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If difficulties arise with these patients treatment associates generic pepcid 40mg otc, it may be simpler to medications before surgery order pepcid 20mg mastercard switch them temporarily to treatment zinc poisoning buy cheap pepcid 40 mg line control with insulin 7mm kidney stone treatment cheap 40 mg pepcid fast delivery, using the glucose plus insulin infusion regimen described above. Emergency surgery the diabetic patient requiring emergency surgery is rather different. If the diabetes is out of control, there is danger from both diabetes and the condition requiring surgery. The patient may well have: Severe volume depletion Acidosis Hyperglycaemia Severe potassium depletion Hyperosmolality Acute gastric dilatation. In these circumstances, medical resuscitation usually has priority over surgical need, since any kind of anaesthesia attempted before correction of the metabolic upset could rapidly prove fatal. Resuscitation will require large volumes of saline with potassium supplementation (under careful laboratory control). There is no point in giving much more than 4 International Units of insulin per hour, but levels must be maintained either by hourly intramuscular injections or by continuous intravenous infusion. If the need for surgery is urgent, use a conduction anaesthetic technique once the circulating volume has been fully restored. Before a general anaesthetic can be given, the potassium deficit and acidosis must also have been corrected, or life-threatening dysrhythmias are likely. The level of blood sugar is much less important; it is better left on the high side of normal. Obesity is often associated with hypertension – though with a very fat arm the blood pressure is difficult to measure and may appear high when in fact it is not. Because of the extra body mass, the cardiac output is greater than in a non-obese person; more work is also required during exertion, which places greater stress on the heart. The association of smoking, obesity and hypertension is often a fatal one, with or without anaesthesia. A fat neck makes airway control and intubation difficult and excess subcutaneous fat leads to difficulty with venepuncture and conduction anaesthesia. For most drugs given intravenously, a 120 kg patient needs only about 130% of the normal dose for an adult of 60–70 kg. The decision to transfuse should be based on both the patient’s condition and the local availability and safety of blood supplies. Where blood supplies are scarce or unsafe, it may be possible to use pre-donation by the patient in elective cases or to use autologous transfusion in emergencies. Minimize the risk of transmission of infection: Never leave syringes attached to needles that have been used on a patient For intravenous injections, use plastic infusion cannulae with injection ports that do not require the use of a needle, wherever possible Ensure that blood spills are immediately and safely dealt with Use gloves for all procedures where blood or other body fluids may be spilled Where blood spillage is likely, use waterproof aprons or gowns and eye protection. The aim is to provide a starting anaesthesia pleasant induction and lack of awareness for the patient, using a technique Never use an unfamiliar that is safe and that provides good operating conditions. Unfortunately, the anaesthetic technique in an ideal anaesthetic drug with all the desired qualities does not exist. It is common emergency Always check your equipment practice, therefore, to combine several drugs, each of which provides a single Make sure you have an component of anaesthesia. In contrast, ether produces a mixture of sleep, analgesia and relaxation but, because of its pungent smell and high solubility in blood, it is rather inconvenient and slow (though safe) for induction of anaesthesia. The muscle relaxants produce muscular relaxation alone and may therefore be used to provide good surgical relaxation during light anaesthesia, allowing the patient to recover rapidly at the end of anaesthesia. Opiate drugs, such as morphine and pethidine, produce analgesia with little change in muscle tone or level of consciousness. The choice of the most suitable combination for any given patient and operation calls for careful thought and planning. Before starting, check that you have the correct patient scheduled for the correct operation on the correct side. The surgeon should mark the operation site with an indelible marker before the patient comes to the operating room. Check that the patient has been properly prepared for the operation and has had no food or drink for the appropriate period of time. It is normal to withhold solid food for six hours preoperatively, but a milk feed can be given to babies up to three hours preoperatively. Clear fluids are regarded as safe up to two hours preoperatively if gastric function is normal. Measure the patient’s pulse and blood pressure, and try to make him or her as relaxed and comfortable as possible. Before you start, check the patient’s progress through the hospital up to this moment. Make sure that: All the apparatus you intend to use, or might need, is available and working If you are using compressed gases, there is enough gas and a reserve oxygen cylinder the anaesthetic vaporizers are connected the breathing system that delivers gas to the patient is securely and correctly assembled Breathing circuits are clean Resuscitation apparatus is present and working Laryngoscope, tracheal tubes and suction apparatus are ready and have been decontaminated Needles and syringes are sterile: never use the same syringe or needle for more than one patient Drugs you intend to use are drawn up into labelled syringes Any other drugs you might need are in the room. Always begin your anaesthetic with the patient lying on a table or trolley that can be rapidly tilted into a head-down position in case of sudden hypotension or vomiting. It will be the technique of choice in many cases, but care is always needed as it is relatively easy to give an overdose or to stop the patient from breathing. If breathing stops, the patient may die unless you can easily ventilate the lungs with a face mask or tracheal tube. The first rule of intravenous induction is that it must never be used in a patient whose airway is likely to be difficult to manage. Intravenous induction will also suddenly reveal any pre-existing dehydration, hypovolaemia or hypotension. These conditions must be corrected preoperatively or there will be a dangerous fall in blood pressure on injection of the drug. Thiopental Thiopental is presented as ampoules of yellow powder that must be dissolved before use in sterile distilled water or saline to make a solution of 2. Higher concentrations are dangerous, especially if accidentally injected outside a vein, and should not be used. The normal practice is to give a “sleep” dose, by injecting the drug slowly, until the patient becomes unconscious and loses the eyelash reflex. The average sleep dose in a healthy adult is 5 mg/kg of body weight, but much less (2 mg/kg) is needed in sick patients. If the patient reports pain, stop injecting immediately because the needle is probably outside the vein and may even have entered an artery. Avoid injection into the elbow, if possible, because it is easy to enter the brachial artery by mistake. Propofol Propofol is a recently introduced, intravenous anaesthetic that can be used for induction of anaesthesia. Its depressant effects on respiration and blood pressure are greater than those of thiopental, especially if it is injected quickly and, after injection, there is often a respiratory arrest requiring manual inflation of the patient’s lungs. Injection is often painful 14 unless a small amount of lidocaine (20 mg of lidocaine in 200 mg of propofol) is added just before injection. Patients are much less drowsy postoperatively; this is an advantage if they have to leave hospital the same day. To avoid bacterial contamination, ampoules must be used immediately after being opened. Ketamine Induction with ketamine is similar in principle to induction with thiopental and the same precautions apply. The patient’s appearance as he or she loses consciousness is different from when barbiturates are used and the patient may not appear to be “asleep”. The eyes may remain open, but the patient will no longer respond to your voice or command or to painful stimuli. If you try to insert an oropharyngeal airway at this stage, the patient will probably spit it out. Muscle tone in the jaw is usually well maintained after ketamine has been given, as is the cough reflex. A safe airway is not guaranteed since, if regurgitation or vomiting of gastric contents occurs, there is still severe danger of aspiration into the lungs. After induction with ketamine, you may choose to proceed to a conventional inhalational anaesthetic, with or without relaxants and intubation. For short procedures, increments of ketamine may be given intravenously or intramuscularly every few minutes to prevent the patient responding to painful stimulation. If your supplies are limited, try to reserve ketamine for cases where there are few suitable alternatives; for example, for short procedures in children when access to the airway may be difficult. Suxamethonium Suxamethonium is a depolarizing, short-acting muscle relaxant which is widely used to facilitate intubation, especially for emergencies.

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Anaphylactic shock caused by formaldehyde in a patient undergoing long term hemodialysis symptoms of high blood pressure proven pepcid 20 mg. S Management Cross-reactivity among organic and inorganic mercury compounds may occur but is not constant for all of them perform patchs-tests (thimerosal 0 symptoms pneumonia order pepcid 20mg amex. Drug rash with eosinophilia and systemic symptoms caused by topical application of mer cury medicine 223 quality pepcid 20 mg. S Clinical manifestations (laryngoscopy treatment of hemorrhoids generic pepcid 20mg, cytoscopy) • General: anaphylactic shock • Cutaneous: contact urticaria (occupational). References Suzukawa M, Komiya A, Koketsu R, et al, Three cases of ortho-phthalaldehyde-induced anaphylaxis after laryn goscopy: detection of specific IgE in serum, Allergol. Health hazards from exposure to ortho-phtalaldehyde, a disinfectant for endoscopes, and preventive measures for health care workers (Article in Japanese). Fujita H, Ogawa M, Endo Y, A case of occupational bronchial asthma and contact dermatitis caused by ortho phtalaldehyde exposure in medical worker, J. S Clinical manifestations After topical use: contact dermatitis, contact urticaria. After systemic administration: • Cutaneous: pruritus, urticaria, angioedema, systemic contact dermatitis after systemic administra tion in patients with previous contact sensitization, reactivation of positive patch-tests. S Diagnostic methods Skin tests Intradermal skin-tests should be performed with a 5% concentration of methylparaben, ethylpara ben, propylparaben, and butylparaben in order to avoid false negatives. Patch-tests: paraben mix (methyl 4 hydroxybenzoate, ethyl 4 hydroxybenzoate, propyl 4 hydroxybenzoate, butyl 4 hydroxybenzoate): 16% in pet. The only difference between such products and parabens is the presence of a hydroxy instead of an amine group in the para position. Paraben allergic contact dermatitis in a patient with livedo reticularis, Contact. Allergy to parahydroxybenzoic acid esters (parahydroxybenzoates or parabens) (Article in French). S Diagnostic methods Skin tests Prick tests: usually negative Intradermal tests: positive in one patient Patch test, 5% in pet: positive in contact dermatitis. With povidone iodine: irritant contact dermatitis may be severe; ulcerations and caustic reaction, toxic epidermal necrolysis like lesions, vasculitis like lesions, allergic contact dermatitis (less frequent). Patch-tests: povidone iodine 10% and 1% in aq; Careful interpretation (irritation). References Pedrosa C, Costa H, Oliveira G, et al, Anaphylaxis to povidone in a child, Pediatr. Allergic contact dermatitis from povidone-iodine: a re-evaluation study (Article in French). Vernassiere C, Trechot P, Commun N, et al, Low negative predictive value of skin tests in investigating delayed reactions to radio-contrast media, Contact. The majority of sulfite reactions are dietary; 3% of total reactions are attributed to drugs. S Clinical manifestations (reported with: novocaine, lidocaine, gentamicin, metoclopramide, vitamin B injection prepara tions, doxycycline) • General: anaphylactic shock. Cosmetics (hair colours and bleaches, skin fading/lighteners, false tan lotion, antiaging cream and moisturizers, facial cleansers, around-eye cream, body washes/cleansers, hair sprays, perfumes, blush, bronzers/highlighters). S Diagnostic methods Skin tests Prick tests (1 to 10 mg/ml), intradermal skin-tests (5 mg/ml), delayed skin-tests with sulfite solution 2% are usually negative. S Management Cyanocobalamin is effective in preventing clinical sulfite reactions. Avoid use: • Foods: easy if the presence of sulfites is indicated on the package label. If not, a detection band can be used, but false negative results are frequent • Drugs: see the drug listing, or use detection band. Use methoxamine, metaraminol or norepinephrine instead of adrenaline in sulfite sensitive sub jects. Levanti C, Ricciardi L, Isola S, et al, Burning mouth syndrome: hypersensitivity to sodium metabisulfite, Acta. A, Foti C, Angelini G, Sulfite contact allergy, Contact Dermatitis, 1994;31(3):172-5 Lodi A, Chiarelli G, Mancini L. S Diagnostic methods the oral challenge with tartrazine is a only reliable method of accurate diagnosis: Urticaria: tartrazine 1,5,25 and 50 mg at 30 minute intervals. S Management Tartrazine free diet and avoidance of all drugs containing tartrazine. Routine tartrazine exclusion may not be beneficial for most asthmatic patients except those very few individuals with proven sensitivity. S Incidence 1 to 25% of positive patch-tests to thimerosal in patients with contact allergy. A positive patch test is a poor predictor of reaction to thimerosal containing vaccine. The high frequency of patch-test reactions to thimerosal is due to sensitization by thimerosal contai ning vaccines. There is a cross-reactivity between thiosalicylate and a degraded photoproduct of piroxicam (sensi tization to thimerosal with photosensitivity to piroxicam). A positive patch-test with thime rosal should often be regarded as an accidental finding with no clinical relevance. A history of ocular sensitivity to thimerosal does not preclude hepatitis B vaccine administration. Replace thimerosal in soft contact lenses care with sterile single-unit preservative-free saline with thermal disinfection or use special preservative-free care system containing only a low concentra tion (0. J, Miller N, et al, Delayed hypersensitivity to thimerosal in Rho (D) immunoglobulin, J. P, Menezes-Brandao F, et al, Sensitivity to thimerosal and photosensitivity to piroxi cam, Contact. Clinical manifestations (onset within 20 minutes after starting dialysis) Major signs: dyspnea, angioedema, burning/heat sensation at the access site or throughout the body. Normally, kininogen is cleared almost completely by kininases during its passage in the pulmonary circulation. Angiotensin-converting enzyme inhibitor-associated angioedema is charac terized by a slower degradation of des-ardinine (9)-bradykinin degradation of des-arginine (9)-bradykinin. Three intravenous iron preparations are currently in use: iron dextran, sodium ferric gluco nate complex in sucrose and iron sucrose. S Mechanisms the dextran molecule rather than the iron moiety is thought to be the culprit. Switch from iron dextran to sodium ferric gluconate (but iron dextran-sensitive patients have a seven-fold higher risk of reaction) or iron sucrose. Safe administration of iron sucrose in a patient with a previous hypersensi tivity reaction to ferric gluconate. Hypersensitivity reactions and deaths associated with intravenous iron prepa rations. Sodium ferric gluconate complex in hemodialysis patients: adverse reac tions compared to placebo and iron dextran. Severe abdominal pain associated with allergic reaction to nafa mostat mesilate in a chronic hemodialysis patient. Anaphylactoid reaction induced by a protease inhibitor, nafamostat mesilate, following nine administrations in a hemodialysis patient. Positive skin reaction test in haemodialysis patients allergic to nafa mostat mesilate. Anaphylactoid reaction induced by nafamostat mesilate in a hemodia lysis patient. Mild reactions (nausea, vomiting, pruritus, sneezing, vasovagal disorders): 3 to 14% (m: 8%). S Diagnostic methods Skin tests Prick tests: 2 mg/ml Intradermal tests: 200 µg/ml. Elevated beta-tryptase in a serum sample collected at the time of an adverse reaction indicates mas sive mast cell activation and anaphylactic shock.

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Four of 7 patients reported complete reso lution and 2 of 7 reported slight improvement medicine ball generic pepcid 40 mg free shipping. It was noted that early steroid administration was associated with faster decrease in antibody titers (Vincent treatment centers in mn order 40 mg pepcid, 2004) treatment scabies purchase pepcid 40 mg amex. Thus treatment rheumatoid arthritis generic 20 mg pepcid free shipping, serial measurements of those titers are often performed after the series of treatments to monitor disease activity and evaluate response. However, response of clinical symptoms has been used to determine treatment course. Morvan’ssyndrome:peripheral gated potassium channel antibodies, limbic encephalitis, acquired neu and central nervous system and cardiac involvement with anti romyotonia, Morvan’ssyndrome,plasmapheresis,plasmaexchange,apheresis, bodies to voltage-gated potassium channels. Immunoasorption ther peutic plasma exchange as a steroid-sparing therapy in a patient with apy in autoimmune encephalitis. Management of voltage-gated potassium channel antibody cal features, management and outcomes of patients with autoimmune disorders. Neuromyotonia with early response to the treatment of autoimmune encephalitis: a pilot study. Potassium channel antibody seropositive voltage-gated potasssium channel-complex antibody. Neu associated encephalopathy: a potentially immunotherapy-responsive form rol Clin Pract. Children present with asymptomatic liver deposits of copper; teenagers with liver disease; and adults with neurological symptoms. Neurologicalsymptoms include Parkinsonism, dystonia, cerebellar and pyramidal symp toms. History of behavioral disturbances is present in half of patients with neurologicaldisease. No laboratory test is diagnostic but suggestive results include low serum ceruloplasmin, increased 24-hour urinary copper excretion, and elevated serum copper. Current management/treatment Asymptomatic patients should be treated, since the disease is almost 100% penetrant. Zinc acetate is non toxic and stimulates metallothionein, which reduces dietary and enterohepatic absorption of copper. It is thetherapyofchoiceforasymptomatic patients or patients with hepatitis or cirrhosis, but without evidence of hepatic decompensation or neurologic/psychiatric symptoms. Trientine has rep laced penicillamine as the primary chelator due to less toxicity. Decreased serum copper may decrease hemolysis, prevent progression of renal failure and provide clinical stabilization. Plasmapheresis for hemo plasma exchange as de-coppering technique in intensive care for an adult in lytic crisis and impending acute liver failure in Wilson disease. Diagnosis and management of fulminant tem as a treatment for acute decompensated Wilson disease. Therapeutic plasmaphe resis as a bridge to liver transplantation in fulminant Wilson disease. Bridging use of plasma exchange and con tinuous hemodiafiltration before living donor liver transplantation in ful 171–354. As a con the overall prevalence of hepatitis C antibody positivity is esti sequence, the North American Society for Pediatric Gastroenterology, mated to be about 1% to 1. As a consequence, the North American Society for Pediatric Supplemental digital content is available for this article. Areas of interest were identified, and small groups Nomenclature in this practice guideline conforms broadly to were assigned to each area. The areas of interest included epide standard usage; however, as with other pediatric liver diseases, miology, diagnosis, monitoring, anticipatory guidance and dis some definitions require additional specification and are summar closures, treatment, side effects of treatment and monitoring for ized in Table 2. It occupies its own genus (Hepacivirus) and there are 6 main nurses, and obstetricians. The metabolic effects and susceptibility to antiviral drugs vary between genotypes (12). The strength of recommendations in the Grading natural history of their liver disease, which reflect changes in the of Recommendation Assessment, Development, and Evaluation composition of their quasispecies compared with the maternal system was classified as outlined in Table 1. The Working Group quasispecies, in part because of interaction with their own host Indeed in around the time of delivery, as indicated by decreased cord blood many children, liver biopsy discloses no obvious histological pH (46), may enhance the risk of infection. Cost-effectiveness analysis based on available epidemio reported in adult studies. These observations raise the issue of learning reported as a risk for transmission in adults (52). These findings include risk (<2%) and this risk may differ in different parts of the world developmental delay, learning disorders, and cognitive deficits less (53–55). The present consensus is that the reflecting decreased executive function (30,31). Spontaneous resolution of infection is an infection by transfusion of blood or blood products is negligible important outcome, although it remains unclear whether children (33). In a infancy, it should be rechecked after 12 months of age to determine large European study, only 14% were mildly symptomatic. Natural history is also affected by social age-appropriate diagnostic work-up will be described. One disadvantage of the antibody-based tests is that they cannot distinguish acute from chronic infection. Liver biopsy should be generally for persons who are at risk for hepatitis, such as youths who live on considered only if the result will influence medical decision the streets or are incarcerated (79,80). In the past, qualitative tests were used for diagnosis because they were more As noted above, there are only a few reported cases of sensitive than the quantitative tests. Anticipatory Guidance and Screening the risk of transmission is between 1% and 5% in monogamous relationships. Nonetheless, special situations of known vertical transmission, siblings should be screened need appropriate handling as delineated in Table 5 (88–97). Based on multiple Control and Prevention and many patient advocate groups suggest smaller open-labeled, uncontrolled single-center and large blinded, revealing this information to sexual partners when appropriate multicenter pediatric studies (101–109) outlined in Table 6, com ( This cytokine can be pegylated by the may be justified because it allows definitive resolution in a sub covalent attachment of large molecule polyethylene glycol to group of patients. Ribavirin is an oral nucleoside analogue with broad Although in adults the presence of bridging fibrosis on liver biopsy activity against viral pathogens and has immunomodulatory effects is an important predictor of future progression to cirrhosis (98), (116). Although the mechanism of action is not entirely clear, this observation has not been confirmed in children (64,99,100). Ribavirin is presently bility of viral eradication and the lack of predictors of progression. These symptoms differentially efficacious (119–122), although one has not conclus include fever, fatigue, myalgias, arthralgias, headaches, and nausea. A ribavirin side effects is essential to intervene in a timely fashion and to avoid dose adjustment was recommended for weight loss of! Recommendations for monitoring during therapy Dose adjustments may be insufficient to ameliorate marrow suppression, and interventions to treat severe or symptomatic Laboratory test to Obtain test on following anemia or neutropenia may be necessary (131). Growth velocity increased after treatment com ation, differentiation, and selected end-cell functional activation. As neutropenia is the most common mine whether the growth inhibition is temporary or long-lasting. With respect to thrombocytopenia, total white cell and absolute neutrophil counts, and, to a lesser bleeding has not been observed in patients with low platelet counts extent, platelets and red cells. The neutropenia usually reaches (<50,000) and dose modifications are rarely necessary. Clinical a sustained nadir by 8 weeks of therapy and returns to baseline implications or advantages of platelet transfusion are both unclear within weeks after cessation of therapy (102,126). The mechanisms leading to the thrombocytopenia essential to perform a baseline neuropsychiatric evaluation and include suppression of megakaryopoiesis, platelet sequestration specifically to survey for signs of depression before initiation of in capillaries (127), and immune-mediated thrombocytopenia therapy. In the North American study, there was no significant until 3 to 6 months into therapy (124). One patient required discontinuation of therapy due to anemia that most commonly manifests in the first month of treat a suicidal gesture (102). The European analysis included reports ment, reaching a nadir by week 4 (124,126). The mechanism of of nervousness, agitation, aggression, mood alteration, anxiety, ribavirin-induced anemia is thought to involve ribavirin metabolites depression, and affective lability (105).

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Staging: Surgery plays a major role in tumour removal symptoms 7 generic pepcid 20 mg, tumour staging and confirmation of diagnosis as well as visualization of whole abdomen symptoms nasal polyps pepcid 40 mg on line. Clinical features: Manifest according to treatment plantar fasciitis discount pepcid 20 mg the site: Abdominal swelling/mass symptoms sleep apnea discount pepcid 40mg on-line, neurological deficit in case of paravertbral tumours, orbital swelling, and skin lesions. Referral: Urgent referral to a specialized centre Treatment: Combined modality approach: Surgery: Is for early disease or organ preservation. Staging: Localised in the retina vs brain involvement (through optic nerve) Referral: Urgent referral to a specialized centre Treatment: Surgery: Enucleation plus as long a segment of the optic nerve as possible. M:F ratio 5:1 Clinical features: Local pain, tender warm and swollen area over the region of the affected bone (usually midshaft – diaphysis of the long tubular bones (femur). Treatment: Aim: Cure Surgery: Lesions amenable to wide excision without causing severe functional disabilities are resected. The disease presentation will vary according to patient’s state of immunity, the intensity of the infection and the presence of accompany conditions such as malnutrition, anaemia and other diseases. Signs and Symptoms inludes: malaise, fever, fatigue, muscle pain, nausea, anorexia, chill, rigors, sweats, headache, cough, vomiting and diarrhea etc. The above signs and symptoms are not specific for malaria and can be found in other disease conditions. Laboratory investigation is mandatory and urgent for all patients admitted with severe malaria. The exception is in children under 5 years living in high malaria transmission areas, if unable to return for follow up or in case the condition worsens, treat as for uncomplicated malaria. Treatment on the basis of clinical suspicion alone should only be considered if parasitological diagnosis is not accessible. The objectives of treatment of uncomplicated malaria are: • To provide rapid and long lasting clinical and parasitological cure • To reduce morbidity including malaria related anaemia • To halt the progression of simple disease into severe and potentially fatal disease Since the progression towards severe and fatal disease is rapid, especially in children under five years of age, it is recommended that diagnosis and initiation of treatment of uncomplicated malaria should be within 24 hours from the onset of symptoms. Note: Artemether-Lumefantrine is not recommended for: • Infants below 5kg body weight: Malaria is quite uncommon in infants below 2 months of age (approximately below 5 kg). Therefore, an artemisinin alone st is the drug of choice as 1 line treatment in the category of neonates and infants below 5Kg, treating as for severe malaria. Injectable quinine remains a suitable alternative where artesunate is not available. Failure to respond to the recommended drug regimen indicates the need for further investigations and appropriate management, with referral if needed. If parasites are found second line treatment should be started and treatment failure recorded. Delay in diagnosis and provision of appropriate treatment may lead to serious complications and even death. In Tanzania the commonest presentations of severe malaria are severe anaemia and coma (cerebral Malaria). Taking and reporting of blood smear must not be allowed to delay treatment unduly. At a health facility the pre-referral dose of parenteral therapy should be initiated without delay. Pre-referral rectal artesunate: Available as suppository containing 50mg or 100mg or 400mg Dosage regimen: Single dose of 10 mg/kg body weight artesunate should be administered rectally. In the event that an artesunate suppository is expelled from the rectum within 30 min of insertion, a second suppository should be inserted and, especially in young children, the buttocks should be held together for 10 min to ensure retention of the rectal dose of artesunate. Table 4: Dosage for initial (pre-referral) treatment using rectal artesunate Weight Age Artesunate Regimen (single dose) (Kg) dose (mg) 5-8. The solution is 60mg/ml artesunate o Dilute with 2ml of 5% dextrose or dextrose/saline. Dosage regimen: Give single dose of 10mg of quinine salt per kg bodyweight (not exceeding a maximum dose of 600mg). The calculated dose should be divided into two halves and then administered by deep intra-muscular injection preferably into the mid anterolateral aspect of the thigh (one injection on each side). The solution is 60mg/ml artesunate o Dilute with 5ml of 5% dextrose or dextrose/saline. Infusions should be discontinued as soon as the patient is able to take oral medication. Hypoglycaemia remains a major problem in the management of severe malaria especially in young children and pregnant women. Intubation/ventilation may be necessary 298 | P a g e • Acute renal failure: exclude pre-renal causes, check fluid balance and urinary sodium. Haemodialysis /haemofiltration (or if available peritoneal dialysis) should be started early in established renal failure. The effects of malaria in pregnancy are related to the malaria endemicity, with abortion more common in areas of low endemicity and intrauterine growth retardation more common in areas of high endemicity. Early diagnosis and effective case management of malaria illness in pregnant women is crucial in preventing the progression of uncomplicated malaria to severe disease and death. Note: During the second and third trimesters of pregnancy Artemether-Lumefantrine is the drug of choice for treatment of uncomplicated malaria First trimester: During the first trimester of pregnancy, treat with quinine plus clindamycin for seven days or quinine alone if clindamycin is not available or unaffordable. Uterine contractions and foetal distress with the use of quinine may be attributable to fever and effects of malaria disease. At present, artemisinin derivatives cannot be recommended in the first trimester of pregnancy. However, they should not be withheld if treatment is considered life saving for the mother, and other suitable antimalarials are not available. They commonly present with one or more of the following signs/symptoms: high fever, hyperparasitemia, low blood sugar, severe haemolytic anaemia, cerebral malaria, pulmonary oedema. The management of severe malaria in pregnant women does not differ from the management of severe malaria in other adult patients, except pregnant women in the first trimester. The risk of quinine induced hypoglycaemia is greater in pregnant than non-pregnant women. It is given intradermally on the right upper arm, above the insertion of the deltoid muscle. Sputum cannot often be obtained from children and in any case it is often negative even on culture. The diagnosis should therefore be based on clinical findings, family history of contact with a smear positive case, X-ray examination and tuberculin testing, culture (if available) and non-response to broad spectrum antibiotic treatment. Older children who are able to cough up sputum should go through the same assessment as adults using smear microscopy as the “gold standard”. These recommendations are based upon the following dosages by body weight: rifammpicin 10mg/kg; isoniazid 5mg/kg; Pyrazinamide 25 mg/kg; ethambutol 25 mg/kg, If Ethambutol is given for any reason for more than 8 weeks, the daily dose must be reduced to 15 mg/kg body weight. Women using contraceptive should be adviced to use pills with higher dose of oestrogen (50mcg) or change to another method 306 | P a g e 2. In case a patient develops jaundice, treatment should be stopped and restarted as soon as the jaundice resolves. If the patient improves follow with a gradual step up introduction of isoniazid followed by rifampicin until full dose. Streptomycin andEthambutol are excreted by the kidneys and should either be avoided or given in a reduced dose. Four different categories of drug resistance have been identified: Mono-resistance: Resistance to one anti-tuberculosis drug Poly-resistance: Resistance to more than one anti-tuberculosis drug, other than both isoniazid and Rifampicin. It is a disease mainly of human beings, which affects people of all races, all ages and both sexes. Patients harboring many bacilli in their bodies, the multi bacillary patients, are the main sources of infection. If not treated, they spread the disease in the community and infect others through coughing and sneezing (droplet infection). These infectious patients represent only about 25% of the registered leprosy patients in Tanzania. The other 75% of patients with few leprosy bacilli, the paucibacillary patients are less infectious. Skin contact with leprosy patients is no longer considered to be an important means of transmission. The different manifestation of leprosy is due to differences in the degree of resistance (immunity) of the human body and not due to different kinds of bacilli. About 75% of children who get infected with leprosy bacilli have such a high resistance that they overcome the disease themselves, without treatment, at very early stage. People who have a fairly high but incomplete immunity to leprosy bacilli will develop paucibacillary leprosy. Leprae, the bacilli may multiply freely and attain large numbers causing multi-bacillary leprosy.

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