Dupuytren Contracture: Most Important Points

Kaposi's Sarcoma

Hyponatremia: Basic Points

Herpes Zoster Ophthalmicus

Plummer Vinson Syndrome

Endometrial Cancer

Separation Anxiety Disorder

Health Care Proxy and Power of Attorney

Seborrheic Dermatitis

Malignant Melanoma

Atopic Dermatitis: Key Points

Atomic dermatitis is a very important disease to study for USMLE

Scleroderma: Major Manifestations

MRSA infection

Hypokalemia

Hyperkalemia:EKG changes, Emergency Treatment

Morton Neuroma

Heparin Induced Thrombocytopenia

Hypokalemia: Symptoms, EKG changes,Treatment

Rh isoimmunization & incompatibility in Pregnancy

Trigeminal Neuralgia: Most Important Things to Know

Antidepressant-Induced Sexual Dysfunction

Rheumatoid Arthritis: Diagnostic Tests and Differential Diagnosis

Third-Trimester Bleeding: Most Important Points

Rheumatoid Arthritis: Key Clinical Symptoms and Signs

Syphilis: Most Important Things to Know

MRSA Infection: Most Important Antibiotics

Neonatal Abstinence Syndrome: Morphine, Methadone and Drug Rehabilitation

Hypocalcemia: Most Important Points

Respiratory Alkalosis: Most Important Points

MRSA Infection: Notes of Important Points

The increasing incidence of skin and soft tissue infections requires family physicians to be familiar with the management of these conditions. Evidence of systemic infection, such as fever, tachycardia, and hypotension, is an indication for inpatient management. Urgent surgical referral is imperative for those with life-threatening or rapidly advancing infections.  In settings where suspicion of methicillin-resistant Staphylococcus aureus (MRSA) is low, beta-lactam antibiotics are the first-line treatments for uncomplicated skin and soft tissue infections without focal coalescence or trauma. When empiric coverage for MRSA is indicated and the infection is uncomplicated,

oral agents, such a

s tetracyclines,

trimethoprim/sulfamethoxazole,

and clindamycin, are preferred.

Vancomycin is the first-line agent for MRSA in hospitalized patients, and

 newer agents, such as

 linezolid,

daptomycin, and

 tigecycline, should be reserved for patients who do not respond to or cannot tolerate vancomycin therapy. .

Community-Acquired MRSA

The recent rapid increase in community-acquired MRSA soft tissue infections has forced physicians to reconsider their approach to routine SSTIs. Recent reports of antimicrobial resistance patterns have found that community-acquired MRSA is responsible for up to 60 percent of SSTIs in U.S. emergency departments.10,11 These rates are higher in certain populations, including ethnic minorities, children, intravenous drug users, patients who have received recent antibiotic treatment, men who have sex with men, residents of long-term care facilities and prisons, and patients receiving hemodialysis.5,12,13 In addition to purulent SSTIs, community-acquired MRSA is associated with other infectious processes, such as necrotizing pneumonia and sepsis.10 Although many patients with community-acquired MRSA infections describe the initial presentation as resembling a spider bite, there are no reliable signs and symptoms to distinguish community-acquired MRSA infections from other purulent SSTIs.13,14

Diagnosis and Assessment of SSTIs

SSTIs in the presence of comorbid infections, such as

 diabetes,

 neutropenia,

 or cirrhosis, are more likely to be severe and caused by uncommon organisms (e.g., Pseudomonas species, Klebsiella species, yeast, fungi).7

Complicated and potentially life-threatening SSTIs are characterized by fever,

 widespread or a rapidly spreading area of involvement, firm and hard feel of subcutaneous tissues, pain disproportionate to examination, skin sloughing, cutaneous bleeding with or without bullae, and skin crepitus.15 Additionally, patients with necrotizing infections may be lethargic or disorientated.7 Rapidly progressive and life-threatening infections warrant urgent surgical referral.3,7,16

 Hospitalization should be considered in patients with the following laboratory findings:

left shift in complete blood count with differential,

elevated serum creatinine level,

reduced serum bicarbonate level,

 elevated creatine kinase level, or

 C-reactive protein level greater than 13 mg per L (123.81 nmol per L).7

 wound cultures of purulent secretions should be performed in patients with multiple or extensive lesions,

fever or other evidence of systemic illness,

prior treatment failure, immunocompromise, trauma, water contact, or animal or human bites.7 If wound cultures are indicated, fluid or tissue specimens should be collected using aseptic technique via needle aspiration or tissue biopsy.

Antimicrobial Treatment

When indicated, antimicrobial therapy for uncomplicated SSTIs is usually initiated empirically. Familiarity with common pathogens and with local flora and resistance patterns is essential in choosing initial agents.

Oral antibiotics that have been shown to be effective against community-acquired MRSA include

 trimethoprim/sulfamethoxazole (Bactrim, Septra),

tetracyclines, and

 clindamycin (Cleocin).3,7

 Local patterns of sensitivity may vary, however. In one study, patients with uncomplicated cellulitis who received five days of antibiotic treatment had similar outcomes to those who were treated for 10 days.26 In patients with widespread or systemic infection, comorbidities, or an inability to tolerate oral treatment, vancomycin is the first-line parenteral anti-MRSA agent, although clindamycin, quinolones, linezolid (Zyvox), tigecycline (Tygacil), and daptomycin (Cubicin) may also be used.3

 If clindamycin therapy is considered,

a D-zone test should be performed to

identify patients with inducible clindamycin resistance.

LINEZOLID

 Linezolid is effective against methicillin-sensitive S. aureus (MSSA) and MRSA, and the nearly equal bioavailability of oral and intravenous preparations makes it a convenient alternative to vancomycin. Because of cost (approximately $1,700 for a 10-day oral course) and the potential for the development of additional drug resistance, linezolid should be reserved for patients with MRSA who do not respond to other agents and for patients with complicated SSTIs in whom alternative treatment has been inferior.

1.As a weak monoamine oxidase inhibitor, linezolid may be associated with an increase in blood pressure.

2. Serotonin syndrome has been reported in patients taking selective serotonin reuptake inhibitors with line-zolid.

3.Linezolid also should be used with caution in patients with chronic kidney disease because it is renally excreted.26

TIGECYCLINE

Tigecycline is indicated for the treatment of complicated SSTIs caused by MSSA and MRSA infections.

The drug is metabolized in the liver; therefore, dosing adjustments are

needed in patients with severely impaired liver function (i.e., those with Child-Pugh classification C cirrhosis).

 No dosing adjustment is needed in patients with renal impairment,

and tigecycline does not alter the effectiveness of warfarin (Coumadin) therapy.31

Tigecycline is administered intravenously.

The most common adverse effects are nausea and vomiting. 

 As with tetracyclines,

tigecycline is not recommended

for use in children.31

DAPTOMYCIN

Daptomycin exhibits bactericidal activity against most gram-positive organisms, including MRSA and vancomycin-resistant enterococci. This unique medication disrupts the ionic electric potentials of the cell membrane by promoting rapid calcium-dependent efflux of potassium from the cell.32,33 In a prospective, open-label study comparing daptomycin with vancomycin for the treatment of complicated SSTIs with risk of MRSA, both groups had complete clinical resolution, with the daptomycin-treated group demonstrating a significantly reduced duration of intravenous therapy and reduced median number of days to achieve clinical cure.34

Daptomycin is administered intravenously.

Potential adverse effects include myopathy and gastrointestinal effects,

such as nausea, vomiting, and diarrhea.

Daptomycin may elevate the prothrombin time and, therefore,

should be used with caution in patients taking warfarin.33

RETAPAMULIN

Retapamulin (Altabax) is a topical antibiotic that has been investigated for use in the treatment of impetigo.

cally significant improvement in outcomes after seven days of retapamulin therapy, compared with placebo.35 Retapamulin has not been compared with topical mupirocin, however.

Prevention of SSTIs

 Standard infection control precautions should be implemented and encouraged for all patients in ambulatory and inpatient settings, including

 proper and frequent handwashing,

use of gloves when managing wounds, and

contact precautions (e.g., use of gowns and gloves, grouping patients with similar infections) for patients with known or suspected MRSA infections.12 To prevent SSTIs, current consensus guidelines support proper foot care among patients with diabetes, tinea pedis, or pedal edema from venous insufficiency or lymphedema.

Eosinophilic Esophagitis

Scleroderma:Major Manifestations

Respiratory Acidosis: Most Important Points

Metabolic Acidosis: What Should You Remember?

Heparin Induced Thrombocytopenia: Most Important Points

Complications of Sinusitis

Anal Fissure: Most Important Points

Pilonidal Cyst: Most Important Points

Fetal Alcohol Syndrome: Most Important Points

Trigeminal Neuralgia: Most Important Points

Hepatic Encephalopathy: Most important points

Anorexia Nervosa: Most Important Points

Bulimia Nervosa

Hypertriglyceridemia: Best Medications

USMLE Questions Review

Generalized Anxiety Disorder

Morton Neuroma and Foot Pain

Whipple Disease

Pheochromocytoma

Diabetic Ketoacidosis

Necrotizing Fasciitis

Necrotizing fasciitis is a rare but extremely aggressive, life-threatening soft-tissue infection of the subcutaneous and fascial tissues often encountered in diabetic patients. The muscle tissues are generally spared. Clinical examination of the skin reveals streaking erythema and sometimes small blisters, arising in the region of an incidental puncture wound. Local induration is always found, and occasionally subcutaneous crepitation caused by gas in the soft tissues is encountered. Air in the soft tissues can usually be seen on plain radiographs in gas-producing clostridial infections. Serial exams are necessary to track the leading edge of the infection, which rapidly progresses in the direction of venous drainage. Emergent surgical debridement of devitalized tissues (sometimes necessitating amputation) along with antibiotics and intensive care treatment for hypotension are required to prevent death.

Subarachnoid Hemorrhage

Intussusception

Digoxin: What should know about it?

AIDS: Most Common Diseases

Aspirin: The Wonder Drug

Molluscum contagiosum

Cholesterol: Prevention of Heart Disease

Deep Venous Thrombosis: Treatment Strategies

Visit our new website www.doctorpaul.org

Wegener Granulomatosis

Pilonidal Cyst

Irritable Bowel Syndrome

Rocky Mountain Spotted Fever

Psittacosis

HELLP SYNDROME

Brain Metastases

Fitz-Hugh-Curtis Syndrome

Gonorrhea in Pregnancy for USMLE

Vibrio Vulnificus: Oysters, Shrimp, and Hurricane Katrina

Norwalk Virus: Cruise Ship Connection

Urinary Tract Infection: Causative Pathogens, Diagnosis

Syphilis

Pulmonary Embolism

Nocardia

Treatment of Depression: A Slide Show

Granuloma Annulare

Malignant Melanoma

Genital Warts: Medications and Treatment

DVT: Treatment Strategies

Hyperkalemia: Management

Infectious Mononucleosis

ACE Inhibitors

Hyperkalemia: EKG changes and Emergency Treatment

Fever Case in Step-2 CS: What Questions Should You Ask?

COPD: Basic Health Care

Tumor Markers in Cancer

Rocky Mountain Spotted Fever

Tarsal Tunnel Syndrome

Obstructive Sleep Apnea: Management

Bulimia Nervosa

Alzheimer Disease

Heriditary Spherocytosis

Metformin: Most Important Points

Diabetic Ketoacidosis: Treatment

Diabetic ketoacidocis, part 1

Slipped Capital Femoral Epiphysis

Post-Traumatic Stress Disorder

Irritable Bowel Syndrome

AIDS: Most Common Diseases

Hepatic Encephalopathy

Myaesthenia Gravis: Presenting Features

Warfarin Toxicity: What Should You Do About It?

SSRI Discontinuation Syndrome

Hypertriglyceredemia: Best Medications Review

USMLE Review Questions on Arthritis, Claudication

USMLE Review Questions with Discussion, Vol.1

Iron Deficiency in Restless Legs Syndrome

Digoxin: What Should You Know About It?

Bipolar Disoder: Mood-Stabilizing Medications

Subdural hematoma and Epidural Hematoma

Major Side-Effects of Adenosine

Oncogenic Viruses

Lyme Disease: Management

Placental Abruption: Clinical Features and Management

Restrictive cardiomyopathy for USMLE

Clopidogrel and Ticlopidine

Hypertrophic Cardiomyopathy

Dilated Cardiomyopathy

Null Hypothesis, Type I and Type II Errors

Atrial Fibrillation

Heart Block

Statins: Our Friends in the War on Cholesterol

Genetic Code

Ganglion Cyst

NASH/Steatosis

Iron Deficiency Anemia: Causes, Diagnosis and Management

Bisphosphonates

Fanconi's Syndrome

Cell Motility: Flagella, Cilia and Their Clinical Importance

Heparin-Induced Thrombocytopenia

Bioenergetics and Role of ATP

Complications of Sinusitis

Cohort and Other Observational Studies

Anal Fissure: Causes, Diagnosis and Management

Pilonidal Cyst and Abscess

Amiodarone: Most Important Points for USMLE

Most Important EKG Findings for USMLE

Subarachnoid Hemorrhage: Star Points

Warfarin: Most Important Points for USMLE

Doctrine of Informed Consent

Changes During Normal Aging

Basic Facts
Aging is a process that requires adaptation to the changes associated wtih the increasing age. Care for the elderly involves, among others, the management of most common clinical conditions that affict the aged such as arthritis, hypertension, diabetes mellitus, urinary incontinence, heart disease, hearing loss, influenza, depression, falls and injuries.
Preventive strategies should be targeted at the major causes of death such as coronary heart disease, cancer, and stroke. Replacement therapy with estrogens and progesterone decreases the incidence of osteoporosis. Principal goal of health care to the elderly: Delaying morbidity and disability.
Physical Activity: Older adults should be counseled on physical exercise when there are no contraindications such as decompensated heart failure, severe aortic stenosis, serious cardiac arrhtymias etc.
Brain: atrophy of the brain tissue, senile plaques, neurofibrillary tangles, loss of memory
Respiratory System: Increase in FRC with aging, decrease in pulmonary diffusing capacity, decrease in arterial oxygen tension
Cardiovascular system: decrease in cardiac index, increase in myocardial stiffness, decrease in arterial compliance, increase in total peripheral vascular resistance
Renal System: glomerulosclerosis, impaired sodium handling
Sleep: Wakefulness After Sleep Onset, Increased number of arousals, insomnia

Which of the following is a common process associated with normal aging?
A.increase in cardiac fibrosis
B. increase in cardiac index
C. Decrease in total peripheral vascular resistance
D. Decrease in WASO (Wakefulness After Sleep Onset)
Answer: A

Action Potential on Cardiac Muscle Cells

Status Epilepticus: Causes, Management

Sensitivity and Specificity

Trigeminal Neuralgia: A Slide Show

Basal Skull Fractures: Slide Show

Fetal Alcohol Syndrome and CAGE Questionnaire

Do's and Don'ts in Step-2 CS: Slide Show

Bisphosphonates: Most Important Points Slide Show

Scleroderma: Presenting Features

Von Willebrand Disease

Pharyngeal Arches: A Brief Introduction

Pelvic Inflammatory Disease

Somogyi Effect vs.Dawn Phenomenon: Tips to remember

Diabetes Mellitus: Most Important Points

Secondary Hypertension: Main Causes

Hypertension: Life-Style Modifications

Hypertension:Classification & Management

Structure and Function of DNA

Transtuzumab and HER-2/neu positive breast cancer

IUDs: Most Important Points