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Cells lining the tubules are irritated by toxicant concentration purchase vasodilan canada prehypertension young, and the formation of crystalline structures from marginally soluble toxicants buy 20 mg vasodilan with visa blood pressure chart high diastolic, (2) detoxification and unmetabolized products are drawn into the cells of the proximal tubule along with water purchase vasodilan online arrhythmia center of connecticut, and remain there while water moves on into the bloodstream, (3) de-conjugation biotransformation, e. Its advantage over sulfanilamide is that it is not extensively metabolized in vivo, and exerts a prolonged action. This can be avoided by drinking a lot of water to keep the solution glomerulus (thin black circle) shows glomerulomegaly and mesangial diluted, so that precipitation does not occur. There is abundant brown pigment, representing broken down hemoglobin, in surrounding tubules (thin blue ovals), and There are also active secretory mechanisms located in the interstitial fibrosis and vascular sclerosis. As with any active process, carrier protein and Before toxicity is observed, the kidney will retain significant enzymes are involved, energy is required, and these secretory amounts of heavy metals, some (Hg, Pb) bound to various pathways can be saturated. The mitochondria are particularly susceptible to damage, and one sees autophagy of damaged subcellular Effects of chemical exposure on renal function can be very organelles and extrusion of denatured proteins, all possibly insidious and subtle, evading detection for a long time. The liver is the main synthesizer of a small damage can occur in the kidney, with complete loss of many (6,500 Dalton, 61 amino acids, 20 of which are cysteine) nephrons, before no reserve capacity remains. Metallothioneins are a surprisingly diverse Nephrotoxic Metals: Cadmium, Lead, Mercury, group of molecules, but they are spread in a vast range to Arsenic, Bismuth, Chromium, Platinum, Thallium, Uranium. At relatively low levels, a variety of signs and symptoms appear: glycosuria, aminoaciduria and polyuria, pointing to When exposure to Cd exceeds the ability of tissues to problems in efficient reabsorption in the proximal tubule. The complex is elevated Blood Urea Nitrogen, renal necrosis, and anuria will excreted via glomerular filtration, but can be reabsorbed in the precede death. It was once thought that free Cd in tubular the histological picture is one of necrotic proximal tubules cells was the toxicant, but more recent evidence shows that the with the adjacent lumen filled with proteinaceous material. It is characterized by deep muscle and bone pain of considerable severity, and bone deformation. Renal effects include proteinuria (particularly low molecular weight proteins), aminoaciduria (with elevated proline and hydroxyproline, suggestive of problems in bone metabolism), glucosuria and reduced absorption of phosphate and enhanced 1 excretion of calcium (hypercalcuria). The effects were seen predominantly in older women, multiparous, calcium, and protein deficient. Cadmium absorption in the gastrointestinal tract can be enhanced by dietary deficiency of calcium, iron, and protein. Being older, and having had a number of children, these women would have been calcium deficient. The source of this Cd was paddy irrigation water taken from a river downstream from a metals mine, which allowed tailings and F9. Pb Lead causes two types of kidney toxicity in humans: Cadmium has worrisome estrogenic effects in cell culture. Data (1) proximal tubular damage reflected in glucosuria, from rats show that cadmium can act as an estrogen mimic in aminoaciduria, hyperphosphaturia and problems of the whole animal, inducing conditions ranging from uterine reabsorption, 5 hyperplasia to early onset of puberty. The of vessels seen at prolonged, high level exposure, resulting in greatest concentrations are found in the liver and kidneys of chronic nephritis. Only the proximal tubular effects can be reversed with There has recently been concern in Sweden over body burdens chelation therapy. If the patient is very elderly, has low Chromium produces proximal tubular damage with glucosuria, parathyroid activity or is suffering from heavy metal toxicity, but lower down than does Hg. The heavy metals that damage the kidneys during excessive infusion therapy are lead, aluminum, 9. Ethylene glycol (car anti-freeze) is biotransformed both in the Tests of renal function should be performed before chelation liver and in the kidneys to oxalic acid, but the kidney is therapy is started. Oxalic acid crystallizes in the lumen dosage is indicated, with sufficient periods of rest between the and in the cells of the tubule into calcium infusions. The final product, glyoxylic acid, can be Mercury is a classical nephrotoxin, used in experimental converted either into formic acid or oxalic acid. Within two days of consumption, subject survives, polyuria follows, lasting many months. These initial symptoms led to progressive hepatic 9-10 necrosis, renal tubular degeneration and death. Substitution of ethylene glycol by In addition to the renal effects, ethylene glycol has other target propylene glycol avoids all renal toxicity. The ethanol should be administered within 8 Carbon tetrachloride and chloroform act predominantly in the hr of exposure in acute cases (ingestion) and be continued for proximal tubule. Renal tubular disease can be caused by a variety of volatile organic solvents, most likely as a consequence of reabsorption into the proximal tubule and biotransformation there into reactive and toxic intermediates. Glomerular damage can also be produced by such agents, a slow progressive disease with an 2,3 insidious onset seen in adults. Tests of Kidney Function the general medical indicators of kidney function are Blood Urea Nitrogen (catabolism of proteins, normal 2. Elevated levels in the serum are indicative of kidney dysfunction, specifically low Glomerular Filtration Rate. Clearance can be higher or lower than the glomerular filtration rate if a substance is actively secreted or reabsorbed, and is routinely assessed by physicians to predict the rate of drug elimination in patients. The relation the rate at which a drug is eliminated between the by the kidneys is commonly most proportional to the clearance of frequently used medical creatinine. It is not always convenient kidney before starting treatment to wait for a parameters creatinine (shown) clearance and the measurement, but it can be estimated glomerular by using the Siersbaek-Nielsen filtration rate. Keep the Glomerular Filtration Rate, in ml/min, evaluates the straightedge at crossing volume of plasma being passed into Bowman’s capsule. But in denominator is the concentration found in plasma from the the presence of shock, injection. Tubular Secretion Rate To evaluate the volume of plasma being passed through the chamber. In Vitro well secreted into the urine by the Initial research on the efficacy and toxicity of drugs is often tubules that about 91% of it is conducted on cell lines that have been transformed, so that they eliminated from the whole plasma may proliferate indefinitely, insuring repeatability of the test. Two Dialysis machines remove toxins from problems are loss of renal characteristics and limited lifespan. The cells, assumed to be from a kidney fibroblast, pass low molecular weight molecules endothelium or epithelium, were transformed in culture with (urea, creatinine, uric acid, adenovirus in the early 1970s. By contrast, kidneys Camptothecin induces apoptosis in a dose-dependent manner in cleanse 1200 l/week. Many of these chemicals are taken into the body not only via inhalation but through the intact skin. Kidney Case #2 Albert worked 24 years as a laborer at a company where lead was handled on a regular basis, for over 40% of his total lifetime. Kidney cells are damaged, resulting in decreased ability to eliminate fluid and solute loads. He had been admitted twice before because of lead poisoning, and within the previous month because of severe 9. He operated an David, a non-smoking police officer, was medically evaluated antique car restoring business, handling a number of plastics, in January 1982. An Intravenous Pyelogram showed no paints, and solvents: toluol, xylol, acetone, isopropyl alcohol, abnormalities of his kidneys or bladder. In March 1984, David methylene chloride, ethylene glycol monoethyl ether, crashed into a utility pole in the automobile chase of a suspect. In January 1985 he had aluminum welding, and then silver brazing for the next 16 bladder cancer at 39 years old, and underwent surgical removal years, followed by electric welding for the last 2 years.

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In certain be possible to use the epidural in very urgent circumstances order 20mg vasodilan visa blood pressure percentile, we may recommend a combined situations purchase cheapest vasodilan and vasodilan hypertension pulmonary. An epidural block is sometimes used to spinal–epidural (as described for labor analgesia) to provide anesthesia even when no catheter is in place order 20 mg vasodilan free shipping blood pressure essential oils. This is performed like a labor epidural block, but it uses larger doses of stronger medicines and takes place in our operative delivery room. Also, regional blocks may not be a good choice with some maternal conditions (such as bleeding or previous spinal surgery). General anesthesia can be started quickly to make the mother unconscious during the delivery. Pregnant women (particularly when in labor) have slower stomach emptying and are at greater risk of aspiration (stomach contents entering the lungs during unconsciousness or anesthesia). To decrease this risk, your anesthesiologist will take special precautions to protect the lungs, including placing a breathing tube in your wind pipe after you are asleep. You will also be given an antacid to drink before anesthesia to neutralize any acid in the stomach. For your safety, it is important not to eat any solid food (including milk products) once you are in active labor, regardless of your plans for delivery or pain relief. Moderate amounts of clear fuids and ice chips are usually allowed in normal labors. If you have a regional block, we often include narcotic medication with the local anesthetic to provide pain relief for most of the frst day after surgery, after the numbness from the anesthetic has worn of. Epidural or spinal narcotics give pain relief by acting at special sites in the spinal cord. Given this way, tiny narcotic doses can keep you comfortable without making you or the baby sleepy. You should not hesitate to take medications to make you comfortable after delivery. In fact, if you are comfortable, you are more likely to be able to care for your baby and succeed in breastfeeding. You will also have the opportunity to discuss your care plan with your anesthesiologist prior to your procedure Please contact us at any time if you have questions. If you have side efects after you go home, please call us directly in Labor and Delivery at (650) 723-5403. These recommendations may For these Guidelines, chronic pain is defined as pain of any be adopted, modified, or rejected according to clinical needs and etiology not directly related to neoplastic involvement, asso constraints and are not intended to replace local institutional ciated with a chronic medical condition or extending in du policies. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, B. They provide basic recommendations the purposes of these Guidelines are to (1) optimize pain that are supported by synthesis and analysis of the current liter control, recognizing that a pain-free state may not be attain ature, expert and practitioner opinion, open forum commen able; (2) enhance functional abilities and physical and psy tary, and clinical feasibility data. Focus these Guidelines focus on the knowledge base, skills, and * Developed by the American Society of Anesthesiologists Task Force on Chronic Pain Management: Richard W. Guidelines do not apply to patients with acute pain from an the Task Force thanks Timothy R. Supported by the American Society of Guidelines do not apply to pediatric patients and do not Anesthesiologists and developed under the direction of the Com mittee on Standards and Practice Parameters, Jeffrey L. A complete bibliography used to develop these Guidelines, arranged alphabetically, is available as Supplemental Digital Content 1, http://links. Application for reporting purposes in this document, only the highest level these Guidelines are intended for use by anesthesiologists of evidence (i. Guidelines recognize that all anesthesiologists or other phy sicians may not have access to the same knowledge base, Category A: Supportive Literature skills, or range of modalities. However, aspects of the Guide Randomized controlled trials report statistically significant lines may be helpful to anesthesiologists or other physicians (P 0. They may also serve as a resource for other Level 1: the literature contains multiple, randomized con physicians, nurses, and healthcare providers (e. They are not intended to Level 2: the literature contains multiple, randomized con provide treatment algorithms for specific pain syndromes. Information from observational studies permits inference of the Task Force developed the Guidelines by means of a beneficial or harmful relationships among clinical interven seven-step process. Second, original published research studies from peer-reviewed journals relevant to chronic pain were reviewed Level 1: the literature contains observational comparisons and evaluated. Task Force held open forums at two major national meetings† Level 3: the literature contains case reports. Sixth, the consult ants were surveyed to assess their opinions on the feasibility of Category C: Equivocal Literature implementing the Guidelines. Seventh, all available informa the literature cannot determine whether there are beneficial tion was used to build consensus within the Task Force to final or harmful relationships among clinical interventions and ize the Guidelines (appendix). Preparation of these Guidelines followed a rigorous methodological Level 2: There is an insufficient number of studies to con process (appendix). Evidence was obtained from two principal duct meta-analysis and (1) randomized controlled sources: scientific evidence and opinion-based evidence. Level 3: Observational studies report inconsistent findings Study findings from published scientific literature were aggre or do not permit inference of beneficial or harmful gated and are reported in summary form by evidence category, relationships. However, the lack of scientific evidence in the literature is described by the following conditions. Meta-analyses from other sources are reviewed but not (2) the available literature cannot be used to assess relation included as evidence in this document. The literature either does not meet the criteria for Guidelines content as defined in the “Focus” of the Guidelines or I. Patient Evaluation does not permit a clear interpretation of findings due to methodological concerns (e. Although no controlled trials were found that address the impact of con All opinion-based evidence relevant to each topic (e. Studies with obser and editorials are informally evaluated and discussed during vational findings for diagnostic sacroiliac joint blocks report the development of Guidelines recommendations. Studies with observational findings and case reports indicate that diagnostic nerve blocks may be useful in deter § When an equal number of categorically distinct responses are mining the location or etiology of pain (e. Diagnostic sacroiliac joint injections or embolization are among the reported complications of pro lateral branch blocks may be considered for the evaluation of vocative discography (Category B3 evidence). Diagnostic selective nerve root blocks may be considered to further evaluate the Recommendations for patient evaluation. The use of sympathetic blocks senting with chronic pain should have a documented history may be considered to support the diagnosis of sympathetically and physical examination and an assessment that ultimately maintained pain. History and physical examination: Pain history should in Peripheral blocks may be considered to assist in the diagnosis of clude a general medical history with emphasis on the chro pain in a specific peripheral nerve distribution. A cography may be considered for the evaluation of selected pa history of current illness should include information about tients with suspected discogenic pain; it should not be used for the onset, quality, intensity, distribution, duration, course, routine evaluation of a patient with chronic nonspecific back and sensory and affective components of the pain in addition pain. Addi Findings from patient history, physical examination, and tional symptoms (e.

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Faster than 60 per minute in an infant less than 2 months old Has the child had convulsions? Faster than 50 per minute in a child between 2-12 months Faster than 40 per minute in a child between 12 months to 5 years? Auscultation of the chest – note the presence of breath sounds generic vasodilan 20mg visa zithromax arrhythmia, Has the child been feeding? Guide only Appendix 4 Antibiotic Dose and regime Common side effects/comments Penicillin: Ampicillin 5 days Adults Oral 250 mg–1 g every 6 hours at least 30 minutes Nausea order 20 mg vasodilan with visa heart attack or gas, vomiting order discount vasodilan heart attack prognosis, diarrhoea. Children under 10 years, any route, half adult dose Amoxycillin Adults May reduce the effectiveness of oral 5 days Oral 250 mg every 8 hours, doubled in severe contraceptive pill. Intravenously: adult 500 mg–1 g 6 hourly Child 50 mg/kg per day in divided doses every 6 hours. Guide only Appendix 4 (continued) Antibiotic Dose and regime Common side effects/comments Tetracyclines Nausea, vomiting and diarroea. Rashes may Tetracycline Adults 250 mg every 6 hours occur – discontinue treatment. Discolouration Increase dose in severe infections to 500 mg of developing teeth if taken by children or every 6–8 hours mothers during pregnancy. Avoid milk products for 1 hour Oral 20–40mg/kg per day in divided doses every before and 2 hours after taking the drug since 6 hours. Blood levels are recommended Children > 1 year 50–100 mg/kg per day in divided in infants under 4 years of age receiving doses every 6 hours. Decrease higher doses as soon as clinically Contraindicated in pregnancy and indicated breastfeeding. Nausea, vomiting, rash severe infections) (may be severe), sore tongue and rarely Children jaundice and serious blood and liver or 6 weeks–5 months kidney disorders. Not usually given in Oral 120 mg every 12 hours pregnancy due to risks to the unborn baby. Definition Those whose sputum is found to be smear negative Tuberculosis is a disease caused by organisms are unlikely to infect others. The results are based on returns of standard data collection form which were sent to 211 countries requesting information. These totals compare with 3 368 879 and 1 292 884 for 1997 demonstrating a 7% increase in cases and an 11% increase in smear positive cases. Country Population Notified Cases New sputum smear Category positive cases in the country All types New sputum Estimated Percentage smear-positive Number detected No. Around 10% of those infected will go on to develop the disease; half will (The more *s, the more important the symptom is). Module 6 Page 167 Risk factors higher proportion of smear negative cultures and Certain groups of people are at special risk of the tuberculin skin test may be negative. Diagnosis may be difficult as X rays may pentamidine, sputum induction, and have an uncharacteristic appearance; there can be a bronchoscopy. This risk group of babies should automatically the reason for this is that with a single specimen receive chemoprophylaxis for six weeks and then only, approximately 25% of microscopically they should be tuberculin skin tested. If the tuberculin skin It is important to obtain good specimens of test is positive after six weeks, chemoprophylaxis sputum. But there may be: • the patient takes his/her medicine as prescribed and for a sufficiently long period. After a year or two (if the patient survives), development of Caseation of the lesion. Liquified caseous fibrosis (scarring) begins, which pulls up the right hilum material may be coughed up. It is usual for anti Tuberculin skin testing tuberculosis drugs to be prescribed for a minimum Although this can be useful in measuring prevalence of six months and administered daily or two or in a community in many poorer countries, three times a week. Chemotherapy regimes are tuberculin skin testing is less reliable than other internationally agreed and are based on the results methods, as it can provide a negative due to of a series of controlled studies. Short-course chemotherapy regimes intermittently (2 or 3 times per week) as when consisting of 4 drugs during the initial phase, and given daily. Ethambutamol is usually only given 2 drugs during the continuation phase, reduce the intermittently when also given with rifampicin. Short-course chemotherapy Treatment regimes have an initial, intensive phase regimes with three drugs during the initial phase, lasting 2 months and a contamination phase and two drugs in the continuation phase, are of usually lasting 4–6 months. During the initial phase, consisting usually of 4 Re-treatment cases drugs, there is rapid killing of tubercle bacilli. Previously-treated patients may have acquired drug Infectious patients become noninfectious within resistance. The vast to harbour and excrete bacilli resistant to at least majority of patients with sputum smear-positive isoniazid. In initially 5 drugs, with 3 drugs in the continuation the continuation phase, fewer drugs are necessary phase. This reduces of the drugs eliminates remaining bacilli and the risk of selecting further resistant bacilli. The duration is categories according to the cost-effectiveness of 4 months, with isoniazid and rifampicin three times treatment of each category. A number in subscript (for example, 3 ) recommended depends on the patient treatment appearing after a letter, is the number of doses of category. If there is no number in for each treatment category that can be used under subscript after a letter, then treatment with that various circumstances and in certain sub-populations. Drug Page 172 Module 6 Note: Some authorities recommend a 7-month pill may choose between two options during continuation phase with daily isoniazid and treatment with rifampicin. Refer back dose of oestrogen (50mcg); or to Table 3 for the drug doses for the currently • she could use another form of contraception. Treatment for patients with liver disease Patients with the following conditions can receive the Now carry out Learning Activity 5. The Isoniazid plus rifampicin, plus one or two non exception is streptomycin which is ototoxic to the hepatoxic drugs such as streptomycin and foetus, should not be used in pregnancy, and can ethambutol, can be used for a total treatment be replaced by ethambutol. Timely and properly applied chemotherapy is the best way to prevent transmission of tubercle bacilli Acute hepatitis (acute viral hepatitis) to her baby. Clinical judgement is and baby should stay together and the baby should necessary. These countries, routine monitoring by sputum culture drugs can, therefore, be given in normal dosage to is not feasible or recommended. In severe renal failure, are available, culture surveys can be useful as part patients should receive pyridoxine with isoniazid of quality control of diagnoses by smear in order to prevent peripheral neuropathy. The treatment response should be monitored by Thioacetazone is excreted partially in the urine, sputum smear examination. In general, two but since the margin is too narrow between a sputum specimens should be collected for smear therapeutic and a toxic dose, patients in renal failure examination at each follow-up sputum check. Negative sputum smears at the times shown in Table 5 indicate good treatment Monitoring the patient during treatment progress, which encourages the patient and the There are two main objectives: health worker responsible for supervising the • To monitor and record the response to treatment, treatment. If a patient has a positive sputum smear for whom bacteriological monitoring is possible.

Halofantrine Halofantrine hydrochloride is an oral schizonticide for all four malarial species vasodilan 20 mg otc hypertension in cats. Qinghaosu (Artemisinin) these drugs are especially useful in treatment of cerebral falciparum malaria generic vasodilan 20 mg with visa hypertension 34 weeks pregnant. Drugs used in amebiasis Amebiasis is infection by the protozoan parasite Entamoeba histolytica order discount vasodilan on-line blood pressure medication ok for pregnancy. E histolytica infection may present as a severe intestinal infection (dysentery), a mild to moderate symptomatic intestinal infection, an asymptomatic intestinal infection, ameboma, liver abscess, or other type 183 of extraintestinal infection. The choice of drug depends on the clinical presentation and on the desired site of drug action, ie, in the intestinal lumen or in the tissues. All of the antiamebic drugs act against Entamoeba histolytica trophozoites, but most are not effective against the cyst stage. Tissue amebicides eliminate organisms primarily in the bowel wall, liver, and other extraintestinal tissues and are not effective against organisms in the bowel lumen. Metronidazole, and tinidazole are highly effective against amebas in the bowel wall and other tissues. Emetine and dehydroemetine act on organisms in the bowel wall and other tissues but not on amebas in the bowel lumen. Asymptomatic Intestinal Infection: the drugs of choice, diloxanide furoate and iodoquinol. Diloxanide furoate or iodoquinol should also be given to eradicate intestinal infection whether or not organisms are found in the stools. An advantage of metronidazole is its effectiveness against anaerobic bacteria, which are a major cause of bacterial liver abscess. Ameboma or Extraintestinal Forms of Amebiasis: Metronidazole is the drug of choice. Dehydroemetine is an alternative drug; chloroquine cannot be used because it does not reach high enough tissue concentrations to be effective (except in the liver). Metronidazole Pharmacokinetics: Oral metronidazole is readily absorbed and permeates all tissues including cerebrospinal fluid, breast milk, alveolar bone, liver abscesses, vaginal secretions, and seminal fluid. Intracellular concentrations rapidly approach extracellular levels whether administered orally or intravenously. Mechanism of Action: the nitro group of metronidazole is chemically reduced by ferredoxin within sensitive organisms. The reduction products appear to be responsible for killing the organisms by reacting with various intracellular macromolecules. Clinical Uses: Metronidazole is active against amebiasis, urogenital trichomoniasis, giardiasis, anaerobic infections, acute ulcerative gingivitis, cancrum Oris, decubitus ulcers, and bacterial vaginitis and Helicobacter pylori infection. Rare adverse effects include vomiting, diarrhea, insomnia, weakness, dizziness, stomatitis, rash, urethral burning, vertigo, and paresthesias. Other Nitroimidazoles Other nitroimidazole derivatives include tinidazole, and ornidazole. They have similar adverse effects Because of its short half-life, metronidazole must be administered every 8 hours; the other drugs can be administered at longer intervals. However, with the exception of tinidazole, the other nitroimidazoles have produced poorer results than metronidazole in the treatment of amebiasis. Chloroquine Chloroquine reaches high liver concentrations and is highly effective when given with emetine in the treatment and prevention of amebic liver abscess. Adverse Effects: Sterile abscesses, pain, tenderness, and muscle weakness in the area of the injection are frequent. Emetine and dehydroemetine should not be used in patients with cardiac or renal disease, in patients with a history of polyneuritis, or in young children or liver abscess. Diloxanide Furoate Diloxanide furoate is directly amebicidal, but its mechanism of action is not known. In the 2gut, diloxanide furoate is split into diloxanide and furoic acid; about 90% of the diloxanide is rapidly absorbed and then conjugated to form the glucuronide, which is rapidly excreted in the urine. For mild intestinal disease, and other forms of amebiasis it is used with another drug. Iodoquinol Iodoquinol is effective against organisms in the bowel lumen but not against trophozoites in the intestinal wall or extraintestinal tissues. Iodoquinol is an alternative drug for the treatment of asymptomatic or mild to moderate intestinal amebiasis. Adverse Effects: Reversible severe neurotoxicity (optic atrophy, visual loss, and peripheral neuropathy). Mild and infrequent adverse effects that can occur at the standard dosage include diarrhea, which usually stops after several days, anorexia, nausea and vomiting, gastritis, abdominal discomfort, slight enlargement of the thyroid gland, headache, skin rashes, and perianal itching. Paromomycin Sulfate Paromomycin is an alternative drug for the treatment of asymptomatic amebiasis. In mild to moderate intestinal disease, it is an alternative luminal drug used concurrently with metronidazole. Paromomycin is both directly and indirectly amebicidal; the indirect effect is caused by its inhibition of bowel bacteria. It can be used only as a luminal amebicide and has no effect in extraintestinal amebic infections. Other Antibiotics the tetracyclines (oxytetracycline) have very weak direct amebicidal action, and useful with a luminal amebicide in the eradication of mild to severe intestinal disease. Erythromycin although less effective can be used in the treatment of luminal amebiasis. Drugs used in Giardiasis and Trichomoniasis Metronidazole is a drug of choice for gardiasis and trichomoniasis, and the alternate drug is tinidazole. Treatment of Leishmaniasis Kala-azar, cutaneous, and mucocutaneous leishmaniasis are caused by the genus Leishmania. Treatment of leishmaniasis is difficult because of drug toxicity, the long courses of treatment, treatment failures, and the frequent need for hospitalization. Patients must be closely monitored in hospital, because adverse effects may be severe. Pentamidine Pentamidine is administered parenterally because it is not well absorbed from the gastrointestinal tract. The drug leaves the circulation rapidly and is bound avidly by the tissues, especially the liver, spleen, and kidneys. Trypanosomiasis: In African trypanosomiasis, pentamidine is an alternative in the hemolymphatic stage of the disease to (1) suramin in Trypanosoma brucei gambiense and T b rhodesiense infections or to (2) eflornithine in T b gambiense infection. Pneumocystosis 187 Adverse Effects: Pain at the injection site is common; infrequently, a sterile abscess develops and ulcerates. Occasional reactions include rash, gastrointestinal symptoms, neutropenia, abnormal liver function tests, serum folate depression, hyperkalemia, and hypocalcemia. Severe hypotension, hypoglycemia, hyperglycemia, hyponatremia, and delayed nephrotoxicity. Most anthelmintics are active against specific parasites; thus, parasites must be identified before treatment is started. Individual Drugs Albendazole Albendazole, a broad-spectrum oral anthelmintic, is used for pinworm infection, ascariasis, trichuriasis, strongyloidiasis, and infections with both hookworm species.