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Query: UMLS:C0036690 (sepsis)
 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Imipenem, the first carbapenem discovered, was developed more than two decades ago in response to an unmet need for a highly potent, broad-spectrum antimicrobial agent with a strong safety profile. It has since been used to treat more than 26 million patients. In an era where antibiotic use has driven antibiotic resistance, choosing appropriate initial therapy for serious infection is critical. Appropriate antibiotic regimens must cover all likely pathogens, be administered promptly at the correct dosage and dosing interval, be well tolerated and prevent the emergence of resistance. While imipenem was initially reserved for use in intractable, serious infections, the benefits of early aggressive therapy are now known, making imipenem a core agent in de-escalation therapy due to proven efficacy and safety for indications such as nosocomial pneumonia, intra-abdominal infection, sepsis and febrile neutropenia. De-escalation therapy with an agent such as imipenem minimizes resistance development by initiating aggressive initial treatment and then tailoring therapy based on patient response and culture results, switching to a less expensive, narrower spectrum antibiotic regimen or shortening the duration of therapy. Imipenem has maintained sustained clinical efficacy, tolerability and in vitro activity against important bacterial pathogens for two decades. We review the factors that continue to make imipenem as appropriate an agent for de-escalation therapy now as it was 20 years ago.
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PMID:Two decades of imipenem therapy. 1699 45

Infectious muscle diseases have very different aetiologies. The viral myositides are proved by clinical and laboratory evidences in various etiologic settings (Influenza A and B, Coxsackie and HIV). The bacterial myositis was considered in the near past a tropical disease, but in our days with migration of people from South to North and the endemia of AIDS it became a problem of the "civilized" world. On the other hand, tuberculous endemia in Central-Eastern Europe, including Romania, results in quite high incidence of osteoarticular tuberculosis. In this section the authors take into consideration some clinical entities, such as psoas abscess, postanginal sepsis, beta-haemolytic streptococcus infection and that caused by Koch bacillus. Other rare musculoskeletal infections such as gas gangrene and non-clostridial anaerobic myonecrosis are also reviewed. Immune depression caused by underlying diseases, therapies, alcoholism or old age is often encountered. The parasitic aetiologies include infestations with Trichinella spiralis, Cysticercus cellulosae, Toxoplasma and Amoeba. The contribution of imagistic methods to diagnosis is emphasised. Ultrasonography associated with CT imaging are usually used, while MRI should be reserved for cases in which axial skeleton is involved. The management is based on appropriate antibiotic therapy and surgery.
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PMID:Infectious muscle disease. 1723 94

This pictorial essay aims to review the literature on the management of pyogenic liver abscess, focusing on the choice of drainage. Articles on the treatment of pyogenic liver abscess, accessed through a MEDLINE search using PubMed, were reviewed. A case series of the authors' experience with clinicopathological correlation is presented to highlight the indication and outcome of each modality of drainage. Intravenous antibiotic is the first line, and mainstay, of treatment. Drainage is necessary for large abscesses, equal to or larger than 5 cm in size, to facilitate resolution. While percutaneous drainage is appropriate as first-line surgical treatment in most cases, open surgical drainage is prudent in cases of rupture, multiloculation, associated biliary or intra-abdominal pathology. Percutaneous drainage may help to optimise clinical condition prior to surgery. Laparoscopic drainage is a feasible surgical option with promising results in the future. Liver resection is reserved for concomitant localised intrahepatic disease and tumour, after control of sepsis. The final verdict on the outcome of percutaneous versus open surgical drainage of pyogenic liver abscesses requires further studies in a controlled trial setting. Nevertheless, in current good clinical practices, the choice of therapy needs to be individualised according to patient's clinical status and abscess factors. They are complementary in the management of liver abscesses.
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PMID:Management of pyogenic liver abscesses - percutaneous or open drainage? 1804 48

Chylothorax is the most common cause of pleural effusion in the newborn. We report three patients with congenital chylothorax and discussed the clinical course and treatment options. Cases 1 and 2 with congenital chylothorax were treated by chest tube placement and total parenteral nutrition (TPN), and were fed a formula rich in medium-chain triglyceride. They were discharged home without any sequelae. Our 3rd case with chylothorax did not respond to the conventional therapies. Octreotide infusion was tried without any benefits and necessitated surgical intervention, but the infant developed chronic lung disease requiring nasal oxygen therapy until three months of age. All three patients developed complications of chylothorax treatment like chest tube dysfunction, pneumothorax, nosocomial sepsis, and cholestasis. Management of congenital chylothorax necessitates a multidisciplinary approach. Treatment options include pleural drainage, cessation of enteral feeding and initiation of TPN. Experience with octreotide treatment is limited. Surgery should be reserved for severe and refractory cases.
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PMID:Report of three cases: congenital chylothorax and treatment modalities. 1824 45

Pressure ulcers which communicate with the hip joint are very difficult to treat. Often, the hip joint is infected with osteomyelitis of the proximal femur resulting in bouts of sepsis and flap failure. These patients require proximal femoral resection and wide debridement in order to eradicate the infection, which in turn results in large and deep cavities. Reconstruction requires either a muscle flap or even a total thigh flap if the defect is very large and the pelvis is involved. In a series of six ischial or ischio-trochanteric pressure sores communicating with the hip joint, following multiple serial debridements, the vastus lateralis, vastus intermedius and rectus femoris muscles were raised as a single musculocutaneous flap ('three muscle flap'), based on the descending branch of the lateral femoral circumflex artery, and transposed into the defect. All patients were paraplegics and had signs of sepsis during admission. Two patients had prior failed reconstructions within 3 months of admission and the others had not been operated on before. The external skin defect of the ulcers ranged from 7 x 5 cm to 30 x 12 cm. After 12 months follow up there was no recurrence of pressure sores or sepsis. The 'three muscle flap' offers the advantage of providing large bulk to fill deep cavities, while preserving the rest of the thigh. The flap elevation is fast and safe and the vascular pedicle is reliable. This technique is not for simple pressure sores, but should be reserved for large pressure sores complicated with large cavities created after resection of the proximal femur.
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PMID:Treatment of large ischial ulcers communicating with the hip joint with proximal femoral resection and reconstruction with a combined vastus lateralis, vastus intermedius and rectus femoris musculocutaneous flap. 1871 37

The diagnosis of disseminated intravascular coagulation (DIC) should encompass both clinical and laboratory information. The International Society for Thrombosis and Haemostasis (ISTH) DIC scoring system provides objective measurement of DIC. Where DIC is present the scoring system correlates with key clinical observations and outcomes. It is important to repeat the tests to monitor the dynamically changing scenario based on laboratory results and clinical observations. The cornerstone of the treatment of DIC is treatment of the underlying condition. Transfusion of platelets or plasma (components) in patients with DIC should not primarily be based on laboratory results and should in general be reserved for patients who present with bleeding. In patients with DIC and bleeding or at high risk of bleeding (e.g. postoperative patients or patients due to undergo an invasive procedure) and a platelet count of <50 x 10(9)/l transfusion of platelets should be considered. In non-bleeding patients with DIC, prophylactic platelet transfusion is not given unless it is perceived that there is a high risk of bleeding. In bleeding patients with DIC and prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), administration of fresh frozen plasma (FFP) may be useful. It should not be instituted based on laboratory tests alone but should be considered in those with active bleeding and in those requiring an invasive procedure. There is no evidence that infusion of plasma stimulates the ongoing activation of coagulation. If transfusion of FFP is not possible in patients with bleeding because of fluid overload, consider using factor concentrates such as prothrombin complex concentrate, recognising that these will only partially correct the defect because they contain only selected factors, whereas in DIC there is a global deficiency of coagulation factors. Severe hypofibrinogenaemia (<1 g/l) that persists despite FFP replacement may be treated with fibrinogen concentrate or cryoprecipitate. In cases of DIC where thrombosis predominates, such as arterial or venous thromboembolism, severe purpura fulminans associated with acral ischemia or vascular skin infarction, therapeutic doses of heparin should be considered. In these patients where there is perceived to be a co-existing high risk of bleeding there may be benefits in using continuous infusion unfractionated heparin (UFH) due to its short half-life and reversibility. Weight adjusted doses (e.g. 10 mu/kg/h) may be used without the intention of prolonging the APTT ratio to 1.5-2.5 times the control. Monitoring the APTT in these cases may be complicated and clinical observation for signs of bleeding is important. In critically ill, non-bleeding patients with DIC, prophylaxis for venous thromboembolism with prophylactic doses of heparin or low molecular weight heparin is recommended. Consider treating patients with severe sepsis and DIC with recombinant human activated protein C (continuous infusion, 24 microg/kg/h for 4 d). Patients at high risk of bleeding should not be given recombinant human activated protein C. Current manufacturers guidance advises against using this product in patients with platelet counts of <30 x 10(9)/l. In the event of invasive procedures, administration of recombinant human activated protein C should be discontinued shortly before the intervention (elimination half-life approximately 20 min) and may be resumed a few hours later, dependent on the clinical situation. In the absence of further prospective evidence from randomised controlled trials confirming a beneficial effect of antithrombin concentrate on clinically relevant endpoints in patients with DIC and not receiving heparin, administration of antithrombin cannot be recommended. In general, patients with DIC should not be treated with antifibrinolytic agents. Patients with DIC that is characterised by a primary hyperfibrinolytic state and who present with severe bleeding could be treated with lysine analogues, such as tranexamic acid (e.g. 1 g every 8 h).
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PMID:Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. 1922 77

Critical limb ischemia (CLI) is the term used to designate the condition in which peripheral artery disease has resulted in resting leg or foot pain or in a breakdown of the skin of the leg or foot, causing ulcers or tissue loss. If not revascularized, CLI patients are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the development of sepsis. The management of CLI requires a multidisciplinary team of experts in different areas of vascular disease, from atherosclerotic risk factor management to imaging, from intervention to wound care and physical therapy. In the past decade, the most significant change in the treatment of CLI has been the increasing tendency to shift from bypass surgery to less invasive endovascular procedures as first-choice revascularization techniques, with bypass surgery then reserved as backup if appropriate. The goals of intervention for CLI include the restoration of pulsatile, inline flow to the foot to assist wound healing, the relief of rest pain, the avoidance of major amputation, preservation of mobility, and improvement of patient function and quality of life. The evaluating physician should be fully aware of all revascularization options in order to select the most appropriate intervention or combination of interventions, while taking into consideration the goals of therapy, risk-benefit ratios, patient comorbidities, and life expectancy. We discuss the incidence, risk factors, and prognosis of CLI and the clinical presentation, diagnosis, available imaging modalities, and medical management (including pain and ulcer care, pharmaceutical options, and molecular therapies targeting angiogenesis). The endovascular approaches that we review include percutaneous transluminal angioplasty (with or without adjunctive stenting); subintimal angioplasty; primary femoropopliteal and infrapopliteal deployment of bare nitinol, covered, drug-eluting, or bioabsorbable stents; cryoplasty; excimer laser-assisted angioplasty; excisional atherectomy; and cutting balloon angioplasty.
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PMID:Medical and endovascular management of critical limb ischemia. 1962 74

Penetrating and blunt force mechanisms frequently result in thoracic trauma. Thoracic injuries cover the spectrum from trivial to lethal, and more than half are associated with head, abdomen or extremity trauma. Fortunately over eighty percent of injuries can be managed non-operatively utilizing tube thoracostomy, appropriate analgesia and aggressive respiratory therapy. Patients requiring emergency thoracotomy are either in shock or have life threatening injuries and, as expected, have significant mortality and morbidity. Injury to the thorax directly accounts for approximately 25% of trauma related mortality and is a contributing factor in another 25%. Early mortality results from haemorrhage, catastrophic injury or associated head or abdominal trauma. Not unexpectedly, late deaths are related to sepsis and organ failure. Blunt injury to the thorax most commonly results from motor vehicle collisions, with motorcycle accidents, pedestrians struck and falls next in frequency. Stab wound and gunshot wounds comprise the vast majority of penetrating injuries. In general the mortality from penetrating injury is higher and related to vascular injury and shock. Mortality from blunt trauma often results from abdominal and, especially, head injury. Rapid assessment and interventions, such as tube thoracostomy and airway control, can be life saving. The patient's haemodynamic status drives early treatment, often necessitating emergency surgery. Detailed imaging studies are reserved for haemodynamically stable patients. The evaluation and treatment of specific thoracic injuries will be discussed, as well as some general principles in treating thoracic trauma.
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PMID:The diagnosis and treatment of non-cardiac thoracic trauma. 2043 98

Postnatal cytomegalovirus (CMV) infection in the newborn can occur from exposure to maternal cervical secretions during birth, ingestion of breast milk, transfusion of blood products or transmission by body fluids of infected people. Breast milk is the main source of infection, given the high rate of CMV-positive mothers excreting CMV in milk. Freezing reduces the risk of CMV transmission by breastfeeding, although it does not eliminate it completely. Pasteurisation prevents such transmission, but it can alter the immunological properties of breast milk. Postnatal CMV infection is usually asymptomatic, as it normally results from viral reactivation in the mother, and the neonate is born with protective antibodies. However, in the very low birth weight premature infant the amount of transferred antibodies is smaller and a symptomatic infection can occur. Symptomatic post-natal CMV infection in the newborn typically causes hepatitis, neutropenia, thrombocytopenia or sepsis-like syndrome. Pneumonitis and enteritis are less common, but very characteristic. Diagnosis is based on urine virus detection at the time of onset of symptoms. Postnatal CMV infection in the newborn generally resolves spontaneously without antiviral treatment. Ganciclovir should be reserved for severe cases. Unlike congenital CMV disease, post-natal CMV infection in the preterm infant does not seem to be associated with hearing loss or abnormal neuro-development in long term follow-up.
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PMID:[Review and guidelines on the prevention, diagnosis and treatment of post-natal cytomegalovirus infection]. 2063 Aug 14

In population-based studies, up to 50% of patients with Crohn's disease suffer from fistulas. Fistulas pose a considerable morbidity including permanent sphincter and perineal tissue destruction as well as professional and personal disabilities. Treatment options have progressed in recent years and fistula closure and fibrosis of the fistula track is achieved in some patients. Depending on severity of symptoms and fistula location, different medical and surgical therapies can be chosen. Internal fistulas such as ileoileal or ileocecal fistulas are either asymptomatic and do not require intervention or they are symptomatic and need surgery alone. They always carry a risk of abscess formation. Symptomatic perianal fistulizing disease can be treated with antibiotics (i.e. metronidazole and ciprofloxacin) for three months and/or immunosuppressant therapy (6-mercaptopurine or azathioprine). More complex cases require therapy with anti-TNF agents. Only few and preliminary data exist on cyclosporine A, tacrolimus or methotrexate in fistulizing Crohn's disease. Therefore, these therapies should mainly be used as second-line therapies. Surgery is reserved for the treatment of perianal sepsis in the presence of abscesses and refractory disease or complications of fistulas, or used in combination with pharmacological approaches. The surgical interventions in perianal disease consist of surgical drainage with or without seton placement, transient ileostomy, or in severe cases, proctectomy. The classification of fistulas in patients with Crohn's disease remains poorly defined and largely investigator dependent. The unresolved challenges in fistula treatment warrant randomized controlled trials for existing and future treatment strategies as well as a better classification system to compare available studies.
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PMID:Fistula treatment: The unresolved challenge. 2092 86


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