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By K. Marius. Bloomfield College.

Such an increase is offset by the even larger increase of plasma volume cheap zebeta 10 mg on-line blood pressure different in each arm, resulting in relative anemia buy zebeta 10 mg with visa blood pressure drops after exercise. The fetus survives in a low-oxygen environment with little reserve oxygen stores, should the supply of oxygen-rich uterine blood be compromised. Animal and human studies demonstrate reduced fetal oxygenation if there is reduced uterine blood flow such as occurs with severe maternal hypotension, hypocarbia, or shock ( 25). Maternal hyperventilation can reduce venous return and shift the maternal oxyhemoglobin dissociation curve to the left. Modest declines in maternal oxygenation seem to be tolerated by the fetus, but substantial degrees of maternal hypoxemia can threaten fetal survival. Uterine vessels during gestation are dilated maximally based on experimental data primarily from pregnant sheep and some human studies. Uterine vessels do not vasodilate after b-adrenergic agonist stimulation, but do vasoconstrict from a-adrenergic agonists. Some obstetric anesthesiologists administer intravenous ephedrine 25 to 50 mg for hypotension during epidural anesthesia. The b-adrenergic effects of ephedrine result in increased cardiac output, which raises systolic pressure and maintains uterine perfusion. Subcutaneous epinephrine provides primarily b-adrenergic stimulation, whereas intravenous epinephrine results in both a- and b-adrenergic effects. For the fetus in distress, such changes can be important, but clearly the uteroplacental circulation is a large shunt. For the same incremental increases in arterial P O2, the leftward shift of the fetal hemoglobin oxygen dissociation curve results in larger increases in fetal P O2 than in maternal blood. Studies in the literature report varying degrees of improvement, deterioration, or no change in clinical course ( 31). A prospective study of 198 pregnancies recorded similar results in that 40% of gravidas had no change in antiasthma medications, 42% required more medications, and 18% of gravidas required fewer medications ( 12). Pregnancy in adolescents with asthma has been associated with many emergency department visits and hospitalizations for asthma ( 34). Accurate serial data were not available to compare preconception and gestational asthma events. Some adolescents with severe asthma may not benefit from antiinflammatory medications such as inhaled beclomethasone dipropionate because of their poor compliance with physician advice and medications ( 34). The combination of poverty, inadequate or no prenatal care, and limited education can complicate adolescent pregnancies ( 35). Clearly, gravidas must not smoke during gestation for their own well-being and that of their children. Aspirin and nonsteroidal antiinflammatory drugs should be withheld in the aspirin-intolerant gravida. Medications It is preferable to recommend antiasthma medications for which established data from human pregnancies are available. Furthermore, inhaled drugs are favored as the potential drug dosage that would cross the placenta is reduced. Organogenesis in human pregnancies is relatively short (days 12 56) compared with animals. The time for fetal growth and development is much longer in humans, whereas it is shorter in animals. About 25% of major malformations are genetically related, and 3% are due to recognized chromosomal abnormalities. Food and Drug Administration classification system for drug administration during gestation must be considered in the context of drug advertising by manufacturers and is not an absolute prohibition on prescription of a drug during gestation, with the exception of a class X agent. Experience with inhaled beclomethasone dipropionate has not identified fetal abnormalities in pregnancies where therapeutic dosages were used at conception or during the first trimester ( 8,9,11,34). Budesonide also has not been associated with harmful effects during conception and the first trimester ( 16). Published experience from Northwestern University with prednisone, beclomethasone dipropionate, or both totals over 300 pregnancies without an increased risk of teratogenesis. Another antiinflammatory drug, cromolyn, has not been associated with an increased risk of congenital malformations in a series of 296 cases ( 39) as well as during use in the United States since 1973 ( 2). Reports on the use of nedocromil, which blocks early and late allergic-induced bronchial reactions and has antieosinophil activity, in the first trimester are meager. The most cautious view would be to withhold nedocromil and use one of the two inhaled corticosteroids mentioned with or without cromolyn. Theophylline is considered appropriate for use during gestation, should it be required ( 2,15,25). The hepatic elimination clearance of theophylline has been shown to decrease in the third trimester by approximately 4% to 6% (40). Protein binding decreases in the second and third trimesters so more free theophylline is available for elimination. Furthermore, increased glomerular filtration rate increases renal clearance of theophylline during gestation. Overall, the last trimester may be associated with 10% increases in the theophylline serum concentrations. Aiming for maximal theophylline serum concentrations of 8 to 15 g/mL should help reduce the likelihood of accumulations of theophylline during pregnancy.

Methotrex- r Because of immobility and steroid therapy patients ate is normally used as rst line buy 5mg zebeta mastercard arteria testicularis, other agents include with rheumatoid arthritis are at high risk for develop- sulphasalazine buy zebeta 10mg free shipping hypertension management guidelines, gold and hydroxychloroquine. Bis- is slow, 10 20 weeks, and all have some degree of phosphonate therapy should be considered in high- toxicity. Synovitis of the spine and large arthrodesis (joint fusion) may be performed for in- joints may occur, and there is both synovitis and enthe- tractable pain at the elbow or wrist; however, there sopathy at the sacroiliac joints. Atlantoaxial sub- intervertebral disc becomes calcied and forms a bony luxation may require surgical stabilisation. As 4 Joint replacement has signicant postoperative these extend up the spine, calcication causes rigidity morbidity but can be an effective longer term treat- and a typical bamboo appearance on X-ray. Clinical features Prognosis Patients develop a gradual onset of episodic low-back The disease generally progresses insidiously in the ma- painandmorningstiffness. Thereisalossofnormallum- jority of cases although most patients experience periods barlordosisduetomusclespasmandsacroiliacjointten- of exacerbation and quiescence. Movement of the spine is restricted in all planes and a limitation of chest expansion may occur. Acute anterior uveitis, aortic regurgitation and (spondyloarthropathies) apical lung brosis are known extra-articular features. Ankylosing spondylitis Denition Ankylosing spondylitis is a chronic inammatory arthri- tis predominantly affecting the axial skeleton, causing pain and progressive stiffness. Pathophysiology r Patients should be encouraged to remain active, avoid Synovitis is histologically the same as that of rheumatoid prolonged bed rest and avoid lumbar supports. Phys- arthritis, although bone resorption is sometimes promi- iotherapy involvement is important. Itislikelythatboththeskinlesionsandthearthritis r Pain and morning stiffness are treated with non- are immunologically mediated. Fivepatternsofarthritis osteotomy may be helpful in patients with severe cur- are seen: vature. There is a wide range of severity: In over 85% there is 3 Symmetrical rheumatoid-like polyarthritis. Psoriatic arthritis Investigations Denition r Blood tests may show raised inammatory markers, Achronic inammatory arthritis occurring with psori- anaemia of chronic disease and presence of autoanti- asis. Other features include 1% of population have psoriasis of which 5% will get periostitis, bone resorption, sacroiliitis and spondyli- arthritis. Second line agents include methotrex- Typically there is an abrupt onset of asymmetrical lower ate and ciclosporin. Achilles ten- have been shown to be effective in reducing the pro- dinitis and plantar fasciitis may also occur. Surgical intervention may have been preceded by a clinical urethritis, prostatitis, prove necessary. Prognosis It is not clear whether any medical intervention has Investigations disease-modifying potential. X-rays are initially normal but may show erosions and features Reactive arthritis similar to ankylosing spondylitis. Denition Management Acute or chronic synovitis that occurs less than 6 weeks Although unlikely to affect the course of arthritis, an- following infections with various organisms, including tibiotics are given for ongoing urethritis. Ophthalmol- Chlamydia, Yersinia, Salmonella, Shigella and Campy- ogy referral is essential for uveitis and the arthritis is lobacter species. Reiter s syndrome is a form of reactive usually managed with nonsteroidal anti-inammatory arthritis with the triad of arthritis, uveitis, and urethritis. The few patients who develop a chronic arthritis are treated as for rheumatoid arthritis. Denition An enteropathic arthritis, sacroiliitis, ankylosing Sex spondylitis or rarely hypertrophic osteoarthritis in as- M > F sociation with ulcerative colitis or Crohn s disease. Sex 1:1 Pathophysiology In early synovitis there is intense hyperaemia with in- Aetiology ammatory inltration. Enteropathicarthritisisaseroneg- into a number of chromosomal loci in relation ative non-erosive synovitis. Intra-articular creased cytotoxic T-cell reactions, increased helper steroid injections may be of value. Connective tissue disorders It is thought that these defects may trigger a cascade of events resulting in the production of autoantibod- Systemic lupus erythematosus ies. Prevalence Pathophysiology 40 per 100,000 in United Kingdom, wide geographic The mechanism by which the aetiological factors inter- variation (1:250 American black women). Systemic symptoms include general malaise, Aetiology fever(sometimeshighandswinging)anddepression(see r Genetics: Up to 60% concordance in monozygotic Fig. Currently studies are underway oles, venules and capillaries) pleura and joint capsules. Diffuse proliferative: crescents in Heart (25%): most severe cases (proteinuria, Pericarditis with small effusions casts, renal failure & hypertension) (tamponade is rare), mild myocarditis iii. Mesangial (usually benign and may remain subclinical) Musculo-articular (95%): Small joint symmetrical pain and myalgia are common but joints appear normal on examination. Immune complex deposition in skin at the dermal cardiolipin is a component of the antigenic mixture epidermal junction, kidney and blood vessels. These occur mainly in the r Nonsteroidal anti-inammatory drugs are rst-line deepveinsofthecalf. Arterialthrombosisinthe r Antimalarials are used for systemic symptoms, refrac- cerebral vessels, coronary, renal and mesenteric arter- tory arthritis and skin disease. Cyclophosphamide is more toxic but may be used in severe diffuse proliferative nephritis or severe neu- Investigations ropsychiatric lupus. Prognosis Generally a good prognosis, chronic forms of the disease Management are seen.

Although If all the above criteria are fullled generic zebeta 5 mg with amex arrhythmia recognition course, the patient is diag- patients who full these criteria can be kept alive by ven- nosed as brainstem dead discount zebeta 5mg on line blood pressure medication used for nightmares, and ventilation may be with- tilation, eventually they will die from other causes. Patients with some evidence of brainstem activity may Clinical features still have a very poor prognosis. Death may occur due to In order to diagnose brainstem death several criteria cardiovascular collapse, e. Parkinson s disease and other r There must be no possibility of drug intoxication, movement disorders including any recent use of anaesthetic agents or paralysing agents. Parkinson s disease r Hypothermia should be excluded and body tempera- ture must be >35C. Denition r There must be no signicant metabolic, endocrine or Acommon degenerative disease of dopaminergic neu- electrolyte disturbance causing or contributing to the rones characterised by tremor, bradykinesia, rigidity and coma. This should be carried out by two experienced clinicians (one a consultant, another an experienced registrar or consultant) on two separate occasions 12 hours apart. Age These tests are designed to show that all brainstem re- Prevalence increases sharply with age. There is little known about the aetiology r Nicotine: Some epidemiological evidence suggests a decreased risk in smokers, but that may be due to Macroscopy/microscopy younger death in this group. Loss of pigment from the substantia nigra due to the r Therearesomefamilialforms,particularlyearly-onset death of melanin-containing dopaminergic neurones. Surviving cells contain spherical inclusions called Lewy bodies hyaline centres with a pale halo. Pathophysiology Investigations The substantia nigra is one of the nuclei of the basal Clinical diagnosis, but other parkinsonian syndromes ganglia. Biochemically This includes a multidisciplinary approach for this there is a loss of dopamine and melanin in the striatum chronic disease, including education, support, physio- which correlates with the degree of akinesia. The basal r Levodopa, a dopamine precursor, is the most im- ganglia project via a dopaminergic pathway to the thala- portant agent used. It is given with an peripheral mus and then to the cerebral cortex, where it integrates dopa-decarboxylase inhibitor (such as carbidopa or withthepyramidalpathwaytocontrolmovement. Hence benserazide) to prevent the conversion of l-dopa to it is sometimes called the extrapyramidal system. Lev- Clinical features odopa exerts most effect on bradykinesia and rigidity The features are asymmetrical. It is in- on periods when they have a good response to the creased by emotion and decreased on action. Increased tone alone may cause lead-pipe movements called dyskinesias, or painful dystonias rigidity. These appear to be due to the progressive (slowness of movement) and hypokinesia (reduced degeneration of the neuronal terminals, such that size of movement). When walking there may be a reduced arm ii On/off phenomenon may be treated by increas- swing and increased pill-rolling tremor. There is a loss of postural tral metabolism of l-dopa and dopamine, so giving reexes. These may be considered rst-line treat- prompt the search for another cause of the symp- ment in young patients. They have a neuroprotective toms, as other causes of parkinsonism do not usually effect in vitro. This can be redressed by anticholinergic drugs such as ben- Other causes of Parkinsonism ztropine and procyclidine. They tend only to be used in mild tremor, and they do not help with akinesia or Denition gait. There are certain disorders that mimic idiopathic r Selegiline is a monoamine oxidase B inhibitor which Parkinson s disease, i. There are also specic Parkinson s plus syndromes r Depression is common, difcult to treat and makes where there is evidence of other neurological decit: Parkinson s disease worse. However surgery carries the risk of haem- rioration, with marked postural instability, frequent orrhage or infarction in 4%, with a 1% mortality. In later disease, be- r High frequency deep brain stimulation suppresses havioural changes such as emotional lability and per- neuronal activity. Bilateral subthalamic nucleus stim- sonality changes, disordered sleep and cognitive loss ulation or globus pallidus stimulation is most useful are features, which may lead to the initial diagnosis of in those with difculty with the on-off phenomenon, dementia. Pathophysiology Cerebrovascular parkinsonism is likely to be due to pro- Prognosis gressive loss of dopaminergic neurons due to small vessel The course of Parkinson s disease is very variable. Drugs which interfere with the dopamine path- averagesurvival is 10 years from onset of symptoms. Normally, the number of repeats is less than 35, but once Benign essential tremor this increases to over 36, the gene product called hunt- Denition ingtin causes the disease. It tends protein causes the neuropathological effects, but it is to present in the teens or in the elderly and affects males thought that the mutant protein may cause biochem- and females equally. Thisresults Treatment is often unnecessary, small doses of a adren- in a loss of inhibition of the dopaminergic pathway, ergic blocker such as propranolol or primidone often re- i. Clinical features The disease usually manifests as progressive cognitive impairment and increasing movement disorder. Chorea Huntington s disease consists of jerky, quasi-purposeful and sometimes ex- Denition plosive movements, following each other but itting Genetically inherited progressive chorea and dementia. The disease shows strong geographical variation, with whites having twice the risk of non-whites and those in higher latitudes (i. Investigations r It is thought that there is an abnormal immune re- Genetic analysis is becoming available for pre- sponse, possibly triggered by an unknown viral anti- symptomatictestingbutthisraisesanethicaldilemma,as gen. However, it is important, as many r Genetic predisposition to the disease monozygotic young adults wish to know their status before embarking twins have a 20 40% concordance, whereas siblings upon having a family. Patients and their families should be offered ge- netic testing and counselling where appropriate.

The course of treatment is for ve days with either co-trimoxazole (the preferred antibiotic drug) zebeta 5 mg low price blood pressure medication make you feel better, or if co-trimoxazole is not available generic 10 mg zebeta heart attack medication, give amoxicillin. The doses of co-trimoxazole or amoxicillin depend on the age or weight of the child, and were summarised earlier in Table 35. What dose of co-trimoxazole syrup would you give this child, and for how many days? If any of your non-severe patients She is between 12 months and ve years, so you should give her 7. You need to know about them so you can teach members of your community how they can protect their children and vulnerable adults from acute otitis media, pharyngitis and pneumonia. Control measures, such as the treatment or isolation of cases, are applied after the occurrence of the disease, with the aim of reducing the transmission of the infectious agents to new susceptible people. Feeding children with adequate amounts of varied and nutritious food to keep their immune system strong. Avoiding irritation of the respiratory tract by indoor air pollution, such as smoke from cooking res; avoid the use of dried cow dung as fuel for indoor res. Haemophilus inuenzae type b (Hib) vaccine at 6, 10 and 14 weeks; The dosages, schedules and Hib is one of the ve vaccines in the pentavalent vaccine used in vaccination routes for Hib, Ethiopia. Immunization also increases control, by reducing the reservoir of infection in the community and increasing the level of herd immunity (described in Study Session 1 in Part 1 of this Module). Children with symptoms of acute otitis media should be identied as soon as possible and treated by wicking the pus from the ear, and giving antibiotics to prevent complications such as deafness, meningitis and pneumonia. Children with symptoms of pharyngitis should be referred to a higher level health facility for assessment and treatment. Children with severe pneumonia are at high risk of death, and should immediately be referred to a higher level health facility to save their lives. C Rheumatic heart disease is the result of the heart becoming infected with bacteria. Early diagnosis and treatment Adequate nutrition Immunization against respiratory tract infections Reduction of indoor smoke pollution Coughing or sneezing into a cloth, or turning away from other people 43 Study Session 36 Louse-Borne Diseases: Relapsing Fever and Typhus Study Session 36 Louse-Borne iseases: Relapsing Fever and Typhus Introduction You already learned about the most widespread vector-borne disease in Ethiopia malaria, transmitted by mosquitoes (Study Sessions 5 12 in Part 1 of this Module). Two other vector-borne diseases of public health importance in Ethiopia are the subject of this study session. They are caused by different bacteria, but are transmitted by the same vector the human body louse (plural, lice). The diseases are louse-borne relapsing fever and louse- borne typhus, which are classied as febrile illnesses because the symptoms always include high fever. In this study session, you will learn about the causes, modes of transmission, symptoms and methods of prevention of these diseases. This will help you to identify patients and quickly refer them to the nearest health centre or hospital for specialist treatment. You are also expected to report any cases of these louse-borne diseases to the District Health Ofce, so that coordinated action can be taken to prevent an epidemic from spreading in your community. Learning Outcomes for Study Session 36 When you have studied this session, you should be able to: 36. The human body louse (species name, Pediculus humanus humanus) is commonly found in the clothes, bedding and on the bodies of people living in overcrowded and insanitary conditions, where there is poor personal hygiene. When body lice are found, for example in clothes, the articles are said to be louse-infested. The bites cause an allergic reaction in the person s skin, which becomes inamed and itches, causing the person to scratch the area. Lice are transmitted from person to person during close contact and when sharing bedding in which eggs have been laid. It is one of the epidemic-prone diseases that can cause small, or large-scale epidemics anywhere in Ethiopia, with an estimated 10,000 cases annually. The bacteria multiply in the gut of the louse, but the infection is not transmitted to new hosts when the louse bites a healthy person. Instead, humans acquire the infection when they scratch their bites and accidentally crush a louse, releasing its infected body uids onto their skin. The bacteria enter through breaks in the skin, typically caused by scratching the itchy louse bites. After entering into the skin, the bacteria multiply in the person s blood and they can also be found in the liver, lymph glands, spleen and brain. The symptoms continue for three to nine days, while the immune system of the patient makes antibodies that attach to the bacteria and clear them from the blood, and the patient appears to recover. The numbers of bacteria gradually increase, and four to seven days after recovering from the rst episode of fever, the patient relapses, i. Almost all the organs are involved and there will be pain in the abdomen and an enlarged liver and spleen, in addition to the other symptoms. Without treatment with special antibiotics, 30% to 70% of cases can die from complications such as pneumonia and infection in the brain, leading to coma (a state of deep unconsciousness) and death. Precautions should be taken by you and by health workers in the hospital or health centre, to avoid close contact with a patient with relapsing fever, to prevent acquiring the infection. Louse-borne typhus (also known as epidemic typhus, jail fever or tessibo beshita in Amharic) is similar in many ways to relapsing fever. They are extremely small bacteria called Rickettsia prowazekii (named after two doctors who died of typhus when they were researching into the disease). Louse-borne typhus has caused major epidemics over many centuries, resulting in millions of deaths during war, famine and mass displacement. The Rickettsia bacteria acquired during a blood meal from an infected person multiply in the gut of the louse and pass out of its body in the louse s faeces, which are deposited on the person s skin. The louse bites are itchy and when the person scratches them, the louse faeces are rubbed into breaks in the skin.

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