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What You Need: Alcohol swabs, Povidone-iodine prep solution, sterile gloves and to wels, gauze, forceps, local anesthesia with ethyl chloride vinyl spray and/or lidocaine 1%, appropriate syringes, needles, and chocolate (Thayer-Martin) media if gonococcal arthritis is suspected. Identify landmarks and mark the entry point with a scratch or indentation on the skin. Anesthetize the skin with the 1% lidocaine with the 10-ml syringe and 22 to 27-gauge needle; continue down to the joint capsule. Select an appropriate needle (usually 20-gauge for knee, shoulder, elbow, or ankle; 25 or 27-gauge for small hand joints). Shoulder: Have patient sit with arm in lap (this positions the shoulder in mild internal rotation and adduction). Direct the needle (20 or 22-gauge 1/2-in needle) to joint space medial to the head of the humerus and just below the palpable tip of the coracoid process. Enter a bulging, inflamed joint space at the wrist dorsally at prominent areas of swelling; such areas are invariably found on the radial or ulnar sides of the wrist during examination. If possible, avoid inserting needles in the palmar or dorsal aspects of the wrist to prevent damaging nerves or blood vessels over the joint. Elbow: Have patient sit with the arm supported horizontal to the ground and the elbow bent at 30fi. Identify insertion site on the lateral aspect of the elbow in the shallow depression immediately anterior and inferior to the lateral epicondyle of the humerus. Knee: Place patient supine with quadriceps muscle relaxed (patella should be freely movable). Identify the insertion site immediately beneath the lateral or medial edge of the patella. Pressure on the opposite side of the joint will make the synovium bulge more prominently and to ward the needle. From the lateral aspect, the entrance site is at the intersection of lines extended from the upper and lateral margins of the patella. Special stains for fungi and acid-fast bacilli should also be performed with chronic joint problems. Protein content: High fluid protein indicates inflammation (Usually 1/3 of serum). It results when internal or external pressure reduces capillary perfusion below the level necessary for tissue viability in a closed fascial space or muscle compartment. This is most common in the leg secondary to blunt trauma (but may occur in the arms) and may be due to crush injury, muscle rupture and burns. The patient will complain of pain, especially with passive movement joints distal to the injury. The other Ps (pallor, paresthesia and pulselessness) are late findings and only strengthen the diagnosis already made. Different from the chronic condition of exertional compartment syndrome that may require elective release, but is not an emergency. This presents with recurrent mild pain in the anterior or lateral compartments of lower leg, sometimes with a foot drop or neurologic signs. Burns: Decrease compartment size with massive edema; coalesces the skin, subcutaneous tissue & fascia in to one tight, constricting eschar; underlying compression of nerves/muscles. Pain on stretch passive movement of the digits may produce pain in the involved ischemic muscles. Paresis muscle weakness due to primary nerve involvement, muscle ischemia, or guarding secondary to pain. Paresthesia or anesthesia a late physical finding in a conscious and cooperative patient is a sensory deficit. Diagnosis for arterial injury usually absent pulses, poor skin color and decreased skin temperature. Diagnosis for nerve damage (neurapraxia): Remarkable paresis or paresthesia, nerve damage (neurapraxia) associated with a fracture or contusion. Administer suitable medications: to alleviate pain and anxiety (see Procedure: Pain Assessment and Control), antibiotic therapy and tetanus prophylaxis for open wounds (see Burns). Moni to r the patient for crush syndrome (similar to Compartment Syndrome, but also suffer distal pulse and neurological damage) and manage accordingly. Splitting and spreading a plaster cast may result in a 65% decrease in intra-compartmental pressure. If symp to ms of neurologic deficit persist more than 1 hour after cast splitting, the cast and all circular dressings must be removed and the limb re-examined. Surgical decom pression, which allows the volume of the compartments to increase, is the primary means of relieving pressure. Treatment: Adequate decompression of the muscular compartments with scissors (fascio to mies). Incise skin 12 centimeters along the anterolateral and posteromedial sides of the leg to allow for release of the anterior and lateral compartments and superficial and deep compartments of the leg, respectively. In the arm, two 5 cm vertical incisions are placed on the dorsum of the hand between the index and middle metacarpals and the ring and small metacarpals. Release of the carpal tunnel is also needed on the volar aspect of the wrist, but due to possible damage to the median nerve, should not be attempted without seeing it done before. Leg and arm wounds are cared for in the routine manner (see Procedure: Skin Mass Removal). Without fractures: Closure in a week (delayed primary closure, if possible) with or without skin grafting. Necrotic muscle is debrided once or twice a week until a satisfac to ry granulation bed is present (see Procedure: Wound Debridement). Prevent development of contractures: the ankle is splinted in the neutral position and the forearm is splinted in the position of function (holding a beer can). If renal insufficiency develops, reduce fluid administration and evacuate the patient. Apply a splint to relieve pain and prevent further harm by immobilizing the underlying bone, the joint above the injury and the joint below the injury. Alternatives for splints: thin boards, sticks, or adjacent body parts for fingers/ to es/legs or to splint an arm against the body. Before applying a splint, inspect skin carefully to ensure that there are no sores or breaks in the skin that should be cleaned and dressed with Telfa before casting. Small puncture wounds might be open fractures and should be treated emergently to decrease the incidence of infection. Patients with open fractures should receive tetanus prophylaxis and antibiotics if available. Immobilize the injury in a position of function (as described below) extending to the joint above and below the fracture. Pad the fracture and joint area with sheet cot to n or Webril in acute injuries and pos to perative cases to provide comfort and lessen the possibility of pressure sores. Wrap the padding smoothly with the turns overlapping about 1 the width of the previous layer. Pad bony prominences with pieces of felt, or use several additional layers of Webril, or cot to n. Use a splint of 10 thicknesses (plies) of casting material on the posterior lower leg and continuing on to the plantar surface of the foot for ankle injuries. Similarly, use 5-ply casting material to make medial and lateral splints for the arm. Rub and mold the splint with your hands over the con to ur of the body part until it is firmly set. Make sure the splint is not circumferential so that there is room for some swelling to occur. Elevate the extremity above heart level to minimize the swelling and maximize comfort. Remember that inflammation and swelling can continue and result in loss of neurovascular function 8 to 12 hours later. Apply the correct amount of traction to the extremity without causing further injury to the patient. What You Need: Moleskin, elastic bandage, felt pads or cot to n, s to ckingette, rope or cord, a spreader bar, soap, water, a razor and blades. If pulses continue to be absent, continue with this task and evacuate as soon as possible.

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They work by a direct effect on the smooth muscle of the gut, causing relaxation and thus reducing abdominal pain. The patient should see an improvement within a few days of starting treatment and should be asked to return to you in 1 week so you can moni to r progress. All antispasmodics are contraindicated in paralytic ileus, a serious condition that fortunately occurs only rarely. The symp to ms would be severe pain, no bowel move ments and possibly vomiting of partly digested food. Side-effects are rare but nausea, dizzi ness, pruritus, rash and headache have occasionally been reported. The drug should not be recommended for pregnant or breastfeeding women or for children. Peppermint oil Peppermint oil has been used for many years as an aid to digestion and has an antispasmodic effect. They are enteric-coated with the intention that the peppermint oil is delivered beyond the s to mach and upper small bowel. Patients should be reminded not to chew the capsules as not only will this render the treatment ineffective, it will also cause irrita tion of the mouth and oesophagus. Occasion ally peppermint oil causes heartburn and so is best avoided in patients who already suffer from this problem. Allergic reactions can occur and are rare; rash, headache and muscle tremor have been reported in such cases. One trial involving 110 people showed improvement in symp to ms of abdominal pain, distension and s to ol frequency. Mebeverine hydrochloride Mebeverine hydrochloride is used at a dose of 135 mg three times a day. The drug should not be recommended for pregnant or breastfeeding women, for chil dren under 10 or for patients with porphyria. It may take a few weeks of experimen tation to find the dose that suits the individual patient. Remind the patient to increase fluid intake to take account of the additional fibre. The evidence for benefit is not strong, as studies have involved small numbers of patients. Antidiarrhoeals Patients who complain of diarrhoea may be describing a frequent urge to pass s to ols, but the s to ols may be loose and formed rather than watery. In two studies involving a to tal of 100 patients, loperamide improved diarrhoea, including frequency of bowel movements, but not abdominal pain or distension. Bran used to be widely recom mended but more recent research indicates that consumption of bran (which contains insoluble fibre) is not helpful and can make symp to ms worse. The sweeteners sorbi to l and fruc to se can make symp to ms worse and they are found in many foods: the patients need to check labels at the supermarket. Cutting out caffeine, milk and dairy products, and choc olate may be worth trying. Remind patients that caffeine is included in many soft drinks and so they should check labels. Others may benefit from traditional acupuncture, reflexology, aroma therapy or homoeopathy. The herbal medicine in this trial was prepared and dispensed by a herbal practi tioner. One of the difficulties in recommending this form of treatment is the lack of control and consistency of the ingredients in herbal preparations. Irritable bowel syndrome in practice Case 1 Joanna Mathers is a 29-year-old woman who asks to speak to the pharmacist. On questioning, she tells you that she has been getting s to mach pains and bowel symp to ms for several months, two or three times a month. She thinks her symp to ms seem to be associated with business lunches and dinners at important meetings and include abdominal pain, a feeling of abdominal fullness, diarrhoea, nausea and sometimes vomiting. In answer to your specific question about morning symp to ms, Joanna says that sometimes she feels the need to go to the to ilet first thing in the morning and may have to go several times. Joanna tells you that she works as a marketing executive and that her job is pressurised and stressful when there are big deadlines or client meetings. If there is no improvement, a different antispasmodic could be tried for a further week, with referral then if needed. She could also be given some time to consider how she might tackle her work pressures. Plenty of information is available on the web, which she could be advised to look at. She is in her early twenties and says she has been getting some upper abdominal pain after food. On further questioning she says that she has had an irritable bowel before but this is different, al though she does admit that her bowels have been troublesome recently and she has noticed some urinary frequency. The best course of action is to refer her to the doc to r for further investigation. A referral to her doc to r is sensible to make a complete assessment of her symp to ms. It is likely that the assessment would just involve listening to her description of her problem, gathering more information and a brief examination of her abdomen. If there was still doubt about the diagnosis, a referral to a gastroenterologist at the local hospital could be made. The main purpose of referral is for a diagnosis as there is no therapeutic advantage. It therefore makes sense to help sufferers to make this connection so they can consider different ways of dealing with stress. However, if Jane did want some medication, a bulk bowel regula to r to help her constipation plus some antispasmodic tablets would be of value. Haemorrhoids are swollen veins, rather like varicose veins, which protrude in to the anal canal (internal piles). Haemorrhoids are often caused or exacerbated by inadequate dietary fibre or fluid intake. The pharmacist must, by careful questioning, differentiate between this minor condition and others that may be potentially more serious. It would be useful to establish whether the patient has a previous his to ry of haemorrhoids and if the doc to r has been seen about the problem. A recent examination by the doc to r that has excluded serious symp to ms would indicate that treat ment of symp to ms by the pharmacist would be appropriate. These three types are sometimes referred to as first, second and third degree, respectively. Predisposing fac to rs for haemorrhoids include diet, sed entary occupation and pregnancy and there is thought to be a genetic element. Pain Pain is not always present; if it is, it may take the form of a dull ache and may be worse when the patient is having a bowel movement. A severe, sharp pain on defecation may indicate the presence of an anal fissure, which can have an associated sentinel pile (a small skin tag at the posterior margin of the anus) and requires referral. It is usually caused by constipation and can often be managed conservatively by correcting this and using a local anaesthetic-containing cream or gel.


  • Togaviridae disease
  • Vipoma
  • Hypofibrinogenemia, familial
  • Hypocalcemia
  • Arteritis
  • Dk phocomelia syndrome
  • Choroiditis
  • Hydantoin antenatal infection
  • Spastic paraplegia glaucoma precocious puberty

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This regimen relies heavily on frequent moni to ring of plasma phenobarbital levels, with titration of the dosage to both the drug level and severity score. This regimen begins with a loading dosage of 20 mg/kg/day, followed by a maintenance dose range of 2 to 6 mg administered daily if the plasma phenobarbital level is therapeutic and the infant is clinically stable. If the plasma concentration needs to be raised, this is accomplished by increasing the frequency of administration to every 12 hours. When an optimal plasma level is obtained (approximately 20 micrograms (mcg)/ml) and the severity score is less than 8, the phenobarbital dosage is maintained for 72 hours. A maintenance dosage of 4 to 6 mg/kg/day is usually adequate to maintain clinical stability. If the to tal score continues to exceed 8, Finnegan and Kaltenbach (1992) recommend increasing the dosage by administering 10 mg/kg of phenobarbital every 12 hours until control is achieved, the blood level reaches 70 mcg/ml, or the infant becomes clinically to xic. Following a clinically stable period of 72 hours, reduction of the serum phenobarbital level by about 15 percent per day can usually be accomplished by administering phenobarbital at a dosage of 2 mg/kg/day. Minor variations in this dosage are based on the clinical severity score and serum phenobarbital level. Phenobarbital is discontinued when the serum level falls below 10 mcg/ml and the severity score is less than 8. The length of treatment of the neonatal opiate abstinence syndrome with phenobarbital is similar to that with paregoric. In one study using the 89 above regimen, Finnegan and Ehrlich (1990) found a mean treatment time of 20 days with phenobarbital compared with 24 days with paregoric. It has the disadvantage, however, of requiring frequent clinical assessments by trained personnel as well as drawing of blood for drug levels, which is expensive, time-consuming, and painful to the infant. Despite some methodologic variation, all of the therapeutic regimens are based on the following principles: complete assessment of the patterns of prenatal drug use will allow for the most appropriate treatment of neonatal abstinence symp to ms; an abstinence scoring system should be used to guide the initiation, maintenance, and discontinuation of drug treatment; paregoric represents the most effective treatment when the neonate has had either sole or major exposure to opiates; phenobarbital is most effective when the infant has been exposed to nonopiates only; and other drugs such as diazepam and chlorpromazine are not appropriate for the treatment of the neonatal opiate abstinence syndrome. Other opiates, such as morphine and methadone, lack enough published data to fully assess their efficacy and safety. Abstinence-associated seizures occur unpredictably, tend to be myoclonic in type, generally occur between 1 and 2 weeks after birth, and are more common when either phenobarbital or no drug is used to treat early signs of opiate abstinence. Part of the reason why studies cite different incidences of these seizures may be the fact that these seizures can easily be missed if tht infants are swaddled in a dimly lit room. A complete metabolic evaluation, including blood sugar, electrolytes, calcium, phosphorus, and magnesium levels should also be performed. If the lower dose is used, a second dose of 10 mg/kg can be administered 10 minutes later if seizures persist. When seizures are controlled, a serum phenobarbital level should be obtained in 24 hours, just prior to starting maintenance therapy at 3 to 5 mg/kg/day divided in to two doses. Paregoric therapy should also be started if the infant has not been previously treated. Little data exist as to the continuing management of infants with abstinence-associated seizures. It appears reasonable to base the ongoing management of these infants on clinical and labora to ry assessments. Once paregoric has been given, phenobarbital may be slowly discontinued at the rate of 1 mg/kg every other day. Following discontinuation of phenobarbital, paregoric may be slowly discontinued as outlined above. If the seizures are not easily controlled despite the administration of phenobarbital and paregoric in adequate doses, other anticonvulsant medications such as diphenylhydan to in may be required. In those cases, however, it is likely that another cause for the persistent seizures will be found. Serial observations of these infants, as well as followup studies at 1 year of age, suggest that these seizures carry an excellent prognosis in the short term. In addition, Bayley developmental test scores remained normal during that period of observation. In that study, 7 of the 14 infants were able to be discharged from the nursery without anticonvulsant medication. As with opiates, life circumstances and behavior of the mother often place the fetus and newborn infant at increased risk for suboptimal perinatal outcome. Similar to treatment for exposure to opiates, treatment of the cocaine exposed neonate rests on an objective assessment of the impact of intrauterine drug exposure. But unlike opiate-exposed infants, cocaine exposed infants do not undergo a physical abstinence or withdrawal. These infants do, however, show signs of neuro to xicity such as transient irritability and tremulousness (Chasnoff et al. In addition, specific neurobehavioral testing has led to a general agreement that these infants evidence lability of state, with wide swings from hyperalertness to reduced reactivity, decreased habituation, and visual tracking difficulties (Chasnoff et al. Cocaine-exposed infants show a very wide spectrum of effects ranging from a lack of obvious symp to ms, to neurobehavioral dysfunction (described above), to more dramatic complications such as seizures (Kramer et al. These serious complications may be due either to an ischemic insult secondary to vasoconstriction or to hemorrhage from acute hypertension. These abnormalities include ischemic injury with cavitary lesions (8 percent), intraventricular hemorrhage (12 percent), subependymal hemorrhage (11 percent), subarachnoid hemorrhage (14 percent), and ventricular dilatation (10 percent). In another study of infants with birth weights under 1,500 grams, however, cocaine exposure did not increase the incidence of intraventricular hemorrhage or periventricular leukomalacia compared with controls (Dusick et al. The subtlety of cocaine related signs and the nature of those neurological abnormalities suggest the need for an assessment such as the Brazel to n Neonatal Behavioral Assessment Scale. An appropriate assessment should focus on areas such as habituation, responsivity, state, and mo to r assessment as well as a more general neurologic evaluation. Although most cocaine-exposed infants show only modest signs of neurodysfunction that do not require the use of pharmacotherapeutic agents, some infants who are excessively irritable appear to benefit from a short course of treatment with phenobarbital. Treatment with an opiate such as paregoric is inappropriate unless significant maternal opiate use compounds the cocaine exposure. If the lower dose of 10 mg/kg is used and seizures persist, that dose should be repeated in 10 to 15 minutes. Phenobarbital levels should be drawn 24 hours after administration of the loading dose. If levels are in the therapeutic range, maintenance therapy, usually at a dose of 5 mg/kg/day, should be started. An important part of the therapeutic management of cocaine-exposed infants is an appropriate nursery environment. In contrast to opiate exposed infants, whose irritability draws the attention of the nursery staff, cocaine-exposed infants tend to wards hyporeactivity and decreased social responsiveness. This may result in these infants being left for periods of time without appropriate stimulation. Cocaine-exposed infants, therefore, should be provided with an individualized program of structured physical contact, including gentle handling with support of the head and body, soft social talking, and eye contact without overstimulation. As with maternal opiate use, intervention programs for cocaine-exposed infants should include mothers and fathers of the infants as much as possible. Parents benefit significantly from inclusion in the assessment and treatment of their infants. This is especially true with the involvement of trained personnel who are skilled in both assessing the infant and working with the parents in a supportive and nonjudgmental manner. Breastfeeding, which could foster mother-infant bonding, is contra indicated if the mother is actively using cocaine. Cocaine may readily pass to the infant through breast milk and may produce a neonatal neuro to xic syndrome including hyper to nia, tremors, apnea, and seizures (Chaney et al. Two studies of amphetamine-exposed infants in Sweden by Eriksson and colleagues (1978, 1981) reported a high perinatal mortality rate, an increased incidence of low birth weight and congenital malforma tions, and neurologic abnormalities including drowsiness, poor feeding, and seizures. Neither of the reports commented on the need for specific treatment in the newborn period. More recently, Oro and Dixon (1987) found a wide range of abnormal ities including abnormal sleep patterns, tremors, poor feeding, hyper active reflexes, abnormal cry, state disorganization, vomiting, sneezing, and tachypnea in a group of 46 infants following intrauterine exposure to cocaine and methamphetamines. Despite these findings, only 1 of 28 methamphetamine-exposed infants required specific treatment.

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For documenta this procedure must not be followed for cap tion, weigh the to tal powder blend and sub sules containing a controlled substance, since tract the initial quantities that were weighed, the amount of drug used and that called for in and the quantity of additional diluent that the prescription must strictly coincide. The powder to be encapsu Tetracycline Capsules lated is placed on a sheet of clean paper Active ingredient: Tetracycline or on a glass or porcelain plate. Some pharma Capsule opaquant: Titanium dioxide cists wear surgical gloves (latex or other material) or finger cots to avoid handling Acetaminophen with Codeine Capsules the capsules with bare fingers. Because the Active ingredients: Acetaminophen 325 mg amount of powder packed in to a capsule Codeine depends on the degree of compression, the phosphate 30 mg pharmacist should punch each capsule in Disintegrant: Sodium starch the same manner and weigh the product glycolate after capping. When nonpotent materials Lubricant/glidants: Magnesium stearate, are placed in capsules, the first filled cap stearic acid sule should be weighed (using an empty Capsule colorants: D&C Yellow No. Such weighings protect Lubricants/ Talc, colloidal silicon against uneven filling of capsules and pre glidants: dioxide mature exhaustion or underuse of the pow Wetting agent: Sodium lauryl sulfate der. Granular material that does not lend itself to the punch method of filling capsules may be poured in to each capsule from the powder filling Hard Capsule shells paper on which it is weighed. When filling a small number of capsules Pharmacists who prepare capsules on a in the pharmacy, the pharmacist may use regular or extensive basis may use a hand the punch method. The the precise number of empty capsules to be various types of machines have capaci filled from the s to ck container. A: With empty capsules in the loader tray, the tray placed on to p of the filler unit. B: the loader inserts the capsules in to the filling unit and is removed, and the to p plate is lifted to sepa rate the caps from the bodies. D: the to p plate is returned to the unit, and the caps are placed on filled capsule bodies. The powder is moved mixing all the ingredients followed by thor around on the plate allowing the capsules to oughly mixing. It is generally necessary to use a tamper empty capsules is placed in the lower plate to aid in packing the powder in the capsules and the upper plate added followed by lock to allow more powder to be accommodated. The upper After all the powder is filled in the cap plate is removed separating the caps from sule bodies, the plate with the capsule caps the bodies of the capsules. The lower plate is then placed on the lower plate and the is loosened allowing the capsules to fall plates are pressed to gether. One manufacturer makes distinctive-looking cap sules by sealing them with a colored band of gelatin (Kapseals, Parke-Davis). Capsules may also be sealed through a heat-welding process that fuses the capsule cap to the body through the double wall thickness at their juncture (10). Industrial capsule-sealing machines are capable of producing 60,000 to 150,000 gelatin-banded, heat-welded, or thermally coupled capsules per hour (12). CleaninG and pOlisHinG the lower plate is removed and the capsules Capsules allowed to fall out of the plate on to a surface Small amounts of powder may adhere to the for examination. The powder Machines developed for industrial use may be bitter or otherwise unpalatable and au to matically separate the caps from empty should be removed before packaging or dis capsules, fill the bodies, scrape off the excess pensing. On a small scale, capsules may be powder, replace the caps, seal the capsules cleaned individually or in small numbers by as desired, and clean the outside of the filled rubbing them with a clean gauze or cloth. On a capsules at up to 165,000 capsules per hour large scale, many capsule-filling machines are (Figs. The formulation must be affixed with a cleaning vacuum that removes such that the filled body contains the accu any extraneous material from the capsules as rate drug dosage. Soft gelatin capsules are made of gelatin to which glycerin or a polyhydric alcohol such Capsule sealing as sorbi to l has been added. They may be sheet of gelatin is carefully placed on to p of the single colored or two to ned and may be im medication, and the to p plate of the mold is put printed with identifying markings. Pressure is then applied to the mold hard gelatin capsules, they may be prepared to form, fill, and seal the capsules simultane with opaquants to reduce transparency and ously. The capsules are removed and washed render characteristic features to the capsule with a solvent harmless to the capsules. Most soft gelatin capsules are prepared by Soft gelatin capsules are used to encapsu the rotary die process, a method developed late and hermetically seal liquids, suspensions, in 1933 by Robert P. By this method, pasty materials, dry powders, and even pre liquid gelatin flowing from an overhead formed tablets. Soft gelatin capsules are phar tank is formed in to two continuous ribbons maceutically elegant and are easily swallowed. At the same time, metered fill material is preparation of soft Gelatin injected between the ribbons precisely at Capsules the moment that the dies form pockets of Soft gelatin capsules may be prepared by the the gelatin ribbons. These pockets of fill plate process, using a set of molds to form the containing gelatin are sealed by pressure capsules, or by the more efficient and produc and heat and then severed from the ribbon. Water-miscible and relatively nonvolatile compounds such as propylene glycol and isopropyl alcohol, depending on fac to rs such as concentration used and packaging conditions Liquids that can easily migrate through the capsule shell are not suitable for soft gela tin capsules. These materials include water above 5% and low molecular weight water soluble and volatile organic compounds such as alcohols, ke to nes, acids, amines, and esters. Solids may be encapsulated in to soft gela tin capsules as solutions in a suitable liquid solvent, suspensions, dry powders, granules, pellets, or small tablets. Are harmless in the quantities used vertical dies that continually open and close 2. Do not exceed the minimum amounts re to form rows of pockets in the gelatin ribbons. Do not interfere with requisite compen the capsules are cut from the ribbons, they fall dial assays and tests in to refrigerated tanks that prevent the cap sules from adhering to one another. Depending on the item, the gelatin capsules include the following (13): container may be required to be tight, well 1. Water-immiscible volatile and nonvolatile closed, light resistant, and/or a combination liquids such as vegetable and aromatic of these. To satisfy the test, the the capsule shells interfere with the analysis, capsules disintegrate completely in to a soft mass having no palpably firm core and only some fragments of the gelatin shell. A, gelatin tank; B, spreader box; C, gelatin ribbon casting drum; D, min eral oil lubricant bath; E, medicine tank; F, filling pump; G, encapsulating mechanism; H, capsule conveyor; I, capsule washer; J, infrared dryer; K, capsule drying tunnel; L, gelatin net receiver. Content labeling requirement Soft Capsules All official capsules must be labeled to ex press the quantity of each active ingredient the gross weight of 10 intact capsules is deter in each dosage unit. Then each capsule is cut open, and the contents are removed by washing with a suitable solvent. The solvent is allowed stability testing to evaporate at room temperature over about Stability testing of capsules is performed as 30 minutes, with precautions to avoid uptake described in Chapter 4 to determine the intrin or loss of moisture. The individual shells are sic stability of the active drug molecule and weighed and the net contents calculated. From the influence of environmental fac to rs such the results of the assay directed in the individ as temperature, humidity, light, formulative ual monograph, the content of the active ingre components, and the container and closure dient in each of the capsules is determined. However, many times, this number of In the pharmacy, capsules may be counted capsule products is available from various manually or by au to mated equipment. In using available medications in hard and soft gelatin this tray, the pharmacist pours a supply of capsules are presented in Tables 7. The soft capsule shells may also contain colorants, opaquants, preservatives, and other agents. Some filled and sweeps the dosage units in to the trough containers are then placed in outer packaging until the desired number is reached. An industrial counting and filling pharmacist closes the trough cover, picks up machine is shown in Figure 7. Capsules the tray, returns the uncounted dosage units are packaged in glass or in plastic contain to the bulk container by means of the lip at ers, some containing packets of a desiccant to the back of the tray, places the prescription prevent absorption of excessive moisture. With this method, the dosage that service nursing homes and hospitals, units remain un to uched by the pharmacist. Typical small because powder, particularly from uncoated scale strip packaging equipment and com tablets, may remain.

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The female mite tunnels in to the epidermis layer and deposits her eggs along the burrow. Scabies is most commonly transmitted by skin- to -skin contact with an infected person and has a worldwide distribution. Subjective: Symp to ms Continuous low-grade pruritus of the genital areas ( to include nipple region in females) with increased itching at night. Objective: Signs Using Basic Tools: Papules, vesicles, and linear burrows intermingled with or obliterated by scratches, dried skin, and secondary infection. The burrow is the home of the female mite, the papules are the temporary invasion of the developing larvae, and the vesicular response is believed to be a sensitization to the invader. The primary locations of invasion include the web spaces of the fingers and to es, the axillae, the fiexures of the arms and legs, and the genital regions ( to include the nipple region of females). The papules of the genital region may persist for weeks to months after the mite has been cleared. Assessment: Diagnosis based on clinical exam and labora to ry/provider isolating evidence from the patient of an infestation-"scabies prep". Differential Diagnosis irritant or allergic dermatitis, arthropod bite reaction, eczema to us dermatitis (see appropriate sections). Apply permethrin 5% cream (Elimite) from the neck down and leave on the skin overnight. Change and wash all undergarments and bedding in hot water prior to showering off the permethrin cream. Dry-clean (or seal in an airtight bag for 2 weeks) clothing items that cannot be washed. Patient Education General: Do not clean the hair or body excessively, as this can lead to excessively dry skin and a 4-61 4-62 secondary focus of pruritus. Often the pruritus persists despite normal hygienic routines if the patient has a hypersensitivity to the mite or its products. Follow-up Actions Reevaluation: Repeat examination for those with continued nocturnal exacerbation of their pruritus. This is the feeding time of the scabies mite and will help differentiate between a hypersensitivity reaction and persistent infestation. Zoonotic Disease Considerations Principal Animal Hosts: Cattle, dogs, and cats Clinical Disease in Animals: Intense pruritus, lesions start on head, neck and shoulders and can spread to the rest of the body. Body lice are seldom found on the body (only getting on the skin to feed), but can be found in the seams of clothing. Subjective: Symp to ms Pediculus humanus capitus (head louse): pruritus of the sides and back of the scalp. Pediculus humanus corporis (body louse): localized or generalized pruritus on the to rso. Pthirus pubis (crab louse): asymp to matic or mild to moderate pruritus in the pubic area for months. Objective: Signs Using Basic Tools: Head Lice: <10 organisms usually identified with naked eye or hand lens. The nit (1 mm oval, gray, firm capsule) cemented to the hair is the egg remnant of a hatched louse. The infestation can be dated from the location of the nit, since they are deposited at the base of the hair follicle and the hair grows 0. Crab Lice: 1-2 mm brown to gray specks in the hair-bearing areas of the genital region. Small erythema to us papules at the sites of feeding, especially in the periumbilical area. Maculae caeruleae are non-blanchable blue to gray macules, 5-10 mm in diameter, at the site of a bite that result from the breakdown of heme by the louse saliva. Assessment: Diagnose based on clinical findings and confirm with identification of lice or nits. Differential Diagnosis irritant or allergic dermatitis, arthropod reaction, seborrheic dermatitis, scabies, eczema to us dermatitis, folliculitis. Clothing items that cannot be washed should be sealed in an airtight bag for 2 weeks or dry-cleaned. Secondary: Relieve pruritus with oral antihistamines, cool baths or compresses, and to pical steroids. Patient Education General: Do not clean the hair or body excessively, as this can lead to excessively dry skin and a secondary focus of pruritus. Subjective: Symp to ms Single, exophytic skin lesion that tends to ulcerate and crust; may be followed by period of healing, then reappearance or multiple raspberry-like lesions. Finally, untreated patients may have bone involvement, resulting in joint pain, difficulty walking or fractures. The primary stage shows a single erythema to us, infiltrated plaque, which eventually heals with scarring. The secondary stage emerges rapidly, with multiple papules that ulcerate and form yellowish crust. The tertiary stage develops after several years and shows deep ulcerated nodules with underlying involvement of bone. Assessment: Diagnose based on clinical findings in an endemic region and confirm with darkfield microscopic exam of the exudates from skin lesions. Patient Education General: Avoid contact with infected persons having active lesions. Transmis sion occurs by direct skin or mucous membrane contact with infected individuals. Subjective: Symp to ms Nonspecific, diffuse, red scaling papules which may coalesce and become hypopigmented over several years. Objective: Signs Using Basic Tools: Acute: Multiple erythema to us macules that may be slightly raised on exposed skin. There are many clinical manifestations, but the most common (vulgaris) is typically expressed as chronic scaling papules and plaques in a characteristic extensor surface distribution. Subjective: Symp to ms Chronic his to ry (months to years) of itching, especially in the anogenital crease and scalp; acute exacerba tions occur in guttate psoriasis and generalized pustular psoriasis; fever, chills, arthritis, and weakness will accompany acute onset of generalized pustular psoriasis. Subtle cases may be suspected in patients with only a slight gluteal crease "pinkening" and nail findings. The arrangement ranges from a few scattered discrete lesions to diffuse involvement without identifiable borders. Use to pical fiuorinated corticosteroids (betamethasone, fiucinolone, clobestasol) in an ointment base. Apply after soaking off the scale in a salt-water bath bid x 2 weeks (then move to non-fiuorinated steroid ointment). Never apply fiuorinated steroid to the face or in occluded areas like the groin or axilla Alternative: Triamcinalone ointment Symp to matic: Hydroxyzine (atarax) 25-75 mg po q4 hrs for pruritus. Empiric: Ultraviolet exposure (20 min exposure to noonday sun) will accelerate the resolution of the lesions. Follow-up Actions Reevaluation: If lesions do not start to thin in 2-3 weeks referral is needed Evacuation/Consultation Criteria: Referral is not usually indicated, unless unstable. It is caused by multiple fac to rs and is more common in those with very curly beard hair. Affected persons may have a genetic predisposition due to abnormal formation of the hair follicle. Curly hair can then penetrate the side of the follicular unit and cause a mechanical irritation in the skin, or the curly hair may exit appropriately and then curl back in to the surface of the face again, causing an irritation. Subjective: Symp to ms Rapid development of papules and pustules in the beard area after shaving. Objective: Signs Using Basic Tools: Follicular-based papules and pustules below the jawline and on the anterior neck. Differential Diagnosis Acne lesions also in other areas Irritant contact dermatitis lesions also in other areas.


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Each system of influence contains roles, norms and rules that shape psychological development. Each of the levels has obvious synergies with social marketing which can act in each arena [33]. The model has been used in interventions on adolescent physical activity using social marketing [34]. Behavioral Ecological Model the Behavioral Ecological Model [35] is an extension of previous behaviour models that focus on the role and influence of selectionist and environmental fac to rs on behaviour, such as the ecological model of health behaviour proposed by McLeroy et al [36]. The model features the integration of public health and behavioural science and places precedence on the function of behaviour, such as the consequences produced by a particular behaviour, over the type or to pography of behaviour. The Behavioral Ecological Model also places emphasis on environmental influences on behaviour. The Behavioral Ecological Model assumes an interaction between physical and social contingencies to explain and control health behaviour. Theory of Reasoned Action, Theory of Planned Behavior and the Integrated Behavioral Model. Intervention mapping: Designing theory and evidence based health promotion programs. Promoting Nutrition and Physical Activity through Social Marketing: Current Practices and Recommendations. Prepared for the Cancer Prevention and Nutrition Section, California Department of Health Services, Sacramen to, California. The behavioral ecological model: Integrating public health and behavioral science. Case Based Pediatrics For Medical Students and Residents Questions and Answers Edi to rs: Loren G. Burns School of Medicine Kapiolani Medical Center For Women And Children Honolulu, Hawaii Copyright 2005, Loren G. True/False: When caring for pediatric patients, it is always more appropriate to use pediatric subspecialists than specialists who may be primarily trained to work with adults. True/False: There is a standard for after hours accessibility that all pediatricians adhere to. True/False: There is variability in the use of pediatric subspecialty care that results from fac to rs other than availability of specialists. If a pediatric subspecialist is not available, the pediatrician has the following choices: a. Send the patient to a pediatric subspecialist regardless of cost and inconvenience. Pediatricians may be concerned about giving after hours telephone advice to parents who call. At what age does the uterine environment play a role in the growth of a child versus the influence on growth by the genetic makeupfi What is the approximate weight gain in grams per day for a healthy term infant from birth to 3 months of agefi How do the growth curves for congenital pathologic short stature, constitutional growth delay, and familial short stature look likefi Developmental and behavioral conditions occur in approximately what percentage of childrenfi What is the best clinical situation to try to identify children with developmental disorders from developmentally normal childrenfi Which of these following methods of identifying children with developmental or behavioral concerns has the worst sensitivityfi Which of the following have been proven problems regarding the standardized parent developmental screening to olsfi An assumption that the screening test done at one point in time will discover all children with every type of developmental problem. When is the best age (out of the following suggestions) for a physician to administer a developmental screening to olfi Which of the following vaccines would be contraindicated in a 4 year old boy receiving immunosuppressive therapy for au to immune hepatitisfi Which vaccine should not be given to an 8 year old girl who has not been immunized previouslyfi Which parenteral vaccine should not be characterized as an attenuated live virus vaccinefi Which passive or active immunization is specifically recommended for women in the second or third trimester of pregnancyfi Increased risk for intussusception was observed as a rare complication following immunization with which vaccinefi True/False: In infants younger than 6 months of age, early intervention for hearing impaired infants is believed to improve the development of speech, language, and cognition, which in turn, decreases the need for special education. What is the best test for assessing hearing deficits in infants older than 6 months of agefi After failing an objective hearing screen, tympanometry testing is conducted and the results are abnormal. True/False: For most problems caused by parental child rearing knowledge deficits, there is good evidence from high quality studies that physicians can change parental behavior through simple counseling in the primary care setting 2. True/False: the anticipa to ry guidance issues for two year olds are very different for boys as compared to girls. Do to the child what the child does to others so they learn why not to do certain things. True/False: Children can develop fluorosis by using fluoride to othpaste and fluoride supplements. True/False: Parents do not need to supervise their two year olds who have already completed swimming lessons. Children can be offered a variety of nutritious foods and be allowed to choose what to eat and how much. It is abnormal for children at this age to eat a lot for one meal, and not much the next. Toddlers and preschoolers often lack the self-control necessary to express anger and other unpleasant emotions peacefully. This method should be considered with certain types of behaviors including impulsive, aggressive, hostile and emotional behaviors. A good rule of thumb is to use five minutes of time out per year of age (for example 25 minutes for a five year old). Which of the following has as an example, not eating all of your dinner and then not having any dessertfi What is the role of the pediatrician in helping parents with common behavioral problemsfi When should a pediatrician refer a patient for more specialized evaluation of behavioral problemsfi The school plan that includes educational programming that can take in to account medical problems such as autism or mental retardation in an 8 year old child is called a/an: a. A 2 year old child with developmental delays in gross and fine mo to r activities can get a free program called a/an: a. Collaborating as the medical home with other related services such as rehabilitative therapists. Should not go to school because school personnel are not trained to care for the tracheos to my. Should not go to school because school personnel cannot handle any emergencies as a result of the tracheos to my. Should go to school as the parents can supervise the care of the child while in school. What are the three main areas affected in children with Autistic Spectrum Disorderfi Most children with language disorders are not usually mentally retarded, while the majority of children with autism are.

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These were featured in 19 studies which accounted for just under one-third of the to tal studies [43-60]. General foodborne illness and foodborne pathogenic infection was the intervention target in four studies [61,62,64,65] whilst diarrhoea was targeted in three studies [25,32,63], one of which targeted both diarrhoea and E. Hepatitis A was the target in two studies [18,58] whilst gastrointestinal infection was cited as the intervention target in one study [37]. Antimicrobial resistance and healthcare-associated infections group Only four of the interventions in the studies targeted antimicrobial resistance and/or healthcare-associated infections [66-69]. Emerging and vec to r-borne diseases group the least frequently targeted group of communicable diseases among the studies was emerging and vec to r-borne diseases, targeted by interventions in three instances [70-72]. Two of the studies targeted Lyme disease, ehrlichiosis, and babesiosis [71-72], while one study targeted schis to somiasis [70]. Nineteen studies were informed by the Health Belief Model, taking in to account perceived beliefs of the target audiences for the interventions. Two of these used the Diffusion of Innovations model to spread an intervention amongst a social group. A single study used a community organisation model, the Locality Development Model. Finally, theoretical frameworks for planning health promotion were used by two studies to inform the intervention. Unless stated otherwise, studies did not provide much detail beyond stating the fact that a theory or model informed the intervention or evaluation. Seven of these studies mentioned using another theory or model in addition to the Health Belief Model [33,36,40,43,57,59,71], most often Social Cognitive Theory, or the related Theories of Reasoned Action and Planned Behaviour. In these 19 studies, the Health Belief Model was used for a wide range of overlapping behaviour change interventions across the six disease groups. Seven studies used the Health Belief Model to inform interventions to increase immunisation or vaccination uptake for influenza, human papilloma virus, hepatitis B, measles and other vaccine-preventable diseases [16,18,27,40,42,51,52]. Five studies used the model to inform hand hygiene interventions with a range of populations [18,30,36,37,68] and four studies used the Health Belief Model to inform hygienic food preparation [18,61,57,64] in different settings. Two studies of Lyme Disease prevention used the Health Belief Model with a view to improving safe tick removal and recognising the symp to ms of tick-borne diseases [71,72]. Two studies evaluated Health Belief Model-based interventions designed to modify unsafe drug preparation practices by injecting drug users in order to prevent and control hepatitis C [43,57]. A single study used the Health Belief Model in a community intervention to reduce antibiotic use and prescription among family doc to rs and parents [33]. Theory of Planned Behavior Five studies described the Theory of Planned Behavior informing the intervention [17,36,59,67,71]. Four of these used the theory in conjunction with other theories or models; three with the Health Belief Model [36,59,71] and one with Social Cognitive Theory [17]. The Theory of Planned Behavior was mentioned for each of the following behaviour change interventions: avoiding tick bites, removing ticks and recognising Lyme Disease symp to ms [71], reducing antibiotic use [17] and increasing hepatitis B screening for non-English speaking migrants to North America [59]. Social Cognitive Theory Social Cognitive Theory, or its earlier version known as Social Learning Theory, was used to inform the intervention in 13 of the studies [14,17,19,23,26,31,33,40,43,57,60,69,71]. Of the thirteen studies which used Social Cognitive Theory, in seven cases it was used alongside another theory or theories, most often those focussed on the health-related behaviour change of individuals such as the Health Belief Model [33,40,43,57,71], the Theory of Reasoned Action and/or Planned Behaviour [17,23,40,43,71]. A range of behaviour types were targeted for change via Social Cognitive Theory informed interventions, for diseases from almost all the disease groupings. Three studies aimed to increase immunisations: Glik [40] and Reynolds [31] based education interventions on Social Cognitive Theory to increase influenza immunisations and Vet [60] used Social Cognitive Theory to inform a website intervention using role models to increase hepatitis B vaccinations. To reduce the prescription of antibiotics in order to decrease antimicrobial resistance, three studies used Social Cognitive Theory in their interventions [14,17,33]. Two studies aimed to reduce hepatitis C infection through one- to -one sessions with a healthcare professional based on Social Cognitive Theory [43,57], (see also [55] described below). Finally, both Hovell [19] and Lewin [23] used Social Cognitive Theory to improve adherence to tuberculosis medicine regimens. Locality Development Model One study used the Community Organisation Locality Development Model in a mass treatment for schis to somiasis infection in a community [70]. Diffusion of Innovations Two studies used the Diffusion of Innovations theory to inform the intervention. Glik [40] used the theory for a process evaluation, measuring the adoption across the country of their Health-Belief-Model-and-Social-Cognitive Theory based educational intervention to increase immunisation among schoolchildren. Ecological models One study used an ecological model of health behaviour change to inform the intervention. An intervention to increase medicine adherence among Latino adolescents in California with latent tuberculosis infection was based on a Behavioral Ecological Model and Social Learning Theory [19]. University students were coached to deliver the intervention to adolescents in their homes or over the telephone. The interventions in seven studies were informed by the Health Belief Model, using or measuring perceived beliefs. Use of the Transtheoretical Model, also referred to as the Stages of Change Model, was mentioned in eight studies, and one study used it for both the intervention design and its evaluation. One study reported that another stage based model, the Precaution Adoption Process Model, was used to design its intervention. Models of interpersonal health behaviour examine the influence of social interactions. Three studies used the community and group model of health behaviour, Diffusion of Innovations, to design an intervention to be spread among a social group. Finally, theoretical frameworks for planning health promotion were used by four studies. Although many of the models may comprise a combination of theories, for this analysis we are using a named model as a single unit. More details are given for each study and model, and any multiple combinations below. Unless stated otherwise, studies did not provide much detail beyond stating the fact that a theory or model informed the intervention design or evaluation. Thus the brochure and skits interventions provided information about the seriousness of influenza.


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Vibrio cholerae 01: Antibiotics can shorten the duration of the illness and thus simplify case management. Tetracycline (or doxycycline) is most widely used, but resistance has been observed in some areas. Although a wide variety of infectious agents cause Nursing care diarrhoea, they are all transmitted through common Nursing care of the patient with infective diarrhoea pathways such as contaminated water, food, and requires: hands. In addition, the hospital must determine the infecting organism and report it to the relevant public health authority; this is of primary importance in epidemic situations. Role of the community the community is responsible for ensuring the maintenance of good standards of food and water hygiene, educating about careful hand washing and other aspects of personal hygiene, and home Page 76 Module 3 Typhoid Definition approximately 600 000 deaths. Typhoid is Typhoid fever (also known as enteric fever) is a predominantly a disease of countries with poor severe systemic infection caused by the Gram sanitation and poor standards of personal and food negative bacterium Salmonella typhi. Multi-drug resistant strains have been a large number of organisms is usually necessary reported in Asia, the Middle East, and Latin America. They are released in to the blood after 10 to constipation and a dry cough may be present. About because of the occurrence of septicaemia during 10% who have typhoid fever excrete the organisms the first week. These may include cholecystitis, for approximately three months after the acute stage pneumonia, myocarditis, arthritis, osteomyelitis of the illness and 2 to 5% of untreated patients and meningitis. Epidemiological summary Age groups affected the organism responsible for typhoid fever was Typhoid can affect any age. Typhoid fever affects Case-fatality rates of 10% can be reduced to less 17 million people in the world annually, with than 1% with appropriate antibiotic therapy. Module 3 Page 77 Diagnosis Treatment of carriers: this can often be very Blood culture is the most important method for difficult to implement, but spread through carriers diagnosis. Isolation of the organism from the s to ol is unusual if good personal hygiene is practised and is more common in the second and third weeks of s to ols are disposed of hygienically. In some cases, isolation of the bacteria in the urine can be used as a diagnostic method. Selective immunization of groups: during an epidemic in an endemic country, selective Methods of treatment immunization of groups such as school children, Four different antibiotics are often used for institutionalized people and healthcare workers is treatment: Ciprofloxacin, Co-trimoxazole, of great benefit. Effective treatment does not always prevent complications, Immunization against typhoid the disease recurring or the patient becoming a There are three types of typhoid vaccine: carrier. It provides equally effective protection as the whole cell vaccine but with fewer Page 78 Module 3 febrile side effects, although it can cause irritation general examination for complications; at the vaccine site. Length Rehabilitation of protection may be less and vaccination may need Recovery may be complete after treatment, but may repeating after one year. The vaccine is unstable at also be delayed with recurrence of the symp to ms room temperature and must be kept refrigerated. Recurrence is more It should be emphasized that whilst these vaccines likely to occur after inadequate treatment. Water and food samples from its prevention suspected sources also need to be tested. The virus most commonly invades Paratyphoid usually has a shorter incubation period, the gastrointestinal tract and a viraemic illness may with diarrhoea from the onset, a more abundant develop. In some cases the virus invades and rash and less commonly develops intestinal destroys the anterior horn cells of the spinal cord. In the most severe cases, the virus attacks the mo to r neurons of the brainstem, causing difficulty in breathing, swallowing and speaking. Epidemiological summary It is thought that poliomyelitis first occurred nearly 6000 years ago in the time of the ancient Egyptians. Evidence for this theory lies in the withered and deformed limbs of some Egyptian mummies. Since the development of the polio vaccine in the mid 1950s, cases of poliomyelitis have diminished dramatically. The disease was brought under control and practically eliminated as a public health problem in industrialized countries. However, muscles of the lower and sub-Saharan limbs are more frequently paralyzed. Two billion children have now been fully in swallowing and speaking, and reduced immunized worldwide. In the meantime, countries free from poliomyelitis must continue to vaccinate in order Age groups affected to prevent the virus reestablishing itself if reintroduced Polio can affect any age and the illness is more severe from other countries. However, the virus most commonly affects children 3 years and under with Manifestations over 50% of all cases occurring in this age group. Although paralytic poliomyelitis is rare, two thirds Non-paralytic poliomyelitis, which produces mild flu of those who develop severe symp to ms will be left like illness with fever, pharyngitis and mild diarrhoea. Severe disability Sometimes viral meningitis with fever and headache is less common in children. Death from poliomyelitis develops, but improves after a few days with complete is usually related to respira to ry failure, for which there recovery. Destruction of the anterior Diagnosis horn cells of the spinal cord and the brain stem occur. However, symp to matic treatment exercise or injections) can increase the likelihood in the form of muscle relaxants and analgesia in the of paralysis to these muscles.

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Control: In man, the prevention of anthrax is based mainly on: (a) control of the infection in animals; (b) prevention of contact with infected animals and contami nated animal products; (c) environmental and personal hygiene in places where products of animal origin are handled (adequate ventilation and work clothing); (d) medical care for cutaneous lesions; and (e) disinfection of fur and wool with hot formaldehyde. Occupational groups at risk may benefit from vaccination with the protective antigen. In the countries of Eastern Europe and in China, a live attenuated spore vaccine is administered by scarification. Pregnant females of any species should not be vaccinated unless they are at high risk of contracting anthrax. Antibiotics should not be administered a few days before or a few days after vacci nation. In general, annual vaccination is sufficient; only in hyperenzootic areas is vaccination at shorter intervals recommended. Immunity is established in approxi mately one week in cattle, but takes longer in horses. In regions where anthrax occurs sporadically, mass vaccination is not justified and should be limited to affected herds. Rapid diagnosis, isolation, and treatment of sick animals with antibi otics (penicillin) are important. To make the diagnosis, it is recommended that blood be taken from a peripheral vessel with a syringe and sent to the labora to ry in a sterile container. Dead animals should be destroyed where they lie as quickly as possible, preferably by incineration. The alternative is to bury them two meters deep and cover them with a layer of lime. In areas where these procedures are not possible, the dead animal should be left intact so that it will start to decompose and, as much as possible, natural orifices and the surrounding soil should be treated with 10% formol (25% formalin). Affected herds should be placed in quarantine, which should last until two weeks after the last case is confirmed, with no animal or animal product allowed out. If anthrax is suspected at a slaughterhouse, all operations should be halted until the diagnosis is confirmed. If positive, all exposed carcasses should be destroyed and the premises carefully disinfected (with a 5% caustic lye solution for eight hours) before operations are resumed. Cutaneous anthrax due to penicillin-resistant Bacillus anthracis transmitted by an insect bite [letter]. Evaluation of serologic tests for diagnosis of anthrax after an outbreak of cutaneous anthrax in Paraguay. Comparative efficacy of Bacillus anthracis live spore vaccine and protective antigen vaccine against anthrax in the guinea pig. Studies on anthrax in food animals and persons occupationally exposed to the zoonoses in Eastern Nigeria. Outbreak of oral-pharyngeal anthrax:An unusual manifestation of human infection with Bacillus anthracis. Serological studies of patients with cutaneous and oral-orophangyngeal anthrax from northern Thailand. Development of antibodies to protective antigen and lethal fac to r components of anthrax to xin in humans and guinea pigs and their rel evance to protective immunity. Etiology: Toxins produced by Clostridium botulinum,which are the most potent known. Group I is highly proteolytic and saccharolytic and includes all the type A strains as well as various type B and F strains. However, not all researchers agree with this scheme and one argument of those favoring a reclassification is the recent discovery of neuro to xigenic strains in Clostridium baratii and C. Arnon (1986) agrees that reclassification would be justified based on logical criteria and taxonomic purity, but questions whether this would improve clinical, microbiological, and epi demiological knowledge. Geographic Distribution: Occurs on all continents, with a marked regional dis tribution that probably reflects the presence in the soil of the microorganism and its different types of to xins. Occurrence in Man: the disease occurs more frequently in the northern hemi sphere than in the southern hemisphere, and can appear sporadically and among groups of people who ingest the same food with the preformed to xin. In that period, there were only three outbreaks affecting more than 10 peo ple, but in 1977, an outbreak of 59 cases involving type B botulinum to xin was described, caused by food eaten in a restaurant (Terranova et al. More than half of the cases reported since 1899 from 45 states occurred in five western states. In the United States, only 4% of the outbreaks origi nated in restaurants, but they represent 42% of the 308 cases occurring between 1976 and 1984. In 1958, several suspected cases of botulism occurred in Brazil when six members of the same family died and others became ill after eating home-canned boiled fish. In 1981, two other suspected cases occurred in Rio de Janeiro, caused by ingestion of an industrially processed food. In Europe and Asia, the occurrence of the illness varies from one country to another. In Poland, which seems to be the country hardest hit by botulism, the majority of cases have occurred in rural areas, as they have in other countries. From 1979 to 1983, there were a to tal of 2,390 cases and 45 deaths, with an average of 478 cases per year (Hauschild, 1989). Infant botulism was recognized for the first time in the United States, and then in Canada, several European countries, and Australia. From 1976 to 1980, 184 cases were recorded in the United States, 88 of which occurred in California and 96 in 25 other states. Currently, infant botulism is the predominant form in the United States, with approximately 100 cases reported each year (Suen et al. The disease has also been described in Argentina, Australia, Canada, the former Czechoslovakia, Great Britain, and Italy. Almost all cases occurred in children under 6 months of age (Morris, 1983) though some occurred in children up to 1 year. Occurrence in Animals: Botulism in animals, including birds, is caused by types C (C alpha and C beta) and D, but there are also outbreaks due to A, E, and B. Botulism in bovines is becoming economically important in some areas, where it can affect a large number of animals. Such areas, generally poor in phosphorus, are found in the southwestern United States, in Corrientes province in Argentina, and in Piaui and Mat to Grosso in Brazil. It is also important in Senegal, where it is believed to cause more cattle loss than any other disease. Recently, various impor tant outbreaks have been recorded due to consumption of bedding silage and bird droppings. Type C to xin was detected in 18 of the 22 sera examined and the same to xin was confirmed in the remains of dead chickens found in the silage (McLoughlin et al. Similar outbreaks also occurred in Brazil and Canada because the bird bed ding used to feed the cattle contained the type C to xin (Bienvenue et al. Animal remains are usually found when botulism outbreaks occur in cattle, especially due to silage; however, no animal remains could be found in the fodder in various cases in the United States and Europe. Bovine poisoning by type B is rare; outbreaks have occurred in Europe (Blood et al. Botulism in sheep is due to type C and has been identified only in western Australia and South Africa. Outbreaks of this form have been described in the United States and Australia (Thomas et al. Botulism in swine is rare because of the natural high resistance of this species to botulinum to xin. Outbreaks diagnosed in Senegal and Australia were caused by type C beta and one in the United States was caused by type B. Botulism in mink can be an important problem owing to their eating habits, if they are not vaccinated as recommended.

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While even the rare occurrence of these catastrophic outcomes may fuel therapeutic zeal, enthusiasm for testing pharmacologic treatments needs to be tempered by consideration of the potential for medications used to treat drug dependence to cause even more harm. Particular caution is required in evaluating the significance and deciding to treat signs or symp to ms of pathologic occurrences rather than pathologic events (hard outcomes). Using fetal moni to ring techniques (Doppler) and ultrasound, some investiga to rs have detected signs of fetal distress associated with abrupt cessation of cocaine in cocaine-dependent women (Christmas et al. It is not clear, however, that the clinical significance of these findings warrants pharmacologic intervention. Researchers need to be mindful of the earlier his to ry of treatments for opiate withdrawal, many of which were considerably more lethal than the disease being treated. Human Subject Issues Conducting clinical trials of pharmacologic treatments for drug dependent pregnant women raises a number of important issues regarding protection of human subjects. First, obtaining informed, voluntary consent from the woman may be problematic, given that many drug dependent women experience considerable coercion to enter treatment because of concerns about retaining child cus to dy or avoiding criminal prosecution. Second, manda to ry reporting requirements in some states may discourage drug-dependent women from enrolling in clinical trials, 211 making it even less feasible to conduct these trials and presenting problems in safeguarding confidentiality. Third, because of the dangers of both drug abuse and medication use during pregnancy, risk-benefit discussions regarding proposed clinical trials of pharmacotherapies for drug-dependent women need to consider carefully the potential benefits of nonpharmacologic treatments. If the risks of continued drug use during pregnancy are believed so extreme as to justify experimentation with medication, these medical risks might also be sufficient to warrant involuntary commitment to a residential facility. Confinement will almost certainly lead to higher rates of abstinence and improved obstetrical and neonatal outcomes compared with any pharmacologic treatment alone. Liability Issues Clinical trials of pharmacologic treatments for drug-dependent pregnant women are likely to become the focus of legal disputes regarding liability for adverse obstetrical events or neonatal outcomes. As a practical matter, concerns about liability are likely to have a chilling effect on the interest of pharmaceutical companies in sponsoring or being involved in clinical trials for drug-dependent pregnant women. For women who have been maintained on an investigational opioid such as buprenorphine, discontinuation may lead to withdrawal symp to ms and possible adverse obstetrical effects. For many medications, there is insufficient information available about the risks to the fetus to provide guidance to the woman about continuation of the pregnancy. It is critical to maintain adequate records about pregnancy outcome or adverse obstetrical or fetal effects associated with exposure to medications used to treat drug dependence. While the initial reports of buprenorphine leading to reductions in cocaine use (Kosten et al. Because pregnancies are likely to occur in women maintained on buprenorphine, it is important to evaluate the risks of tera to genicity and adverse effects on the fetus. It will also be important to evaluate buprenorphine dosing requirements during pregnancy and any long-term behavioral tera to genicity associated with its use. A second reason for investigating buprenorphine as a treatment for pregnant opioid-dependent women is that its pharmacologic profile suggests that it may be safer than methadone for use during pregnancy. While methadone and other full agonists cause increasing respira to ry depression at higher doses, there is a flattening of respira to ry depression and other mu agonist effects at higher doses of buprenorphine, making the lethality of overdose less for buprenorphine than for methadone. In 213 addition, abrupt discontinuation of buprenorphine leads to less severe withdrawal than abrupt discontinuation of methadone. Additionally, there may be fewer problems with neonatal withdrawal in children of buprenorphine maintained pregnant women. Although there are important reasons to evaluate buprenorphine maintenance in pregnant opioid-dependent women, insufficient data are available from preclinical or clinical investigations to evaluate its safety. In one study, which compared subcutaneous administration of methadone (4 or 8 milligrams per kilogram [mg/kg]), buprenorphine (1 or 2 mg/kg), and vehicle in rats, methadone 8 mg/kg led to significant reductions of enkephalin levels in the striatum of rat pups while the lower dose of methadone and neither dose of buprenorphine had any effect on enkephalin levels (Tiong and Olley 1988). Buprenorphine, however, was associated with significantly decreased survival of rat pups (53 percent and 65 percent mortality by day 5 for buprenorphine 1 or 2 mg/kg, compared with 2 percent vehicle-treated, 13 percent methadone 4 mg/kg, and 0 percent methadone 8 mg/kg). The lack of data regarding the safety of buprenorphine as a maintenance agent during pregnancy points to an urgent need to conduct preclinical studies evaluating buprenorphine to xicity and tera to genicity during pregnancy. Until these studies are completed, it would not be prudent to conduct clinical trials of buprenorphine for the treatment of pregnant opioid-dependent women. It is not clear what should be done in situations when a woman becomes pregnant while maintained on buprenorphine. It may be prudent to withdraw her from buprenorphine and transfer her to methadone maintenance, but an argument could also be made that women who have responded well to buprenorphine should be continued on it throughout pregnancy. If the decision is made to substitute methadone for buprenorphine, close moni to ring of the woman and the fetus for signs of 214 withdrawal or distress during this transition period is indicated. If the safety of buprenorphine for use during pregnancy is supported by preclinical studies, investigations in pregnant women will be needed to establish data regarding optimal dose and adverse effects. Nicotine Replacement Benowitz (1991) presented a cogent analysis arguing in favor of using nicotine replacement during pregnancy to facilitate abstinence from cigarette smoking. Although cigarette smoking leads to substantially increased risk of spontaneous abortion (odds ratio of 1. In a meta-analysis of studies of nicotine gum, nicotine replacement was associated with 27 percent cigarette abstinence at 6 months compared with 18 percent for placebo. As noted by Benowitz, the risks of smoking result from exposure to nicotine, carbon monoxide, and other components of cigarette smoke. While the risks of exposure to nicotine alone include effects on uteroplacental circulation leading to low birth weight and possible behavioral tera to genicity, nicotine replacement (approximately 15 to 20 mg nicotine) leads to nicotine levels (10 to 15 nanograms per milliliter [ng/ml]) slightly lower than that caused by smoking 1 pack of cigarettes per day (20 to 35 ng/ml with each cigarette delivering approximately 1 mg nicotine). Depending on the particular delivery system, nicotine levels at night during transdermal replacement may slightly exceed levels found in smokers. Thus there will be a net decrease in overall risk if nicotine replacement leads to abstinence from cigarette smoking. There is a question of potential increased to xicity if a woman continues to smoke while receiving nicotine replacement (especially the patch), but even this additional risk may be lessened somewhat by the development of to lerance to nicotine effects and the relatively flat dose-response curve for cardiovascular effects. While the efficacy of desipramine has been supported by both open-label, nonrandomized studies and some randomized, controlled, double-blind clinical trials (Levin and Lehman 1991), negative findings have also been reported (Kosten et al. In a recent me&analysis, Levin and Lehman (1991) identified seven randomized controlled clinical trials of desipramine that provided data regarding treatment retention and abstinence. They concluded that desipramine had no effects on treatment retention, but that desipramine treated subjects were more likely to abstain from cocaine compared with placebo-treated subjects. Data from even the most positive of the early studies of desipramine (Gawin et al. Significant differences were obtained only after excluding subjects who dropped out within 2 weeks from the analysis (about 30 percent). Six-month followup data documented persistent abstinence in about half of subjects who achieved 3 weeks continuous abstinence during the 8-week trial, but by the 6-month followup, no differences were evident between desipramine and placebo-treated subjects (Kosten et al. The limited information regarding the safety of desipramine use during pregnancy probably precludes further investigation at this time. Desipramine is a metabolite of imipramine and is the major drug found in fetal circulation following treatment with imipramine. Two studies have documented behavioral effects of desipramine administration during pregnancy on the neonatal rat (Ali et al. In addition to these complications, data from nonpregnant humans suggest that there may be an increased likelihood of cardiovascular complications associated with cocaine use during initiation of desipramine treatment. Adverse effects of bromocriptine include hypotension, nausea, and fainting, and there is a case report suggesting an increased risk of cardiovascular complications (hypertension, vasospasm, pulmonary edema) associated with bromocriptine treatment of a cocaine abusing postpartum woman (Bakht et al.


  • https://cdn.ymaws.com/www.aoasm.org/resource/resmgr/OMED2015/McClain_Exam_Upper_Extremity.pdf
  • https://www.ndhealth.gov/Disease/Documents/Resources/MRSA%20Book/QandA2.pdf
  • https://www.aftercancer.co/wp-content/uploads/2015/11/NCCN-Distress-management-guidelines.pdf
  • https://www.nm.org/-/media/Northwestern/Resources/patients-and-visitors/patient-education-tests-procedures/northwestern-medicine-electromyography-emg.pdf?la=en
  • https://www.engenderhealth.org/files/pubs/gender/mrhc-3/participant/mrh_3p.pdf

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