By T. Gambal. National-Louis University.
Genetic and genomic occurred in the 20th century kamagra 50mg free shipping, accelerated the research is helping scien study of all these areas of science generic 100 mg kamagra with amex. Now buy 50 mg kamagra free shipping, at tists tackle many the start of the 21st century 50 mg kamagra with visa, opportunities questions in this have never been greater for turning scientiﬁc area. Without even organs in action, thinking, we sweat to maintain body tempera scientists hope to ture, get hungry when we need energy and feel learn how these tired when we need to sleep. Those who work at the intersection of computer science and biology often combine and analyze data from many different sources, look ing for informative patterns. Through an approach known as knowledge engineering, Rzhetsky and his team write computer programs that scan the contents The program ﬁrst scans scientiﬁc papers of thousands of published scientiﬁc papers. Next, it evaluates the search GeneWays, focuses mainly on research literature results and makes sure they don’t overlap. They do know that jellyﬁsh essential to modern don’t ﬂash at each other in the dark, nor do they cell biology experiments glow continuously. Fruit ﬂy sperm cells glow bright green when they of the millions of proteins major role in advancing the study of genes and express the gene for green ﬂuorescent protein. The information then goes to a database that Rzhetsky and other scientists use to build large networks of molecular interactions. Rzhetsky and his team used GeneWays to iden tify risk genes for Alzheimer’s disease, a complex condition thought to be caused by many factors. In analyzing the data, Rzhetsky found important “nodes,” molecules that play key roles in the dis ease gene network that GeneWays modeled. These predicted molecular interactions were later conﬁrmed by other researchers working in a lab, underscoring the value of computer model ing as a way to learn more about the molecular basis of disease. Andrey Rzhetsky uses the computer program GeneWays to locate important “hubs” of activity (large spheres) within massive gene networks. It’s important to realize that, in most cases, genetic information cannot offer deﬁnitive proof that a disease will occur. But if you have a very strong family history of breast cancer, for exam ple, there may be a faulty gene in your family that Hard Questions increases your risk of getting the disease. If you carry either of est dilemmas to emerge from this research is a these gene variants, your lifetime risk of getting social and ethical one. That is, how should people breast cancer is signiﬁcantly higher than it would make use of information about their own genes? These concerns Only about 5 percent of all breast cancer include the potential for discrimination on the can be traced to a known, inherited gene basis of a person’s risk of disease or susceptibility variant. For example, you might health information from being used or shared want to begin getting mammograms or other without your knowledge. If cancer is found The New Genetics I 21stCentury Genetics 79 very early, it is usually more treatable, and the this gene can cause the disease, and those are odds for a cure are much higher. Currently, diagnostic laboratories across the How can there be 30 different variants of United States offer genetic tests for almost 2,000 one gene? Perhaps the most wellknown example of nucleotides produces one variant, a change in a chromosome problem is Down syndrome, in another produces another variant, and so on. So the standard chromosome abnormality, or even by one gene genetic screening test for this disease scans for variant. Cystic ﬁbrosis, for example, is due to a all of the more than 30 variants known to cause faulty gene, but more than 30 different variants of cystic ﬁbrosis. Even years from now, when One thing you might consider is whether you researchers know more about the molecular could do something with what you learn from roots of disease, genetic tests will rarely provide a genetic test. In most cases, they won’t even You’ve already read about what you could provide “yes” or “no” answers. But what about a predict whether a person’s risk of getting a disease condition that shows up in middleaged or older is relatively high, low or somewhere in between. Good Advice Since the story of genes and health is so complicated and is likely to stay that way for a while, it is very important to consider genetic information in context. Health care professionals known as genetic counselors can be a big help to people who are thinking about getting a genetic test. In addition to identifying suspects Genetic ﬁngerprinting is not limited who leave traces at the scene of a crime to people. It can ﬁnd small but poten (for example, strands of hair, drops of tially deadly traces of diseasecausing bacteria in food or water, determine whether an expensive horse was sired by a Kentucky Derby winner or ﬁgure out whether a puppy’s parents were ﬁrst cousins. The chances of a molecular ﬁngerprint being the same in two people or two organisms are vanishingly small. Genetic counselors do their work Is a person who gave a blood or tissue sample in many different settings, including hospitals, entitled to proﬁts from a company that develops private clinics, government agencies and uni a drug based on genetic information in her sam versity laboratories. An interesting aspect of the job is that genetic Can a blood or tissue sample that was donated counselors address the needs of entire families, for one purpose be used for an entirely different rather than just individual patients. Many of the most Field Study The word most often used to refer to This usually involves transferring genetic mate applications of genetic research, espe rial from one kind of organism into another. Using cially those leading to products for the same techniques that were developed for put human use, is biotechnology. It ting genes into animals for research purposes, involves techniques that use living scientists can create crop plants with desirable organisms—or substances derived traits, such as improved ﬂavor or better resistance from those organisms—for various to insect pests. Transferring speciﬁc genes is practical purposes, such as making a faster and more efﬁcient than traditional breeding biological product. One major application of biotech The United States is home to far more geneti nology is in agriculture. Actually, this is cally modiﬁed crops than anywhere else in the hardly new: Humanity has engaged in world. In 2009, 85 percent of the country’s corn, agricultural biotechnology for 10,000 88 percent of its cotton and 91 percent of its soy years or more. Many traditional farming beans were cultivated from seeds genetically practices, from plant breeding to animal modiﬁed to resist plant pests and certain herbi husbandry, are really forms of biotech cides used to control weeds. Many believe that agricultural biotechnology is But in today’s agricultural industry, an important driver for improving world health. Traditionally, when an inventor comes up with a new idea and wants to sell it—whether it’s a radiocontrolled toy boat or a customized laboratory chemical—he or she submits an appli cation to the U. Patents give inventors time to optimize their products and control how their inventions are used, allowing them to make money from their creativity. But opposition from farmers and consumers within and outside the United States has clouded agricultural biotechnology’s future. Some object to the development of plants that are naturally resistant to herbicides, partly out of concern that the trait might jump to weeds, making them impossible to destroy. Environmental advocacy groups worry that genetically modiﬁed plants may impact the future biodiversity of our planet by harming beneﬁcial insects and possibly other organisms. Environmental Protection Agency has stated that there is no evidence to date that indicates that biotech crops have any adverse effects on nontargeted wildlife, plants or beneﬁcial insects. Biotechnology helps agricultural scientists create Of course, careful ﬁeld tests of newly created, crops with desired traits. The majority of cotton and soybeans in the United States are grown with genetically modiﬁed plants and animals are genetically modiﬁed seeds that resist viruses and essential to be sure that they cause no harm to other plant pests. But patents have been issued to use patented genetic information may need to for speciﬁc medical uses of genetic information. Patent and Trademark Ofﬁce to establish guidelines for what kind of genetic information can be patented. Since this area of medical research is an evermoving target, government scientists, policymakers and the courts continue to clarify patent and licensing issues in the hope of keeping data that is valuable for research in the public domain. The New Genetics I 21stCentury Genetics 85 Careers in Genetics Opportunities to be part of genetic and genomic research have never been greater or more exciting. In addition to studying human genes, scientists are gathering information about the genes of many other living things, from microbes that cause disease to model organisms like mice and Drosophila, livestock and crop plants. Although computers do some of the work, this avalanche of information has to be analyzed by thousands and thousands of human brains. In addition to identifying genes, scientists must generated by life scientists, is especially short ﬁgure out what the genes do and—even more of qualiﬁed workers. We need laboratory scientists, doctors to do Many careers in genetics and genomics clinical research and treat patients, genetic coun require advanced degrees such as a Ph.
Platelet dysfunction may stem from an intrinsic platelet defect or from an extrinsic factor that alters the function of otherwise normal platelets buy kamagra 50mg free shipping. Hereditary disorders of platelet function The most common hereditary intrinsic platelet disorders are a group of mild bleeding disorders that may be considered disorders of amplification of platelet activation generic 100 mg kamagra with visa. Thrombasthenia is a rare hereditary platelet defect that affects platelet surface membrane glycoproteins kamagra 50mg without prescription. Thrombasthenia patients may have severe mucosal bleeding (eg 100 mg kamagra otc, nosebleeds that stop only after nasal packing and transfusions of platelet concentrates). Bernard-Soulier syndrome is another rare autosomal recessive disorder that affects surface membrane glycoproteins. Acquired platelet dysfunction Acquired abnormalities of platelet function are very common because use of aspirin, which predictably affects platelet function, is ubiquitous. Aspirin, which modestly prolongs the bleeding time in many healthy persons, may markedly increase the bleeding time in patients with an underlying platelet dysfunction or who have a severe coagulation disturbance (eg, patients who have been given therapeutic heparin or those with severe hemophilia). Platelets may become dysfunctional, prolonging the bleeding time, as blood circulates through a pump oxygenator during cardiopulmonary bypass surgery. Thus, regardless of platelet numbers, patients who bleed excessively after cardiac surgery and who have a long bleeding time should be given platelet concentrates. During bypass surgery, giving aprotinin (a protease inhibitor that neutralizes plasmin activity) reportedly prevents prolongation of the bleeding time and reduces the need for blood replacement. The bleeding time may shorten transiently after vigorous dialysis, administration of cryoprecipitate, or desmopressin infusion. Coagulation disorders Decreased or defective synthesis of one or more of the coagulation factors can cause bleeding. Hemophilia may result from gene mutations: point mutations involving a single nucleotide, deletions of all or parts of the gene, and mutations affecting gene regulation. About 50% of cases of severe hemophilia A result from a major inversion of a section of the tip of the long arm of the X chromosome. Each son of a carrier has a 50% chance of being a hemophiliac, and each daughter has a 50% chance of being a carrier. Minor trauma can result in extensive tissue hemorrhages and hemarthroses, which, if improperly managed, can result in crippling musculoskeletal deformities. Bleeding into the base of the tongue, causing airway compression, 389 Hematology may be life threatening and requires prompt, vigorous replacement therapy. They rarely have spontaneous hemorrhages; however, they will bleed severely (even fatally) after surgery if not managed correctly. These techniques have also been applied to the diagnosis of hemophilia A by chorionic villus sampling in the 8- to 11- wk fetus. Acquired Coagulation Disorders The major causes of acquired coagulation disorders are vitamin K deficiency, liver disease, disseminated intravascular coagulation, and development of circulating anticoagulants. Liver disease-related coagulation disorders Liver disease may disturb hemostasis by impairing clotting factor synthesis, increasing fibrinolysis, or causing thrombocytopenia. In patients with fulminant hepatitis or acute fatty liver of pregnancy, hemostasis is disturbed through decreased production and consumption of clotting factors in intravascular clotting. If secondary fibrinolysis is extensive enough to deplete plasma 2-antiplasmin, a loss of control of fibrinolysis adds to the bleeding tendency. The most vulnerable organ is the kidney, where fibrin deposition in the glomerular capillary bed may lead to acute renal failure. This is reversible if the necrosis is limited to the renal tubules (acute renal tubular necrosis) but irreversible if the glomeruli are also destroyed (renal cortical necrosis). Coagulation disorders caused by circulating anticoagulants Circulating anticoagulants are endogenous substances that inhibit blood coagulation. Occasionally, antibodies cause bleeding by binding prothrombin, not by neutralizing clotting factor activity. Although the prothrombin-antiprothrombin complex 396 Hematology retains its coagulant activity in vitro, it is rapidly cleared from the blood in vivo, resulting in acute hypoprothrombinemia. These heparin-like anticoagulants are found mainly in patients with multiple myeloma or other hematologic malignancies. Therapy with cyclophosphamide and corticosteroids has suppressed antibody production in some nonhemophiliacs. Immunosuppression should be attempted in all nonhemophiliacs, with the possible exception of the postpartum woman, whose antibodies may disappear spontaneously. Because immunosuppressants do not seem to influence antibody production in hemophiliacs, they are not recommended. Although the anticoagulant interferes with the function of procoagulant phospholipid in clotting tests in vitro, patients with only the lupus anticoagulant do not bleed excessively. Paradoxically, for an unknown reason, patients with the lupus anticoagulant are at increased risk for thrombosis, which may be either venous or arterial. Repeated first-trimester abortions, possibly 398 Hematology related to thrombosis of placental vessels, have also been reported. If such a patient experiences a thrombotic episode, long-term prophylaxis with anticoagulant therapy is usually advised. A subset of patients with the lupus anticoagulant develop a second antibody--the non-neutralizing a n t i b o d y t o p r o t h r o m b i n t h a t i n d u c e s hypoprothrombinemia. The specificity of the test for the lupus anticoagulant is increased by correction of a prolonged clotting time by phospholipids (particularly hexagonal phospholipid). It is measured by determining the time required for bleeding to stop from small subcutaneous vessels that have been severed by a standardized incision. The method is no more recommended today owing to the following drawbacks: • It is not possible to standardize the depth of the wound • If the patient has a significant bleeding disorder, bleeding into the soft subcutaneous tissue in the earlobe could lead to a large hematoma. The Ivy Method Principle Three incisions are made on the volar side of the arm using a lancet known as a Stylet that has a shoulder to limit the depth of the cut. Advantages • Standardized incision • Improved standardization of the pressure in the 401 Hematology vascular system because a sphygmomanometer cuff around the upper arm maintains venous pressure within narrow limits. Equipment • Sphygmomanometer • Stop watches • Circular filter paper • 70% alcohol • Cotton wool pads or gauze • Disposable stylets (with 2mm pointed blades) • Sterile bandages Procedure 1. Apply the manometer cuff around the upper arm; gently cleanse the forearm with an alcohol pad allow to dry. Make three cuts on the lower arm, preferably on the anterior side where there is no hair; avoid superficial veins. Start one stop watch for each puncture wound when bleeding begins; in general bleeding starts within 30 seconds, if not, spread the wounds slightly between two fingers (this does not change the result). Gently blot the blood with a circular filter paper at 15 second intervals; avoid direct contact of the filter paper with the wound as this may remove the platelet plug and aggravate bleeding. Normal Values Children: < 8 minute Adults: < 6 minutes *Each laboratory should establish its own normal range which will depend on whether a lateral or longitudinal incision is made and precise determination of the end point. Apply firm pressure to the template while introducing the blade at a right angle on the upper portion of the template slot. After the test, the template and gauge must be washed thouroughly with surgical soap then rinsed well with water and autoclaved or sterilized by a gas such as ethylene chloride. Interpretation Prolonged bleeding times are demonstrable in patients with: • Thrombocytopenia with a platelet count of < 50 x 109/l. Whole Blood Coagulation Time Method of Lee and White Principle: Whole blood is delivered using carefully controlled venipuncture and collection process into standardized glass tubes. It is prolonged in defects of intrinsic and extrinsic coagulation and in the presence of certain pathological anticoagulants and heparin. Venous blood is withdrawn using normal precautions and a stop watch is started the moment blood appears in the syringe. Deliver 1ml of blood into each of four 10 x 1cm dry, chemically clean glass tubes which have previously been placed in a water bath maintained at 37oC. After 3 minutes have elapsed, keeping the tubes out of the water bath for as short time as possible, tilt them individually every 30 seconds. The clotting time of each tube is recorded separately and the coagulation time is reported as an average of the four tubes. Clot Retraction: Classic Method Principle: Clot retraction is a measure of: (1) the amount of fibrin formed and its subsequent contraction, (2) the number and quality of platelets, since platelets have a protein that causes clot retraction. Since the fibrin clot enmeshes the cellular elements of the blood, a limit is set to the extent fibrin contracts by the volume of red blood cells (the hematocrit). Clot retraction is directly proportional to the number of platelets and inversely proportional to the hematocrit. Normal Values: 48-64% (average 55%) Observation of the Clot Examination of a clot in a tube gives information on: • The concentration of fibrinogen • The number and function of platelets, and • The activity of the fibrinolytic system Result 1.
Dr Chiang is to be congratulated for her exceptional industry and enthusiasm in converting an idea into a reality purchase kamagra 100mg mastercard. Julian Verbov Professor of Dermatology Liverpool 2009 Preface to the 2nd edition Nicole and I are gratifed by the response to this Handbook which clearly fulfils its purpose cheap 50mg kamagra with visa. The positive feedback we have received has encouraged us to slightly expand the text and allowed us to update where necessary buy kamagra 50 mg without a prescription. Julian Verbov Professor of Dermatology Liverpool 2014 5 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Foreword to First edition There is a real need for appropriate information to meet the educational needs of doctors at all levels kamagra 50 mg without a prescription. The hard work of those who produce the curricula on which teaching is based can be undermined if the available teaching and learning materials are not of a standard that matches the developed content. Any handbook must meet the challenges of being comprehensive, but brief, well illustrated, and focused to clinical presentations as well as disease groups. It should find a home in the pocket of students and doctors in training, and will be rapidly worn out. I wish it had been available when I was in need, I am sure that you will all use it well in the pursuit of excellent clinical dermatology! Dr Mark Goodfield President of the British Association of Dermatologists 6 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors What is dermatology? Ability to examine skin, hair, nails and mucous membranes systematically showing respect for the patient 5. Ability to record findings accurately in patient’s records Taking a dermatological history • Using the standard structure of history taking, below are the important points to consider when taking a history from a patient with a skin problem (Table 1). Taking a dermatological history Main headings Key questions Presenting complaint Nature, site and duration of problem History of presenting complaint Initial appearance and evolution of lesion* Symptoms (particularly itch and pain)* Aggravating and relieving factors Previous and current treatments (effective or not) Recent contact, stressful events, illness and travel History of sunburn and use of tanning machines* Skin type (see page 70)* Past medical history History of atopy i. General terms Terms Meaning Pruritus Itching Lesion An area of altered skin Rash An eruption Naevus A localised malformation of tissue structures Example: (Picture Source: D@nderm) Pigmented melanocytic naevus (mole) Comedone A plug in a sebaceous follicle containing altered sebum, bacteria and cellular debris; can present as either open (blackheads) or closed (whiteheads) Example: Open comedones (left) and closed comedones (right) in acne 10 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Table 4. Distribution (the pattern of spread of lesions) Terms Meaning Generalised All over the body Widespread Extensive Localised Restricted to one area of skin only Flexural Body folds i. Configuration (the pattern or shape of grouped lesions) Terms Meaning Discrete Individual lesions separated from each other Confluent Lesions merging together Linear In a line Target Concentric rings (like a dartboard) Example: Erythema multiforme Annular Like a circle or ring Example: Tinea corporis (‘ringworm’) Discoid / A coin-shaped/round lesion Nummular Example: Discoid eczema 12 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Table 6. Colour Terms Meaning Erythema Redness (due to inflammation and vasodilatation) which blanches on pressure Example: Palmar erythema Purpura Red or purple colour (due to bleeding into the skin or mucous membrane) which does not blanch on pressure – petechiae (small pinpoint macules) and ecchymoses (larger bruise-like patches) Example: Henoch-Schönlein purpura (palpable small vessel vasculitis) 13 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Hypo- Area(s) of paler skin pigmentation Example: Pityriasis versicolor (a superficial fungus infection) De- White skin due to absence of melanin pigmentation Example: Vitiligo (loss of skin melanocytes) Hyper- Darker skin which may be due to various causes (e. Morphology (the structure of a lesion) – Primary lesions Terms Meaning Macule A flat area of altered colour Example: Freckles Patch Larger flat area of altered colour or texture Example: Vascular malformation (naevus flammeus / ‘port wine stain’) Papule Solid raised lesion < 0. Morphology - Secondary lesions (lesions that evolve from primary lesions) Terms Meaning Excoriation Loss of epidermis following trauma Example: Excoriations in eczema Lichenification Well-defined roughening of skin with accentuation of skin markings Example: Lichenification due to chronic rubbing in eczema Scales Flakes of stratum corneum Example: Psoriasis (showing silvery scales) 18 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Crust Rough surface consisting of dried serum, blood, bacteria and cellular debris that has exuded through an eroded epidermis (e. Hair Terms Meaning Alopecia Loss of hair Example: Alopecia areata (well-defined patch of complete hair loss) Hirsutism Androgen-dependent hair growth in a female Example: Hirsutism Hypertrichosis Non-androgen dependent pattern of excessive hair growth (e. Nails Terms Meaning Clubbing Loss of angle between the posterior nail fold and nail plate (associations include suppurative lung disease, cyanotic heart disease, inflammatory bowel disease and idiopathic) Example: (Picture source: D@nderm) Clubbing Koilonychia Spoon-shaped depression of the nail plate (associations include iron-deficiency anaemia, congenital and idiopathic) Example: (Picture source: D@nderm) Koilonychia Onycholysis Separation of the distal end of the nail plate from nail bed (associations include trauma, psoriasis, fungal nail infection and hyperthyroidism) Example: (Picture source: D@nderm) Onycholysis Pitting Punctate depressions of the nail plate (associations include psoriasis, eczema and alopecia areata) Example: (Picture source: D@nderm) Pitting 22 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Background Knowledge • This section covers the basic knowledge of normal skin structure and function required to help understand how skin diseases occur. Ability to describe the difficulties, physical and psychological, that may be experienced by people with chronic skin disease Functions of normal skin • These include: i) Protective barrier against environmental insults ii) Temperature regulation iii) Sensation iv) Vitamin D synthesis v) Immunosurveillance vi) Appearance/cosmesis Structure of normal skin and the skin appendages • The skin is the largest organ in the human body. The skin appendages (structures formed by skin-derived cells) are hair, nails, sebaceous glands and sweat glands. The average epidermal turnover time (migration of cells from the basal cell layer to the horny layer) is about 30 days. Composition of each epidermal layer Epidermal layers Composition Stratum basale Actively dividing cells, deepest layer (Basal cell layer) Stratum spinosum Differentiating cells (Prickle cell layer) Stratum granulosum So-called because cells lose their nuclei and contain (Granular cell layer) granules of keratohyaline. Stratum corneum Layer of keratin, most superficial layer (Horny layer) • In areas of thick skin such as the sole, there is a fifth layer, stratum lucidum, beneath the stratum corneum. This occurs in 3 main phases: a) anagen (long growing phase) b) catagen (short regressing phase) c) telogen (resting/shedding phase) • Pathology of the hair may involve: a) reduced or absent melanin pigment production e. Stages of wound healing Stages of wound healing Mechanisms Haemostasis ● Vasoconstriction and platelet aggregation ● Clot formation Inflammation ● Vasodilatation ● Migration of neutrophils and macrophages ● Phagocytosis of cellular debris and invading bacteria Proliferation ● Granulation tissue formation (synthesised by fibroblasts) and angiogenesis ● Re-epithelialisation (epidermal cell proliferation and migration) Remodelling ● Collagen fibre re-organisation ● Scar maturation 27 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Emergency Dermatology • These are rapidly progressive skin conditions and some are potentially life- threatening. Ability to recognise and describe these skin reactions: - urticaria - erythema nodosum - erythema multiforme 2. Ability to recognise these emergency presentations, discuss the causes, potential complications and provide first contact care in these emergencies: - anaphylaxis and angioedema - toxic epidermal necrolysis - Stevens-Johnson syndrome - acute meningococcaemia - erythroderma - eczema herpeticum - necrotising fasciitis 28 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Urticaria, Angioedema and Anaphylaxis Causes ● Idiopathic, food (e. A large number of inflammatory mediators (including prostaglandins, leukotrienes, and chemotactic factors) play a role but histamine derived from skin mast cells appears to be the major mediator. Local mediator release from mast cells can be induced by immunological or non-immunological mechanisms. Stevens-Johnson syndrome may have features overlapping with toxic epidermal necrolysis including a prodromal illness. Herpes zoster (shingles) infection due to varicella-zoster virus affecting the distribution of the ophthalmic division of the fifth cranial (trigeminal) nerve Note: Examination for eye involvement is important Learning outcomes: Ability to describe the presentation, investigation and management of: - cellulitis and erysipelas - staphylococcal scalded skin syndrome - superficial fungal infections 36 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Erysipelas and Cellulitis Description ● Spreading bacterial infection of the skin ● Cellulitis involves the deep subcutaneous tissue ● Erysipelas is an acute superficial form of cellulitis and involves the dermis and upper subcutaneous tissue Causes ● Streptococcus pyogenes and Staphylococcus aureus ● Risk factors include immunosuppression, wounds, leg ulcers, toeweb intertrigo, and minor skin injury Presentation ● Most common in the lower limbs ● Local signs of inflammation – swelling (tumor), erythema (rubor), warmth (calor), pain (dolor); may be associated with lymphangitis ● Systemically unwell with fever, malaise or rigors, particularly with erysipelas ● Erysipelas is distinguished from cellulitis by a well-defined, red raised border Management ● Antibiotics (e. Ability to recognise: - Bullous pemphigoid - Pemphigus vulgaris 52 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Bullous pemphigoid Description ● A blistering skin disorder which usually affects the elderly Cause ● Autoantibodies against antigens between the epidermis and dermis causing a sub-epidermal split in the skin Presentation ● Tense, fluid-filled blisters on an erythematous base ● Lesions are often itchy ● May be preceded by a non-specific itchy rash ● Usually affects the trunk and limbs (mucosal involvement less common) Management ● General measures – wound dressings where required, monitor for signs of infection ● Topical therapies for localised disease - topical steroids ● Oral therapies for widespread disease – oral steroids, combination of oral tetracycline and nicotinamide, immunosuppressive agents (e. Learning objectives: Ability to formulate a differential diagnosis, describe the investigation and discuss the management in patients with: - chronic leg ulcers - itchy eruption - a changing pigmented lesion - purpuric eruption - a red swollen leg 55 Dermatology: Handbook for medical students & junior doctors 56 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 57 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 58 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 59 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 60 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 61 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 62 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 63 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 64 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Management Management and therapeutics • Treatment modalities for skin disease can be broadly categorised into medical therapy (topical and systemic treatments) and physical therapy (e. They consist of active constituents which are transported into the skin by a base (also known as a ‘vehicle’). The common forms of base are lotion (liquid), cream (oil in water), gel (organic polymers in liquid, transparent), ointment (oil with little or no water) and paste (powder in ointment). Learning objectives: Ability to describe the principles of use of the following drugs: - emollients - topical/oral corticosteroids - oral aciclovir - oral antihistamines - topical/oral antibiotics - topical antiseptics 65 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Emollients Examples ● Aqueous cream, emulsifying ointment, liquid paraffin and white soft paraffin in equal parts (50:50) Quantity ● 500 grams per tub Indications ● To rehydrate skin and re-establish the surface lipid layer ● Useful for dry, scaling conditions and as soap substitutes Side effects ● Reactions may be irritant or allergic (e. Ability to perform the following tasks: - explain how to use an emollient or a topical corticosteroid - make a referral - write a discharge letter - write a prescription for emollient - take a skin swab - take a skin scrape - measure the ankle-brachial pressure index and interpret the result 2. Describe the principles of prevention in: - pressure sores - sun damage and skin cancer 68 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Patient education How to use emollients ● Apply liberally and regularly How to use topical corticosteroids ● Apply thinly and only for short-term use (often 1 or 2 weeks only) ● Only use 1% hydrocortisone or equivalent strength on the face ● Fingertip unit (advised on packaging) – strip of cream the length of a fingertip Preventing pressure sores ● Pressure sores are due to ischaemia resulting from localised damage to the skin caused by sustained pressure, friction and moisture, particularly over bony prominences. Taking a skin scrape • Skin scrapes are taken from scaly lesions by gentle use of a scalpel in suspected fungal infection (to show evidence of fungal hyphae and/or spores) and from burrows in scabies (see page 59). Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. We could like to extend our gratitude to our university /Health Science College/ for keeping the atmosphere conductive for the preparation of this module. Finally, it is our pleasure to acknowledge all those, who have directly and/or indirectly provided us with administrative and logistic support that ultimately facilitated the development and preparation of the module. What are the salient features in the clinical evaluation of a patient suspected to have diabetes that aid you in labeling him/her as having type 1 or type 2 diabetes mellitus? What should the first step be in managing a known diabetic when he /she presents with loss of consciousness in the absence of a laboratory facility that could help you determine the random blood sugar? One of the following is not the site for subcutaneous injection during management of diabetes mellitus. He should have a snack, such as cheese, sandwich and a glass of milk, an hour before the play and should carry a fast acting source of glucose 3 B. He should not go on to play because the possible side effects of extraordinary activates are just unpredictable C. It is known that majority of lower extremity amputation are performed in a diabetic patient like Ato kebede. Why is there a discrepancy between the whole blood glucose concentration and the plasma glucose concentration? In a person with normal glucose metabolism, the blood glucose level usually increases rapidly after carbohydrates are ingested, but returns to a normal level after A. Which of the following organs uses glucose from digested carbohydrates and stores it as glycogen for later use as a source of immediate energy by the muscles? The health officer on duty examined him and the findings were an acutely sick looking boy who was conscious and in respiratory distress. On further questioning it was found out that he lives in a one room thatched roofed house with his seven siblings and parents. There is no window in the house; the cattle are kept in the same room and firewood is burned in the same room.