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The term pleural effusion is used to describe a non-purulent serous effusion which sometimes forms in pneumonia acne medication prescription discount 40 mg aknesil with mastercard, tuberculosis acne after shaving cheap 20 mg aknesil with amex, malignante disease etc Empyema is used to describe a purulent pleural effusion when pus is found in the pleural space acne toner buy aknesil in united states online. Peritonitis means inflammation of the peritoneum, which is the serous membrane that lines the peritoneal cavity. Ascites refers to the accumulation of fluid in the pentional cary causing abdominal swelling. Commensales No microbial flora Collection is carried out by a medical officer - 2-3ml without anticogulent, to see whether clotting occurs. Peptidoglycan(Mucopeptide): Polysaccharide polymer which provide the rigid exoskeleton of the cell wall. It is important in the pathogenesis of infection like eliciting production of cytokines and opsonic antibodies; chemoattractant for polymorphs;and activate complement 2. Catalase- Produced by staphylococci Converts H202 into H20 and 02 175 Medical Bacteriology Catalase test differentiates staphylococci(catalase-positive) from streptococci(catalase-negative). Coagulase may deposit fibrin on the surface of organism and alter ingestion by phagocytic cells. Clumping factor: A surface compound that is responsible for adherence of the organism to fibrinogen and fibrin Produced by Staphylococcus aureus Determines Invasive potential of the organism. Multiple (A-E, G-I, K-M) soluble heat-stable, gut enzyme resistant toxins which act on neural receptors 176 Medical Bacteriology in the gut to stimulate vomiting center in the central nervous system. Epidermolytic toxin A: Chromosomal gene product and heat stable Epidermolytic toxin B: Plamid mediated and heat labile. Endocarditis and meningitis: Infection of heart tissue and leptomeninges respectively. Characterized by abrupt onset of high fever, vomiting, diarrhea, myalgia, scarlatiform rash,and hypotension with cardiac and renal failure in the most severe disease. Vancomycin Prevention and control Source of infection is shedding human lesions, the human respiratory tract and skin Contact spread of infection occur in hospitals Treatment of nasal carriers with topical antiseptics or rifampin and anti-staphylococcal drug 2. Most streptococci grow in solid media as discoid colonies Capsular streptococcal strains give rise to mucoid colonies They are aerobic bacteria in which growth is enhanced with 10% carbondioxide. They are widely distributed in nature and are found in upper respiratory tract, gastrointestinal tract and genitourinary tract as normal microbial flora. The currently used classification is based on colony growth characteristics, pattern on blood agar, antigenic composition of group specific cell wall substance and biochemical reaction 181 Medical Bacteriology. Serologic specificity of the cell wall group specific substance and other cellwall capsular antigens 3. None appearance colorless, clear, Sharply defined zone Greenish discoloration (reduced hemoglobin) No change Gamma Enterococci Alpha Viridans Designation Beta Example S. Group-specific cell wall antigen Streptococcal cell wall obtained carbohydrate is the basis for serologic grouping of streptococci (Lancefield groups A-H, K-U) 183 Medical Bacteriology 2. M protein They are found in hair-like projections of the streptococcal surfaceand determine virulence Major virulent factor for group A streptococci. T substance: Acid and heat labile unlike M protein, and has no relation to virulence of streptococci. R protein Streptococcus pyogenes (Group A -hemolytic streptococci) the most pathogenic member of the genus It is present as a commensal in the nasopharynx in a variable proportion of healthy individuals. It is an active proteolytic enzyme which lyses fibrin by catalytic conversion of plasminogen to plasmin. Has been given intravenously for the the treatment of pulmonary edema and of arterial and venous thrombosis 2. Streptodornase: Streptococcal deoxyribonuclease 184 Medical Bacteriology Mixtures of streptokinase and streptodornase are used in "enzymatic debridement" 3. Hyaluronidase: Spreading factor It degrades the ground substance of connective tissue (hyaluronic acid) and aids in spreading infectious microorganoism 5. Hemolysins: Two types Streptolysin O and Streptolysin S Antistreptolysin O antibody titer > 1:200 todd: Supportive evidence for Acute reheumatic fever 2. Erythrogenic toxin: Pyrogenic exotoxins It is responsible for the erythematous rash in scarlet fever.

Note: A nichrome wire loop must not be used because this may give a false positive reaction skin care 101 tips 40mg aknesil sale. Results Active bubbling -No release of bubbles -Positive test Catalase produced Negative test No catalase produced Note: if the organism has been cultured on an agar slope skin care tips in urdu buy aknesil 30 mg, pour about 1ml of the hydrogen peroxide solution over a good growth of the organism acne facials generic aknesil 30mg visa, and look for the release of bubbles. Caution: performing the test on a slide is not recommended because of the risk of contamination from active bubbling. If the rapid slide technique is used, the hydrogen peroxide solution should be added to the organism suspension after placing the slide in a petridish. The dish should then be covered immediately, and the preparation observed for bubbling through the lid. The test is based on the ability of an organism to use citrate as its only source of carbon and ammonia as its only source of nitrogen. Growth in the medium is shown by turbidity and a change in colour of the indicator from light green to blue, due to the alkaline reaction, following citrate utilization. Note: Care must be taken not to contaminate the medium with carbon particles, such as from a frequently flamed wire. It is usually recommended that a tube test should be performed on all negative slide tests. A tube test must always be 65 Medical Bacteriology performed if the result of the slide test is not clear, or when the slide test is negative and the Staphylococcus has been isolated from a serious infection. Note: Occasionally citrate-utilizing organisms such as Klebsilla can cause the clotting of citrated plasma in the tube test. It is also possible for human plasma to contain inhibitory substances which can interfere with coagulase testing. Method for slide test (to detect bound coagulase) Place a drop of physiological saline on each end of a slide, or on two separate slides. Emulsiy a colony of the test organism in each of the drops to make two thick suspensions. Note: Colonies from a mannitol salt agar culture are not suitable for coagulase testing. This is used to differentiate any granular appearance of the organism form true coagulase clumping. Negative coagulase control: Escherichia coli or Staphylococcus epldermids Method for tube test (detect free coagulase) Dilute the plasma 1 in 10 in physiological saline (mix 0. Take three small test tubes and label: T = Test organism (18-24h broth culture) Positive control (18-24h staph. Aureus broth Pos = culture) Neg = Negative control (sterile broth) A suitable broth is brain heart infusion Pipette 0. It is particularly useful if plasma is not available to peform a coagulase test or when the results of a coagulase test are difficult to interpret. Observe blacking of the medium Lead acetate paper test to detect H2S When a sensitive technique for detecting H2S production is required, the lead acetate paper test is recommended. Inoculate a tube or bottle of sterile peptone water or nutrient broth with the test organism. Insert a lead acetate paper strip in the neck of the bottle or tube above the medium, and stopper well. Motility Test this is shown by a spreading turbidity from the stab line or a turbidity throughout the medium (compare with an uninoculated tube). Principle A heavy inoculum of the test organism is incubated in a broth containing nitrate. After 4 hours, the broth is tested fro the reduction of nitrate to nitrite by adding sulphanilic acid reagent. If nitrite is present, the acid reagent is diazotizex and forms a pink-red compound with alpha-naphthylamine.

Most salivary gland tumours are brighter on T2 than T1 images but this difference is minimal in prominently cellular tumours acne natural treatment aknesil 5 mg visa. Lesions with higher water content skin care 50s proven aknesil 5 mg, such as human immunodeficiency virus related parotid cysts acne no more book cheap 40mg aknesil mastercard, Warthin tumours, cystadenomas and cystadenocarcinomas, and cystic mucoepidermoid carcinomas, have a bright T2 signal. Correlation of the clinical impression, cytologic diagnosis and radiographic imaging studies can then guide along different treatment pathways. Unnecessary surgery can be avoided in approximately one third of cases 668 especially in: (1) patients whose salivary gland lesion is part of a more generalized disease process, (2) inflammatory lesions where a clinical suspicion of malignancy is low, (3) Hormones Endogenous hormones have been reported in normal and neoplastic salivary glands, but some of the results have been conflicting. Estrogen receptors were found in nearly 80% of normal glands in males and females and four out of eight salivary tumours in women had estrogen receptor levels similar to those of "hormonally dependent" breast carcinomas 606. However, more recent studies have not confirmed this finding and questioned the methodology 616. Estrogen receptors have been reported in a minority of cases of acinic cell carcinoma, mucoepidermoid carcinoma 1214 and salivary duct carcinoma 134, but were not detected in adenoid cystic carcinoma 616,1214,1732,2335. Estrogen or estrogen receptors have been reported in pleomorphic adenomas in some studies 1214,1764,1946, but in others, estrogen receptors were absent 1851. They have been detected in a minority of pleomorphic adenomas 892,1214 but high levels of expression were reported in recurrent pleomorphic adenomas and this was thought to be a prognostic factor 892. However, a recent study failed to show progesterone receptors in all the benign salivary tumours examined 1851. Progesterone receptors were seen in 2/10 acinic cell carcinomas and 3/10 mucoepidermoid carcinomas 1214 but were not detected in salivary duct carcinoma 134. They have been reported in adenoid cystic carcinomas in some studies 1214,1965 but in others they were absent, or present in only a few tumours 616,1214. Androgen receptors are present in over 90% of salivary duct carcinomas 711, 712,1265. A recent study showed immunoreactivity for androgen receptors in all their cases of salivary duct carcinoma, carcinoma ex pleomorphic adenoma and basal cell adenocarcinoma 1851. There was also staining for the receptors patients in poor health who are not good operative candidates, (4) patients with metastasis to a salivary gland or adjacent lymph node, (5) some examples of lymphoproliferative disease 763 or (6) in a primary soft tissue or skin appendage lesion arising in the area of a major salivary gland. The rate of correctly establishing a diagnosis as benign or malignant ranges from 81-98% in most recent reports. However, a specific diagnosis can only be made in approximately 60-75% of cases 668. False negative diagnoses due to inadequate sampling appear to be the most frequent error. Frozen section examination When considering all head and neck sites, the accuracy of frozen section diagnoses of the salivary gland is the most controversial. A review of 2460 frozen sections from 24 series revealed an overall accuracy rate for a benign or malignant diagnosis, excluding deferred diagnoses, of 96% 379,900,1697,2170, 2900. If one subdivides the salivary gland lesions into benign and malignant groups, the accuracy rate (98. This was frequently called mucoepidermoid carcinoma or adenoid cystic carcinoma 904. Mucoepidermoid carcinoma is the malignancy most frequently associated with a false negative benign frozen section diagnosis, while acinic cell carcinoma, adenoid cystic carcinoma, carcinoma ex pleomorphic adenoma and an occasional lymphoma have also caused difficulty. Recent changes in the staging system include a revision in the definition of T3 and the division of T4 into tumours that are resectable (T4a) and unresectable (T4b) 947,2418. Spiro and coworkers have successfully applied the criteria used for squamous cell carcinoma of the oral cavity, pharynx, larynx, and sinus to mucoepidermoid carcinoma 2305,2863. Genetics the goal of the molecular biological studies of salivary gland tumours is to define objective markers that may supplant the subjective phenotypic evaluation in the diagnosis, biological assessment and therapeutic stratification of patients with these tumours. Upon binding to its ligand, a signalling cascade is initiated to stimulate growth and differentiation of haematopoietic cells 835. Studies of C-kit in salivary gland tumours have largely focused on adenoid cystic carcinoma and findings vary considerably. C-kit expression appears to be restricted to adenoid cystic carcinoma 1215,2006 and myoepithelial carcinomas 1215 but absent in polymorphous low-grade adenocarcinoma 2006 and other types of salivary gland tumours 1215. None of the highly expressed tumours manifested genetic mutations at exons 11 & 17.

Soucek Definition Meningioma is a benign tumour usually forming intracerebrally acne jeans sale order cheapest aknesil, but sometimes seen involving bony structures around the brain including the middle ear acne disease cheap aknesil amex. Clinical features Patients present clinically with hearing change skin care secrets buy generic aknesil pills, otitis media, pain, and/or dizziness / vertigo. Macroscopy Gross appearances are those of a granular mass with a gritty consistency. Histopathology Microscopically the neoplasm in the middle ear shows the same histological features of any of the well-described subtypes of intracranial meningioma. The most common variety seen in the middle ear is the meningothelial type, in which the tumour cells form masses of epithelioid, regular cells often disposed into whorls. Expression of S-100 protein identifies spindle cell tumours as of neurogenic origin, thus excluding spindle cell meningioma. Epidemiology Meningioma of the middle ear affects women more than men, shows an age range of between 10 and 80 years with a mean age of 49. Localization Meningiomas occur at a number of sites in the temporal bone, including the internal auditory meatus, the jugular foramen, the geniculate ganglion region and the roof of the Eustachian tube 1830. The most common temporal bone site for primary meningioma is in the middle ear cleft. In a recent study (36 patients), most tumours involved the middle ear, but a few involved adjacent structures such as the external canal or temporal bone. Vimentin and epithelial membrane antigen are expressed in the majority of meningiomas and cytoker- A B. A variety of different growth patterns can be seen, but the meningothelial nature of the neoplasm is always maintained. Soucek Definition A benign nerve sheath tumour arising in the internal auditory canal. Unilateral vestibular schwannoma accounts for 5-10% of all intracranial tumours and for most of the cerebellopontine angle tumours. Etiology Solitary vestibular schwannoma occurs sporadically, and does not seem to be associated with a gene mutation. Localization Vestibular schwannoma was formerly considered to arise most commonly at the glial-neurilemmal junction of the eighth cranial nerve. In one study of five temporal bones with small vestibular schwannomas, the tumour arose more peripherally 2834. Growth takes place from the site of origin of the tumour, both centrally onto the cerebellopontine angle and peripherally along the canal. Vestibular schwannoma is usually unilateral, but may be bilateral, in which case the condition is neurofibromatosis 2. Clinical features Progressive unilateral hearing loss (90% of patients) and tinnitus (70% of patients) are the clinical manifestations, due to cochlear involvement. The neoplasm may grow slowly for years without causing symptoms and may be first diagnosed only at post-mortem. Surgical removal may be carried out by drilling from the external canal through the temporal bone or by craniotomy and middle fossa approach to the internal auditory meatus, or by stereotactically guided gamma knife surgery. Small tumours either do not widen the canal at all or produce only a small indentation in the bone. The larger tumours often have a mushroom shape with two components, the stalk - a narrower, elongated part in the canal - and an expanded part in the region of the cerebellopontine angle. The bone of the internal auditory canal is widened funnel-wise as the neoplasm grows. The vestibular division of the eighth nerve may be identified on the surface of the tumour and attached to it while the cochlear division is often stretched by the neoplasm, but not attached to it. Histopathology Vestibular schwannoma is a neoplasm of the nerve sheath / Schwann cells. This tumour typically shows closely packed spindle cells, often with palisaded nuclei and Verocay bodies (Antoni A areas) and less cellular areas with a loose reticular pattern and microcystic degeneration sometimes containing numerous xanthoma cells (Antoni B). The spindle cells frequently are moderately pleomorphic, but mitotic figures are rare.

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