The Medical clinics of North America
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Over the last decade, the medical treatment of inflammatory bowel disease (IBD) has been revolutionized, with increasing use of both immunomodulatory and biologic medications. Corticosteroids have increasingly been shown to increase the risk of serious and opportunistic infections, both independently and in combination with immunomodulator and biologic agents. ⋯ It is unclear if anti-tumor necrosis factor-alpha agents increase overall infectious risk in patients with IBD, but the available literature has demonstrated an increased risk of opportunistic infections, particularly in terms of tuberculosis and histoplasmosis. Combination therapy likely increases the risk of opportunistic infections in patients with IBD but this has not yet been conclusively proved.
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Fistulas manifest frequently in Crohn disease and can result in significant morbidity and often lead to the need for surgical intervention. Historically, it has been more difficult to obtain complete fistula closure in patients with perianal Crohn disease. Anti-tumor necrosis factor-alpha agents and the use of more accurate imaging modalities such as magnetic resonance imaging and rectal endoscopic ultrasound have enhanced the ability to manage fistulizing Crohn disease. A combined medical and surgical approach usually presents the best option for most patients.
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Many emerging pathogens present in the skin and are of interest to dermatologists. Recent epidemics of measles, avian flu, and SARS demonstrated how an organism can rapidly spread worldwide because of airline travel. Travelers are often contagious before they are aware that they have the disease, contributing to the spread. This article reviews bacterial, mycobacterial, fungal, and viral pathogens important to dermatologists.
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Clinicians are increasingly asked what they can do to evaluate and lower the risk of perioperative cardiac complications. Approximately 4 decades ago, there were few tools to guide the evaluation of perioperative risk. ⋯ None of these tests, however, were designed to identify perioperative cardiac risk. This article reviews the literature on perioperative risk assessment, risk reduction, and testing modalities in patients with cardiac disease, along with the role of perioperative angioplasty and the current American College of Cardiology/American Heart Association guidelines.
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Anemia is commonly encountered in the preoperative patient. Determination of the cause of the anemia can affect perioperative surgical and medical management and outcome. ⋯ The authors review the evaluation of anemia and evidence regarding perioperative blood transfusions. Recommendations on the treatment of anemia, including perioperative blood transfusions, are outlined.