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Slow breaths at low pressure better than fast/high pressure (gastric distension) calan 240 mg online arrhythmia games. Ventilate just sufficiently to make chest rise and fall For no more than 10 secs purchase generic calan on-line blood pressure medication effects on sperm, check circulation discount calan 120mg hypertension fatigue. If over 8, carotid best If no circulation or less than 60 bpm, external chest compression. Rate of 100 bpm, ratio of compressions to ventilations is 5:1 Kids over 5, heel of one hand, depth approx. If iv access time consuming, then 18 gauge perpendicular into anterior surface of tibia, 1 3 cm below tibial tuberosity. Every 2 loop give adrenaline Ventilation: Harder in kids use two people to do bag-mask. Beware of barotrauma If hypovolaemia 20 ml/kg saline or Ringers Defibrillation Produces a simultaneous depolarisation of myocardial fibres allows coherent rhythm th th 478 4 and 5 Year Notes Ideally within 90 seconds, preferably within 8 minutes. Only effective treatment is defibrillation No organised depolarisation doesnt contract as a unit. Dont give via endotracheal tube Lignocaine, 1 mg/kg: for ventricular ectopy and stable ventricular tachycardia. Intraosseous in infants Fluid replacement: warmed crystalloid (watch for cerebral oedema) or colloid, blood where indicated. It is the principle of justice not the principle of autonomy that creates a right to treatment Doctors should not make decisions based on their assessment of the patients quality of life. Can revise decision to resuscitate as the probability of poor outcome grows or other information (e. Only relevant to investigating cause not to treatment Examples of allergens: Drugs: 50% of fatalities. Steroids: prevent late symptoms Promethazine 25 mg slow iv or im (H1 antagonist) + H2 antagonist (e. Will grip throat not chest Adult obstruction Partial obstruction distressed and coughing. If conscious and adequate air encourage coughing and spitting nothing else Ask if they are choking: if cant talk, breath or cough then: Remove obvious obstruction from mouth (only if unconscious may bite). Hook with other hand Back slapping: lean well forward onto one hand, 5 sharp slaps between shoulder blades with heel of other hand. If lying down, roll face down onto your thigh Abdominal thrusts (Heimlich manoeuvre): fists over midline above naval, always below xiphoid process and ribs. If infective cause then medical emergency Only intervene if childs attempts to clear the obstruction are clearly ineffective and there is inadequate respiration For infants (<1 year) and children, 5 back blows with the childs head below the level of the chest if possible Then 5 chest thrusts to sternum in supine position: sharp, vigorous and rate of 20 bpm Check mouth: grasp tongue and jaw and lift. Dont put finger into mouth unless foreign body is clearly visible Reassess airway. If not breathing, attempt to ventilate Repeat back slaps, chest thrusts, attempted ventilation. See Replacement fluids, page 550 for fluid resuscitation Good nutrition critical: calorie and protein requirements. Dont lower blood pressure too low too fast cerebral autoregulation may be been reset to a higher blood pressure Near Drowning Effective immediate resuscitation critical. Impaired drug metabolism watch for toxicity Monitor fluids during rewarming Emergency Management 487 Hyperthermia Heat Exhaustion: hypovolaemic shock due to fluid loss through sweating. Cool, restore volume, position supine with legs raised Heat stroke: failure of heat regulation through failure to sweat. Only useful if low Vd, small molecule and low protein binding (eg lithium, theophylline, salicylates, alcohol and barbiturates) Whole bowel irrigation: Go Lightly Xray prep Questionable effectiveness: Emesis: Not effective? Causes emesis in 90% within 15 30 minutes Gastric lavage: large bore catheter through mouth. Of the remainder, 15% is metabolised to a metabolite that combines with glutathione. Supportive treatment Anticonvulscents: carbamazepine Bronchodilators: theophylline Cocaine benzodiazepines Carbon Monoxide 100% oxygen, treat cerebral oedema. Recurrence 20% Secondary: in any lung disease Treatment: Insert 14g iv cannula into midaxillary line at level of nipple (any lower and may get diaphragm) Hissing of air is diagnostic th th 490 4 and 5 Year Notes Remove needle and leave cannula in place. Open Pneumothorax Sucking wound cant create ive intrathoracic pressure Occlusive dressing and positive pressure Massive Haemothorax 1500 ml in thorax or > 200 ml per hour Mainly penetrating wounds of pulmonary vessels (e. If great vessels affected usually dont survive Significant amount of blood needs surgical removal thoracotomy Flail Chest Needs lots of force so suspect pulmonary contusion as well Independent segment of chest wall paradoxical movement. So do random cultures in the hope of getting a hit Definitions: Bacteraemia: no host response. Happens all the time (eg after cleaning teeth) Septicaemia: sustained bacteria in the blood stream on going delivery of bugs into the blood stream from a replicating focus (dont multiply in blood). Coli, -haemolytic streptococci Group B (eg streptococcus agalactiae normal vaginal flora), rarely listeria Children < 14 years: H. Reduces fever and gives misleading impression of clinical improvement Antibiotic regimes: Empiric antibiotic treatment: Neonate 3 mths: Amoxycillin 50 mg/kg (for listeria) + Ceftriaxone 50 mg/kg (E coli and Strep). All cases should have audiologist check within 6 8 weeks of discharge Death in 5%, 10 15% pneumococcal meningitis, 20% in fulminant meningococcaemia Meningococcal Disease Cause: Neisseria Meningitidia Epidemiology: 10-year epidemic started in 1990 with about 50 reported cases. Current case fatality rate is 3 5 % Leading infectious cause of death in children 500 reported cases in 2000. Nasal carriage higher in adults than children Rifampicin: 4 doses, 600 mg bd for adults, 10 mg/kg bd for kids (very high dose). Broad spectrum antibiotic Offer to index case (if only treated with penicillin), all intimate, household and day-care contacts during last 10 days Contraindications: pregnancy (use single dose ceftriaxone), liver disease. May get purpura in flexures Tongue affected white then strawberry red Streptococcus Toxic Shock Syndrome: First described in children. Spreads along facial planes Infection of subcutaneous tissue progressive destruction of fascia and fat but may spare the skin itself. Normally first 3, except if from Pacific Islands where use all 4 due to isoniazid resistance. Recurrences usually less severe and become less frequent Diagnosis: clinical suspicion. There are two antigenic types of Herpes Simplex Virus: Type 1 is associated with lesions on the face and fingers, and sometimes genital lesions. Prevalence: 70% of population Type 2 is associated almost entirely with genital infections, and affects the genitalia, vagina, and cervix and may predispose to cervical dysplasia. Acyclovir Infectious Diseases 503 Genital Herpes (type 2) Description: Painful, recurrent condition. Neonatal transmission is rare (1 in 10,000 live births), but carries risk of ophthalmic infection caesarean section indicated if active blisters at delivery Prevention of genital herpes: Condoms with new partner (although doesnt eliminate risk). Avoid sex during an outbreak Can have extra genital lesions on thighs and buttocks. Can radiculoneuropathy urinary retention/constipation Treatment of Genital Herpes (type 1 or 2): Acute: Acyclovir 200 mg 5 times daily for 5 days. Symptomatic treatment: salt bathing, local anaesthetic creams, oral analgesia, oral fluids.

Penile inflatable implant The man causes the erection by using the pump to shift fluid from the reservoir into the inflatable tubes discount calan 80 mg visa hypertension 2006. Although less common in younger men discount calan 120mg line pulse pressure 27, it is usually a more urgent condition for these individuals cheap 240mg calan with mastercard blood pressure chart guidelines. Erectile dysfunction requires understanding in areas such as pharmacology, cardiology, psychology andrology, endocrinology and urology. Erectile dysfunction in general medical practice: Prevalence and clinical correlates. Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study. Diagnosis and management of erectile dysfunction: A guide for practice in Australia. Prevalence of erectile dysfunction in France: Results of an epidemiological survey of a representative sample of 1004 men. The Canadian Study of Erectile high potential for patient and partner treatment satisfaction. To help the patient and partner establish their objec- longstanding relationships exist between the couple and tives of treatment. To select diagnostic tests based on presenting com- tic alliance which may translate into improved clinical plaints and goals of therapy. To offer treatment choices with comprehensive infor- remain an essential resource for several important reasons: mation on cost, likelihood of success and common 1. Second-line intracavernous and intraurethral vasoac- which would satisfy the patient and partner goals tive therapy may be outside of the practice pattern of treatment. To choose approaches which are reversible when- severe vascular disease or poorly controlled diabe- ever possible. Determine the timing of onset, nature of the prob- Dynamic infusion cavernosography and caver- lem, and signifcance to the partner (if applicable). Establish a likely underlying etiology based on his- A monogamous, heterosexual relationship should not be tory, physical exam, and lab testing. Focused physical examination (directed at anatomic, vascular and neural systems essential for erections). The greatest utility of these questionnaires not add signifcantly to duration of the doctor-patient may be in establishing a response to therapy and determin- encounter. The primary goals of psychotherapy are ment or discomfort for some patients; therefore, every effort to reduce or eliminate performance anxiety, to understand the should be made to ensure privacy and personal comfort. Nocturnal penile tumescence may include fasting glucose, lipid profle and, in select cases, and rigidity testing using Rigiscan should take place for a hormone profle. Hormone profles are used to identify or at least 2 nights, measuring 2 to 5 overnight erections. Vascular testing suggested as a valuable addition to the evaluation and good general practice. This test is Diabetes Association guidelines)2 testing and potential treat- performed less frequently in Canada since the advent of ment for low levels of testosterone is appropriate. In the appropri- sound is normal, as indicated by a peak systolic blood fow ate patient, once treatment with exogenous testosterone is >30 cm/sec and a resistance index >0. If the ultrasound initiated, ongoing follow-up is mandatory according to pub- is abnormal, however, arteriography and dynamic infusion lished guidelines. Patients and partners are made aware of reserved generally for cases of high-fow priapism or planned effcacy, risks and benefts of appropriate treatments, taking vascular bypass. A penile angiogram allows visualization into consideration preferences and expectations. Oral ther- of the penile circulation and directs embolization for the apy failure may often be salvaged by patient re-education unusual case of penile injury induced high-fow priapism. Neuro-physiological testing Success, Unsuccessful This form of testing generally continue consider third-line allows us to measure the sacral treatment therapy refex arc, an indirect measure of the perineal neural integrity, and Penile implant surgery has limited clinical availability and utility. Basic screening tests include the identifcation of car- umented hypogonadism is an option. Local therapy (intracavernous or intraurethral treatment or investigations may be appropriate. Bella is a member of the advisory boards for Lilly, Actavis, American Medical Systems, and Coloplast. There is a Use with alpha blockers potential risk of signifcant hypotension when using non-selective alpha blockers. The assessment of vascular risk with erectile dysfunction: the role of the cardiologist and general physician. J Sex Med investments in many pharmaceutical companies through his diversifed retirement plan. Combination of psychological intervention and phosphodisterase-5 inhibitors for erectile dysfunction: A narrative review and meta-analysis. Standardization of vascular assessment of erectile dysfunc- tion: Standard operating procedures for duplex ultrasound. Standard operating procedures for neurophysiologic assessment of male sexual setting: Importance of risk factors for diabetes and vascular disease. Brock G, Harper W; for Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Guidelines on male sexual dysfunction: Erectile dysfunction and in hypogonadal men with erectile dysfunction: A systematic review. Oral phosphodiesterase-5 inhibitors and hormonal treatments for erectile dysfunction: A systematic review 2002;9:1583-87. Impact of a frst treatment with phosphodiesterase inhibitors 9-200911030-00150 on men and partners quality of sexual life: Results of a prospective study in primary care. Implants, mechanical devices, and vascular surgery for erec- J Sex Med 2010;7:3572-88. MedLine search was supplemented by the term premature ejaculation in all search fields. All articles published between January 2009 (previous update) and January 2013 were considered for review. The Expert Panel has also identified critical problems and knowledge gaps, setting priorities for future clinical research. Grading aims to provide transparency between the underlying evidence and the recommendation given. Table 1: Level of evidence* Level Type of evidence 1a Evidence obtained from meta-analysis of randomised trials. Alternatively, absence of high level of evidence does not necessarily preclude a grade A recommendation, if there is overwhelming clinical experience and consensus. There may be exceptional situations where corroborating studies cannot be performed, perhaps for ethical or other reasons and in this case unequivocal recommendations are considered helpful. Whenever this occurs, it is indicated in the text as upgraded based on panel consensus. The quality of the underlying scientific evidence - although a very important factor - has to be balanced against benefits and burdens, values and preferences, and costs when a grade is assigned (4-6). But whenever these data are available, the expert panel will include the information.

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Although there are numerous species of ameba that inhabit the human intestinal tract buy calan 80 mg without prescription hypertension abbreviation, E cheap 80mg calan amex blood pressure pulse rate. Its manifestations vary from the asymptomatic carrier state buy 240 mg calan free shipping blood pressure medication in the morning or at night, to a severe fulminating illness with mucosal inflammation and ulceration. Asymptomatic carriers harbor cysts in their stools, have no evidence of tissue invasion, but since the cysts are resistant to the outside environment, the disease can be transmitted by these individuals who are unaware of their infective potential. This is in marked contrast to patients with acute or chronic invasive disease, who harbor a trophozoite that cannot survive outside the host. The acute illness is characterized by diarrhea with the passage of blood and mucus, and by abdominal pain. In its most severe form amebasis may mimic fulminating ulcerative colitis, and may progress to a toxic dilation (toxic megacolon) and perforation of the colon. During the acute illness, trophozoites may be recovered in the stool, from biopsies of shallow ulcers in the rectum, or from smears of rectal mucus. Chronic infectious features may develop many years after the patient has left an endemic area. Patients present with nonspecific bowel complaints and may show radiologic changes in the distal small bowel and colon that mimic ulcerative colitis, cancer or tuberculosis. The indirect hemagglutination test can help detect patients with invasive disease. Systemic dissemination of the ameba may involve other organs, such as the brain, lung, pericardium and liver. Therapeutic agents used for the treatment of amebiasis act at selected sites: intraluminally, intramurally or systemically. However, because metronidazole is less effective against organisms within the bowel lumen, iodoquinol (650 mg t. Shaffer 218 - Cryptosporidia Cryptosporidia are a genus of protozoa classified within the subclass Coccidia. In immunocompetent persons, cryptosporidia infection presents as a transient, self-limiting diarrheal illness lasting from one to seven days. This electron micrograph of cryptosporidiosis in the small bowel shows the characteristics intracellular but extracytoplasmic location of the organisms. Drugs and Chemicals Since almost every drug can cause diarrhea, the first question to ask a patient is What medications, both prescribed and over-the-counter, are you currently taking? Although many drugs can cause diarrhea, little is understood about the ways in which they do so. It may occur months after antibiotic exposure, and may occur without a past history of antibiotic use. The frequency of diarrhea or colitis does not appear to be related to dose or route of administration of the First Principles of Gastroenterology and Hepatology A. Symptoms can occur while the patient is on the antibiotic, or within six weeks following its discontinuation. The diarrhea can be devastating, with up to 30 bowel movements in a 24-hour period. The diarrhea may be associated with varying degrees of abdominal pain and low-grade fever. Depending on the severity of the diarrhea and the amount of fluid loss, hypotension, shock and even death have been reported. In many patients the problem is self-limiting and resolves spontaneously with discontinuation of the antibiotic. In recent years, a number of newly recognized and apparently more virulent strains of C. The presence of copious amounts of mucus and typical raised white pseudomembrane plaques which are not washed away are characteristic features seen on sigmoidoscopy. Colonoscopy is recommended, because the plaques may be seen in the right colon beyond the reach of the sigmoidscope, and the diagnosis would be otherwise missed. If it is certain that there is no other likely cause for the diarrhea, treatment can be undertaken while awaiting assay results, although it is usually possible to quickly obtain a sigmoidoscopy to demonstrate the pseudomembranes. If symptoms are resolving with discontinuance of the antibiotic, no further therapy may be indicated. Vancomycin is poorly absorbed and central nervous system and renal toxic effects are uncommon. The high cost of this medication limits its use, even though the eradication rate of the C. It must be stressed that the vancomycin must be given orally, and not systematically. If oral therapy cannot be used, as with severe ileus or recent surgery, parenteral metronidazole is used. Cholestyramine (Questran) binds the toxin and can provide symptomatic relief even though it will not eliminate the microorganism. In extreme cases of fulminant non- responsive disease, colectomy, may be necessary. Magnesium-Containing Antacids The osmotically-induced diarrhea produced by Mg2+ is usually mild. A change to a magnesium-free, aluminum-containing antacid is all that is required to control the diarrhea. The use of magnesium-containing antacids is a common cause of diarrhea in dyspeptic patients. Magnesium can be used to induce diarrhea by rare patient with the Mnchausen syndrome who seek medical attention for self-induced problems. Antiarrhythmic Drugs The antiarrhythmic drugs most commonly associated with diarrhea include quinidine, procainamide and disopyramide. Other Medications Colchicine, often administered for acute gout, produces diarrhea as a common side effect. The mechanism of the diarrhea is unknown, but may relate to an intestinal cytotoxic effect of colchicine. Chronic Diarrhea Mechanisms There are at least four basic mechanisms that cause chronic diarrhea, including osmotic, secretory and exudative factors, and abnormal intestinal transit (Table 12). If the diarrhea ceases when fasting, then an osmotic cause for the diarrhea is suspected. A significant osmotic gap in the stool water may be present but, under normal clinical circumstances, this is not measured. Examples include diarrhea after ingesting milk (and resulting from lactase deficiency), taking drugs such as magnesium- containing antacids, or the excessive use of artificial sweeteners (eg. If the patients diarrhea persists when fasting (such as may occur at nighttime when the diarrhea awakens the person from sleep), a secretory diarrhea is likely. Secretory diarrhea usually arises from infection or inflammation associated with toxigenic and invasive bacteria.

Without more detailed and comprehensive information discount 80 mg calan with amex blood pressure medication hair loss, we cannot have an accurate picture of how antibiotics are sold discount calan 240 mg with visa blood pressure 40 over 70, distributed order cheap calan on line arrhythmia 25 years old, and used in food animal production. The absence of this is likely to hamper policymakers and healthcare leaders trying to tackle antibiotic resistance because changes and trends cannot be accurately tracked, and resources may not be focused where they are most needed. Examples of Comprehensive Data Collection Systems Successful models do exist for collecting and analyzing how and why antibiotics are used in food animal production (See Box C). It is collected from three sources allowed to dispense antibiotics: veterinary pharmacies, veterinarians and feed mills. These different models for data collection Illustrate different approaches to ensuring farm anonymity. In Denmark, the government can access farm-specifc data more freely, but the public must make a special request to access it. Data Collection The following recommendations encompass a discussion of the essential data that should be collected (See Box D), potential sources of data, as well as options for metrics that synthesize the available data and allow for comparisons of antibiotic use. However, the agency has no system in place to collect ongoing and comprehensive use data, nor does it have any stated intention to build such a system. Development of unifed data collection systems in Denmark and the Netherland has been critical to their success in reducing antibiotic use (over baseline levels) by 47% and 64%, respectively. That system should be mandatory, not voluntary, and should be comprehensive enough to encompass certain essential data. Data Collection Efforts to Denmark and the Netherlands The limited data on antibiotic use in U. Both countries have robust, proftable meat and poultry industries where they raise animals in intensive, industrial-style operations not unlike those in the U. Both have adopted policy and practice changes that have helped to signifcantly curtail unnecessary antibiotic use in food animal production. In each country, the changes include improved monitoring of antibiotics sold and used in food-producing animals as well as surveillance to identify patterns of resistance in people, retail meat and in food-producing animals. Antibiotic sales, use and surveillance information for each country also are integrated into a 123,124 single annual report. The enhanced systems for collecting and integrating data in the two countries have informed additional policy interventions over time by identifying areas in need of improvement. They also have made it possible to benchmark how well veterinarians and/or farms use antibiotics relative to their peers. These systems have been crucial in enabling the countries to reach their antibiotic use goals and reduction targets as well as keep antibiotic resistance in animal populations at low levels. Denmark Responding to public concern about levels of antibiotic use in food-producing animals, and possible impacts on human health, Denmark began taking a series of important steps in 1995, including improving data collection. Later that year, industry and government together set a goal for reducing antibiotic use by 50% within fve years. Certain minimum data are essential to capture a meaningful picture of how and why antibiotics are being used in animal agriculture. Ideally, the following additional information also would be collected to provide a more complete understanding of use and resistance patterns: Dose of the antibiotic administered; Production class (dairy cattle vs. Until a better system is put into place to collect more data States and private actors in the U. For example, Californias efforts to eliminate unnecessary and inappropriate law addressing antibiotic use in livestock includes a use, as well as to allow for comparisons with other requirement to monitor antibiotic sales and usage. This measures the could collect and report use information to amount of antibiotics sold per amount of livestock the public, as they do in the Netherlands. The longer-term goal should be to transition marketers and buyers also can help increase to use of an animal defned daily dose metric, a drug transparency by requiring suppliers either to report and animal species-specifc measure that requires the antibiotic use to them directly, or to participate in collection of additional data. Enhancing Surveillance and Data Integration to Inform Antibiotic Use Policy The previous section described three streams of data currently being collected in the U. Individually, each data stream provides some meaningful information, but the usefulness of the data is shortchanged by a failure to combine the different data streams into an integrated analysis to provide a more comprehensive picture of antibiotic use in food-producing animals. In addition, there is a lack of uniformity between agencies in terms of which indicator species they monitor (see Table 4). And now There are two key reasons to sequence the genes colistin-resistant bacteria, likely enriched by overuse of bacteria such as E. Second, these bacteria Enhancing Surveillance and Data are more commonly found in livestock and other Integration environments so resistance trends are more easily monitored in these bacteria. Reports from both countries also contain additional information such as yearly Finally, transmissible plasmids have been discovered livestock/production data (such as that available recently on U. When genes that are resistant to both of these medicines eventually land on the same plasmid, and Recommendation No. Later detection, on the other hand, may least eight are bacteria that have been detected both result in being able to recognize that a problem in U. We therefore recommend livestock associated antibiotic-resistant bacteria the following specifc expansions: have been found to colonize the nasal passages of swine and poultry workers, and also can cause skin 11a. Expand surveillance for emerging resistance and soft tissue infections in workers, as well as other using next generation sequencing technology. These sequencing efforts should be transmitted from food-producing animals/retail be expanded to a wider array of bacteria, including meat to people have been characterized by several E. The agencies should set up a publicly accessible database or make use of existing databases for the timely release of genome sequencing data. Beyond the federal level, state veterinary laboratories have an important role to play in improved surveillance by publicly reporting on resistance found among food producing animals. For example, in 2016, the MinnesotaVeterinary Diagnostic Laboratory published fndings on resistance in Salmonella from clinical samples from 2006 to 2015 in swine and cattle. Conclusion 35 Conclusion Antibiotic resistance is an urgent public health threat that demands immediate action. Drug-resistant infections are on the rise, making antibiotics less effective and putting routine and common and life-saving procedures in jeopardy. Antibiotic resistance is changing the practice of modern medicine by compromising our ability to treat sick people and animals. It is estimated that by 2050 a person will die every three seconds from a drug- resistant infection and $100 trillion in global economic productivity will have been lost. However, this report focuses specifcally on antibiotic use in food-producing animals because 70% of medically important antibiotics sold in the U. This Commission wants to keep the existing arsenal of antibiotics effective for as long as possible. Our recommendations are steps that will help ensure that on-farm use of medically important antibiotics is monitored and reduced, and that there will be adequate surveillance of the development and spread of antibiotic resistant bacteria. Success, we believe, depends on leadership that builds on approaches that have proven successful elsewhere. While state and federal policymakers have important roles to play, action is need from all stakeholders. Health professionals and hospitals, as well as food companies and other major meat and poultry purchasers also have key roles to play. Steps must be taken today to help ensure that our existing supply of antibiotics stay as effective as possible, now and for future generations.