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#GarjoToux
Reflex responses evoked by C-fiber activation include increased airway parasympathetic nerve activity, and the chemoreflex, characterized by apnea (followed by rapid shallow breathing), bradycardia, and hypotension
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Anatomy and neuro-pathophysiology of the cough reflex arc
are generally quiescent throughout the respiratory cycle but are activated by chemical stimuli such as capsaicin, bradykinin, citric acid, hypertonic saline solution, and sulfur dioxide (SO2). <span>Reflex responses evoked by C-fiber activation include increased airway parasympathetic nerve activity, and the chemoreflex, characterized by apnea (followed by rapid shallow breathing), bradycardia, and hypotension. Stimulants of C-fibers such as capsaicin, bradykinin, SO2, and citric acid evoke cough in conscious animals and in humans, and capsaicin desensitization abolishes citric acid-induced c




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Sex-related differences in cough reflex sensitivity explain the observation that women are more likely than men to develop chronic cough [18-20]
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Anatomy and neuro-pathophysiology of the cough reflex arc
C-fibers such as capsaicin, bradykinin, SO2, and citric acid evoke cough in conscious animals and in humans, and capsaicin desensitization abolishes citric acid-induced coughing in guinea pigs. <span>Sex-related differences in cough reflex sensitivity explain the observation that women are more likely than men to develop chronic cough [18-20]. The mechanical events of a cough can be divided into three phases [21]: 1. Inspiratory phase: Inhalation, which generates the volume necessary for an effective cough. 2. Compression ph




#GarjoToux
The specific pattern of the cough depends on the site and type of stimulation. Mechanical laryngeal stimulation results in immediate expiratory stimulation (sometimes termed the expiratory reflex), probably to protect the airway from aspiration; stimulation distal to the larynx causes a more prominent inspiratory phase, presumably to generate the airflow necessary to remove the stimulus.
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Anatomy and neuro-pathophysiology of the cough reflex arc
s, resulting in high expiratory airflow and the coughing sound. Large airway compression occurs. The high flows dislodge mucus from the airways and allow removal from the tracheobronchial tree. <span>The specific pattern of the cough depends on the site and type of stimulation. Mechanical laryngeal stimulation results in immediate expiratory stimulation (sometimes termed the expiratory reflex), probably to protect the airway from aspiration; stimulation distal to the larynx causes a more prominent inspiratory phase, presumably to generate the airflow necessary to remove the stimulus. During vigorous coughing, intrathoracic pressures may reach 300 mm Hg and expiratory velocities approach 800 kilometers per hour [22]. While these pressures and velocities are responsib




#GarjoToux
Cough-induced rib fractures are another painful and potentially serious complication of chronic cough. Fractures often involve multiple ribs, particularly ribs five through seven. Women with decreased bone density are at the greatest risk of this complication; however, fractures can occur in patients with normal bone density as well [24]
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Anatomy and neuro-pathophysiology of the cough reflex arc
many of the complications of cough, including exhaustion, self-consciousness, insomnia, headache, dizziness, musculoskeletal pain, hoarseness, excessive perspiration, urinary incontinence [23]. <span>Cough-induced rib fractures are another painful and potentially serious complication of chronic cough. Fractures often involve multiple ribs, particularly ribs five through seven. Women with decreased bone density are at the greatest risk of this complication; however, fractures can occur in patients with normal bone density as well [24]. A nonproductive cough is a well-recognized complication of treatment with angiotensin converting enzyme (ACE) inhibitors, occurring in up to 15% of patients treated with these agents [




#GarjoToux
During vigorous coughing, intrathoracic pressures may reach 300 mm Hg and expiratory velocities approach 800 kilometers per hour [22]
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Anatomy and neuro-pathophysiology of the cough reflex arc
probably to protect the airway from aspiration; stimulation distal to the larynx causes a more prominent inspiratory phase, presumably to generate the airflow necessary to remove the stimulus. <span>During vigorous coughing, intrathoracic pressures may reach 300 mm Hg and expiratory velocities approach 800 kilometers per hour [22]. While these pressures and velocities are responsible for the beneficial effects of cough on mucus clearance, they are also responsible for many of the complications of cough, including




#GarjoToux
A nonproductive cough is a well-recognized complication of treatment with angiotensin converting enzyme (ACE) inhibitors, occurring in up to 15% of patients treated with these agents [25]. Although the pathogenesis of the cough is not known with certainty, it has commonly been hypothesized that accumulation of bradykinin, which is normally degraded in part by ACE, may stimulate afferent C-fibers in the airway [26]
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Anatomy and neuro-pathophysiology of the cough reflex arc
cularly ribs five through seven. Women with decreased bone density are at the greatest risk of this complication; however, fractures can occur in patients with normal bone density as well [24]. <span>A nonproductive cough is a well-recognized complication of treatment with angiotensin converting enzyme (ACE) inhibitors, occurring in up to 15% of patients treated with these agents [25]. Although the pathogenesis of the cough is not known with certainty, it has commonly been hypothesized that accumulation of bradykinin, which is normally degraded in part by ACE, may stimulate afferent C-fibers in the airway [26]. The important observation that cough does not appear to occur with increased frequency in patients treated with angiotensin II receptor antagonists (which do not increase kinin levels)




#GarjoToux
Another rare cause of chronic cough is Holmes-Adie syndrome due to autonomic dysfunction affecting the vagus nerve [36] patients present anisocoria, abnormal deep tendon reflexes, and patchy areas of hyperhidrosis or anhidrosis
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Anatomy and neuro-pathophysiology of the cough reflex arc
usual cause of chronic dry cough [33]. The etiology of the ‘ear-cough’ (or oto-respiratory) reflex is related to stimulation of the auricular branch of the vagus nerve (Arnold's nerve) [34,35]. <span>Another rare cause of chronic cough is Holmes-Adie syndrome due to autonomic dysfunction affecting the vagus nerve [36] patients present anisocoria, abnormal deep tendon reflexes, and patchy areas of hyperhidrosis or anhidrosis. In adults, habit (also known as ‘psychogenic’) cough may rarely be the cause of a chronic cough that remains troublesome despite a thorough evaluation, including ruling out tic disorde




#GarjoToux
Irritation of the external auditory canal by impacted foreign bodies or cerumen is another unusual cause of chronic dry cough [33]. The etiology of the ‘ear-cough’ (or oto-respiratory) reflex is related to stimulation of the auricular branch of the vagus nerve (Arnold's nerve) [34,35]
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Anatomy and neuro-pathophysiology of the cough reflex arc
viduals [32]. Following tonsillectomy, these patients had decreased cough sensitivity and significantly improved symptom control. At this moment, these observations need further investigations. <span>Irritation of the external auditory canal by impacted foreign bodies or cerumen is another unusual cause of chronic dry cough [33]. The etiology of the ‘ear-cough’ (or oto-respiratory) reflex is related to stimulation of the auricular branch of the vagus nerve (Arnold's nerve) [34,35]. Another rare cause of chronic cough is Holmes-Adie syndrome due to autonomic dysfunction affecting the vagus nerve [36] patients present anisocoria, abnormal deep tendon reflexes, and




#GarjoToux
Differences among several sites from which cough stimuli can originate may result in variations in the sounds and patterns of coughing
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Anatomy and neuro-pathophysiology of the cough reflex arc
osis. In adults, habit (also known as ‘psychogenic’) cough may rarely be the cause of a chronic cough that remains troublesome despite a thorough evaluation, including ruling out tic disorders. <span>Differences among several sites from which cough stimuli can originate may result in variations in the sounds and patterns of coughing. Laryngeal stimulation produces a choking type of cough without a preceding inspiration. Inadequate mucociliary clearance mechanisms (as in bronchiectasis or cystic fibrosis) may produc




#GarjoToux
Laryngeal stimulation produces a choking type of cough without a preceding inspiration
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Anatomy and neuro-pathophysiology of the cough reflex arc
thorough evaluation, including ruling out tic disorders. Differences among several sites from which cough stimuli can originate may result in variations in the sounds and patterns of coughing. <span>Laryngeal stimulation produces a choking type of cough without a preceding inspiration. Inadequate mucociliary clearance mechanisms (as in bronchiectasis or cystic fibrosis) may produce a pattern of coughing with less violent acceleration of air and a sequence of interrup




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Inadequate mucociliary clearance mechanisms (as in bronchiectasis or cystic fibrosis) may produce a pattern of coughing with less violent acceleration of air and a sequence of interrupted expirations without any intervening inspiration
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Anatomy and neuro-pathophysiology of the cough reflex arc
s from which cough stimuli can originate may result in variations in the sounds and patterns of coughing. Laryngeal stimulation produces a choking type of cough without a preceding inspiration. <span>Inadequate mucociliary clearance mechanisms (as in bronchiectasis or cystic fibrosis) may produce a pattern of coughing with less violent acceleration of air and a sequence of interrupted expirations without any intervening inspiration. Awareness of cough varies considerably: it can be distressing when it appears suddenly, especially if associated with discomfort due to chest pain, dyspnea, or copious secretions, whil




#GarjoToux
Since cough is an important defensive reflex, required to maintain the health of the lungs, people who do not cough effectively are at risk of atelectasis, recurrent pneumonia, and chronic airways disease from aspiration and retention of secretions
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Anatomy and neuro-pathophysiology of the cough reflex arc
st pain, dyspnea, or copious secretions, while a cough that develops over decades (e.g. in a smoker with chronic bronchitis) may be hardly noticeable or may be considered normal by the patient. <span>Since cough is an important defensive reflex, required to maintain the health of the lungs, people who do not cough effectively are at risk of atelectasis, recurrent pneumonia, and chronic airways disease from aspiration and retention of secretions. Many disorders can impair the ability to cough effectively, which may result in persistent cough. The elderly, newborns, lung transplant recipients, and patients with paralysis or neur




#GarjoToux
The vagus is the most important afferent nerve, although the glossopharyngeal and trigeminal nerves may operate, depending on the receptors involved
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
demonstrated or suspected in other sites, including the pharynx, peripheral airways, and other intra- or extrathoracic sites such as pleura, ear canals, tympanic membrane, and even the stomach. <span>The vagus is the most important afferent nerve, although the glossopharyngeal and trigeminal nerves may operate, depending on the receptors involved. A medullary cough center has been postulated with no proof of its precise anatomic location. This "center" is under the influence of the higher voluntary nerve centers, which may initi




#GarjoToux
The combination of a high airflow and airway narrowing results in the expulsion of an airstream with a linear velocity sometimes nearing the speed of sound.
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
ngs once the glottis is open. In addition, the pressure difference between the outside and the inside of the intrathoracic airways during phase 4 causes their dynamic compression and narrowing. <span>The combination of a high airflow and airway narrowing results in the expulsion of an airstream with a linear velocity sometimes nearing the speed of sound. The blast of air thus produced is capable of expelling the secretions with a great force. The site and the extent of the dynamic compression are determined by the lung volumes. With lar




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With large lung volumes, only the trachea and large bronchi are compressed; with smaller lung volumes, more distal airways are also narrowed
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
speed of sound. The blast of air thus produced is capable of expelling the secretions with a great force. The site and the extent of the dynamic compression are determined by the lung volumes. <span>With large lung volumes, only the trachea and large bronchi are compressed; with smaller lung volumes, more distal airways are also narrowed. With each successive cough without an intervening inspiration, as seen in patients with chronic bronchitis, lung volumes become smaller, and the cough becomes effective also in removin




#GarjoToux
Variation in sounds of coughing is due to several factors, including the nature and quantity of secretions, anatomic differences and pathologic change of the larynx and other air passages, and the force of the cough
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
e cycle repeats itself. The characteristic explosive sound of coughing results from the vibrations of the vocal cords, mucosal folds above and below the glottis, and the accumulated secretions. <span>Variation in sounds of coughing is due to several factors, including the nature and quantity of secretions, anatomic differences and pathologic change of the larynx and other air passages, and the force of the cough. Vibrations of coughing also help in dislodging secretions from the airway walls. The small amounts of tracheobronchial secretions normally produced are very effectively handled by the




#GarjoToux
With an adequate function of the mucociliary escalator, the cough has no additional benefit in removing the amount of secretions formed under normal conditions. In pathologic states, however, when the mucociliary function is ineffective or insufficient because of the quantity or alteration of the physical properties of secretions, the cough becomes essential for airway clearance
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
ts formation and its clearance maintains a thin protective layer of mucus for trapping and removing the impurities of the inspired air while preventing the excessive accumulation of secretions. <span>With an adequate function of the mucociliary escalator, the cough has no additional benefit in removing the amount of secretions formed under normal conditions. In pathologic states, however, when the mucociliary function is ineffective or insufficient because of the quantity or alteration of the physical properties of secretions, the cough becomes essential for airway clearance. Although coughing is most effective when the excessive secretions are accumulated in the large, centrally located airways, it also plays an important role in clearing the peripheral ai




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Mucous sputum is clear or translucent and viscous, containing only small numbers of microscopic elements. Purulent sputum is off-white, yellow or green, and opaque. It indicates the presence of large numbers of white blood cells, especially neutrophilic granulocytes. In asthmatics, the sputum may look purulent from the eosinophilic cells. Red coloration, uniform or streaky, is usually due to its mixture with blood. Carbon particles discolor the sputum gray (as in cigarette smokers) or black (as in coal miners or with smoke inhalation)
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
ic tissues or cells, aspirated vomitus, or other foreign particles. Gross appearance and other physical characteristics of the sputum are the result of its content of these and other materials. <span>Mucous sputum is clear or translucent and viscous, containing only small numbers of microscopic elements. Purulent sputum is off-white, yellow or green, and opaque. It indicates the presence of large numbers of white blood cells, especially neutrophilic granulocytes. In asthmatics, the sputum may look purulent from the eosinophilic cells. Red coloration, uniform or streaky, is usually due to its mixture with blood. Carbon particles discolor the sputum gray (as in cigarette smokers) or black (as in coal miners or with smoke inhalation). Go to: Clinical Significance As a cardinal manifestation of respiratory diseases, coughing is one of the most common symptoms encountered in clinical medicine. Being a physiologic refl




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Pathologic conditions causing the cough are usually the ones that irritate the airways, increase their irritability, result in their deformation, or increase the tracheobronchial secretions
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
may be a voluntary act or may result from nervous habit. Although the clinical significance of coughing in many instances is trivial, it may be an indication of a serious intrathoracic disease. <span>Pathologic conditions causing the cough are usually the ones that irritate the airways, increase their irritability, result in their deformation, or increase the tracheobronchial secretions. These factors may operate singly or in various combinations. Sputum production with coughing occurs when the respiratory tract secretions are beyond the ability of the mucociliary mech




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Sputum production with coughing occurs when the respiratory tract secretions are beyond the ability of the mucociliary mechanism to deal with them
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
es that irritate the airways, increase their irritability, result in their deformation, or increase the tracheobronchial secretions. These factors may operate singly or in various combinations. <span>Sputum production with coughing occurs when the respiratory tract secretions are beyond the ability of the mucociliary mechanism to deal with them. The most common cause of the acute cough of clinical significance is viral tracheobronchitis. The cough in this transient and self-limited condition is, at the beginning, nonproductive




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Inflammation of the respiratory tract mucosa, from infectious or noninfectious causes, results in hyper-reactivity of the cough receptors. This results from the alteration of the surface epithelium, making them more sensitive to the cough-producing effect of commonly occurring mild irritants such as cold air, respiratory pollutants, deep or fast respiration, and excessive use of the larynx. At times, the mechanical irritation of coughing itself brings about more coughing
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
gh in this transient and self-limited condition is, at the beginning, nonproductive and quite annoying; later it becomes productive of mucous or mucopurulent sputum before it begins to subside. <span>Inflammation of the respiratory tract mucosa, from infectious or noninfectious causes, results in hyper-reactivity of the cough receptors. This results from the alteration of the surface epithelium, making them more sensitive to the cough-producing effect of commonly occurring mild irritants such as cold air, respiratory pollutants, deep or fast respiration, and excessive use of the larynx. At times, the mechanical irritation of coughing itself brings about more coughing. Inflammation, in addition, increases the secretions. In acute viral respiratory tract infection, post-nasal drip may be another cause for triggering the cough. Other infectious, as wel




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As chronic bronchitis and lung cancer are very uncommon among nonsmokers, a chronic persistent cough has a different significance in this population. Airway hyperreactivity, the hallmark of bronchial asthma, is a rather common condition in which the cough may be the predominant or even the sole manifestation
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
ncer has become most feared among the people with a chronic cough. The cough in lung cancer may develop de novo when there is no underlying chronic bronchitis and may be its only manifestation. <span>As chronic bronchitis and lung cancer are very uncommon among nonsmokers, a chronic persistent cough has a different significance in this population. Airway hyperreactivity, the hallmark of bronchial asthma, is a rather common condition in which the cough may be the predominant or even the sole manifestation. Patients with hyperreactive airways, without other manifestations of asthma, may have a chronic cough for as long as several years until the condition is suspected, accurately diagnose




#GarjoToux
Left-sided heart failure not only results in a cough with acute pulmonary edema but also may be a cause of a chronic nocturnal cough. Recurrent aspiration is another condition in which the cough characteristically occurs in a supine position. Foreign-body aspiration should always be considered in the differential diagnosis of the chronic cough. After the initial coughing or choking episode at the time of its aspiration, the cough may restart and continue long after the incident
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
o clear the throat are very suggestive of this disorder. The chronic cough may be a manifestation of many other pathologic conditions involving the intra- and extrathoracic organs (Table 38.1). <span>Left-sided heart failure not only results in a cough with acute pulmonary edema but also may be a cause of a chronic nocturnal cough. Recurrent aspiration is another condition in which the cough characteristically occurs in a supine position. Foreign-body aspiration should always be considered in the differential diagnosis of the chronic cough. After the initial coughing or choking episode at the time of its aspiration, the cough may restart and continue long after the incident. Other, less common intraluminal or compressing lesions of the tracheobronchial tree, chronic inflammatory or fibrosing lung diseases, and extrapulmonary lesions may have cough as their




#GarjoToux
Chronic expectoration of large amounts of purulent and foul-smelling sputum is strongly suggestive of bronchiectasis. Sudden production of such a sputum in a febrile patient indicates a lung abscess. Rust-colored purulent sputum in pneumococcal pneumonia, currant jelly and sticky sputum in klebsiella pneumonia, and blood-tinged foamy sputum in pulmonary edema are other examples in which the diagnosis of the underlying disease is strongly suggested
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Cough and Sputum Production - Clinical Methods - NCBI Bookshelf
of a dry, annoying, and often incessant cough, which disappears only after the discontinuation of these agents. Characteristics of expectorated sputum often suggest the diagnosis of its cause. <span>Chronic expectoration of large amounts of purulent and foul-smelling sputum is strongly suggestive of bronchiectasis. Sudden production of such a sputum in a febrile patient indicates a lung abscess. Rust-colored purulent sputum in pneumococcal pneumonia, currant jelly and sticky sputum in klebsiella pneumonia, and blood-tinged foamy sputum in pulmonary edema are other examples in which the diagnosis of the underlying disease is strongly suggested. A cough with the expectoration of blood (hemoptysis) is discussed in Chapter 39. Go to: References Coulter DM, Edwards IR. Cough associated with captopril and enalapril. Br Med J. 1987




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Total urinary protein excretion in the normal adult should be less than 150 mg/day.
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opics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2020. | This topic last updated: Jan 22, 2020. INTRODUCTION — <span>Total urinary protein excretion in the normal adult should be less than 150 mg/day. Higher rates of protein excretion that persist beyond a single measurement should be evaluated, as they often imply an increase in glomerular permeability that allows the filtration of




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In this study of 1011 patients, of whom 68 had a kidney biopsy, the ratio of the urine albumin to total protein concentration was generally less than 0.4 in patients with tubular or overflow proteinuria and greater than 0.4 in patients with predominantly glomerular proteinuria
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se. Measuring the urine concentrations of both albumin and total protein (with either two separate tests or with a urine protein electrophoresis) can help determine the type of proteinuria [2]. <span>In this study of 1011 patients, of whom 68 had a kidney biopsy, the ratio of the urine albumin to total protein concentration was generally less than 0.4 in patients with tubular or overflow proteinuria and greater than 0.4 in patients with predominantly glomerular proteinuria. Glomerular proteinuria — Glomerular proteinuria is due to increased filtration of macromolecules (such as albumin) across the glomerular capillary wall. This is a sensitive marker for




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In one study of more than 2000 patients, for example, a urine dipstick for proteinuria of 2+ or higher was predictive of significant proteinuria (urine protein-to-creatinine ratio (UPCR) greater than or equal to 500 mg/g) regardless of the specific gravity; however, a urine dipstick for proteinuria of trace or 1+ was only predictive of significant proteinuria if the specific gravity was 1.025 or less [9]
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n urine concentration. Limited data suggest that using the urine-specific gravity to judge urine concentration may improve the ability to identify abnormal proteinuria with the dipstick [9,10]. <span>In one study of more than 2000 patients, for example, a urine dipstick for proteinuria of 2+ or higher was predictive of significant proteinuria (urine protein-to-creatinine ratio (UPCR) greater than or equal to 500 mg/g) regardless of the specific gravity; however, a urine dipstick for proteinuria of trace or 1+ was only predictive of significant proteinuria if the specific gravity was 1.025 or less [9]. False positive urine dipstick results may occur in the following settings: ●After the use of iodinated radiocontrast agents [11]. Thus, the urine should not be tested for protein with




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False positive urine dipstick results may occur in the following settings:

● After the use of iodinated radiocontrast agents [11]. Thus, the urine should not be tested for protein with the standard dipstick for at least 24 hours after a contrast study.

● With a highly alkaline urine (pH greater than 8) [12,13].

● In the presence of gross hematuria and a urocrit (the percent of urine volume comprised of red blood cells) greater than 1 percent [14].

● When specific antiseptics (eg, chlorhexidine, benzalkonium) are used for clean-catch urine samples [15]

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mg/g) regardless of the specific gravity; however, a urine dipstick for proteinuria of trace or 1+ was only predictive of significant proteinuria if the specific gravity was 1.025 or less [9]. <span>False positive urine dipstick results may occur in the following settings: ●After the use of iodinated radiocontrast agents [11]. Thus, the urine should not be tested for protein with the standard dipstick for at least 24 hours after a contrast study. ●With a highly alkaline urine (pH greater than 8) [12,13]. ●In the presence of gross hematuria and a urocrit (the percent of urine volume comprised of red blood cells) greater than 1 percent [14]. ●When specific antiseptics (eg, chlorhexidine, benzalkonium) are used for clean-catch urine samples [15]. Sulfosalicylic acid test — In contrast to the urine dipstick, which primarily detects albumin, SSA detects all proteins in the urine at a sensitivity of 5 to 10 mg/dL [1]. Use of SSA i




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As a general rule in adults under the age of 50 years, daily creatinine excretion should be 20 to 25 mg/kg (177 to 221 micromol/kg) of lean body weight in men and 15 to 20 mg/kg (133 to 177 micromol/kg) of lean body weight in women. From the ages of 50 to 90 years, there is a progressive 50 percent decline in creatinine excretion (to approximately 10 mg/kg in men, lower in women) due primarily to a fall in muscle mass. Formulas that incorporate race and weight with or without serum phosphorous in addition to age and sex may improve the estimation of creatinine excretion
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(Over- and under-collections are common.) The adequacy of the collection can be estimated by quantifying the 24-hour urine creatinine and comparing this value to the expected urine creatinine. <span>As a general rule in adults under the age of 50 years, daily creatinine excretion should be 20 to 25 mg/kg (177 to 221 micromol/kg) of lean body weight in men and 15 to 20 mg/kg (133 to 177 micromol/kg) of lean body weight in women. From the ages of 50 to 90 years, there is a progressive 50 percent decline in creatinine excretion (to approximately 10 mg/kg in men, lower in women) due primarily to a fall in muscle mass. Formulas that incorporate race and weight with or without serum phosphorous in addition to age and sex may improve the estimation of creatinine excretion. This is discussed elsewhere in more detail. (See "Assessment of kidney function", section on 'Limitations of using creatinine clearance' and "Patient education: Collection of a 24-hour




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However, the UPCR may produce errors when applied to the individual patient, especially in those who consistently excrete much more (or less) than 1 g/day of creatinine (which is typical for younger men and many younger women) or in those who are losing or gaining muscle mass
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ine is equivalent to 3.4 mg/mmol creatinine. The UPCR is easy for patients and providers, and the correlation with daily protein excretion is reasonably good on the population level (figure 1). <span>However, the UPCR may produce errors when applied to the individual patient, especially in those who consistently excrete much more (or less) than 1 g/day of creatinine (which is typical for younger men and many younger women) or in those who are losing or gaining muscle mass. (See 'Limitations of the UPCR and UACR' below.) The UPCR and the UACR in spot urine samples are both supported by Kidney Disease: Improving Global Outcomes (KDIGO) as appropriate metho




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The UPCR is useful on the population level because the average 24-hour urine creatinine excretion for the population is assumed to be approximately 1000 mg/day (8.84 mmol/day) per 1.73 m2.
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daily creatinine production. ●Urine protein excretion can vary throughout the day (especially resulting from exercise and posture) and from day to day [27]. Influence of the urine creatinine — <span>The UPCR is useful on the population level because the average 24-hour urine creatinine excretion for the population is assumed to be approximately 1000 mg/day (8.84 mmol/day) per 1.73 m2. Since the denominator of the UPCR is in grams of creatinine (ie, grams of protein per 1 gram of creatinine), the UPCR is an accurate estimate of 24-hour proteinuria only in someone who




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● In individuals with large muscle mass, in whom creatinine excretion may be much higher than 1000 mg/day, the UPCR (or UACR) will underestimate proteinuria.

● In a cachectic patient or a patient with small muscle mass, in whom creatinine excretion may be much lower than 1000 mg/day, the UPCR (or UACR) will overestimate proteinuria

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1170 mg/day [30]. In addition, the accuracy of the ratio is diminished if creatinine excretion is either markedly higher or lower than the average population value of 1000 mg/day. Specifically: <span>●In individuals with large muscle mass, in whom creatinine excretion may be much higher than 1000 mg/day, the UPCR (or UACR) will underestimate proteinuria. ●In a cachectic patient or a patient with small muscle mass, in whom creatinine excretion may be much lower than 1000 mg/day, the UPCR (or UACR) will overestimate proteinuria. The following studies illustrate how variability in the urine creatinine among individuals can create erroneous estimates of 24-hour proteinuria: ●In a study of 16,000 men and women re




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In addition, all patients with persistent proteinuria that is greater than 500 mg/day for total protein (or an estimated protein excretion rate [ePER] greater than 0.5 g/day) or greater than 300 mg/day for albumin (or an estimated albumin excretion rate [eAER] greater than 300 mg/day) should be referred to a nephrologist for decisions regarding further evaluation and management (eg, kidney biopsy, discussed below)
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tiple myeloma: Clinical features, laboratory manifestations, and diagnosis".) ●A kidney ultrasound examination to rule out structural causes (eg, reflux nephropathy, polycystic kidney disease). <span>In addition, all patients with persistent proteinuria that is greater than 500 mg/day for total protein (or an estimated protein excretion rate [ePER] greater than 0.5 g/day) or greater than 300 mg/day for albumin (or an estimated albumin excretion rate [eAER] greater than 300 mg/day) should be referred to a nephrologist for decisions regarding further evaluation and management (eg, kidney biopsy, discussed below). Role of kidney biopsy — A kidney biopsy should generally be done in all patients with proteinuria of more than 3.5 g/day (ie, nephrotic range) or if non-nephrotic proteinuria is associ




Flashcard 6198131297548

Question
2 - 2020 USP - RP Você é médico(a) de família e comunidade e faz parte de uma equipe da Estratégia Saúde da Família. Semanalmente, um psiquiatra vêm até sua unidade para discutir casos complexos e realizar ações de educação permanente em saúde mental. Eventualmente, você também entra em contato, por telefone, com o psiquiatra sobre o manejo de pacientes com quadros agudos. O processo de trabalho descrito acima e a estratégia criada pelo Ministério da Saúde em 2008 são, respectivamente: A) matriciamento e Programa de Melhoria do Acesso e da Qualidade. B) telessaúde e Núcleo de Apoio à Saúde da Família. C) telessaúde e Programa de Melhoria do Acesso e da Qualidade. D) matriciamento e Núcleo de Apoio à Saúde da Família
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Flashcard 6198132346124

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Vamos começar relembrando que o matriciamento corresponde o suporte técnico-pedagógico realizado por profissionais de diversas áreas especializadas a uma equipe interdisciplinar, a fim de de ampliar o campo de atuação e qualificar suas ações aumentando a resolubilidade. O apoio matricial será formado por um ou mais profissionais que não têm, necessariamente, relação direta e cotidiana com o usuário, mas cujas tarefas serão de prestar apoio às equipes de referência. Desta forma, é possível atuar em saúde com duas ou mais equipes, num processo de construção compartilhada, aumentando a integralidade e atuando de acordo com a equidade! Afinal, não são todos os casos que necessitam de apoio matricial. Perceba que é exatamente isso que está acontecendo aqui… O psiquiatra do Núcleo de Apoio à Saúde da Família está realizando um apoio matricial com a equipe de Saúde da Família. Resposta: letra D.

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his paper demonstrates that the traditional categoriza- tion of innovation as either incremental or radical is in- complete and potentially misleading and does not account for the sometimes disastrous effects on industry incumbents of seemingly minor improvements in techno- logical products
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We show that architectural in- novations destroy the usefulness of the architectural knowledge of established firms, and that since architec- tural knowledge tends to become embedded in the struc- ture and information-processing procedures of estab- lished organizations, this destruction is difficult for firms to recognize and hard to correct. Architectural innovation therefore presents established organizations with subtle challenges that may have significant competitive implica- tions.
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We de- fine innovations that change the way in which the components of a product are linked together, while leaving the core design concepts (and thus the basic knowledge un- derlying the components) untouched, as "architectural" inno- vation.^
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