fungi (Histoplasma capsulatum, Coccidioides immitis) and infections with atypical mycobac- teria occur. Especially in patients with advanced immunodeficiency, pulmonary disease might be an indicator of a systemic infection (e. Rapid invasive diagnostics are advisable in patients with low CD4 T cells. PCP patients typically have dyspnea and a non- productive cough. A large quantity of discoloured sputum is more likely to indicate a bacterial cause or a combination of infections. These patients usually see a doctor after 3-5 days of discomfort (Cilloniz 2014). Someone who has had PCP previously is at higher risk of having it again. A patient with COPD might have just an exac- erbation of his pulmonary disease. Under 200 CD4, PCP is unlikely with cotrimoxazole prophylaxis and the risk of bacterial pneumonia may be reduced (Beck 2001). When pentamidine inhalation is used for PCP prophylaxis, however, atypical PCP can present in the upper lobes. Respiratory symptoms after starting ART might result from immune reconstitution and inflammatory syndrome (IRIS). IRIS may have infectious and non-infectious causes (Grubb 2006). Low CD4 T cell count and high viral load are risk factors. In a retrospective analysis, IRIS was seen in 30% of patients with TB, atypical mycobacteriosis and cryptococcosis (Shelburn 2005). Because of HLA testing, hypersensitivity to abacavir is rarely seen today. Dyspnea (13%), cough (27%) and pharyngitis (13%) are common symptoms of hypersensi- tivity (Keiser 2003). T-20 seems to increase the risk of bacterial pneumonia, at least among smokers. Dyspnea and tachypnea are also seen as symptoms of lactic acidosis secondary to NRTI therapy. Smoking is more harmful to HIV+ than to negative persons, and is more common (Crothers 2011). Smoking promotes local immunodeficiency in the lung. It reduces the number of alveolar CD4 T cells and the production of important pro-inflammatory cytokines (Wewers 1998) and suppresses the phago- cytic capacity of alveolar macrophages (Elssner 2004). Both HIV-associated and -inde- pendent pulmonary diseases are more common in smokers. This applies to bacter- ial pneumonia and PCP, but also to asthma, COPD and pulmonary carcinoma (Hirschtick 1996, Crothers 2011).
TZDs: Not graded In September 2010 generic 60 ml rumalaya liniment overnight delivery, the US Food and Drug Administration restricted access for Pioglitazone rosiglitazone and combination products that contain rosiglitazone due to an Rosiglitazone increased risk of cardiovascular adverse events discount rumalaya liniment 60 ml otc. Low We found no evidence of increased all-cause mortality or cardiovascular mortality with pioglitazone; some studies suggest reduced risk of all-cause and cardiovascular mortality with pioglitazone. High Evidence from systematic reviews, RCTs, and observational studies indicate that both pioglitazone and rosiglitazone increase the risk of heart failure (odds ratios range from 1. High Evidence from systematic reviews, RCTs, and observational studies indicate that both pioglitazone and rosiglitazone increase the risk of edema (odds ratios range from 2. High The risk of hypoglycemia is reduced with TZDs when compared with sulfonylureas; the risk is similar to the risk with metformin. What is the comparative tolerability and frequency of adverse events for newer diabetes medications, TZDs, and drug combinations (administered as fixed dose combination products or dual therapy) for children and adults with diabetes mellitus? Strength of a Drugs evidence Conclusion Moderate Both TZDs resulted in a similar weight increase. Moderate Risk of fractures is increased among patients exposed to TZDs (OR 1. This risk appears to be increased among women (OR 2. These findings are consistent with the results of the ADOPT trial. Low Adverse events occurring with pioglitazone and rosiglitazone were similar in head-to-head trials. FDCPs and Harms in children Dual Therapy: Insufficient We did not find any evidence meeting inclusion/exclusion criteria on children Avandamet Actoplus Met Harms in adults Avandaryl Insufficient We found no head-to-head trials that compared harms between any 2 FDCPs. Rosiglitazone Metformin + Avandamet or dual therapy with metformin plus rosiglitazone Pioglitazone Low Similar rates of withdrawals due to adverse events with Avandamet /dual therapy Glimepiride + groups and monotherapy groups (3 trials ranging from 24 to 32 weeks). Rosiglitazone Glimepiride + Low Similar or slightly higher rates of hypoglycemia with Avandamet /dual therapy Pioglitazone groups and monotherapy groups (3 trials ranging from 24 to 32 weeks). Metformin + Sitagliptin Low Similar rates of adverse cardiovascular events with Avandamet /dual therapy and monotherapy, but duration of studies may not have been sufficient to reliably Avandamet or assess adverse cardiovascular events (3 trials ranging from 24 to 32 weeks). The rosiglitazone 2 included trials were a 28 week trial (N=874) comparing 2 dosages of Avandaryl and glimepiride with glimepiride monotherapy and rosiglitazone monotherapy, and a 20 week trial (N=40) comparing concurrent use of rosiglitazone and glimepiride with rosiglitazone monotherapy. What is the comparative tolerability and frequency of adverse events for newer diabetes medications, TZDs, and drug combinations (administered as fixed dose combination products or dual therapy) for children and adults with diabetes mellitus? Strength of a Drugs evidence Conclusion Moderate Weight gain was slightly greater with Avandaryl or dual therapy than with monotherapy. Low Overall incidences of adverse events were similar across treatment arms: 50. Reports of severe adverse events were also similarly distributed among the arms: 1. Fewer withdrawals due to adverse events occurred in the Actoplus Met and pioglitazone alone arms compared with the metformin alone arm (3. Low Diarrhea, hypoglycemia, and gastrointestinal events were reported most frequently in patients on metformin monotherapy and least frequently in patients on pioglitazone alone, with patients on Actoplus Met reporting rates in between those for metformin and pioglitazone. Evidence with sitagliptin was limited to 1 trial ((N=1,091, with outcomes reported at 24 and 54 weeks) 31, 32 and metformin including dual therapy with sitagliptin and metformin. Low Gastrointestinal adverse effects were commonly reported (15−31% across all treatment arms) and were similar between sitagliptin 100 plus metformin 2000 and metformin 2000 monotherapy at 24 weeks (24. Rates were slightly higher for sitagliptin 100 plus metformin 1000 compared with sitagliptin 100 monotherapy or with metformin 1000 monotherapy at 24 weeks (17. Low Weight loss for subjects treated with sitagliptin plus metformin (−0. Low The combination of sitagliptin plus metformin resulted in slightly greater improvements in total cholesterol (at 24 weeks: −3. Are there subgroups of patients based on demographics (age, racial groups, gender), comorbidities (drug- disease interactions, obesity), or other medications (drug-drug interactions) for which newer diabetes medications differ in efficacy/effectiveness or frequency of adverse events? Strength of a Drugs evidence Conclusion Amylin Insufficient We found insufficient evidence to draw any firm conclusions about whether there agonists: are subgroups of patients based on demographics, comorbidities, or other Pramlintide medications for which newer diabetes medications differ from each other in DPP-IV efficacy/effectiveness or frequency of adverse events. GLP-1 agonists: Exenatide Liraglutide TZDs: Insufficient We found insufficient evidence to draw any firm conclusions about whether there Pioglitazone are subgroups of patients based on most demographic characteristics, Rosiglitazone comorbidities, or other medications for which newer diabetes medications differ in efficacy/effectiveness or frequency of adverse events. The evidence that was found is generally hypothesis-generating, using post hoc pooled analyses or post hoc subgroup analyses in an exploratory manner. Moderate Some studies reported that the risk of fractures is increased with TZD use in 204, 309 women, but not in men. On analysis of data from ADOPT found hazard ratios comparing rosiglitazone with metformin and glyburide were 1. A systematic review and meta-analysis reported an increased risk among women (OR 2. FDCPs and Insufficient We found no studies meeting inclusion/exclusion criteria that provided evidence Dual Therapy to determine whether there are subgroups of patients based on demographics, comorbidities, or other medications for which newer diabetes medications differ from each other in efficacy/effectiveness or frequency of adverse events Abbreviations: FDCP, fixed-dose combination product; HbA1c, OR, odds ratio; RCT, randomized controlled trial; RR, relative risk, SE, standard error; TZD, thiazolidinedione; WMD, weighted mean difference. CONCLUSIONS All of the included medications were efficacious for reducing HbA1c and none of the newer medications appear to cause weight gain.