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This property is especially beneficial in patients with either hypovolemic or cardiogenic shock as well as in patients with asthma. The drug is lipophilic and enters the brain circulation very quickly, but like the barbiturates, it redistributes to other organs and tissues. However, it is not widely used, because it increases cerebral blood flow and induces postoperative hallucinations (a finightmaresa ), particularly in adults. Propofol is widely used and has replaced thiopental as the first choice for anesthesia induction and sedation, because it produces a euphoric feeling in the patient and does not cause postanesthetic nausea and vomiting. This makes propofol very useful for such surgeries as resection of spinal tumors, in which somatosensory evoked potentials are monitored to assess spinal cord functions. Some therapeutic advantages and disadvantages of the anesthetic agents are summarized in ure 11. The small, unmyelinated nerve fibers that conduct impulses for pain, temperature, and autonomic activity are most sensitive to actions of local anesthetics. At physiologic pH, these compounds are charged; it is this ionized form that interacts with the protein receptor of + the Na channel to inhibit its function and, thereby, achieve local anesthesia. However, its toxicity and abuse have limited its use to topical application in anesthesia of the upper respiratory tract. By adding the vasoconstrictor epinephrine to the local anesthetic, the rate of anesthetic absorption is decreased. Adverse effects result from systemic absorption of toxic amounts of the locally applied anesthetic. Seizures and cardiovascular collapse are the most significant of these systemic effects. Mepivacaine should not be used in obstetric anesthesia due to its increased toxicity to the neonate. Allergic reactions may be encountered with procaine, which is metabolized to paminobenzoic acid. Overview Depression is a serious disorder that afflicts approximately 14 million adults in the United States each year. The lifetime prevalence rate of depression in the United States has been estimated to include 16 percent of adults (21 percent of women, 13 percent of men), or more than 32 million people. The symptoms of depression are intense feelings of sadness, hopelessness, and despair, as well as the inability to experience pleasure in usual activities, changes in sleep patterns and appetite, loss of energy, and suicidal thoughts. Mechanism of Antidepressant Drugs Most clinically useful antidepressant drugs potentiate, either directly or indirectly, the actions of norepinephrine and/or serotonin in the brain. Conversely, the theory envisions that mania is caused by an overproduction of these neurotransmitters. It fails to explain why the pharmacologic effects of any of the antidepressant and antimania drugs on neurotransmission occur immediately, whereas the time course for a therapeutic response occurs over several weeks. Furthermore, the potency of the antidepressant drugs in blocking neurotransmitter uptake often does not correlate with clinically observed antidepressant effects. This suggests that decreased uptake of neurotransmitter is only an initial effect of the drugs, which may not be directly responsible for the antidepressant effects. It has been proposed that presynaptic inhibitory receptor densities in the brain decrease over a 2 to 4week period with antidepressant drug use. This downregulation of inhibitory receptors permits greater synthesis and release of neurotransmitters into the synaptic cleft and enhanced signaling in the postsynaptic neurons, presumably leading to a therapeutic response ure 12. Both of these antidepressant drug classes exhibit little ability to block the dopamine transporter. Both citalopram and fluoxetine are racemic mixtures, of which the respective Senantiomers are the more potent inhibitors of the serotonin reuptake pump. Approximately 40 percent of depressed patients treated with adequate doses for 4 to 8 weeks do not respond to the antidepressant agent.

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Leukaemoid reactions can be distinguished from chronic numerous orange cytoplasmic granules. Eosinophils have myeloid leukaemia by a normal leucocyte alkaline substantial proinflammatory and cytotoxic activity and phosphatase activity and absence of the Philadelphia play an important part in the pathogenesis of various 4 chromosome. These distinguished from eosinophils by large metachromatic children also have an exaggerated leukaemoid response to (purpleblack) granules rich in histamine, serotonin, and 7 stress. Mast cells are related to, but distinct from, Familial cold urticaria and leucocytosis is an unusual basophils. Basophils are bilobed, whereas mast cells are syndrome of leucocytosis, fever, urticaria, rash, and longlived cells that reside in tissues rather than peripheral muscle and skin tenderness on exposure to cold. Malignant disorders are discussed in the Chronic idiopathic neutrophilia Chronic inflammation second paper on white cells in this series. In these disorders Viral infections: infectious mononucleosis; cytomegalovirus; hepatitis; the degree of neutrophilia is moderate, and it may be mumps; varicella; rubeola; rubella; herpes simplex virus; herpes associated with monocytosis. The clinical presentation of Stress neutrophilia can occur within minutes of exercise EpsteinBarr virus infection in young adults may be or emotional or physical stress, or after surgery, seizures, confused with acute lymphoblastic leukaemia; the two or epinephrine injection. The increase in neutrophil disorders are distinguished on the basis of bonemarrow count, small in most cases, is thought to be related to examination, lymphocyte immunophenotyping, and movement of neutrophils from the marginated pool into 13 serological findings. This druginduced neutrophilia can be should be tested for antibodies specific for EpsteinBarr distinguished from neutrophilia due to an acute infection virus. Lymphocytosis is rarely seen in bacterial infections, agonists, such as theophylline, produce an acute with the exception of Bordetella pertussis infection, in which neutrophilia by releasing neutrophils from the marginated the lymphocyte count typically rises to more than pool. A similar picture can occur in dose; therefore, blood counts must be carefully monitored serum sickness after administration of antithymocyte during growthfactor administration. Several leukaemic of chemotherapy in a timely way; after autologous and disorders are also characterised by monocytosis and are a allogeneic bonemarrow transplantation, to limit the time result of a primary stemcell defect. Chronic to engraftment and recovery from neutropenia; in bone myelomonocytic leukaemia is a disorder of older people, marrow failure including myelodysplastic syndromes; in with features of both a myelodysplastic disorder and a patients with primary or secondary neutropenia resulting 14 chronic myeloproliferative disease. Chronic myelomonocytic leukaemia Lymphocytosis occurs commonly after many viral Acute myeloid leukaemia (M5 subtype) infections (panel 2). Children present with absolute neutrophil counts vary among ethnic groups; the malaise, bleeding, and fever.

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In both cases, patients present with clear rhinorrhea, no other allergic symptoms or history, and allergy tests are negative. Vasomotor rhinitis is ofen triggered by food, temperature change, or sudden bright light. Intranasal steroid sprays are the best treatment for nonallergic and vaso motor rhinitis. Lowgrade fever, facial discomfort, and purulent nasal drainage are also common symptoms. Treatment is symp tomatic, with antipyretics, hydration, analgesics, and decongestants rec ommended, as needed. Antibiotic treatment of the common cold is discouraged, but unfortunate ly, patients ofen request (or demand) antibiotics early in the course of viral illness. When spontaneous recovery occurs, they assume that the antibiotics were responsible. This is a major cause of excessive antibiotic use and has contributed to the surge in antibiotic resistance. Patients may exhibit several of the major symptoms (facial pressure/ pain, facial congestion/fullness, purulent nasal discharge, nasal obstruc tion, anosmia) and one or more of the minor symptoms (headache, fever, fatigue, cough, toothache, halitosis, ear fullness/pressure). The organisms responsible are similar to the organisms that cause acute otitis media and include Streptococcus pneumoniae, Haemophilus infuenzae, and Moraxella catarrhalis. By defnition, acute rhinosinusitis persists less than one month, and subacute rhinosinusitis lasts more than one month but less than three months. Chronic sinusitis is defned by symptoms that persist more than three months, and usually has a diferent underlying microbiol ogy with increased numbers of anaer obic organisms. The treatment of choice for acute rhi nosinusitis (as well as acute otitis media) has been a 10day course of either amoxicillin or trimethoprim/ sulfamethoxazole. Note purulent drainage cians to consider using amoxicillin/ extending from the middle meatus over the inferior turbinate. Antihistamines and topical ste roids are not usually indicated, unless allergy is also a major concern. Patients with sinusitis should be referred to an otolaryngologist if they have three to four infections per year, an infection that does not respond to two threeweek courses of antibiotics, nasal polyps on exam, or any complications of sinusitis. Acute frontal, eth moid, and sphenoid sinusitis that are not appropriately treated or do not respond to therapy can have serious consequences. Tese veins can quite eas ily transmit organisms or become pathways for propagation of an infected clot. Terefore, the diagnosis of acute frontal sinusitis with an airfuid level requires aggressive antibiotic therapy. Pain is severe, and patients usually require hospital admission for treatment and close observation. Topical vasoconstriction to shrink the swollen mucosa around the nasofrontal duct and restore natural drainage into the nose should begin in the clinic and continue throughout the hospital stay. If frontal sinusitis does not greatly improve within 24 hours, the frontal sinus should be surgically drained to prevent serious intracranial infections. Ethmoid Sinusitis Severe ethmoid sinusitis can result in orbital cellulitis or abscess. While one might assume the double vision is due to the involvement of the nerves of the cavernous sinus, it can also be caused by an abscess located in the orbit. If an abscess is present, it will require surgical drainage as soon as possible, so the patient should be referred to an otolaryngologist. The infection has spread retrograde and and even cavernous sinus he has developed a frontal abscess. Cavernous sinus thrombosis is a complication with even more grave implications than meningitis or brain abscess, and it carries a mortality of approximately 50 percent.

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Serologic tests are available through commercial and state laboratories and the Centers for Disease Control and Prevention. Coadministration of corticosteroids with mebendazole or albendazole often is recommended when systemic symptoms are severe. Corticosteroids can be lifesaving when the central nervous system or heart is involved. However, Trichinella organisms in wild animals, such as bears and raccoons, are resistant to freezing. People known to have ingested contaminated meat recently should be treated with albendazole (or mebendazole). Clinical manifestations in symptomatic pubertal or postpubertal female patients consist of a diffuse vaginal discharge, odor, and vulvovaginal pruritus and irritation. Vaginal discharge usually is yellowgreen in color and may have a disagreeable odor. Clinical manifesta tions in symptomatic men include urethritis and, more rarely, epididymitis or prostatitis. The presence of T vaginalis in a child or preadolescent should raise suspicion of sexual abuse. T vaginalis acquired during birth by female newborn infants can cause vaginal discharge during the frst weeks of life but usually resolves as maternal hormones are metabolized. The jerky motility of the protozoan and the movement of the fagella are distinctive. Microscopy has 60% to 70% sensitivity for diagnosis of T vaginalis in vaginal secretions of a symp tomatic female but is less sensitive if she is asymptomatic. The presence of symptoms and the identifcation of the organism are related directly to the number of organisms. Two pointofcare tests are available when no microscope is available: an immunochromatographic capillary fow dipstick and a nucleic acid probe test. Treatment with tinidazole (2 g, orally, in a single dose) appears to be similar or even superior to metronidazole. Both drugs are approved for this indication in adults and adolescents, and metronidazole also is approved in children (see Drugs for Parasitic Infections, p 848). Topical vaginal preparations should not be used, because they do not achieve therapeutic concentrations in the urethra or perivaginal glands. Sexual partners should be treated concurrently, even if asymptom atic, because reinfection is a major factor in treatment failures. T vaginalis strains with decreased susceptibility to metronidazole have been reported. If treatment failure occurs with metronidazole and reinfection is excluded, either metronidazole (either 250 mg, 3 times daily for 7 days, or 375 mg, 2 times daily for 7 days) or tinidazole (2 g, orally, in a single dose) can be used. If treatment failure occurs with either of these regimens, then either metronidazole (2 g, daily for 5 days) or tinidazole (2 g, daily for 5 days) can be used. Consultation is available from the Centers for Disease Control and Prevention at If the pregnant woman is symptomatic, treatment should be considered regardless of week of gestation.