By Z. Leif. Utah Valley State College.
Te present study animals have reached maturity and with negligible weight loss provides the frst experimental evidence that administration [13 order 25 mg endep otc symptoms dust mites, 14] buy generic endep 25 mg online medications gabapentin. However, 100% mortality occurred in diabetic mice towards phage therapy was once more accompanied by a within 36 h, in contrast to 100% in nondiabetic mice at renewed interest and reappraisal of the beginning of the 21st 48 h. Te innocuous nature of phage was demon- diabetic bacteremic mice than in nondiabetic bacteremic strated by adding high-titer T4 phage stock to the drinking 8 BioMed Research International (a) (b) (c) (d) Figure 6: Histopathology of the spleen. In vitro characterization of phage showed it resistant Enterococcus faecium  and methicillin-resistant was able to multiply very rapidly on a P. A report on the treatment of single on the morphology the phage is tentatively placed in the cases of human burns, wounds indicates that bacteriophage Siphoviridae family . In contrast, nondiabetic bacteremic Hence, in the present work, an observational evaluation mice were rescued even when treatment was delayed up to of the healing potential of newly isolated bacteriophage in 20 h afer lethal bacterial challenge. BioMed Research International 9 (a) (b) (c) (d) Figure 7: Histopathology of the liver. Te with earlier studies which showed a marked diference in survival rate between phage treated and the control groups the efect of phage therapy was observed in groups treated is statistically signifcantly diferent. It is well teremic mice by delaying treatment was reduced, suggesting known that drugs are catabolized and removed from the that stressed animals are more sensitive to various factors; in body (half life span), whereas phage keeps on multiplying this case either the phage itself or trace amounts of endotoxins until all host bacteria are followed in the circulation and and exotoxins are present in the phage preparations. It has been reported that a small animals did not display apparent reactions to these factors, population of mutant I phage survived in the circulation, as evidenced by the lack of any adverse efects in the control with a concomitant alteration to major head protein E . Similar fndings comparison of the outcome of treatment of diabetic and non- were reported in the treatment of P. Histological analysis confrmed that the organ Evaluation of results confrmed that a single intraperitoneal damage in the treated group was less severe than in the antibi- injection of the phage dose was more efcacious than the otic and untreated animals. Te reduction in bacterial load severe impairment in most critical organs, especially the liver was refected in the lower morbidity and mortality observed and spleen in the mice treated with antibiotic and untreated 10 BioMed Research International (a) (b) (c) (d) Figure 8: Histopathology of the lung. Karchmer, targets extracellular bacteria and also the role of phagocytosis “Infections in patients with diabetes mellitus,” New England in bacterial removal . Ferreira,“Experi- mental model of induction of diabetes mellitus in rats,” Acta Cirurgica Brasileira,vol. Livermore, “Of Pseudomonas, porins, pumps and car- teriophage as antibacterial agents,” Proceedings of the National bapenems,” Journal of Antimicrobial Chemotherapy,vol. Du Pont, “Histopathological evaluation of scalds and contact therapy for Staphylococcus aureus bacteremia in streptozotocin- burns in the pig model,” Burns, vol. James, “Infectious complications in patients with diabetes domonas aeruginosa cystic fbrosis strains: frst steps towards mellitus,” International Diabetes Monitor,vol. Rossini, “Streptozotocin induced pancre- atic insulitis: new model of diabetes mellitus,” Science,vol. Chaudhry, “A clinico-microbiological study of diabetic foot ulcers in an Indian tertiary care hospital,” Diabetes Care, vol. Brussow,¨ “Human volunteers receiving Escherichia coli phage T4 orally: a safety test of phage therapy,” Antimicrobial Agents and Chemotherapy,vol. Soothill, “Treatment of experimental infections of mice with bacteriophages,” Journal of Medical Microbiology,vol. Wright, “Bacterial resistance to antibiotics: enzy- matic degradation and modifcation,” Advanced Drug Delivery Reviews,vol. Zuber, “T4 phages against Escherichia coli diarrhea: potential and problems,” Virology, vol. Ackermann, “Frequency of morphological phage de- scriptions in the year 2000,” Archives of Virology,vol. Loessner, “Application of bacteriophages for detection and control of foodborne pathogens,” Applied Microbiology and Biotechnology,vol. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and speciﬁcally disclaim any implied warranties of merchantability or ﬁtness for a particular purpose.
When we come to understand that a secreting organ is continually growing secreting cells buy 25 mg endep visa medications resembling percocet 512, and that these withdraw from the blood the worn-out materials of our bodies endep 25mg visa symptoms zyrtec overdose, we will be in a position to use remedies with better success. Evidently it is possible to so over-stimulate or over-work an excretory organ, that this function of cell- production will be very much diminished or altogether arrested. The best remedies to increase secretion are those that act mildly and stimulate vital function. All can succeed with it, yet successes will be in proportion to the physician’s acuteness of observation, and to some extent upon his knowledge of remedies. We study not so much the grosser manifestations of disease, but the more delicate shadings and combinations, and our therapeutics requires that we have a most intimate knowledge of the influence of remedies upon the human body. In this field of study the physician will find a beauty and certainty, in the practice of medicine that will give zest to investigation, and as it is pursued he will find greater and greater success. The question has been asked, “In what does your theory of specific medication differ from Homœopathy? The law, similia similibus, upon which the Homœopathic practice is based, is defined in two ways. One contends that the drug, used for cure, “produces the essential morbid condition” when proven in health. The other, “that it produces similar symptoms,” but not the exact pathological condition. The truth in this law of similia similibus, is, that certain agents, called medicines, act on particular organs, parts, and functions of the human body in a uniform manner. If an agent directly and uniformly produces an influence upon a particular part, it is more likely to be used as a remedy in disease of that part than another which does not influence the part at all. Remedies are, therefore, those agents which directly and uniformly influence an organ, part, or function. The question then comes up, are they remedies because “they will produce a similar state of disease,” or because they are opposed to diseased action? The remedy is a remedy because it will produce the exact diseased condition, or at least the exact symptoms of such condition. I contend that a drug is a specific remedy: first, because it influences uniformly and directly the part or function diseased; and second, because it opposes such diseased action. I would, therefore, write the law of cure, contraria contrariis opponenda, instead of similia similibus. Grauvogl, in his “Lehrbuch Der Homœopathy,” says: - “The conception of a specific remedy expresses the mutual relation existing between it and parts of the organism, which has to be ascertained empirically by physiological provings of drugs. For some part of the organism is in a relation of immunity, for other parts of attraction, for others again one of repulsion and always vice versa. To solve this problem we have the natural law according to which quantity contains the measure of the movement and counter-movement; consequently for therapeutic purposes, the correct dose consists in a quantity of force of the indicated quality which is equal to the quantity of force of the morbific agent, and in its movements runs in a contrary direction to the quality of the latter. The old dogma of phlogosis and antiphlogistics, and the new doctrine of impaired vitality and restorative medication, guides the empirical use of remedies in the one or other direction. We may lay it down as an axiom, from which it is never safe to depart, that - No medicine should be given, unless the pathological condition and the indications for its use are clearly defined. It is much better to employ a placebo, than run the risk of doing harm by medication. Good nursing is an essential element in the successful practice of medicine, and always requires direction by the physician; keeping the stomach in good condition for the reception of food and medicine, is of first importance, and requires attention. Following this is the selection of proper food, its preparation, and the time for its administration. These alone very well repay the careful attention and thought of the physician, even if he can not see an indication for the employment of remedies. If we can see clearly that the condition of disease is one of depression - that in proportion as a man is sick, his vitality is lessened, such means as will increase the power to live, or the resistance of the body to death, will be suggested. As we have stated before, we make an analysis of the disease and divide it into its component parts, before making a prescription of medicine.
Suspected chanchroid 156 Look for Gram negative coccobacilli showing bipolar staining Additional culture Blood agar (aerobic and anaerobic) purchase endep 25mg free shipping symptoms your having a boy, macCokey agar cheap endep 10 mg amex medicine natural,and cooked meat medium, if puerperal sepsis or septic abortion is suspected Sabourand medium, if vaginal candidiasis is suspected and yeast cell not detected microscopically Serum culture, if chancroid is suspected ⇒H. Gemsa stained smear: If donovanosis is suspected Dark field preparation, if syphilis is suspected. Colleciton, transport and examination of cerebrospinal fluid Possible pathogens Gram positive S. Fungi: Cryptococcus neoformans Parasites: Trypanosoma species Naegleria fowleri Acanthamoeba species and rarely the larvae of Angiostrongylus cantonensis and Dirofilaira immitis Note: 1. Inflammation of the meninges (membranes that cover the brain and spinal cord) is called meningitis. Pathogens reach the meninges in the blood stream or occasionally by spreading from nearby sites such as the middle ear or nasal sinuses. This rare form of meningitis is caused by helminthes larvae such as Angiostrongylus cantonensis and Dirofilaria imitis • Meningitis of the newborn (neonatal meningitis) is caused mainly by E. Commensals No normal microbial flora Collection of Csf • It should be collected by medical officer in aspectic procedure • The fluid is usually collected from the arachnoid space. A sterile wide-bore needle is inserted th th between the 4 and 5 lumbar vertebrate and C. If typanosomes are present, they will not be found because they are rapidly lyzed once the C. The fluid should be handled with special care because it is collected by lumbar puncture and only a small amount can be withdrawn. This is because sample No 1 may contain blood (due to a traumatic lumbar puncture) which will affect the accuracy of the cell count and biochemical estimations. Yellow-red (after centrifuting) The fluid may also appear xanthromic if the patient is jaundiced or when there is spinal constriction. This should be transferred to a slide, pressed out, alcohol- fixed, and stained by the Ziel-Neelsen method I. Test the specimen biochemically - Glucose estimation ½ - 2/3 of that found in blood, i. Culture the specimen (sample No 1) It is necessary, if the fluid contains cells and, or, the protein concentration is abnormal. If a delay is unavoidable, the fluid should be 0 kept at 35-37 C (never refrigerated). Additional MacConkey and blood agar if the patiente is a newborn infant 0 incubate both plate at 35-37 C overnight - E. If capsulated yeast cells are seen in the microscopial preparations, 0 inoculate a plate of sabouraud agar. Incubate at 35-37 C for up to 72hours, cheeking for growth after overnight incubation. The term septicaemia refers to a severe and often fatal infection of the blood in which bacteria multiply and release toxins in to the blood stream. In typhoid, salmonella typhi can be detected in the blood of 75-90% of patients during the first 10 days of infection and in about 30% of patients during the third week. Collection and culture of Blood and Borne marrow 9 Blood and bone marrow require culturing immediately after collection, before clotting occurs. Choice of culture media 9 Because septicaemia is such a serious condition, it is essential to use media that will provide the fastest 167 growth and isolation of as wide a range of pathogens as possible. Because the bacteria can be seen growing on the slope, the need to subculture on a solid medium every few days is avoided, thus reducing the risk of contamination. It prevents clotting of the blood and neutralize the natural bactericidal substances in fresh blood. Aminobenzoic acid: This neutralizes the action of sulphonamides should these be present in the blood. Collect and culture the specimen Blood • It should be collected before antimicrobial treatement has been started and at the time the patient’s temperature is beginning to rise. Insert the needle through the rubber line of the bottle cap and dispense 5ml of blood into each culture bottle. Incubate the inoculated media: Thioglycollate broth 0 At 35-37 C for up to 2 weeks, examining and sub-culturing • Look for visible signs of bacterial growth such as turbidity above the red cell layer, colonies growing on top of the red cells (“cotton balls”), haemolysis, gas bubbles and clots. Synovitis means inflammation of the synovial membrane (living of a joint capsule). Arthritis may be caused by bacteria (infective arthritis), rheumatoid arthritis, gout and pseudogout, osteoatrhtitus 3.
For burns that are highly irregular in shape buy endep 10 mg with mastercard symptoms questionnaire, such as tar injuries or grease splatters generic endep 25mg without prescription treatment zoster, a “hand count” method may be helpful. Inhalation Injury The presence or absence of inhalation injury is a major determinant of survival in burns. Hammond tract are rare, generally occurring only with the inhalation of super- heated steam. What commonly is thought of as a respiratory “burn” is a response to inhalation of the products of combustion, or carbon monoxide toxicity. Incomplete products of combustion, such as alde- hydes, nitrogen dioxide, and hydrochloric acid, can cause direct parenchymal lung damage. Carbon monoxide, with an afﬁnity for oxygen more than 200 times that of hemoglobin, seriously can impair oxygen delivery to tissues. Early diagnosis of inhalation injury can be difﬁcult, and it usually is a clinical diagnosis supported by an index of suspicion. The strongest correlation for a pulmonary injury is a history of being burned in an enclosed space coupled with the presence of facial burns or the history of patient incapacitation from drugs or alcohol. The serum carbon monoxide level may be used to tailor therapy, but it may be unreliable if supplemental oxygen already has been administered. The concen- tration of carboxyhemoglobin is reduced by 50% for each 40-minute period of treatment with high-ﬂow oxygen. Bronchoscopy has been advocated as a diagnostic tool, but it adds little to the accuracy of the history and the physical examination. Since signs and symptoms of inhalation injury may appear over an 18- to 36-hour period, patients at risk or patients suspected of being at risk should be admitted for a 24-hour period of observation. Steroid therapy is not beneﬁcial and carries a risk of superimposed infection; bronchodilator therapy and aggressive chest physiotherapy are advantageous. Prophylactic antibiotics are not recommended due to the risk of selection pressure for the emergence of resistant organ- isms. The airway should be secured before edema necessitates a surgical airway; tracheostomy or cricothyroidotomy carries a higher morbidity and mortality rate. Treatment: The First 24 Hours The purpose of ﬂuid resuscitation in the early postburn period is reex- pansion of plasma volume within the extracellular space. Delivery of sodium ion into the extracellular space results in reestablishment of 34. All agree, however, that restoration of plasma volume is essential in preventing renal failure and shock. As in the case presented at the beginning of the chapter, these lines may be placed through the burn wound if access sites are limited. This formula is a rough guide, however, and one ﬁfth of patients need more and one ﬁfth need less. In some formulas, colloids in the form of albumin or fresh frozen plasma are added in the second 24 hours or when the capillary leak has stopped. A diuretic phase begins on the third to ﬁfth postburn day with mobilization of the resuscitation ﬂuid. Emergency care of burns, either major or minor, requires adequate tetanus prophylaxis. The burn wound is anaerobic, and cases of clini- cal tetanus have been described even from superﬁcial second-degree injuries. For those never immunized, both passive and active immunization using tetanus immune human globulin (Hyper- Tet) is suggested. Efforts are directed at maintaining body temperature and prevent- ing hypothermia. Iced saline is not used for initial debridement or wound coverage in the emergency department for that reason. Early in the management scheme, practitioners must determine if the patient requires hospital admission and whether resources for good burn care exist in their institution. Guidelines for admission have been developed by the American College of Surgeons and the American Burn Association (Table 34. Transfer to a specialized burn center is warranted if all components of the burn team are not available at the receiving institution. Treatment: After the Emergency Department The mainstay of burn treatment is good wound care, with attention to principles of infection control coupled with early wound closure and adequate nutritional support. All blisters should be debrided except for those on the palms and soles if they are intact.
Their complete structure and function are not known precisely purchase endep 25mg without prescription treatment goals and objectives, despite decades of intensive research purchase 75 mg endep free shipping symptoms 0f pregnancy. Spontaneous mutants have been isolated, however, showing a changed ribosome structure, mediating a lowered binding of linezolid, resulting in resistance. Also, clinical isolates of sev- eral gram-positive cocci, among them Staphylococcus aureus,have shown resistance. This is in parallel to what has been observed for other synthetic antibacterial agents, such as quinolones (i. Otherwise, they are very different in chemical struc- ture, mechanisms of action, and in many cases also in clinical use. These substances, possibly with the exception of linezolid, could be viewed as agents that evolution has brought forth as a means of competition among soil bacteria, which we have discovered, isolated, and put to use in ﬁghting bacterial disease. It was discovered in a synthesis program originally based on observation of the antibacterial properties of an oxoquinoline, found as a by-product of the industrial synthesis of the malaria drug chloroquine. They are distributed as inexpensive and efﬁcient anti- bacterial agents, particularly against urinary tract infections caused by gram-negative enterobacteria. In the end the telephoning person has to sit with her head very close to the phone. The gyrase enzyme has four pairwise identical sub- units: two A subunits (97 kDa) and two B subunits (90 kDa). The corresponding enzymes with gyrase function in human mammalian cells are structurally so different that they are not recognized by the quinolones, which are then selective in their action on bacteria. From a microbiological point of view, it was then a new antibacterial agent against which the microbial world had not selected resistance. Also, the quinolones are synthetic agents that the microbial world could not be expected to have come across earlier in its history. Nalidixic acid had to be given in very large doses, however, with side effects occurring. The antibacterial effect was very much enhanced by the introduction of 6-ﬂuoro and 5-piperidine groups in the molecule, to allow lower doses for the clinical effect. This important breakthrough for the antibacterial use of quinolones was made by Japanese chemists in the mid-1970s, and allowed the introduction of that larger group of quinolones, today being very important in the treatment of bacterial infections. As examples of these ﬂuoro- quinolones, ciproﬂoxacin (8-2), norﬂoxacin (8-3), oﬂoxacin (8-4), levoﬂoxacin (8-5), and moxiﬂoxacin (8-6) could be mentioned. They all have the mechanism of action described earlier and have similar antibacterial spectra. It should be mentioned that quinolones are absorbed rapidly and completely after oral intake, and that they are concentrated in and excreted with the urine, where 10 to 15% of the dose given is to be found in an active form and at a concentration that gives a good antibacterial effect in the urinary tract. Norﬂoxacin is also a good prophylactic agent against infections with gram-negative enterobacteria in patients with granulocytopenia. Ciproﬂoxacin has a broad antibacterial spectrum which includes most of the clinically important pathogens. Its largest effect is against gram-negative rods, but gram-positive cocci such as streptococci and staphylococci show an inter- mediate susceptibility. Ciproﬂoxacin is very effective against typhoid fever and other septic Salmonella infections, that is, Salmonella infections penetrating the bloodstream. Treatment with ciproﬂoxacin and other quinolones is the only alternative, with oral administration for infections with Pseudomonas aerugi- nosa. With increasing resistance to traditionally used antibacterial agents against Mycobacterium tuberculosis (Chapter 9), quinolones have also become important remedies in the treatment of tuber- culosis and can substantially shorten the multidrug treatment regimens for this disease. Ciproﬂoxacin is one of the most com- monly used antibacterial agents in the world. About a decade ago ciproﬂoxacin acquired doubtful fame when American civil servants lined up to get this remedy (Cipro) for prophylaxis against anthrax disease, which terrorists threatened to spread to federal authorities through letters containing spores of Bacillus anthracis. Oﬂoxacin, levoﬂoxacin, and moxiﬂoxacin have antibac- terial spectra similar to those of norﬂoxacin and ciproﬂoxacin. Spontaneous mutations would change the protein to lower its afﬁnity for the inhibiting quinolone. A second form of resistance is efﬂux; that is, the resistant bacterium has acquired a mechanism that while spending energy is able to pump the quinolone out of the bacterial cell. The third mechanism of resistance was quite unexpectedly relatively recently found to be plasmid-borne. This can be looked at as a very low frequency, but as a consequence, under the powerful selection pressure of a very large consumption of quinolones, it has led to widespread resistance with clinical difﬁculties in treat- ing infections.
Treatment focuses on drug abstinence endep 75 mg on-line symptoms rabies, coupled with social and treatm ent outcom es generic endep 75 mg with mastercard treatment of pneumonia. Observable results of psychological change requiring a multidi- therapy, including decreased use of illicit mensional effort along with intensive mutu- psychoactive substances, improved physical al help and support. Combination of considered the best indicator of treatment amount of medication and frequency and program effectiveness. Therapeutic dosage levels that specifies the services to be provided should be determined by what each patient and their frequency and schedule (adapted needs to remain stable. Many addiction among the patient, program physician, and treatment programs use a 12-Step structure treatment providers. Originally used symptoms after abrupt discontinuation of as a measure of program effectiveness, or rapid decrease in use of a substance that urine testing now is used to make program- has been used consistently for a period. Fundam ental Ethical Principles Beneficence (Benefit) According to Beauchamp and Childress (2001), the medical principle of beneficence emphasizes that treatment providers should act for the benefit of patients by providing competent, timely care within the bounds of accepted treatment practice. The principle of beneficence is satisfied when treatment providers make proper diagnoses and offer evidence-based treatments, that is, treatments drawn from research that provides statistical data about outcomes or from consensus-based stan- dards of care. Beneficence is compromised when diagnoses are question- able or when outcome data do not validate a diagnosis or treatment. Autonom y Autonomy, like beneficence, springs from the ideal of promoting patientsí best interests. However, whereas beneficence emphasizes the application of provider knowledge and skills to improve patient health, autonomy emphasizes respect for patientsí rights to decide what treat- ment is in their best interests (Beauchamp and Childress 2001). Usually, patientsí and physiciansí goals for treatment are identical, but, when they differ, physicians generally accord patients the right to make 297 their own choices and accept the fact that Justice patientsí values may differ from physiciansí The principle of justice emphasizes that treat- values. For example, a physician might focus ment providers should act with fairness on extending a patientís life, whereas the (Beauchamp and Childress 2001). Sometimes patient might be more concerned with the this principle is expressed as the duty of quality of that life. Normally, standard medical prac- Besides emphasizing that clinicians should act tice does not permit an exception when patients fairly toward patients, the principle of justice make the ìwrongî choice and the physician imposes a responsibility to advocate politically ìknows better. Nonm alfeasanceóìFirst, Do Ethics in Practice No Harm î The principle of nonmalfeasance emphasizes Conflict Betw een Beneficence that health care providers should not harm or injure patients (Beauchamp and Childress and Autonom y 2001). The risks associated with ï W hat is the proper balance between respect injecting or otherwise ingesting substances of for a patientís autonomy and a providerís abuse produced under unknown conditions are responsibility for that patientís health? Patients come under the ï Should the patient or the clinician decide care of professionals who monitor adverse drug what is in a patientís best interests? His position is that he has stopped his use of illicit opioids entirely, which was his goal entering treat- ment. These strategies with provider views of what is in their best ìare based on the assumption that patients interests risk administrative discharge or other have the necessary skills to produce drug-free sanctions. A working familiarity with their best interests such studies provides treatment providers with a reasonable basis to choose beneficence over ï Disagreement about goals between patients autonomy when they conclude that they know and treatment providers better than patients what is in patientsí best ï Attention to community concerns interest. These providers might draw on agents of conventional society (Hunt and lessons from physicians caring for patients with Rosenbaum 1998). Based on the complain because they have a sense of power- disease model underlying comprehensive main- lessness and do not want to jeopardize their tenance treatment, total abstinence may be treatment. Rather than assuming that the tilt the continuing but reduced presence of symp- toward beneficence is always correct, treatment toms, they are not defining addiction as a dis- providers and administrators should ask them- ease. The long-term goal is always reducing or selves in each case whether they are striking eliminating the use of illicit opioids and other a proper balance between these two fundamen- illicit drugs and the problematic use of pre- tal principles. This dependence was particularly troubling to them because of the increasing insecurity of subsidized slots. Many users expressed concern about once having entered the system and accepting its lifestyle with little or no warning they would be ejected from it. Involuntary discharge ment, in most cases, will halt their recovery or appears to breach practitionersí duties to put precipitate relapse (Knight et al. Involuntary dations addressing involuntary withdrawal discharge of such a patient, although not in his from treatment for nonpayment of fees or her best interests, takes into account the (www.
Patients with new-onset symptoms are treated medically to relieve symptoms of congestive heart failure or angina order 50mg endep mastercard symptoms women heart attack. Congestive heart failure is treated with diuretics cheap 50 mg endep with amex symptoms brain tumor, digoxin, and afterload reduction when it can be tolerated. Great care must be taken in patients with aortic stenosis to avoid overdiureseis or too much preload reduction (with nitroglycerine and diuretics), which can result in inadequate ﬁlling of the left ventricle and subsequent syncope or low output. Heart rate must be controlled with beta-blockers digoxin or calcium channel blockers to permit adequate chamber ﬁlling, espe- cially when stenotic lesions are present. Anticoagulants are needed for patients in atrial ﬁbrillation to prevent systemic embolization. There is some evidence that the use of the calcium channel blocker Procardia in asymptomatic patients with aortic insufﬁciency may delay their need for surgery. Once diagnostic studies have been completed, recommendations for chronic medical therapy or surgery are made. Heart Murmurs: Acquired Heart Disease 275 must be made on an individual basis and must involve an informed consent from the patient and family. Medical therapy is used for those patients when it is believed the surgical risk is too high or their long-term beneﬁt is not sufﬁcient for surgery. Others who are not yet ready for surgery receive medical therapy but are followed closely until indications for surgery become manifest. As noted, the surgical management of valvular heart disease is dependent on the risk-beneﬁt ratio for the patient. Unfortunately, this is not always so clear when the risk of the operation is high and the beneﬁt to an individual patient not clear. However, generalized indi- cations for surgery have evolved based on short- and long-term outcome studies. Detailed diagnostic and therapeutic guidelines are well summarized in “Consensus Statement on Management of Patients with Valvular Heart Disease,” developed by a combined task force of the American Heart Association and the American College of Cardiology. Any patient with symptomatic aortic stenosis should undergo valve replacement unless there are signiﬁcant contraindica- tions or the patient’s life expectancy is otherwise severely limited. Even those patients with signiﬁcant organ dysfunction secondary to the low output state may be considered. In the past, it also was believed those asymptomatic patients with aortic stenosis and a valve area of less than 1cm2 or a gradient >60mmHg also should undergo valve replacement. More recently, with the ability to follow patients closely with echocar- diography, surgery may be delayed until symptoms develop without increased risk to the patient as long as surgery occurs rapidly fol- lowing the onset of symptoms. Studies have shown that a patient with aortic insufﬁciency and a normal ven- tricle can undergo replacement with little surgical risk. On the other hand, once the ventricle begins to fail, the risk increases dramatically. Even in the absence of symptoms, increased operative mortality occurs in the presence of indicators of deteriorating ventricular function. At the present time, valve replacement is the recommended treat- ment for surgical correction of aortic valvular diseases. There are a few patients with aortic insufﬁciency in whom valvuloplasty has been successful, although replacement remains the standard. Spotnitz Mitral Stenosis and Mitral Insufﬁciency Mitral valve disease is different from aortic valvular disease in that reconstructive surgery often can be done instead of replacement of the valve. The operative mortality has been less with a repair when the long-term risks of a prosthetic valve are avoided. Mitral stenosis was the ﬁrst valve problem approached surgically and was performed suc- cessfully in the late 1940s several years before the ﬁrst successful use of the heart lung machine (by Gibbon3 in 1953). In any case, either direct commissurotomy and reconstruction, if needed, of the subvalvular apparatus are performed, or valve replacement is done. Because of the success of mitral valvuloplasty for mitral stenosis and the detailed diagnostic images of the valves now obtainable by echocardiography, certain patients with mitral stenosis are treated using percutaneous methods in the catheterization laboratory using balloon dilators (larger balloons but similar technique to angioplasty) with good success.