W. Karmok. Metropolitan State College of Denver.
Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease cheap lyrica 150 mg online. Cunha Infectious Disease Division purchase lyrica 75 mg otc, Winthrop-University Hospital discount lyrica uk, Mineola, New York, and State University of New York School of Medicine, Stony Brook, New York, U. Urosepsis is bacteremia from a urinary tract source, which is diagnosed by culturing the same organism from urine and blood. Community-acquired urosepsis occurs in non-leukopenic compromised hosts, those with preexisting renal disease, or those with anatomical abnormalities of the urinary tract. Nosocomial urosepsis may occur in normal as well as abnormal hosts due to the presence of stones, stents, or nephrostomy tubes (1–5). Urosepsis is accompanied by bacteremia with systemic symptoms with or without hypotension (6–8). Immune defects related to malignancy and/or chemotherapy do not diminish mucosal defenses, e. Catheter-associated bacteriuria in the hospital does not result in urosepsis in normal hosts. Urosepsis from urologic instrumentation/procedures may occur in normal or abnormal hosts (4,5,9–12) (Table 2). Because the uropathogens causing community-acquired versus nosocomially acquired urosepsis are dissimilar, different therapeutic approaches are required for community- acquired and nosocomially acquired urosepsis (5,9,11) (Table 3). The interaction between microorganisms and the host determines the systemic response rather than the origin of the infection. The clinical diagnostic approach is to identify systemic disorders or urinary tract abnormalities that predispose to urosepsis, i. Gram stain and culture of the urine with urinalysis plus blood cultures are the definitive diagnostic tests. Indwelling (short-term) Normal Low No antibiotics Remove Foley catheter as non-obstructed Foley soon as possible. Urosepsis due to cystitis in compromised hosts has no localizing signs (1,4,5) (Table 4). Table 4 Differential Diagnosis of Acute Cystitis, Rental Stone, Acute Pyelonephritis Clinical findings Acute cystitis Rental stone Acute pyelonephritis. Symptoms Abdominal pain Suprapubic discomfort Unilateral back pain Unilateral back pain Dysuria þ À þ. Urosepsis in Critical Care 291 Nosocomial urosepsis follows recent urologic instrumentation usually <72 hours. The diagnosis should be considered when a patient becomes septic after a urologic procedure. Patients presenting from the community with urosepsis often have stone or structural ureteral, bladder, or renal abnormality, acute prostatitis/prostatic abscess, or acute pyeloneph- ritis. In acute pyelonephritis, the Gram stain provides a rapid, presumptive, otherwise unexplained microbiologic diagnosis, which should guide antibiotic selection. Patients with acute prostatitis may become septic, but urosepsis often accompanies prostatic abscesses (3–8) (Table 5). Prostatic abscess is a difficult diagnosis in a septic patient without any localizing signs. Similarly, in a patient who has a history of prostatitis and no other explanation for fever/hypotension sepsis, a prostatic abscess should be considered in the differential diagnosis. Gram-positive cocci in chains are group B or D streptococci, since gram-positive cocci in clusters represent S. With the exception of epididymitis in the elderly, community- acquired urosepsis does not require P. Table 6 Community-Acquired Urosepsis: Therapeutic Approach Urosepsis- associated syndrome Microorganisms Urine Gram stain Empiric coverage. Urosepsis in Critical Care 293 Table 7 Nosocomial Urosepsis: Therapeutic Approach Urosepsis- associated syndrome Usual uropathogens Urine Gram stain Empiric coverage. The importance of pre-existing urinary tract disease and compromised host defenses. Role of fluoroquinolones in the treatment of serious bacterial urinary tract infections. Efficacy and safety of colistin (colistimethate sodium) for therapy of infections caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii in Siriraj Hospital, Bangkok, Thailand. Polymyxin B for the treatment of multidrug-resistant pathogens: a critical review. Pseudomonas aeruginosa susceptible only to colistin in intensive care unit patients. Once daily tigecycline therapy of multidrug-resistant and non-multidrug resistant gram- negative bacteremias. Polymyxin B and doxycycline use in patients with multidrug-resistant Acinetobacter baumannii infections in the intensive care unit. In vitro activity of tigecycline and comparators against carbapenem-susceptible and resistant Acinetobacter baumannii clinical isolates in Italy. Treatment with tigecycline of recurrent urosepsis caused by extended-spectrum-beta-lactamase-producing Escherichia coli. Considerations in control and treatment of nosocomial infections due to multidrug-resistant Acinetobacter baumannii. Severe Skin and Soft Tissue Infections 17 in Critical Care Mamta Sharma and Louis D. John Hospital and Medical Center, and Wayne State University School of Medicine, Detroit, Michigan, U. Most of these infections are superficial and treated with regimens of local care and antimicrobial therapy. However, others like necrotizing infections are life-threatening and require a combined medical and surgical intervention. Prompt recognization and treatment is paramount in limiting the morbidity and mortality associated with these infections, and thus a thorough understanding of the various etiologies and presentation is essential in the critical care setting. It is also important to discriminate between infectious and noninfectious causes of skin and soft tissue inflammation. A detailed history and examination are necessary to narrow the possible etiologies of infection. In many instances, surface cultures are unreliable and misleading because surface-colonizing organisms can be mistaken for pathogens. In instances in which the diagnosis is in doubt, aspiration, biopsy, or surgical exploration of the skin can be considered. Typically, soft tissue infections result from disruption of the skin by exogenous factor, extension from subjacent infection, or hematogenous spread from a distant site of infection.
Traditionally buy lyrica 75 mg on-line, double-drug antibiotic therapy was used to treat serious systemic K cheap lyrica 75mg on-line. Because *33% of tigecycline is excreted into the urine buy 150mg lyrica with mastercard, therapeutic urinary concentrations may not be achievable with the usual tigecycline dosing, i. Acinetobacter colonization of aqueous solutions in respiratory support equipment is usually responsible for A. In excluding outbreaks, nearly always Acinetobacter isolates recover from respiratory secretions, represent colonization rather than infection indicative of A. This 518 Cunha can be achieved most simply by avoiding the unnecessary treatment of colonized respiratory secretions or urine (6,7,10). Pseudomonas aeruginosa susceptible only to colistin in intensive care unit patients. Efficacy and safety of colistin (colistimethate sodium) for therapy of infections caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii in Siriraj Hospital, Bangkok, Thailand. Intravenous polymyxin B for the treatment of nosocomial pneumonia caused by multidrug-resistant Pseudomonas aeruginosa. Colistin-resistant isolates of Klebsiella pneumoniae emerging in intensive care unit patients: first report of a multiclonal cluster. Extended spectrum beta-lactamase-producing Klebsiella pneumoniae chronic ambulatory peritoneal dialysis peritonitis treated successfully with Polymyxyin B. Surveillance cultures and duration of carriage of multidrug-resistant Acinetobacter baumannii. Emergence of resistant Acinetobacter baumannii in critically ill patients within an acute care teaching hospital and long-term acute care hospital. Clinical and economic impact of multidrug resistance in nosocomial Acinetobacter baumannii bacteremia. Polymyxin B and doxycycline use in patient with multidrug-resistance Acinetobacter baumannii infections in the intensive care unit. Post-neurosurgical meningitis due to multi-drug resistant Acinetobacter baumanii treated with intrathecal colistin: case report and review of the literature. Antimicrobial effects of varied combinations of meropenem, sulbactam, and colistin on a multidrug-resistant Acinetobacter baumannii isolate that caused meningitis and bacteremia. Antibiotic Kinetics in the Febrile 29 Multiple-System Trauma Patient in Critical Care Donald E. Fry Northwestern University Feinberg School of Medicine, Chicago, Illinois and Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, U. Judicious and appropriate antibiotics are important for preventive indications when the traumatized patient requires a surgical procedure. Specific antibiotic therapy is necessary when infectious complications occur at the site of injury. Nosocomial infections occur at numerous locations during the critical care management and during the prolonged convalescence of these patients, antimicrobial chemotherapy for treatment. In the patient with an injury severity score > 30, antibiotics are employed frequently during the hospitalization and the emergence of resistant and unusual pathogens make the appropriate management of the infectious complications of these patients a formidable challenge. The principals in the utilization of antibiotics for different indications in the trauma patient have become established over the last several decades. For preventive indications, the antibiotic should be given immediately prior (<60 minutes) to the skin incision for invasive interventions. The antibiotic should have activity against the likely pathogens to be encountered in the procedure. Prolonged preventive antibiotics after the procedure do not benefit the patient and should be stopped within 24 hours of the procedure. Infections that occur at the site of traumatic injury require antibiotic therapy against the clinically suspected and the culture-documented pathogens, in conjunction with aggressive surgical drainage and debridement of the primary focus. Because of the impact of the critical care unit, hospital microflora, and antecedent antibiotic treatment, nosocomial infections will notoriously be secondary to resistant organisms and must have susceptibility evidence to guide choices of treatment. Although the above principals in the use of antibiotics are generally accepted, infection continues to be the major cause of death for injured patients without severe head injury who survive the initial 48 hours following the insult. The reasons for infectious deaths in the face of optimum antibiotic utilization are (i) the magnitude of contamination exceeds the capacity of the host and therapy to control, (ii) profound immunosuppression attends the injury, and (iii) antimicrobial resistance produces an array of pathogens that become very elusive to treat. An important consideration that should be contemplated is whether the pathophysiologic changes of the severely injured patient create a clinical scenario where otherwise conventional antibiotic strategies may fail. This chapter will detail the systemic changes that are the result of the systemic activation of the human inflammatory cascade, and why these changes require a reassessment of antibiotic dosing strategies in febrile multiple-trauma patients. Finally, new strategies for the utilization of antibiotics in these patients will be proposed. The biological processes that comprise pharmacokinetics include absorption, volume of distribution, biotransformation, and drug excretion. For antibiotics, the quantitative evaluation of each of these components is used to design the dose and the treatment interval that will be employed for clinical trials and 522 Fry subsequent use of the drug. The clear objective of pharmacokinetic assessment is to provide antibiotic concentrations, which will ensure activity against the likely pathogens that are consistent with quantitative susceptibility information. A second objective is to maintain antibiotic concentrations within the nontoxic concentrations. In the process of drug develop- ment, antibiotics are studied in healthy, normal volunteers. Even in phase 3 prospective, randomized trials, the severity of illness that is evaluated with a new antibiotic product is not extreme. Witness the fact that phase 3 trials of peritonitis customarily are studying largely perforative appendicitis patients. The studies are geared to have few, if any, deaths, and obviously the studies are aimed at having no differences in the clinical outcomes. Only when new antibiotics are approved for use is there a meaningful trial of the drug in a critically ill population. Absorption of antibiotics that will be used in the multiple-system trauma patient will be nearly 100% since all are given intravenously. This results in rapid distribution of the drug throughout the body water compartments to which it will have access. Intramuscular antibiotic administration would generally not be prudent in the trauma patient because severe soft tissue injury, shock, and expanded interstitial water volume would make systemic uptake less dependable. Oral antibiotics have generally not had a place in trauma patients during hospitalization since many will have nasogastric tubes in place or may have post-injury gastrointestinal ileus. The favorable bioavailability of quinolones, linezolid, and perhaps others in development may result in some reevaluation of the use of oral antibiotics in hospitalized trauma patients. Utilization of the gastrointestinal tract for nutritional support has been very effective in many trauma patients, and the intestinal tract may evolve as a route for the administration of antibiotics. The distribution of the antibiotic after administration becomes a critically important issue.
Systemic antimicrobial therapy in full dosage should be initiated (amphotericin B or one of the newer agents in the case of fungal infections) lyrica 150 mg online. The patient should be prepared for surgery and taken to the operating theater as soon as possible to excise the infected tissue buy lyrica 150 mg low cost, which in the case of invasive fungal infection may necessitate major amputation to encompass extensive subcutaneous transfascial spread purchase 150 mg lyrica with amex. Before excision of a wound harboring an invasive bacterial infection, one-half of the daily dose of a broad- spectrum penicillin (e. A second clysis should be performed immediately before operation if more than six hours have elapsed from the initial clysis. The clysis therapy will prevent further proliferation of the invading organisms and reduce the number of viable bacteria and their metabolic byproducts disseminated by operative manipulation of the infected tissue. In the case of invasive fungal infection, clotrimazole cream or powder should be applied to the infected area as soon as the diagnosis is made and prior to excision. Following excision of an area of invasive bacterial burn wound infection, the excised wound should be dressed with 5% mafenide acetate soaks. The patient should be returned to the operating room 24 to 48 hours later for thorough wound inspection and further excision of residual infected tissue if necessary. That process is repeated until the infection is controlled and no further infected tissue is evident at the time of re-examination. If the wound infection was caused by a fungus, mafenide acetate soaks should not be used since they may promote further fungal growth; Dakin’s soaks or a silver containing dressing should be used. Successful treatment of patients with extensive burns involving the head and neck has been associated with an increased occurrence of superficial staphylococcal infections in healed and grafted wounds of the scalp and other hair-bearing areas. Those focal areas of suppuration have been termed “burn wound impetigo,” which, if uncontrolled, can cause extensive epidermal lysis of the healed and grafted burns. Daily cleansing and twice daily topical application of mupirocin ointment typically controls the process and permits spontaneous healing of the superficial ulcerations. They do not sterilize the burn wound but limit bacterial proliferation in the eschar and maintain microbial density at levels that do not overwhelm host defenses and invade viable tissue. Even so, manipulation of the wound by cleansing or surgical excision can result in bacteremia. In the 1970s, before early excision became commonplace, wound manipulation was associated with an overall 21% incidence of transient bacteremia (36). The incidence of bacteremia, which increased in proportion to the extent of burn and the vigor of the manipulation, provided the rationale for perioperative antibiotic administration as described above. The previously noted decrease in invasive bacterial burn wound infection stimulated Mozingo et al. The incidence of bacteremia was related to both the extent of burn and the time that had elapsed after the burn injury. Wound manipulation in patients with burns of less than 40% of the total body surface did not elicit bacteremia. In patients with more extensive burns, the incidence of bacteremia was 30% overall when wound manipulation occurred on or after the 10th post-burn day and rose to 100% in patients whose burns involved more than 80% of the total body surface (37). Those findings can justify omission of perioperative antibiotics for patients with burns of less than 40% of the total body surface, and perhaps even for those with more extensive burns who undergo excision prior to the 10th day after burn. Bacteremia may also occur in association with uncontrolled infection in other sites. In a critically ill burn patient with life threatening complications, recovery of multiple organisms from a single blood culture, or different organisms from successive blood cultures, indicate severe compromise of host resistance and should not be interpreted as contamination of the cultures. An antibiotic or antibiotics effective against all of the recovered organisms should be administered to such a patient at maximum dosage levels and the septic source of the blood- borne organisms should be identified and controlled. Historically, gram-negative septicemia and candidemia significantly increased mortality above that predicted on the basis of the extent of burn, but gram-positive septicemia had no demonstrable effect upon predicted mortality (38). Current techniques of wound care and improvements in general care of the burn patient have not only reduced the incidence of bacteremia but have also significantly ameliorated the comorbid effect of gram- negative septicemia (39). In a nine-year study, investigators compared 4059 paired aerobic and anaerobic cultures from burned patients and found only four anaerobic isolates (all Propionibacterium), none of which were associated with infection. However, they noted that 46 cultures with isolated bacteria, or 13% of those with identified bacteria, were found only in the anaerobic bottle. They concluded that detection of significant anaerobic bacteremia in burned patients is very rare, and anaerobic cultures are not needed for this purpose. However, anaerobic culture systems are also able to detect facultative and obligate bacteria; deletion of anaerobic culture medium may have deleterious clinical impact. In fact, traditional signs of infection such as elevation of white blood cells, increasing neutrophil content, or temperature elevation are not reliable (40). Other signs such as enteral feeding intolerance, thrombocytopenia, and increasing insulin resistance may be better signs of sepsis (41). Once the diagnosis of sepsis is secure, a clear source of infection from the burn wound, pneumonia, or bacteremia may still be elusive. This is usually associated with progression of multiple organ failure when a source is not Infections in Burns in Critical Care 369 identified and controlled. In fact, investigators have shown that 17% of burned patients who develop sepsis associated with multiple organ failure will not have a preceding diagnosis of infection (42). In this condition, a thorough search should be made for an infectious source, including careful and repeated examination of the wound. Other potential sources include the urinary tract, endocarditis, catheter related sepsis, and meningitis. If a source is still not found, it is conceivable that an overwhelming signal of inflammation from the wound could be the cause. It must be emphasized that this is a diagnosis of exclusion, and even after the diagnosis is made, the search for a source of infection must continue. Of late, investigators have been in search of genetic markers that herald the development of sepsis, which could be related to the condition described earlier. This early work signifies that slight genetic differences are likely to result in different responses to injury such as a burn. Identification of these alleles may eventually assist practitioners in the care of these patients who are at risk and even mandate treatment modifications. These initially present as papules with or without an erythematous rash that progress to vesicles and pustules. Crusted, shallow, serrated lesions at the margin of a healing or recently healed partial thickness burn, particularly in the nasolabial area, are typical of herpes simplex virus-1 infections. Titers for antibodies to cytomegalovirus and herpes simplex virus-1 may be found to increase, and intranuclear inclusion bodies in a biopsy specimen from the lesion may also be found. Excision is not required for the treatment of herpetic burn wound infections unless secondary invasive bacterial infection occurs in the herpetic ulcers, in fact, no changes in mortality or length of stay was found in those with viral infections and those without (44). The cutaneous ulcerations of herpetic infections should be treated with twice-a-day application of a 5% acyclovir ointment to decrease symptoms. Identified viral infection is usually self-limited, but in severe cases, consideration can be given to systemic or topical treatment with acyclovir or ganciclovir.
Store it in plastic containers discount lyrica 75 mg visa, opener discount lyrica 150mg line, a utility knife buy 150 mg lyrica overnight delivery, a small canister fire such as soft drink bottles. Store at least a 3-day supply of pliers, tape, a compass, matches in a foods that require no refrigeration, prepa- waterproof container, aluminum foil, plas- ration, or cooking (and little or no tic storage containers, a signal flare, paper water). If you must heat food, go to a and pencil, needles and thread, a shut-off camping goods store for options that do wrench for turning off household gas and not require electricity or natural gas. A meats, fruits, and vegetables; canned map showing the precise location of local juices, milk, and soup (if powdered, store shelters may be available in advance from extra water); staples, particularly sugar, your local emergency-preparedness office. Have on hand an adequate as peanut butter, granola bars, and trail supply of toilet paper and/or towelettes, mix; vitamin pills; special foods for soap, liquid detergent, feminine supplies, infants, elderly persons, or persons on personal hygiene items, plastic garbage special diets; and “comfort foods” such bags with ties for personal sanitation as cookies, hard candy, sweetened cere- uses, a plastic bucket with a tight lid, dis- als, lollipops, instant coffee, and tea. A first least one complete change of clothing aid kit should include sterile adhesive and footwear per person, preferably bandages in assorted sizes, four to six 2- items that are easy to clean. Depending inch sterile gauze pads, four to six 4-inch on your location, you may also need to sterile gauze pads, hypoallergenic adhe- include sturdy shoes or work boots, hats sive tape, three triangular bandages, and gloves, coats and/or rain gear, ther- three rolls of 2-inch sterile roller band- mal underwear, blankets or sleeping ages, three rolls of 3-inch sterile roller bags, and sunglasses. Remember family members and/or liquid), thermometer, two tongue with special needs, such as infants and depressors, a tube of petroleum jelly or elderly or disabled persons. For babies, other lubricant, assorted sizes of safety store an adequate supply of formula, dia- pins, cleansing agent and/or soap, a pers, bottles, powdered milk, and med- medicine dropper, two pairs of latex ications. Contact your local remember essentials such as heart and American Red Cross chapter to obtain a high blood pressure medication, insulin basic first aid manual. Over-the-counter eyeglasses, and games and books for drugs that you might need in an emer- entertainment. Ask a physician or phar- gency include aspirin or nonaspirin pain macist about how to store prescription relievers, antidiarrhea medication, medications. Keep these advised by the Poison Control Center), records in a waterproof, portable con- and laxatives. Keep the items you passports, Social Security cards, immu- would most likely need during an evacua- nization records, bank account numbers, tion in an easy-to-carry container, such as credit card account numbers and http://www. Single-gene diseases numbers, and family records (such as typically describe classic simple Mendelian patterns birth, marriage, and death certificates). All items should be stored in air-tight plastic bags, and the stored diseases, rickettsial See rickettsial diseases. For example, a couple may be discordant disease of the lymphoid cells and of cells from the for a sexually transmitted infection, with one part- reticuloendothelial system (lymph nodes and ner having it and the other not. A patient with lymphoproliferative disorder example, a discordant graft is a transplant between has proliferation and accumulation of lymphoid members of very different species. For a specific disease, see the spe- that give rise to the red blood cells, the granulocyte cific disease (such as Addison disease) under its (types of white blood cells), and the platelets alphabetical listing. The four major myeloproliferative disorders are poly- disease, metabolic See metabolic disease. Also, an artery is osteoarthritis of the knees, hips, and lower back; said to dissect when its wall is torn, as in a dissect- sleep apnea; and Pickwickian syndrome. Examples of polygenic conditions include some dissociation In psychology and psychiatry, a per- forms of coronary disease, hypertension, asthma, ceived detachment of the mind from the emotional and diabetes. Dissociation is charac- the simultaneous presence of several genes, they are terized by a sense of the world as a dreamlike or not inherited as simply as single-gene diseases. Multiple personality disorder is a ing achondroplasia, Huntington’s disease, cystic http://www. For diver- distal The more (or most) distant of two (or ticulitis to occur, there must be outpouchings of the more) things. Diverticulitis can be thigh bone is the end of that bone that is by the diagnosed with barium X-rays of the colon or with knee, most distant from the end that is near the hip. In severe diverticulitis, with high fever distal hereditary myopathy See muscular dys- and pain, patients are hospitalized and given intra- trophy, distal. Surgery is necessary for persist- ent bowel obstruction and for abscesses that do not diuresis Excretion of urine, typically in large vol- respond to antibiotics. All diuretics cause a person to “lose water,” but they do so by diverse means, diverticulosis The condition of having divertic- including inhibiting the kidney’s ability to reabsorb ula, small outpouchings from the large intestine sodium, thus enhancing the loss of sodium and con- (colon). Diverticulosis can occur anywhere in the sequently water in the urine (loop diuretic); enhanc- colon but is most typical in the sigmoid colon, the S- ing the excretion of both sodium and chloride in the shaped segment of the colon located in the lower- urine so that water is excreted with them (thiazide left part of the abdomen. The incidence of diuretic); or blocking the exchange of sodium for diverticulosis increases with age. As a person ages, potassium, resulting in excretion of sodium and the walls of the colon weaken, and this weakening potassium but relatively little loss of potassium permits the formation of diverticula. Diverticulosis sets by yet other mechanisms, and some have other the stage for inflammation and infection of the effects and uses, such as in treating hypertension. Substances in food and keeps the bowels moving, keeps the pressure in the drinks, such as coffee, tea, and alcoholic beverages, colon within normal limits, and slows or stops the may act as diuretics. Diverticula can occur Loop diuretics are very strong, and they should be throughout the colon but are most common near the used only under constant medical supervision. They end of the S-shaped segment of the colon located in can deplete the electrolyte balance, cause dehydra- the lower-left part of the abdomen (the sigmoid tion, reduce blood volume, and worsen certain colon). About 1 in every 50 people has a blocks the exchange of sodium (salt) and potas- Meckel diverticulum. Meckel diverticula are usually sium, encouraging the excretion of sodium and located about 2 feet before the junction of the small therefore of water, but generally allowing potassium bowel and the colon (the large intestine) in the to be retained. Meckel diverticula can become inflamed, ulcerate, and perforate (break diuretic, thiazide A diuretic that works by open or rupture), which can cause obstruction of encouraging excretion of both sodium (salt) and the small bowel. A patient may dizziness Painless head discomfort with many have a diurnal fever rather than a nocturnal one. Laypersons use it to energy expenditure, such as brain and muscle tis- describe a variety of conditions, ranging from light- sues. Doctor of Osteopathy, an osteopathic physi- the function of oxidative-phosphorylation enzymes in cian. In a only rare but also rarely diagnosed because it mim- nonmedical context, a professor of history might be ics many of the symptoms of cerebral palsy. Diseases inherited in an autosomal dom- are often used when initial studies shows particular inant manner typically affect both males and females promise. Autosomal dominant double-jointed Popular term to describe a joint diseases include achondroplasia (dwarfism with that is unusually flexible. Medically, the joint is said short arms and legs), Huntington disease (a form of to be hyperflexible, hyperextensible, or hypermo- progressive dementia), and neurofigromatosis (a bile. People whose fingers are hypermobile have neurologic disorder with an increased risk of malig- higher rates of arthritis in the hands. X-linked dominance is due to genes hypermobility is a feature of Ehlers-Danlos syn- on the X chromosome. An example is a type of hereditary rickets douche Usually, a stream of water applied into called hypophosphatemic rickets. Experiments have shown that a person can communicate with a person who is dreaming. Dowager’s hump An abnormal outward curva- Dreaming is not uniquely human; cats and dogs ture of the thoracic vertebrae of the upper back. The content vertebrae due to osteoporosis leads to forward of dreams is sometimes the topic of psychoanalysis.