Ganfyd - Recent changes [en]

Gleason grading system

2009-11-20T21:59:55Z

predominant pattern rules

←Older revision		Revision as of 21:59, 20 November 2009
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-	~~[[Image:Gleason.jpg\|right\|Gleason histological grades.]]~~	+	{{BiteBox\|Gives a total score between 2 and 10 (6 to 10 in practice). 10 is worse).}}
-	{{BiteBox\|~~2 '''grades''', written as a '''sum''' to give~~ a ~~'''~~score~~'''~~ between 2 and 10 (6 to 10 in practice; 10 is worse).}}	+	A pathological grading system used for [[prostate cancer]]. It depends on skilled interpretation of the microscopic patterns formed by the cancer which may vary from one area of cancer to the next. The system is widely used, has been extensively studied and appears to be valid for prognosis.
-	A pathological grading system used for [[prostate cancer]]. It depends on skilled interpretation of microscopic ~~appearance of the tissue based on the~~ patterns formed which may vary from one area of cancer to the next. ~~5 categories or '''grades''' were described based on increasingly disordered architecture. On a historical/pedantic note, although the terms pattern and grades are commonly~~ used ~~interchangeably~~, ~~in his original work Gleason described 9 patterns that were then classified into the five grades. The first 2 are rare entities, with grade 1~~ and ~~2 occuring as the primary grade in only 0.5% and 1.8% of the original specimens. It~~ appears even less frequently in more contemporary series such that there is doubt over the genuine malignant nature of these patterns.<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=17493232 Berney DM. Low Gleason score prostatic adenocarcinomas are no longer viable entities. Histopathology. 2007 May; 50(6):683-90.]<small>([http://dx.doi.org/10.1111/j.1365-2559.2007.02596.x Link to ~~article] – subscription may~~ be ~~required~~.~~)</small></ref>~~	+

-	~~The scoring~~ system is ~~denoted by~~ the ~~predominant pattern followed by the next most common pattern, e~~.~~g. 3+4. Where only one pattern predominates~~, ~~the pattern is doubled, i~~.e. ~~3+3. Some centres will also denote the third most common pattern, i.e. 3+4 (5 tertiary). There~~ is ~~scope for much confusion ("Gleason 4 tumour" could mean 2+2 or 4+4)~~ and~~, although tedious,~~ it ~~may be helpful to be explicit in notation by including the component grades, i.e. Gleason score 7 (4+3), which has~~ the ~~added advantage~~ of ~~distinguishing between 4+3 and 3+4~~.	+	While the system can be used reliably on large resection specimens, there is less agreement on how to apply the grading system to needle core biopsies. Transrectal ultrasound-guided 'sextant' biopsies result in 6 cores per side, each representing as little as 0.04% of an average 40g prostate. It is impossible to know how representative a single core is and there is a dilemma over how to manage small foci of higher grade tumour—does it represent the edge of a larger lesion or a negligibly small area of high grade tumour.

	The grade of tumour should be distinguished from its stage, which is by a [[Prostate adenocarcinoma/TNM\|TNM system]].		The grade of tumour should be distinguished from its stage, which is by a [[Prostate adenocarcinoma/TNM\|TNM system]].
		+
		+	==The 5 Grades==
		+	[[Image:Gleason.jpg\|right\|Gleason histological grades.]]
		+	5 categories or '''grades''' were described based on increasingly disordered architecture. On a historical/pedantic note, although the terms 'pattern' and 'grades' are commonly used interchangeably, in his original work, Gleason described 9 patterns that were then grouped into the five grades based on outcomes.
		+
		+	The first 2 are rare entities, with grade 1 and 2 occuring as the primary grade in only 0.5% and 1.8% of the original specimens. It appears even less frequently in more contemporary series. The rarity of the entity and the excellent prognosis of these lesions casts doubt over the genuine malignant nature of these patterns as they can closely resemble benign adenosis/atypical adenomatous hyperplasia.<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=17493232 Berney DM. Low Gleason score prostatic adenocarcinomas are no longer viable entities. Histopathology. 2007 May; 50(6):683-90.]<small>([http://dx.doi.org/10.1111/j.1365-2559.2007.02596.x Link to article] – subscription may be required.)</small></ref>
		+
		+	==Scoring==
		+	Whereas most cancer grading is based on the worst-looking areas, no matter how infrequent, Gleason scoring is based on the predominant patterns. The score itself is therefore described by the most common pattern (primary grade) followed by the next most frequent pattern (secondary grade), e.g. 3+4. Where only one pattern predominates, the pattern is doubled, i.e. 3+3. Some centres will also denote the third most common pattern, i.e. 3+4 (5 tertiary).
		+
		+	A judgement of the predominant type is easy to make in radical prostatectomy specimens, but less so in core biopsies, where, as mentioned, it is difficult to know how representative each core is.
		+
		+	There is scope for much confusion ("Gleason 4 tumour" could mean 2+2 or 4+4) and, although tedious, it may be helpful to be explicit in notation by including the component grades, i.e. Gleason score 7 (4+3), which has the added advantage of distinguishing between 4+3 and 3+4.

	==History==		==History==
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	== External link ==		== External link ==
-	[http://pathology2.jhu.edu/gleason/ Johns Hopkins university site to improve pathologists' knowledge of, and facility with, Gleason grading.] ~~a useful deep discussion and resource~~	+	*[http://pathology2.jhu.edu/gleason/ Johns Hopkins university site to improve pathologists' knowledge of, and facility with, Gleason grading.]

	{{refsec}}		{{refsec}}

Verumontanum

2009-11-20T12:50:53Z

def

New page

Ridge in the prostatic [[urethra]] at about the level of where the [[seminal vesicle]]s join the urethra.

[[Category: Anatomy]]
[[Category: Urology]]

Prostate specific antigen

2009-11-20T12:27:36Z

variations on PSA

←Older revision		Revision as of 12:27, 20 November 2009
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	PSA is a poor [[screening]] test for [[cancer]] of the [[prostate]].		PSA is a poor [[screening]] test for [[cancer]] of the [[prostate]].

-	~~Normal levels 0~~.1-4.~~0 ng/ml~~.	+	PSA is a serine protease belonging to the kallarein family. It is single-chain glycoprotein coded for at 19q13.4. It is produced by prostate cells and excreted into prostatic fluid where its physiological role is to help the seminal coagulum to dissolve by proteolysis.

-	~~PSA~~ is ~~a protein that is normally produced by prostate cells~~. ~~The protein~~ is ~~found in prostatic fluid~~ and ~~its physiological role is~~ to ~~help~~ the ~~seminal coagulum~~ to ~~dissolve~~. ~~It is single~~-~~chain glycoprotein coded for at 19q13.4~~	+	Normal levels 0.1-4.0 ng/ml, though it is better to think of age-specific ranges rather than absolute cut-off values. There is an overlap between normal, benign disease and malignant disease. Attempts have been made to increase the diagnositc utility of PSA in several ways:
		+	*PSA velocity - monitoring the rate of increase over a period of time)
		+	*PSA density - amount of PSA produced relative to the volume of prostate as measured ultrasonographically).
		+	*PSA fractions - measuring free PSA versus PSA bound to α-2-macroglobulin

	==Limitations==		==Limitations==
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	==History==		==History==
-	Several proteins found only in seminal fluid were described in 1971. PSA was was subsequently isolated and characterised in 1973. <ref>One of the original papers isolation and characterising PSA. [[Pubmed:4631694\|Li TS, Beling CG. Isolation and characterization of two specific antigens of human seminal plasma. Fertil Steril. 1973 Feb;24(2):134-44.]]</ref> It was named PSA in 1979 and prior to that had also been referred to as gamma seminoprotein <ref>[[Pubmed:5106556\|Hara M, Koyanagi Y, Inoue T, Fukuyama T. [Some physico-chemical characteristics of " -seminoprotein", an antigenic component specific for human seminal plasma. Forensic immunological study of body fluids and secretion. VII] Nippon Hoigaku Zasshi. 1971 Jul;25(4):322-4. Japanese.]]</ref> and p30 <ref>[[Pubmed:744956\|Sensabaugh GF. Isolation and characterization of a semen-specific protein from human seminal plasma: a potential new marker for semen identification. J Forensic Sci. 1978 Jan;23(1):106-15.]]</ref>. One of its earliest intended uses was as a forensic tool in rape cases. <ref>[[Pubmed:3881667\|Graves HC, Sensabaugh GF, Blake ET. Postcoital detection of a male-specific semen protein. Application to the investigation of rape. N Engl J Med. 1985 Feb 7;312(6):338-43.]]</ref>	+	Several proteins found only in seminal fluid were described in 1971. PSA was was subsequently isolated and characterised in 1973.<ref>One of the original papers isolation and characterising PSA. [[Pubmed:4631694\|Li TS, Beling CG. Isolation and characterization of two specific antigens of human seminal plasma. Fertil Steril. 1973 Feb;24(2):134-44.]]</ref> It was named PSA in 1979 and prior to that had also been referred to as gamma seminoprotein <ref>[[Pubmed:5106556\|Hara M, Koyanagi Y, Inoue T, Fukuyama T. [Some physico-chemical characteristics of " -seminoprotein", an antigenic component specific for human seminal plasma. Forensic immunological study of body fluids and secretion. VII] Nippon Hoigaku Zasshi. 1971 Jul;25(4):322-4. Japanese.]]</ref> and p30 <ref>[[Pubmed:744956\|Sensabaugh GF. Isolation and characterization of a semen-specific protein from human seminal plasma: a potential new marker for semen identification. J Forensic Sci. 1978 Jan;23(1):106-15.]]</ref>. One of its earliest intended uses was as a forensic tool in rape cases. <ref>[[Pubmed:3881667\|Graves HC, Sensabaugh GF, Blake ET. Postcoital detection of a male-specific semen protein. Application to the investigation of rape. N Engl J Med. 1985 Feb 7;312(6):338-43.]]</ref>

	==Physiology==		==Physiology==

Gleason grading system

2009-11-20T11:13:33Z

range 6-10 in practice

←Older revision		Revision as of 11:13, 20 November 2009
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-	~~{{stub}}~~	+	[[Image:Gleason.jpg\|right\|Gleason histological grades.]]
-	{{BiteBox\|1 to 10, 10 is worse}}	+	{{BiteBox\|2 '''grades''', written as a '''sum''' to give a '''score''' between 2 and 10 (6 to 10 in practice; 10 is worse).}}
-	A pathological ~~scoring~~ system used for [[prostate cancer]]. It depends on skilled interpretation of microscopic appearance of the tissue ~~- its~~ patterns ~~of differentiation -~~ which ~~tends to~~ vary from area to ~~area~~.	+	A pathological grading system used for [[prostate cancer]]. It depends on skilled interpretation of microscopic appearance of the tissue based on the patterns formed which may vary from one area of cancer to the next. 5 categories or '''grades''' were described based on increasingly disordered architecture. On a historical/pedantic note, although the terms pattern and grades are commonly used interchangeably, in his original work Gleason described 9 patterns that were then classified into the five grades. The first 2 are rare entities, with grade 1 and 2 occuring as the primary grade in only 0.5% and 1.8% of the original specimens. It appears even less frequently in more contemporary series such that there is doubt over the genuine malignant nature of these patterns.<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=17493232 Berney DM. Low Gleason score prostatic adenocarcinomas are no longer viable entities. Histopathology. 2007 May; 50(6):683-90.]<small>([http://dx.doi.org/10.1111/j.1365-2559.2007.02596.x Link to article] – subscription may be required.)</small></ref>

-	~~It was devised in~~ the ~~1960s and 1970s~~ by ~~Dr [[Donald F Gleason]] and members of~~ the ~~US Veterans Administration Cooperative Urological Research Group<ref>[[Pubmed:14976540\|Humphrey PA~~. ~~Gleason grading and prognostic factors in carcinoma of the prostate~~. ~~Modern pathology : an official journal of~~ the ~~United States and Canadian Academy~~	+	The scoring system is denoted by the predominant pattern followed by the next most common pattern, e.g. 3+4. Where only one pattern predominates, the pattern is doubled, i.e. 3+3. Some centres will also denote the third most common pattern, i.e. 3+4 (5 tertiary). There is scope for much confusion ("Gleason 4 tumour" could mean 2+2 or 4+4) and, although tedious, it may be helpful to be explicit in notation by including the component grades, i.e. Gleason score 7 (4+3), which has the added advantage of distinguishing between 4+3 and 3+4.
-	~~of Pathology~~, ~~Inc~~. ~~2004;17:292-306~~.~~]] <small>([http://dx~~.~~doi~~.~~org/10~~.~~1038/modpathol~~.~~3800054 Direct link] – subscription~~ may be ~~required~~.)~~</small></ref>~~.	+

-	~~It is separate from the grading of the spread~~ of tumour, which is by a [[TNM ~~staging~~\|TNM system]].	+	The grade of tumour should be distinguished from its stage, which is by a [[Prostate adenocarcinoma/TNM\|TNM system]].
		+
		+	==History==
		+	It was devised in the 1960s and 1970s by Dr [[Donald F Gleason]] and members of the US Veterans Administration Cooperative Urological Research Group (VACURG).<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=5948714 Gleason DF. Classification of prostatic carcinomas. Cancer chemotherapy reports. Part 1. 1966 Mar; 50(3):125-8.]</ref><ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=4813554 Gleason DF, Mellinger GT. Prediction of prognosis for prostatic adenocarcinoma by combined histological grading and clinical staging. The Journal of urology. 1974 Jan; 111(1):58-64.]</ref><ref>[[Pubmed:14976540\|Humphrey PA. Gleason grading and prognostic factors in carcinoma of the prostate. Modern Pathology 2004;17:292-306.]] <small>([http://dx.doi.org/10.1038/modpathol.3800054 Direct link] – subscription may be required.)</small></ref>

	== External link ==		== External link ==
-	[http://pathology2.jhu.edu/gleason/ Johns Hopkins university site to improve pathologists' knowledge of, and facility with, Gleason grading.] a useful deep discussion and resource	+	[http://pathology2.jhu.edu/gleason/ Johns Hopkins university site to improve pathologists' knowledge of, and facility with, Gleason grading.] a useful deep discussion and resource
		+
	{{refsec}}		{{refsec}}

Image:Gleason.jpg

2009-11-20T10:50:01Z

uploaded "[[Image:Gleason.jpg]]" Gleason patterns. Having searched quite a bit on the internet and several textbooks, the diagram is reproduced almost universely without mention of special permission and I presume is in the public domain (happy to be corrected).

New page

Gleason score

2009-11-20T09:51:47Z

[[Gleason score]] moved to [[Gleason grading system]] better to talk about entire system, not just score

New page

Fine needle aspiration

2009-11-19T10:55:41Z

sub

←Older revision		Revision as of 10:55, 19 November 2009
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	;Disruption of cell architecture : The nature of the procedure destroys the architecture of the tissue. For this reason, FNA of lymph nodes or thyroid adenomas can be inconclusive. Core [[biopsy\|biopsies]], wedge biopsies or even excision biopsy may be more appropriate in these situations.		;Disruption of cell architecture : The nature of the procedure destroys the architecture of the tissue. For this reason, FNA of lymph nodes or thyroid adenomas can be inconclusive. Core [[biopsy\|biopsies]], wedge biopsies or even excision biopsy may be more appropriate in these situations.
	;Operator variability : Best results need both a experienced aspirator and experienced cytologist with mechanisms for mutual feedback to maintain standards. Sometimes the aspirator and cytologist are one and the same.		;Operator variability : Best results need both a experienced aspirator and experienced cytologist with mechanisms for mutual feedback to maintain standards. Sometimes the aspirator and cytologist are one and the same.
-	;Limited material : As only 1-2 slides are usually sent for each sample, there will be insufficient material if further specialised stains or immunocytochemistry are required. [[Liquid-based cytology]] can allow material stretched to several slides and also allows processing into a 'clot' that can be treated like a histological specimen, i.e. can be used to produce further microscopic sections.	+	;Limited material : As only 1-2 slides are usually sent for each sample, there will be insufficient material if further specialised stains or immunocytochemistry are required. [[Liquid-based cytology]] can allow material to be stretched to several slides and also allows processing into a 'clot' that can be treated like a histological specimen, i.e. can be used to produce further microscopic sections.

	[[Category: Breast surgery]]		[[Category: Breast surgery]]

Sanfilippo syndrome

2009-11-19T08:55:03Z

starter for 0.1

New page

{{SubjectBox}}
A genetically determined, recessively inherited [[lysosomal enzyme deficiency]]. The CNS deteriorates progressively.

{{stub}}

Fine needle aspiration

2009-11-18T21:31:38Z

can also be done with radiological guidance

←Older revision		Revision as of 21:31, 18 November 2009
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	'''Fine needle aspiration(FNA)''' is a technique of sampling cells for cytological analysis. Cells are collected using a sharp [[needle]] that is inserted in and out of the tissue while simultaneously aspirating with a [[syringe]].		'''Fine needle aspiration(FNA)''' is a technique of sampling cells for cytological analysis. Cells are collected using a sharp [[needle]] that is inserted in and out of the tissue while simultaneously aspirating with a [[syringe]].

-	It is a useful way of obtaining a tissue diagnosis of suspicious lumps near the skin surface, most commonly [[thyroid cancer\|thyroid]] lumps or [[breast cancer\|breast]] lumps. The cells obtained are smeared onto a slide and fixed, or put into liquid transport media for later cytological processing.	+	It is a useful way of obtaining a tissue diagnosis of suspicious lumps near the skin surface, most commonly [[thyroid cancer\|thyroid]] lumps or [[breast cancer\|breast]] lumps. Deeper lesions can be reached with radiological guidance or, in hard to reach organs such as the pancreas, through endoscopic ultrasound. The cells obtained are smeared onto a slide and fixed, or put into liquid transport media for later cytological processing.

	Drawbacks of FNA are:		Drawbacks of FNA are:
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	[[Category: Breast surgery]]		[[Category: Breast surgery]]
-	[[Category: ~~Histopathology~~]]	+	[[Category: Cytopathology]]
	[[Category: Oncology]]		[[Category: Oncology]]
	[[Category: Practical procedures]]		[[Category: Practical procedures]]

Meckel's diverticulum

2009-11-17T19:01:15Z

←Older revision		Revision as of 19:01, 17 November 2009
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	*2-3 inch long		*2-3 inch long
	*2-3 feet from ileocaecal valve}}		*2-3 feet from ileocaecal valve}}
-	Congenital abnormality of the small bowel caused by persistence of the embryological vitello-intestinal duct. ~16% symptomatic in two series. Of the symptomatic diverticula in these series, 43-60% contained heterotopic mucosa.<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=6600203 Mackey WC, Dineen P. A fifty year experience with Meckel's diverticulum. Surgery, gynecology & obstetrics. 1983 Jan; 156(1):56-64.]</ref><ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15729078 Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Annals of surgery. 2005 Mar; 241(3):529-33.]</ref> Meckel diverticula may contain [[~~heterotopic~~]]/[[~~ectopic~~]] gastric or pancreatic tissue or even tissue of liver, lymphoid or carcinoid origin.	+	Congenital abnormality of the small bowel caused by persistence of the embryological vitello-intestinal duct. ~16% symptomatic in two series. Of the symptomatic diverticula in these series, 43-60% contained heterotopic mucosa.<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=6600203 Mackey WC, Dineen P. A fifty year experience with Meckel's diverticulum. Surgery, gynecology & obstetrics. 1983 Jan; 156(1):56-64.]</ref><ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15729078 Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Annals of surgery. 2005 Mar; 241(3):529-33.]</ref> Meckel diverticula may contain [[ectopic]] (strictly speaking [[heterotopic]]) gastric or pancreatic tissue or even tissue of liver, lymphoid or carcinoid origin.

	==Complications==		==Complications==
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	Dependent on circumstances (acute bleed vs chronic anaemia in young person).		Dependent on circumstances (acute bleed vs chronic anaemia in young person).
-	*[[Pertechnetate\|~~technetium~~-99m pertechnetate]] scintigraphy to detect heterotopic gastric mucosa in the lower abdomen. Less than 10% of Meckel's diverticula contain gastric-type mucosa, but it is present in >90% of cases where rectal bleeding is due to Meckel's.	+	*[[Pertechnetate\|Technetium-99m pertechnetate]] scintigraphy to detect heterotopic gastric mucosa in the lower abdomen. Less than 10% of Meckel's diverticula contain gastric-type mucosa, but it is present in >90% of cases where rectal bleeding is due to Meckel's.
	*Labelled red cell scan - maybe more suitable if on-going bleeding. Has the advantage of being able to localise other sources of bleeding.		*Labelled red cell scan - maybe more suitable if on-going bleeding. Has the advantage of being able to localise other sources of bleeding.
	*[[Mesenteric angiography]]		*[[Mesenteric angiography]]

Diabetes mellitus

2009-11-17T11:29:03Z

Blood tests: other tests

←Older revision		Revision as of 11:29, 17 November 2009
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	==Investigations==		==Investigations==
	===Blood tests===		===Blood tests===
		+	The primary test for diabetes is a measurement of sugar level. Urine sugar levels can rule in diabetes, but not wholly rule it out in its early stages. They are simple and cheap.
		+
	In an asymptomatic patient any diagnostic test for diabetes must be repeated on a separate occasion. In a symptomatic patient, or a patient with specific complications of diabetes mellitus, one diagnostic test will suffice.		In an asymptomatic patient any diagnostic test for diabetes must be repeated on a separate occasion. In a symptomatic patient, or a patient with specific complications of diabetes mellitus, one diagnostic test will suffice.
	*Diagnostic		*Diagnostic
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	*[[Lipid]] profile		*[[Lipid]] profile
	*[[HbA1c]] (not used for diagnosis, only for follow up).		*[[HbA1c]] (not used for diagnosis, only for follow up).
		+
		+	C-peptide may be measured as a proxy for endogenous insulin secretion. Antibodies to islet cells may indicate whether diabetes is early type 1 or is type 2, in the minority of cases where this is not clinically evident.

	===Radiology===		===Radiology===

Churg-Strauss syndrome

2009-11-17T10:20:39Z

←Older revision		Revision as of 10:20, 17 November 2009
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		+	{{SubjectBox}}
		+	[[Category:Respiratory medicine]]
		+	[[Category:Eponyms]]
		+	[[Category:Vasculitides]]
	'''Churg-Strauss syndrome'''(Allergic granulomatosis angiitis) is a vasculitis of small to medium sized blood vessels characterised by:		'''Churg-Strauss syndrome'''(Allergic granulomatosis angiitis) is a vasculitis of small to medium sized blood vessels characterised by:
	#Eosinophilia		#Eosinophilia
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	*Very rarely glomerulonephritis		*Very rarely glomerulonephritis

-	~~[[Category:Respiratory medicine]]~~	+	==External links==
-	~~[[Category:Eponyms]]~~	+	*[[Wikipedia:Churg–Strauss syndrome\|Wikipedia ''Churg–Strauss syndrome'' page]]
-	[[~~Category~~:~~Vasculitides~~]]	+

Azithromycin

2009-11-16T23:41:14Z

long half life

←Older revision		Revision as of 23:41, 16 November 2009
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	===Side effects===		===Side effects===
	===Special advice===		===Special advice===
		+
	==Pharmacology==		==Pharmacology==
		+	Long [[half-life]] (in the order of 60-70 hours) so single-dose may be effective for certain conditions.
		+
	{{stub}}		{{stub}}

	[[Category: Antibiotics]] [[Category: Macrolides]] [[Category: Medicines]]		[[Category: Antibiotics]] [[Category: Macrolides]] [[Category: Medicines]]

Testicular tumours

2009-11-16T23:07:16Z

dual classification system

←Older revision		Revision as of 23:07, 16 November 2009
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-	{{~~subjectBox~~}}	+	{{SubjectBox}}
		+	Often present as testicular lumps.
		+
		+	Broadly categorised into germ cell tumours and non-germ cell tumours. Within the germ cell tumours, there are 2 classification systems.
		+
	==Germ cell tumours==		==Germ cell tumours==
-	*[[~~Seminoma~~]]	+	Thought to derive from a common precursor lesion known as intratubular germ cell neoplasia - undifferentiated (IGCNU). This precursor lesion was first described as 'carcinoma ''in situ''' in 1978.<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=27442 Skakkebaek NE. Carcinoma in situ of the testis: frequency and relationship to invasive germ cell tumours in infertile men. Histopathology. 1978 May; 2(3):157-70.]</ref>
-	*[[Teratoma]]	+
-	*[[~~Mixed~~ germ cell tumour]]	+	Divided into [[seminoma]]s and non-seminomas.
		+
		+	===Non-seminoma===
		+	2 classification systems: the 2004 WHO classification and the British Testicular Tumour Panel (BTTP) classification.<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=17557862 Berney DM. Staging and classification of testicular tumours: pitfalls from macroscopy to diagnosis. Journal of clinical pathology. 2008 Jan; 61(1):20-4.]<small>([http://dx.doi.org/10.1136/jcp.2006.045732 Link to article] – subscription may be required.)</small></ref>
		+
		+	The latter is used mainly in the UK and Ireland, whilst the WHO classification is more international and has less cumbersome and less confusing labels. Whereas the term 'teratoma' is used in several BTTP entities, it has a more restricted use in the WHO classification. The WHO classification included malignant teratoma - immature, which was abbreviated to MTI and was a potential source of confusion with the BTTP MTI which stood for malignant teratoma - intermediate. The WHO classification is used below with the BTTP equivalents in braces.
		+	*[[Choriocarcinoma]] (Malignant teratoma - trophoblastic)
		+	*[[Embryonal carcinoma]] (Malignant teratoma - undifferentiated)
		+	*[[Teratoma]] (Teratoma - differentiated)
		+	*[[Yolk sac tumour]] (Yolk sac tumour)
		+	*Mixtures of the above are termed [[mixed germ cell tumour]]s (Malignant teratoma - intermediate)
		+
	==Non-germ cell tumours==		==Non-germ cell tumours==
	*[[Malignant lymphoma]]		*[[Malignant lymphoma]]
-	*[[Yolk sac tumour]]
	*[[Interstitial cell tumour]] or ''Leydig cell tumour''.		*[[Interstitial cell tumour]] or ''Leydig cell tumour''.
	*[[Sertoli cell tumour]]		*[[Sertoli cell tumour]]
	*metastases		*metastases
-	*[[~~adenomatoid~~ tumour]]	+	*[[Adenomatoid tumour]]
-	*[[~~paratesticular~~ sarcoma]]	+	*[[Paratesticular sarcoma]]
		+
		+	{{refsec}}
		+
		+	[[Category: Urology]]
		+	[[Category: Oncology]]

Azithromycin

2009-11-16T22:32:47Z

Clinical Use:

←Older revision		Revision as of 22:32, 16 November 2009
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	==Clinical Use==		==Clinical Use==
	===Indications===		===Indications===
		+	Preferred antibiotic for [[Chlamydia]]
	===Administration===		===Administration===
	''Oral''		''Oral''

Chlamydia trachomatis

2009-11-16T11:50:46Z

←Older revision		Revision as of 11:50, 16 November 2009
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	{{WarningBox\|It is absolutely vital to have a chaperone present in all such examinations.}}		{{WarningBox\|It is absolutely vital to have a chaperone present in all such examinations.}}
	*External genitalia including [[testes]] in males		*External genitalia including [[testes]] in males
-	*Urethral swab (specialised transport medium)	+	*Urethral swab (specialised transport medium) (Insert 1-4 cm, rotate once)
	*Screen for other STDs via high vaginal swab in females		*Screen for other STDs via high vaginal swab in females
	*Offer [[HIV]] screening to suitably counselled patients		*Offer [[HIV]] screening to suitably counselled patients
		+
		+	* Self-applied vaginal swab by females.
		+
		+	In the UK recently screening programmes for asymptomatic sexually active young adults have demonstrated a lower incidence of Chlamydia than was assumed or suggested by those introducing them.

	==Investigations==		==Investigations==
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	==Treatment==		==Treatment==
	===Medical===		===Medical===
-	===Contact tracing===	+	[[Azithromycin]] 1 gram stat is the most usual treatment.
		+
		+	===[[Contact tracing]]===
		+
	===Counselling about risk===		===Counselling about risk===

Renal artery stenosis

2009-11-14T17:51:33Z

wanted

New page

{{SubjectBox}}
'''Renal artery stenosis (RAS)''',is the narrowing of one or both renal arteries or their branches and causes about 5% of chronic kidney disease.
{{KeyPointsBox|Suspect if hypertension:
*Onset > 160/100 mm Hg after 50 years of age
*With no family history of hypertension
*Associated with renal impairment (especially if worsens after [[:Category:Angiotensin receptor blocker|sartin]] or [[:Category:Angiotensin converter enzyme inhibitor|ACE inhibitors]])
*Drug resistant
}}
==Causes==
# [[Atheroma]]
#* Associated with more than doubling risk of [[coronary artery disease]], [[stroke]] and [[peripheral vascular disease]]
# [[Fibromuscular dysplasia]]
# Other causes are rare
==Treatment==
*Stop aggravating drugs such as [[:Category:Angiotensin converter enzyme inhibitor|ACE inhibitors]]
*In fibromuscular dysplasia [[balloon angioplasty]]
*Best management of atherosclerotic RAS unclear
**Medical treatment directed at controlling BP and atheroma ([[statins]] and [[aspirin]])
**Paradoxically there is now evidence that mortality is lower in those with RAS treated with [[:Category:Angiotensin converter enzyme inhibitor|ACE inhibitors]] at a risk of doubling acute renal failure hospitalisations<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=18760140 Hackam DG, Duong-Hua ML, Mamdani M, Li P, Tobe SW, Spence JD, Garg AX. Angiotensin inhibition in renovascular disease: a population-based cohort study. American heart journal. 2008 Sep; 156(3):549-55.]<small>([http://dx.doi.org/10.1016/j.ahj.2008.05.013 Link to article] – subscription may be required.)</small></ref>
**Revascularisation can be considered if medical therapy fails
{{draft}}
{{refsec}}
[[Category:Nephrology]]

Aspirin

2009-11-14T17:01:36Z

update kidney risk as poorly known.

←Older revision		Revision as of 17:01, 14 November 2009
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	A small dose of Aspirin reduces the risk of first or subsequent [[MI]], death from MI and of ischaemic [[stroke]]. Any dose of aspirin increases [[Therapeutic bleeding risk\|the risk of bleeding]], chiefly [[gastrointestinal haemorrhage]]. All these risks increase with age and all have a cloud of other risk factors and modifiers. In secondary prevention it is {{CE B}} after any atherosclerotic ischaemic cardiovascular or cerebrovascular presentation<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=11786451 Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ (Clinical research ed.). 2002 Jan 12; 324(7329):71-86.]</ref><ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=17636787 Keller TT, Squizzato A, Middeldorp S. Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular disease. Cochrane database of systematic reviews (Online). 2007; (3):CD005158.]<small>(Epub) </small><small>([http://dx.doi.org/10.1002/14651858.CD005158.pub2 Link to article] – subscription may be required.)</small></ref>.		A small dose of Aspirin reduces the risk of first or subsequent [[MI]], death from MI and of ischaemic [[stroke]]. Any dose of aspirin increases [[Therapeutic bleeding risk\|the risk of bleeding]], chiefly [[gastrointestinal haemorrhage]]. All these risks increase with age and all have a cloud of other risk factors and modifiers. In secondary prevention it is {{CE B}} after any atherosclerotic ischaemic cardiovascular or cerebrovascular presentation<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=11786451 Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ (Clinical research ed.). 2002 Jan 12; 324(7329):71-86.]</ref><ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=17636787 Keller TT, Squizzato A, Middeldorp S. Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular disease. Cochrane database of systematic reviews (Online). 2007; (3):CD005158.]<small>(Epub) </small><small>([http://dx.doi.org/10.1002/14651858.CD005158.pub2 Link to article] – subscription may be required.)</small></ref>.

-	The benefits appear varied between the sexes, with meta-analysis of 6 trials, mainly in secondary prevention, in about 100 000 people suggesting aspirin reduces stroke in women (by 17%) and MI in men (by 32%). The risk of bleeding, may also be sex dependent - 72% and 68% increased in women and men respectively<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16418466 Berger JS, Roncaglioni MC, Avanzini F, Pangrazzi I, Tognoni G, Brown DL. Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials. JAMA : the journal of the American Medical Association. 2006 Jan 18; 295(3):306-13.]<small>([http://dx.doi.org/10.1001/jama.295.3.306 Link to article] – subscription may be required.)</small></ref>. The evidence has accumulated that aspirin is {{CE_U}} in all primary prevention scenarios<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=19293073 Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force. Annals of internal medicine. 2009 Mar 17; 150(6):405-10.]</ref>. It is also is {{CE_U}} in secondary prevention after a presentation with peripheral vascular disease not needing procedural intervention<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=19436018 Berger JS, Krantz MJ, Kittelson JM, Hiatt WR. Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease: a meta-analysis of randomized trials. JAMA : the journal of the American Medical Association. 2009 May 13; 301(18):1909-19.]<small>([http://dx.doi.org/10.1001/jama.2009.623 Link to article] – subscription may be required.)</small></ref>.	+	The benefits appear varied between the sexes, with meta-analysis of 6 trials, mainly in secondary prevention, in about 100 000 people suggesting aspirin reduces stroke in women (by 17%) and MI in men (by 32%). The risk of bleeding, may also be sex dependent - 72% and 68% increased in women and men respectively<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16418466 Berger JS, Roncaglioni MC, Avanzini F, Pangrazzi I, Tognoni G, Brown DL. Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials. JAMA : the journal of the American Medical Association. 2006 Jan 18; 295(3):306-13.]<small>([http://dx.doi.org/10.1001/jama.295.3.306 Link to article] – subscription may be required.)</small></ref>. The evidence has accumulated that aspirin is {{CE_U}} in all primary prevention scenarios<ref name="pmid:19293073">[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=19293073 Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force. Annals of internal medicine. 2009 Mar 17; 150(6):405-10.]</ref>. It is also is {{CE_U}} in secondary prevention after a presentation with peripheral vascular disease not needing procedural intervention<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=19436018 Berger JS, Krantz MJ, Kittelson JM, Hiatt WR. Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease: a meta-analysis of randomized trials. JAMA : the journal of the American Medical Association. 2009 May 13; 301(18):1909-19.]<small>([http://dx.doi.org/10.1001/jama.2009.623 Link to article] – subscription may be required.)</small></ref>.


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	====Side effects====		====Side effects====
	=====Commoner important=====		=====Commoner important=====
-	*Upper gastro-intestinal. All NSAIDs are associated with serious gastrointestinal side effects. For non-selective NSAIDs these were most common with [[azapropazone]] and least common with [[Ibuprofen]]. [[:Category:Coxib\|Selective cyclo-oxygenase-2 inhibitors]] are associated with a lower risk of gastrointestinal side effects	+	*Upper gastro-intestinal. All NSAIDs are associated with serious gastrointestinal side effects. For non-selective NSAIDs these were most common with [[azapropazone]] and least common with [[Ibuprofen]]. [[:Category:Coxib\|Selective cyclo-oxygenase-2 inhibitors]] are associated with a lower risk of gastrointestinal side effects. However this effect is negated if the coxib is given with low dose aspirin. It is now known that in primary prevention low dose aspirin has no net benefit in normal western populations due to the incidence of serious bleeding side effects approaching that of vascular events prevented<ref name=pmid:19887685">[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=19887685 Aspirin for primary prevention of cardiovascular disease? Drug and therapeutics bulletin. 2009 Nov; 47(11):122-5.]<small>([http://dx.doi.org/10.1136/dtb.2009.10.0045 Link to article] – subscription may be required.)</small></ref>. Only male diabetics may be an exception if the goal is to prevent myocardial infarction<ref name=pmid:19897665">[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=19897665 De Berardis G, Sacco M, Strippoli GF, Pellegrini F, Graziano G, Tognoni G, Nicolucci A. Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials. BMJ (Clinical research ed.). 2009; 339:b4531.]<small>(Epub) </small></ref>.
	**[[Dyspepsia]]		**[[Dyspepsia]]
	**Haemorrhage		**Haemorrhage
-	*Renal failure (especially in combination with [[diuretics]] and drugs acting on [[angiotensin]] system)	+	*Renal failure (especially in combination with [[diuretics]] and drugs acting on [[angiotensin]] system). In elderly patients renal function with low dose aspirin decreases by about 19%<ref name="pmid:17125112">[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=17125112 Segal R, Lubart E, Leibovitz A, Iaina A, Caspi D. Renal effects of low dose aspirin in elderly patients. The Israel Medical Association journal : IMAJ. 2006 Oct; 8(10):679-82.]</ref> and this is worse if patients already on a diuretic<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=18077925 Sweileh WM. Potential adverse effects of a low-dose aspirin-diuretic combination on kidney function. International journal of clinical pharmacology and therapeutics. 2007 Nov; 45(11):601-5.]</ref>. There is a dose related effect with patients already on an ACE inhibitor but this is more marked at doses of 160mg and above<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=18794027 Juhlin T, Jönsson BA, Höglund P. Renal effects of aspirin are clearly dose-dependent and are of clinical importance from a dose of 160 mg. European journal of heart failure : journal of the Working Group on Heart Failure of the European Society of Cardiology. 2008 Sep; 10(9):892-8.]<small>([http://dx.doi.org/10.1016/j.ejheart.2008.06.014 Link to article] – subscription may be required.)</small></ref>. Aspirin chronic use has long been known to be associated with chronic renal failure that can be modelled on a lifetime accumulated dose model<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=11752356 Fored CM, Ejerblad E, Lindblad P, Fryzek JP, Dickman PW, Signorello LB, Lipworth L, Elinder CG, Blot WJ, McLaughlin JK, Zack MM, Nyrén O. Acetaminophen, aspirin, and chronic renal failure. The New England journal of medicine. 2001 Dec 20; 345(25):1801-8.]<small>([http://dx.doi.org/10.1056/NEJMoa010323 Link to article] – subscription may be required.)</small></ref>. The risk of overt chronic renal failure in secondary prevention is about 10 times less than the number of myocardial infarctions prevented in the same time period however !
	*Fluid retention		*Fluid retention
	=====Rarer Important=====		=====Rarer Important=====
	*Cardiovascular events. This may be related to degree of cyclo-oxygenase-2 inhibition		*Cardiovascular events. This may be related to degree of cyclo-oxygenase-2 inhibition
	*Asthma		*Asthma
		+	*Gout -Low dose aspirin blocks renal excretion of urate, typically by about 17%<ref name="pmid:17125112">[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=17125112 Segal R, Lubart E, Leibovitz A, Iaina A, Caspi D. Renal effects of low dose aspirin in elderly patients. The Israel Medical Association journal : IMAJ. 2006 Oct; 8(10):679-82.]</ref>. The patient with an acute flare of gout and their physician have different perceptions as to the importance of this issue.
	=====List of NSAID side-effects - many rare=====		=====List of NSAID side-effects - many rare=====
-	Some NSAIDs are more likely to cause these side-effects than others but they all appear to be class side-effects	+	Some NSAIDs are more likely to cause these side-effects than others but they all appear to be class side-effects. Aspirin certainly can cause many of them at full treatment doses, as well as tinnitus ++
	*Gastro-intestinal		*Gastro-intestinal
	**[[Gastritis]]		**[[Gastritis]]