Toxic megacolon: diagnosis and treatment challenges

In adults, toxic megacolon is a relatively uncommon but potentially lethal complication of inflammatory bowel disease (IBD), infectious colitis, or ischemic colitis caused by cancer chemotherapeutic agents. Patients have distension of the colon and signs of toxicity such as elevated temperature, hypotension, decreased level of consciousness and electrolyte imbalances. Factors thought to increase the risk include premature discontinuation of IBD medications; procedures that increase colon trauma, such as barium enema and colonoscopy; medications that decrease gastrointestinal motility; and electrolyte imbalances, especially hypokalemia. Differential diagnosis is made based on the patient's history and results of stool cultures and assay for Clostridium difficile toxin. Medical management in the intensive care unit includes careful monitoring, fluid volume and electrolyte replacement, bowel rest and decompression, antibiotic therapy, and cessation of medications that slow gastric motility. Surgical management may be necessary if there are signs of deterioration, perforation, hemorrhage, or sepsis.     

Diastolic heart failure: challenges of diagnosis and treatment

Diastolic heart failure, a major cause of morbidity and mortality, is defined as symptoms of heart failure in a patient with preserved left ventricular function. It is characterized by a stiff left ventricle with decreased compliance and impaired relaxation, which leads to increased end diastolic pressure. Signs and symptoms are similar to those of heart failure with systolic dysfunction. The diagnosis of diastolic heart failure is best made with Doppler echocardiography. Based on current knowledge, pharmacologic treatment of diastolic heart failure should focus on normalizing blood pressure, promoting regression of left ventricular hypertrophy, avoiding tachycardia, treating symptoms of congestion, and maintaining normal atrial contraction when possible. Diuretic therapy is the mainstay of treatment for preventing pulmonary congestion, while beta blockers appear to be useful in preventing tachycardia and thereby prolonging left ventricular diastolic filling time. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers may be beneficial in patients with diastolic dysfunction, especially those with hypertension. Evidence from adequately powered randomized controlled trials, however, is not available yet. The outcomes of ongoing clinical trials may provide much-needed information to move from intuitive treatment to therapy based on evidence that matters: decreased morbidity and mortality and improved quality of life.     

The diagnosis and treatment challenges in nosocomial pneumonia

Pneumonia is the second most common type of nosocomial infection and is most prevalent in patients who are mechanically ventilated. Nosocomial pneumonia (NP) is the leading contributor to mortality in patients, accounting for approximately 50% of deaths in patients with hospital-acquired infections. Several factors place patients at risk for developing NP, including prolonged length of hospital stay and local epidemiology. Gram-positive pathogens such as Streptococcus pneumoniae and, more recently, Staphylococcus aureus, as well as atypical organisms such as Legionella spp are increasingly associated with NP. Emerging antimicrobial resistance among these organisms confounds treatment interventions. Lack of local definitive information and patient comorbidities further complicate the physician's treatment decisions. The role of invasive pulmonary diagnostic techniques remains problematic and controversial. Studies, however, have shown that early initiation of appropriate empiric therapy is essential to improving patient outcome and reducing mortality. This article will review therapeutic options and appropriate antimicrobial agents for use in the treatment of nosocomial pneumonia in the era of emerging drug resistances.     

Pheochromocytoma: challenges in diagnosis and nursing care

Pheochromocytomas are catecholamine-secreting tumors arising from chromaffin cells of the sympathoadrenal system, which includes the adrenal medulla and sympathetic ganglionic tissue. The effects of catecholamine excess cause potentially fatal symptomologies and end-organ damage if not diagnosed and treated. If diagnosed and removed surgically, most of these patients can be cures. Pheochromocytomas are rare and affect from two to eight per million people. There are 800 deaths in the United States annually as a result of complications. Of patients who have pheochromocytomas diagnosed at autopsy, 75% died suddenly from myocardial infarction or cerebral vascular catastrophe. Challenges in diagnosis, tumor location, and treatment are considerable.     

Peripartum cardiomyopathy: challenges in diagnosis and management

Introduction: Peripartum cardiomyopathy (PPCM) is one of the leading causes of maternal mortality all over the world. Fortunately, some of the most important answers to the “PPCM puzzle” are emerging:

Areas covered: This is an update that includes current and recent research results. These developments hold promise to importantly decrease mortality from PPCM and increase recovery rates.

Expert commentary: Increasing risks for the development and severity of PPCM include a genetic predisposition and the presence of any form of hypertension in pregnancy. Earlier recognition/diagnosis of PPCM confers greater opportunity for full recovery. Important biomarkers have the potential to help to recognize PPCM earlier and to provide better treatment. “Follow the Guidelines” is good advice for the best opportunity to achieve full recovery. These include the use of diuretics, BB, ACEI/ARB in tolerable dosages. Phasing out specific treatments appears to be safe for some; but the process must be individualized.     

Overcoming challenges in the diagnosis and treatment of parasitic infectious diseases in migrants

ABSTRACT

Introduction: Recent increases in population movements have created novel health challenges in many areas of the World, and health policies have been adapted accordingly in several countries. However, screening guidelines for infectious diseases are not standardized and generally do not include comprehensive screening for parasitic infections.

Areas covered: Malaria, Chagas disease, leishmaniasis, amebiasis, filariases, strongyloidiasis, and schistosomiasis are reviewed, focusing on the challenges posed for their diagnosis and management in vulnerable populations such as migrants. The methodology included literature searches in public databases such as PubMed.gov and Google Scholar and search of the US National Library of Medicine online database of privately and publicly funded clinical studies (ClinicalTrials.gov) until November 2019.

Expert opinion: Parasitic infections which may remain asymptomatic for prolonged periods, leading to chronic infection and complications, and/or may be transmitted in non-endemic areas are ideal candidates for screening. Proposed strategies to improve diagnosis in vulnerable groups such as migrants include facilitating access to healthcare in a multi-dimensional manner considering location, individual characteristics, and timing. Limitations and availability of specific diagnostic techniques should be addressed and focus on drug and vaccine development for these neglected infections should be prioritized through collaborative initiatives with public disclosure of results.     

Vulvodynia and vulvar vestibulitis: challenges in diagnosis and management

Vulvodynia is a problem most family physicians can expect to encounter. It is a syndrome of unexplained vulvar pain, frequently accompanied by physical disabilities, limitation of daily activities, sexual dysfunction and psychologic distress. The patient's vulvar pain usually has an acute onset and, in most cases, becomes a chronic problem lasting months to years. The pain is often described as burning or stinging, or a feeling of rawness or irritation. Vulvodynia may have multiple causes, with several subsets, including cyclic vulvovaginitis, vulvar vestibulitis syndrome, essential (dysesthetic) vulvodynia and vulvar dermatoses. Evaluation should include a thorough history and physical examination as well as cultures for bacteria and fungus, KOH microscopic examination and biopsy of any suspicious areas. Proper treatment mandates that the correct type of vulvodynia be identified. Depending on the specific diagnosis, treatment may include fluconazole, calcium citrate, tricyclic antidepressants, topical corticosteroids, physical therapy with biofeedback, surgery or laser therapy. Since vulvodynia is often a chronic condition, regular medical follow-up and referral to a support group are helpful for most patients.     

Hepatitis C: treatment challenges

Hepatitis C is a significant public health problem, yet transmission can be prevented and the disease is treatable. Nurses have a key role in delivering care.     

Preimplantation genetic diagnosis: recent triumphs and remaining challenges

Over the last 20 years, preimplantation genetic diagnosis (PGD) has changed from being an experimental procedure to one that is carried out in specialized diagnostic centers worldwide. Genetic awareness and the rapid identification of germline mutations or chromosomal abnormalities enable individuals to know their risk of transmitting a genetic disease before they have children. This has created a demand for PGD from couples who wish to avoid terminations of affected pregnancies. Although PGD is expensive because it requires couples to go through IVF, there is a trend for diagnosis to move towards automation, which will reduce cost and the need for specialized expertise. This will allow diagnosis to be carried out in routine molecular diagnostic laboratories.     

Standardising HbA1c-based diabetes diagnosis: opportunities and challenges

Globally, the incidence of diabetes mellitus is rising at an alarming rate and has become a health crisis that threatens the economies of all nations. Therefore, diagnosing diabetes has become an important issue in the management of diabetes. Glycated hemoglobin (HbA1c) is now recommended as a means to diagnose diabetes, but its use still has limitations. In this article, the biology, measurement, standardization, and opportunities and challenges of the use of HbA1c to diagnose diabetes are reviewed. More specifically, its use in China and the Asian region is discussed in detail.