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Four Year Prognostic Index

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2121. Prostatitis, Bacterial (Diagnosis)

with such longer courses. Nonsteroidal anti-inflammatory drugs (NSAIDs) and alpha blockers help with symptom relief. Alpha blockers may also help to decrease recurrences, by diminishing urinary obstruction. See and . Next: Background Prostatitis has been challenging to classify and diagnose. The "traditional" classification of prostatitis was based on 10 years of clinical experience with the "four-glass test" as landmarked by Meares and Stamey in 1968. [ ] The traditional classification described four (...) , prostatitis is the most common urologic problem in men younger than age 50 years. It is the third most common urologic problem in older men. Previous Next: Prognosis Treatment success rates with the administration of trimethoprim-sulfamethoxazole (TMP-SMZ) approach 30%-40%, while success rates with fluoroquinolones are 40%-75%. Relapses are common and can be treated with another course of antibiotics. If repeat treatment fails, consider a low, suppressive dose of antibiotics. Infection often persists

2014 eMedicine.com

2122. Onychomycosis (Diagnosis)

likely to have onychomycosis than children. Onychomycosis has been reported to occur in 2.6% of children younger than 18 years but as many as 90% of elderly people. Previous Next: Prognosis The goals for antifungal therapy are mycological cure and a normal looking nail. Mycological cure can be evaluated at the end of treatment, while clinical cure requires several more months owing to slow nail growth. [ ] Clinical trials have repeatedly demonstrated higher efficacy for terbinafine compared (...) of the frequent association of onychomycosis with traumatic toenail dystrophies. Onychomycosis caused by molds, particularly Fusarium species, are often not responsive to systemic therapy. Recurrence (relapse or reinfection) of onychomycosis is not uncommon, with reported rates ranging from 10-53%. [ ] Fungal infections of the fingernails have a much more favorable prognosis than toenail infections. Previous Next: Patient Education Patients should be educated about the use of appropriate footwear, especially

2014 eMedicine.com

2123. Hypertensive Heart Disease (Diagnosis)

concentric left ventricular hypertrophy. Two-dimensional echocardiogram (parasternal short axis view at the aortic valve level) from a 70-year-old woman showing mild aortic sclerosis. Calculating LV mass On 2-dimensional (2-D) and M-mode examination, the interventricular septum is thickened, as is the posterior wall (>1.1cm). LVH is defined quantitatively as an increase in the LV mass or the LV mass index (LVMI), which is defined as LV mass divided by body surface area. Various formulas have been used (...) in patients with LVH. [ ] The increased risk of cardiovascular events with LVH depends on its type. Concentric LVH poses the greatest risk of such events, as much as a 30% risk over a 10-year period in one study, compared with a 15% risk with eccentric remodeling and a 9% risk without any LVH. The degree of LVH, as assessed by LV mass index (LVMI), is also related to the cardiovascular mortality rate, with a relative risk of 1.73 for men and 2.12 for women for each 50g/m 2 increase in the LVMI over a 4

2014 eMedicine.com

2124. Hypomagnesemia (Diagnosis)

on maintenance dialysis, patients with the lowest serum magnesium levels (< 1.30 mEq/L) were at highest risk for death (hazard ratio, 1.63; 95% confidence index, 1.30-1.96). [ ] Hypomagnesemia is a common development in critically ill sepsis patients, and indicates a poor prognosis. Although evidence is derived largely from observational studies, it shows a significant association between hypomagnesemia and with increased need for mechanical ventilation, prolonged intensive care unit stays, and increased (...) are the major components of tight-junction strands in the TAL, where the reabsorption of magnesium occurs. [ , ] Twenty-four members of the family have been described. [ ] Mutations in the claudin-16 (previously known as paracellin-1) and claudin-19 genes cause a human hereditary disease, familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC), which is characterized by excessive renal magnesium and calcium wasting, polyuria, recurrent urinary tract infections, bilateral nephrocalcinosis

2014 eMedicine.com

2125. Infective Endocarditis (Diagnosis)

%, from 3.19 per 10,000 elderly patients in 1993 to 3.95 per 10,000 in 2003. [ ] This increase in age has continued, with the mean age of patients in 2009 at 60.8 years. [ ] IE is 3 times as common in males as in females. It has no racial predilection. Previous Next: Prognosis Prognosis largely depends on whether or not complications develop. If left untreated, IE is generally fatal. Early detection and appropriate treatment of this uncommon disease can be lifesaving. The overall mortality rate has (...) England Journal of Medicine . [ , , ] IE currently can be described as infective endocarditis in the era of intravascular devices, as infection of intravascular lines has been determined to be the primary risk factor for Staphylococcus aureus bloodstream infections (BSIs). has become the primary pathogen of endocarditis. [ ] As it evolves, IE continues to pose significant clinical challenges. The mortality rate within one year of acquiring infection is almost 30%. Because of lack of funding to conduct

2014 eMedicine.com

2126. Infertility (Diagnosis)

: Elizabeth E Puscheck, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG Share Email Print Feedback Close Sections Sections Infertility Overview Practice Essentials Infertility is the failure to conceive (regardless of cause) after 1 year of unprotected intercourse. This condition affects approximately 10-15% of reproductive-aged couples. Female and male factor infertility Female factors that affect fertility include the following categories: Cervical: Stenosis or abnormalities of the mucus-sperm (...) Excessive exercise Inadequate diet associated with extreme weight loss or gain Advanced age Evaluation of infertility Infertility is a problem that involves both partners. Diagnostic testing is unnecessary if the couple has not attempted to conceive for at least 1 year, unless the woman is age 35 years or older, or if they have a history of a male factor infertility, endometriosis, a tubal factor, diethylstilbestrol (DES) exposure, pelvic inflammatory disease, or pelvic surgery. A complete infertility

2014 eMedicine.com

2127. Hypoalbuminemia (Diagnosis)

with serum albumin levels of less than 35 at 3 months following discharge from the hospital have a 2.6 times greater 5-year mortality than those with a serum albumin levels greater than 40. Hypoalbuminemia has also been studied as an important prognostic factor among subsets of patients, such as patients with severe , burns, [ ] and regional enteritis ( ) and has recently been associated with an increased risk of reintubation. [ ] Whether or not hypoalbuminemia is merely a marker of severe protein (...) have hypoalbuminemia. Hypoalbuminemia can be caused by various conditions, including , hepatic cirrhosis, , and malnutrition; however, most cases of hypoalbuminemia are caused by acute and chronic inflammatory responses. Serum albumin level is an important prognostic indicator. Among hospitalized patients, lower serum albumin levels correlate with an increased risk of morbidity and mortality. The presentation, physical examination findings, and laboratory results associated with hypoalbuminemia

2014 eMedicine.com

2128. Hypokalemia (Diagnosis)

If the urine potassium level is higher than 40 mEq/L, consider diuretics. If diuretic use has been excluded, measure arterial blood gases (ABG) and determine the acid-base balance. Alkalosis suggests one of the following: Vomiting Bartter syndrome Gitelman syndrome Mineralocorticoid excess Depending on history, physical examination findings, clinical impressions, and urine potassium results, the following tests may be appropriate, but they should not be first-line tests unless the clinical index (...) . [ , ] As the adrenal and pancreatic hormonal systems play important roles in potassium homeostasis, this would not be surprising; however, the molecular mechanisms by which these potassium channels signal changes in hormone secretion and activity have still not been determined. Muscle contains the bulk of body potassium, and the notion that muscle could play a prominent role in the regulation of serum potassium concentration through alterations in sodium pump activity has been promoted for a number of years

2014 eMedicine.com

2129. Incontinence, Urinary: Nonsurgical Therapies (Diagnosis)

study revealing detrusor instability in a 75-year-old man with urge incontinence. Note the presence of multiple uninhibited detrusor contractions (phasic contractions) that is generating 40- to 75-cm H2O pressure during the filling cystometrogram (CMG). He also has small bladder capacity (81 mL), which is indicative of poorly compliant bladder. The following points regarding the clinical presentation should be sought when obtaining the history: Severity and quantity of urine lost and frequency (...) , and urodynamic studies may be needed in selected patients (see ). Videourodynamic studies are reserved to evaluate complex cases of stress urinary incontinence. Videourodynamic studies combine the radiographic findings of a voiding cystourethrogram and multichannel urodynamics. Go to for more information on this topic. Types of urinary incontinence Four types of urinary incontinence are defined in the Clinical Practice Guideline issued by the Agency for Health Care Policy and Research: stress, urge, mixed

2014 eMedicine.com

2130. Psoriatic Arthritis (Overview)

of the psoriasis relates to the pattern of joint involvement. In another study, pustular psoriasis was associated with more severe psoriatic arthritis. (See Prognosis.) Psoriatic arthritis occurring in patients over age 60 years (elderly onset psoriatic arthritis) has a more severe onset and more a destructive outcome than does psoriatic arthritis in younger patients. The course of psoriatic arthritis is usually characterized by flares and remissions. The patterns of psoriatic arthritis involvement (...) found the rate of psoriatic arthritis in patients with psoriasis to be 30.2%. [ ] A systematic review and meta-analysis of 266 studies concluded that worldwide, approximately one in five persons with psoriasis has psoriatic arthritis. [ ] A systematic review and meta-analysis of 28 studies estimated that the global average prevalence of psoriatic arthritis is 133 per 100,000 population (95% confidence index [CI], 107–164 per 100,000), and the incidence is 83 per 100,000 persons per year (95% CI, 41

2014 eMedicine.com

2131. Psychosocial and Environmental Pregnancy Risks (Overview)

, especially congenital anomalies. The rate of congenital anomalies in the general population is 3% for defects that are detectable at birth in live-born infants and 6% for defects detected by the end of the first year of life. Because the baseline risk is small, if an exposure conveys a modestly increased risk, a large population of infants is required to detect an increase in anomalies. In addition, the gestational window is critical because exposures outside certain gestational periods may be nontoxic (...) following exposure, borderline infants are rendered mentally retarded at relatively low exposures. Stochastic effects do not show a threshold, and they occur in the later years of the exposed individual's life. Fetal x-ray exposure has been associated with later-onset childhood leukemias and solid tumors. The demonstrated relative risk in multiple case-control studies is 1.39 (95% confidence interval [CI], 1.3-1.49). This increased risk was documented by the Oxford Survey of Childhood Cancers

2014 eMedicine.com

2132. Psoriatic Arthritis (Overview)

of the psoriasis relates to the pattern of joint involvement. In another study, pustular psoriasis was associated with more severe psoriatic arthritis. (See Prognosis.) Psoriatic arthritis occurring in patients over age 60 years (elderly onset psoriatic arthritis) has a more severe onset and more a destructive outcome than does psoriatic arthritis in younger patients. The course of psoriatic arthritis is usually characterized by flares and remissions. The patterns of psoriatic arthritis involvement (...) found the rate of psoriatic arthritis in patients with psoriasis to be 30.2%. [ ] A systematic review and meta-analysis of 266 studies concluded that worldwide, approximately one in five persons with psoriasis has psoriatic arthritis. [ ] A systematic review and meta-analysis of 28 studies estimated that the global average prevalence of psoriatic arthritis is 133 per 100,000 population (95% confidence index [CI], 107–164 per 100,000), and the incidence is 83 per 100,000 persons per year (95% CI, 41

2014 eMedicine.com

2133. Psoriatic Arthritis (Overview)

of the psoriasis relates to the pattern of joint involvement. In another study, pustular psoriasis was associated with more severe psoriatic arthritis. (See Prognosis.) Psoriatic arthritis occurring in patients over age 60 years (elderly onset psoriatic arthritis) has a more severe onset and more a destructive outcome than does psoriatic arthritis in younger patients. The course of psoriatic arthritis is usually characterized by flares and remissions. The patterns of psoriatic arthritis involvement (...) found the rate of psoriatic arthritis in patients with psoriasis to be 30.2%. [ ] A systematic review and meta-analysis of 266 studies concluded that worldwide, approximately one in five persons with psoriasis has psoriatic arthritis. [ ] A systematic review and meta-analysis of 28 studies estimated that the global average prevalence of psoriatic arthritis is 133 per 100,000 population (95% confidence index [CI], 107–164 per 100,000), and the incidence is 83 per 100,000 persons per year (95% CI, 41

2014 eMedicine.com

2134. Prostatitis, Bacterial (Overview)

with such longer courses. Nonsteroidal anti-inflammatory drugs (NSAIDs) and alpha blockers help with symptom relief. Alpha blockers may also help to decrease recurrences, by diminishing urinary obstruction. See and . Next: Background Prostatitis has been challenging to classify and diagnose. The "traditional" classification of prostatitis was based on 10 years of clinical experience with the "four-glass test" as landmarked by Meares and Stamey in 1968. [ ] The traditional classification described four (...) , prostatitis is the most common urologic problem in men younger than age 50 years. It is the third most common urologic problem in older men. Previous Next: Prognosis Treatment success rates with the administration of trimethoprim-sulfamethoxazole (TMP-SMZ) approach 30%-40%, while success rates with fluoroquinolones are 40%-75%. Relapses are common and can be treated with another course of antibiotics. If repeat treatment fails, consider a low, suppressive dose of antibiotics. Infection often persists

2014 eMedicine.com

2135. Obesity (Overview)

Obstructive sleep apnea Gastroesophageal reflux disease (GERD) Some cancers (eg, endometrial, breast, and colon) [ , , ] Asthma A study by Abdullah et al indicated that not only the severity of a patient’s obesity but its duration as well is associated with the individual’s risk of developing type 2 diabetes mellitus. Based on a more than four decade follow-up of 5132 participants in the Framingham Offspring Study, the investigators found a significant rise in type 2 diabetes risk as obese-years increased (...) associated with overweight or obesity, and among white men, 15.6% were. Data also show the more recent the birth year, the greater effect obesity has on mortality rates. [ , ] The researchers used data from 19 consecutive waves of the National Health Interview Survey covering 1986 through 2004 and linked those data with mortality information in the National Death Index through 2006. [ , ] This study is the first to account for differences in age, birth cohort, sex, and race in analyzing Americans’ risk

2014 eMedicine.com

2136. Normal and Abnormal Puerperium (Overview)

. These individuals should be appropriately counselled on lifestyle interventions or medical management options (i.e. metformin, insulin) to optimize their glycemic control. Those who have a normal postpartum glucose tolerance test should be appropriately counselled that there is still a 7 fold risk of developing type 2 diabetes later in life and up to 50% of women with GDM will develop diabetes over 20 years after her pregnancy. [ ] Therefore the American Diabetes Association (ADA) recommends patients with GDM (...) and normal results of postpartum screening have repeat testing every 3 years because of the increased risk of developing diabetes in the future. [ ] Contraception options should be discussed before the mother leaves the hospital. Although she may not be ready to decide about which method to initiate, she should be educated about the options that are safe based on any medical comorbidities and consistent with her future fertility desires. It is important to initiate contraception during the postpartum

2014 eMedicine.com

2137. Molluscum Contagiosum (Overview)

in the Congo (formerly Zaire). In New Guinea, the annual infection rate for children younger than age 10 years was found to be 6%. In cooler climates, spread within households is less common, and infection is more common at a later age. Use of school swimming pools is correlated with childhood infections, with a peak incidence in children aged 10-12 years in Scotland and 8 years in Japan. Prevalence appears to be increasing in all age groups. Previous Next: Prognosis The prognosis in molluscum contagiosum (...) ). The prognosis and therapy are different for each of these groups. Molluscum contagiosum is most common in children who become infected through direct skin-to-skin contact or indirect skin contact with fomites, such as bath towels, sponges, and gymnasium equipment. Lesions typically occur on the chest, arms, trunk, legs, and face. Hundreds of lesions may develop in intertriginous areas, such as the axillae and intercrural region (see the image below). Lesions may rarely occur on the mucous membranes

2014 eMedicine.com

2138. Molluscum Contagiosum (Overview)

in the Congo (formerly Zaire). In New Guinea, the annual infection rate for children younger than age 10 years was found to be 6%. In cooler climates, spread within households is less common, and infection is more common at a later age. Use of school swimming pools is correlated with childhood infections, with a peak incidence in children aged 10-12 years in Scotland and 8 years in Japan. Prevalence appears to be increasing in all age groups. Previous Next: Prognosis The prognosis in molluscum contagiosum (...) ). The prognosis and therapy are different for each of these groups. Molluscum contagiosum is most common in children who become infected through direct skin-to-skin contact or indirect skin contact with fomites, such as bath towels, sponges, and gymnasium equipment. Lesions typically occur on the chest, arms, trunk, legs, and face. Hundreds of lesions may develop in intertriginous areas, such as the axillae and intercrural region (see the image below). Lesions may rarely occur on the mucous membranes

2014 eMedicine.com

2139. Molluscum Contagiosum (Overview)

in the Congo (formerly Zaire). In New Guinea, the annual infection rate for children younger than age 10 years was found to be 6%. In cooler climates, spread within households is less common, and infection is more common at a later age. Use of school swimming pools is correlated with childhood infections, with a peak incidence in children aged 10-12 years in Scotland and 8 years in Japan. Prevalence appears to be increasing in all age groups. Previous Next: Prognosis The prognosis in molluscum contagiosum (...) ). The prognosis and therapy are different for each of these groups. Molluscum contagiosum is most common in children who become infected through direct skin-to-skin contact or indirect skin contact with fomites, such as bath towels, sponges, and gymnasium equipment. Lesions typically occur on the chest, arms, trunk, legs, and face. Hundreds of lesions may develop in intertriginous areas, such as the axillae and intercrural region (see the image below). Lesions may rarely occur on the mucous membranes

2014 eMedicine.com

2140. Mitral Valve Prolapse (Overview)

. [ ] They also undergo mitral surgery less often than men and exhibit excess long-term mortality but equivalent survival after valve surgery compared to men. [ ] Previous Next: Prognosis Mitral valve prolapse (MVP) has a widely varying prognostic spectrum, although most patients with MVP remain asymptomatic and have a near-normal life expectancy. Approximately 5-10% have progression to severe mitral regurgitation (MR). [ , ] Overall, young patients (age >50 years) with normal left ventricular function (...) click and late-systolic MR murmur Treatment measures for asymptomatic patients with minimal disease Reassurance of the benign prognosis Initial echocardiography for risk stratification; if no clinically significant mitral regurgitation and thin leaflets are observed, clinical examinations and echocardiographic studies can be scheduled every 3-5 years Encouragement to pursue a normal, unrestricted lifestyle with vigorous exercise Treatment measures for patients with symptoms of autonomic dysfunction

2014 eMedicine.com

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