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Splenic Injury

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1341. Rheumatoid Arthritis (Diagnosis)

others have a chronic progressive illness. Prognostic factors Intervention with DMARDs in very early RA (symptom duration < 12 weeks at the time of first treatment) provides the best opportunity for achieving disease remission. [ ] Better detection of early joint injury has provided a previously unappreciated view of the ubiquity and importance of early joint damage. Nonetheless, predicting the long-term course of an individual case of RA at the outset remains difficult, though the following all (...) ) and swollen joint count after 12 weeks of methotrexate administration were most associated with radiographic progression at week 52. [ ] The prognosis of RA is generally much worse among patients with positive RF results. For example, the presence of RF in sera has been associated with severe erosive disease. [ , ] However, the absence of RF does not necessarily portend a good prognosis. Other laboratory markers of a poor prognosis include early radiologic evidence of bony injury, persistent anemia

2014 eMedicine.com

1342. Rheumatoid Arthritis (Diagnosis)

others have a chronic progressive illness. Prognostic factors Intervention with DMARDs in very early RA (symptom duration < 12 weeks at the time of first treatment) provides the best opportunity for achieving disease remission. [ ] Better detection of early joint injury has provided a previously unappreciated view of the ubiquity and importance of early joint damage. Nonetheless, predicting the long-term course of an individual case of RA at the outset remains difficult, though the following all (...) ) and swollen joint count after 12 weeks of methotrexate administration were most associated with radiographic progression at week 52. [ ] The prognosis of RA is generally much worse among patients with positive RF results. For example, the presence of RF in sera has been associated with severe erosive disease. [ , ] However, the absence of RF does not necessarily portend a good prognosis. Other laboratory markers of a poor prognosis include early radiologic evidence of bony injury, persistent anemia

2014 eMedicine.com

1343. Reoviruses (Diagnosis)

a hospitable environment for viral replication, the in vitro data do not suggest that the cells serve as a long-term reservoir of virus. The CTF virus infects the bone marrow in the initial phases of infection but does not persist. Viral replication occurs in the bone marrow, lymph nodes, spleen, heart, and liver of rhesus monkeys but without histological abnormalities. Human erythrocytes are known to carry the virus, and the virus has been shown to replicate in erythroblasts and reticulocytes of infected (...) metastases from breast cancer. Gene Ther . 2004 Nov. 11(21):1579-89. . Norman KL, Lee PW. Reovirus as a novel oncolytic agent. J Clin Invest . 2000 Apr. 105(8):1035-8. . Clarke P, Debiasi RL, Goody R, Hoyt CC, Richardson-Burns S, Tyler KL. Mechanisms of reovirus-induced cell death and tissue injury: role of apoptosis and virus-induced perturbation of host-cell signaling and transcription factor activation. Viral Immunol . 2005. 18(1):89-115. . Kim M, Chung YH, Johnson RN. Reovirus and tumor oncolysis. J

2014 eMedicine.com

1344. Renal Trauma (Diagnosis)

: indications for radiographic evaluation. Urology . 1994 Sep. 44(3):406-10. . Al-Qudah HS, Santucci RA. Complications of renal trauma. Urol Clin North Am . 2006 Feb. 33(1):41-53, vi. . Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. J Urol . 1996 Dec. 156(6):2014-8. . Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma . 1989 Dec. 29(12):1664-6. . Santucci RA, McAninch JW, Safir M, Mario LA, Service S, Segal (...) occur in settings other than those thought of as a classic trauma setting. At most trauma centers, blunt trauma is more common than penetrating trauma, thereby making blunt renal injuries as much as 9 times more common than penetrating injuries. Both kidneys are at equal disposition for injury. [ ] Genitourinary (GU) tract injuries, while typically not lethal, require clinical knowledge pertaining to each GU organ to avoid unwanted outcomes (eg, loss of renal function, urinary incontinence

2014 eMedicine.com

1345. Percutaneous Endourology (Diagnosis)

disease; thus, the supine position has been established to help overcome these drawbacks. Theoretical advantages of the supine position include safer and easier positioning for the patient, less cardiovascular change and risk, no need for patient reposition, and possible shorter operating time. Theoretical disadvantages of the supine position include anterior/lateral puncture sites, potentially increasing the risk for visceral organ injury (eg, colon, liver, spleen); collapse of the collecting system (...) the left due to the presence of the liver on the right side. It lies adjacent to the 12th rib, liver, duodenum, and hepatic flexure of the colon. The left kidney is adjacent to the 11th and 12th ribs, pancreas, spleen, and splenic flexure of the colon. The kidney may change location with changes in patient position and respiration. Normally, kidneys do not exceed 8-9 cm excursion when a patient stands from a supine position. With the respiratory cycle, the kidneys naturally move in a vertical direction

2014 eMedicine.com

1346. Neonatal Lupus Erythematosus (Diagnosis)

. The most common clinical manifestations are dermatologic, cardiac, and hepatic. Some infants may also have hematologic, central nervous system, or splenic abnormalities. The mother produces immunoglobulin G (IgG) autoantibodies against Ro (SSA), La (SSB), and/or U1-ribonucleoprotein (U1-RNP), and they are passively transported across the placenta. The presence of maternal anti-SSA/Ro and anti-SSB/La antibodies increases the risk of bearing infants with NLE; rarely, NLE is due to maternal passage of U1 (...) neonatal lupus congenital heart block. Eur J Immunol . 2000 Oct. 30(10):2782-90. . Boutjdir M, Chen L, Zhang ZH, Tseng CE, El-Sherif N, Buyon JP. Serum and immunoglobulin G from the mother of a child with congenital heart block induce conduction abnormalities and inhibit L-type calcium channels in a rat heart model. Pediatr Res . 1998 Jul. 44(1):11-9. . Briassouli P, Halushka MK, Reed JH, et al. A central role of plasmin in cardiac injury initiated by fetal exposure to maternal anti-Ro autoantibodies

2014 eMedicine.com

1347. Myelophthisic Anemia (Diagnosis)

to , , , , and for complete information on these topics. Next: Etiology Generally, in myelophthisic anemia, a form of fibrosis, occurs secondary to injury by nonhematopoietic cells or pathogens. This fibrosis destroys the normal hematopoietic cells and their supportive stromal cells. The bone marrow becomes infiltrated by collagen, reticulin, and other forms of fibrosis, which replace the normal, hematopoietic cells. The most common causes of extensive bone marrow infiltrative damage or invasion without much structural (...) hematopoiesis in the liver and spleen, causing hypertrophy of these organs. Secondary myelofibrosis is due to implantation or invasion by malignant cancer cells that have metastasized because of implantation of blood-borne tumor cells from a distant cancer. The most common sources are cancers of the lung, , and prostate [ ] and sarcomas. Nonmalignant causes of myelophthisis include the following: Inflammatory cells, miliary tuberculosis, and fungal infections Macrophage proliferation in storage diseases

2014 eMedicine.com

1348. Neutropenic Enterocolitis (Diagnosis)

, in conjunction with intestinal mucosal injury and immune compromise. [ ] Many factors have been described that may potentially play a role in the pathogenesis of neutropenic enterocolitis, including the following: Mucosal injury caused by cytotoxic drugs – However, mucosal injury can occur in the absence of cytotoxic drug therapy, and neutropenia itself can cause mucosal ulcerations Cecal distention – Whether primary or secondary to vinca alkaloids, cecal distention may compromise the blood supply, leading (...) . It is felt that cecal distensibility and limited blood supply may predispose the cecum to injury more often than other areas. Previous Next: Etiology Although cytotoxic chemotherapeutic agents account for most cases of neutropenic enterocolitis, other conditions may also predispose some patients to develop this condition. The cytotoxic chemotherapeutic agents include cytosine arabinoside, vinca alkaloids, and doxorubicin. Other drugs that have been implicated anecdotally include paclitaxel, docetaxel

2014 eMedicine.com

1349. Neurosarcoidosis (Diagnosis)

lymphatic collections in solid organs (eg, spleen, liver) and lymphoid tissue surrounding glandular organs such as the parotid and lacrimal glands. Debate continues as to whether sarcoidosis results from a dysfunctional immune system or a secondary response to environmental antigens. Sarcoid granulomas may be seen in solid organs such as liver, kidney, and spleen. Neurosarcoidosis results from nervous system involvement by sarcoid granulomas. The lesion consists of lymphocytes and mononuclear phagocytes (...) nerve layers may be involved. Occasionally, myelin loss is prominent, with appearance of myelin ovoids. Whether the latter are caused by compression from the granulomas, by regional toxic effects, or by specific targeting of the myelin sheath is unclear. Tajima suggested a predominance of helper T cells in the sarcoid granulomas. Inflammation of the vasa nervorum or the arterioles to the muscles can result in ischemic injury or severe vasculitic neuropathy. A significantly higher prevalence

2014 eMedicine.com

1350. Neutropenia (Diagnosis)

product transfusions. Felty syndrome is a syndrome of rheumatoid arthritis, splenomegaly, and neutropenia. Splenectomy shows an initial response, but neutropenia may recur in 10-20% of patients. Treatment is directed toward rheumatoid arthritis. In complement activation–mediated neutropenia, hemodialysis, cardiopulmonary bypass, and extracorporeal membrane oxygenation (ECMO) expose blood to artificial membranes and can cause complement activation with subsequent neutropenia. In splenic sequestration (...) colony-stimulating factor. Semin Arthritis Rheum . 1999 Oct. 29(2):82-99. . MacVittie TJ. Therapy of radiation injury. Stem Cells . 1997. 15 Suppl 2:263-8. . Mac Manus

2014 eMedicine.com

1351. Lower Gastrointestinal Bleeding (Diagnosis)

, erythematous, edematous, and ulcerated. In severe Crohn disease, the inflammatory process may extend into the serosa, leading to colonic perforation. Ischemic colitis is a disease of the elderly population and is commonly observed after the sixth decade of life. This condition is the most common form of ischemic injury to the digestive system, frequently involves the watershed areas, including the splenic flexure and the rectosigmoid junction. Ischemia causes mucosal and partial-thickness colonic wall (...) by a mesentery. A comprehensive understanding of small bowel and colonic vascular anatomy is essential for any physician performing a primary lower gastrointestinal procedure for hemorrhage or other conditions. The ileocolic, right colic, and middle colic branches of the superior mesenteric artery supply blood to the cecum, ascending, and proximal transverse colon, respectively. The superior mesenteric vein drains the right side of the colon, joining the splenic vein to form the portal vein. The inferior

2014 eMedicine.com

1352. Liver Disease and Pregnancy (Diagnosis)

in patients with ICP has been recorded to be as high as 11%, [ ] and the cause of mortality is still unknown. Fetal mortality does not seem to be due to chronic uteroplacental insufficiency, but rather to an acute anoxic injury. Some believe that meconium, which complicates up to 45% of these pregnancies, causes umbilical vein constriction, thereby leading to fetal death and hypoxia. The cause of increased meconium passage remains unknown. Animal studies have demonstrated that high maternal bile acid (...) . [ ] As most women who develop HELLP syndrome have preeclampsia, it is also a risk factor. Etiology HELLP syndrome is caused by several mechanisms that, when combined, result in hemolysis, liver necrosis with elevated transaminases, and thrombocytopenia. The initial source of the insult is unknown, but all patients have evidence of endothelial injury with fibrin deposit that causes a microangiopathic and platelet activation and consumption, leading to . The fibrin deposits cause obstruction in the hepatic

2014 eMedicine.com

1353. Lyme Disease (Diagnosis)

or blood, After entering the circulation, the organism shows a distinct tropism for the skin, heart, central nervous system (CNS), joints, and eyes. Any part of the body can be affected, however; spirochetes have also been demonstrated histologically in bone marrow, the spleen, lymph nodes, the liver, testes, and the placenta during early hematogenous dissemination. The clinical manifestations of Lyme disease generally follow three stages of disease progression: early localized, early disseminated (...) have suggested a primary role of astrocytes and microglial cells in the pathogenesis of neuroborreliosis. Interleukin 6 (IL-6) production by astrocytes and subsequent oligodendrocyte apoptosis have been proposed as mechanisms of cell injury. [ ] The organism also can persist in the skin for very long periods. Experimentally, the spirochete can penetrate human fibroblasts and live intracellularly, even when the extracellular medium contains ceftriaxone at concentrations well above bactericidal

2014 eMedicine.com

1354. Lyme Disease (Diagnosis)

or blood, After entering the circulation, the organism shows a distinct tropism for the skin, heart, central nervous system (CNS), joints, and eyes. Any part of the body can be affected, however; spirochetes have also been demonstrated histologically in bone marrow, the spleen, lymph nodes, the liver, testes, and the placenta during early hematogenous dissemination. The clinical manifestations of Lyme disease generally follow three stages of disease progression: early localized, early disseminated (...) have suggested a primary role of astrocytes and microglial cells in the pathogenesis of neuroborreliosis. Interleukin 6 (IL-6) production by astrocytes and subsequent oligodendrocyte apoptosis have been proposed as mechanisms of cell injury. [ ] The organism also can persist in the skin for very long periods. Experimentally, the spirochete can penetrate human fibroblasts and live intracellularly, even when the extracellular medium contains ceftriaxone at concentrations well above bactericidal

2014 eMedicine.com

1355. Lyme Disease (Diagnosis)

or blood, After entering the circulation, the organism shows a distinct tropism for the skin, heart, central nervous system (CNS), joints, and eyes. Any part of the body can be affected, however; spirochetes have also been demonstrated histologically in bone marrow, the spleen, lymph nodes, the liver, testes, and the placenta during early hematogenous dissemination. The clinical manifestations of Lyme disease generally follow three stages of disease progression: early localized, early disseminated (...) have suggested a primary role of astrocytes and microglial cells in the pathogenesis of neuroborreliosis. Interleukin 6 (IL-6) production by astrocytes and subsequent oligodendrocyte apoptosis have been proposed as mechanisms of cell injury. [ ] The organism also can persist in the skin for very long periods. Experimentally, the spirochete can penetrate human fibroblasts and live intracellularly, even when the extracellular medium contains ceftriaxone at concentrations well above bactericidal

2014 eMedicine.com

1356. Lyme Disease (Diagnosis)

or blood, After entering the circulation, the organism shows a distinct tropism for the skin, heart, central nervous system (CNS), joints, and eyes. Any part of the body can be affected, however; spirochetes have also been demonstrated histologically in bone marrow, the spleen, lymph nodes, the liver, testes, and the placenta during early hematogenous dissemination. The clinical manifestations of Lyme disease generally follow three stages of disease progression: early localized, early disseminated (...) have suggested a primary role of astrocytes and microglial cells in the pathogenesis of neuroborreliosis. Interleukin 6 (IL-6) production by astrocytes and subsequent oligodendrocyte apoptosis have been proposed as mechanisms of cell injury. [ ] The organism also can persist in the skin for very long periods. Experimentally, the spirochete can penetrate human fibroblasts and live intracellularly, even when the extracellular medium contains ceftriaxone at concentrations well above bactericidal

2014 eMedicine.com

1357. Pancreatitis, Chronic (Diagnosis)

information, see the and the , as well as and . Previous Next: Pathophysiology Whatever the etiology of chronic pancreatitis, [ ] pancreatic fibrogenesis appears to be a typical response to injury. This involves a complex interplay of growth factors, cytokines, and chemokines, leading to the deposition of extracellular matrix and fibroblast proliferation. In pancreatic injury, the local expression and release of transforming growth factor beta (TGF-beta) stimulates the growth of cells of mesenchymal (...) of metabolizing alcohol (and probably other xenobiotics, such as drugs, tobacco smoke, environmental toxins, and pollution) cause oxidative stress within the pancreas and may lead to cellular injury and organ damage, especially in the setting of malnutrition. Oxidative and nonoxidative pathways metabolize ethanol. Alcohol dehydrogenase oxidatively metabolizes ethanol first to acetaldehyde and then to acetate. When the alcohol concentration increases, cytochrome P-450 2E1 is induced to meet the metabolic

2014 eMedicine.com

1358. Menorrhagia (Diagnosis)

: Signs of severe volume depletion (eg, anemia) Obesity Signs of androgen excess (eg, hirsutism) Ecchymosis Purpura Pronounced acne General examination should include evaluation of the following: Visual fields Bleeding gums Thyroid evaluation Galactorrhea Enlarged liver or spleen Pelvic examination should evaluate for the following: Presence of external genital lesions Vaginal or cervical discharge Uterine size, shape, and contour Cervical motion tenderness Adnexal tenderness or masses (especially (...) in patients older than 40 years) According to an international expert panel, an underlying bleeding disorder should be considered when a patient has any of the following: Menorrhagia since menarche Family history of bleeding disorders Personal history of 1 or more of the following: (1) Notable bruising without known injury, (2) bleeding of the oral cavity or gastrointestinal tract without an obvious lesion, or (3) epistaxis of more than 10 minutes’ duration (possibly necessitating packing or cautery) See

2014 eMedicine.com

1359. Psychosocial and Environmental Pregnancy Risks (Diagnosis)

Food and Drug Administration require labeling MRI devices to indicate that the safety of MRI with respect to the fetus has not been established. In general, most studies evaluating MRI safety during pregnancy show no ill effects. Injury to the fetus is not a significant risk during prenatal MRI. Intravenous gadolinium is teratogenic at high and repeated doses in animal studies. Gadolinium does cross the placenta, where it is excreted by fetal kidneys. The 2007 American College of Radiology Guidance

2014 eMedicine.com

1360. Pyoderma Gangrenosum (Diagnosis)

diseases, diabetes, and trauma. In a process termed pathergy, new ulcerations may occur after trauma or injury to the skin in 30% of patients who already have pyoderma gangrenosum. (See , , and .) Patients with pyoderma gangrenosum may have involvement of other organ systems that manifests as sterile neutrophilic infiltrates. Culture-negative pulmonary infiltrates are the most common extracutaneous manifestation. [ , ] Other organs systems that may be involved include the heart, the central nervous (...) system, the gastrointestinal (GI) tract, the eyes, [ , ] the liver, the spleen, the bones, and the lymph nodes. (See and .) Therapy for pyoderma gangrenosum involves the use of anti-inflammatory agents, including antibiotics, corticosteroids, immunosuppressive agents, and biologic agents. The prognosis is generally good; however, the disease can recur and residual scarring is common. (See , , and .) Etiology The etiology of pyoderma gangrenosum is poorly understood, but dysregulation of the immune

2014 eMedicine.com

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