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Chest radiography: Since 90% of patients with with symptoms for less than two years whereas Sarcoidosis have pulmonary involvement generic lioresal 25 mg with amex muscle relaxant food, the chronic sarcoidosis is disease presentation for more chest radiograph is usually abnormal (Fig order lioresal line spasms cerebral palsy. This presentation is more common among whites and is seen in less than 4% of cases among Asians safe 25mg lioresal quetiapine spasms. Although the fever in sarcoidosis is low grade (rarely exceeds l02°F) and weight loss less than 6 kilograms discount 10mg lioresal with amex muscle relaxant topical, these consti- tutional symptoms are more common among Asians and Afro-Americans than Caucasians. Pulmonary Sarcoidosis More than 90% of all patients with Sarcoidosis have their lungs involved and more than 60% or patients have respiratory symptoms. Lymphoid system 33% – Cervical, axillary and inguinal nodes are commonly involved – The posterior cervical nodes are more commonly involved than the anterior cervical – Enlarged nodes are discrete non-tender, mobile and do not form sinuses – Splenic involvement is minimal but may rarely cause anemia, leuko- penia, thrombocytopenia and pressure symptoms 2. Skin 25 % – Erythema nodosum is seen in acute forms of sarcoidosis and is common in Caucasian’s and remits in 6-8 week – Biopsy of E. Nodosum lesions does not reveal characteristic granuloma – Lupus pernio are discoloring indurated plaques seen on lips, nose, cheeks and ears and common in Afro-Americans. It represents a chronic form – Other skin lesions include maculopapular eruptions, subcutaneous nodules, alopecia, hypo-and hyper-pigmented areas and most importantly changes in old scars 3. Ocular 11-83 % – Acute or chronic anterior or posterior uveitis, conjunctival follicles, lachrymal gland involvement keratoconjunctivitis sicca, dacryocystitis and retinal vasculitis 4. The most common lesions are cranial neuropathies (7th, 5th and 8th nerves) hypothalamic and pituitary lesions are common – Space occupying lesions, peripheral neuropathy (mononeuritis multiplex) and neuromuscular involvement are seen in chronic cases. Liver 50-80 % Although granulomas in the liver are common serious liver dys- function is rare. Musculoskeletal 25 to 39 % Arthralgias involving the knees, ankles, elbows, wrists and small system joints of hands and feet are common but arthritis is rare. Upper airways 5 to 10 % – Hoarseness, laryngeal or tracheal obstruction, nasal congestion sinusitis and saddle-nose deformities may be seen. G-I tract Less than 1 % – Stomach is most commonly involved – Sarcoidosis may mimic Crohn’s disease, tuberculosis, fungal infection or pancreatic neoplasm’s 10. Exocrine glands 6 to 40% – Combination of fever, parotid enlargement, facial palsy is called ‘Heerfordt’s” syndrome – Involvement of lachrymal glands may cause sicca syndrome 11. Endocrine 2 to 10 % Hypercalcemia with hypercalciuria is the commonest manifestation – Diabetes insipidus may be seen in pituitary or hypothalamic involvement 12. Renal – Renal calculi and nephrocalcinosis are the commonest presentations – Rarely interstitial nephritis, glomerulopathies or nephrotic syndrome due to sarcoidosis is seen 13. The flip side to this is the fact that certain radiographic signs are rarely seen with pulmonary sarcoidosis. Pulmonary function test: These tests are indicated for all patients as measuring initial lung impair- ment and to provide a baseline to assess improve- ment or deterioration of the lung disease. Pulmonary function is impaired in only 20% of stage one disease whereas it is abnormal in 40 to 70% of patients with higher stages of the disease. Obstructive impairment is common in-patients with endobronchial disease, laryngeal disease or tracheal or bronchial stenosis. A subgroup of patients has bronchial hyperresponsiveness to methacholine and airway obstruction that may respond to bronchodilators. Skin tests and cutaneous anergy: Cutaneous Anergy is a well-recognized feature of Sarcoidosis. It is due to impaired cutaneous response to antigens that elicit delayed type hypersensitivity reactions (like the tuberculin test) and may be due to a distribution of T cells to sites of inflammation and the presence of local inhibitors of delayed type hypersensitivity reactions. This antigen pattern on a total body scan may support the is not available in India and has been cut of diagnosis but is rare. This protein probably originates from exclusion of other diseases capable or producing a the activated epitheloid cells and macrophages similar histologic picture (Table 12. Gallium 67 scans: In-patients with active sarcoi- the following goals: dosis there is enhanced uptake of Ga67 in the – Provide histologic confirmation of the disease. As pointed out earlier 85% of all remissions occur in the first two years of the disease and only 2–8% of patients with spontaneous remissions have relapses. In these patients clinical and radiological features Nevertheless some of the indications for systemic may be diagnostic. Prognosis of sarcoidosis is also influ- should be monitored for response for 1 to 3 enced by its clinical presentation. Patients showing no response beyond 3 like Löfgren’s syndrome tends to have better pro- months are unlikely to respond later. Patients should be Sarcoidosis 297 monitored for relapse up to three years of Patients relapsing after steroid therapy require stopping therapy. Topical steroids may be useful frequent monitoring whereas patients with spon- in skin lesion, iritis/uveitis, and nasal polyps or taneous remissions are less likely to relapse. Some studies have shown benefits with severe extrapulmonary disease require long- with inhaled steroid in cases of pul-monary term follow up. During follow up all patients should sarcoidosis but this needs further evaluation. Chloroquin: It is efficacious in-patients with muco nation, chest radiograph and tests of organ function. In one study there was a weak 250 mg/day for six months and can be repeated at six monthly intervals. Cytotoxic agents: In refractory cases, methotrexate concentration and single-breath carbon monoxide and Azathioprine have been shown to be useful. Exhaled nitric oxide Cyclophosphamide has been tried in cases concentration was found to be elevated in patients resistant to these agents. These agents have been with sarcoidosis but this concentration did not used with or without prednisolone. Metho- depend on the radiographic staging, activity or trexate is used in a dose of 10–25 mg/week. Azathioprine is used at 50–200 mg/day and Several new radiological signs have been Cyclophosphamide at 50–150 mg/day metho- described in sarcoidosis (1) The “sarcoid galaxy trexate and azathioprine have been shown to be sign” due to bilateral coalescent angiocentric safer and more efficacious than cyclophos- pulmonary nodules with tiny peripheral satellite phamide. Cyclo- with a variety of underlying pulmonary disorders sporin inspite of its severe toxicity may be useful but which have not been reported in sarcoidosis in some cases of refractory neurosarcoidosis. Newer therapies are recommended in recent Lung and organ transplantation has been tried times for sarcoidosis. In neurosarcoidosis the use of in cases of end stage sarcoidosis but recurrence may radiation therapy remains an appropriate therapy occur in donor organ and may require immuno- option with minimal adverse sequelae if primary suppression. New agents, including years after presentation to assess progress or need pentoxifylline, thalidomide, and infliximab have for intervention. Recognition of distinctive Neurosarcoidosis: An unusual indication for radio- patterns of gallium-67 distribution in sarcoidosis. An increase in exhaled nitric oxide is not associated with activity in pulmonary 1999;115:275-276. Health status of individuals, community or a nation is determined by interplay of two ecological Particles and fibers: Grain dusts, sand dust, coal dust universes of man, the internal environment and the and wood dust, silica, and beryllium, are examples external environment that surrounds him.

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Acute laryngitis usually crowding 10mg lioresal with amex muscle relaxer 86 67, an average person can have 2-3 attacks clears in a few days while complications of pharyn- per year generic lioresal 10 mg with amex back spasms 5 weeks pregnant. The onset is sudden with sore throat generic 25 mg lioresal with visa muscle relaxant usa, gotonsillitis are usually due to bacterial infections Respiratory Tract Infections 87 leading to peritonsillar abscess (quinsy) lioresal 10 mg lowest price skeletal muscle relaxants quiz, cervical Influenza abscess, retropharyngeal abscess, rheumatic fever It is a specific acute illness caused by a group of and acute glomerulonephritis. Paracetamol rather Effective lifelong vaccination is not possible due to than aspirin should be used for fever to avoid antigenic drifts and shifts. Clinical features include Reye’s syndrome while the role of vitamin C is cough, fever, generalized bodyache and malaise. Antibiotics are used only if there is uncomplicated cases recovery occurs in 3-5 days. Penicillin is the drug of disease, however, may be complicated by tracheitis, choice, while erythromycin is used in case of bronchopneumonia and secondary bacterial pneu- penicillin allergy. Toxic cardiomyopathy, encephalitis, post- avoided for fear of causing rash in cases of infec- influenzal demyelinating encephalopathy, Guillain tious mononucleosis. Oral Amantadine in doses of 100-200 mg per day in adults can reduce the duration of illness. Pneumonia used to be Acute Laryngotracheo-bronchitis (Croup) the leading cause of death prior to the introduction These conditions, which overlap frequently occur of effective antibiotic therapy and modern means of following infection with any of the common viruses. Cyanosis and contraction of of drug resistant organisms in hospitals and conta- accessory muscles of respiration may be seen in minated equipment, availability of newer anti children. Because discomfort or chest tightness are additional of the non-specificity of clinical and radiographic symptoms. Clinical examination is often normal or findings and limitations of diagnostic testing for occasionally wheeze and coarse crackles may be identifying the etiological organisms the initial noted. Pneumonia occurs when the oral/intravenous steroids may be used in severe lung defences are overcome leading to multi- cases. Other management includes temperature control The following classification is used for practical and oxygen administration in case of respiratory purposes, which is based on the etiological failure. Classification of Pneumonia Anatomical/Radiological Classification Etiological Classification a. Lobar: Resulting in homogenous opacification of Viral pneumonia, bacterial pneumonia, parasitic and segment and or lobe with air bronchogram on fungal pneumonia. Viral pneumonia: The organisms are influenza A and B, adenovirus, Varicella, respiratory syncitial virus, measles, parainfluenza, cytomegalovirus, corona virus, coxsackie virus and rhinovirus. Influenza is the most common in adults, occurring in epidemics while measles is common in childhood. Viral pneumonias are usually benign but occasionally may be complicated by bacterial pneumonias. Bacterial pneumonia: They are the commonest and the frequently encountered organisms as shown in Table 3. The most frequent way by which pneumonia occurs is thus by colonization of the oropharynx by the pathogenic organisms and subsequent aspiration. The routes of acquiring infection are: Aspiration: Aspiration of the oropharyngeal organisms is the commonest mechanism, which is increased by states in which ability to cough is depressed. In elderly people and in hospital patients in addition to the above gram-negative bacilli are Fig. Inhalation: Transmission of viral infections, infections by atypical organisms and tuberculosis is by this route. Blood spread: Hematogenous spread from a focus elsewhere may occur with gram-negative and Staphylococcal bacteremia. Lobular: Consists of nodular or patchy irregular opacities in involved areas of lung seen in Healthy young adults S. Interstitial: Resulting in interstitial (reticulo- > 45 years Mycoplasma nodular) pattern on radiographs as seen in Patients of diabetes S. In healthy Organ transplant, Legionella individuals aspiration of droplets from naso- renal failure pharynx occurs during sleep. Clinical history: Age > 65 years, presence of coexistent with adequate sensitivity and specificity. The failure, chronic liver failure, congestive heart failure, typical features include cough with purulent sputum previous hospitalization, post-splenectomy, chronic production, fever and dyspnea. Viral and atypical alcohol abuse and malnutrition pneumonias usually present with constitutional b. On examination, bronchial output < 20 ml/hr breath sounds and crackles may be noted. Atypical due to irregular filling in the background of presentations include fever, cough with mucoid emphysema. Coexisting conditions like bronchial sputum, myalgia, malaise and extra-pulmonary obstruction, pleural effusions may be also be symptoms like diarrhea and confusion. Current chest film should be characteristics like the sputum being usually rusty compared with old films to confirm the acute in Pneumococcal pneumonia, mucoid in viral and episode of illness. Sputum examination: Gram’s staining of expecto- pneumonia can act as aid to diagnosis. Elderly rated sputum should be performed prior to patients usually report fewer symptoms. Ideal sputum sample presen-ting clinical features including history, features more than 25 neutrophils, less than 5 physical examination, routine laboratory and squamous epithelial cells and presence of alveolar roentgenographic evaluation does not allow the macrophages. This ideal During the initial evaluation decision regarding the sputum sample can be cultured for aerobic and tests required, the severity of illness and the anaerobic organisms. Staphylococcus and emperical therapy to be instituted at home or Klebsiella are non-fastidious organisms, which hospital needs to be taken. Invasive the possibility of pneumonia the following investi- procedures like transtracheal aspiration, broncho- gations should be carried out. Pre-treatment, two blood cultures obtained from separate sites with a time gap of 10 minutes may be done. Serological testing, cold agglutinin measurements are not to be routinely performed. They may be occasionally useful for retrospective confirmation of suspected diagnosis or for epidemiological studies. The advanced diagnostic tests are primarily used for epidemiological evaluations and in the assessment of the patients whose illness does not resolve despite appropriate emperic therapy. Most potential pathogens recovered from expectorated sputum represent contaminants from the upper respiratory tract thus interpretation The rationale for obtaining etiological diagnosis should be on the basis of clinical correlation, Gram is to permit optimum antibiotic selection, to identify stain findings and culture quantification. The the prevalence of resistance and to identify epi- following chart can be used as a guide in the initial demiologically significant pathogens like Legionella. Beta lactamase inhibitor Additional therapy in the form of oxygen, hydration and ionotropes Miscellaneous: Moraxella, + Erythromycin or newer may be required in hospitalized patients. One of the other reasons for poor response to antibiotic therapy may Therapy should not be changed in the first 72 hours be non-infectious etiology of the chest radiograph, unless there is marked clinical deterioration.

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In such instances order lioresal 10 mg with visa muscle relaxant pregnancy, the research staff may be able to correct the data themselves if too much time has not elapsed purchase discount lioresal online muscle relaxant starts with c. Because data collection and data entry are often done by different research staff cheap lioresal 25 mg without prescription muscle relaxant flexeril 10 mg, it may be more difficult and time consuming to make such clarifications once the information is passed onto data entry staff best purchase lioresal muscle relaxant stronger than flexeril. One way to simplify the data screening process and make it more time efficient is to collect data using computerized assessment instruments. Computerized assessments can be programmed to accept only responses within certain ranges, to check for blank fields or skipped items, and even to conduct cross-checks between certain items to identify potential inconsistencies between responses. Another major benefit of these programs is that the entered data can usually be electronically transferred into a permanent database, thereby automating the data entry procedure. Although this type of computerization may, at first glance, appear to be an impossible budgetary expense, it might be more economical than it seems when one considers the savings in staff time spent on data screening and entry. Whether it is done manually or electronically, data screening is an essential process in ensuring that data are accurate and complete. Generally, the researcher should plan to screen the data to make certain that– Data Management, Processing and Analysis 203 1. Constructing a Database Once data are screened and all corrections made, the data should be entered into a well-structured database. When planning a study, the researcher should carefully consider the structure of the database and how it will be used. In many cases, it may be helpful to think backward and to begin by anticipating how the data will be analyzed. This will help the researcher to figure out exactly which variables need to be entered, how they should be ordered, and how they should be formatted. Moreover, the statistical analysis may also dictate what type of program you choose for your database. For example, certain advanced statistical analysis may require the use of specific statistical programs. While designing the general structure of the database, the researcher must carefully consider all the variables that will need to be entered. Forgetting to enter one or more variables, although not as problematic as failing to collect certain data elements, will add substantial effort and expense because the researcher must then go back to the hard data to find the missing data elements. The Data Codebook In addition to developing a well-structured database, researchers should take the time to develop a data codebook. A data codebook is a written or computerized list that provides a clear and comprehensive description of the variables that will be included in the database. Moreover, it serves as a permanent database guide, so that the researcher, when attempting to reanalyze certain data, will not be stuck trying to remember what certain variable names mean or what data were used for a certain analysis. Ultimately, the lack of a well-defined data codebook may render a database un-interpretable and useless. At a bare minimum, a data codebook should contain the following elements for each variable: • Variable name • Variable description • Variable format (number, data, text) • Instrument or method of collection • Date collected • Respondent or group • Variable location (in database) • Notes 204 Research Methodology for Health Professionals Data Processing–Quantitative Data Data can be processed manually (using data master sheets or manual compilation of the questionnaires) or by computer using a micro-computer and existing software/self-written programs for data analysis. It involves categorizing the data, coding, and summarizing the data in data master sheets, manual compilation without master sheets, or data entry and verification by computer. Categorizing Categorical variables and numerical variables are to be categorized separately; otherwise if it comes to notice during data analysis that the categories had been wrongly chosen, one cannot reclassify the data anymore. Coding If the data are to be entered in a computer for subsequent processing and analysis, it is essential to develop a coding system. For computer analysis, each category of a variable can be coded with a letter, group of letters or word, or be given a number. For example, the answer ‘yes’ may be coded as ‘Y’ or 1; ‘no’ as ‘N’ or 2 and ‘no response’ or ‘unknown’ as ‘U’ or 9. When finalizing the questionnaire, for each question one should insert a box for the code in the right margin of the page. Summarizing the Data in Data Master Sheets, Manual Compilation, or Compilation by Computer 1. Data master sheets / data master table If data are processed by hand, it is often most efficient to summarize the raw research data in a so-called data master sheet, to facilitate data analysis. On a data master sheet all the answers of individual respondents are entered by hand. For short simple questionnaires, one may put all possible answers for each question in headers at the top of the sheet and then list or tick the answers of the informants one by one in the appropriate columns. For example, the straightforward answers of the smoking questionnaire for male smokers could be processed as follows: Master sheet for smokers (males): Data Management, Processing and Analysis 205 No. Compilation by hand (without using master sheets): When the sample is small (less than 30) and the collected data is limited, it might be more efficient to do the compilation manually. If a team of 2 persons work together, use either manual sorting or tally counting. To do tally counting, the basic procedure is: One member of the compiling team reads out the information while the other records it in the form of a tally (e. After tally counting, add the tallies and record the number of subjects in each group. Computer compilation Before we decide to use a computer, we have to be sure that it will save time or that the quality of the analysis will benefit from it. The larger the sample, the more beneficial in general the use of a computer will be. Choosing an appropriate computer program: A number of computer programs are available in the market that can be used to process and analyze research data. Data entry: To enter data into the computer you have to develop a data entry format, depending on the program you are using. After deciding on a data entry format, the information on the data collection instrument will have to be coded (e. During data entry, the information relating to each subject in the study is keyed into the computer in the form of the relevant code (e. Note that data entry can be done through the private sector, which may be fast and not too expensive. Health office staff who are not accustomed to this work tend to be slow and make many errors in entry. Programming: If we use computer personnel to analyze the data, it is important to communicate effectively with them. The researcher should tell the computer personnel: • the names of all the variables in the questionnaire; • the location of these variables in relation to the data for one subject, i. Computer outputs: The computer can do all kinds of analysis and the results can be printed. It is important to decide whether each of the tables, graphs, and statistical tests that can be produced makes sense and should be used in our report. Data analysis (details are given in chapter no 12 and 13): Quantitative Data Analysis of quantitative data involves the production and interpretation of frequencies, tables, graphs, etc. Some guidelines are as follows: 208 Research Methodology for Health Professionals The Data can be Analyzed in Seven Steps Step 1: Take a sample of questionnaires and list all answers for a particular question. Take care to include the source of each answer you list (in the case of questionnaires one can use the questionnaire number), so that one can place each answer in its original context, if required. Step 2: To establish categories, first read carefully through the whole list of answers.

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Steep in-plane approach to the median nerve from the lateral aspect of the forearm avoids the radial artery and the superfcial radial nerve buy lioresal without prescription spasms hands. The hand should be relaxed so that the median nerve is mobile and not under tension purchase lioresal master card muscle relaxant xanax. Wrist hyperextension stretches the median nerve and can lead to impairment of nerve function 4 if prolonged buy lioresal once a day muscle relaxant list by strength. Therefore discount lioresal 10mg with mastercard muscle relaxant elemis muscle soak, median nerve block should be performed with the wrist in neutral position. Median nerve block proximal to the elbow is often used in the recovery room following surgery because of the presence of surgical dressings covering the forearm. If this approach is used, care must be taken to avoid puncturing the brachial artery because this can result in median epineurial 5,6 hematoma. Although the median artery normally evolutes during development, persistent median artery can be detected with high-resolution ultrasound in about 25% of asymptomatic indi- 7 viduals. Persistent median artery is sometimes associated with high division or bifd median nerve, in which cases the artery is often in the middle of the divided nerve. When the persistent median artery is eccentrically located with respect to the nerve, the block should target the nonarterial side of the nerve to avoid intraneural hematoma. Motor block of the opponens pollicis can be tested by having the patient touch the base of the small fnger with the thumb against resistance. Wrist hyperextension leads to median nerve conduction block: implications for intra-arterial catheter placement. Median-nerve neuropathy after percutaneous puncture of the brachial artery in patients receiving anticoagulants. Sonographic diagnosis and treatment of a median nerve epineural hematoma caused by brachial artery catheterization. Persistent median artery in the carpal tunnel: color Doppler ultraso- nographic fndings. External photograph showing the in-plane (A) and out-of-plane (B) approaches to median nerve block in the forearm. For in-plane technique, the needle approaches from the lateral aspect of the forearm. Sonograms illustrating the in-plane (A) and out-of-plane (B) approaches to median nerve block. Because the local anesthetic is primarily distributed over the surface of the nerve, additional local anesthetic is then deposited underneath the nerve. In this variation the persistent median artery lies within the same connective tissue bundle as the median nerve and can divide it into two parts. When this condition is identifed, the needle tip is placed on the side of the nerve away from the artery. The ulnar nerve provides sensation of the dorsal and palmar sides of the ulnar aspect of the hand. It leaves the neurovascular bundle in the axilla to travel through the cubital tunnel. The dorsal cutaneous 1,2 branch leaves the ulnar nerve in the forearm proximal to the wrist. At the level of the hamate, the ulnar nerve divides into its superfcial sensory branch and its deep motor branch. Suggested Technique The ulnar nerve is usually blocked just proximal to its juncture with the ulnar artery in the 3 forearm. The needle tip is placed within the fascial plane that connects the ulnar nerve and ulnar artery using an in-plane approach from the lateral side of the forearm. To access this plane with the block needle it is best to puncture the fascia and slowly inject as the needle is pulled back. A relatively common (3%-10%) anatomic variant is superfcial ulnar artery, whereby the 4 ulnar artery lies superfcial to the fexor muscles. Neurologic Assessment Neurologic assessment of ulnar nerve block includes testing sensation of the ulnar side of the hand. Motor block assessment can be performed by testing the dorsal and palmar inter- ossei functions. The dorsal cutaneous branch of the ulnar nerve: an anatomic clarifcation with six case reports. An in-plane approach is demonstrated whereby the needle tip is placed between the ulnar artery and ulnar nerve (A and B). After injection, local anesthetic is distributed around the ulnar nerve (C) and tracks along the nerve (D). In this variation, the ulnar artery lies superfcial to the fexor muscles and is not adjacent to the ulnar nerve. The nerve is a branch of the lumbar plexus that provides cutaneous sensation from the lateral aspect of the thigh. As with other small nerves, it is necessary to scan along the length of the nerve to confrm nerve identity. The best imaging technique is to slide the transducer along the known course of the nerve with the nerve viewed in short axis. It is useful for skin graft harvests and surgical procedures with lateral incisions of the thigh. It is one of the few lower extremity blocks for weight-bearing patients (this group also includes ankle block and saphenous block). Ultrasound imaging may be useful for the diagnosis and treatment of meralgia paresthetica (from Greek meros for “thigh,” and algos for “pain”). Abnormal nerve morphology has been described in patients with meralgia paresthetica. The fascial planes that lie over the anterior border of the sartorius muscle (in particular, the fascia lata) can be separated by infltrating local anesthetic between these layers. If light probe pressure is applied, the nerve can be seen within the tissue between these two fascial 7 layers for needle tip placement. This view is parallel to the course of the nerve and perpendicular to the course of the artery. Is a blockade of the lateral cutaneous nerve of the thigh an alternative to the classical femoral nerve blockade for knee joint arthroscopy? Ultrasound-guided blockade of the lateral femoral cutane- ous nerve: technical description and review of 10 cases. Ultrasound-guided lateral femoral cutaneous nerve block for meralgia paresthetica. Ultrasound-guided treatment of meralgia paresthetica (lateral femoral cutaneous neuropathy): technical description and results of treatment in 20 consecutive patients.