CAUSES OF ACUTE BACTERIAL MENINGITISStreptococcus pneumoniaIn North American series, infection with S. pneumoniae is overall the most common cause of acute bacterial meningitis, occurring in more than 50% of community-acquired cases. Pneumococcal meningitis occurs with the highest incidence in patients 6 to 24 months of age and those over 65 years of age, but it can be seen across all age groups. It can be associated with significant neurologic complications, particularly deafness. A number of conditions can allow more severe disease, and these include asplenism, multiple myeloma, alcoholism, malnutrition, cirrhosis, and renal disease. The organisms may be identified in the cerebrospinal fluid (CSF) as lancet-shaped gram-positive cocci in pairs. The mortality rate associated with pneumococcal meningitis is 19% overall, although this is much higher in elderly and debilitated people. Beta-lactam-resistant pneumococcus has emerged over the last decade, leading to revised recommendations for empiric therapy that now include vancomycin.
Neisseria meningitidesInfection with N. meningitidis occurs most commonly in children and young adults and carries a mortality rate of 3% to 13%. Most people acquire the disease from an asymptomatic carrier through face-to-face contact. Certain host factors can predispose individuals to disease, and these include age, level of immunity, and the presence of alcoholism. The incubation period of N. meningitidis is typically 2 to 10 days, with an initial presentation of fever and malaise followed by headache, nausea, vomiting, stiff neck, and a maculopapular, purpuric, or petecheal rash. The rash is evident with concomitant meningococcemia and evolves rapidly. The organisms appear as gram-negative diplococci on Gram stain of the CSF.
Listeria monocytogenesInfection with L. monocytogenes is the second most common cause of meningitis in people older than 60 years. The incidence of listeriosis varies from year to year in different regions and is occasionally associated with outbreaks related to contaminated deli meats and dairy products. Since cell-mediated immunity is involved in Listeria defense, patients with depressed cellular immunity are at particular risk for infection with this agent. In addition to those with comorbidities, Listeria meningitis can occur sporadically in healthy adults, although most commonly in elderly people. While the disease is associated with a high mortality rate (exceeding 20%), when it occurs in otherwise healthy people, the mortality rate is low. Listeria appears as a gram-positive rod on Gram stain of the CSF, but it is rarely visualized.
Group В StreptococciGroup В streptoccal infection accounts for up to 4% of cases of meningitis in adults and is most often a consideration in peripartum and neonatal patients. However, group В streptococcal meningitis can also be seen in non-pregnant patients, particularly the elderly and those with underlying diabetes mellitus or cirrhosis. Often a distant infectious site, such as endometritis or endocarditis, is present. The organisms appear as gram-positive cocci in pairs and chains.
Gram-Negative BacilliGram-negative rods can be associated with acute bacterial meningitis in neonates, neurosurgical patients, immuno-suppressed hosts, and elderly people. Escherichia coli and Klebsiella pneumoniae are the most common gram-negative pathogens isolated. Meningitis can also occur in the context of gram-negative sepsis.
Haemophilus influenzaSince the use of the conjugated Haemophilus influenzae В vaccine, Haemophilus influenzae is no longer a major pathogen in infant and childhood meningitis. Fewer than 1200 cases per year are now reported to the Centers for Disease Control and Prevention, with fewer than 300 cases occurring in children. Haemophilus meningitis in anyone older than 6 years is uncommon and suggests other underlying conditions such as sinusitis, otitis media, pneumonia, diabetes, alcoholism, asplenism, a CSF leak, or an immune deficiency. The organisms can be identified as small gram-negative coccobacilli on Gram stain of the CSF.
StaphylococciStaphylococcus aureus meningitis is most commonly associated with prior neurosurgery, head trauma, or CSF shunt infections. One sees gram-positive cocci in clusters on Gram stain. S. aureus meningitis can also be seen in cases of underlying infective endocarditis, paraspinal infection, sinusitis, osteomyelitis, or pneumonia. Staphylococcus epidermidis is the most common pathogen seen in CSF shunt infections.
Miscellaneous PathogensNocardia species, long filamentous gram-positive rods, may cause meningitis in patients with underlying immunosuppression. Capnocytophaga canimorsus, a gram-negative rod, is a rare cause of meningitis and can be seen in association with dog and cat bites, most fulminantly in asplenic people. It is a fastidious organism that is not grown on standard culture. Thus, it should be considered when gram-negative rods are identified in the CSF and no growth is seen with subsequent cultures. Group A streptococci are a rare cause of meningitis and are seen typically in those with predisposing sinusitis or otitis media.*1/348/5*

TYPES OF SUICIDE: SUCCEEDERS, ATTEMPTERS, AND THREATENERSAlcohol use and suicide go together. Recall from Chapter 1 that in 65% of all suicide attempts the individual had been drinking, and that 40% of all successful suicides are related to alcohol. The suicide rate in alcoholics is fifty-five times that of the general population. Before we all commit suicide ourselves over these statistics, we should consider why suicide and alcohol are related, and what we can do about it.For practical purposes, there are several different groups to be considered when examining suicide. First are the succeeders, those who succeed and intended to. Classically, these are lonely white men over 50 years of age or lonely teenagers. They use violent means such as a gun or hanging, and their methods are calculated and secretive. Second are those who succeed but did not intend to. These are the attempters. Classically they are white women, ages 20 to 40, often with interpersonal conflicts, whose “method” is pills, and whose action is an impulsive response. At tempters die by mistake or miscalculation. For example, they lose track of dosage, or something goes wrong with their plans for rescue. The attempter’s intent is not so much to die as to elicit response from the environment. Emergency-room psychology, which dismisses this client with a firm kick in the pants, is inappropriate. Someone who is trying to gain attention by attempting suicide is in reality quite sick and deserves care. Third are the threateners, who use suicide as a lethal weapon: “If you leave me, I’ll kill myself.” They are often involved in a pathological relationship. These people usually do not follow through, but are frightened and guilt-ridden. It is a good idea for the therapist to challenge the threat and quickly remove the deadlock it has created.*161\331\2*

SYMPTOMATIC ASTHMA MEDICATION: BETA-AGONISTSAlso called adrenaline-like — or sympathomimetic — drugs, beta-agonists imitate the action of adrenaline, a natural hormone that we all have in our bodies. Some of the commonly prescribed brands of beta-agonists are Berotec, Ventolin, Bricanyl, Alupent and Respolin. These drugs are available as syrup, tablets, metered-dose aerosol inhalers, solutions for nebulizers and powdered inhalants. In extreme cases, they are injected by a doctor.Adrenaline-like drugs are commonly used at the onset of an acute asthma attack. It is advisable to commence treatment as soon as the first symptoms of an impending attack, such as tightness in the chest, become apparent. These drugs may be prescribed regularly if a person has persistent symptoms, and they are often beneficial to people who are prone to exercise-induced asthma. Beta-agonist medicines are available in the following forms:metered-dose aerosolsCommonly called puffers, metered dose aerosols are the most common way of taking beta-agonists. Puffers give maximum benefit for the smallest dose of medicine, so doctors tend to favour them over tablets and liquids. (Children under two years are usually treated with syrups and/or nebulizers.) When administered properly, puffers are very effective and safe, with a minimum of minor side effects. They enable the medicine to reach deep into the lungs and act immediately to reduce symptoms. But it is vital that the correct technique of application be used, or else the spray will not penetrate into the lungs and much of the dose will be wasted.Children under the age of six, elderly patients and some others are frequently unable to use puffers effectively. People who find the correct puffer techniques hard to master are advised to use a ‘spacer’ attached to their puffer. (The correct method for using a spacer is detailed in Chapter Four.)inhaled powdersAdrenaline-like drugs are also available as powder containing capsules or 200-dose dispenser Turbuhaler, which are particularly useful for people who find it difficult to use the metered aerosol devices. One inhaled dose of powder is approximately equal to one or two inhalations from an equivalent puffer. Two of the most widely used powders are Ventolin Rotacaps and Bricanyl Turbuhaler.Powder capsules are simple to use. The capsules are inserted into a specially designed plastic holder. A device in the holder splits open the capsule and releases the powder. The powder is inhaled with deep breaths and the capsule is usually emptied in one to four inhalations. To make sure you get the full dose, hold your breath for a few seconds after each inhalation.It is important to read the instructions carefully on how to inhale the powder. The powder containing capsules should be stored in a cool, dry place as they will not release the full amount of powder if they become moist.PUMPS AND NEBULIZERSSome bronchodilators are available in a solution form to be used in a nebulizer. Doctors often advise the use of a pump and nebulizer for people who are unable to use puffers or powder inhalers correctly. It is quite simple to use a nebulizer and pump. The bronchodilator solution is placed into the chamber of the nebulizer and the pump drives air through the nebulizer to create a mist from the solution. As the mist from a nebulizer is the form of medication best distributed t hroughout the bronchial system, this method of treatment is particularly effective for acute attacks of asthma.SIDE EFFECTS OF SYMPTOMATIC DRUGSIt is important to remember that the side effects of medications are nearly always less serious and distressing than the symptoms or long-term effects of the disease they are controlling.Some of the common side effects of the adrenaline-like drugs include palpitations and increased heart rate, tremors or shaking, sleeplessness and, occasionally, hyperactivity (mainly in children). Usually these side effects are very slight; some people experience no noticeable side effects at all after symptomatic medication.*16\148\2*

Anal canal

Swabs of the anal canal or ‘rectal culture’ can be obtained without using a proctoscope although use of a proctoscope is recommended as it increases the chances of obtaining a satisfactory specimen. Faeces should be avoided and obvious exudate swabbed.

Insert a sterile cotton-tipped applicator moistened with sterile saline approximately one inch into the anal canal.

Move the swab from side to side in the anal canal to sample crypts. Allow 10 to 30 seconds for absorption of organisms on to the swab.

Oropharynx

Swab the posterior pharynx and tonsillar crypts with a cotton-tipped applicator.

Transport media

Most microorganisms causing STD are fastidious and fragile and require careful handling if culture is to be successful. Arrangements should be made with the laboratory for the supply of transport media and the rapid transfer of specimens. Stuart’s transport medium can be used for bacteria and yeasts.
*25/56/1*
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Endocervical canal

A vaginal speculum should be used to visualise the cervix. The speculum should be moistened with warm water, do not use any other lubricant.

Remove excess cervical mucus, preferably with a cotton ball held in ring forceps.

Insert a sterile cotton-tipped applicator into the cervical canal; rotate swab; allow 10 to 30 seconds for absorption of organisms on to the swab.

Vagina
Use a sterile cotton-tipped applicator to obtain swabs of the lateral wall of the vagina or the posterior fornix.

Urethra
Wipe away frank pus and exudate. Use a sterile bacteriological loop or a disposable plastic loop or a sterile urethral swab moistened with sterile saline.
The loop or swab is inserted several centimetres to reach the columnar epithelium of the anterior urethra which is scraped.
*24/56/1*
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CANCER: INTRODUCTIONThe statistics on cancer do not make for pleasant reading, but if we are to take a cool and objective look at this disease, we had better confront them. Cancer intrudes on many individual lives and has a major impact on the national life of many countries. One in three people will develop a cancer and about one in four will die of cancer. These statistics must be viewed against the fact that we can successfully treat and have almost eliminated a number of other diseases. Life expectancy has increased in the richer parts of the world. This will lead to more cancer cases because the disease is commoner in older people. The human and economic cost of the incidence of cancer is enormous and defies accurate assessment. A vast range of cancer treatment services, from surgery to terminal care, are provided by the health-care systems of developed countries. Sometimes these treatments produce cures and sometimes they fail. They are always expensive. A recent conservative estimate by the government of the cost of hospital care for cancer in the United Kingdom was ?2 billion each year. The cost in terms of the suffering for patients and their families cannot be gauged. Over ?100 million is spent annually on cancer research in the United Kingdom, mainly from charitable donations, and large sums are spent by government and international agencies throughout the world on registering, studying and analysing the information about cancer patients.Above and beyond these daunting statistics lies the very special fear that cancer generates in people’s minds. Even though expert modern cancer care can sometimes cure and almost always control the major symptoms of the disease, many people stiff fear cancer more than the other common serious and life-threatening diseases of our times. They see it as an especially ‘sneaky’ disease, often lurking unrecognized and symptomless until discovered by accident. They may view cancer with despair as ‘the enemy within’ – an uninvited attack by die body on itself. They use euphemisms like ‘the big C’ as if uttering the very word ‘cancer’ will render them vulnerable. Misplaced fears of acquiring cancer by contact with cancer patients still persist and it is not unknown for cancer patients to feel lonely, guilty or inadequate (emotions which are not usually associated with other common diseases).Health-care professionals themselves are not immune from emotional responses to this disease. For doctors, cancer generates a number of challenges. Some of the surgeon’s largest and most complex operations will be carried out on cancer patients. For the physician, cancer presents some of the most difficult diagnoses and testing questions about appropriate treatment. Experts in diagnostic procedures in the laboratory or in the reading of diagnostic X-rays and scans are faced with the challenge of detecting a cancer when it is early and treatable. It is hardly surprising that cancer care can generate the most tremendous satisfaction for the doctor who is successful in curing or controlling the disease. Nor should it surprise anyone that the most dismal sensations of frustration and failure are sometimes felt by doctors when they confront the results of cancer care. The care of cancer patients may present particular challenges to nurses too, placing heavy demands upon their dedication. Those who manage health care are under constant pressure to find more resources for cancer treatment and care against competing demands on their limited budgets. The very success of modern medical science in understanding, curing or eliminating other diseases which were once viewed with horror raises the emotional stakes for those involved in cancer research and therapy.Cancer is ‘news’. Unfortunately, the news is often presented with morbid glamour. It can give an impression of cancer as some kind of scourge which has been visited upon us or which we have brought on ourselves. New cancer hazards are presented to us at every turn – in our choice of food, in the nature of our occupations, in the location of our homes, in our technological advances and in the simple act of drinking water from a tap – and we may be left feeling guilty, bewildered or helpless. Early diagnosis by screening is a very topical subject, but the success of screening remains restricted to a few types of cancer at present. Cancer treatment by surgery, radiotherapy, chemotherapy and, more recently, biological therapy is having an impact and great improvements in outlook have been achieved with some cancers over the last two decades. Great strides are being made in the biological sciences and we need to consider whether these are likely to generate major advances in cancer treatment in the near future.*2\194\4*

In the car

On a long car journey with your children, make sure that you stop frequently to let them stretch and run a little, or to have a drink or a snack. Children hate being cooped up for long periods of time.

Choose your roadside stops carefully, and keep an eye on your children, particularly if there is a lot of traffic around. Take games and toys along with you that are appropriate for children to play in the car. If your child suffers from motion sickness, it is best for him to avoid reading or writing in the car.

Going overseas

If you are travelling overseas with your child, speak to your doctor well before you leave about special immunisations. This varies according to the countries you are travelling to, and is updated constantly. Vaccinations are available against typhoid, cholera, hepatitis B, meningitis, yellow fever, tetanus and polio. Tablets are available against malaria, and gamma globulin injections as prevention against hepatitis A. Your doctor will be able to advise you which, if any, of these your children require oeiore travel, some capital cities also have travel centres where this information is available.

You may want to make up a special travel kit, to carry with you in case of illness. Your doctor can give you advice on what to put in it. If your child takes any medications, be sure to carry a sufficient quantity of them with you. Your doctor can also provide you with a letter giving a summary of your child’s health record.

*119\90\8*

Would you risk it? I’m not going to die having sex. I’d sooner live without sex than die trying to have it.

HUSBAND

Fewer than one person in four returns to “pre-heart attack” sexuality. Almost none of these persons have any physical or medical reason not to return to sexual activity, but fear, lack of knowledge, diminished self-concept, general depression, or physician neglect of this important area of their rehabilitation got in the way. There were seldom significant organic reasons to avoid sexual interaction, but poor education from their doctor and reluctance to communicate about sex with their doctor or spouse robbed them of the opportunity to return to intimacy.

My interviews suggest that depression, whether from lack of information, lack of self-esteem, or fear, is at the core of the problem. “Will I ever be able to work again, work like I used to?” asked one man. “I just can’t imagine being like I was before.” I have never talked with a patient who reported such concerns who did not also have sexual concerns, for sex cannot be separated from our concept of self, our work, and our sexual “workability.”

The lack of specific discussion of heart disease and its relationship to sex implies a negative message to the patient. “I thought because he didn’t say a word about it that he thought I’d be crazy to even think it, so I stopped thinking it. At least, I tried. Every time I had sex it was like I decided I would die for it if I had to.” This patient expresses the concern of most of the heart patients with whom I have counseled: forget the whole thing or risk your life.

When some information was given about sex and heart disease, it was usually wrong. Wait about six months for the heart muscle to heal, was a rule of thumb, followed by the now infamous “two flights of stairs” advice. If patients could walk up two flights of stairs without heart symptoms, they could have sex. Medicine apparently assumed that climbing stairs is the closest analogy to having sex. It makes one wonder how doctors have sex. The effect of such advice was to raise anxiety, as the patient waited for the weeks to pass to attempt the stair-climbing. Few health-care workers thought to study the effects of the anxiety caused by such delay and anticipation> the effects that such an emotional state could have on me healing heart.

Research data indicate that maximal heart rate during a typical workday is actually higher than that achieved during orgasmic contractions. Blood-pressure changes with sexual activity also are not at a risk level in the absence of other illness factors. Of course, each case is different, but unless the doctor can tell you why you should not have sex, then you would probably benefit from sex, not just survive it. I have never found that waiting for healing was helpful in any illness. Getting better is an active, not passive state, and diseases of the heart may be healed more easily by loving than waiting.

*270\97\8*