Central nervous system (CNS) infections are extremely serious group of diseases.
The cerebral cortex and spinal cord are confined within the restricted boundaries of the skull and bony spinal canal.
Infection, inflammation and oedema therefore have serious consequences, often leading to tissue infarction that in turn results in permanent neurologic damage or death.
Therefor, early diagnosis and prompt treatment is very important
Central nervous system (CNS) infections are extremely serious group of diseases.
The cerebral cortex and spinal cord are confined within the restricted boundaries of the skull and bony spinal canal.
Infection, inflammation and oedema therefore have serious consequences, often leading to tissue infarction that in turn results in permanent neurologic damage or death.
Therefor, early diagnosis and prompt treatment is very important
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
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STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Drug Discovery and Development .....NEHA GUPTA
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
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This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
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4. PATHOGENESIS
M. tuberculosis reaches the brain , meninges and spinal cord by
hematogenous route.
Tubercles are formed- ‘RICH FOCUS’.
In patients with poor immunity tubercles will enlarge, undergo
caseation.
Rupture of tubercles in to the subarachnoid space or ventricular
system will produce meningitis.
Deeply seated tubercles – Tuberculoma, tuberculos abscess.
7. INFLAMMATORY MENINGEAL
EXUDATE
Thick tuberculous exudate is formed in the subarachnoid space.
Exudate is gelatinous and granular; contains PMNL, RBCs,
macrophages, lymphocytes and monocytes.
Tubercles may be formed, may contain Mycobacteria.
Optic chiasma, Inter peduncular fossa,Sylvian fissure, Surface of
Pons,Cerebellum and Cerebral hemispheres, Ventricles.
8. VASCULITIS
Inflammation of vessels traversing the exudate.
Terminal portion of internal carotid artery and proximal portion
of middle cerebral artery within the sylvian fissure are the sites
commonly affected.
Occlusion of vessels, leading to ischemia and infarction.
9. DISTURBANCE OF CSF FLOW AND
ABSORPTION
Oedema of brain parenchyma or exudate will block the spinal
aqueduct or foramina of 4 th ventricles.
Impaired absorption and circulation of CSF - Hydrocephalus.
10. ENCEPHALITIS
‘‘Border Zone Encephalitis’- Tissue reaction adjacent to the
zone of thick adherent exudate.
Thrombosed vessels may produce infarction.
C/C hydrocephalus will produce atrophy of both gray matter
and white matter.
Diffuse cerebral oedema, demyelination and hemorrhagic leak.
11. CLINICAL FEATURES
Presentation is more acute in children.
Indolent course in adult.
H/o precipitating conditions like viral or bacterial infections,
immunisation, head trauma may be present.
Symptoms
fever
Headache
Vomiting
Siezures
Abnormal behaviour
Cranial nerve involvement- blindness, deafness.
altered sensorium.
13. Staging system
STAGE 1 (Early)
Nonspecific symptoms.
Few or no clinical signs of meningitis
Fully conscious and alert.
STAGE 2 (Intermediate)
Signs of meningitis
Drowsiness or lethargy
Cranial nerve palsy
STAGE 3(Advanced)
Stupor or coma
Systemic toxicity
Gross paresis or paralysis
14. INVESTIGATIONS
Routine laboratory studies
ESR - normal or elevated
Leucopenia or luekocytosis
Serum electrolytes- Hyponatremia,
- Hypochloremia.
CXR-evidence of healed pulmonary tuberculosis or
miliary tuberculosis
Mantoux test- negative in 10-15% of children and 50%
of adults.
Extra neural cultures- Sputum, Gastric lavage, urine,
lymph node, bone marrow, liver.
15. CSF STUDIES
Opening pressure -High (>180mm of H2O)
-Low in spinal block
Clear or slightly opalescent
Rarely haemorrhagic due to vasculitis.
High CSF protein . COB WEB PHENOMENON- ‘Pellicle’
formation -due to high concentration of fibrinogen
Hypoglycorrhachia- moderately depressed CSF sugar
Cell count is increased with lymphocyte predominance.
16. CSF STUDIES …
MICROBIOLOGICAL INVESTIGATIONS
Demonstration of mycobacteria in CSF.
Smear will be positive only in <25% of cases.
Bacterial yield can be increased by
Using pellicle
Centrifuged sediment
Repeated CSF sampling
Using fluorochrome staining.
Ventricular and cisternal fluid.
Culture of CSF for mycobacteria.
17. OTHER DIAGNOSTIC TESTS
Immunological tests
Antigens - ELISA or RIA for soluble tuberculous antigens.
Antibodies –ELISA test to detect IgG and IgM antibodies
18. BIOCHEMICAL ASSAYS
Adenosine deaminase (ADA)
Sensitivity-73%-100%.
Radiolabelled Bromide Partition Test
Based on the disruption of BBB in TBM.
Oral or IV (82 Br) Ammonium bromide.
Concentration of radio isotope in serum and CSF is
determined simultaneously after 1-2 days of equilibrium.
Normal serumBr : CSF Br > 3.
TBM < or = 1.6.
Tuberculostearic acid in CSF.
Sensitivity - 95%, specificity-99%.
19. Diagnostic Test …
Molecular techeniques.
Polymerase Chain Reaction (PCR)
Radiological investigations
Plain radiograph of the skull -
Calcification of basal meninges or brain parenchyma,
Destruction of skull due to extension of infection.
Separation of sutures due to hydrocephalus in children.
20. Diagnostic Test …
Angiographic evaluation
‘Angiographic Triad of TBM’
Hydrocephalic pattern of vessels.
Narrowing of vessels at the base of brain.
Narrowed or occluded small and medium sized vessels with
scanty collaterals.
21. Plain CT Head
Findings are nonspecific
Ventricular enlargement due to hydrocephalus.
Periventricular lucency due to ependymal exudate.
Areas of low attenuation –Infarction.
Contrast enhanced CT
Increased meningeal enhancement
MRI with gadolinium enhancement
More sensitive
Thickened cranial nerves can be identified.
MR Angiography-
Vascular narrowing.
23. SEROUS (STERILE) TBM
.
Results when tubercles rupture into the meninges without
releasing any viable mycobacterium
Tuberculoprotein is responsible for the immunological reaction
Distinctive CSF profile and good clinical prognosis.
CSF- Increased pressure, Protein and cell count with normal
sugar.
Complete recovery can occur without treatment in days to weeks
25. Anti tuberculous chemo therapy
PRINCIPLES
Drugs should cross the BBB to achieve a level above MIC
Chemotherapy should be directed against both intra cellular
and extracellular organisms
Multiple drugs should be used to prevent emergence of drug
resistance
26. DRUGS
1st line drugs
INH
• Small non protein bound molecule
• Excellent penetration of both inflammed and noninflammed
meninges.
• CSF concentration much higher than MIC .
• In TBM CSF concentration is about 90% of plasma
concentration
RIFAMPICIN
• Poor CSF penetration
• In TBM concentration just above MIC will be obtained
27. Drugs …….
PYRAZINAMIDE
Effective against intracellular organisms in acidic pH
Excellent CSF penetration
CSF concentration is equal to serum concentration in presence of
inflammation.
ETHAMBUTOL
CSF penetration is poor in the absence of inflammation.In
inflammed meninges CSF level is 10-50% of plasma level
STREPTOMYCIN
Good penetration of inflammed meninges
28. Drugs …..
2nd line drugs
Good CSF penetration for -
ETHIONAMIDE
CYCLOSERINE
OFLOXACIN
AMINO-GLYCOSIDES
Poor CSF penetration for -
PAS
29. Treatment regimens
WHO
Short course chemo therapy
2 months intensive phase with HREZ
+
4 months continuation phase with HR
ATS
2 months intensive phase with HREZ
+
6-8 months continuation phase with HR
30. RNTCP Guide lines
In patients with TB meningitis on CAT-I treatment 4 drugs used during
intensive phase – HRZE should be replaced by HRZS as
ETHAMBUTOL does not penetrate CSF
Continuation phase for the treatment of TBM and spinal TB with
neurological complication should be given for 6-7 months ,extending the total
duration of treatment to 8-9 months
31. STEROIDS
Inflammatory process in TBM is a hypersensitivity response to
tuberculous antigens
Most beneficial in patients with complications
Clinical stage 2 and above
Raised ICT
Cerebral edema
Stupor
FND
Spinal block
Hydrocephalus
Basal optico chiasmatic pachymeningitis
32. Steroids ……
Prednisolone 60 mg daily or 1 mg/kg /day
Dexamethasone 8-16 mg daily or 0.3-0.6 mg/kg/day
DURATION
3-6 weeks; slowly tapered over 2-4 weeks
CSF PARAMETERS affected
Opening pressure
Protein content
Leucocyte count
33. Surgery
Relief of hydrocephalus
Ventriculo peritoneal shunt
Temporary external ventricular drains
34. CNS TUBERCULOMA
Unruptured tubercles will be walled of from the adjacent
parenchyma by fibrous capsule.
Single or multiple.
Sites-Cerebral hemispheres, basal ganglia, brain
stem,cerebellum,Substance of spinal cord.
Clinical features -Siezures ,Increased ICT,FND.
CSF study -Not contributory.
Contrast enhanced CT
Uniform contrast enhancement
Ring enhancing lesion.
35. CNS Tuberculoma…
Biopsy- ‘Gold standard’ investigation.
Caseating granuloma.
AFB smear and culture.
Treatment
Medical treatment with ATT,Steroids,Anticonvulsants.
Surgery
36. TUBERCULOUS BRAIN ABSCESS
Results from liquefaction of caseous core of the granuloma.
Acute clinical presentation - Fever,headache,FND
Diagnosis by CT head or MRI
Treatment
-ATT - poor response
-Surgery
37. SPINAL CORD TUBERCULOSIS
Inflammatory lesions - arachnoiditis,vasculitis
Space occupying lesions - Tuberculomas (intramedullary or
epidural)
Subarachnoid space is filled with thick tuberculous exudate.
Nerve roots traversing the space are compressed
Vessels are inflammed and narrowed.
Adjacent parenchyma –edematous,demyelinated,atrophic.
38. SPINAL CORD TB …
Presents with acute onset of spinal block,
transverse myelitis like syndrome, slow ascending paralysis
CSF - Not obtained in spinal block.
- High protein, low sugar ,lymphocytic pleocytosis.
Myelography
CT scan and MRI-enhance subarachnoid exudate.
Treatment- ATT,steriods, surgery.
39. PROGNOSIS
Mortality has declined with the introduction of effective ATT.
Prognosis depends on
Stage at diagnosis and start of treatment.
Extremes of age.
Co-existance of miliary disease.
42. AIDS & CNS TB
Common form of extra-pulmonary TB in AIDS patients
Commonest CNS infection in AIDS in some parts of the world
Atypical features
Coincident infection with other CNS opportunistic pathogens
Standard anti tuberculous therapy is effective