By Q. Bozep. Concordia College, Bronxville, New York. 2019.

When to Change from Steroid Contraception to Postmenopausal Hormone Therapy A common clinical dilemma is when to change from estrogen-progestin con- traception to postmenopausal hormone therapy 100 mg avanafil free shipping. It is important to change because even with the lowest estrogen dose steroid contraceptive available order avanafil without prescription, the estrogen dose is 4-fold greater than the standard postmenopausal dose 50mg avanafil mastercard, and with increasing age avanafil 100 mg with mastercard, the dose-related risks with estrogen become sig- nifcant. An empiric approach allows patients to enter their mid-50s on low-dose steroid contraception and then switches to a postmenopausal hormone regimen. This approach is strongly recommended for women on extended regimens or continuous dosing and women who want protection against an unexpected ovulation and pregnancy. Depot-medroxyprogesterone acetate will prevent the appearance of the two common markers for the onset of menopause: the loss of menstrual periods and hot fushing. Knowing a woman is postmenopausal is important in order to minimize, if not eliminate, the risk of pregnancy, and there is reason to be concerned over the relatively low estrogen state associ- ated with depot-medroxyprogesterone acetate. We are reluctant to follow the empiric practice that allows women to con- tinue estrogen-progestin contraceptives to age 55 because we believe there is some urgency to expeditiously transfer the patient from the low estrogen state associated with depot-medroxyprogesterone acetate to the early bene- fts provided by a program of postmenopausal hormone therapy. Remember the bone loss associated with the use of depot-medroxyprogesterone acetate (as discussed in Chapter 6). Although it is unlikely that bone loss occurs suf- fciently to raise the risk of osteoporosis later in life, women who discontinue depot-medroxyprogesterone acetate at or near their menopause should be encouraged to use hormone therapy in order to regain the lost bone. Preventive Health Care for Older Women Preventive health care for women is especially important during the tran- sition years. Tey include contraception, cessation of smoking, prevention of heart disease and osteoporosis, maintenance of mental well-being (including sexuality), and cancer screening. Management of the transition years should be sig- nifcantly oriented to preventive health care, and the use of contraception can now legitimately be viewed as a constituent of preventive health care. For example, a useful observation to bring to our patient’s attention is the following: continuous use of oral contraception for 10 years by women with a positive family history for ovarian cancer can reduce the risk of epithelial ovarian cancer to a level equal to or less than that experienced by women with a negative family history. Patients deserve to know the facts and need help in dealing with the state of the art and the uncertainty expressed in the media’s coverage of research fndings. But there is no doubt that patients are infuenced in their choice by their clinician’s advice and attitude. While the role of a clinician is to provide the education necessary for the patient to make proper choices, one should not lose sight of the powerful infuence exerted by the clinician in the choices ultimately made. Kirby D, Short L, Collins J, Rugg D, improved contraceptive use, Am J Public Kolbe L, Howard M, Miller B, Health 97:150, 2007. DiCenso A, Guyatt G, Willan A, women, 1982–1988, Fam Plann Perspect Griffith L, Interventions to reduce unin- 22:206, 1990. Kirby D, the impact of schools and medroxyprogesterone acetate, levonorg- school programs upon adolescent sexual estrel implants, and oral contraceptives, behavior, J Sex Res 39:27, 2002. Harper C, Balistreri E, Boggess J, Leon ceptive pill in a private adolescent prac- K, Darney P, Provision of hormonal tice, Adolesc Pediatr Gynecol 7:29, 1994. Centers for Disease Control and Pre- ethinylestradiol, Contraception 53:75, vention, Prevalence of sexually transmit- 1996. Toivonen J, Luukkainen T, Alloven H, practices of urban teens using Norplant Protective effect of intrauterine release contraceptive implants, oral contracep- of levonorgestrel on pelvic infection: tives, and condoms for contraception, three years’ comparative experience of Am J Obstet Gynecol 180:929, 1999. Bilian X, Liying Z, Xuling Z, Mengchun progesterone acetate, oral contraceptive J, Luukkainen T, Allonen H, Pharma- pills, or the patch? Raine T, Harper C, Leon K, mineral density among adolescent Darney P, Emergency contraception: women using and discontinuing depot advance provision in a young, high-risk medroxyprogesterone acetate contracep- clinic population, Obstet Gynecol 96:1, tion, Arch Pediatr Adolesc Med 159:139, 2000. Mintz G, Gutierrez G, Deleze M, Trends in oral contraceptive use and ciga- Rodriguez E, Contraception with rette smoking, Arch Fam Med 3:438, 1994. Fotherby K, the progestogen-only pill and ing gestodene on coagulatory factors, thrombosis, Br J Fam Plann 15:83, 1989. Istre O, Trolle B, Treatment of menor- menopause in women using oral contra- rhagia with the levonorgestrel intrauter- ceptives, Fertil Steril 66:101, 1996. Suvanto-Luukkonen E, Kauppila A, treatment of endometrial hyperplasia—a the levonorgestrel intrauterine system long-term follow-up study, Eur J Obstet in menopausal hormone replacement Gynecol Reprod Biol 139:169, 2008. Varila E, Wahlstrom T, Rauramo I, the levonorgestrel-releasing intrauterine A 5-year follow-up study on the use of system (Mirena) in a 36-year-old woman, a levonorgestrel intrauterine system in Int J Gynecol Cancer 16:1445, 2006. Raudaskoski T, Tapanainen J, Tomas E, hyperplasia to adenocarcinoma despite Luotola H, Pekonen F, Ronni-Sivula H, intrauterine progesterone treatment with Timonen H, Riphagen F, Laatikainen the levonorgestrel-releasing intrauterine T, Intrauterine 10 microg and 20 microg system, Obstet Gynecol 111:547, 2008. Because reversible contraceptive methods are not perfect, more than a third of American couples use sterilization instead, and sterilization is now the predominant method of contraception in the world. Over the past 20 years, over 1 million Americans each year have undergone a sterilization operation, and recently, more women than men. Currently, 39% of reproductive-aged American women rely on contraceptive sterilization: 27% undergo tubal occlusion (11 million women), and 11% depend on their partners’ vasectomies (4 million men). Contracepting Women 15–444,5 Percent 31 31 30 28 27 27 27 27 1973 26 25 25 1982 23 1988 20 1995 18 2002 15 15 12 12 11 11 10 9 9. The frst report was published in 1881 by Samuel Lungren of Toledo, Ohio, who ligated the tubes at the time of cesarean section, as Blundell had suggested 58 years earlier. Because of many failures, the Madlener technique was supplanted in the United States by the method of Ralph Pomeroy, a prominent physician in Brooklyn, New York. This method, still popular today, was not described to the medical profession by Pomeroy’s associates until 1929, 4 years afer Pomeroy’s death. Frederick Irving of the Harvard Medical School described his technique in 1924, and the Uchida method was not reported until 1946. Sterilization Few sterilizations were performed until the 1930s when “family planning” was frst suggested as an indication for surgical sterilization by Baird in Aberdeen. In 1965, Sir Dugald Baird delivered a remarkable lecture, entitled “The Fifh Freedom,” calling attention to the need to alleviate the fear of unwanted pregnancies and the important role of sterilization. The annual number of vasectomies began to decline, and the number of tubal occlusion operations increased rapidly. This is accurately attributed to dra- matic decreases in costs, hospital time, and pain because of the introduction of laparoscopy and minilaparotomy methods. Tese methods have allowed women to undergo sterilization operations at times other than immediately afer childbirth or during major surgery. Sterilization Laparoscopy and minilaparotomy have led to a profound change in the convenience and cost of sterilization operations for women. The shorter length of stay achieved from 1970 to 1975 represented a savings of more than $200 million yearly in health care costs and a tremendous increase in convenience for women eager to return to work and their families. The great majority of sterilization procedures are accomplished in hos- pitals by physicians in private practice, but a rapidly increasing proportion is performed outside of hospitals in ambulatory surgical settings, including physicians’ ofces. Vasectomy has long been more popular in the United States than any- where else in the world, but why do not more men use it? Another is that men have been frightened by reports, ofen from ani- mal data, of associations with autoimmune diseases, atherosclerosis, and, most recently, prostatic cancer. Efficacy of Sterilization Laparoscopic and minilaparotomy sterilizations are not only convenient but also almost as efective at preventing pregnancy as were the older, more complex operations. Vasectomy is also highly efective once the sup- ply of remaining sperm in the vas deferens is exhausted. Approximately 50% of men will reach azoospermia at 8 weeks, but the time to achieve azoospermia is highly variable, reaching only about 60% to 80% afer 12 weeks. The methods using complicated equipment, such as spring- loaded clips and silastic rings, fail for technical reasons more commonly than do simpler procedures such as the Pomeroy tubal ligation. It is hardly surprising that more complicated techniques of tubal occlu- sion have higher technical failure rates. What is surprising is the fnding that characteristics of the patient infuence the likelihood of failure even when technical problems are controlled for in analytical adjustments. In a careful study of this issue, two patient characteristics, age and lactation, demonstrated a signifcant impact. Tese fndings probably refect the greater fecundity of younger women and the contraceptive contribution of lactation. For this reason, some clinicians routinely perform a uterine evacuation or curettage prior to tubal occlusion. It seems more reasonable (and cost efective) to exclude pregnancy by careful history tak- ing, physical examination, and an appropriate pregnancy test prior to the sterilization procedure. Terefore, during the course of counseling, all patients should be made aware of the possibility of failure as well as the intent to cause permanent, irreversible sterility. It is important to avoid giving patients the impression that the tubal occlusion procedure is foolproof or guaranteed.

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The source of bacteria that colonize the upper airway is most likely the patient’s own lower intestinal flora avanafil 50mg fast delivery, but the nasal sinuses and stomach can also harbor bacteria that can subsequently reach the lung buy 100mg avanafil with amex. The coexistence of nosocomial sinusitis and pneumonia has been documented generic avanafil 100 mg visa, often with the same organisms buy avanafil pills in toronto, and both infections can be promoted by the presence of a nasogastric or nasotracheal tubes [4]. In addition to promoting sinusitis, the endotracheal tube and the nasogastric tube can also serve as additional pathways for bacterial entry to the lung. Any organisms that reach the inside of the endotracheal tube can proliferate to large numbers because this site is free from host defenses, and a biofilm commonly lines the interior of the endotracheal tube and can contain as 6 many as 10 organisms per cm of the tube surface [54]. Interestingly, the ventilator circuits are usually contaminated by the patient, as the circuit becomes colonized in large numbers, as bacteria proliferate in the water condensate in the tubing. If handled carefully, the circuits are not a major source of pneumonia pathogens, and the incidence of pneumonia is not increased even when ventilator circuit tubing is never changed during the course of therapy [4]. The gastrointestinal tract, particularly the stomach, can serve as a reservoir for bacteria, and several investigators have shown that Gram- negative bacilli can move retrograde from the stomach to the oropharynx and then antegrade into the lung [57]. The stomach can be the source of 20% to 40% of the enteric Gram-negative bacteria that colonize the trachea of intubated patients, but it is difficult to determine if these colonizing gastric bacteria also lead to pneumonia. One of the ways that the stomach can be an important source of pneumonic organisms is through the mechanism of reflux and aspiration. When a nasogastric tube is used for feeding, it can promote aspiration, especially when a large- bore tube is used with a bolus feeding method rather than with a continuous infusion of enteral nutrients, and when the patient is kept in a supine position [58]. When a nasogastric tube is present, it may promote pneumonia if the gastric contents have a pH above 4 to 6, as can occur with the use of antacids, H blockers, and enteral feeding. The Canadian Critical Care Trials Group reported that acidified enteral feeds preserve gastric acidity and substantially reduce gastric colonization among critically ill patients; however, in one study, there was no impact on the incidence of pneumonia with this intervention [59]. Increases of gastric volume can be detrimental and promote aspiration, thus accounting for the observation that when continuous enteral feeding leads to an elevation of gastric pH (and presumably an elevation of gastric volume), the incidence of pneumonia is higher than when continuous feeding is used but does not raise pH [60]. Another way to minimize the impact of the stomach and to avoid aspiration is to keep patients in a semierect position whenever possible, particularly because the supine position can favor aspiration when a nasogastric tube is in place [58]. However, this position may not favor secretion clearance from the lung, and the lateral Trendelenburg position may be better for this purpose. Risk factors for Gram-negative colonization of the upper and lower respiratory tract are similar and include antibiotic therapy, endotracheal intubation, smoking, malnutrition, general surgery, and therapies that raise gastric pH [52]. Additional risk factors for oropharyngeal colonization include azotemia, diabetes, coma, hypotension, advanced age, and underlying lung disease. Additional risk factors for tracheobronchial colonization include chronic bronchitis, cystic fibrosis, ciliary dysfunction, tracheostomy, bronchiectasis, acute lung injury, and viral infection [51]. One pathogenetic mechanism that links many of the clinical risk factors for upper and lower airway colonization is a cell–cell interaction termed bacterial mucosal adherence. Many clinical disease states can alter the oropharyngeal or tracheal epithelium, making the cell surface more receptive for binding by such bacteria as P. Diseases that result in an increased number of oropharyngeal and tracheal cell bacterial receptors are many of the same processes that promote colonization of these sites [51]. One study of intubated patients demonstrated the rapidity with which the endotracheal tube itself became colonized with enteric Gram-negatives and found that colonization took place despite the use of bacterial filters in the ventilator circuit [62]. Colonization is a common finding among intubated patients, and the presence of potential pathogens in the respiratory secretions of intubated patients is to be expected, and does not require therapy unless there are clinical signs of infection. In addition, many illnesses can be complicated by pneumonia because they require therapy with medications that interfere with immune function. Genetic variation may explain why patients, who have certain inherited patterns of immune responses, are more prone to severe forms of pneumonia, and even mortality, than others. Although the exact incidence of viral pneumonias is unknown, these agents may account for up to one third of all community-acquired cases. The most common pathogen identified in pneumonias arising out of the hospital is the pneumococcus, and among the elderly, although pneumococci are still the most common pathogens, enteric Gram-negative organisms may be responsible for 20% to 40% of all cases of pneumonia, and anaerobes and H. Of note, patients with mixed pyogenic pneumonia more frequently developed shock when compared with patients with single pyogenic pneumonia (18% vs. Bacterial co-infection was more common with parainfluenza and influenza viruses and less common with respiratory syncytial virus and rhinoviruses. When evaluating a patient with pneumonia, it is important to understand the status of each individual’s respiratory host defense system to predict which possible pathogen is most likely (Table 181. If the patient has a serious underlying illness, then organisms of less intrinsic virulence that would ordinarily be eliminated by a normal host can be responsible. When an alcoholic has pneumonia, anaerobes and Klebsiella pneumoniae become more likely; those with chronic bronchitis may be infected with nontypeable H. Certain historical information can be valuable, such as an appropriate travel or exposure history that suggests specific etiologic pathogens (Table 181. Gram- negative organisms are more common with aspiration, especially in the health care environment, including the nursing home [68]. Oropharyngeal commensals such as viridans group streptococci, coagulase-negative staphylococci, Neisseria species, and Corynebacterium species can produce infection of immunocompromised hosts and some immunocompetent patients. These resistant organisms are a particular concern for severely ill patients with other risk factors, including poor functional status, prior antibiotic therapy, immune-suppressive therapy, and a history of recent hospitalization. Because many of the symptoms of pneumonia result from the host inflammatory response, patients who have altered immune function have less dramatic symptoms. Thus, those with advanced age, chronic lung disease, cardiac disease, renal failure, diabetes, immunosuppressive therapy, and other chronic illnesses have not only an increased incidence of pneumonia but also a less distinct and subtler clinical presentation. General Features of Nosocomial Pneumonia A major controversy is how to determine when hospital-acquired (particularly ventilator-associated) pneumonia is present. In addition, the elderly and immunosuppressed may have few clinical findings when pneumonia develops in the hospital. Limited sputum production due to impaired immunologic status and mobilization of leukocytes compound the difficulties of diagnosis. If these features exist along with isolation of a potential pathogen from the sputum, then this organism is deemed to be responsible for the infection. The findings of a positive blood culture or radiographic cavitation add to the likelihood of pneumonia being present. The use of biomarkers, both in the serum and in the respiratory secretions, may help in making this difficult diagnosis. Then the immune competence of the patient, the types of comorbid diseases present, and the existence of risk factors for specific pathogens should be defined to identify the most likely etiologic pathogens. Historical data, physical examination, and laboratory findings pertinent to diagnoses will also be helpful for determining which etiologic agent is responsible and what specific therapy should be instituted (see Tables 181. For example, contact with animals, especially birds, rats, and rabbits, can suggest the diagnosis of psittacosis, plague, and tularemia, respectively. Historical Information the history can be used to determine if the patient has pneumonia as the cause of his or her acute illness, recognizing that certain populations, such as the elderly, may have an altered, nonclassical presentation. Among elderly and compromised hosts, the infection may be heralded only by lethargy and confusion [69]. Among compromised hosts with malignancy or immunosuppressive therapy, the presentation may be so stunted that pneumonia may only be discovered only at autopsy. Hemoptysis is an important historical feature, since it implies tissue necrosis and is most common with pyogenic streptococcal pneumonia (groups A to D), anaerobic lung abscess, S. Microaspiration of anaerobic organisms leading to pneumonia is more likely with a history of preexisting severe periodontal disease or with a history of seizure disorder, altered consciousness, or esophageal obstructive disease. Extrapulmonary symptoms may give clues to specific etiologic agents, with diarrhea and abdominal discomfort being seen in patients with Legionella sp. In addition, the specific antibiotics used in the past 2 weeks should be recorded, since the pathogens causing the current infection are likely to be resistant to those agents. Physical Examination the physical examination is valuable for suggesting the presence of pneumonia and for grading its severity. Relative bradycardia is a frequent finding in many pneumonias caused by Mycoplasma, Legionella, and Chlamydophila organisms [93]. Horder spots (pale macular rash), long considered part of the presentation of psittacosis, should lead the clinician to look for other evidence of this infection. Ecthyma gangrenosum, an indurated, round skin lesion with a central dark area surrounded by erythema, is characteristic of Gram-negative septicemia, especially with P.

The reason for choosing artemisinin is its rapid clearance of parasitemia and resolution of symptoms buy avanafil 100 mg without a prescription. They reduce the parasite management of uncomplicated malaria number by approximately 10 100mg avanafil overnight delivery,000 fold (104) in each asexual in children cycle purchase avanafil 100 mg otc. The second important reason is its rapid elimination Malaria in children has some unique features buy avanafil 50mg with visa. Young from the body so that the residual concentration of the drug children below 5 years of age, whose passive immunity does not provide a selective filter for resistant parasites. Falciparum malaria can be rapidly and absence of significant resistance till date. It has also progressive leading to rapid clinical deterioration; hence the advantage of reducing gametocyte carriage and thus this group needs constant monitoring. Children can tolerate transmission of malaria which is particularly important in antimalarial drugs better than adults and their symptoms malaria control. If artemisinin is combined with other rapidly eliminated Malaria parasite develops resistance to drugs randomly antimalarials like tetracycline or clindamycin, a seven days due to de novo genetic mutations. Here lies the importance of or lumefantrine shorter courses of treatment (3 days) will prescribing highly effective treatment regimen in hyper- be effective and also ensure adherence. Slowly eliminated parasitemic patients and ensuring good adherence to partner drug persists at parasiticidal concentration until all prescribed drugs. For 5–14 kg body weight one been suggested that all falciparum cases may be treated tablet twice daily. Currently there are insufficient safety and tolerability data on Severe life-threatening malaria is nearly always due to mefloquine at its recommended dosage of 25 mg/kg body weight in P. Mefloquine shares cross resistance with quinine which is still an effective drug in our country. Health planners of our country do to be treated in the same line of complicated malaria not advocate use of mefloquine. Advantage of artemether lumefantrine combination is that High degree of suspicion of severe malaria is of utmost lumefantrine is not available as monotherapy and has never been importance and any delay in initiation of treatment can used alone for the treatment of malaria. Lumefantrine absorption is enhanced by co-administration with fatty food like milk. Confirmation of the diagnosis is preferable but Drug sensitivity Recommended treatment one should not delay the treatment if it needs more than P. All these three interventions hours (total dose 25 mg base/kg) are equally important and to be taken care of simultaneously. In case of vivax malaria to prevent relapse primaquine should be given in a dose of 0. Chloroquine should not be given in empty stomach and in high the patient antimalarials should be given according to the fever. A single dose of deficiency, they should preferably be screened for the same prior primaquine (0. Clindamycin 20 mg/kg/day in 2 divided doses Then 12 hours after the start of loading dose give a for 7 days maintenance dose of 10 mg salt/kg over 2 hours. Doxycycline is preferred to tetracycline as it can be given once daily clindamycin is added to quinine as soon as the patient is and does not accumulate in renal failure. The dose of quinine should be divided between two sites, half the dose in each anterior thigh. Tetracycline or doxycycline pump over 30 minutes, followed immediately by 10 mg or clindamycin should be added as above. Artemisinin are the most rapidly acting of all known • If there is no clinical improvement after 48 hours of antimalarial drugs, they often produce a 10,000 fold parenteral therapy the maintenance dose of quinine reduction of parasites per asexual cycle. Thus they can stop parasite • Quinine should not be given subcutaneously as this maturation, particularly from the less pathogenic may cause skin necrosis. Convulsions may be supportive management very subtle with nystagmus, salivation or twitching of an isolated part of the body. Effort should be given to exclude • Rapid clinical assessment with respect to level of other treatable causes of coma (e. Patients should be given good nursing care, pressure, rate and depth of respiration, anemia, state of convulsions should be treated with diazepam/midazolam hydration and temperature. Children with hyperparasitemia due to acute destruction • Oxygen therapy and respiratory support should be of red cells may develop severe anemia. Also maintain intake output chart and watch for Deep breathing with indrawing of lower chest wall without hemoglobinuria. Correct Blood smear examination every 6–12 hours for hypovolemia, treat anemia and prevent seizures. Asexual parasitemia generally disappears after 72 hours It is common in children below 3 years especially with of therapy. It also occurs in • In case of quinine parasite count may remain patients treated with quinine. Manifestations are similar unchanged or even rise in first 18–24 hours which to those of cerebral malaria so it can be easily overlooked. However, parasite count should fall after blood glucose are not available assume hypoglycemia 24 hours of quinine therapy and should disappear in symptomatic patient and treat accordingly. Of the various complications of falciparum malaria the bibliography common and important ones in children are as follows: 1. Guidelines for Diagnosis and Treatment of Malaria in India • Respiratory distress (acidosis) 2009. This may affect viscera, skin or mucous membranes caused organism is capable of producing rapid tissue destruction by infection due to parasites of genus Leishmania. In India, etiological agent is a protozoal parasite, Leishmania the diagnosis of kala-azar is usually clear from clinical donovani, a hemoflagellate. Parasitization of reticuloendothelial differentiated from tropical splenomegaly, malaria, system, such as spleen, liver, lymph node and bone marrow, Hodgkin disease, leukemia, tuberculosis and hemolytic accounts for the salient features of the disease. When the onset is typhoid-like, kala-azar should be differentiated from enteric fever, septicemia, miliary epidemiology tuberculosis, brucellosis and hepatic amebiasis. Kala-azar Kala-azar is distributed worldwide with about 12 million with malaria-like onset needs differentiation from malaria, people infected and about 1. In India, it is endemic in Bihar, West Bengal, Orissa, Assam, Sikkim Laboratory diagnosis and eastern Uttar Pradesh but sporadic cases have been reported from different parts of the country. Human beings are bone marrow, spleen, liver and lymph node aspirates or the only reservoir of infection in India. The splenic aspiration or less confined to rural areas, especially those along rivers and smear examination is the most sensitive (95–98%) (Ganga-Brahmaputra) and lakes. Bone marrow aspiration is usually without any risk and positive in 75–85% clinical features of cases. Lymph node aspiration and liver biopsy are positive the incubation period is 2–6 months but there may be wide in 60% and 50% of cases, respectively. A large majority in kala-azar usually shows anemia, thrombocytopenia, of the cases have insidious onset though acute onset may leukopenia with neutropenia, marked eosinopenia and rarely be seen with high fever and rapidly enlarging spleen. Fever, serological Tests hepatosplenomegaly and pallor are seen in more than 95% • aldehyde test (Napier test):It is simple and non-specific of cases. The increase in immunoglobulin skin, polymorphic waxy non-ulcerating nodules and sparse, is the basis of this test. The sensitivity of this test is falling and brittle hairs are the additional manifestations. Rarely it may present as bleeding; may occur in children with cirrhosis, malaria and multiple epistaxis, hematemesis, melena and retinal hemorrhage. In this test, 1 or 2 drops of formalin (40%) are the serious complications may occur in kala-azar added to 1–2 mL of patient’s serum in a test tube. The and include pneumonia, dysentery, severe hemorrhage, egg white jellification of serum with opacification within agranulocytosis, acute glomerulonephritis, amyloidosis, 2–20 minutes indicates strongly positive reaction, and 226 papilledema, jaundice and cancrum oris. Some authors recommend this drug as first line anti- the disease during and after therapy. It a phosphocholine analog which was developed as anti- is simple, cheap and effective. A titer of 1:1600 or above malignant drug has shown to be highly active against is taken as positive. Splenectomy needs to be reserved for cases with poor management response to conventional anti-leishmanial drug and massive splenomegaly. In the last decade, a lot of new Prior to splenectomy, children must be vaccinated against parenteral drugs have been tried and found to be effective Meningococcus, Pneumococcus and H.

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Maternal anemia (iron-deficiency) person holds head to touch the head piece order avanafil 100 mg without prescription, align the body affects development of neurotransmitters irreversibly cheap generic avanafil canada. Record the length to the Puberty is the process of physical maturation from child to nearest 0 order genuine avanafil. At puberty generic avanafil 100 mg free shipping, a second growth spurt occurs, being earlier height in girls by 1 1/3–2 years than in boys, giving rise on the It is measured standing for a child with minimum clothing average, to a difference in adult height between men and without shoes and socks, standing with feet parallel on an women of about 14–15 cm. The head is held erect with lower border of the eye orbit in the same horizontal Growth assessment in infancy plane as the external canal of the ear (Frankfort plane). In general, length in normal term infants increases about 30% by 5 months of age and more than 50% by 12 months of age. Infants grow 25 cm during the first year; and height at 4 years is about double of the birth length. In boys, half the adult height is attained around 2 years of age; while in girls, height at 19 months is about half the adult height. Weighing scale is checked for zero, center genesis imperfecta and mucopolysaccharidosis. Position the tape just above the eyebrows, above the ears and around the biggest part midarm circumference on the back of the head. This is measured on the left upper arm mid-way between the head circumference measurement in infancy the acromion and olecranon processes. In field surveys, it helps in diagnosis of mal/under- nutrition: a value more than 13. In children of European origin, the arm span should approximate the height (intermediate-length arms). Asians have proportionally shorter arms than Europeans, and Africans have significantly longer arms. If more than 95th centile, it Percentiles suggests obesity and less than 5th centile, undernutrition Percentiles describe the frequency distribution of (thin). In adolescents, calculate with the weight and height anthropometric parameters like weight, height, skull values in relation to the sexual maturity. Fiftieth percentile is the average Indian children are different than the National Center for (median) line for the given population. Any child with parameters below or above or Harpenden’s skinfold calipers are used. Measurements these limits or those who cross percentiles after 2 years of are done as follows: age needs careful evaluation. On palpable points of the iliac crests in the midaxillary lines, the other hand, if he is in the 85th percentile for height by a fiber glass tape. Hip is measured on the maximum and weight, and follows that pattern consistently over extension of the buttocks. A the data on affluent Indian children were collected range of ±2 Z scores includes 95. Average daily On first birthday 46–47 cm, 35% increase from birth weight gain during: size • First 3 months: 30 g At 2 years age 48 cm • 3–6 months: 20 g (birth weight doubles by 5–6 months of age) At 5 years 50–51 cm • 6–9 months: 15 g • 9–12 months: 12 g (birth weight triples by first birthday) 12 years 52 cm • 1–3 years: 8 g (around 3 kg/year). Children from six countries provided • Less than 7 cm/year for less than 4 years of age the data measurements, which were not representative of • Less than 6 cm/year for 4–6 years their country of residence, and were selected on the basis of • Less than 4. The sectional data for physical growth and sexual development median final height in boys is higher by 0. Their observations reference data for assessing physical growth and sexual are similar to those recently published by Marwaha et al. These “growth which needs immediate action to control or prevent and charts” (s 3. On both growth charts based on data (birth to 18 years of age) by the high and low ends of the scale, creating new reference Agarwal et al. This was also recommended in growth chart curves with these changes may not be beneficial from a evaluation study by Khadgawat et al. It is important to note that in spite of unprecedented flattens after 14 tears if age (sjewubg as cinoared ti economic growth since 1991, Indian women remain short by Agarwak et al. Physical growth parameters and prevention of overweight and obesity in assessment in adolescence. Their value resides in helping to determine the degree to which physiological needs for growth and the linear growth patterns of these highly selected, healthy development are met during the important childhood infants were strikingly similar between countries, supporting period. Beyond their usefulness in assessing children’s the view that they represent a standard against which the nutritional status, many government and United Nation growth of all children can be assessed, wherever they live agencies rely on growth charts to measure the general well- and however they are fed. The standards are derived from the list of charts available is as follows: children who were raised in environments that minimized • Length/height-for-age constraints to growth such as poor diets and infection. In • Weight-for-age addition, their mothers followed healthy practices such as • Weight-for-length breastfeeding and not smoking during and after pregnancy. These charts thus are • Arm circumference-for-age prescriptive standards and not descriptive references. Thus these Doctors and health care workers find it difficult to interpret charts are recommended for assessing the pattern of infant various cut offs for diagnosis of underweight, overweight, growth and harmonize growth assessment systems within stunting, wasting, etc. Another key characteristic of the applicability of Who charts in india and new standards is that they explicitly identify breastfeeding around the World as the biological norm and establish the breastfed child as the normative model for growth and development. Growth curves for school age children and 1,493 affluent Indian children on all zones of India, published adolescents. Training Course on Child Growth referral to specialized centers in developing countries such Assessment. The changes encompass aspects of sexuality and early appearance of pubic hair and spots. The initial event of puberty is an increase in pulsatile Pubescent children are those in whom secondary sexual release of gonadotropin hormone releasing hormone characters and early genital changes are appearing. While • Adolescent growth spurt neurons that utilize excitatory and inhibitory amino acids • Change in body composition (muscle/fat) as transmitters represent major players in the trans-synaptic • Skeletal maturity. It is essentially the activation of the hypothalamic-pituitary-gonadal axis that induces and enhances the progressive ovarian and differences between Boys and Girls testicular sex hormone secretion that are responsible for For boys, testosterone is the principal sex hormone. It the profound biological, morphological and psychological induces the characterization known as virilization. The male “growth spurt” also begins later, accelerates more slowly and lasts longer before the epiphysis fuse. It promotes growth Growth Spurt of breasts and uterus, and is responsible for the pubertal • Period extends for 4 years in girls and 6 years in boys to growth spurt, epiphysis maturation and closure. Estradiol being a good stimulator of “growth hormone” doubles the growth velocity. The growth in the post enarche period is limited as girls can gain 5–6 cm in linear growth only. Puberty is associated with change in body shape like hip growth, increase in body fat from 16% to 28% and reduction in lean body mass from 80% to 72%. The age of menarche is around 12–13 years Rapid pubertal growth occurs once testes are more than (12. Actually testicular growth starts as early as 10 years • Estradiol is the main hormone in females influencing of age, associated with enlargement of seminiferous the pubertal development, i. The growth spurt in boys is on usually occurs between ages of 12 years and 13 years. The areola across pubes majority Menarche Height gain similar begins to darken in color. The average adult male • eyes: Growth in axial diameters results in a tendency to has about 150% of the lean body mass of an average “myopia” in adolescence. Muscle growth can • voice: Growth of larynx, pharynx and lungs leads to continue even after boys are biologically adult. Rising levels of androgens can change the fatty acid the greatest effect can usually be seen in the upper chest composition of perspiration resulting in a more “adult” and shoulder muscles. As in girls, another androgen effect is increased lengthen, giving young men a heavier bone structure and secretion of oil (sebum) from the skin and the resultant 97 longer arms and legs. Acne cannot be prevented or heavier bones and nearly twice as much skeletal muscles.

Suprapubic cystostomy tubes are of small caliber and therefore do not function effectively with severe hematuria and retained clots order generic avanafil canada. Instead purchase avanafil online pills, open surgical placement of a large caliber tube is necessary if urethral catheterization is impossible avanafil 200mg mastercard. Technique There are two general types of percutaneous cystostomy tubes that range in size from 8 to 14 Fr purchase avanafil 50mg without prescription. The Stamey device is a polyethylene Malecot catheter with a luer lock hub that fits over a hollow needle obturator. When the obturator is locked to the hub of the catheter, the Malecot flanges are pulled inward (closed), and the system is ready for use. The Bonanno catheter uses a flexible 14-Fr Teflon tube, which is inserted over a hollow 18-gauge obturator. The second type of percutaneous cystostomy tube consists of a trocar and sheath, which are used to penetrate the abdominal wall and bladder. The patient is placed in the supine position; a towel roll may be placed under the hips to extend the pelvis. The suprapubic region is clipped, prepared with 10% povidone-iodine solution, and draped with sterile towels. After obtaining consent and performing a time-out, 1 % lidocaine is used to anesthetize the skin, subcutaneous tissues, rectus fascia, and retropubic space. A 22-gauge spinal needle with a 5-mL syringe is directed vertically and advanced until urine is aspirated. If the bladder is smaller or if the patient had previous pelvic surgery, the needle is directed at a 60-degree caudal angle. Insertion of the cystostomy tube is predicated on the feasibility of bladder puncture and after the angle and depth of insertion is established with the spinal needle. The angle, distance from the pubis, and position of the catheter in relation to the bladder wall are demonstrated. Two hands are used to grasp the system to provide a forceful, but controlled, thrust through the abdominal wall. A syringe attached to the end of the obturator is used to aspirate urine and confirm obturator placement. This prevents the catheter tip from withdrawing into the retropubic space when the bladder decompresses. After unlocking the obturator from the catheter, the obturator acts as a guide while the catheter is advanced into the bladder. When using a Stamey catheter, the catheter can be gently withdrawn until the Malecot flanges meet resistance against the anterior bladder wall. After the bladder is penetrated, urine appears at the hub of the suprapubic catheter introducer (trocar plus sheath). Pulling the tab at the top of the peel-away sheath allows the remaining portion of the sheath to be removed away from the catheter. The Lawrence suprapubic catheter does not require extra fixation, because the balloon on the Foley catheter secures it in place. When using a Stamey catheter or a Foley catheter, bladder spasms can be prevented by withdrawing the tube until it meets the anterior bladder wall and then advancing 2 cm back into the bladder. This medication should be discontinued before removing the suprapubic tube to prevent urinary retention. A suprapubic tube that ceases to drain is usually caused by kinking of the catheter or displacement of the catheter tip into the retropubic space. If necessary, suprapubic catheters may be replaced using either an exchange set (available for Stamey catheters) or by dilating the cystostomy tract. Penetration of the peritoneal cavity or bowel perforation produces peritoneal or intestinal symptoms and signs. This complication can be avoided by attempting the procedure only on well-distended bladders and using a midline approach no more than 4 cm above the pubis. Hematuria can occur secondary to laceration of a submucosal vessel or rapid decompression of a chemically distended bladder. Complications associated with the catheter include loss of a portion of the catheter in the bladder, calcification of the catheter, or bladder stone formation. When chronically distended bladders are decompressed, patients are at risk of postobstructive diuresis. Patients who are at greatest risk include those with azotemia, peripheral edema, congestive heart failure, and mental status changes. The experienced urologist will generally not use ultrasonography to perform percutaneous cystostomy; as, in their expert hands, the procedure can be performed with a high degree of safety [14]. The exception would be when there is history of lower abdominal surgery, where the risk of bowel injury is increased. It is unusual for an intensivist to perform percutaneous cystostomy, but, should the need arise, ultrasonography is particularly helpful to the less experienced operator, as the fluid-filled bladder can be readily identified with ultrasonography [7]. This allows for accurate identification of safe site, depth, and angle for device insertion into the bladder, similar in principle to that required for thoracentesis or paracentesis. Using a transverse imaging plane, the phased array probe (or curvilinear abdominal probe if available) is placed immediately above the pubic bone in the midline. When filled to moderate extent, the bladder has a square configuration; when distended, it becomes rounded in shape. By angling the probe from the transverse plane downward into the pelvis, the entire structure can be examined. The risk that the bowel might be in the target area is of special concern, if there is history of lower abdominal surgery. The depth and best angle for device insertion is determined, followed by performance of the procedure. This pitfall may be avoided by identifying bowel loops within the ascites, and by detection of ascites elsewhere in the abdomen. Ultrasonography also has useful application for the performance of difficult urethral catheterization. The tip of the catheter may enter the bladder with drainage of urine, but with the catheter balloon remaining in the proximal urethra at the level of the prostate. When there is difficulty with catheter insertion and uncertainty concerning the position of the catheter balloon, real-time ultrasonography of the bladder during catheter insertion allows the intensivist to determine proper balloon position prior to its inflation. It constitutes an essential part of the evaluation for arthritis of unknown cause, frequently with the intent to rule out a septic process [1–3]. They may present similarly but require markedly different treatments, thus necessitating early arthrocentesis and prompt synovial fluid analysis. In the intensive care unit, it is most commonly performed to rule out septic arthritis or crystalline arthritis. As many types of inflammatory arthritis mimic septic arthritis, synovial fluid analysis is essential in differentiating the various causes of inflammatory arthritis [4,7] (Table 26. Therefore, patients presenting with acute monoarthritis or oligoarthritis require prompt arthrocentesis with subsequent synovial fluid analysis, preferably before initiation of treatment. In a septic joint, serial joint aspirations are often required to remove accumulated inflammatory or purulent fluid. This accomplishes complete drainage of a closed space and allows serial monitoring of the total white blood cell count, Gram stain, and culture to assess treatment response. Inflammatory fluid contains many destructive enzymes that contribute to cartilage and bony degradation; removal of the fluid may slow this destructive process [8,9]. Additionally, arthrocentesis allows for injection of long-acting corticosteroid preparations into the joint space, which may be a useful treatment for various inflammatory and noninflammatory forms of arthritis [10]. This requires a meticulous physical examination to differentiate arthritis from periarticular inflammation. Fluid is stroked from the medial joint line into the suprapatellar pouch and then from the suprapatellar pouch down along the lateral joint line. If a large effusion is present, one can detect a ballotable patella by pushing it against the femur with the right index finger while applying pressure to the suprapatellar pouch with the left hand [13]. B: Slide the hand down the lateral aspect of the joint line and watch for a bulge medial to the joint. If coagulopathy is present and septic arthritis is suspected, every effort should be made to correct the coagulopathy (with fresh- frozen plasma or alternate factors; see Chapters 88 & 89 Disorders of Hemostasis) before joint aspiration.

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Direct-Acting Adrenergic Agonists Direct-acting agonists bind to adrenergic receptors on effector organs without interacting with the presynaptic neuron order avanafil 200 mg on line. The first three are naturally occurring neurotransmitters avanafil 50mg low price, and the latter is a synthetic compound purchase cheap avanafil. In the adrenal medulla cheap avanafil express, norepinephrine is methylated to yield epinephrine, which is stored in chromaffin cells along with norepinephrine. On stimulation, the adrenal medulla releases about 80% epinephrine and 20% norepinephrine directly into the circulation. At low doses, β effects (vasodilation) on the vascular system predominate, whereas at high doses, α effects (vasoconstriction) are the strongest. Epinephrine strengthens the contractility of the myocardium (positive inotrope: β action) and increases its rate of contraction (positive chronotrope: β action). Epinephrine constricts arterioles in the skin, mucous membranes, and viscera (α effects), and it dilates vessels going to the liver and skeletal muscle (β effects). Therefore, the cumulative effect is an increase in systolic blood pressure, coupled with a slight decrease in diastolic pressure due to β receptor–mediated vasodilation in the skeletal muscle2 vascular bed (ure 6. Respiratory Epinephrine causes powerful bronchodilation by acting directly on bronchial smooth muscle (β action). It also2 inhibits the release of allergy mediators such as histamine from mast cells. Hyperglycemia Epinephrine has a significant hyperglycemic effect because of increased glycogenolysis in the liver (β effect),2 increased release of glucagon (β effect), and a decreased release of2 insulin (α effect). Lipolysis Epinephrine initiates lipolysis through agonist activity on the β receptors of adipose tissue. Bronchospasm Epinephrine is the primary drug used in the emergency treatment of respiratory conditions when bronchoconstriction has resulted in diminished respiratory function. Thus, in treatment of anaphylactic shock, epinephrine is the drug of choice and can be lifesaving in this setting. Within a few minutes after subcutaneous administration, respiratory function greatly improves. Anaphylactic shock Epinephrine is the drug of choice for the treatment of type I hypersensitivity reactions (including anaphylaxis) in response to allergens. Cardiac arrest Epinephrine may be used to restore cardiac rhythm in patients with cardiac arrest. Local anesthesia Local anesthetic solutions may contain low concentrations (for example, 1:100,000 parts) of epinephrine. Epinephrine greatly increases the duration of local anesthesia by producing vasoconstriction at the site of injection. Epinephrine also reduces systemic absorption of the local anesthetic and promotes local hemostasis. Intraocular surgery Epinephrine is used in the induction and maintenance of mydriasis during intraocular surgery. Pharmacokinetics Epinephrine has a rapid onset but a brief duration of action (due to rapid degradation). The preferred route for anaphylaxis in the outpatient setting is intramuscular (anterior thigh) due to rapid absorption. It may also be given subcutaneously, by endotracheal tube, or by inhalation (ure 6. It can trigger cardiac arrhythmias, particularly if the patient is receiving digoxin. Epinephrine can also induce pulmonary edema due to increased afterload caused by vasoconstrictive properties of the drug. Patients with hyperthyroidism may have an increased production of adrenergic receptors in the vasculature, leading to an enhanced response to epinephrine, and the dose must be reduced in these individuals. Inhalation anesthetics also sensitize the heart to the effects of epinephrine, which may lead to tachycardia. Nonselective β-blockers prevent vasodilatory effects of epinephrine on β receptors, leaving α receptor stimulation unopposed. However, when administered in therapeutic doses, the α- adrenergic receptor is most affected. Vasoconstriction Norepinephrine causes a rise in peripheral resistance due to intense vasoconstriction of most vascular beds, including the kidney (α effect). The weak β activity of2 2 norepinephrine also explains why it is not useful in the treatment of bronchospasm or anaphylaxis. Baroreceptor reflex Norepinephrine increases blood pressure, and this stimulates the baroreceptors, inducing a rise in vagal activity. The increased vagal activity produces a reflex bradycardia, which is sufficient to counteract the local actions of norepinephrine on the heart, although the reflex compensation does not affect the positive inotropic effects of the drug (ure 6. When atropine, which blocks the transmission of vagal effects, is given before norepinephrine, stimulation of the heart by norepinephrine is evident as tachycardia. Therapeutic uses Norepinephrine is used to treat shock (for example, septic shock), because it increases vascular resistance and, therefore, increases blood pressure. In addition, norepinephrine is a potent vasoconstrictor and may cause blanching and sloughing of skin along an injected vein. If extravasation (leakage of drug from the vessel into tissues surrounding the injection site) occurs, it can cause tissue necrosis. Impaired circulation from norepinephrine may be treated with the α receptor antagonist phentolamine. Alternatives to phentolamine include intradermal terbutaline and topical nitroglycerin. Its nonselectivity is a disadvantage and the reason why it is rarely used therapeutically. Isoproterenol produces intense stimulation of the heart (β effect), increasing1 heart rate, contractility, and cardiac output (ure 6. Isoproterenol also dilates the arterioles of skeletal muscle (β effect), resulting in decreased peripheral resistance. Because of its2 cardiac stimulatory action, it may increase systolic blood pressure slightly, but it greatly reduces mean arterial and diastolic blood pressures (ure 6. The adverse effects2 of isoproterenol are similar to the β receptor–related side effects of epinephrine. For example, at higher doses, it causes vasoconstriction by activating α receptors,1 whereas at lower doses, it stimulates β cardiac receptors. In addition, D and D dopaminergic receptors, distinct1 1 2 from the α- and β-adrenergic receptors, occur in the peripheral mesenteric and renal vascular beds, where binding of dopamine produces vasodilation. D receptors are also found on presynaptic adrenergic neurons, where their2 activation interferes with norepinephrine release. Cardiovascular Dopamine exerts a stimulatory effect on the β receptors of the heart, having both positive inotropic and1 chronotropic effects (ure 6. At very high doses, dopamine activates α receptors on the vasculature, resulting1 in vasoconstriction. Renal and visceral Dopamine dilates renal and splanchnic arterioles by activating dopaminergic receptors, thereby increasing blood flow to the kidneys and other viscera (ure 6. These receptors are not affected by α- or β-blocking drugs, and in the past, low-dose (“renal-dose”) dopamine was often used in the prevention or treatment of acute renal failure. However, more recent data suggest there is limited clinical utility in the renal protective effects of dopamine. Therapeutic uses Dopamine can be used for cardiogenic and septic shock and is given by continuous infusion. It raises blood pressure by stimulating the β receptors on the heart to increase cardiac output, and α receptors on blood vessels to increase1 1 total peripheral resistance. Increased blood flow to the kidney enhances the glomerular filtration rate and causes diuresis. By contrast, norepinephrine can diminish blood supply to the kidney and may reduce renal function. Dopamine is also used to treat hypotension, severe heart failure, and bradycardia unresponsive to other treatments. Adverse effects An overdose of dopamine produces the same effects as sympathetic stimulation. It is used as a rapid-acting1 vasodilator to treat severe hypertension in hospitalized patients, acting on coronary arteries, kidney arterioles, and mesenteric arteries. Headache, flushing, dizziness, nausea, vomiting, and tachycardia (due to vasodilation) may occur with this agent. The drug increases cardiac output and does not elevate oxygen demands of the myocardium as much as other sympathomimetic drugs.

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