Diary/2021년 2021. 8. 23. 15:54



Hormone Therapy and Other Treatments for Symptoms of Menopause

The results of large clinical trials have led physicians and patients to question the safety of hormone therapy for menopause. In the past, physicians prescribed hormone therapy to improve overall health and prevent cardiac disease, as well as for symptoms



Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer when used for more than three to five years.


Therefore, in women with a uterus, it is recommended that physicians prescribe combination therapy only to treat menopausal symptoms such as vasomotor symptoms (hot flashes) and vaginal atrophy, using the smallest effective dosage for the shortest possible duration.


Although estrogen is the most effective treatment for hot flashes, nonhormonal alternatives such as low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives. 


Women with a uterus who are using estrogen should also take a progestogen to reduce the risk of endometrial cancer. 


Women who cannot tolerate adverse effects of progestogens may benefit from a combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene.


black cohosh, botanical products, omega-3 fatty acid supplements - not helping


One systematic review suggests modest improvement in hot flashes and vaginal dryness with soy products, and small studies suggest that clinical hypnosis significantly reduces hot flashes.


Patients with genitourinary syndrome of menopause may benefit from vaginal estrogen, nonhormonal vaginal moisturizers, or ospemifene (the only nonhormonal treatment approved by the U.S. Food and Drug Administration for dyspareunia due to menopausal atrophy). 


There is no evidence that using low-dose vaginal estrogen increases the risk of breast cancer recurrence.


Risks and Benefits of Hormone Therapy

combined oral regimen consisting of conjugated equine estrogen and medroxyprogesterone with placebo, and found that the combined regimen increased the risk of coronary artery disease, breast cancer, stroke, and venous thromboembolism (VTE). The study also found a decreased risk of colorectal cancer, hip fractures, and total fractures with combined hormone therapy.


women without a uterus  = those taking estrogen alone -> had no significant change in risk of coronary heart disease or breast cancer.

but increase in strokes and VTE (similar to the trial of combined estrogen and progestogen)


Estrogen - Stroke, VTE


combined hormone therapy had a significantly increased risk of breast cancer and VTE, and a reduction in hip fractures. In contrast, women taking estrogen alone had a significantly reduced risk of breast cancer.


timing hypothesis : starting hormone therapy early in menopause (compared with starting it 10 years or more after the onset of menopause) may be cardioprotective because of estrogen's apparent ability to slow the progression of atherosclerosis in younger women.


Vasomotor Symptoms : common in women with a higher body mass index, with lower income and education, who smoke cigarettes, or who are black


Estrogen is the most effective therapy for hot flashes

there is no evidence that lowering the ambient temperature; using fans; exercising; or avoiding triggers, such as alcohol and spicy foods, improves hot flashes

 transdermal estrogen, which avoids the first-pass liver effect, may have a lower risk of VTE compared with oral estrogen


 the dosage may be increased after evaluating for effectiveness during the first eight weeks of therapy, with reassessment annually or as needed.


Progestogens can cause fatigue, dysphoria, and fluid retention. 


Patients with a uterus who cannot tolerate these adverse effects may benefit from Duavee, a combination of 0.45-mg conjugated equine estrogen and the selective estrogen receptor modulator bazedoxifene, which is approved by the FDA for treating hot flashes and preventing osteoporosis. Bazedoxifene does not stimulate the endometrium.  Duavee is contraindicated in women who have a history of breast cancer or VTE. 


The levonorgestrel-releasing intrauterine system (Mirena) is an off-label option for providing local progestogen to the endometrium for patients who cannot tolerate systemic therapy.


Low-dose paroxetine (Brisdelle) is the only nonhormonal medication approved by the FDA to treat hot flashes,  Patients taking tamoxifen should not use paroxetine because of inhibition of the hepatic enzyme cytochrome P450 2D6, which decreases the effectiveness of tamoxifen.  Desvenlafaxine (Khedezla) and venlafaxine do not inhibit CYP2D6 and are appropriate alternatives.


Other nonhormonal options include gabapentin (Neurontin) and pregabalin (Lyrica). These medications can cause dizziness and other adverse effects, and should be titrated from a lower dosage.



Deciding When to Discontinue Hormone Therapy

after three to five years. Clinicians should inform patients that some women will have a difficult time stopping hormone therapy. 


Transitioning from Contraception to Hormone Therapy


Genitourinary Syndrome of Menopause


This condition affects up to one-half of women during menopause. In 2014, a consensus conference endorsed the new term genitourinary syndrome of menopause to replace the terms vulvovaginal atrophy and atrophic vaginitis, partly because the older terminology does not encompass the extent of genital tract symptoms many women experience.


Thinning of the vulvar mucosa may cause vulvar burning, irritation, or constriction of the introitus, resulting in entry dyspareunia.


vaginal estrogen, nonhormonal vaginal moisturizers, and the newer oral systemic estrogen agonist-antagonist ospemifene (Osphena). It is reasonable to try nonhormonal therapy as a first-line option to alleviate vulvovaginal symptoms caused by genitourinary syndrome of menopause.

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Learning/Medicine 2021. 8. 20. 15:36



Nongenital Herpes Simplex Virus

Nongenital herpes simplex virus type 1 is a common infection usually transmitted during childhood via nonsexual contact. Most of these infections involve the oral mucosa or lips (herpes labialis). The diagnosis of an infection with herpes simplex virus typ




Nongenital herpes simplex virus type 1 is a common infection usually transmitted during childhood via nonsexual contact. 


 Most of these infections involve the oral mucosa or lips (herpes labialis). The diagnosis of an infection with herpes simplex virus type 1 is usually made by the appearance of the lesions (grouped vesicles or ulcers on an erythematous base) and patient history. However, if uncertain, the diagnosis of herpes labialis can be made by viral culture, polymerase chain reaction, serology, direct fluorescent antibody testing, or Tzanck test. The differential diagnosis of nongenital herpes simplex virus infection includes aphthous ulcers, acute paronychia, varicellazoster virus infection, herpangina, herpes gestationis (pemphigoid gestationis), pemphigus vulgaris, and Behçet syndrome. Oral acyclovir suspension is an effective treatment for children with primary herpetic gingivostomatitis. Oral acyclovir, valacyclovir, and famciclovir are effective in treating acute recurrence of herpes labialis (cold sores). Recurrences of herpes labialis may be diminished with daily oral acyclovir or valacyclovir. Topical acyclovir, penciclovir, and docosanol are optional treatments for recurrent herpes labialis, but they are less effective than oral treatment.



HSV invades and replicates in neurons, as well as in epidermal and dermal cells. The virus travels from the skin during contact to the sensory dorsal root ganglion, where latency is established. Oral HSV-1 infections reactivate from the trigeminal sensory ganglia, affecting the facial, oral, labial, oropharyngeal, and ocular mucosa.


Recurrent infections may be precipitated by various stimuli, such as stress, fever, sun exposure, extremes in temperature, ultraviolet radiation, immunosuppression, or trauma. The virus remains dormant for a variable amount of time.


Oral HSV-1 usually recurs one to six times per year. The duration of symptoms is shorter and the symptoms are less severe during a recurrence.


Clinical Presentation
In primary oral HSV1, symptoms may include a prodrome of fever, followed by mouth lesions with submandibular and cervical lymphadenopathy. The lesions usually heal within 10 to 14 days. 


In recurrent herpes labialis, symptoms of tingling, pain, paresthesias, itching, and burning precede the lesions in 60 percent of persons. The lesions then appear as clusters of vesicles on the lip or vermilion border. The vesicles may have an erythematous base. The lesions subsequently ulcerate and form a crust. Healing begins within three to four days, and reepithelization may take seven to eight days.


Herpetic keratitis is an HSV infection of the eye. Common symptoms are eye pain, light sensitivity, and discharge with gritty sensation in the eye. Slit lamp need. 


Herpetic whitlow is a vesicular lesion found on the hands or digits.  It occurs in children who suck their thumbs or medical and dental workers exposed to HSV-1 while not wearing gloves. Herpes gladiatorum is often seen in athletes who wrestle. Herpetic sycosis is a follicular infection with HSV that causes vesiculopapular lesions in the beard area. It is often caused by autoinoculation from shaving. 


HSV infection is one of the most common causes of erythema multiforme.




by the appearance of the lesions and the patient's history. if the pattern of the lesions is not specific to HSV, its diagnosis can be made by viral culture, PCR, serology, direct fluorescent antibody testing, or Tzanck test. Viral culture should be obtained from vesicles when possible. The swab should be sent in special viral transport media directly to the laboratory (or placed on ice if transport will be delayed).




Oral acyclovir suspension (Zovirax; 15 mg per kg five times per day for seven days) can be used to treat herpetic gingivostomatitis in young children. Children should be treated symptomatically with oral analgesics and cold, soothing foods such as ice pops and ice cream.




The patients took oral valacyclovir (2 g twice for one day) and applied clobetasol 0.05% gel (twice per day for three days) at onset of symptoms. - good result 



Topical treatment for herpes labialis is less effective than oral treatment. 

Treatment with docosanol cream, when applied five times per day and within 12 hours of episode onset, is safe and somewhat effective. OTC



Oral acyclovir is effective in suppressing herpes labialis in immunocompetent adults with frequent recurrences. 

oral acyclovir (400 mg twice per day)

oral valacyclovir (500 mg per day)

patients receiving treatment for cancer, acyclovir was found to be effective in the prevention of HSV infections.  In another study, daily valacyclovir (500 mg per day) and acyclovir (400 mg twice per day) were equally effective in the prevention of recurrent HSV eye disease.


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Learning/Medicine 2021. 8. 19. 21:57



Adhesive capsulitis is a common cause of shoulder pain and limited movement. The objectives of this review were to assess the efficacy and safety of corticosteroid injections for adhesive capsulitis and to evaluate the optimum dose and anatomical site of injections. PubMed and CENTRAL databases were searched for randomised trials and a total of ten trials were included. Results revealed that corticosteroid injection is superior to placebo and physiotherapy in the short-term (up to 12 weeks). There was no difference in outcomes between corticosteroid injection and oral nonsteroidal anti-inflammatory drugs at 24 weeks. Dosages of intra-articular triamcinolone 20 mg and 40 mg showed identical outcomes, while subacromial and glenohumeral corticosteroid injections had similar efficacy. The use of corticosteroid injections is also generally safe, with infrequent and minor side effects. Physicians may consider corticosteroid injection to treat adhesive capsulitis, especially in the early stages when pain is the predominant presentation.



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Learning/Medicine 2021. 8. 19. 18:26



The most common etiology is viral gastroenteritis, a self-limited disease.


Risk factors and signs of inflammatory diarrhea and/or severe dehydration can direct any needed testing and treatment.


Most patients do not require laboratory workup, and routine stool cultures are not recommended. 


 Treatment focuses on preventing and treating dehydration.


Diagnostic investigation should be reserved for patients with severe dehydration or illness, persistent fever, bloody stool, or immunosuppression, and for cases of suspected nosocomial infection or outbreak.


Oral rehydration therapy with early refeeding is the preferred treatment for dehydration. Antimotility agents should be avoided in patients with bloody diarrhea, but loperamide/simethicone may improve symptoms in patients with watery diarrhea.


Probiotic use may shorten the duration of illness.


When used appropriately, antibiotics are effective in the treatment of shigellosis, campylobacteriosis, Clostridium difficile, traveler's diarrhea, and protozoal infections.


Prevention of acute diarrhea is promoted through adequate hand washing, safe food preparation, access to clean water, and vaccinations.


Acute diarrhea is defined as stool with increased water content, volume, or frequency that lasts less than 14 days.


In patients with acute diarrhea, stool cultures should be reserved for grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, immunosuppression, and suspected nosocomial infections.


Routine testing for ova and parasites in acute diarrhea is not necessary in developed countries, unless the patient is in a high-risk group (i.e., diarrhea lasting more than seven days, especially if associated with infants in day care or travel to mountainous regions; diarrhea in patients with AIDS or men who have sex with men; community waterborne outbreaks; or bloody diarrhea with few fecal leukocytes).


The first step to treating acute diarrhea is rehydration, preferably oral rehydration.


Combination loperamide/simethicone may provide faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort than either medication alone.


Antibiotics (usually a quinolone) reduce the duration and severity of traveler's diarrhea.


Clinically, acute infectious diarrhea is classified into two pathophysiologic syndromes, commonly referred to as noninflammatory (mostly viral, milder disease) and inflammatory (mostly invasive or with toxin-producing bacteria, more severe disease)

Bacterial infections are more often associated with travel, comorbidities, and foodborne illness


Salmonella, Campylobacter, Shigella, and Shiga toxin–producing Escherichia coli (enterohemorrhagic E. coli).



The onset, duration, severity, and frequency of diarrhea should be noted, with particular attention to stool character (e.g., watery, bloody, mucus-filled, purulent, bilious).


evaluated for signs of dehydration, including decreased urine output, thirst, dizziness, and change in mental status


Vomiting is more suggestive of viral illness or illness caused by ingestion of a preformed bacterial toxin.


Symptoms more suggestive of invasive bacterial (inflammatory) diarrhea include fever, tenesmus, and grossly bloody stool.


A food and travel history is helpful to evaluate potential exposures.


Children in day care, nursing home residents, food handlers, and recently hospitalized patients are at high risk of infectious diarrheal illness. Pregnant women have a 12-fold increased risk of listeriosis, which is primarily contracted by consuming cold meats, soft cheeses, and raw milk. 


Recent sick contacts and use of antibiotics and other medications should be noted in patients with acute diarrhea. Sexual practices that include receptive anal and oral-anal contact increase the possibility of direct rectal inoculation and fecal-oral transmission.


The history should also include gastroenterologic disease or surgery; endocrine disease; radiation to the pelvis; and factors that increase the risk of immunosuppression, including human immunodeficiency virus infection, long-term steroid use, chemotherapy, and immunoglobulin A deficiency.





The primary goal of the physical examination is to assess the patient's degree of dehydration. Generally ill appearance, dry mucous membranes, delayed capillary refill time, increased heart rate, and abnormal orthostatic vital signs can be helpful in identifying more severe dehydration. Fever is more suggestive of inflammatory diarrhea.


Diagnostic Testing


STOOL CULTURES : grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, or immunosuppression. 

CLOSTRIDIUM DIFFICILE TESTING patients who develop unexplained diarrhea while using antibiotics or within three months of discontinuing antibiotics. 

OVA AND PARASITES Indications for ova and parasite testing include persistent diarrhea lasting more than seven days, especially if associated with infants in day care or travel to mountainous regions; diarrhea in persons with AIDS or men who have sex with men; community waterborne outbreaks; or bloody diarrhea with few fecal leukocytes







FEEDING BRAT diet (bananas, rice, applesauce, and toast) and the avoidance of dairy are commonly recommended, supporting data for these interventions are limited

ANTIDIARRHEAL MEDICATIONS  loperamide (Imodium) may reduce the duration of diarrhea. loperamide/simethicone combination has demonstrated faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort compared with either medication alone. Loperamide may cause dangerous prolongation of illness in patients with some forms of bloody or inflammatory diarrhea and, therefore, should be restricted to patients with nonbloody stool.

antisecretory drug bismuth subsalicylate (Pepto-Bismol) is a safe alternative in patients with fever and inflammatory diarrhea.


overuse of antibiotics can lead to resistance (e.g., Campylobacter), harmful eradication of normal flora, prolongation of illness (e.g., superinfection with C. difficile), prolongation of carrier state (e.g., delayed excretion of Salmonella), induction of Shiga toxins (e.g., from Shiga toxin–producing E. coli), and increased cost.

when used appropriately, antibiotics are effective for shigellosis, campylobacteriosis, C. difficile, traveler's diarrhea, and protozoal infections.

Antibiotic treatment of traveler's diarrhea (usually a quinolone) is associated with decreased severity of illness and a two-or three-day reduction in duration of illness. If the patient's clinical presentation suggests the possibility of Shiga toxin–producing E. coli (e.g., bloody diarrhea, history of eating seed sprouts or rare ground beef, proximity to an outbreak), antibiotic use should be avoided because it may increase the risk of hemolytic uremic syndrome. Conservative management without antibiotic treatment is less successful for diarrhea lasting more than 10 to 14 days, and testing and treatment for protozoal infections should be considered.  Antibiotics may be considered in patients who are older than 65 years, immunocompromised, severely ill, or septic. 




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Learning/Medicine 2021. 8. 17. 13:37

 conjugated (direct hyperbilirubinemia) or unconjugated (indirect hyperbilirubinemia)?


An increase in unconjugated bilirubin in serum results from overproduction, impairment of uptake, or impaired conjugation of bilirubin. An increase in conjugated bilirubin is due to decreased excretion into the bile ductules or leakage of the pigment from hepatocytes into serum.





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Learning/Medicine 2021. 8. 17. 13:32

In patients with cholestasis, the alkaline phosphatase is typically elevated to at least four times the upper limit of normal.


The gamma-glutamyl transpeptidase (GGT) may also be elevated in the setting of cholestasis.


 Patients with a predominantly cholestatic pattern typically undergo a right upper quadrant ultrasound to further characterize the cholestasis as intrahepatic or extrahepatic; the latter is suggested by biliary tract dilatation.


To confirm that an isolated elevation in the alkaline phosphatase is coming from the liver, a GGT level or serum 5'-nucleotidase level should be obtained. These tests are usually elevated in parallel with the alkaline phosphatase in liver disorders but are not increased in bone disorders. An elevated serum alkaline phosphatase with a normal GGT or 5'-nucleotidase should prompt an evaluation for bone diseases.


An elevated bone alkaline phosphatase is indicative of high bone turnover, which may be caused by several disorders including healing fractures, osteomalacia, hyperparathyroidism, hyperthyroidism, Paget disease of bone, osteogenic sarcoma, and bone metastases. We generally refer such patients to an endocrinologist for evaluation. Initial testing may include measurement of serum calcium, parathyroid hormone, 25-hydroxy vitamin D, and imaging with bone scintigraphy.


Differential diagnosis — If the alkaline phosphatase elevation is isolated (ie, the other routine liver biochemical test levels are normal), is confirmed to be of hepatic origin, and persists over time, chronic cholestatic or infiltrative liver diseases should be considered. The most common causes include partial bile duct obstruction, primary biliary cholangitis (PBC), primary sclerosing cholangitis, and certain drugs, such as androgenic steroids and phenytoin. Infiltrative diseases include sarcoidosis, other granulomatous diseases, amyloidosis, and, less often, unsuspected cancer that is metastatic to the liver.

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