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Assessment: This case illustrates the late presentation of prosthetic valve endo- carditis caused by S buy generic fluvoxamine 50mg on-line. These patients frequently require prolonged antibiotic therapy and often surgical intervention for debridement and replacement of the prosthetic valve buy fluvoxamine 50mg mastercard. These postoperative infections are thought to be caused by organ- isms inoculated at time of surgery discount 50mg fluvoxamine with visa. The presentation is usually in the first 2 3 months after surgery order 50mg fluvoxamine mastercard, but can occur several months after. She devel- ops evidence of pulmonary embolism which requires surgical therapy with replace- ment of the pulmonary valve. Echocardiography cannot differentiate acute myocarditis from dilated cardiomyopathy. Definition Myocarditis is characterized by an inflammatory infiltrate of the myocardium with necrosis/degeneration of the myocytes. It is estimated that 50 80% of pediatric patients with acute presentation of dilated cardiomyopathy have myocarditis as the underlying cause. Coxsackievirus type B and parvovirus B19 are common viral agents implicated in myocarditis. In South America, Chagas disease caused by Trypanosoma cruzi is the commonest cause. Toxicity to medications such as antimicrobials and chemotherapeutic medications such as anthracyclines has been implicated in the cause of myocarditis. Hypersensitivity reactions to certain medications represent a particular type of cardiomyopathy. Pathology The gold standard for diagnosing myocarditis has been the pathological findings on endomyocardial biopsy. The cellular infiltrate is usually lymphocytic, but can also include eosinophils and plasma cells. There is usually variable and patchy myocyte degeneration and necrosis, which sometimes makes biopsy diagnosis difficult. Recently, immunohistochemical staining of biopsies has allowed the identifica- tion of viral genomes in the affected cardiac tissues. Other more advanced staining has allowed for the characterization of different immune mediated reactions of the involved myocytes to the causative agents. In all stages, direct damage to myocytes and inflammatory reaction leads to loss of myocytes and fibrous tissue formation, thus diminishing the contractility of the myocardium. The onset is usually heralded by a viral prodrome consisting of fever, upper respiratory and gastrointestinal symptoms, thought to coincide with the viremic stage of the disease. Older children and adolescents are more likely to have chest pain, easy fatigue and general malaise, exercise intolerance and abdominal pain, or even arrhythmias and syncope. On physical examination, infants might have pallor and appear dusky in addition to the findings of congestive heart failure signs. Respiratory distress is the next most common finding, fol- lowed by hepatomegaly and abnormal heart sounds or a heart murmur of mitral regurgitation. Jugular venous distension is more likely in older children, as this is an unreliable sign in the younger age group. Chest X-Ray Chest X-ray may show the presence of cardiomegaly and increased pulmo- nary vascular markings or frank pulmonary edema in almost half of patients (Fig. Arrhythmias such as ventricular or supraventricular tachycardia or atrio- ventricular block can also be seen. Echocardiography The typical findings include the presence of a dilated left ventricle with decreased systolic function in most patients (Chap. Echocardiography may also reveal the presence of mitral valve regurgitation and pericardial effusion. Pulmonary vasculature is prominent due to congested pulmonary venous circulation secon- dary to poor ventricular function due to myocarditis Laboratory Investigations The gold standard for the diagnosis of myocarditis historically has been endomyo- cardial biopsy. However, this is not routinely done due to the low sensitivity of the procedure (3 63%) and the often patchy involvement of the myocardium. Elevation of the cardiac enzymes especially involving cardiac troponins is posi- tive in about 1/3 of patients. Cardiac Catheterization This is not routinely performed in the workup of patients with myocarditis. The main indication for this procedure is to perform endomyocardial biopsy, which is invasive and has higher complication rate in younger age groups. It is estimated that about one quarter of pediatric patient cases of dilated cardiomyopathy is caused by acute myocarditis. The differential diagnosis of the presenting manifestations in infants include sepsis, metabolic disturbances, inherited metabolic disorders, mito- chondrial myopathies and anomalous origin of the left coronary artery from the pul- monary artery. The differential diagnosis in older children includes idiopathic and inherited cardiomyopathy, chronic tachyarrhythmia, and connective tissue diseases. This includes use of intravenous inotropic support with Dopamine, Dobutamine, and Milrinone. Intravenous after-load reducing agents like sodium nitroprusside are used in the acute intensive care setting.

There is conflict between the principle of justice and other principles of health care The concepts of justice considered here are protective of the individual quality fluvoxamine 100mg, rather than the community 100 mg fluvoxamine with amex. Consider the ethics of a pilot scheme that offered financial incentives (10 travel expenses) to street-workers who were playing a significant role in the local transmission of 216 gonorrhoea buy fluvoxamine 50mg amex, but whose uptake of clinic services was poor due to the overriding demands of drug addiction that made sexual health a low priority for the women cheap 50 mg fluvoxamine with visa. It may also have violated the women s autonomy by exploiting their desperate need for money. Furthermore, it might be seen to support, or collude with, illegal drug use by financing the purchase of heroin. On the other hand, the initiative resulted in sexual health benefits for the women and the community. Moreover, it is of fundamental ethical importance to sexual health services because of the particularly private nature of sexual behaviour, the stigma that accompanies sexual disease, and the damage to relationships if infidelities are exposed. Without a promise of confidentiality, people may be less likely to seek treatment for infections, or co-operate with partner notification. Discussions or examinations would not be overheard or observed by anyone who is not involved in the delivery of care, unless the patient has given prior consent Protection of patient records (paper or electronic). They would be stored in locked cabinets when the clinic is closed Protection of the identity of service users. Enquirers would not be told whether an individual has an appointment, or is attending Protection of data or photographs capable of identifying an individual patient. These would not be used for teaching, research, epidemiological surveillance or publications, without consent Protection of patient information. Details of a named patient s sexual history, diagnosis or care would not be shared with a third party outside the care team unless requested by the patient, or required by law Patients to understand the limits to confidentiality Negotiation of an acceptable means of contacting each patient, should the need arise Discretion when encountering a third party in the process of partner notification or patient recall Ethical dilemmas in relation to confidentiality Difficulties arise in relation to confidentiality when: 217 Confidentiality is against the patient s interests Breaches of confidentiality might be justified if this is necessary in order to protect a patient from harm. Patient confidentiality is harmful to others Health advisers sometimes have to choose between protecting a patient s confidentiality and protecting others from harm. Arguments for warning the partner might be that she has a right to know so she can protect herself, and that the health adviser has a professional duty to prevent the transmission of infection, where possible. An alternative view might be it is ultimately the duty of the patient, not the health adviser, to inform the partner. Breaching confidentiality could be very damaging to the patient, who may lose his relationship with the partner as a consequence. He could also find it hard to access health services in the future if trust has been destroyed. The duty of care to a patient makes it very difficult to take a course of action that inflicts harm. Some would therefore argue that the health adviser has a greater duty to protect the interests of patients than of other citizens. There is also the consideration that breaching confidentiality may be detrimental to sexual health in the long term if infected individuals were discouraged from seeking care or giving any information about partners. Confidentiality requires other moral principles to be breached In some situations confidentiality cannot be fully protected unless the health adviser is prepared to lie, or collude with lies told by patients. For example, a health adviser may consider posing as a friend or work colleague to allay the suspicion of a third party encountered during provider referral. The justification for this lie might be that it protects the patient and honours the trust placed in the service, without appearing to harm anyone else. This overriding commitment to confidentiality may benefit the sexual health of the wider community by making services more accessible. On the other hand it could be regarded as unprofessional to tell lies - a breach of public trust that health care workers will tell the truth. This may undermine confidence in services and jeopardise the public standing of health professionals. These will include the rights of all affected individuals Clarify your particular professional duties in the situation Consider the potential consequences of each action, for all individuals that might be affected. This might include the patient, a contact, the community or a health care worker Clarify any facts that might influence the decision Discuss with other health advisers. Ensure you have the professional support of at least one other health adviser before committing to a course of action Discuss with other members of the multidisciplinary team. Seek a consensus of support for any action Work within all relevant codes of professional conduct. An individual health adviser may be bound by the Nursing and Midwifery Council Code of Professional Conduct for Nurses, or the British Association for Counselling and Psychotherapy Ethical Framework for Good Practice in Counselling and Psychotherapy, in addition to the Code of Professional Conduct for Sexual Health Advisers (See Ch. The principles of autonomy, beneficence, non-maleficence, justice and confidentiality can guide reasoned moral choices. It is good practice to discuss ethical difficulties with colleagues, and to document such discussions. Further examples of ethical issues are discussed elsewhere in the manual: Ethical issues in partner notification, Ch. The manual for health advising practice 2003, London, Department of Health: page in this manual?

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In Colour the other 20% of normal individuals buy 50mg fluvoxamine with mastercard, venous The disc is pink but often slightly paler on the pulsation at the disc can be induced by gentle temporal side buy fluvoxamine 100 mg line. The central cup might be lled in by drusen small hyaline deposits quality fluvoxamine 100mg, which can be found on the surface or buried in the sub- stance of the disc cheap 100 mg fluvoxamine fast delivery. Alternatively, the central cup might be hollowed out further by a congenital pit in the disc. The central cup can be lled in by persistent rem- a nants of the hyaloid artery (Bergmeister s papilla), which runs in the embryo from disc to lens. Some of these and other congenital abnor- malities of the disc can be associated with visual eld defects that are not progressive but which can cause diagnostic confusion. Pale Disc Optic Atrophy Optic atrophy means loss of nerve tissue on the disc, and the resulting abnormal pallor of the disc must be accompanied by a defect in the visual eld,but not necessarily by a reduction in b the visual acuity. The number of small vessels, which can be counted on the disc, is sometimes used as an index of atrophy in difcult cases. Central Cup Classication of the causes of optic atrophy The centre of the disc is deeper (i. The terms primary and second- (or less) of the total disc diameter in normal ary atrophy are also used but because these subjects. The ratio between the vertical diame- terms are confusing a simple aetiological ter of the cup and the total disc diameter is classication will be used here. Thus, the borne in mind that it is not usually possible to normal cup-to-disc ratio is <0. Even the cupped, pale disc of chronic glaucoma can be mimicked Haemorrhages by optic atrophy because of chiasmal compres- Haemorrhages are never seen on or adjacent sion. If present, they warrant optic disc, there is more gliosis than when it is further investigation. A number of poisons can specically more grey or yellowish-grey than white and the damage the optic nerve; methyl alcohol is cribriform markings often seen in optic atrophy a classical example. Other toxic agents central retinal artery or vein, giant cell include ethambutol, isoniazid, digitalis arteritis and nonarteritic anterior and lead. The optic nerve can be damaged Following disease in the optic nerve, for by indirect injury if bleeding occurs into example optic neuritis, or compression of the dural sheath. The disc can After the nerve has been damaged,a period become atrophic as a direct result of the of a few weeks elapses before the nerve chronic swelling, irrespective of its cause. Such striction of the visual eld and scattered an injury can result in complete and per- pigmentation in the fundus. As the condi- manent blindness in the affected eye but a tion advances toward blindness, the discs degree of recovery is achieved in a small become atrophic. Optic atrophy might also proportion of cases, if decompression of appear in certain families without any the nerve sheath is undertaken early. It is also seen in the rare but distressing This is a serious sign because it could be caused cerebroretinal degeneration, which pres- by raised intracranial pressure and an intracra- ents with progressive blindness, epilepsy nial space-occupying lesion. Apparent Swelling The margins of the optic disc might be ill- dened and even appear swollen in hyper- metropic eyes. Vascular The disc can be swollen in congestive cardiac failure or in patients with severe chronic emphy- sema. Optic atrophy caused by pituitary compression of in anterior ischaemic optic neuropathy. The most common causes of raised intracranial pressure are cerebral tumours, hydrocephalus idiopathic (benign) intracranial hypertension, subdural haematoma, malignant hypertension and cerebral abscess. Diagnosis of papilloedema entails careful examination of the optic disc, which must be backed up with visual eld examination and colour fundus photography. The latter is esp- ecially helpful when repeated,to show any change in the disc appearance. Fluorescein angiography can also be of great diagnostic help in difcult cases when abnormal disc leakage occurs. Optic Neuritis This most commonly occurs in association with a plaque of demyelination in the optic nerve in patients with multiple sclerosis. The central association with arterial disease and one must vision is usually severely affected, in contrast take pains to exclude temporal arteritis in with papilloedema, but optic neuritis occurs in the elderly. Postoperative Other Causes Swelling of the disc is not uncommon in the immediate postoperative period after intra- Chronic intraocular inammation,such as anter- ocular surgery. It is not usually eye disease can sometimes be marked by disc regarded to be of serious signicance, because swelling (diabetic papillopathy). In severe cases the swelling regresses following normalisation of thyroid orbitopathy, the orbital congestion of the intraocular pressure. True Papilloedema Papilloedema is swelling of the optic discs because of increased intracranial pressure.

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So it is an interesting puzzle why antigenic variants do not spread as in many other viruses buy generic fluvoxamine 100mg on-line. Perhaps the very high infectiousness of measles causes the common strain to spread so widely in the host population that little heterogeneity occurs among hosts in immune memory proles fluvoxamine 100mg free shipping. If memory responds against a few dierent epitopes 100 mg fluvoxamine visa, then no single-step mutational change allows a measles variant to spread between previously infected hosts buy 50 mg fluvoxamine otc. The only nearby susceptible class of hosts arises from the inux of naive newborns, which depends on thebirthrate of the host population. This explanation for the lack of antigenic variation suggests that the epidemiological properties of the parasite and the demographic struc- ture of the hosts aect the patterns of molecular variation in antigens. These population processes do not control the possible types of varia- tion or the molecular recognition between host and parasite, but instead shape the actual distribution of variants. The lack of variation may simply reect conservation of some essential viral function in a domi- nant antigen, such as binding to host receptors. My point here is that the lack of molecular variation does not necessarily mean that the expla- nation resides at the molecular level. Population processes can strongly inuence the distribution of molecular variants. For example, ve or so amino acids determine most of the binding energy between an antibody and an antigen. Often a single amino acid substi- tution in the antigen can abolish the defensive capability of a particular antibody specicity for a matching epitope. This type of recognition is qualitative, in which a single change determines whether or not recog- nition occurs. But the dynamics of an infection within a host depend on all of the parasite s epitopesandallofthe specic B and T cell lineages that recognize dierent epitopes. The interactions within the host between the population of parasites and the populations of dierent immune cells determine immunodominance, the number of dierent epitopes that stimulate a strong immune response. Immunodominance sets the number ofamino acid substitutions need- ed to avoid host recognition. This aggregaterecognition at the level of individual hosts controls the spread of antigenic variants through a pop- ulation of previously exposed hosts. Thus, molecular interactions aect immunodominance, and immunodominance sets the pace of evolution- arychange and the distribution of variants in parasite populations. Low- anity binding did not stimulate division of B cell lineages, whereas high-anity antibodies bound the antigen so eectively that the B cell receptors received little stimulation. Intermediate anity provided the strongest stimulation for initial expansion of B cell clones. After initial stimulation and production of IgM, the next phase of B cell competition occurs during anity maturation and the shift to IgG production. The B cell receptors with the highest on-rates of binding for antigen tended to win the race to pass through anity maturation. This competition for T cell help apparently depends on the rate at which B cells acquire antigens rather than on the equilibrium anity of binding to antigens. Equilibrium anity is the ratio of the rate at which bonds form (on- rate) to the rate at which bonds break (o-rate). The contrast between the early selection of equilibrium anity (on:o ratio) and the later se- lection of on-rate may provide insight into the structural features of binding that separately control on-rates and o-rates. Switching expression between variants may allow the para- site to escape recognition by immune responses directed at previously expressed variants. Alternatively, a sequence of variants may exploit the mechanisms of immune recognition and regulation to interfere with the ability of the host to mount new responses to variants expressed later in the sequence. Variants can potentially interfere with new host responses by exploiting original antigenic sin the tendency of the host to enhance a cross-reactive response to a previously encountered anti- gen instead of generating a new and more focused response to a novel variant. How do the dierent molecular mechanisms of escape and im- mune interference shape the diversity and cross-reactivity of variants stored within each parasite s genome? For example, IgM antibodies with relatively low anity and high cross-reactivity control Borrelia hermsii, aspirochetewithanarchivallibrary of variants (Barbour and Bundoc 2001). By contrast, many parasites face control by the more highly spe- cic IgA and IgG antibodies. Parasites with archival variants haveparticularlyinteresting dynamics within hosts. If the variants are produced too quickly, the host develops specic immunity against all types early in the infection, and the infec- tion cannot persist for long. If the variants arise too slowly, the parasite risks clearance before switching toanoveltype. Thus, the pacing of molecular switches in the parasite must be tuned to the dynamics of the host s immune response.