Nanakram Agarwal, MD, MPH, FACS

• Professor of Surgery
• New York Medical College
• Chief of Surgical Intensive Care Unit
• Our Lady of Mercy Medical Center
• Bronx, New York

If the child experiences any sign of bleeding from the stomach or bowels after taking this medicine cholesterol medication starting with a order lasuna mastercard. Testicular torsion the principal cause of testicular torsion is when the tunica vaginalis fails to encase the testicle and the testis hangs free from the vascular structures leading to a partial or complete venous occlusion cholesterol medication reactions cheap lasuna online. This can lead to ischaemia (tissue death) and could result in a loss of one or both testicles cholesterol medication leg cramps generic lasuna 60caps with visa. It is estimated that 1 in 4000 males under 25 years of age will experience testicular torsion cholesterol comes from which source order lasuna in india, with a peak onset of 13 years (Ta et al cholesterol eggs per day purchase 60caps lasuna with mastercard. Disorders of the reproductive systems Chapter 14 Red Flag Testicular torsion is a surgical emergency and requires urgent surgical intervention cholesterol bacon cheapest lasuna. Most hospital trusts will have a protocol and nurses must ensure that surgeons are informed immediately a child/young person attends with testicular pain. It is important that the parent and child are warned that the surgeons may react very quickly if torsion is suspected. The authors, following an extensive review of the literature, concluded that history and examination and speed is more important. Urinalysis should be performed to rule out infection but should not delay surgery, if required. The physical care required to treat the patient is essential and any delay in providing surgical intervention can have serious repercussions in the postoperative period. The importance of psychological care associated with an emergency surgical intervention is outlined in the following box. Because the time from diagnosis is so short there is little opportunity to discuss theatre and pre and postoperative care with the young person or the parent. The removal of a testicle can cause both physical and psychological trauma to the young man and his family. Apart from the physical difference in his scrotum, there are also psychological effects. Although a prosthetic can be fitted so the scrotum looks normal, there is the undecided issue of future fertility. Many sexual health services focus solely on women but there are some local services, and nationally the Brook Centres offer counselling around a range of sexual issues. Similarities exist between both systems, with the endocrine system producing hormones required for biological development, sexual arousal and puberty. The female reproductive system is predominantly hidden inside the body and the urinary system is collocated but not a part of the sexual organs. The function of the female reproductive system is to produce ova and allow fertilisation of the ova to take place and the fetus to grow inside it. After birth, the reproductive system also prepares the breasts to feed the infant. As with the male reproductive system, it is expected that the reader has an indepth knowledge of the anatomy and physiology of the system including the issues of puberty and menstrual cycle. There are a range of conditions affecting female reproductive health and this chapter will concentrate on some of the most common (see Table 14. It should be a normal part of life but the aforementioned authors suggest that problems in menstruation are responsible for loss of education as girls frequently do not seek medical help with significant health problems relating to abnormalities. Primary dysmenorrhoea can be described as painful menstruation in women with a normal pelvic anatomy. The physiology behind dysmenorrhoea is an increased production of the hormone prostaglandins by the endometrium causing uterine contraction and pain. The pain can be associated with cramps, nausea and vomiting, and syncope (fainting). It can be very debilitating for some women and has been associated with missed days in school and a deficit in education (Azurah et al. The literature also indicates that girls and adult women are unlikely to seek medical help and endure symptoms that may indicate an underlying pathology. However, it would appear that girls do not always discuss problems with their parents, and nurses need to use opportunities to take a menstrual history from girls whenever an overall health history is taken and allow girls and their parents to discuss any issues relating to dysmenorrhoea. Abdominal pain in girls Almost all girls will have abdominal pain at one time or another. Most of the time, it is not caused by a serious medical problem; however, sometimes abdominal pain may be a sign of something serious. The young person with abdominal pain requires a thorough examination and history taking is key. However, the history involves asking personal questions in a manner that is both respectful and nonjudgemental. It is important to establish a rapport, and it may be advantageous to have time alone with the young person to allow them to give you information that they may not want shared with their parent (Forcier, 2009). History should include: Dysmenorrhoea Endometriosis Pelvic inflammatory disease Adhesions Constipation Irritable bowel syndrome Lactose intolerance Coeliac disease Chronic cystitis Gastrointestinal Urological Other Source: Bean & Rowell 2014. With prepubescent and pubescent girls, a urine test for urinalysis and a pregnancy test are required to rule out infection and pregnancy. This can be a difficult subject to broach with both the young person and her parent/carer as some parents feel it is totally unnecessary and insulting. It is particularly difficult in families where sex has never been discussed and sex education in school has been denied. In most cases parents make a joke of it and give consent; however, some parents will try to refuse consent. Generally, medical staff will not be able to proceed with an exploration of the causes of abdominal pain without the pregnancy test and most parents accept this. The nurse and other members of the multidisciplinary team have to understand the key issues associated with consent. It is essential that the nurse is able to provide answers to these three questions in order to provide safe and effective, patientcentred care. Abdominal pain is not only a symptom of gynaecological ill health, but it is important to understand that it will be one of the differential diagnoses to consider. Equally it is important to highlight that it is not the only cause of abdominal pain in adolescent girls. It is not unusual to find Lego, plastic, tissues and other items as the cause for the discharge. History of toileting behaviour is vital, particularly when establishing if the child wipes her own bottom unsupervised. If discharge is bloodstained McGreal and Wood (2013) state that this is an indication for a gynaecology referral. A play specialist carrying out distraction therapy may mean the child will allow the doctor to separate the labia and visualise the lower vagina. This may reveal a foreign body although this is unlikely to be successfully removed without sedation, such as ketamine or a general anaesthetic. Swabs are most likely to grow anaerobic bacteria, followed by group A beta haemolytic streptococcus. Medication Alert Ketamine sedation is used very successfully in emergency departments and day units as a means to avoid full anaesthesia. Disorders of the reproductive systems Chapter 14 Caution: ketamine must only be administered by senior medical or anaesthetic staff. Side effects: diplopia, hallucinations, nausea, nightmares, tachycardia, transient psychotic effects, vomiting. Caution for administration: nurses should note that ketamine is a controlled drug and should be stored appropriately. It is likely to be very upsetting for the child as she may be taken into care pending investigation. Psychological care There is little written about the effect on parents of being asked if their child may have been abused, but it is a question that may be asked in the course of the investigation of vaginal discharge. Parents may feel very shocked and angry, especially when a cause other than abuse is found. Children who have had an intimate examination may also feel very vulnerable and upset. However, with treatment for the discharge, it is hoped that this will be short lived. All nurses must be aware of the effects of hospitalisation on families and they must strive to make a hospital admission as pleasant as it can be. For many children vaginal discharge is due to poor hygiene or irritants and can be treated with advice about the contributing factors. This is an important aspect of the nursing care of any child with vaginal irritation regardless of the cause. Chapter 14 Disorders of the reproductive systems Health promotion advice in this case is extremely important and it can be time consuming to explain it to children and their families. There are many advice leaflets available, which are produced either nationally or locally. There is a wealth of literature addressing issues regarding sexual health or sexual ill health. It is important to recognise some of the issues: 324 Schalet has written comparing the attitude of Dutch parents with that of American parents, and highlights an acceptance by Dutch parents of teenage sexual behaviour, which results in discussions and less risky behaviours. The Dutch have consistently had the lowest rates of teenage pregnancy and sexually transmitted infections in Europe (Schalet, 2011). There is an overwhelming amount of literature looking at various aspects of young people and sexual behaviour, enough to fill an entire book, but in essence, the rest of this chapter is an attempt to highlight some of the issues and hopefully encourage you to read more widely around the subject. Sexual activity Sexual activity in young people is monitored statistically using two measures: the rate of sexually transmitted infections and the teenage pregnancy rate (Schalet, 2011). Sexually transmitted infections continue to rise despite government screening and treatment campaigns aimed at the under 25s. Disorders of the reproductive systems Chapter 14 Contraception There are a number of different methods of contraception available. The philosophy of family centred care with a partnership between parents and young people is integral to our way of working, but this is challenged when young people seek emergency contraception or if you have to suggest emergency contraception following an assault. Mary is seen by a staff nurse and is triaged; she asks for emergency contraception. The department has a nurseled protocol so the triage nurse carries out the first part of the protocol before she is seen by another nurse. A senior nurse interviews Mary and takes a full medical and sexual history: Allergies = nil Medication = nil Medical history = nil Sexual history: Mary has a 15yearold boyfriend called Tom. Mary had discussed the idea of starting contraception with her mother who told her father and he was very angry and said as she was not 16, she could not have sex, and if she did have sex, Tom would go to prison. They tried to use a condom but it fell off and Mary is petrified of getting pregnant. She is adamant that her parents must never find out and she wants emergency contraception. The nurse clarified if they meant to have sex and what sexual activity took place, it was penetrative sexual intercourse. Chapter 14 Disorders of the reproductive systems Mary is required to take the drug in front of the nurse as per protocol to avoid the risk of a young girl obtaining emergency contraception for another young person. The side effects were discussed and what to do in the event of her vomiting in the next hour. Emergency contraception for girls under the age of 16 may raise issues of both sexual health and child protection. As a result of this a thorough assessment is required to rule out any exploitation. Confidentiality Explain to the young person that you may have to refer them to another agency or refer them to another specialist. If she is under 13 years old, she is deemed to have been raped in the eyes of the law and regardless of the age of the partner is considered to be at risk. Emergency contraception can still be dispensed but safeguarding team/Children Schools and Families and Child Protection Police need to be contacted immediately. It is important that you are able to interview your young patient alone at least for part of the consultation in case she is being coerced in some way.

Latanoprost may cause darkening of the eyelid skin and changes to the eyelashes cholesterol test preparation alcohol order 60caps lasuna free shipping, including increased thickness cholesterol medication pravastatin 60caps lasuna with visa, length cholesterol test milton keynes discount lasuna 60 caps, and darkening cholesterol test doctors buy lasuna 60caps on line. Latanoprost contains benzalkonium chloride cholesterol medication in the news generic 60 caps lasuna with mastercard, which may be absorbed by contact lenses cholesterol medication side effects erectile dysfunction buy 60caps lasuna with visa. If using more than one ophthalmic product, wait at least 5 minutes in between application of each medication Storage considerations: Protect this medication from light. Additionally, with once-daily administration and limited systemic side effects, the prostaglandin analogs are considered first-line therapy in the management of open-angle glaucoma. This change occurs slowly, may not present for several months to a year, and is likely to be permanent. Tafluprost may cause darkening of the eyelid skin and changes to the eyelashes, including increased thickness, length, and darkening. Tafluprost does not contain benzalkonium chloride, although it is still recommended to remove contact lenses before instillation of the solution. Storage considerations: Cartons and unopened foil pouches should be refrigerated and protected from moisture. Once the pouch is opened, single-use containers may be stored in the opened foil pouch at room temperature for up to 28 days. Each single-use container has adequate solution to treat both eyes (if applicable); discard immediately after use. Nonselective beta blockers (timolol, levobunolol, carteolol, and metipranolol) affect beta-1 and beta-2 receptors, whereas selective beta blockers (betaxolol) affect only beta-1 receptors. Travoprost may cause darkening of the eyelid skin and changes to the eyelashes, including increased thickness, length, and darkening. Once-daily dosing should not be exceeded because more frequent administration may decrease the effectiveness of travoprost Although systemic adverse effects are limited, local side effects are notable for changes in iris, eyelid, and eyelash pigmentation Travoprost 0. Systemic reactions include bradycardia, hypotension, exacerbation of congestive heart failure, bronchospasm, fatigue, dizziness. Administer other topical ophthalmic medications used concomitantly at least 10 minutes before the gel-forming solution. These agents are considered first-line therapy for the treatment of open-angle glaucoma. Because of the risk of systemic adverse events, these drugs are contraindicated in patients with severe pulmonary disease, bradycardia, second- or third-degree heart block, overt heart failure, and cardiogenic shock. Note: Timoptic-Ocudose does not contain benzalkonium chloride and may be useful in patients receiving multiple ocular products containing preservatives or in those with existing corneal damage Adverse Reactions: Most Common Temporary burning and stinging following instillation, allergic conjunctivitis, itching, conjunctival hyperemia, conjunctival folliculosis, excessive tearing Adverse Reactions: Rare/Severe/Important Local adverse reactions include blepharitis, blurred vision, corneal erosion, eye pain, eyelid edema, eyelid erythema, superficial punctuate keratitis. Systemic adverse reactions include hypertension, bradycardia, exacerbation of congestive heart failure, bronchospasm, fatigue, dizziness. Ophthalmic alpha-2 agonists also reduce aqueous humor production; however, they also increase aqueous humor outflow via the uveoscleral pathway of the eye. Among the alpha-agonists, brimonidine has the lowest incidence of this side effect, affecting approximately 5% to 9% of patients in clinical trials. Because of the risk of systemic adverse events with ophthalmic beta blockers, these drugs are contraindicated in patients with severe pulmonary disease, bradycardia, second- or third-degree heart block, overt heart failure, and cardiogenic shock. If used, clinicians should exercise extreme caution, monitor carefully, and use the lowest effective dose. It is commonly seasonal and is usually associated with exposure to pollen, ragweed, dust, or mold spores. Pharmacotherapy options used to treat acute episodes of allergic conjunctivitis include artificial tears and combination topical antihistamines/topical vasoconstrictor products. For frequent episodes or seasonal and perennial allergies, the agents of choice are topical antihistamines and mast cell stabilizers. It takes 5 to 14 days to see optimal effects with mast cell stabilizers, thus they are best initiated 2 to 4 weeks before allergy exposure rather than as treatment for acute symptoms. They are considered drugs of choice because they effectively work on both the chronic and acute symptoms of allergic conjunctivitis. Others: Azelastine, epinastine, bepotastine, alcaftadine, emedastine, pheniramine Mast cell stabilizers: Cromolyn sodium, nedocromil sodium, lodoxamide, pemirolast Ketotifen Brand Names Alaway, Claritin Eye, Zaditor, Zyrtec Itchy Eye, Eye Itch Relief, TheraTears Allergy Mechanism of Action for the Drug Class these agents block the effects of histamine by selectively blocking H1 receptors. Systemic adverse reactions include flulike symptoms, headache, pharyngitis, rhinitis Dosing Instill 1 drop into the affected eye(s) twice a day at an interval of every 8 to 12 hours; do not exceed 2 applications/day. Adverse Reactions for the Drug Class: Rare/Severe/Important Secondary infection, decreased vision, hypersensitivity, keratitis, photophobia, rash Olopatadine Brand Names Pataday, Patanol, Pazeo Generic Name Olopatadine Counseling Points for the Drug Class For ophthalmic use only To avoid contamination, do not touch tip of container to eye or any other surface Remove contact lenses before using this medication; wait 15 minutes following administration to reinsert. In addition, these agents are often used in the setting of chemical, thermal, or foreign body injury to the eye and in the immediate postocular surgical setting to decrease inflammation and scar tissue formation. Steroids may delay wound healing, so they are generally not recommended for minor abrasions or injury. In general, steroids do not have a role in the treatment of simple conjunctivitis and should not be used in most cases of viral conjunctivitis; their use may prolong and exacerbate the severity of viral ocular infections. Their anti-inflammatory action is likely related to their ability to inhibit edema, fibrin deposition, capillary dilation, and leukocyte migration. They are also known to decrease the activity of inflammatory mediators, such as prostaglandins and leukotrienes. Adverse Reactions: Most Common Transient burning, stinging, irritation upon instillation; foreign body sensation; chemosis; itching; dry eye; excessive tearing; blurry vision; photophobia. Long-term use of these agents has Usage Various ocular inflammatory conditions, allergic conjunctivitis, postoperative pain, and inflammation following ocular surgery Key Points Pregnancy Category C Dosing Allergic conjunctivitis: Loteprednol 0. It is frequently prescribed to prevent and treat seasonal allergies; however, use for > 14 days should only occur under the supervision of a medical professional. The steroid component suppresses the inflammatory response; however, it is also likely to delay or slow wound healing. Rx Only Dosage Forms Suspension, ointment Usage Steroid-responsive inflammatory ocular conditions with infection or risk of infection; chronic anterior uveitis; corneal injury from chemical, radiation or thermal burns; penetration of foreign bodies Pregnancy Category C Dosing Members of the Drug Class In this section: Tobramycin/dexamethasone Others: Multiple combination products are available containing the following antibacterial agents: Neomycin, neomycin/ polymyxin B, gentamicin, tobramycin, chloramphenicol, bacitracin, sulfacetamide; multiple combination products are available containing the following steroid components: Hydrocortisone, prednisolone, dexamethasone, loteprednol Tobramycin/Dexamethasone Mechanism of Action Dexamethasone is a potent corticosteroid that inhibits the inflammatory response by inhibiting interleukin-1 and various other cytokines that mediate inflammatory responses. It also decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and decreasing capillary permeability. Tobramycin is an aminoglycoside antibiotic that provides activity against susceptible organisms by irreversibly binding to the 30S ribosomal subunit, disrupting bacterial protein synthesis, and causing cell death. Suspension: Instill 1 or 2 drops into the affected eye(s) every 4 to 6 hours Severe infections: Instill 1 or 2 drops every 2 hours for the first 24 to 48 hours, and then decrease administration to every 4 to 6 hours Ointment: Apply 0. Which of the following statements is correct regarding the benefits of nasolacrimal occlusion Which of the following statements regarding application of an antibiotic ophthalmic ointment is false Which of the following agents is available as a preservative-free ophthalmic solution Which of the following "generic name-brand name" pairs are not correctly matched When using ophthalmic products, patients should be counseled about all of the following, except: a. Nasolacrimal occlusion is most effective for ophthalmic solutions and suspensions 10. Which of the following ophthalmic agents is most likely to have systemic adverse effects potentially limiting its use Which of the following statements is true regarding ophthalmic erythromycin ointment Erythromycin ointment is effective for the treatment of neonatal Chlamydia ocular infections 17. Neomycin, bacitracin, polymyxin B Neomycin, polymyxin B, hydrocortisone Neomycin, polymyxin B, gramicidin Neomycin, polymyxin B, dexamethasone 18. Instill 1 drop into the affected eye(s) twice a day, approximately 12 hours apart c. Instill 2 drops into the affected eye(s) twice a day, approximately 12 hours apart d. Ophthalmic beta blockers are considered first-line agents in the treatment of glaucoma d. Which of the following agents may be used for longterm treatment of ocular hypertension Brimonidine has been associated with systemic side effects such as hypotension and bradycardia c. Brimonidine has been associated with an allergictype reaction in a small percentage of patients in clinical trials d. In which of the following situations would loteprednol be contraindicated for use A 78-year-old woman who is recovering from ocular surgery and has developed inflammation 27. Zioptan containers can be used for multiple doses if stored in the refrigerator 28. Increased iris pigmentation Transient burning upon instillation Decreased heart rate Increased eyelash length 22. The recommended duration of treatment with topical antihistamines is 5 to 7 days b. Ophthalmic beta blockers have been associated with the following systemic adverse effects except: a. Tiotropium Respimat is the only long-acting inhaled anticholinergic used in the chronic treatment of asthma not responding to therapy with moderate-high dose inhaled corticosteroids and long-acting beta-2 agonists. The most common adverse reaction associated with the inhalation preparations is dry mouth, upper respiratory tract infections, and nasopharyngitis. Glycopyrrolate competitively and reversibly inhibits acetylcholine at the muscarinic receptor subtypes, 1 and 3, which cause bronchodilation. Tiotropium, aclidinium, and umeclidinium are long-acting agents, selective to the M3 receptors. The inhaler must be "primed" 2 times before taking the first dose from a new inhaler or when the inhaler has not been used for more than 3 days 2. Insert the metal canister into the top of the mouthpiece and remove the protective dust cap from the mouthpiece 3. Inhale slowly through your mouth and, at the same time, press firmly once on the canister, continuing to breathe deeply 6. Wait at least 15 seconds before repeating steps 1 through 7 for the next inhalation 9. Wash the mouthpiece through the top and bottom with warm running water for at least 30 seconds. Counseling Points Should not be used to treat acute bronchospasms the dose indicator tells you how many doses are left Discard inhaler 45 days after removing the inhaler from the sealed pouch or after the labeled number of inhalations have reached zero (whichever occurs first) Directions for proper administration technique: 1. The inhaler is ready for use when the colored control window changes from red to green 3. Prior to inhaling the dose, exhale fully (do not exhale into the inhaler), then close lips tightly around the inhaler mouthpiece and inhale (rapidly, steadily, and deeply); do not hold the green button down while inhaling 4. Keep breathing in until a "click" is heard to ensure that the full dose has been administered 5. Ensure that the dose was delivered correctly by observing the control window, which should have changed from green to red. When control window has been verified as red, replace the protective cap on the inhaler for the next use. Should not be used to treat acute bronchospasms Capsule is for inhalation only via the Neohaler device; do not swallow capsules If a dose is missed, administer the next capsule at the usual time; do not use two capsules at one time and do not use > 2 capsules/day (maximum: 31. Hold the base of the inhaler firmly and tilt the mouthpiece to open the inhaler 3. Hold your breath for at least 5 to 10 seconds or for as long as you comfortably can while taking the inhaler out of your mouth 11. Hold your breath as long as it is comfortable and, at the same time, take the inhaler out of your mouth 12. To get the full dose of the medication, you must breathe out completely and repeat steps 9 through 11. Counseling Points the dose indicator tells you how many doses are left If you open and close the cover without inhaling the medicine, you will lose the dose Discard inhaler 6 weeks after opening the foil tray or after the labeled number of inhalations have reached zero (whichever comes first) Use proper administration technique: 1. When you are ready to inhale a dose, open the cover of the inhaler and slide the cover down to expose the mouthpiece. They are not typically used chronically for allergic rhinitis due to the potential for sedation, but they are still used in some cases because many of these agents are available without a prescription. These agents are generally used on an as-needed basis, depending on the indication. Chronic use of these agents should be avoided in the elderly due to their sedative and anticholinergic effects. Sedation is the most common adverse reaction associated with these agents, and concomitant drugs that cause sedation should be avoided. Diphenhydramine and promethazine have the most significant anti-muscarinic properties, which lead to their anti-emetic effects and lessen rhinorrhea in the common cold. The preferred route of the injectable formulation is deep intramuscular injection. Most commonly used for motion sickness or as an antiemetic but may be used for allergic reactions Promethazine is available in multiple dosage forms Use with caution in children > 2 years of age. They are used to treat these chronic conditions due to the low risk of adverse events. These agents are more commonly used than the first-generation antihistamines because of the decreased risk of sedation. Cetirizine is considered a preferred antihistamine for the treatment of rhinitis in pregnant women. Benzonatate is chemically related to anesthetic agents in the para-amino-benzoic acid class. Adverse Reactions: Rare/Severe/Important Oropharyngeal anesthesia, if capsules are chewed or dissolved in mouth; burning sensation in eyes; hypersensitivity reactions (including bronchospasm, laryngospasm, cardiovascular collapse) related to local anesthesia from sucking or chewing the capsules; hallucinations Members of the Drug Class In this section: Benzonatate Others: Carbetapentane (note that codeine, dextromethorphan, and hydrocodone are covered in the Combination Cough/Cold Products section) Contraindication Patients with a history of a prior reaction to related anesthetic agents.

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Unfortunately cholesterol levels ldl cheap 60 caps lasuna overnight delivery, frequent use of fluoroquinolones has led to inevitable increases in antimicrobial resistance does cholesterol medication make you cough 60caps lasuna otc, particularly in P cholesterol test online discount lasuna 60caps. Fluoroquinolones may exacerbate myasthenia gravis and should be avoided in patients with a known history of myasthenia gravis cholesterol test sainsburys order cheap lasuna line. The safety and efficacy of fluoroquinolones in children < 18 years of age (except for the use of ciprofloxacin following exposure to inhalational anthrax and in children with cystic fibrosis) cholesterol levels of different meats generic 60 caps lasuna free shipping, pregnant women cholesterol jones purchase 60 caps lasuna free shipping, and lactating women has not been established. Ciprofloxacin is one of two fluoroquinolones with clinically useful activity against P. It is Levofloxacin has strong Gram-negative and Grampositive activity, and it is useful in both hospital- and community-acquired infections such as pneumonia Levofloxacin is one of two fluoroquinolones with clinically useful activity against P. Moxifloxacin has potent activity against many Gram-positive organisms and has more activity against anaerobic bacteria than other fluoroquinolones. However, resistance among anaerobes rose quickly and it should not be used as monotherapy for many intra-abdominal infections. The sulfonamides were the first antibiotics made available and introduced the antibiotic era. They are still used today, most commonly in trimethoprim/ sulfamethoxazole, where the two active ingredients work together in susceptible bacteria. Serum creatinine values may increase during therapy but not reflect true renal dysfunction. However, trimethoprim/sulfamethoxazole can lead to renal dysfunction through crystallization or acute interstitial nephritis. Trimethoprim/sulfamethoxazole is pregnancy category C, but it is contraindicated during late-stage pregnancy because sulfonamides can lead to kernicterus in the newborn. For some patients, the benefits of therapy may outweigh this risk because infection in the mother can have dire consequences for the fetus. Usage Members of the Drug Class In this section: Vancomycin Others: Dalbavancin, oritavancin, teicoplanin (outside of the United States), telavancin (a lipoglycopeptide) Injection: Treatment of systemic infections caused by Gram-positive organisms, including those of the respiratory tract, bloodstream, skin and skin-structure, gastrointestinal system, and genitourinary tract Oral: C. Clindamycin has good activity against staphylococci, streptococci, and anaerobic organisms. Generic Name Clindamycin Rx Only Dosage Forms Capsule, injection Mechanism of Action for the Drug Class Clindamycin binds to the 50S subunit of bacterial ribosomes, suppressing protein synthesis. Community-associated strains are much more likely to be susceptible than hospital-acquired strains. Although they are generally well tolerated, clarithromycin and erythromycin are strong inhibitors of the cytochrome P450 enzyme system, and clinicians must be wary of drug interactions with them. However, monitoring is suggested in patients receiving digoxin, theophylline, ergotamine derivatives, triazolam, warfarin, and other agents known to be metabolized via the cytochrome P450 enzyme system. Pregnancy Category C Dosing Counseling Points Immediate-release suspension and tablet can be taken without regard to food, while the extendedrelease suspension should be administered on an empty stomach (at least one hour before or 2 hours after a meal) Parenteral product should not be given as a bolus injection or intramuscularly Patients who vomit immediately after taking azithromycin may need to be redosed, but they should not do this without consulting their healthcare provider Rising resistance rates to macrolides in Streptococcus pneumoniae have led to decreased efficacy for azithromycin. Azithromycin has a very long terminal half-life, which allows for short-course therapy for many indications Increasing resistance to macrolides in Treponema pallidum have led to azithromycin treatment failures. It should not be used for the treatment of early Syphilis or used with caution if alternative therapies are not feasible. This effect also causes more diarrhea with erythromycin than with other macrolides. It has one use, the treatment of acute uncomplicated cystitis (a urinary tract infection). Therapeutic concentrations of nitrofurantoin are not reached anywhere in the body but the bladder. It has become more useful over time as resistance to fluoroquinolones, trimethoprim/sulfamethoxazole, and other first-line drugs has increased, particularly in E. However, it can cause hemolytic anemia in newborns and should be avoided in pregnant women who are at term. It is unique in that it only has clinically useful activity against anaerobic organisms and is thus frequently used in anaerobic infections. Rx Only Dosage Forms Tablet, extended-release tablet, capsule, injection, topical gel Usage Treatment of anaerobic bacterial infections, C. It is generally used as a first-line agent in mild to moderate cases due to its significantly lower cost. They have activity against many Gram-positive organisms, some atypical, and Mycobacterium tuberculosis. They comprise a very large class of antibiotics and range from agents with broad antimicrobial spectra to those with a more narrow spectrum. Key Point for the Drug Class Use with caution in patients who are allergic to other beta-lactam antibiotics Members of the Drug Class In this section: Amoxicillin, amoxicillin/clavulanate, penicillin, piperacillin/tazobactam Others: Ampicillin, cloxacillin, dicloxacillin, nafcillin, oxacillin Mechanism of Action for the Drug Class Penicillins limit bacterial cell growth in susceptible bacteria by inhibiting transpeptidase enzymes (also known as penicillin-binding proteins). This prevents cross-linking of peptidoglycan strands, thereby inhibiting synthesis of the bacterial cell wall. If susceptibility information is not known, amoxicillin/ clavulanate is a better choice for most patients. Twice-daily dosing is associated with significantly less diarrhea the 250 mg and 500 mg tablets contain the same quantity of clavulanic acid; therefore, do not substitute two 250 mg tablets for one 500 mg tablet Amoxicillin/clavulanate has a significantly broader antimicrobial spectrum than amoxicillin alone. That is advantageous in treating some potentially drugresistant infections but is not needed in those likely to be drug susceptible. They are still useful for many indications; however, and they are drugs of choice in several tick-borne diseases. Mechanism of Action for the Drug Class Tetracyclines inhibit bacterial protein synthesis by reversibly binding to the 30S ribosomal subunit, resulting in a bacteriostatic effect. Use in children 8 years of age and younger only when the benefit outweighs the risk. The normal-release formulation of minocycline is used for this indication as well. They are often used in combination in the treatment of tuberculosis, usually with other agents as well. Usage Treatment of active and latent tuberculosis Pregnancy Category C Dosing Mechanism of Action for the Drug Class Isoniazid inhibits the synthesis of mycolic acids, an essential component of the mycobacterial cell wall. Careful monitoring of patients on concomitant drugs that are metabolized via the liver is recommended. Examples of drugs that are known to be cleared more rapidly by rifampin include phenytoin, disopyramide, quinidine, warfarin, apixaban, rivaroxaban, dabigatran, edoxaban, protease inhibitors, azole antifungals, diltiazem, nifedipine, barbiturates, beta blockers, chloramphenicol, clarithromycin, digoxin, oral contraceptives, doxycycline, oral hypoglycemic agents, levothyroxine, methadone, narcotic analgesics, tricyclic antidepressants, tacrolimus, cyclosporine, and theophylline. Key Points Rifampin Brand Names Rifadin, Rimactane Generic Name Rifampin Counseling Point Rifampin will turn bodily fluids orange or red. Contact lenses may be permanently stained by this red color and should not be worn during rifampin therapy. Rx Only Dosage Forms Capsule, injection Usage Active and latent tuberculosis, treatment of asymptomatic carriers of N. Rifabutin is a related drug with somewhat less potent enzyme induction that may be used in place of rifampin for some indications In the treatment of active tuberculosis, combination therapy is always needed. It is sometimes used in combination with other antibacterial drugs for the treatment of resistant or difficult-to-treat bacterial infections. Two agents are available: amphotericin B, which is given systemically; and nystatin, which is given as topical therapy only. Corticosteroids: May potentiate the potassium-wasting effect Premedicate with diphenhydramine and/or acetaminophen to minimize infusion reactions Ensure adequate hydration by providing boluses of saline before and after the infusion to reduce the incidence of nephrotoxicity Infuse over at least 2 hours to decrease infusionrelated reactions Lipid formulations of amphotericin B are commercially available. Key Points Mechanism of Action for the Drug Class Polyenes bind to ergosterol in the fungal cell wall, causing cell-wall instability and leakage of cytoplasmic contents Members of the Drug Class In this section: Amphotericin B, nystatin Amphotericin B Brand Names Amphocin, Fungizone Nystatin Brand Name Mycostatin Generic Name Amphotericin B deoxycholate Generic Name Nystatin Rx Only Dosage Form Injection Rx Only Dosage Forms Suspension, powder, oral and vaginal tablets, cream, ointment Usage Systemic fungal infections caused by yeasts, molds, and dimorphic fungi; empiric antifungal therapy in febrile neutropenia; leishmaniasis 3 Usage Treatment and prophylaxis of cutaneous, mucocutaneous, and superficial candidal infections Pregnancy Category B Dosing Anti-Infective Agents Pregnancy Category C (Oral and Topical) and A (Vaginal) Dosing 0. Fatal overdoses have occurred when the incorrect formulation has been given at the incorrect dose. Patient should swish in the mouth before swallowing when treating oral candidiasis. The excellent bioavailability of some of those drugs allows for oral therapy of systemic infections. Dosing Mechanism of Action of the Drug Class Azole antifungals inhibit the production of ergosterol, a component of the fungal cell membrane, by inhibiting fungal cytochrome P450 enzymes. Itraconazole should be discontinued if signs or symptoms of heart failure develop during treatment. In addition, acid-suppressing agents have less of an effect on the bioavailability of the oral solution. Due to the low bioavailability of the oral form and the need for frequent administration, the prodrug valacyclovir was developed. Because it evolves so frequently, designing effective vaccines and drugs that always work is nearly impossible. Oseltamivir is an oral drug for the treatment of influenza that can shorten the duration of illness, particularly when it is started quickly after influenza symptoms begin. Like all anti-influenza agents, its effectiveness is dependent on the susceptibility of the dominant influenza strains of the season. Brand Name Tamiflu Rx Only Anti-Infective Agents Dosage Form Capsule, suspension Usage Treatment of influenza, prophylaxis of influenza in unvaccinated persons Mechanism of Action of the Drug Class Oseltamivir is a neuraminidase inhibitor. It prevents the influenza viral neuraminidase enzyme from releasing new virions (viruses) from infected host cells, preventing further replication. New formulations of influenza vaccine that are not derived from eggs have decreased the number of patients who cannot be vaccinated. Patients who do not receive the vaccine and contract influenza need to be vaccinated for influenza after they have recovered Oseltamivir is most effective when started early. Although the package insert says it must be started within 48 hours of symptoms beginning, clinicians often start it later, particularly for severely ill or hospitalized patients. Rechallenging with abacavir after an initial reaction can be fatal and is not recommended. They are often used in combination with nucleoside/nucleotide reverse transcriptase inhibitors. Specific recommendations are available and differ between acid-reducing agents and the level of treatment experience of the patient. It is recommended that all protease inhibitors be used with a pharmacokinetic enhancer. Counseling Point Separate administration with antacids or multivitamins, which contain polyvalent cations. Elvitegravir Brand Name Vitekta (discontinued), Stribild (coformulated with cobicistat, emtricitabine, tenofovir disoproxil fumarate), Genvoya (coformulated with cobicistat, emtricitabine, tenofovir alafenamide) Elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate should not be initiated in patients with CrCl < 70 ml/min; discontinue if CrCl declines to < 50 ml/min while patient is on therapy Elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide is not recommended for use in patients with CrCl < 30 ml/min Adverse Reactions: Most Common Diarrhea Generic Name Elvitegravir Adverse Reactions: Rare/Severe/Important None Rx Only Dosage Form Tablet Major Drug Interactions Drugs Affecting Elvitegravir Polyvalent cations (aluminum, magnesium, calciumcontaining antacids) lower elvitegravir concentrations. Administer 2 hours after or 6 hours before Many more drug interactions since elvitegravir is always coformulated with cobicistat; all cobicistat drug interactions apply. Each combination differs in the genotypes they are active against, drug-drug interactions and adverse effects. Key Point for the Drug Class Black Box Warning: Reactivation of hepatitis B viral infection can occur with treatment of direct-acting, antihepatitis C medications. Members of the Drug Class In this section: ledipasvir/sofosbuvir, elbasvir/grazoprevir Others: daclatasvir, ombitasvir/paritaprevir/ritonavir, ombitasvir/paritaprevir/ritonavir/dasabuvir, simeprevir, sofosbuvir, sofosbuvir/velpatasvir Mechanisms of Action for the Drug Class Direct-acting antivirals are typically given as coformulated combination regimens. Which of the following drugs interacts with alcohol to produce a disulfiram-like reaction Which of the following drugs have a very long half-life, allowing short-course therapy for many indications Which of the following drugs only has one approved indication: treatment of uncomplicated urinary tract infection Which of the following drugs should be avoided in combination with serotonin modulators Genital herpes Urinary tract infection Influenza Hepatitis C virus Review Questions 77 15. Which of the following integrase strand transfer inhibitors have a drug-drug interaction with metformin Which of the following falsely elevates coagulation tests and its concomitant use with heparin is contraindicated Which of the follow nucleoside/nucleotide reverse transcriptase inhibitors requires hepatic dose adjustments Which of the following antibiotics treats infections caused by Pseudomonas aeruginosa Which of the following is a topical antibiotic used in the treatment of minor skin infections Which one of the following medications cause a class drug interaction with all integrase strand transfer inhibitors The most notable side effects include bone marrow suppression, nausea and vomiting, and mucositis, as well as long-term complications, such as sterility and secondary malignancies. Those drugs have a wide dosing range based on the indication and route of administration. Most anthracyclines, with the exception of valrubicin, are administered intravenously and most notable for causing cardiotoxicity. The anthracyclines administered intravenously are vesicants that can cause severe skin necrosis if extravasation occurs.

Anaphase I One chromosome from each pair moves to each pole cholesterol-lowering nutraceuticals and functional foods discount lasuna 60 caps without prescription, so that there are now 23 chromosomes at each end of the spindle Telophase I the cell membrane now divides the cell into two halves cholesterol medication pravachol discount lasuna online american express. Each daughter cell now has half the number of chromosomes that each parent cell had cholesterol lowering food plan purchase lasuna in india. Genetics Chapter 2 Second meiotic division During the second meiotic division cholesterol deposition definition cheapest lasuna, both of the cells produced by the first meiotic division now divide again how many cholesterol in eggs quality 60 caps lasuna. That way cholesterol levels british heart foundation purchase lasuna 60caps mastercard, when the gametes fuse during reproduction, there are still only 23 pairs of chromosomes per human cell. Of the 23 pairs of chromosomes, 22 pairs are autosomal and one pair consists of the sex chromosomes. Male sex chromosomes are designated by the letter Y, and female chromosomes are designated by the letter X. Phenotype = the actual observed characteristics, such as physical properties and development/behaviour (although environment also plays a large part in these). Mendel demonstrated that members of a pair of alleles separate clearly during meiosis. We all have a pair of genes (alleles) at each locus, but because of the process of meiosis we can only pass one of those pairs of genes to our child. At the same locus on a chromosome, the father has the two alleles Aa and the mother has the two alleles Bb. When they reproduce, the father can pass either gene A or gene a (both are at the same locus and are therefore alleles) and the mother can pass on either gene B or gene b. However, each child can only inherit one of gene A or gene a from the father and one of gene B or gene b from the mother. Note that dominant genes are usually given capital letters, whilst recessive genes are usually given lower case letters. So, there is a 25% chance that any child will inherit one of those pairs of genes from its parents. Gametogenesis is the production of haploid sex cells so each carries onehalf of the genetic makeup of the parents. This now brings us to the concept of dominant and recessive genes, which is important in many health disorders that we may encounter, as well as determining such characteristics as eye colour and hair colour, and so forth. Dominant genes and recessive genes Remember that at each locus, the two alleles can be either dominant or recessive. How many of the offspring would carry at least one dominant gene, and how many would carry only recessive genes at this locus The answer is that three out of the four children (75%) would carry at least one dominant gene, and one out of the four children (25%) would carry both recessive genes. Of course, in real life, all four children may inherit the same pair of genes at this locus, or maybe two will inherit the same genes. So there is a 1 in 4 chance at each pregnancy that the children will carry a certain genotype. The gene for brown hair carried by the mother was the dominant gene in this instance. The answer is 50% or a 1 in 2 risk of a child having an autosomal dominant disorder. As a dominant gene is always expressed in the phenotype, then statistically there will be a 50% chance of any child having the disease, because the child could inherit gene a. Of course, any child who carries gene A will have a 100% chance of having the disease, there is no escaping it. Autosomal recessive inheritance and ill health Autosomal recessive diseases occur when both parents are carrying the same defect on a recessive gene at the same locus. Both parents have to carry the defective gene otherwise the child cannot be affected by the disease. In autosomal recessive diseases, if the child (or parent) only carried the defect on one gene, then s/he is a carrier of that disease, and can pass that defective gene on to his (or her) children. They in turn could pass it on to their children, who, if they inherit it, would also be carriers, and this situation could continue through many generations until the carrier has children with someone who is also a carrier of that mutant gene. There is then a risk of their children being either a carrier, or having the disorder. Two children possess an affected gene, but they also contain an unaffected dominant gene, so they are both carriers. However, always remember that children who are carriers can pass the affected gene onto their children. Remember that the odds are the same for each child born to those parents (LeMone & Burke, 2008)! Morbidity and mortality of dominant versus recessive disorders Autosomal dominant disorders are generally less severe than recessive disorders because if someone carries the affected gene they would have that disorder, whereas with autosomal recessive disorders a person can be a carrier but not have the disease. If autosomal Chapter 2 Genetics 46 dominant disorders were as severe and fatal as many autosomal recessive disorders, then the disease would die out as all the people with an affected autosomal dominant gene would normally die before being old enough to pass it on to their offspring. First, look at the possibilities of having a boy or a girl when you decide to have a baby. With these disorders, only the boys can be affected, and only girls may be carriers but unaffected. Mother Xx Unfortunately, the Y gene is unable to block the action of the abnormal gene, so he is a carrier and is also affected. His skin was so painful that he could not bear anyone to touch it, or even wear clothes. According to his mother he had been playing all afternoon in the garden and paddling pool wearing just swimming trunks. Although his mother had put sun cream on him after lunch, by playing in the paddling pool the sun cream had been washed away quite early on, and then he had tired himself out and fallen asleep on the grass where there was no shade. When he woke up, he was in such pain and so unwell that his mother quickly drove him to the hospital. William was first seen by the specialist nurse on duty who gently took his vital signs and reassured both his mother and William. The nurse immediately alerted the doctor on duty, because it was apparent that this could be more serious than a straightforward case of sunburn, and that he may have heatstroke. Red Flag When a young child is admitted into hospital as an emergency, there has been no time for the family to prepare, so the nurse has to be aware of the actual and potential disturbance to the family. Thus it is important to be aware of the needs of the whole family, for example, checking whether there are any other young children in the family, and who will be able to look after them if one of the parents is with the child in hospital. This is particularly important if a parent is unable to stay with the sick child because of other family or work commitments. Spontaneous mutation Now to briefly mention another way in which an unusual or abnormal gene can occur in an individual and cause genetic disorders. Genetics Chapter 2 Conclusion this introduction to genetics has demonstrated just how important it is for you to understand the subject, because not only do our genes make us what we are, but they can also leave us susceptible to certain diseases and affect how we respond to treatment for diseases, and indeed, how we live our lives, work, develop relationships, and survive in the world. Paediatric nurses often come across patients who have a genetic disease (because many of the most serious conditions manifest at a very early age, if not at birth); consequently, throughout your career as a nurse, you will need to explain things, not only to children diagnosed with a genetic disease, but also to their families as they struggle to come to terms not only with their child being ill, but maybe also their guilt as they realise that their child is ill because of their genes. Finally, in recent years, there has been much interest in using genetic therapy to treat illnesses, with varying levels of success. However, probably the most exciting and, to date, successful gene therapy is that used to treat a very few of the many primary immunodeficiency diseases, which, unlike secondary immunodeficiencies (see Chapter 5, Inflammation, immune response and healing), have a genetic cause. Since then this treatment has been used successfully in children with this disorder, and occasionally on children with other severe immune disorders, and research continues to try and improve this technique for other genetic disorders. Importantly, in June 2016, it was widely reported that, within the next 10 years, scientists plan to recreate entire human cells from scratch. This could then be a major step in creating a whole new range of medical treatments and cures for genetic diseases. However, the ethical, legal and social implications of this research will need to be assessed and deliberated upon. Consequently, it is important that nurses become familiar with this subject because, within their working life, they are likely to be involved in caring for children undergoing gene therapy. Sustained correction of Xlinked severe combined immunodeficiency by ex vivo gene therapy. Chapter 3 Cancer Tanya Urquhart-Kelly Aim the aim of this chapter is to introduce the reader to the basic principles that are associated with cancer; understanding these principles can help the reader provide care that is evidencebased, compassionate and competent. Refinement of treatment through clinical trials, has not only improved cure rates to over 82%, compared to less than 30% in the 1960s, but also reduced the associated burden of morbidity and mortality from treatment side effects. Biology of cancer Childhood cancers differ from adult cancers as they are histologically very diverse (Stiller, 2004), whereas most adult cancers are carcinomas. Cancer Chapter 3 Pathogenesis of cancers Cells reproduce to grow in number or replace those that die off naturally. These then selfreplicate at which point the cell splits into two leaving each daughter cell with 23 chromosomes, which duplicate to create identical pairs. Mitosis is controlled by a number of master regulatory genes which tell cells to either continue to divide or stop. Over the last decade there have been significant advances made in understanding the molecular genetics of several childhood cancers (PritchardJones, 1996). They increase the speed of cell division (proliferation), block differentiation and act in a dominant manner, i. Chronological mutation of all three of these cancer genes may be involved in the development and progression of a single cancer. The protein is mutated or inactivated in about 60% of cancer cases; it is found in increased amounts in a wide variety of transformed cells. Aetiology of cancers Genetic predisposition Inherited variants in p53 cause a familial cancer syndrome called LiFraumeni syndrome; in these families, the affected relatives develop a diverse set of malignancies including leukaemia, breast carcinomas, sarcomas (bone tumours), and brain tumours at unusually early ages. There are other known genetic predispositions for some cancers, for example, children with Down syndrome are known to have a higher risk of developing leukaemia (Siegel, Naishadham & Jemal, 2013). It is therefore likely that there are genes on chromosome 21 that increase the risk of some cancers while others have an opposite effect. This is a classic example of a cancer resulting from an inherited genetic abnormality. It is not unusual for families to contain more than one affected member and in more than one generation. Often a familial link for childhood cancer will only come to light following the diagnosis of a second sibling. Environmental factors Despite numerous literature reviews of environmental or exogenous exposures, there is little evidence of these being firmly established as risk factors for childhood cancer (Stiller, 2004b). They include: neonatal administration of vitamin K, parental use of medications and drugs, proximity to electromagnetic fields, parental employment and exposure to potential mutagens (Vora, 2016). More than 67 years ago, a correlation between antenatal obstetric diagnostic Xrays and cancer in the offspring were discovered (Stewart et al. At that time it was thought that 5% of all childhood cancers were as a result of in utero irradiation. However, this number has reduced and is attributable to significantly lower numbers of women being exposed to irradiation in pregnancy. International variations in the incidence of childhood lymphoma are therefore apparent (Stiller, 2004a). Solid tumours may present with a mass of increasing size (more evident with weight loss), pain, malaise and abnormalities of the central nervous system (particularly headaches, early morning vomiting, altered eye appearances and disturbed vision). It is common for these generic symptoms to be attributed to other common childhood diseases. Commonly seen symptoms in leukaemia and lymphoma include: 55 Staging cancers the stage of a cancer is often used to describe its size and whether it is found in only one part of the body (localised disease) or if it has spread beyond its original site (metastatic disease). Combinations of these are used for risk stratification purposes to determine the intensity of treatment a particular patient should receive. Patients who show slow clearance of blast cells from their blood or bone marrow following induction therapy are associated with a higher risk of relapse than those who do not. Staging occurs following the cancer diagnosis and can be helpful in giving an indication of the prognosis. Staging can be decided on following other investigations such as blood tests and imaging. Knowing the particular type and stage of a cancer helps in decision making regarding the most appropriate treatment. Thus it is common that childhood neoplasms are classified according to histology rather than the primary site. Some pathologists also grade the tumours, but practice varies widely around the world, with the majority not grading tumours at all.