By F. Kerth. Roger Williams University.
This modality has Thalidomide potently inhibits production of tumor been shown to be effective in treating basal cell and necrosis factor (TNF) and interleukin (IL) 12 discount zyloprim 300 mg with mastercard medications safe during pregnancy, and its squamous cell skin cancers order 300 mg zyloprim medications joint pain, although a limiting toxicity effect on these and other cytokines may account for has been that patients remain extremely photosensitive some of its clinical effects. Thalidomide is approved for use in the United Aminolevulinic acid (ALA HCl, Levulan Kerastick) is States for the treatment of cutaneous manifestations indicated for the treatment of nonhyperkeratotic actinic of erythema nodosum leprosum, a potentially life- keratosis of the face and scalp. It has two components, threatening systemic vasculitis that occurs in some pa- an alcohol solution vehicle and ALA HCl as a dry solid. The ROS pro- Thalidomide is a highly teratogenic drug, characteris- duce cytotoxic effects that may explain therapeutic efﬁ- tically causing phocomelia (aplasia of the midportions of cacy. Thalidomide should be prescribed to women of childbearing potential only when no acceptable alterna- tive exists. Because it is not known whether thalidomide DAPSONE is present in the ejaculate of males receiving the drug, Although dapsone (Avlosulfon) is most often used as an male patients must use a latex condom when engaging in antimicrobial agent, it has important antiinﬂammatory sexual activity with women of childbearing potential. Mupirocin binds to bacterial isoleucyl- transfer RNA synthetase and prevents the incorpora- Like dapsone, the antimalarial drugs chloroquine, hy- tion of isoleucine into protein sequences. Mupirocin is droxychloroquine, and quinacrine are useful in some most effective against gram-positive bacteria. Metronidazole is Antimalarial drugs have many effects, including im- a synthetic nitroimidazole derivative that reduces in- pairment of lysosomal phagosomal activity, inhibition ﬂammation by an unknown mechanism. Other selected of neutrophilic iodination and locomotion, and diminu- topical antibiotics are listed in Table 41. Chloroquine (Aralen) and hydroxychloroquine (Plaquenil) also form complexes with hepatic por- DRUGS FOR CUTANEOUS FUNGAL phyrins and can chelate iron, thereby enhancing their INFECTIONS urinary excretion. Both drugs have an afﬁnity for melanin, which may at least partially explain their oph- Like bacterial infections of skin, cutaneous fungal in- thalmological toxicities (retinopathy). Low-dose chloroquine is Systemic Agents used for the therapy of porphyria cutanea tarda in pa- Griseofulvin tients in whom phlebotomy has failed or is contraindi- Griseofulvin (Fulvicin, Grifulvin V) has been used cated. Other skin diseases in which the drugs are useful safely and effectively for decades for dermatophyte in- (after sunscreens and avoidance of sun exposure) in- fections of scalp and nails and for more widespread skin clude polymorphous light eruption and solar urticaria. The drug is generally well toler- longer than it is for malaria, and therefore, dose-related ated, even in the long-term courses necessary for nail toxicities are important. Reversible alterations include ciliary body dysfunction and corneal changes with edema and Ketoconazole deposits. Irreversible retinopathy also occurs; however, it is less common with quinacrine than with the other two Ketoconazole (Nizoral) is approved for treating der- drugs. Toxicity may be asymptomatic, but the earliest matophyte infections unresponsive to griseofulvin and symptoms are night blindness, scotoma, or tunnel vision. Noninfectious skin eruptions, such as acne vulgaris and acne rosacea, are Clindamycin Acne vulgaris Erythromycin Acne vulgaris often treated with systemic antibiotics. The mechanism Metronidazole Acne rosacea of action is not clear, although tetracycline inhibits li- Bacitracin Superﬁcial infection (gram-positive pases derived from resident ﬂora in the sebaceous folli- bacteria) cle (Staphylococcus epidermidis, Propionibacterium ac- Polymixin B Superﬁcial infection (gram-negative nes). These lipases cleave irritating fatty acids from bacteria) Neomycin Superﬁcial infection (mainly gram- triglycerides in sebum, presumably contributing to cuta- negative bacteria) neous inﬂammation. Topical Agents Fluconazole Many effective topical agents are available both with Fluconazole (Diﬂucan) may be better absorbed and is and without a prescription for treating cutaneous der- possibly less hepatotoxic than ketoconazole, but it is matophyte infections and seborrheic dermatitis (Table considerably more expensive, an important considera- 41. Itraconazole DRUGS FOR CUTANEOUS VIRAL Itraconazole (Sporanox), a triazole, is highly lipophilic INFECTIONS and concentrates in skin. It is approved for both cuta- The speciﬁc antiviral agents used to treat cutaneous in- neous deep fungal infections and dermatophyte nail dis- fections caused by herpes simplex and varicella zoster ease, for which shorter courses of therapy are probably viruses are discussed in Chapter 50. Pulse therapy, whereby the drug is adminis- tered for 1 week and then the patient is off treatment for 3 weeks between pulses, may reduce toxicity without Interferons compromising antifungal efﬁcacy. Interferons -2b (Intron-A), -nl, and -n3 (Alferon N) have both intrinsic antiviral effects and antiproliferative Terbinaﬁne and immunomodulatory actions. These interferons are Terbinaﬁne (Lamisil), an antifungal drug, is highly approved for intralesional therapy of refractory or re- lipophilic and concentrates in stratum corneum and nail current condylomata (genital warts). It is very effective for many dermatophyte infec- ﬂulike symptoms, nausea, depression of the white blood tions, especially those of the nails, with which it may cell count, and mild diminution in hematocrit.
It is related by its domed upper surface to the diaphragm buy zyloprim 100mg with visa treatment renal cell carcinoma, which separates it from pleura purchase zyloprim 300 mg with amex atlas genius - symptoms, lungs, pericardium and heart. Its postero-inferior (or visceral) surface abuts against the abdominal oesophagus, the stomach, duodenum; hepatic ﬂexure of colon and the right kidney and suprarenal, as well as carrying the gall-bladder. The liver is divided into a larger right and small left lobe, separated superiorly by the falciform ligament and postero-inferiorly by an H-shaped arrangement of fossae (Fig. Two subsidiary lobes are marked out on the visceral aspect of the liver between the limbs of this H— the quadrate lobe in front and the caudate lobe behind. The ligamentum teres is the obliterated remains of the left umbilical vein which, in utero, brings blood from the placenta back into the fetus. The liga- mentus venosum is the ﬁbrous remnant of the fetal ductus venosus which shunts oxygenated blood from this left umbilical vein to the inferior vena cava, short-circuiting the liver. It is easy enough to realize, then, that the grooves for the ligamentum teres, ligamentum venosum and inferior vena cava, representing as they do the pathway of a fetal venous trunk, are con- tinuous in the adult. Lying in the porta hepatis (which is 2in (5cm) long) are: 1the common hepatic duct—anteriorly; 2the hepatic artery—in the middle; 3the portal vein—posteriorly. As well as these, autonomic nerve ﬁbres (sympathetic from the coeliac 94 The abdomen and pelvis Coronary ligament Left triangular ligament Left lobe Falciform ligament Round ligament (ligamentum teres) Gall-bladder Right lobe (a) Gall-bladder Porta hepatis Quadrate lobe Right lobe Hepatic artery Hepatic portal vein Fissure for ligamentum teres Common Left lobe hepatic Caudate lobe duct Fissure for ligamentum venosum Left hepatic vein (b) Inferior vena cava Groove + GB lig. The gastrointestinal adnexae 95 axis and parasympathetic from the vagus), lymphatic vessels and lymph nodes are found there. Peritoneal attachments The liver is enclosed in peritoneum except for a small posterior bare area, demarcated by the peritoneum from the diaphragm reﬂected on to it as the upper and lower layers of the coronary ligament. The falciform ligament ascends to the liver from the umbilicus, somewhat to the right of the midline, and bears the ligamentum teres in its free border. The ligamentum teres passes into its ﬁssure in the inferior surface of the liver while the falciform ligament passes over the dome of the liver and then divaricates. Its right limb joins the upper layer of the coronary liga- ment and its left limb stretches out as the long narrow left triangular ligament which, when traced posteriorly and to the right, joins the lesser omentum in the upper end of the ﬁssure for the ligamentum venosum. The lesser omentum arises from the ﬁssures of the porta hepatis and the ligamentum venosum and passes as a sheet to be attached along the lesser curvature of the stomach. Structure The liver is made up of lobules, each with a solitary central vein which is a tributary of the hepatic vein which, in turn, drains into the inferior vena cava. In spaces between the lobules, termed portal canals, lie branches of the hepatic artery (bringing systemic blood) and the portal vein, both of which drain into the central vein by means of sinusoids traversing the lobule. Branches of the hepatic duct also lie in the portal canals and receive ﬁne bile capillaries from the liver lobules. Segmental anatomy The gross anatomical division of the liver into a right and left lobe, demar- cated by a line passing from the attachment of the falciform ligament on the anterior surface to the ﬁssures for the ligamentum teres and ligamentum venosum on its posterior surface, is simply a gross anatomical descriptive term with no morphological signiﬁcance. Studies of the distribution of the hepatic blood vessels and ducts have indicated that the true morphological and physiological division of the liver is into right and left lobes demar- cated by a plane which passes through the fossa of the gall-bladder and the fossa of the inferior vena cava. Although these two lobes are not differenti- ated by any visible line on the dome of the liver, each has its own arterial and portal venous blood supply and separate biliary drainage. This mor- phological division lies to the right of the gross anatomical plane and in this the quadrate lobe comes to be part of the left morphological lobe of the liver while the caudate lobe divides partly to the left and partly to the right lobe (Fig. Note that the quadrate lobe is morphologically a part of the left lobe while the caudate lobe belongs to both right and left lobes. The right and left morphological lobes of the liver can be further subdi- vided into a number of segments, four for each lobe (Fig. The student need not learn the details of these, but of course to the hepatic surgeon, car- rying out a partial resection of the liver, knowledge of these segments, with their individual blood supply and biliary drainage, is of great importance. At the hilum of the liver, the hepatic artery, portal vein and bile duct each divide into right and left branches and there is little or no anastomosis between the divisions on the two sides (Fig. From the region of the porta hepatis, the branches pass laterally and spread upwards and down- The gastrointestinal adnexae 97 Fig. Note that the quadrate lobe is supplied exclusively by the left hepatic artery and drained by the left hepatic duct. The hepatic veins (Figs 72c, 74) These veins are massive and their distribution is somewhat different from that of the portal, hepatic arterial and bile duct systems already described. These pass upwards and backwards to drain into the inferior vena cava at the superior margin of the liver. Their terminations are somewhat variable but usually the central hepatic vein enters the left hepatic vein near its termination. In addition, small hepatic venous tributaries run directly backwards from the substance of the liver to enter the vena cava more dis- tally to the main hepatic veins.
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