Archive for December, 2010

SUPERFICIAL FUNGAL INFECTIONS: TINEA, TINEA PEDIS, ETC

Posted on December 31, 2010, under Anti-Infectives.

Tinea
Tinea infections are caused by dermatophytes from three genera, Trichophyton, Microsporum, and Epidermophyton. The lifetime risk of dermatophyte infection is between 10% and 20%. These infections are typically named for the site that is infected.
Because other skin diseases mimic fungal infections, it is best to confirm the presence of fungus. Culture can be reserved for complicated cases, but it is very simple to perform a potassium hydroxide (KOH) preparation for microscopy. Scales should be scraped from the leading edge of lesions and placed on a microscope slide. One or two drops of KOH (10-20%) are added and a cover slip placed on top. The slide is then either heated or allowed to sit at room temperature for 10 to 15 minutes. A microscope is then used to search for the branching hyphae characteristic of dermatophyte infections. A drop of ink or fungal stain can make the hyphae easier to find.
Tinea Pedis
Tinea pedis, or athlete’s foot, is the most common dermatophytic infection. Tinea pedis typically occurs in hot and humid weather when the patient is wearing occlusive footwear. It can present in three patterns (sometimes all in the same patient):
- Interdigital (especially third and fourth spaces) maceration and cracking
- Scaling, hyperkeratotic lesions in a ballet shoe or moccasin distribution
- Scattered, very pruritic, vesiculobullous lesions
Tinea cruris
Tinea cruris, or jock itch, is a caused by Epidermophyton floccosum or Trichophyton rubrum infection of the intertriginous areas in male patients.
Tinea Corporis
Tinea corporis, or ringworm, is caused by T. rubrum or by Trichophyton verrucosum or Microsporum canis (from animal contact). Tinea corporis can refer to tinea anywhere except the scalp, beard, hands, or groin. The classic ringworm appearance demonstrates annular plaques with erythema and scaling. The center clears to a dusky or brown color as the lesion extends radially. Unlike other tinea infections, tinea corporis occurs in exposed areas.
Treatment
First-line treatment for tinea is topical, with allylamines (naftifine, butenafine, terbinafine) being slightly more effective. Treatment should be continued for 1 week after cure. This will typically take 2 weeks for tinea corporis and tinea cruris. Tinea pedis may require 4 weeks of treatment. Chronic or resistant cases may require the use of oral agents such as itraconazole, terbinafine, griseofulvin, or once-weekly fluconazole. Environmental factors are also important in treatment and prevention. Keeping clothing, shoes, and skin dry can be very helpful. Treating shoes with antifungal powder may also be helpful. When tinea is especially inflamed and pruritic, some clinicians will use a topical steroid in conjunction with antifungal therapy, at least early in therapy. This approach helps to alleviate symptoms quickly and may even hasten resolution of the infection.
*114/348/5*

SUPERFICIAL FUNGAL INFECTIONS: TINEA, TINEA PEDIS, ETCTineaTinea infections are caused by dermatophytes from three genera, Trichophyton, Microsporum, and Epidermophyton. The lifetime risk of dermatophyte infection is between 10% and 20%. These infections are typically named for the site that is infected.Because other skin diseases mimic fungal infections, it is best to confirm the presence of fungus. Culture can be reserved for complicated cases, but it is very simple to perform a potassium hydroxide (KOH) preparation for microscopy. Scales should be scraped from the leading edge of lesions and placed on a microscope slide. One or two drops of KOH (10-20%) are added and a cover slip placed on top. The slide is then either heated or allowed to sit at room temperature for 10 to 15 minutes. A microscope is then used to search for the branching hyphae characteristic of dermatophyte infections. A drop of ink or fungal stain can make the hyphae easier to find.
Tinea PedisTinea pedis, or athlete’s foot, is the most common dermatophytic infection. Tinea pedis typically occurs in hot and humid weather when the patient is wearing occlusive footwear. It can present in three patterns (sometimes all in the same patient):- Interdigital (especially third and fourth spaces) maceration and cracking- Scaling, hyperkeratotic lesions in a ballet shoe or moccasin distribution- Scattered, very pruritic, vesiculobullous lesions
Tinea cruris Tinea cruris, or jock itch, is a caused by Epidermophyton floccosum or Trichophyton rubrum infection of the intertriginous areas in male patients.
Tinea CorporisTinea corporis, or ringworm, is caused by T. rubrum or by Trichophyton verrucosum or Microsporum canis (from animal contact). Tinea corporis can refer to tinea anywhere except the scalp, beard, hands, or groin. The classic ringworm appearance demonstrates annular plaques with erythema and scaling. The center clears to a dusky or brown color as the lesion extends radially. Unlike other tinea infections, tinea corporis occurs in exposed areas.
TreatmentFirst-line treatment for tinea is topical, with allylamines (naftifine, butenafine, terbinafine) being slightly more effective. Treatment should be continued for 1 week after cure. This will typically take 2 weeks for tinea corporis and tinea cruris. Tinea pedis may require 4 weeks of treatment. Chronic or resistant cases may require the use of oral agents such as itraconazole, terbinafine, griseofulvin, or once-weekly fluconazole. Environmental factors are also important in treatment and prevention. Keeping clothing, shoes, and skin dry can be very helpful. Treating shoes with antifungal powder may also be helpful. When tinea is especially inflamed and pruritic, some clinicians will use a topical steroid in conjunction with antifungal therapy, at least early in therapy. This approach helps to alleviate symptoms quickly and may even hasten resolution of the infection.*114/348/5*

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ALCOHOL COUNSELING: COUNSELORS WITH TWO HATS

Posted on December 15, 2010, under Anti Depressants-Sleeping Aid.

Many of the workers in the alcohol field are themselves recovering alcoholics. Long before national attention was focused on alcoholism, private rehabilitation centers were operated, often staffed by sober alcoholics. In the evolutionary process of recovery, many alcoholics find themselves working in many capacities, in many different types of facilities. We must say here that we do not believe that simply being a recovering alcoholic qualifies one to be a counselor. There is more to it than that. That view ignores the skill and special knowledge that many alcoholics working in the field have gained, on the job, and often without benefit of any formal training. They have had a harder row to hoe and deserve a lot of respect for sticking to it.
Being a recovering alcoholic has some advantages for a counselor but also some clear disadvantages. Being a counselor may at times be the most confusing for the recovering alcoholic who is also in AA. Doing AA Twelfth Step work and calling it counseling won’t do, from the profession’s or AA’s point of view. Twelfth Step work is voluntary and has no business being used for bread earning. AA’s traditions are clearly against this. AA is not opposed to its members working in the field of alcoholism, if they are qualified to do so. If you are an AA member and also an alcohol counselor, it is important to keep the dividing line in plain sight. The trade calls it “wearing two hats.” There are some good AA pamphlets on the subject, and the AA monthly magazine, The Grapevine, publishes articles for two-hatters from time to time. A book, The Para-Professional in the Treatment of Alcoholism, by Staub and Kent, covers a lot of territory on two-hatting very well.
A particular bind for two-hat counselors comes if attending AA becomes tied to their jobs more than their own sobriety. They might easily find themselves sustaining clients at meetings and not being there for themselves. A way to avoid this is to find a meeting you can attend where you are less likely to see clients. It is easy for both you and the clients to confuse AA with the other therapy. The client benefits from a clear distinction as much, if not more, than you. There is always the difficulty of keeping your priorities in order. You cannot counsel if you are drinking yourself. So, whatever you do to keep sober, whether it includes AA or not, keep doing it. Again, when so many people out there seem to need you, it is very difficult to keep from overextending. A recovering alcoholic simply cannot afford this. (If this description fits you, stop reading right now. Choose one thing to scratch off your schedule.) It is always easy to justify skimping on your own sober regimen because “I’m working with alcoholics all the time.” Retire that excuse. Experience has shown it to be a counselor killer.
Another real problem is the temptation to discuss your job at AA meetings or discuss clients with other members. The AAs don’t need to be bored by you any more than by a doctor member describing the surgical removal of a gallbladder. Discussing your clients, even with another AA member, is a serious breach of confidentiality. This will be particularly hard, especially when a really concerned AA member asks you point-blank about someone. The other side of the coin is keeping the confidences gained at AA and not reporting to coworkers about what transpired with clients at an AA meeting. Hopefully, your nonalcoholic coworkers will not slip up and put you in a bind by asking. It is probably okay to talk with your AA sponsor about your job if it is giving you fits. However, it is important to stick with you, and leave out work details and/or details about clients.
Watch out if feelings of superiority creep in toward other “plain” AA members or nonalcoholic colleagues.-Recovery from alcoholism does not accord you magical insights. On the other hand, being a nonalcoholic is not a guaranteed route to knowing what is going on, either. Keep your perspective as much as you’re able. After all, you are all in the same boat, with different oars. To quote an unknown source: “It’s amazing how much can be accomplished if no one cares who gets the credit.”
*187\331\2*

ALCOHOL COUNSELING: COUNSELORS WITH TWO HATSMany of the workers in the alcohol field are themselves recovering alcoholics. Long before national attention was focused on alcoholism, private rehabilitation centers were operated, often staffed by sober alcoholics. In the evolutionary process of recovery, many alcoholics find themselves working in many capacities, in many different types of facilities. We must say here that we do not believe that simply being a recovering alcoholic qualifies one to be a counselor. There is more to it than that. That view ignores the skill and special knowledge that many alcoholics working in the field have gained, on the job, and often without benefit of any formal training. They have had a harder row to hoe and deserve a lot of respect for sticking to it.Being a recovering alcoholic has some advantages for a counselor but also some clear disadvantages. Being a counselor may at times be the most confusing for the recovering alcoholic who is also in AA. Doing AA Twelfth Step work and calling it counseling won’t do, from the profession’s or AA’s point of view. Twelfth Step work is voluntary and has no business being used for bread earning. AA’s traditions are clearly against this. AA is not opposed to its members working in the field of alcoholism, if they are qualified to do so. If you are an AA member and also an alcohol counselor, it is important to keep the dividing line in plain sight. The trade calls it “wearing two hats.” There are some good AA pamphlets on the subject, and the AA monthly magazine, The Grapevine, publishes articles for two-hatters from time to time. A book, The Para-Professional in the Treatment of Alcoholism, by Staub and Kent, covers a lot of territory on two-hatting very well.A particular bind for two-hat counselors comes if attending AA becomes tied to their jobs more than their own sobriety. They might easily find themselves sustaining clients at meetings and not being there for themselves. A way to avoid this is to find a meeting you can attend where you are less likely to see clients. It is easy for both you and the clients to confuse AA with the other therapy. The client benefits from a clear distinction as much, if not more, than you. There is always the difficulty of keeping your priorities in order. You cannot counsel if you are drinking yourself. So, whatever you do to keep sober, whether it includes AA or not, keep doing it. Again, when so many people out there seem to need you, it is very difficult to keep from overextending. A recovering alcoholic simply cannot afford this. (If this description fits you, stop reading right now. Choose one thing to scratch off your schedule.) It is always easy to justify skimping on your own sober regimen because “I’m working with alcoholics all the time.” Retire that excuse. Experience has shown it to be a counselor killer.Another real problem is the temptation to discuss your job at AA meetings or discuss clients with other members. The AAs don’t need to be bored by you any more than by a doctor member describing the surgical removal of a gallbladder. Discussing your clients, even with another AA member, is a serious breach of confidentiality. This will be particularly hard, especially when a really concerned AA member asks you point-blank about someone. The other side of the coin is keeping the confidences gained at AA and not reporting to coworkers about what transpired with clients at an AA meeting. Hopefully, your nonalcoholic coworkers will not slip up and put you in a bind by asking. It is probably okay to talk with your AA sponsor about your job if it is giving you fits. However, it is important to stick with you, and leave out work details and/or details about clients.Watch out if feelings of superiority creep in toward other “plain” AA members or nonalcoholic colleagues.-Recovery from alcoholism does not accord you magical insights. On the other hand, being a nonalcoholic is not a guaranteed route to knowing what is going on, either. Keep your perspective as much as you’re able. After all, you are all in the same boat, with different oars. To quote an unknown source: “It’s amazing how much can be accomplished if no one cares who gets the credit.”*187\331\2*

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ASTHMA AND SEX

Posted on December 12, 2010, under Asthma.

Sexual problems of any degree can have a detrimental effect on relationships and one’s self-esteem. While a whole range of sexual problems are identified and openly discussed between individuals, special counsellors, doctors, patients and through the media, there is little discussion about the sexual difficulties and embarrassment that can be encountered by asthmatics.
A large number of general practitioners said that none of their asthma patients had ever mentioned any sexual difficulties relating to asthma. When further questioned, they admitted they had never asked their patients if sexual activity triggered an attack. Another group of general practitioners said they had discussed sexual activity with some of their asthmatic patients. In these instances, it was usually the doctor who brought up the subject. According to Dr L:
I have a number of patients who get asthma during or after sexual activity, but unfortunately most of them were reticent to broach the subject. Many of my patients who have had heart attacks or a stroke have brought up the subject of their future sex life. I think these patients feel more confident to discuss such personal issues because they have very often been counselled by a social worker or a physiotherapist while in hospital. It has been made clear to them that having problems with sexual anxiety after an illness is very normal and affects most people. Because most asthmatics are not chronically sick and can be perfectly well prior to any physical activity, they do not realize that their problem is common, and many lack the confidence to discuss it with their doctor. I make a point to give my asthmatic patients an opportunity to discuss all aspects of their asthma and its effect on their lives by asking a few leading questions. While many would not have brought up the sexual aspect themselves, they are relieved and reassured after talking with me.
If you have encountered problems with your asthma during sexual activity, you are not alone. Asthmatics are vulnerable during sexual activity because they are exposed to a number of common triggers: exercise, bedding and dust, as well as possible irritants such as scented soap, perfume, hair spray and aftershave.
Fear of developing asthma during sex can be very distressing for both partners. It is important to be totally frank with your partner if you are worried about your asthma. Explain to him or her what asthma is and how it can affect you. In a caring relationship, the asthmatic should expect and receive support and understanding. It is also important to know that most asthmatics are able to enjoy a regular and perfectly normal sex life.
Anxiety about having an asthma attack during sexual activity can, in itself, induce asthma symptoms, admits Roberta, 32:
No matter how well I was feeling, or how high my peak flow meter reading, I used to become breathless and tight in the chest when I made love. Since I started using Ventolin about five minutes prior to going to bed, this problem has disappeared. I still get short of breath if I have a cold or a slight chest infection, which is the time my asthma always seems to be worse. Fortunately, I have an understanding partner who always makes sure my Ventolin is at hand. When I was younger, I was very embarrassed by using Ventolin before, during or after sexual activity, but now I couldn’t care less. We even joke about it sometimes.
Pre-medication is common among asthmatics who know that they normally wheeze or become breathless during sexual activity. Which medicine to take and when to take it should be discussed with your doctor.
When considering one’s sex life, it is a good idea to try and eliminate or reduce any known triggers. William, 47, certainly found this to be the case when he met his future wife:
When I met my wife, she was addicted to a certain brand of perfume. I did notice that I developed a cough and a slight tightness in my chest the first time we went out together, but it was not till I had an acute attack of asthma in bed one night that I realized that I was having an allergic response to her very strong perfume. Our first sexual encounter ended up with me in the casualty department of Royal North Shore Hospital. While I occasionally wheeze a bit during sexual activity, I have not had a bad attack since my wife stopped wearing perfume.
Frankness and understanding between sexual partners, supported if necessary by counselling and prescribed premedication, should resolve most problems and allay any fears about asthma during sexual activity. If you have any problems, you should feel free to talk with your doctor. A caring and understanding doctor should be able to discuss this aspect of your asthma without making you feel awkward or embarrassed.
*45\148\2*

ASTHMA AND SEXSexual problems of any degree can have a detrimental effect on relationships and one’s self-esteem. While a whole range of sexual problems are identified and openly discussed between individuals, special counsellors, doctors, patients and through the media, there is little discussion about the sexual difficulties and embarrassment that can be encountered by asthmatics.A large number of general practitioners said that none of their asthma patients had ever mentioned any sexual difficulties relating to asthma. When further questioned, they admitted they had never asked their patients if sexual activity triggered an attack. Another group of general practitioners said they had discussed sexual activity with some of their asthmatic patients. In these instances, it was usually the doctor who brought up the subject. According to Dr L:I have a number of patients who get asthma during or after sexual activity, but unfortunately most of them were reticent to broach the subject. Many of my patients who have had heart attacks or a stroke have brought up the subject of their future sex life. I think these patients feel more confident to discuss such personal issues because they have very often been counselled by a social worker or a physiotherapist while in hospital. It has been made clear to them that having problems with sexual anxiety after an illness is very normal and affects most people. Because most asthmatics are not chronically sick and can be perfectly well prior to any physical activity, they do not realize that their problem is common, and many lack the confidence to discuss it with their doctor. I make a point to give my asthmatic patients an opportunity to discuss all aspects of their asthma and its effect on their lives by asking a few leading questions. While many would not have brought up the sexual aspect themselves, they are relieved and reassured after talking with me.If you have encountered problems with your asthma during sexual activity, you are not alone. Asthmatics are vulnerable during sexual activity because they are exposed to a number of common triggers: exercise, bedding and dust, as well as possible irritants such as scented soap, perfume, hair spray and aftershave.Fear of developing asthma during sex can be very distressing for both partners. It is important to be totally frank with your partner if you are worried about your asthma. Explain to him or her what asthma is and how it can affect you. In a caring relationship, the asthmatic should expect and receive support and understanding. It is also important to know that most asthmatics are able to enjoy a regular and perfectly normal sex life.Anxiety about having an asthma attack during sexual activity can, in itself, induce asthma symptoms, admits Roberta, 32:No matter how well I was feeling, or how high my peak flow meter reading, I used to become breathless and tight in the chest when I made love. Since I started using Ventolin about five minutes prior to going to bed, this problem has disappeared. I still get short of breath if I have a cold or a slight chest infection, which is the time my asthma always seems to be worse. Fortunately, I have an understanding partner who always makes sure my Ventolin is at hand. When I was younger, I was very embarrassed by using Ventolin before, during or after sexual activity, but now I couldn’t care less. We even joke about it sometimes.Pre-medication is common among asthmatics who know that they normally wheeze or become breathless during sexual activity. Which medicine to take and when to take it should be discussed with your doctor.When considering one’s sex life, it is a good idea to try and eliminate or reduce any known triggers. William, 47, certainly found this to be the case when he met his future wife:When I met my wife, she was addicted to a certain brand of perfume. I did notice that I developed a cough and a slight tightness in my chest the first time we went out together, but it was not till I had an acute attack of asthma in bed one night that I realized that I was having an allergic response to her very strong perfume. Our first sexual encounter ended up with me in the casualty department of Royal North Shore Hospital. While I occasionally wheeze a bit during sexual activity, I have not had a bad attack since my wife stopped wearing perfume.Frankness and understanding between sexual partners, supported if necessary by counselling and prescribed premedication, should resolve most problems and allay any fears about asthma during sexual activity. If you have any problems, you should feel free to talk with your doctor. A caring and understanding doctor should be able to discuss this aspect of your asthma without making you feel awkward or embarrassed.*45\148\2*

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