Loading

Astelin

By H. Barrack. Columbia College of Missouri.

Lassailly F astelin 10 ml discount, Foster K purchase 10 ml astelin mastercard, Lopez-Onieva L purchase 10 ml astelin overnight delivery, Currie E, Bonnet D. Quantitative imaging imaging reveals structural and functional heterogeneity in different bone of haematopoietic stem and progenitor cell localization and hypoxic marrow compartments: functional implications on hematopoietic stem status in the bone marrow microenvironment. Maintenance of the and osteogenesis by a specific vessel subtype in bone. Endothelial and oxygen concentration in the bone marrow of live animals. Pedersen M, Lofstedt T, Sun J, Holmquist-Mengelbier L, Pahlman S, 12. Haematopoietic stem cells and early lymphoid Ronnstrand L. Stem cell factor induces HIF-1alpha at normoxia in progenitors occupy distinct bone marrow niches. Thrombopoietin enhances haematopoietic stem cells form a unique bone marrow niche. Frank2 1Department of Medicine (Hematology), Oncology & Institute for Cellular Engineering, and 2Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD A better understanding of risks associated with allogeneic blood transfusions (ABTs), along with a growing population of patients who do not accept transfusions, have led to the emergence of new treatment paradigms with “bloodless medicine. Bloodless management for surgical patients includes treatment of preoperative anemia, use of autologous blood salvage, and minimizing blood loss with procedures. Other adjuncts for both medical and surgical patients include minimizing blood loss from laboratory testing using pediatric phlebotomy tubes and conservative testing. Anemia can be treated with erythropoiesis-stimulating agents, as well as iron, folate, and B12 when indicated. Although there are limited retrospective studies and no prospective studies to guide management, prior reports suggest that outcomes for surgical patients managed without ABTs are comparable to historic controls. A recent risk-adjusted, propensity- matched, case-control study of outcomes of all hospitalized patients who refused ABT at a large academic health center showed that bloodless management was not an independent predictor of adverse outcomes. Surprisingly, there was a lower overall mortality in the bloodless group and discharge hemoglobin levels were similar for both bloodless and control groups. Further research is now needed to optimize therapy and identify novel interventions to manage bloodless patients. Lessons learned from bloodless patients are likely to benefit all patients given recent evidence suggesting that patients who avoid ABTs do as well, if not better, than those who accept transfusions. The majority of JW ● To outline currently available approaches to manage anemia patients will agree to accept these products because they are or bleeding in “bloodless patients” considered to be “minor blood fractions” according to their religious ● To discuss areas in need of further research to advance doctrine. Importantly, the JW faith currently includes 8 million bloodless medicine people worldwide, with 1. As discussed here, these Introduction patients provide a unique challenge to health care providers, Although blood transfusions are among the most common medical particularly when presenting for surgeries or invasive procedures procedures performed in hospitalized patients, a better understand- that can be associated with significant blood loss or for complex ing of transfusion risks, together with a growing population of medical illnesses. Here, we outline prior studies on bloodless management and discuss the ap- At most centers, the majority of patients who request bloodless proaches used at our institution to care for patients who refuse medicine are members of the Jehovah’s Witness (JW) faith. We close Based on religious beliefs, these individuals do not accept blood with suggestions for further studies to guide management of products considered to be “primary components,” which includes bloodless patients. Because recent evidence suggests that bloodless RBCs, WBCs, platelets, or plasma. A few are to diagnose and treat anemia and minimize blood loss. Surgical subsequent studies used a propensity-matched control group, which patients who present for preoperative evaluations should be screened is a statistical matching technique that attempts to account for for both anemia and bleeding diatheses. The prevalence of anemia confounding variables and decrease bias associated with these in patients who present for elective surgery is highly variable, 9,11,15 variables. The majority of studies with propensity-matched ranging from 5% to 75% depending on the patient population, 9,11,15 18 controls, however, have focused on cardiac surgery. Interest- underlying pathology, and definition of anemia. The World Health ingly, 2 of these studies reported similar outcomes between patients Organization defines anemia as a hemoglobin 12 g/dL for women 11,15 who accept ABT compared with those who do not. Moreover, a and 13 g/dL for men, which provides useful guidelines for most 18 recent study of cardiac surgery patients and a propensity-matched patient populations. Ideally, the diagnosis of anemia should be control group actually showed a lower incidence of myocardial made at least 4-8 weeks before an elective procedure to ensure infarction and reoperation for bleeding in the bloodless patient adequate time for evaluation, therapy, and correction of the 9 4,8 group. There were also shorter durations of mechanical ventilation, anemia. This proves to be a challenge for many institutions, shorter length of both ICU and total hospital stays, and better 1-year because preoperative evaluations are often done less than 1 week survival in the bloodless patients. Iron deficiency is the most common form of anemia that bloodless management can yield similar, and possibly better, worldwide and is often associated with renal insufficiency and outcomes for a subset of patients. Not surprisingly, anemia is a academic health center found similar outcomes in bloodless patients significant predictor of RBC transfusion in patients who accept 18 compared with expected outcomes based on Society of Thoracic ABT. Intriguingly, recent evidence suggests that RBC transfu- 8 Surgeons risk models and historical controls. The favorable sions to treat anemia is an additive risk factor for adverse outcomes 18 outcomes were observed for both elective and urgent cardiac independent of the anemia itself. Although the average age for all patients in this study was are relatively common and can be associated with both anemia and 19 slightly younger (63. Patients with VWD 21 studies, this report describes a practical approach to patients can be managed with desmopressin (DDAVP) or VWF concentrates 8 19 undergoing bloodless cardiac surgeries. All patients were evaluated (Humate-P or cryoprecipitate) if acceptable to the patient. In by a “bloodless team” and consented for an itemized list of blood addition, many patients take drugs or supplements that interfere products they would accept or refuse. Details of laboratory evalua- with platelet function and can cause excessive bleeding, such as tions were not described, but anemia was managed preoperatively cyclooxygenase inhibitors (aspirin, celecoxib, etc) or platelet adeno- with intravenous iron supplementation and subcutaneous erythropoi- sine diphosphate receptor (P2Y12) inhibitors (clopidogrel, prasug- etin (40 000-60 000 IU/week) to achieve a target hemoglobin of rel, etc). Therefore, patients on these agents are instructed to stop 14-16 g/dL or a measure that correlates with RBC volume (RCV) them before surgical procedures. Similarly, elderly patients with 8 (Hb body weight in kilograms) of 1200. The target value of 1200 atrial fibrillation are frequently on anticoagulation therapy such as was chosen because the investigators noted an increased risk for warfarin, and need to receive appropriate counselling regarding ABT in patients with a value 800 who were hospitalized at their when to stop these agents and whether they will require shorter- institution.

generic astelin 10 ml on line

Randomized controlled trials of beta blockers for post myocardial infarction Author buy astelin american express, Year Study Country design Eligibility criteria Exclusion criteria Mrdovic 2007 RCT Consecutive patients who presented with clinical and Contradictions for beta blocker therapy including electrocardiographic signs of acute anterior wall ST Killip class 3 or 4 heart failure purchase discount astelin on-line, systolic arterial elevation myocardial infarction (STEMI) and LV EF of < hypotension of <90 mm Hg buy generic astelin canada, bradycardia of <50 45% on the echocardiogram performed within the first beats per minute, second- or third-degree 72 hrs from the onset of symptoms. Also excluded were those already treated with adrenergic blockers or agonists or calcium-channel blockers. Beta blockers Page 104 of 494 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 7. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Interventions (drug, regimen, Allowed other medications/ Method of outcome assessment and Country duration) interventions timing of assessment Mrdovic 2007 Inhospital: Carvedilol vs. Metoprolol Patients were reviewed at 6-month metoprolol tartrate 50 mg bid Concomitant therapy: intervals for the assessment of tolerability carvedilol 12. Secondary end point: time to composite hard events (t-CHE) including cardiovascular death and nonfatal reinfarction. Health related quality of life: Short Form-36 (SF-36) questionnaire with 36 items and 8 domains. Each group of domains was reduced to a summary measure. Beta blockers Page 105 of 494 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 7. Randomized controlled trials of beta blockers for post myocardial infarction Number Number Author, Age screened/ withdrawn/ Year Gender eligible/ lost to fu/ Country Ethnicity Other population characteristics (diagnosis, etc) enrolled analyzed Mrdovic 2007 Carvedilol Diabetes Car= 26. Randomized controlled trials of beta blockers for post myocardial infarction Author, Method of adverse Year effects Country Outcomes assessment? Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Withdrawals due to adverse events Country Adverse effects reported (%, adverse n/enrolled n) Comments Mrdovic 2007 Only patients who were withdrawn from the study due to Inhospital: car=8 (5%) vs. Beta blockers Page 108 of 494 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 7. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Study Country design Eligibility criteria Exclusion criteria Acebutolol vs placebo Boissel RCT At least 2 of the following risk factors: Heart rate <45 beats/min; complete 1990 (1) Typical chest pain of ≥ 1 hour in duration, typical Q auriculoventricular block and acute heart failure France waves and significant release of cardiac enzyme(s) that required treatment with ≥ 2 drugs of different (2) admitted for this acute event > 2 and < 22 days classes (e. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Interventions (drug, regimen, Allowed other medications/ Method of outcome assessment and Country duration) interventions timing of assessment Acebutolol vs placebo Boissel Acebutolol 400 mg daily NR Primary outcome: Total death 1990 Placebo x 1 year France Treatment initiated within 2-22 days Fair quality post-MI Beta blockers Page 110 of 494 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 7. Randomized controlled trials of beta blockers for post myocardial infarction Number Number Author, Age screened/ withdrawn/ Year Gender eligible/ lost to fu/ Country Ethnicity Other population characteristics (diagnosis, etc) enrolled analyzed Acebutolol vs placebo Boissel Mean age=62. Randomized controlled trials of beta blockers for post myocardial infarction Author, Method of adverse Year effects Country Outcomes assessment? Acebutolol vs placebo Boissel Acebutolol (n=298) vs placebo (n=309) nr 1990 France Total mortality: 17 (5. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Withdrawals due to adverse events Country Adverse effects reported (%, adverse n/enrolled n) Comments Acebutolol vs placebo Boissel Acebutolol (n=298) vs placebo (n=309) Acebutolol (n=298) vs placebo (n=309) 1990 France Angina pectoris: 98 (32. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Study Country design Eligibility criteria Exclusion criteria Carvedilol vs placebo Basu RCT Chest pain; ECG changes; serum concentration of Already on ACE or beta blockers; contraindications 1997 creatine kinase; MB isoform consistent with diagnosis to ACE or beta blockers; Killip class IV heart failure; UK cardiogenic shock; severe bradycardia; hypotension; second to third degree heart block; Fair quality left bundle branch block; severe valvular disease; insulin-dependent DM; renal failure; known malignancy; other severe disease; pregnancy Beta blockers Page 114 of 494 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 7. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Interventions (drug, regimen, Allowed other medications/ Method of outcome assessment and Country duration) interventions timing of assessment Carvedilol vs placebo Basu Carvedilol (car) 2. Randomized controlled trials of beta blockers for post myocardial infarction Number Number Author, Age screened/ withdrawn/ Year Gender eligible/ lost to fu/ Country Ethnicity Other population characteristics (diagnosis, etc) enrolled analyzed Carvedilol vs placebo Basu Mean age: car=60; pla=60 Site of MI: 416 146 analyzed 1997 % male: car=84; pal=84. Randomized controlled trials of beta blockers for post myocardial infarction Author, Method of adverse Year effects Country Outcomes assessment? Carvedilol vs placebo Basu Serious cardiac events: car=18(24%); pla=31(43. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Withdrawals due to adverse events Country Adverse effects reported (%, adverse n/enrolled n) Comments Carvedilol vs placebo Basu Dizziness(% patients): car=6. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Study Country design Eligibility criteria Exclusion criteria Anonymous, 2001; RCT >18 years; stable, definite MI occurring3-21 days prior Required continued diuretics or inotropes; McMurray 2005 to randomization; left-ventricular ejection fraction of uncontrollable heart failure; unstable angina; International 40% or less; receipt of concurrent treatment with ACE uncontrolled hypertension; bradycardia; unstable RCT inhibitors for at least 48 hours and stable dose for 24+ insulin-dependent DM; continuing indication for hours unless proven intolerance to ACE inhibitors; beta blockers for any condition other than heart Carvedilol Post- heart failure appropriately treated with diuretics and failure; requiring ongoing therapy with inhaled beta Infarct Survival ACE inhibitors during acute phase agonists or steroids Control in LV Dysfunction (CAPRICORN) Fair quality Beta blockers Page 119 of 494 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 7. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Interventions (drug, regimen, Allowed other medications/ Method of outcome assessment and Country duration) interventions timing of assessment Anonymous, 2001; Carvedilol (car) up to 50 mg daily ACE inhibitors(% patients)=98 Patients were reviewed every 3 months McMurray 2005 Placebo (pla) x 1. Randomized controlled trials of beta blockers for post myocardial infarction Number Number Author, Age screened/ withdrawn/ Year Gender eligible/ lost to fu/ Country Ethnicity Other population characteristics (diagnosis, etc) enrolled analyzed Anonymous, 2001; Carvedilol: Smoking history: NR/NR/1959 Permanent McMurray 2005 Mean age 63 Current - Car=33%; Pla=32% randomized withdrawals(excludi International 73% male Previous - Car=27%; Pla=25% ng death): RCT Placebo: Never - Car=39%; Pla=43% car=192(20%); Mean age 63 Medical history: pla=175(18%)/lost Carvedilol Post- 74% male Previous MI - Car=31%; Pla=29% to fu nr/1959 Infarct Survival Previous angina - Car=57%; Pla=54% analyzed Control in LV Previous hypertension - Car=55%; Pla=52% Dysfunction Previous DM - Car=21%; Pla=23% (CAPRICORN) Other vascular disease - Car=17%; Pla=16% Previous revascularization - Car=12%; Pla=11% Fair quality Hyperlipidemia - Car=32%; Pla=33% SIte of MI: Anterior - Car=59%; Pla=54% Inferior - Car=21%; Pla=21% Other - Car=20%; Pla=25% Medications at time of randomization: ACE inhibitor - Car=98%; Pla=97% Aspirin - Car=86%; Pla=86% Beta blockers Page 121 of 494 Final Report Update 4 Drug Effectiveness Review Project Evidence Table 7. Randomized controlled trials of beta blockers for post myocardial infarction Author, Method of adverse Year effects Country Outcomes assessment? Anonymous, 2001; Co-primary endpoints(# patients/%) NR McMurray 2005 All-cause mortality: car=116(12%); pla=151(15%) (P=0. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Withdrawals due to adverse events Country Adverse effects reported (%, adverse n/enrolled n) Comments Anonymous, 2001; NR NR Original primary endpoint (all- McMurray 2005 First 30 days of the trial: cause mortality) amended International car=2. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Study Country design Eligibility criteria Exclusion criteria Metoprolol vs placebo Anonymous RCT Ages 45-74; hospitalized for acute MI History of CABG; permanent pacemaker; 1987 contraindication to beta blocker therapy; conditions USA likely to require beta blocker therapy; administration of any beta blocker within 3 days Lopressor before the start of pre-entry evaluation; planned Intervention Trial therapy with aspirin, sulfinpyrazone clofibrate;=, or dipyridamole; life threatening conditions other than Fair quality CHF; conditions likely to affect protocol compliance; history of adverse reaction to metoprolol or its analogues. Randomized controlled trials of beta blockers for post myocardial infarction Author, Year Interventions (drug, regimen, Allowed other medications/ Method of outcome assessment and Country duration) interventions timing of assessment Metoprolol vs placebo Anonymous Metoprolol (met) 200 mg daily Interim visits conducted at 1, 3, 7 and 12 1987 Placebo (pla) x 1 year months USA Treatment interval: 5-15 days post- Lopressor MI Intervention Trial Fair quality Hjalmarson, 1981 Metoprolol (met) 15 mg Arrhythmias: iv lidocaine or Physician examination at 1-week and 3 Herlitz, 1984 intravenously; 200 mg orally procainamide months after inclusion Herlitz, 1997 Placebo (pla) CHF: furosemide 40-80 mg iv, then Sweden oral Treatment interval(mean): 11. Randomized controlled trials of beta blockers for post myocardial infarction Number Number Author, Age screened/ withdrawn/ Year Gender eligible/ lost to fu/ Country Ethnicity Other population characteristics (diagnosis, etc) enrolled analyzed Metoprolol vs placebo Anonymous Mean age = 58 Previous medical history: NR/NR/2395 Withdrawn: 1987 % Male = 83% MI = 14. Randomized controlled trials of beta blockers for post myocardial infarction Author, Method of adverse Year effects Country Outcomes assessment? Metoprolol vs placebo Anonymous Total mortality (# patients/%) NR 1987

purchase cheap astelin

Diversity and dominance among TCR recognizing HLA-A2 order astelin 10 ml on-line. Survival of long-lived plasma cells is independent of antigen order astelin discount. Pilin gene phase variation of Moraxella bovis is caused by an inversion of the pilin gene purchase generic astelin from india. TH cells primed during influenza virus infection providehelpforqualitatively distinct anti- body responses to subsequent immunization. Molecular epidemiology of group A strepto- coccus-M type-1 infections. DNA replication promotes high-frequency homologous recombination during Autograha californica multiple nuclear polyhedrosis virus infection. Studies of the binding properties of influenza hemagglutinin receptor-site mutants. Evolution subverting essentiality: dispensability of the cell attachmentArg-Gly-Asp mo- tif in multiply passaged foot-and-mouth disease virus. Proceedings of the National Academy of Sciences USA 94:6798–6802. Global distribution of the CCR5 gene 32-basepair deletion. A quantitative, single-cell PCR analysis of an antigen-specific TCR repertoire selected during an in vivo CD8 response: direct evidence for a wide range of clone sizes with uniform tissue distribution. The diversity of antigen-specific TCR repertoires reflects the relative complexity of epitopes recognized. Single-cell PCR analysis of TCR repertoires selected by antigen in vivo: ahighmagnitudeCD8response is comprised of very few clones. A very high level of crossreactivity is an essential feature of the T-cell receptor. Serological characteristics of a ‘new’ serotype of influenza Avirus:the Hong Kong strain. Bulletin of the World Health Organization 41:461–468. Swine influenza virus and the recycling of influenza A viruses in man. Antibody recognition of picornaviruses and escape from neutralization: a structural view. Mutational analysis of dis- continuous epitopes of foot-and-mouth disease virus using an unprocessed capsid promoter precursor. Antigenic hetero- geneity of a foot-and-mouth disease virus serotype in the field is mediated by very limited sequence variation at several antigenic sites. Extensive antigenic heterogeneity of foot-and-mouth disease virus of serotype C. Molecular mechanisms of serum 292 REFERENCES resistance of human influenza H3N2 virus and their involvement in virus adaptation in a new host. The surface gly- coproteins of H5 influenza viruses isolated from humans, chickens, and wild aquatic birds have distinguishable properties. Avian influenza Avirusesdifferfromhuman viruses by recognition of sialyloligosaccharides and gangliosides and by a higher conservation of the HA receptor-binding site. Proceedings of the National Academy of Sciences USA 90:4384– 4388. Johns Hopkins University Press, Baltimore, Maryland. Single- and multi-hit kinetics of immuno- globulin G neutralization of human immunodeficiency virus type 1 by mon- oclonal antibodies. Philosophical Transac- tions of the Royal Society of London B 355:315–316. Escape of human immunodeficiency virus from immune control. Parasite dose determines the Th1/Th2 nature of the response to Leishmania major independently of infection route and strain of host or parasite. Pattern of nucleotidesubstitution and rate heterogeneity in the hypervariable regions I and II of human mtDNA. Molecular basis of surface antigen variation in Neisseria. Cooperation and conflict in the evolution of individuality. Extensive diversity in the recogni- tion of influenza virus hemagglutinin by murine T helper clones. Partitioning of genetic variation between regulatory and coding gene segments: the predominance of software variation in genes en- coding introvert proteins. Natural variation in immune responsiveness, with special reference to immunodeficiency and promoter polymorphism in class II MHC genes. Computer-assisted analysis of envelope protein sequences of seven human immunodeficiency isolates: predictions of antigenic epitopes in con- served and variable regions. Germline TCR- Arestriction of immunoglobulin E responses to allergen. Integrin ανβ3res- cues melanoma cells from apoptosis in three-dimensional dermal collagen. Proceedings of the National Academy of Sciences USA 91:8856–8860. New polymor- phism of the human T-cell receptor AV28S1 gene segment. Identification of the nonamer peptide from influenza A matrix protein and the role of pockets of HLA-A2 in its recognition by cytotoxic T lymphocytes. Immunobiology of cytotoxic T-cell escape mutants of lymphocytic choriomeningitis virus. Neutralization of picor- naviruses: support for the pentamer bridging hypothesis. Adaptive evolu- tion of highly mutable loci in pathogenic bacteria. The evolu- tion of RNA viruses: a population genetics view.

buy discount astelin on line

purchase astelin pills in toronto

Tensing the abdominal wall child is a common reason for women to make re- muscles tends to lessen intra-abdominal pain order astelin 10 ml visa, peated visits to a health facility astelin 10 ml low price, especially in under- whereas the pain will be made worse if the patho- resourced countries where bearing children is 10 logy is in the abdominal wall buy cheap astelin line. Abdominal palpation should commence in a Past and present contraceptive use should be re- pain-free site and proceed systematically around the corded, together with any unpleasant side-effects. Any tender areas, obvious masses It is helpful to know whether there is a history or loaded bowel should be noted. The timing of this enquiry depends on the rapport built up with the client, and it can be done Speculum examination at any appropriate time during the consultation. This is advisable for women who are sexually Although not clearly understood, there appears to active, and should always be performed if there be a relationship between chronic pelvic pain and has been post-coital bleeding, an abnormal vaginal childhood sexual abuse, especially if there is con- 6 discharge or if the client has never had their cer- tinuing abuse into adulthood. Sometimes bluish deposits of endometriosis can be seen in the posterior fornix. Cervical screening is not readily available in under- The physical examination resourced countries and many women with cervical The physical examination is important for eliciting cancer present with untreatable late-stage disease. It is also Opportunistic detection of early cervical cancer a ‘psychodynamic event’9 and the way the client gives the only chance for surgical cure when radio- responds may give an insight into the way they feel. If the cervix looks Read more on the gynecological examination in normal and vaginal inspection with acetic acid Chapter 1 if you feel unsure about the different (VIA) is a service that is locally available, informa- procedures. An explanation should be given about tion can be given to the client so that if appropriate how the examination will be conducted, starting she can attend at her convenience (see Chapter 26 with the need to perform an abdominal examina- on how to do VIA). Intimate examinations Vaginal examination are usually consented to, but they can in themselves cause much distress especially if a woman has been Inspection of the vulva will reveal signs of irrita- in an abusive relationship. The health provider tion, inflammation, ulcers, warts or discharge. Women who who has not been sexually active or anyone who decline vaginal examinations should not be made prefers not to have this done. If digital examination to feel they have compromised their chances of is declined or not tolerated, gentle examination 69 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS with a long cotton-wool bud may be agreed upon Investigations and can give useful information. Urine, stool and pregnancy testing Initial digital examination should be with one finger to minimize discomfort so that potential Simple dipstick testing of urine, preferably on a painful areas can be better localized. If well toler- midstream specimen, should be performed. If ated, two fingers can be inserted later to aid further macroscopic hematuria is present the client needs examination. Gentle palpation of the anterior further investigation, but always check she is not vaginal wall will determine any urethral or bladder menstruating! The presence of leukocytes or nitrites base tenderness. Examination of the posterior may indicate cystitis and if the client is sympto- vaginal wall and posterior fornix will reveal any matic a course of antibiotics should be prescribed tender nodules that could indicate endometriosis. If microscopic Asking the client to contract and relax her pelvic hematuria is detected the sample should be sent for floor muscles, together with gentle digital exami- microscopy to exclude schistosomiasis, and consid- nation of the muscles, can assess pain originating in eration given to testing for tuberculosis. Bimanual examination will losis can mimic almost any disease and in endemic determine the size, position, mobility or fixation areas should not be forgotten. Microscopic hema- of the uterus, whether the uterus is tender and turia is quite common and can occur after exercise whether there are any obvious adnexal masses. Before referral for more extensive investi- gations the test should be repeated twice. Urinary Additional examinations tract cancer is extremely rare in women under 4011. Other medical causes (including sickle cell disease) Women with the following signs and symptoms would be inferred from the history. Microscopy of need additional investigations and possibly referral: a stool sample should also be arranged, as parasitic • Rectal bleeding/blood in stool: proctoscopy, infections can cause abdominal/pelvic pain. A full • Pelvic or abdominal mass, including fibroids blood count with differential is a good basic test if (see Chapter 19): ultrasound and possible available. Other blood tests should be ordered de- surgery pending on the clinical findings and their local • Ascites: ultrasound and if possible cytology of availability. Abdominal dia screening or presumptive treatment for ultrasound should be used to assess the uterus and chlamydia and gonorrhea followed by reassess- ovaries in adolescents with pelvic pain, in women ment after 4 weeks who decline a vaginal examination and all women • Cervix suspicious of carcinoma: biopsy of who have an abdominal mass. Transvaginal scan- cervical lesion/urgent surgery as deemed ning is superior to abdominal scanning for visual- appropriate izing pelvic masses and is useful for detecting • Excessive weight loss: HIV test, consider poss- adenomyosis and small endometriomas that would ible malignancy indicate endometriosis, or hydrosalpinx that would 70 Chronic Pelvic Pain indicate chronic pelvic inflammatory disease. Peri- infertility, endometriosis in a first-degree relative, toneal deposits of endometriosis will not be visual- and immune disorders14. The vaginal probe can be used to identify Three different forms of endometriosis have particularly tender areas, and an experienced ultra- been described, and any mixture of lesions is sonographer is able to detect the position and possible15: mobility of the ovaries. Immobility of an ovary 12 • Peritoneal endometriosis, where endometriosis may be predictive of endometriosis or adhesions. Infertility investigations • Endometriomas, which are ovarian cysts lined Infertility is probably one of the commonest causes with endometrial-like tissue and containing a of chronic pelvic pain in under-resourced coun- thick, tarry, ‘chocolate-like’ fluid. If this is the working diagnosis, investigations between the vagina and rectum. If the client has not come with her part- small and barely visible, to lesions causing large ner she should be encouraged to return with him so ovarian cysts, extensive adhesions and sometimes that they can be seen together. The commonest infiltrating into the bowel and/or bladder. However, normally fertile women and men in under-resourced countries do not have have also been found with endometriosis. Inferti- access to the treatment options available in richer lity is to be expected when endometriosis causes countries, but compassionate management should adhesions with blockage or distortion of the fallo- instill hope, as it is rarely possible to state that a pian tubes, but for reasons not fully understood woman will never be able to conceive. The following condi- A working diagnosis of endometriosis is made from tions are the most likely to cause chronic pelvic a combination of symptoms and physical findings. It is possible for Transvaginal ultrasound if available (or abdominal more than one condition to be present in the same ultrasound in those not sexually active) may be individual: helpful, especially for diagnosing endometriomas. It is an estrogen- micturition dependent condition, with symptoms usually • Past diagnosis of irritable bowel syndrome appearing after the menarche and resolving after • Past history of ovarian cysts the menopause. Risk factors for endometriosis • Difficulty conceiving include: early age at menarche, short menstrual • Past episodes of pelvic inflammatory disease cycles, heavy menstrual flow, painful menstruation, • Sleep disturbances. They should be and increasing the dose if breakthrough bleeding offered treatment depending on whether or not occurs.