The detection of basophil leucocytosis is use- times demonstrated to be secreted by tumour cells ful in making the distinction between a myeloprolifera- [176 alavert 10mg generic milk allergy symptoms 1 year old,177] cheap 10 mg alavert with visa allergy forecast richmond va. Eosinophilia may also occur as a reaction tive neoplasm and a reactive condition order alavert australia allergy testing yakima wa, since only in Quantitative changes in blood cells 241 Table 6. Using multivari- Primary myelofbrosis Systemic mastocytosis ate analysis, lymphocytosis has been found predictive of Some cases of Ph‐positive acute lymphoblastic leukaemia mortality in hospitalised patients with general trauma Basophilic leukaemia or central nervous system injury [218]. Reactive basophilia In assessing a lymphocytosis it is important to con- Myxoedema (hypothyroidism) sider cytology as well as the lymphocyte count and both Ulcerative colitis should be assessed in relation to the age and clinical Juvenile rheumatoid arthritis [90] features of the patient. Children are more prone than Immediate hypersensitivity reactions Oestrogen administration adults to both lymphocytosis and reactive changes in Hyperlipidaemia lymphocytes, and even apparently healthy children Administration of interleukin 3 [73] may have some lymphocytes showing atypical features. Lymphoma [184] Lymphocytosis can occur without there being any Unknown nature cytological abnormality. This is usual when lymphocyto- Idiopathic hypereosinophilic syndrome sis is due to redistribution of lymphocytes (e. Post‐splenectomy lymphocytosis is usually mild, with only minor atypical features. However, it is important to realise that post‐splenectomy counts Lymphocytosis can be in excess of 10 × 109/1 and misdiagnosis as a lym- phoproliferative disorder has occurred. Large granular Lymphocytosis is an increase in the absolute lympho- lymphocytes are often prominent in post‐splenectomy cyte count above that expected in a healthy subject of lymphocytosis. Since the lymphocyte counts of infants mild lymphocytosis without cytological abnormalities. There are no gender or ethnic differ- granular lymphocytes can occur as a reactive change, e. The exception is large granular lymphocyte Monocytosis leukaemia, in which the neoplastic cells are usually cyto- logically indistinguishable from normal cells. The mature lymphocytes, but in fact subtle abnormalities are absolute monocyte count is higher in neonates than at Quantitative changes in blood cells 243 other stages of life. A rise occurs in pregnancy in parallel In examining a flm of a patient with an unexplained with the rise in the neutrophil count. Some of the com- monocytosis, evidence of chronic infection or myelodys- mon causes of monocytosis are shown in Table 6. A case of serum sick- Exercise ness due to tetanus antitoxin, for example, was found to Caffeine [216] 9 Chronic infection including miliary tuberculosis [224], congenital have 3. In reactive plasmacy- syphilis [225], typhoid fever [226] and leishmaniasis [227] tosis the plasma cells are usually mature, but occasion- Rocky Mountain spotted fever [90] ally plasmablasts are present. Plasma cells can contain Malaria [65] and babesiosis [228] vacuoles or, occasionally, crystals. Atypical lymphocytes Chronic infammatory conditions including Crohn disease, and plasmacytoid lymphocytes can also be present and ulcerative colitis, rheumatoid arthritis and systemic lupus cells of other lineages can show reactive changes. Recovery from bone marrow suppression Administration of desmopressin [77] Myocardial infarction [234] Table 6. Thrombocytosis is usually Blood flm and count the result of increased marrow production of platelets, Increased platelet size, platelet anisocytosis, the pres- either autonomous or reactive. Following splenectomy ence of poorly granulated platelets, circulating megakar- and in hyposplenism, thrombocytosis is due to redistri- yocyte nuclei or micromegakaryocytes and an increased bution of platelets. Some of the causes of thrombocyto- basophil count are all suggestive of a primary bone sis are shown in Table 6. It should be Large platelets are also seen in hyposplenism, whereas noted that as more and more routine platelet counts are in reactive thrombocytosis platelets are generally small performed on very sick patients, the percentage of even and normally granulated. The blood flm may also show very high platelet counts that are reactive is increasing abnormalities of other lineages, which indicate the cor- and myeloproliferative neoplasms are now responsible rect diagnosis. The features of hyposplenism should be for only 10–15% of counts greater than 1000 × 109/1. Platelet count >1000 × 109/l [273] >900 × 109/l [274] >1000 × 109/l [275] >500 × 109/l [276] Patients (n) 102 526 280 777 Cause Cases attributable (%) Malignant disease 45 27 11. Counts of greater than (i) defective production of red cells; (ii) reduced red cell 1500 × 109/l are usually indicative of a myeloprolifera- survival in the circulation due to haemolysis or blood tive neoplasm, but reactive thrombocytosis with counts loss; (iii) increased pooling of essentially normal red as high as 2000 × 109/l [275] and even 6000 × 109/l [277] cells in a large spleen; or (iv) sequestration of abnormal have been reported. Anaemia may be an isolated abnormality or indicative of increased platelet size and platelet anisocy- there may be pancytopenia (see below). Blood flm and count The blood flm and count commonly give a clue to the Further tests cause of the anaemia by showing microcytosis, macro- The cause of reactive thrombocytosis is usually readily cytosis or a specifc type of poikilocyte. When the cause is associated with these features are discussed in Chapter not apparent a bone marrow aspirate, trephine biopsy, 8. Indirect evidence favour- anaemia may have been caused by haemolysis or haem- ing a reactive thrombocytosis includes an increased orrhage. Various other rare and curious diffcult to distinguish iron defciency with a marked causes of anaemia exist, e. Causes of pure red cell aplasia are detailed a judicious trial of iron therapy may be needed. In these anaemia cases the differential diagnosis is more limited, as sum- marised in Table 6. Parvovirus B19‐induced In the perinatal period, the conditions responsible Drug‐induced [292], e. Other rare causes include anaemia phenytoin, isoniazid, ribavirin [295] Transient erythroblastopenia of childhood Table 6. Feto‐maternal haemorrhage (including following external cephalic version, amniocentesis, antepartum haemorrhage and abdominal Bone marrow infltration in carcinoma, lymphoma (Hodgkin trauma) lymphoma, non‐Hodgkin lymphoma), chronic lymphocytic Twin‐to‐twin haemorrhage leukaemia, multiple myeloma, acute lymphoblastic leukaemia or Haemorrhage resulting from amniocentesis or cordocentesis other malignant disease Myeloproliferative neoplasms, particularly primary myelofbrosis and Neonate chronic myelogenous leukaemia Haemorrhage from the cord or the placenta or internal haemorrhage Acute myeloid leukaemia and the myelodysplastic syndromes (e. Gaucher disease Twin–twin transfusion during birth Acute haemolysis (including erythroblastosis fetalis) Haemolytic disease of the newborn (e. Occasional Anaemia of chronic disease neonates are anaemic as a result of haemoglobin H dis- Bone marrow suppression by cytotoxic chemotherapy or other ease, Blackfan–Diamond syndrome, Pearson syndrome, bone marrow‐damaging drugs cartilage‐hair hypoplasia, congenital sideroblastic anae- Aplastic anaemia Pure red cell aplasia mia or osteopetrosis [310]. In the fetus and neonate, Acute leukaemia haemolytic anaemia may be the result of transplacen- Myelodysplastic syndromes (most cases) tal passage of antibodies (alloantibodies or, less often, maternal autoantibodies) or on intrauterine infections by micro‐organisms that in later life do not usually cause anaemia (e. The consequences of anae- count it is important not only to consider whether the mia also differ from those at other periods of life. Severe value falls within the reference range, but also whether anaemia in the fetus can lead to hydrops fetalis, a con- it is appropriate to the degree of anaemia and to any dition characterised by gross oedema of the fetus and shortening of red cell life span. In the haemolytic anaemia should have a reticulocyte count neonate, because of the immaturity of the liver, severe above the normal range; lack of reticulocytosis in such haemolysis can lead to marked hyperbilirubinaemia a patient may indicate pure red cell aplasia or folic acid with resultant brain damage. Further tests Leucopenia When the cause of anaemia is not apparent from the clinical history or the blood flm and count, other Leucopenia is a reduction of the total white cell count tests are needed. Those most likely to be useful are: (i) below that expected in a healthy subject of the same a reticulocyte count; (ii) assay of serum ferritin or of age, gender, physiological status and ethnic origin. It serum iron and transferrin concentrations; (iii) serum can result from a decrease in the neutrophil count, B12 and red cell folate assays; and (iv) tests of renal, thy- the lymphocyte count or both and cannot be inter- roid and hepatic function. If these investigations do not preted without knowledge of the differential count. When there is an unexplained leu- ciated with leucopenia rather than leucocytosis and coerythroblastic anaemia, other than during an acute the presence of leucopenia in a febrile patient can illness, a bone marrow aspirate and trephine biopsy are therefore be of some diagnostic use.

In Polycythaemia contrast order alavert 10mg visa allergy treatment holistic, secondary polycythaemia is generally medi- ated by increased erythropoietin production order online alavert allergy medicine levothyroxine, usually The term polycythaemia purchase alavert discount allergy store, strictly speaking, should indi- occurring either as a physiological response to hypoxia cate an increase in the number of red cells in the circu- or as a result of inappropriate secretion by a diseased lation but, in practice, the term is used for an increase kidney or by a tumour. Causes of polycythaemia are of the haemoglobin concentration (Hb) and haemato- summarised in Table 6. A raised Hb can be due to a decreased plasma volume occur- ring either acutely or chronically. An acute decrease in Reticulocytosis plasma volume can be caused by shock, when there is a loss of fuid from the intravascular compartment, or by Either the percentage or absolute reticulocyte count dehydration. With rare exceptions, an which can be very striking, occurs in the idiopathic cap- increased reticulocyte percentage indicates an increased illary leak syndrome [1]. Again with rare toxic shock syndrome, resulting from a bacterial toxin, exceptions, an increased absolute reticulocyte count and in capillary leak syndromes associated with viral indicates an increased marrow output of erythrocytes. Drinking a litre of water in a short Often both the percentage and absolute count are period of time causes a transient increase in Hb due to increased, but a patient with signifcant anaemia may increased sympathetic activity (which is followed by a have an increased percentage of reticulocytes without gradual reduction) [2]; this is unlikely to be noted other an increase in the absolute count. A chronic decrease in Causes of an increased reticulocyte count are shown plasma volume is sometimes due to cigarette smoking, in Table 6. Healthy neonates have Intra‐uterine twin‐to‐twin transfusion both a higher neutrophil count than is normal at other Intra‐uterine maternal‐to‐fetal transfusion stages of life and also a left shift. Similarly, women in Placental insuffciency and intrauterine hypoxia Small‐for‐dates babies the reproductive age range have somewhat higher neu- Post‐mature babies trophil counts than men, the count varying with the Maternal pregnancy‐associated hypertension menstrual cycle. During pregnancy, a marked rise in the Maternal smoking Maternal diabetes mellitus neutrophil count occurs and this is further accentuated Chromosomal abnormalities during labour and the postpartum period. In addition, Down syndrome pregnancy is associated with a left shift (with myelo- Trisomy 13 syndrome Trisomy 18 syndrome cytes and even a few promyelocytes appearing in the Neonatal thyrotoxicosis blood), with ‘toxic’ granulation and with Döhle bodies. Neonatal hypothyroidism Neutrophil leucocytosis is usually due to redistribution of Congenital adrenal hyperplasia Delayed cord clamping white cells or increased bone marrow output. Rarely, there Underwater labour with late cord clamping [38] is a prolongation of the period a neutrophil spends in the circulation. Vigorous exercise can double the neutro- Response to therapy in a patient with defciency of vitamin B12, phil count. The absolute number of lymphocytes, mono- folic acid or iron cytes, eosinophils and basophils also increases, but because Recovery from bone marrow (or erythroid) suppression or failure Administration of erythropoietin of the more striking increase in neutrophil numbers the Hypoxia increase of other cell types may go unnoticed. If exercise Diabetes mellitus (possibly representing compensated haemolysis) [39] is both severe and prolonged a left shift can occur, indicat- Rare causes ing that there is then increased bone marrow output in Delayed maturation of reticulocytes (in myelodysplastic syndrome) Genetic haemochromatosis [40] addition to redistribution. Patients do not usually undergo severe exercise before having a blood sample taken, but Leucocytosis epinephrine (adrenaline) administration and epileptiform convulsions can mobilise neutrophils similarly and even Leucocytosis is an increase in the total white blood cell severe pain can have an effect on the neutrophil count. It most often results from an increase in Corticosteroids also alter neutrophil kinetics. The output neutrophils, but sometimes from an increase in lympho- from the bone marrow is increased and there is a concomi- cytes and occasionally from an increase in eosinophils or tant decrease in egress to the tissues. Experiments in rabbits from the presence of abnormal myeloid or lymphoid cells suggest there is also mobilisation of neutrophils from the in the blood. Leu- occur, the elevation being predominantly due to neutro- cocytosis is predictive of a worse prognosis in sickle cell philia but with some increase also in the absolute mono- disease [41]. It is an adverse prognostic indicator in acute cyte count, and with a fall in the absolute eosinophil and coronary syndrome, stroke and pulmonary embolism lymphocyte counts. Neutrophilia in pathological conditions usually Neutrophil leucocytosis – neutrophilia results from increased output from the bone marrow, which more than compensates for any increased egress Neutrophil leucocytosis or neutrophilia is the elevation to the tissues. The major causes (and some minor of the absolute neutrophil count above that expected causes) of neutrophilia are shown in Table 6. When the eosinophil count is greatly elevated (greater An increased neutrophil count can be of adverse than 10 × 109/1) the likely causes are far fewer (Table prognostic signifcance. Allergic conditions causing eosinophilia are nosis in sickle cell anaemia and for short‐term prog- usually readily apparent from the patient’s medical nosis in unstable angina and following myocardial history but, in the case of parasitic infections, the lab- infarction. Maternal smoking Maternal fever Those who have been in areas of Africa where Schis- Prolonged intrapartum oxytocin administration tosoma haematobium occurs should have serology plus Administration of dexamethasone microscopy of a terminal urine specimen. Fetal factors In hospital patients, eosinophilia can be a useful sign Stressful delivery of drug allergy. Following bone marrow transplantation, Birth asphyxia or other hypoxia eosinophilia may be a feature of graft‐versus‐host dis- Crying ease and has been found to be predictive of extensive Physiotherapy scleroderma‐like changes [166]. In patients with Meconium aspiration syndrome symptoms suggestive of obstructive pulmonary dis- Hyaline membrane disease with pneumothorax ease, the presence of eosinophilia usually indicates a Thrombocytopenia with absent radii reversible or asthmatic component, although it does not necessarily indicate allergic rather than other trig- gering factors [173]. In uncomplicated asthma the eosinophil leucocytosis – eosinophilia eosinophil count is rarely in excess of 2 × 109/l. Higher counts, often in association with deteriorating pulmo- Eosinophil leucocytosis or eosinophilia is the eleva- nary function, may indicate either allergic aspergillosis tion of the eosinophil count above levels observed in healthy subjects of the same age with no history of allergy. Contrary to earlier reports, fever), acute urticaria, allergic bronchopulmonary aspergillosis counts do not differ between different ethnic groups. Disease Parasite Usual degree of eosinophilia∗ Protozoan Dientamoeba fragilis infection [95] Dientamoeba fragilis Absent or mild [96] Isospora belli infection [95] Isospora belli Absent, in immunosuppressed patients, or mild [96] Blastocystis hominis infection [97] Blastocystis hominis Eosinophilic myositis Sarcocystis hominis Rarely causes marked eosinophilia [98] Giardiasis Giardia lamblia Rarely causes marked eosinophilia [99] Nematode (roundworm) infections Hookworm infection Ancylostoma duodenale (Old World hookworm) Absent in chronic infection, mild or Necator americanus (New World hookworm) moderate during stage of larval Ancylostoma ceylanicum [100] migration through the lung (Löffer Ancylostoma caninum syndrome) [96] Cutaneous larva migrans Ancylostoma braziliense (dog and cat hookworm) [101] Rarely associated with eosinophilia Ancylostoma caninum (dog hookworm) [101] Gnathostoma doloresi [102] Epidemic eosinophilic enteritis [103] Ancylostoma caninum (dog hookworm) Ascariasis Ascaris lumbricoides (large intestinal roundworm) Absent during adult stage, moderate during stage of larval migration through the lungs (Löffer syndrome) [96] Strongyloidiasis Strongyloides stercoralis (threadworm)† Absent, mild or moderate; moderate during stage of larval migration through the lungs (Löffer syndrome) [96]; usually present in stronglyloides hyperinfection in immunosuppressed subjects Trichuriasis [101] Trichuris trichiuria (whipworm) Absent or mild [96] Trichinellosis, trichinosis [101] Trichinella spiralis (trichina worm) Moderate or marked during the acute phase [96] Capillariasis [101,104,105] Hepatic infection by Capillaria hepatica (Calodium hepaticum), a roundworm of rodents, or intestinal infection by Capillaria philippinensis Trichostrongyliasis [101,106] Trichostrongylus colubriformis (a roundworm of sheep) Anisakidodis [107] Anisakis simplex and Anisakis pegreff (anasakiasis) Parasitic worms of fsh Contracaecum osculatum Pseudoterranova decipiens (pseudoterranovosis) Enterobiasis Enterobius vermicularis (pinworm or threadworm†) Rarely causes eosinophilia but may do so when there is enteritis [108] Filariasis (lymphatic flariasis including Wuchereria bancrofti (Bancroft’s flaria) Mild, moderate or marked, marked in tropical pulmonary eosinophilia Brugia malayi (Malayan flaria) tropical pulmonary eosinophilia [96] resulting from occult lymphatic Brugia timori (Timorian flariasis) flariasis) Loiasis [101] Loa loa (eyeworm) Moderate or marked [96] Onchocerciasis (river blindness) [101] Onchocerca volvulus (blinding flaria) Mild, moderate or marked [96] Mansonellosis [101] Mansonella perstans Diroflariasis (tropical eosinophilia, Diroflaria immitis (dog heartworm), Diroflaria eosinophilic pneumonia) repens (roundworm of dogs, cats and foxes) [109] Dracunculiasis [101] Subcutaneous infection by Dracunculus medinensis (Guinea worm) Spirurina type X infection [110] (continued) 238 Chapter 6 Table 6. Ascaris suum [113,114] Capillaria hepatica Eosinophilic myositis (Tasmania and Haycocknema perplexum [115] Mild eosinophilia Queensland) Trematode (fuke) infection Clonorchiasis Clonorchis sinensis (Oriental or Chinese liver fuke) Absent or mild in chronic infection, may be moderate or marked in acute infection Fascioliasis (liver fuke infection) Fasciola hepatica (sheep liver fuke) [116] Mild, moderate or marked during Fasciola gigantica [101] stage of larval migration [96] Metorchis conjunctus (North American liver fuke) [117] Fasciolopsiasis (intestinal fuke infection) Fasciolopsis buski (large intestinal fuke) [101,106] Marked eosinophilia Heterophyiasis or echinostomiasis [101] Heterophyes heterophyes or Echinostoma spp (intestinal fukes) Opisthorchiasis [101] Opisthorchis viverrini (a South‐East Asian liver fuke) Usually absent or mild, may be or Opisthorchis felineus (a Russian liver fuke, also moderate or marked in early found in Italy) infection Paragonimiasis, distomiasis [101] Paragonimus westermani (Oriental lung fuke) [118] Marked eosinophilia Schistosomiasis Schistosoma mansoni Usually absent or mild but may Schistosoma haematobium be moderate to high in acute Schistosoma intercalatum schistosomiasis (Katayama Schistosoma mekongi fever) [96] Cestode (tapeworm) infection Cysticercosis Larval stage of Taenia solium (pig tapeworm) Absent or mild, may be moderate if encysted larvae die and release antigen [96] Echinococcosis (hydatid cyst) Larval stage of Echinococcus granulosus Absent or mild, may increase if cysts (dog tapeworm) rupture or leak [96] Coenurosis [101 Coenurus cerebralis (larval stage of a dog tapeworm, Taenia multiceps, which rarely occurs in man) Hymenolepsiasis [101] Hymenolepis nana (dwarf tapeworm) Sparganosis [101] Spirometra ssp, e. Sparganum mansoni Absent or mild Arthropods Scabies (ectoparasite) [119] Sarcoptes scabiei Pentastomiasis (endoparasite) [120] Armillifer moniliformis, Porocephalus taiwana, Armillifer agkistrodontis (tongue worms) Myiasis [121] Cutaneous larvae of fies ∗Mild = 0. The Churg–Strauss syndrome is a variant of polyarteritis nodosa character- Parasitic infections, e. Patients are also seen with some features of Hodgkin lymphoma classical polyarteritis nodosa and some of the Churg– Acute lymphoblastic leukaemia Strauss syndrome: this has been referred to as ‘chronic Chronic eosinophilic leukaemia necrotising vasculitis’ or ‘the overlap syndrome’. Allergic bronchopulmonary aspergillosis In Hodgkin lymphoma, isolated eosinophilia has been Hypersensitivity reactions to drugs (such as sulindac, associated with a better prognosis [179]. In some fenoprofen, ibuprofen, diclofenac, tenidap [167], amoxicillin, patients with an initially unexplained eosinophilia, an clarithromycin [168]) and chemicals (such as zinc, chromium or beryllium) occult T‐cell clone can be demonstrated [180]. Cocaine pneumonitis In a minority of cases, eosinophilia is neoplastic rather Churg–Strauss variant of polyarteritis nodosa and systemic than reactive. Bronchocentric granulomatosis [172] An absolute, or even a relative, eosinophilia can be Chronic idiopathic eosinophilic pneumonia useful in the intensive care ward setting, in alerting clini- Idiopathic hypereosinophilic syndrome cians to the possibility of adrenal insuffciency. Incidental eosinophilia in a blood count has been criterion in making the diagnosis of the Churg–Strauss found to be sometimes predictive of Hodgkin lymphoma syndrome or the overlap syndrome. The There remains a group of patients with persistent, combination of the characteristic X‐ray appearance with moderate or marked eosinophilia for which no cause eosinophilia has been considered suffcient to make the can be found despite detailed investigation. It is usually associated with widespread malignant disease, but rarely may pro- vide a clue to a localised tumour. Neutropenia is a reduction of the absolute neutro- phil count below that expected in a subject of the Reticulocytopenia same age, gender, physiological status and ethnic origin. It is particularly important to use an appro- Reticulocytopenia means that there is a reduction in priate reference range in individuals with African the absolute reticulocyte count below that expected in a ancestry, to avoid a misdiagnosis of neutropenia, healthy subject of the same age. Usually the reticulocyte since Africans and, to a lesser extent Afro‐Americans Quantitative changes in blood cells 249 and Afro‐Caribbeans, have neutrophil counts much as in immune neutropenias; and (vii) rapid egress lower than those of Caucasians. Neutropenia may be to the tissues when the bone marrow output cannot an isolated phenomenon or part of a pancytopenia. Mechanisms of neutropenia include: (i) inadequate An unexpected apparent neutropenia on an auto- production by the bone marrow because of reduced mated counter should always be confrmed on a blood stem cell numbers, bone marrow replacement or flm since it may be factitious (see Chapter 4).

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The tibial nerve divides into the medial calcaneal best alavert 10 mg allergy under eye, medial plantar cheap alavert online amex allergy testing ashby de la zouch, and lateral plantar branches near 1 the ankle cheap 10mg alavert amex allergy testing kerry. In some subjects the takeoff of the medial calcaneal branch from the tibial nerve can be imaged above the ankle joint. This neurovascular bundle, consisting of one artery and two veins, can have a Mickey Mouse ears appearance if light touch with the transducer is applied (similar to the appearance of the brachial artery and veins near the elbow). However, tibial nerve imaging can be diffcult in some surgical patients with peripheral vascular disease because vascular landmarks for the nerve are not present. Tibial nerve block in the leg avoids the footdrop that occurs with more proximal popliteal block of the sciatic nerve. Suggested Technique The tibial nerve can be approached in-plane from the posterior (Achilles) or anterior (tibial) side in supine position with the leg externally rotated using a short-axis view of the neuro- vascular bundle. The best point of tibial nerve imaging in the leg is usually halfway between the medial malleolus and the bulk of the gastrocnemius-soleus muscle complex in the calf. Place the block needle tip between the posterior tibial artery and the tibial nerve so as to enter the neurovascular compartment. With the posterior approach the Achilles tendon can lie close to the point of needle entry. With the anterior approach the saphenous vein can be close to the needle path near the skin surface. Externalphotographshowingposterior- to-anterior in-plane approach to tibial nerve block in the distal leg. This location is proximal to where the tibial nerve divides into its medial plantar, lateral plantar, and medial calcaneal branches. With a broad and deep view, both the tibia and fbula can be imaged deep to the nerve. Tibial nerve block in the distal leg showing the in-plane approach from posterior to anterior. Local anesthetic surrounds the tibial nerve and separates it from the posterior tibial artery. After injection, local anesthetic is distributed around the tibial nerve (A) and tracks along the nerve (B). This sonogram was obtained after ankle block performed using surface landmarks (not ultrasound guidance). Intercostal nerves are diffcult to image with ultrasound because they are small and often covered by the caudal edge of the corre- 1 sponding rib. Proximal intercostal nerves are found in the classic subcostal position in 17%, in the midzone in 73%, and in the inferior supracostal position in 10% of anatomic speci- mens. Doppler 2 ultrasound has been used to locate intercostal arteries for intercostal block. Intercostal arteries are 3 to 4 mm in diameter and can be detected in an acoustic window 4 cm from 3 the midline. Ultrasound-guided intercostal nerve block has been used for acute and chronic pain 4 management. Intercostal nerve blocks can be used for breast surgery and are best placed at T3, T4, and T5 for this procedure. This nerve supplies the lower abdominal wall and is not closely associated with the 12th rib. Suggested Technique Intercostal nerve imaging can be performed in the sitting, lateral, or prone position. This is particularly important when imaging the intercostal nerves above the ffth rib because of the overlying scapula and paraspinous muscles. When intercostal blocks are performed in sitting position, the right-handed opera- tor stands and turns to the patient’s right to view the imaging display regardless of the side of the block. In this location the nerves are shallow and relatively centrally located before branching. This also gives the block needle room to clear the inferior rib for in-plane approach. Because of the caudal angulation of the ribs, the transducer has a slight oblique orientation, with the trans- ducer and block needle directed slightly away from the midline. Hand-on-needle hub approach provides optimal needle control for intercostal blocks. Sonograms can sometimes demonstrate three layers of the intercostal muscles (external, 6 internal, and innermost) covering the pleural line. The neurovascular bundle lies between the internal and innermost intercostal muscles. Intercostal interspaces have a fying-bat 7 appearance on sagittal ultrasound scans because of acoustic shadowing of the ribs. For intercostal block the needle tip is placed near the caudal edge of the rib so that the needle tip can be identifed between the acoustic shadows from the bone. If the needle tip is placed in the correct layer, the local anesthetic will distribute under the rib. With intercostal nerve blocks, rapid and high peak plasma levels of local anesthetic are expected. One of the potential ben- efts of ultrasound guidance is reduction of the risk for pneumothorax. The chance of devel- oping a pneumothorax depends on the amount of aerated lung tissue traversed by the needle. The lung is particularly fragile in patients with chronic obstructive lung disease and emphy- sema. Demonstration of postinterventional lung sliding and comet-tail artifact from the pleura rule out pneumothorax. This examination is best performed over the nondependent portion of the lung (the anterior chest in supine position). Another potential beneft of ultrasound guidance for intercostal block is the avoidance of arterial puncture. This is particularly note- worthy because the tracking between the lower border of the ribs and the neurovascular bundle is not always precise. There is variability of the relationship between the caudal edge of the ribs and the neurovascular bundle, especially at the lower rib levels and farther from the paravertebral region. In this location the nerves are shallow and relatively centrally located before branching. The lung is particularly fragile in patients with chronic obstructive lung disease and emphysema. Ultrasound-guided intercostal nerve block for traumatic pneumothorax requiring tube thoracostomy. Thoracic paravertebral spread using two different ultrasound-guided intercostal injection techniques in human cadavers. External photograph showing the approach to intercostal nerve block in sitting position (A). The corresponding sonogram of the intercostal interspace before needle placement is shown (B).

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The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. The relationship between psychological factors and performance on the Biering-Sørensen back muscle endurance test. Core stability exercises in individuals with and without chronic nonspecific low back pain.

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The range of 150 to 200 beats/min is tolerated variably order 10mg alavert allergy symptoms kiwi, according to the factors noted previously cheap alavert 10 mg fast delivery allergy shots fatigue. Once the rate reaches and exceeds 200 beats/min buy 10 mg alavert with amex milk allergy symptoms in 5 year old, there are symptoms in virtually all patients. The algorithm proposed by Brugada may be helpful in making this distinction, and the algorithm is both sensitive (99%) and specific (96. If not, the diagnosis is supraventricular tachyarrhythmia with aberrant intraventricular conduction. After applying the preceding criteria, a second stepwise algorithm is applied (Fig. A patient who has no hemodynamic compromise can be treated medically, at least initially. Intravenous amiodarone, lidocaine, procainamide, β-blockers, and other oral agents may be given initially depending on the clinical scenario. Elimination of ischemia and correction of electrolyte abnormalities are recommended. Maneuvers including temporary pacing and agents that increase heart rate should be used. Offending agents should be stopped whenever possible, and antidotes should be administered in the case of overdosage and poisoning. Sotalol was seen to be the most effective, although even with sotalol, the recurrence rate was disappointing. Although both of these trials showed a decrease in arrhythmic deaths, no survival benefit was recorded. Calcium channel blockers are used primarily in the management of supraventricular tachyarrhythmia. In broad terms, the substrate can be divided into two categories: the structurally normal heart and the structurally abnormal heart. Various modalities are available to determine the cardiac structure and function, which include electrocardiography, cardiac catheterization, echocardiography, nuclear imaging, and magnetic resonance imaging. A cardiac magnetic resonance imaging or cardiac positron emission tomography scan may also be useful to rule out the presence of cardiac sarcoidosis, which also would fall into the category of the structurally abnormal heart. For longer term therapy in the symptomatic patient, β-blockers are typically the first-line agents and can be effective in up to 50% of patients. The nondihydropyridine calcium channel blockers may also be effective in 25% to 50% of patients. Very effective medications are sotalol and amiodarone, with up to 90% success rate in eliminating symptoms, but potential side effects may limit their use. Patients who wish to potentially avoid lifelong medications or who are refractory to medical therapy can be considered for ablation, which has variable success rate depending on the location. Ablation procedures, although generally safe, may be associated with infrequent but life- threatening complications, including cardiac perforation and tamponade. Various cardiac ion channel disturbances can predispose to ventricular arrhythmias. Clinical presentation includes syncope or sudden death as a result of torsade de pointes, and usually an autosomal dominant transmission pattern. Left cardiac sympathetic denervation can be used as an adjunctive therapy to reduce recurrence of arrhythmias. Two culprit genes have been identified thus far: calsequestrin 2 (autosomal recessive pattern) and cardiac ryanodine receptor (autosomal dominant pattern). At the cellular level, ischemia may alter action potentials, prolong refractoriness of cells, and uncouple the cell-to-cell propagation of depolarization. The biochemical milieu in which the cells exist with respect to ion concentrations, acid–base balance, and so forth can be altered. Also, the myocardial damage as a result of infarction is structurally heterogeneous. Therefore, scar tissue and healthy tissue are admixed in the region of the infarction. As described before, a reentrant circuit requires two functionally distinct pathways with unidirectional block in one pathway and slowed conduction down a second pathway. Of the 278 patients studied, 183 patients were determined to have ischemic causes. Other causes included electrolyte abnormalities, antiarrhythmic drug interaction, and “other (illicit drug use, sepsis, hypoxia, electrocution, drowning). It may be seen with digitalis toxicity, but can also be present in healthy adults and children with no structural heart disease. Accelerating the sinus rhythm with atropine or atrial pacing can be useful to suppress the accelerated idioventricular rhythm. All patients should be receiving chronic optimal medical therapy and have a life expectancy >1 year. Again, all patients should be receiving chronic optimal medical therapy and have a life expectancy >1 year. Muscular dystrophies, particularly Duchenne muscular dystrophy and myotonic dystrophy, have been associated with frequent defects in the conduction system. Heart block and bundle branch block as well as sudden death because of ventricular tachyarrhythmias are well- recognized complications of these muscular disorders. Mitral valve prolapse has been uncommonly linked to sudden death, although ventricular arrhythmias are not uncommon. Arrhythmogenic right ventricular cardiomyopathy is a cardiomyopathy that begins in the right ventricle and often progresses to involve the left ventricle. The combination of the scarring and the late potentials provides the anatomic substrate for reentry. Ablation via catheters is often successful, but only temporizing, because the generalized involvement tends to give rise to arrhythmias at a different locus later in the disease course. Patients are advised against intense exercise, because this may promote the incidence and progression of arrhythmias. Antiarrhythmic therapy and anti-inflammatory therapy are generally combined in the treatment of these patients. Chagas disease, caused by the parasite Trypanosoma cruzi, is a well-known cause of cardiomyopathy, particularly in South and Central America. Anomalous aortic origin of the coronary artery is recognized as a cause of sudden death and/or exercise-induced death in young individuals. In an autopsy study of over 200 patients conducted by the Armed Forces Institute of Pathology, the most common coronary anomalies included the right coronary artery and left main coronary artery arising from the left sinus, the left main and right coronary arteries arising from the right sinus, single coronary artery from the aorta, and the left main or left anterior descending artery arising from the pulmonary artery. Patients whose coronary arteries take an interarterial course (between the pulmonary artery and the aorta) may develop exercise-induced ischemia and/or sudden death. Surgical revascularization in patients with symptomatic coronary anomalies has been well described. Surgical treatment for patients with high-risk coronary anomalies who are asymptomatic is controversial.

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Crutches are generally useful for the frst 1 week to 2 weeks until the pa- tient is able to walk without a limp cheap 10mg alavert mastercard allergy treatment in japan. B • Early therapy involves effusion control cheap alavert 10 mg on-line allergy medicine overdose symptoms, progression of motion and weight bearing cheap alavert 10mg on line allergy shots oklahoma city, and quadriceps sets. Both bundles were elongated at lower fexion angles of the knee and shortened with increasing degrees of knee fexion. However, additional considerations are appropriate: • Consider alterations in anatomy from prior procedure(s). These must be flled, particularly if they communicate with or are close to the new tunnel(s). This can be done with a one- or two-stage reconstruction with bone grafting of the defect(s). We highly recommend two- stage revision for tunnel osteolysis greater than 14 mm to 15 mm. Note that the interference screw secures both the plug anteriorly and the graft posteriorly. Note that the stainless steel drill bit effectively smooths the screw edges as it is drilled past the titanium screw. This is because previous tunnels, even when flled, can affect graft fxation and the load-to-failure depends on the extra-cortical fxation when an undersized interference screw is used for aperture fxation. An extended button and interference screw was used for femoral fxation, while a bioabsorbable screw and sheath plus sutures tied over a small staple was used for tibial fxation. The graft is secured on the femoral side at the lateral femoral epicondyle, tunnelled beneath the iliotibial band, and secured on the tibia at a point between Gerdy’s tubercle anteriorly and the fbular head posteriorly. In general, it is advisable to add 2 months to return to running and return to sport. This technique allows the surgeon to do the reconstruction without the necessity of doing a double-staged procedure. This is a technical note describing a method of leaving previously placed femoral hardware during revision reconstruction to avoid the diffculty associated with its removal and the management of resulting bony defects. Examination/Imaging • It is essential to obtain a complete history of the patient’s expected remaining growth, which includes determining the heights of parents, siblings, recent growth spurt, Tanner stage, and menarche in females. If graft diameter is approximately 7 mm or • Increasing the tibial tunnel drill guide angle less, consider supplementing with contralateral hamstring tendon. Hui C, Roe J, Ferguson D, Waller A, Salmon L, Pinczewski L: Outcome of anatomic transphyseal ante- rior cruciate ligament reconstruction in Tanner stage 1 and 2 patients with open physes, Am J Sports Med 40:1093–1098, 2012. They report excellent clinical outcomes with high levels of return to desired activities. Intraoperative computed tomography scanning with three-dimension- al (3D) reconstruction was used to confrm the precise localization of the all-epiphyseal femoral and tibial tunnels. The authors described their technique of an all-inside transepiphyseal reconstruction for patients who are Tanner stage 1, stage 2, or stage 3 and uses a quadrupled hamstring autograft. Sus- pensory fxation is used on both the femur and tibia as to not rely on interference fxation in the epiphyseal bone. Case examples for two patients who underwent the all-inside, all-epiphyseal reconstruction and their postoperative rehabilitation protocol are reported with excellent outcomes. However, after fuoroscopic visualization of the Beath pin through the far medial portal to the anatomic center of the femoral footprint, the images confrmed the authors’ suspicion that the horizontal trajectory of pin would cause appreciable injury to lateral distal femoral physis. The authors abandoned this technique and proceeded with an all-epiphyseal two-incision femoral-tunnel technique. This is the frst study in the literature to warn against using the far medial portal for femoral tunnel placement to avoid injury to the distal femoral physis. The normal side is compared with the injured side commonly used in transtibial and tibial (Fig. Patient in lateral decubitus position with ment of Posterior Cruciate Ligament Ruptures. The posteromedial bundle and/or meniscofemoral ligaments may be preserved during this step. This tun- nel should be at approximately the 9:30 o’clock position and 11 mm posterior and inferior to the articular margin of the medial arch point and 10 mm to 11 mm superior to the posterior point of the articular cartilage margin. The lesion should be re-approximated to the sizer to save bone graft for later placement in origin of the femoral footprint, taking into consideration both the anterolateral bundle the patella. This may be alleviated by placing the bone plug at the proximal-most part of the tibial tunnel and also rounding the edge of the proximal tunnel with a rasp. Chapter 57: Posterior Cruciate Ligament Reconstruction: Transtibial Double-Bundle Tech- nique. The eminences can be palpated, with the medial eminence being • Very important to completely clear off soft tissues to “dock” cylindrical bone block. Step 4: Graft Passage and Fixation • For both the transtibial and inlay techniques, the graft is passed from the tibia to the femur. A measuring guide can be used to • Confrm placement of all fxation devices measure screw length before placement. Many occur during sporting activ- ity, while others occur during motor vehicle accidents. Chapter 55: Decision Making and Surgical Treatment of Posterior Cruciate Ligament Ruptures. Chapter 55: Decision Making and Surgical Treatment of Posterior Cruciate Ligament Ruptures. Postoperative Care and Expected Outcomes • Like any ligament reconstruction, return-to- play criteria is still a moving target and subject • Immediate postoperative period to signifcant controversy. This paper describes the accuracy of diagnosis using magnetic resonance imaging of the knee. The authors reviewed the benefts and downfalls of each graft choice and also suggested methods of fxation that maximize the beneft of each graft. Kopkow C, Freiberg A, Kirschner S, Seidler A, Schmitt J: Physical examination tests for the diagnosis of posterior cruciate ligament rupture: a systematic review, J Orthop Sports Phys Ther 43:804–813, 2013. The double-bundle reconstruction demonstrated increased resist- ance to posterior translation compared with the single-bundle reconstruction. If there is excessive excursion of the tendon, move the wire/drill bit and re- check. Position knee in approximately 30° of fexion during fxation with slight varus force applied to knee. Step 3: Allograft Reconstruction Semimembranous • Variety of allografts can be used for this technique. Review article characterizing the anatomy of the medial side of the knee and outlining diagnostic and treatment strategies. The feet are passively externally ro- tated and the thigh-foot angle is measured and compared side to side.

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Further history reveals that she had an episode of right flank pain and hematuria 6 months ago purchase alavert from india allergy forecast vancouver wa. Each structure in the popliteal space may be involved by one or two conditions that cause a mass or swelling order alavert 10 mg line allergy medicine green box. In visualizing the anatomy purchase alavert 10mg overnight delivery allergy symptoms sinus, one encounters the skin, subcutaneous tissues, muscles, bursae, veins, arteries, lymphatics, nerves, and bones. Skin: The skin may be involved by urticaria, sebaceous cysts, carbuncles, lipomas, hemangiomas, and various other skin masses. Subcutaneous tissue: Lipomas, sarcomas, and cellulitis are the main lesions encountered. Muscle: Contusions of the gastrocnemius and semimembranosus muscles may cause a mass in the popliteal fossa. Bursae: Popliteal cysts (Baker cysts) may result from filling of the bursa between the gastrocnemius and semimembranosus muscles with a gelatinous or serous substance. Artery: An aneurysm of the popliteal artery may result from atherosclerosis or a gunshot wound. When there is a loud bruit over the artery and distention of the veins, an arteriovenous fistula should be considered. Lymphatics: Enlarged popliteal nodes may result from infections in the distal portion of the extremity, tuberculous adenopathy, or metastatic malignancy. Bone: Exostosis arising from the epiphyseal cartilage of the femur is a well-defined tumor of children or young adults. Medullary giant cell tumors, fibrosarcomas of the periosteum, and osteomyelitis may present as a mass in this area also. If these have negative findings, it may be wise to consult an orthopedic surgeon before any other tests are done. Before doing this, it is wise to rule out a varicocele by watching for the disappearance of the mass on elevation of the leg. I—Inflammation and intoxication suggest posterior urethritis, prostatitis, and cystitis, as well as aphrodisiac drugs such as sildenafil citrate, alcohol, cannabis, indica, camphor, and damiana. N—Neoplasms suggest two common causes of priapism—chronic lymphatic or myeloid leukemia and nasal polyps. The N also suggests neurologic disorders such as neurosyphilis, multiple sclerosis, and diabetic neuropathy. T—Trauma recalls not only direct trauma to the penis producing a local hematoma but also trauma to the spinal cord with fractures or contusion. Approach to the Diagnosis The diagnosis of priapism usually depends on the association of other symptoms and signs (e. A careful history of the patient’s sexual activities to rule out too frequent masturbation or sexual excesses may be indicated. The former presents a diffuse enlargement, soft in consistency, and the prostate varies in size from a plum to an orange. Prostate carcinomas, in contrast, present as a stony, hard nodule in the lateral superior or inferior areas in the early stages or as a diffuse, hard, nodular enlargement in the more advanced stages. The approach is different for the patient presenting with a urethral discharge or difficulty voiding, because then one must include acute and chronic prostatitis and prostatic abscess in the differential. The only trick that might be useful in remembering it is to keep in mind the ages 20, 40, 60, and 80. In general, 20-year-old men usually have acute prostatitis from gonorrhea or other bacteria. The 40-year-old men usually have chronic prostatitis from previous gonorrhea or from nonspecific prostatitis. The 60-year-old men generally have prostatic hypertrophy, and 684 the 80-year-old men most likely have prostatic carcinoma. However, it is important to remember that any one of these diseases may appear at the ages of 40, 60, and 80. Approach to the Diagnosis The main consideration in diagnosing a prostatic mass is to rule out carcinoma. If the mass is located in the posterior lobes, there is further support for the diagnosis. Ultrasonography can be done for further localization before proceeding with a biopsy. If there is no urethral discharge, one can elicit a discharge by prostatic massage. However, this should not be done if the patient has fever and significant tenderness of the prostate. It is better to proceed with antibiotic therapy and reexamine the patient after the fever has subsided. If benign prostatic hypertrophy is suspected, cystoscopy and retrograde pyelography can be done. In addition to the common bacterial infection, one should not forget tuberculosis, schistosomiasis, viral hepatitis, syphilis, and malaria. N—Neoplasm category includes Wilms tumor, renal cell carcinoma, papilloma of the renal pelvis and bladder, and multiple myeloma. I—Intoxication category includes toxic reactions to gold, mercury, gentamicin, penicillamine, captopril, and anticonvulsants. C—Congenital causes should bring to mind polycystic kidneys, Alport syndrome, Fabry disease, horseshoe kidney, and other congenital anomalies. A—Allergic and autoimmune should call to mind acute glomerulonephritis, collagen diseases, Wegener granulomatosis, Henoch–Schönlein purpura, amyloidosis, sarcoidosis, and chronic interstitial nephritis. T—Trauma: The kidneys are involved in various forms of trauma causing proteinuria, but usually there is associated hematuria. Stones should also be included in this category because they cause trauma, inducing proteinuria and hematuria. Approach to the Diagnosis The first step is to determine whether the proteinuria is caused by infection. Generalized skin conditions such as dermatitis herpetiformis, atopic dermatitis, and exfoliative dermatitis are also more likely to show obvious skin manifestations and severe itching. These conditions are to be distinguished from cutaneous syphilis, where there is no itching at all, and psoriasis and pemphigus, where the itching is minimal. Numerous other skin conditions cause pruritus, but we are more concerned with the systemic causes because they are more difficult to diagnose. Primary biliary cirrhosis may begin with pruritus without jaundice because the liver must turn more than 30 g of bile salts (the cause of the itching) a day to only 1 g of bilirubin. Thus, although there may be enough function left to turn over the bilirubin, there is not enough to turn over the bile salts. Diabetes mellitus may cause pruritus, particularly vulvar, where it predisposes to moniliasis. Renal disease may also cause pruritus, presumably because of the retention of toxic waste products. Pruritus during the first trimester of pregnancy called pruritus gravidarum may be due to retention of bile salts. In addition to systemic conditions mentioned above, one should search for local conditions in the anus and rectum (pruritus ani), especially hemorrhoids (internal ones may not be obvious), anal fissure, anal abscess or fistula, and anal moniliasis or pinworms.