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In developed countries medications 73 buy 25 mg antivert mastercard, the age specific incidence of epilepsy showed a U-shaped pattern treatment 4 ulcer order antivert 25mg otc, with higher rates for children and the elderly (over 65 years) than for adults medicine naproxen 500mg purchase 25 mg antivert fast delivery, whereas in developing countries incidence peaks among children and young adults medicinenetcom medications generic antivert 25 mg line. In most population-based prevalence and incidence surveys treatment wpw generic 25 mg antivert with mastercard, no cause is found and precise diagnosis remains difficult medications hypertension buy antivert 25mg on-line. Epilepsy can be associated with significant morbidity due to the effects of seizures and/or treatment. Epilepsy is associated with stigma and relevant psychological, social, cognitive, and economic repercussions. People with epilepsy commonly encounter problems in the following areas: education; employment; driving; personal development; psychiatric and psychological aspects and social and personal relationships (2). Moreover, it has to be noted that epilepsy may be the manifestation of an underlying pathology. Deaths related to epilepsy may be attributable to underlying disorders (causing a symptomatic epilepsy), or to the epilepsy itself, as in chronic epilepsy. The diagnosis of epilepsy is primarily clinical and based on a detailed description of the events before, during and after a seizure given by the person and/or witness. Seizures are generally described in two major groups: primary generalized seizures (including tonic-clonic seizures) and partial seizures. Given the wide variability in the frequency and severity of seizures of epilepsy syndromes, defining treatment success is not an easy task. No threshold relative to the frequency is mentioned, therefore a frequency of one seizure per year can be regarded as treatmentresistant. The relative efficacy of new compounds has to be inferred by means of systematic reviews and meta-analyses, but such comparative effectiveness research shows a lack of conclusive evidence to determine a prescribing hierarchy accounting for differences in efficacy or tolerability. Systematic reviews and clinical trials considered patients affected by a variety of epileptic syndromes (new onset generalized epilepsy, new onset partial epilepsy, drug-resistant generalized epilepsy and drug-resistant partial epilepsy). Focal seizures data from direct and indirect comparisons show that lamotrigine and carbamazepine provided the best combination of seizure control and treatment failure. Results for generalized epilepsy suggest that valproate might be the best choice: time to 12month remission occurred significantly less rapidly on lamotrigine monotherapy compared to sodium valproate (moderate quality 62 evidence). A Cochrane systematic review published in 2016 compared lamotrigine and carbamazepine. Summary of evidence: harms (from the application) Lamotrigine as add-on (versus placebo) in drug-resistant epilepsy Cochrane reviews found that the addition of lamotrigine to current anticonvulsant therapy increases side effects. The adverse events significantly associated with lamotrigine were: ataxia, dizziness, diplopia, and nausea. Another review, in addition to the adverse events already mentioned, rash and headaches were the other common side effects reported. Other harms: Anti-epileptic drugs have been associated with an increased risk of suicidal behaviour and ideation (24). Lamotrigine during pregnancy: A Cochrane systematic review published in 2016 assessed congenital malformation outcomes in case of monotherapy treatment of epilepsy in pregnancy. This review included prospective cohort controlled studies, cohort studies set within pregnancy registries and randomised controlled trials (25). Children exposed to lamotrigine in utero were not found to be at increased risk for major malformation compared with children born to women without epilepsy and to women with untreated epilepsy. On the other side, children exposed to carbamazepine, phenytoin, and valproic acid were at a higher risk of malformation compared with children born to women without epilepsy and to women with untreated epilepsy. Similarly, children exposed to phenobarbital and topiramate were at a higher risk of malformation compared with children born to women without epilepsy. These data are quite reassuring, although the possibility of occurrence of Stevens-Johnson syndrome (in about one of 1000 cases) should be carefully considered. A total of 40 cases of aseptic meningitis occurring in adults and paediatric patients taking lamotrigine were reported from 1994 to 2009, out of over 46 million prescriptions dispensed (31). Other considerations: Topiramate and lamotrigine are the two drugs with the broadest indications, both in pediatric and adult populations. It also noted that lamotrigine has been reported to be a valid alternative as monotherapy to carbamazepine and valproate. The Committee recommended that a comparative effectiveness and safety review of lamotrigine with other alternatives. Addition of lamotrigine compared wiht adding placebo in people with drug-resistant epilepsy characterised by generalised seizures. Double-blind, placebo-controlled study of lamotrigine in primary generalized tonic-clonic seizures. Lamotrigine versus carbamazepine monotherapy for epilepsy: an individual participant data review. Efficacy and Tolerability of Antiepileptic Drugs in Patients with Focal Epilepsy: Systematic Review and Network Meta-analyses. Valproic Acid versus Lamotrigine as First-line Monotherapy in Newly Diagnosed Idiopathic Generalized Tonic -Clonic Seizures in Adults - A Randomized Controlled Trial. A randomized, double-blind comparison of antiepileptic drug treatment in the elderly with new-onset focal epilepsy. Monotherapy treatment of epilepsy in pregnancy: congenital malformation outcomes in the child. Lamotrigine use in pregnancy and risk of orofacial cleft and other congenital anomalies. The impact of enzyme-inducing antiepileptic drugs on antiretroviral drug levels: a case-control study. Strongyloidiasis Is globally distributed and is endemic in the tropics and subtropics (1, 2). In low- and middle-income countries, strongyloidiasis is endemic; children are at highest risk of chronic infection. Parasitic worm infections are associated with malnutrition, impaired growth, and cognitive development of children and poor school performance. This will be obtained by treating at least 75% of the children in endemic areas (an estimated 873 million) (3). Summary of evidence: benefits (from the application) Strongyloidiasis the application presented the results of a 2016 Cochrane systematic review (8) that includes four studies comparing ivermectin versus albendazole. However, the review noted that this result was based on only two trials with a small number of participants (n=94). Belizario et al (11) and Knopp et al (13) reported that albendazole-ivermectin is not more effective at eliminating A. One study evaluated the efficacy of albendazole-ivermectin against hookworm infections (13). The results indicated that the co-administration is more effective at curing hookworms than albendazole alone. The application concluded that the evidence demonstrates ivermectin to be a highly efficacious treatment of strongyloidiasis, with greater efficacy than albendazole, mebendazole and thiabendazole and increased efficacy in children under 5 years of age. Zaha et al (18) found significant liver abnormalities in two ivermectin dosage groups. The abnormalities were mild, transient and not clinically important in both groups. For example, when administered to subjects with high Loa loa microfilariaemia, ivermectin has been associated with severe adverse reactions such as neurological signs, encephalopathy and coma (22). In case of confirmed loiasis hyper-endemicity alternative treatment schemes should be considered. Between 2007 and 2015, there have been over 33 million tablets of ivermectin administered with albendazole in the lymphatic filariasis programme. This corresponds to approximately 11 adverse events per one million treatments, without taking into account drugs administered before 2007 or in 2016. Sixty three resulted in death (likely due to causes other than ivermectin itself). Full assessment of the health status of individuals before treatment to exclude sick individuals is recommended (7). It is recommended that ivermectin not be administered to children less than 90 cm tall or weighing less than 15kg, pregnant women, lactating women in the first week after birth and severely ill individuals. Other considerations: Committee Recommendations: N/A the Expert Committee acknowledged the favourable benefit to harm ratio, and the public health impact of ivermectin in the treatment of intestinal helminith infections. It may be used in combination with albendazole for treatment of soil-transmitted helminthiasis. Soil-transmitted helminthiases: eliminating soil-transmitted helminthiases as a public health problem in children: progress report 2001-2010 and strategic plan 2011-2020 Geneva: World Health Organization; 2012. Global numbers of infection and disease burden of soil transmitted helminth infections in 2010. Preventive chemotherapy in human helminthiasis - Coordinated use of anthelminthic drugs in control interventions: a manual for health professionals and programme managers Geneva: World Health Organization; 2006. Ivermectin versus albendazole or thiabendazole for Strongyloides stercoralis infection. A comparative trial of a single-dose ivermectin versus three days of albendazole for treatment of Strongyloides stercoralis and other soil-transmitted helminth infections in children. Datry A, Hilmarsdottir I, Mayorga-Sagastume R, Lyagoubi M, Gaxotte P, Biligui S, et al. Treatment of Strongyloides stercoralis infection with ivermectin compared with albendazole: results of an open study of 60 cases. A comparison of the efficacy of single doses of albendazole, ivermectin, and diethylcarbamazine alone or in combinations against Ascaris and Trichuris spp. Albendazole and mebendazole administered alone or in combination with ivermectin against Trichuris trichiura: a randomized controlled trial. Efficacy and safety of albendazole plus ivermectin, albendazole plus mebendazole, albendazole plus oxantel pamoate, and mebendazole alone against Trichuris trichiura and concomitant soil-transmitted helminth infections: a four-arm, randomised controlled trial. A randomized, double-blind, multicenter clinical trial on the efficacy of ivermectin against intestinal nematode infections in China. Randomised placebo-controlled comparison of ivermectin and albendazole alone and in combination for Wuchereria bancrofti microfilaraemia in Haitian children. A randomized double-blind placebo-controlled field trial of ivermectin and albendazole alone and in combination for the treatment of lymphatic filariasis in Ghana. Treatment of co-infection with bancroftian filariasis and onchocerciasis: a safety and efficacy study of albendazole with ivermectin compared to treatment of single infection with bancroftian filariasis. The Expert Committee included clinical infection syndromes requiring antibiotics that are commonly encountered globally. The main focus was on empiric treatment choices for common, important (mostly) community-acquired infections that are broadly applicable in the majority of countries. As a general rule, alternative options for allergy were not considered by the Expert Committee when discussing first and second choice medicines for each syndrome. Severity of infection was considered when relevant to differentiate choices and help optimize antibiotic selection. Empiric therapy for each clinical infection syndrome includes first and second choice of antibiotics. The first choice antibiotics are those generally recommended based on available evidence and are usually narrow spectrum agents with positive benefit-to-risk ratios and low resistance potential. Second choices are more broad spectrum antibiotics with a less favourable benefit-to-risk ratio and higher resistance potential. Hence while there is considerable overlap between the two lists, there will be inevitable differences as well, including the names of antibiotic groupings. Cefixime is listed as a second-choice option for acute invasive bacterial diarrhoea/dysentery and Neisseria gonorrhoeae. Given its remarkably long halflife, azithromycin carries the higher risk of resistance among the macrolides. Clarithromycin is listed as a first-choice option for Helicobacter pylori, community acquired pneumonia (severe), and as a second-choice option for pharyngitis. Overuse of carbapenems has been associated with increasing prevalence of infections due to resistant organisms. This group was identified in order to improve targeted access according to available recommendations and reduce the risk of development of resistance to these last-resort antibiotics. For example the Committee noted that allergy skin testing on all patients before penicillin use is required in some regions and recommended strongly against routine use of this practice. This practice is unnecessary, and it drives the use of broader spectrum antibiotics, such as cephalosporins and macrolides, leading to increased levels of bacterial resistance. Regular and prolonged shortages of antibiotics on the Access list are a threat to responsible antibiotic use, as they force clinicians to use broader spectrum antibiotics that are sometimes less efficacious and more toxic for patients. The Expert Committee noted the development of the key principles of access and stewardship: Antibiotic stewardship is a strategy aimed at ensuring that antibiotics are used responsibly. Responsible antibiotic use is a balance between best efficacy for the patient, and minimization of the risk of adverse effects, both for the patient (classical adverse events, C. Antibiotic stewardship is a behaviour change strategy, and is thus a complex and system-wide intervention. Antibiotic stewardship programmes should use a combination of interventions, in all settings (primary care, hospitals), and at all levels (local, national, international). A single intervention is not enough, multiple interventions must be associated, and adapted to the local context. These programmes can have a positive impact, provided that sufficient resources are made available in a sustainable manner, with strong political and institutional support. However, disseminating recommendations at a local or national level is not enough, and a detailed and long-term implementation plan must be rolled out in order to bring change. Longterm monitoring of indicators is of course necessary to assess the impact of the stewardship programme, and to adapt it.
For the real number crunchers medicine 7253 pill antivert 25 mg low price, here are the statis tics: Close contacts medications knee cheap 25mg antivert with mastercard, such as household members symptoms quitting tobacco generic 25 mg antivert free shipping, of someone with pulmonary tuberculosis have a 30% chance of being infected chapter 7 medications and older adults order antivert 25 mg mastercard. Tiny tubercles (as the granulomas are called) are often too small to be seen even on chest X-ray medicine 257 cheap 25mg antivert mastercard. Sometimes the chest film will suggest recent infection by showing hilar lymph node enlarge ment or calcifications medications bad for your liver buy cheap antivert 25 mg line. Primary Tuberculosis 1) Mycobacterium tuberculosis is usually transmit ted via aerosolized droplet nuclei from the aerosolized respiratory secretions of an adult with pulmonary tuberculosis. This adult will shower the air with these secretions when he coughs, sings, laughs, or talks. Here there will be a small area of pneumoni this with neutrophils and edema, just like any bacterial pneumonia. As cell-mediated immunity develops, 1) the infection can be contained so that the patient will not even realize he was infected, or 2) it can become a symptomatic disease. A Ghon focus accom panied by perihilar lymph node calcified granulomas is called a Ghon, or Ranke, complex. These groups do not have as powerful a cell-me diated immune system as do healthy adults, so the organisms are not suppressed. Even if un treated, the majority of these persons will control the in fection and have healing by encapsulation of the organisms in granulomas, often with calcification. Occa sionally, infection will not be contained and the person will become overtly ill with worsening pulmonary and/or disseminated disease. In severe untreated cases the lung infiltrates will advance to lung necrosis, forming holes in the lungs or cavities. Overt or manifest primary tuberculosis: Large caseous granulomas develop in the lungs or other organs. In the lungs the caseous material eventually liquifies, is extruded out the bronchi, and leaves behind cavitary lesions, shown here with fluid in the cavities (called "cavitary lesions with air-fluid levels" on chest X-ray). The infection can occur in any of the organ systems seeded during the primary infection. It is presumed that a temporary weakening of the immune system may precipitate reactivation. The organ systems that can be involved in tuberculosis: 1) Pulmonary tuberculosis: this is the most com mon site of reactivation tuberculosis. The infection usually occurs in the apical areas of the lung around the clavicles. It normally reactivates in the upper lobe because oxygen tension is the highest there, due to decreased pulmonary circulation, and Mycobacterium tuberculosis is an aerobic bacterium. Clinically, the patients usually present with a chronic lowgrade fever, night sweats, weight loss, and a pro ductive cough that may have blood in it. This slow ero sive infection occurs as the host macrophages and T-cells battle to wall off the bacteria. Whenever you have an infection of any organ system, tuberculo sis will be somewhere on your differential diag nosis list. The treatment and control of tuberculosis is compli cated and will be discussed in the mycobacterial antibi otics chapter (See Chapter 19). Despite this he managed to elude authorities and travel on more than one international flight. Just like the old days before effective antibi otics, surgery is often required to remove the focus of in fection. It is impossible to grow this bacterium on artificial media; it has only been grown in the footpads of mice, in armadillos, and in monkeys. The World Health Organizations estimates there are around 2 million persons infected with Mycobacterium lep ra e worldwide, with the majority of cases in 6 coun tries: India, Brazil, Burma, Indonesia, Madagascar, and Nepal. Infection occurs when a person (who for unknown reasons is susceptible) is exposed to the respiratory secretions or, less likely, skin lesions of an infected individual. The clinical manifestations of leprosy are dependent on 2 p henomena; 1) the bacteria appear to grow better in cooler body temperatures closer to the skin surface. Cell-mediated immunity once again plays an impor tant role in the pathogenesis of this disease. The cellular immunity that limits the spread of the bacteria also causes inflammation and granulomas, particularly in skin and nerves. The nasal cartilage can be destroyed, creating a saddlenose deformity, and there is inter nal testicular damage (leading to infertility). Most peripheral nerves are thickened, and there is loss of sensation in the extremities in a glove and stocking distribution. The inability to feel in the fin gers and toes leads to repetitive trauma and secondary infections, and ultimately contraction and resorption of the fingers and toes. Tuberculoid leprosy: the macrophage gob bling up the Mycobacterium leprae acid-fast rods demon strates the high cell-mediated resistance of tuberculoid leprosy. The delayed hypersensitivity reaction is intact, so the lepromin skin test is usually positive. The patient demonstrates localized superficial, unilateral skin and nerve involvement. Non-motile * Remember, mycolic acids are also found in Nocardia (which also is acid fast) 1. Cord factor: only found in virulent strains (May be responsible for release of tumor necrosis factor (cachecti n), causing weight loss) 8. Mycobacteria g row and use the carbon, allowing early detection (in 1 -2 weeks) even before colon ies can be see n. M iddle and lower lung nodular and bronchiectatic disease i n middle-aged female non-smokers. Skin, nerves, eyes and testes i nvolved bilaterally: m ultiple skin lumps and bumps, leonine facies, saddle nose, peripheral neuropathy, digit absorption, blindness and infertility in men (from testicular damage) B. Dapsone (type 1 & type 2) Can occur with treatment (see leprosy drug text for details) on artificial lab media; Can only be cultured in certain animals, such as m ice foot pads, armadillos or monkeys 2. Common cause of Fever of clarithromycin, rifampin or rifabutin, and ethambutol 2. Pulmonary disease: usually requ i res surgery combined with antibiotics for cure (need susceptibilities to guide therapy). Macrolides (clarith romycin, azith romycin), combined with intravenous agents (amikacin, cefoxitin, o r imipenem). Two agents with in vitro activity: amikacin, ciprofloxacin, sulfonamides, clarith romycin, etc. It measures the ability of the host to mount a delayed hypersensitivity reaction against antigens of Mycobacterium leprae. This test is more prognostic than diagnostic and is used to place patients on the immuno logic spectrum. It usually presents in one of two ways; 1) as upper lung cavitary disease, predominantly in male smokers, or 2) as lower and middle lung involvement with bronchiectasis and nodular infiltrates in middle aged non-smoking women. In this group it is felt that these women have some as yet undefined underlying predis position. Healthy immunocompetent persons rarely develop disease despite continued, likely daily, exposure. The incidence of disease due to these organ isms has been increasing, likely due to increased aware ness and improved laboratory diagnosis. These patients often present with unexplained fevers, weight loss, diarrhea, and general malaise, with an elevation of alkaline phosphatase on their routine labs. Recommended Review Articles: Diagnosis and Treatment of Disease Caused by Nontuberculous Mycobacteria: the Official Statement of the American Thoracic Ma Z, Lienhardt C, et al. The Mycoplasmataceae are the tiniest free-living organ isms capable of self-replication. Their only protective layer is a cell membrane, which is packed with sterols (like cholesterol) to help shield their cell organelles from the exterior environ ment. Due to the lack of a rigid cell wall, Mycoplasmat aceae can contort into a broad range of shapes, from round to oblong. The lack of a cell wall explains the ineffectiveness of antibiotics that attack the cell wall (penicillin, cephalosporin), as well as the effectiveness of the antiri bosomal antibiotics erythromycin and tetracycline. There are 2 pathogenic species of Mycoplasmat aceae, Mycoplasma pneumoniae and Ureaplasma urealyticum. Diagnostic tests include: 1) Cold agglutinins: Patients infected with Mycoplasma pneumonia can develop monoclonal IgM. Penicillin and cephalosporin fail to tear down the cell membrane, while they successfully destroy the cell wall of a nearby gram-positive Streptococcus. Mycoplasma pneumoniae Mycoplasma pneumoniae causes a mild, self-limited bronchitis and pneumonia. It is the number one cause of bacterial bronchitis and pneumonia in teenagers and young adults. Following transmission via the respiratory route, this organism attaches to respiratory epithelial cells with the help of protein Pl (an adhesin virulence factor). After a 2-3 week incubation period, infected patients will have a gradual onset of fever, sore throat, malaise, and a persistent dry hacking cough. This is referred to as walking pneumonia, because clinically these patients do not feel very sick. Chest X-ray reveals a streaky infiltrate, which usually looks worse than the clinical symptoms and physical exam suggest. Most symptoms resolve in a week, although the cough and infiltration (as seen on X-ray) may last up to 2 months. Although Mycoplasma is a bacterium, the nonproductive cough and the streaky infiltrate on the chest X-ray are more consis tent with a viral (atypical) pneumonia (see Chapter 13, page 1 15). They develop by the first or second week of the Mycoplasma pneumoniae infection, peak 3 weeks after the onset of the illness, and slowly decline over a few months. After placing this tube on ice, the blood will clump together if the patient has developed the cold agglutinin antibodies. Amazingly, when you lift the tube out of the ice, the clumped blood will unclump as it warms in the palm of your hand. A fourfold rise in antibody titer between acute and convalescent samples is diagnostic of a recent infection. These media must be rich in choles terol and contain nucleic acids (purines and pyrim idines). After 2-3 weeks, a tiny dome-shaped colony of Mycoplasma will assume a "fried-egg" appearance. Cultured colonies of Mycoplasma pneumoniae, the most significant human pathogen in this genus, do not form a halo. Again, be cause the Mycoplasma have no cell wall, the {:l-lactam antibiotics do not work. The mainstays of treatment for Mycoplasma pneumoniae are the macrolides (azithromycin, clarithromycin), tetracyclines (doxycy cline) and quinolones (ciprofloxacin, levofloxacin). We call these drugs "atypical coverage" since they cover the atypical bacteria Mycoplasma, Legionella, and Chlamydia, which in addition to viral pneumonia all cause atypical pneumonia (atypical pneumonia was so named because the penicillins did not work for these pneumonias). Smallest bacteria capable of growth & reproduction outside a living cell (smaller than some vi ruses. Mycoplasma, as it produces Tiny colonies when Ureaplasma urealyticum is part of the normal flora in 60% of healthy sexually active women and commonly infects the lower urinary tract, causing urethritis. Urethritis is characterized by burning on urination (dysuria) and sometimes a yellow mucoid discharge from the urethra. Neisseria gonorrhoeae and Chlamydia trachomatis are the other 2 bacteria that cause urethri this (see Chapter 13, page 1 14). Ureaplasma urealyticum can be identified by its ability to metabolize urea into ammonia and carbon dioxide. Acute respiratory infection due to Mycoplasma pneumoniae: current status of diagnostic methods. Chest X-ray will show patchy i nfiltrates that look worse than physical exam and a d ry, non-productive hacking cough (doxycycline) 3. Dome-shaped colonies with 'fried egg" appearance or "mulberry" appearance (in the case of Mycoplasma pneumoniae) 2. Fortunately, scien tists have continued to develop new types of penicillins, as well as other antibiotics that are able to overcome most of the bacterial defenses. You will see later that changing the antennae, adding another antenna, or building a basement will create new types of penicillin with differing spectrums of activity and potencies. You will recall (see Chapter 1) that b oth gram-po sitive and gram-negative bacteria possess peptidoglycans in their cell walls. These are composed of repeating disac charide units cross-linked with amino-acids (peptides). The penicillin must evade the bacterial defenses and penetrate the outer cell-wall layers to the inner cyto plasmic membrane, where the transpeptidase enzymes are located. Because penicillin binds to transpeptidase, this enzyme is also called the penicillin-binding protein. Resistance to Beta-Lactam Antibiotics Bacteria defend themselves from the penicillin family in 4 ways. Gram-positive bacteria and gram-negative bacteria use different mechanisms: 1) One way that gram-negative bacteria defend themselves is by preventing the penicillin from pene trating the cell layers by altering the porins. Remember that gram-negative bacteria have an outer lipid bilayer around their peptidoglycan layer (see Chapter 1). The antibiotic must be the right size and charge to be able to sneak through the porin channels, and some penicillins cannot pass through this layer. Because gram-positive bacteria do not have this perimeter defense, this is not a defense that gram-positives use.
Infantswith meconium aspiration may develop persistent pulmo naryhypertensionofthenewbornwhichmaymakeit difficulttoachieveadequateoxygenationdespitehigh pressure ventilation (see below for management) medicine januvia cheap 25mg antivert with mastercard. Transient tachypnoea of the newborn Thisisbyfarthecommonestcauseofrespiratorydis tressinterminfants symptoms 5 days past ovulation cheap 25mg antivert visa. The condition usually settles within the first day of life but can take several days to resolve completely symptoms whiplash buy antivert 25 mg low cost. Infants with respiratory distress will usually require 172 investigationtoidentifyanyinfection symptoms sleep apnea buy discount antivert 25mg line. Persistent pulmonary hypertension of the newborn this lifethreatening condition is usually associated withbirthasphyxia treatment carpal tunnel buy generic antivert 25mg online,meconiumaspiration 4d medications order antivert 25 mg on-line,septicaemia or respiratory distress syndrome. Asaresultofthehighpulmonary vascular resistance, there is righttoleft shunting withinthelungsandatatrialandductallevels. In contrast, congenital viral infections and earlyonset infection with Listeria 1 2 3 Neonatal medicine 173 4 Box 10. Theriskofearlyonsetinfectionisincreasedifthere hasbeenprolongedorprematureruptureoftheamni otic membranes, and when chorioamnionitis is clini callyevidentsuchaswhenthemotherhasfeverduring labour. Theseverityoftheneonatalpresentationdependson the duration of the infection in utero. Up to half of infants born to mothers who carry groupBstreptococcusarecolonisedontheirmucous membranesorskin. Nosocomially acquired infections are an inherent risk in a neonatal unit,andallstaffmustadherestrictlytoeffectivehand hygienemeasurestopreventcrossinfection. Inneona tal intensive care, the main sources of infection are indwelling central venous catheters for parenteral nutrition,invasiveprocedureswhichbreaktheprotec tivebarrieroftheskin,andtrachealtubes. Characteristicfeatures aremeconiumstainingoftheliquor,unusualinpreterm infants, a widespread rash, septicaemia, pneumonia andmeningitis. This can be removed by applying silver nitrate while protecting the surrounding skin to avoid chemical burns,orbyapplyingaligaturearoundthebaseofthe exposedstump. Mortalitydueto localiseddiseaseislow,but,evenwithaciclovirtreat ment, disseminated disease has a high mortality with considerablemorbidityafterencephalitis. Women with a history ofrecurrentgenitalinfectioncanbedeliveredvaginally as the risk of neonatal infection is low and maternal treatment before delivery minimises the presence of virusatdelivery. A more troublesome discharge with redness of the eye may be due to staphylococcal or streptococcal infection and can be treated with a topicalantibioticeyeointment,e. Purulent discharge with conjunctival injection and swellingoftheeyelidswithinthefirst48hoflifemay beduetogonococcalinfection. Chlamydia trachomatis eye infection usually presents with a purulent discharge, together with swellingoftheeyelids(Fig. Hypoglycaemia Hypoglycaemiaisparticularlylikelyinthefirst24hof lifeinbabieswithintrauterinegrowthrestriction,who are preterm, born to mothers with diabetes mellitus, 1 2 3 Neonatal medicine 175 4 10 Neonatal medicine are largefordates, hypothermic, polycythaemic or ill foranyreason. High concentrationintravenousinfusionsofglucoseshould begivenviaacentralvenouscathetertoavoidextrava sationintothetissues,whichmaycauseskinnecrosis and reactive hypoglycaemia. If there is difficulty or delayinstartingtheinfusion,orasatisfactoryresponse is not achieved, glucagon or hydrocortisone can be given. Mostare inheritedpolygenically,buttheymaybepartofasyn drome of multiple abnormalities. Adenoid ectomyisbestavoided,astheresultantgapbetween theabnormalpalateandnasopharynxwillexacerbate feeding problems and the nasal quality of speech. There may be difficulty feeding and, as the tongue falls back, there is obstruction to the upper airways which may result in cyanotic episodes. Gastrointestinal disorders Oesophageal atresia Oesophageal atresia is usually associated with a tracheooesophageal fistula. It occurs in 1 in3500livebirthsandisassociatedwithpolyhydram nios during pregnancy. There may be aspiration intothelungsofsaliva(ormilk)fromtheupperairways and acid secretions from the stomach. Atresia or stenosisofthebowelandmalrotationaretreatedsur gically, after correction of fluid and electrolyte deple tion. Ingastroschisis,thebowelprotrudesthrough a defect in the anterior abdominal wall, adjacent to Figure 10. For parents of infants born too early, too small or too sick: Available at. Deviation from the normneedstoberecognisedandtheunderlyingcause identified and treated. Childhood phase Thisisaslow,steadybutprolongedperiodofgrowth that contributes 40% of final height. Thyroid hormone, vitamin D and steroids also affect cartilage cell division and bone formation. Fetal this is the fastest period of growth, accounting for about 30% of eventual height. The same sex steroids cause fusion of the epiphyseal growth plates and a cessation of growth. If puberty is early, which is not uncommoningirls,thefinalheightisreducedbecause ofearlyfusionoftheepiphyses(seebelow). Thisphaseischaracterisedbyarapidbutdecelerating growth rate, and accounts for about 15% of eventual height. Standardsfor a population should be constructed and updated every generation to allow for the trend towards earlierpubertyandtalleradultstaturefromimproved childhood nutrition. Thenewchartsarebased on the optimal growth of healthy children totally Calibration checked Head straight, eyes and ears level Gentle upward traction on mastoid process Knees straight Barefoot, with feet flat on floor Heels touching back of board 182 Figure 11. These charts allowforthelowerweightoftotallybreastfedinfants andarethereforelesslikelytoidentifysomebreastfed babiesasunderweightandmayalsoallowearlyiden tification of bottlefed babies gaining weight too rapidly. Thebandson the growth reference charts have been chosen to be twothirds of a standard deviation apart and corre spond approximately to the 25th, 9th, 2nd and 0. Familial Mostshortchildrenhaveshortparentsandfallwithin the centile target range allowing for midparental height. Constitutional delay of growth and puberty these children have delayed puberty, which is often familial, usually having occurred in the parent of the same sex. Mostof thesechildrenwillbenormal,thoughshort,withshort parents, but the further the child is below these cen tiles,themorelikelyitisthattherewillbeapathologi cal cause. Adisadvantageofusingheightvelocitycalculationsis thattheyarehighlydependentontheaccuracyofthe height measurements and so tend not to be used outsidespecialistgrowthunits. Theheightcentileofachildmustbecomparedwith the weight centile and an estimate of their genetic targetcentileandrangecalculatedfromtheheightof their parents. When treated,catchupgrowthrapidlyoccursbutoftenwith a rapid entry into puberty that can limit final height. Congenital hypothyroidism is diagnosed soon after birthbyscreeningandsodoesnotresultinanyabnor malityofgrowth. Growth hormone deficiency this may be an isolated defect or secondary to pan hypopituitarism. Noniatrogenic Cushing syndrome is very unusual in childhood and may be caused by pituitary or adrenal pathology. Inadequatenutritionmaybeduetoinsuf ficient food, restricted diets or poor appetite associ ated with a chronic illness, or from the increased nutritional requirement from a raised metabolic rate. This condition may be extremely difficult to identify,butaffectedchildrenshowcatchupgrowthif placedinanurturingenvironment. Growth hormone treatment of short stature Growth hormone deficiencyistreatedwithbiosynthetic growth hormone, which is given by subcutaneous injection,usuallydaily. Extreme short stature There are a few rare conditions that cause extreme short stature in children. Both con genital adrenal hyperplasia and precocious puberty lead to early epiphyseal fusion so that eventual height is reduced after an early excessive growth rate. Excessiveheight in prepubertal or early pubertal adolescent females and males can be treated with oestrogen therapy andtestosteronetherapy,respectively,toinducepre maturefusionoftheepiphyses,butasitproducesvari able results and has potentially serious sideeffects, it is seldom undertaken. Surgical destruction of the epiphyses in the legs may also be considered in extremecases. During the first few months of life, the head circumference may increase across centiles, especially if small for gestational age. Ifthereisarapid increase in head circumference, raised intracranial pressureshouldbeexcluded. At9monthsofage,hewasrushedtohospitalashe wasunrousablefromprofoundhypoglycaemiasec ondarytothedeliberateadministrationofinsulinby his mother, who had diabetes. Although Tim was takeninto care and had no further hypoglycaemic episodes, his head circumference shows cessation ofgrowth. Asymmetric heads Skullasymmetrymayresultfromanimbalanceofthe growthrateatthecoronal,sagittalorlambdoidsutures, although the head circumference increases normally. Occipitalplagiocephaly,aparallelogramshapedhead with flattening of the back of the skull, is seen with increased frequency since the advice to parents that babiesshouldsleeplyingontheirbacktoreducethe riskofsuddeninfantdeathsyndrome. Preterminfants maydeveloplong,flatheadsfromlyingontheirsides for long periods on the hard surface of incubators unlessprovidedwithasoftsurfacetolieonandtheir head position is changed frequently (see. The sutures of the skull bones start to fuse during infancy but do not finally fuse until late childhood. Itmostoften affects the sagittal suture, when it results in a long narrowskull(Fig. Rarelyitaffectsthelambdoid suturetoresultinskullasymmetry,whichneedstobe differentiated from plagiocephaly, where there is asymmetric flattening of one side of the skull from positionalmoulding. Coronal Sagittal Lambdoid Normal skull sutures Frontal protuberance Fused sagittal suture Figure 11. Females this is usually idiopathic or familial and follows the normal sequence of puberty. Precocious puberty in females is commonly due to the premature onset of normal puberty. In gonadotropin independent cases, the source of excess sex steroids needs to be identified. Premature breast development (thelarche) this usually affects females between 6 months and 2 years of age. Premature pubarche (adrenarche) Thisoccurswhenpubichairdevelopsbefore8yearsof ageinfemalesandbefore9yearsinmalesbutwithno other signs of sexual development. It is most com monlycausedbyanaccentuationofthenormalmatu ration of androgen production by the adrenal gland (adrenarche). In older boys, lowdose intramuscular testosterone will accelerate growth as well as induc ing secondary sexual characteristics. Eventually the target height will bereachedasgrowthinaffectedchildrenwillcontinue forlongerthanintheirpeers. Before the most appropriate sex of rearing is decided upon, the karyotype needs to be determined, adrenal and sex hormone levels measured, and ultrasound of the internalstructuresandgonadsperformed. For this reason, there is a move toward delaying definitive surgery to allow the affected indi vidualtogiveinformedconsenttoanyreconstructive procedures. Its incidence is about 1 in 5000 births, and it is commoner in the offspring of consanguineous marriages. About80%arealsounabletoproducealdos terone, leading to salt loss (low sodium and high potassium)(Fig. Diagnosis this is made by finding markedly raised levels of the metabolic precursor 17hydroxyprogesterone in the blood. After detailed explanation with her parents, she was started on oral hydrocortisone and fludrocortisone replacement therapy and oral saltreplacement(NaCl). Males in a saltlosing crisis require saline,dextroseandhydrocortisoneintravenously. Thelongtermmanagementofbothsexesiswith: Prenataldiagnosisandtreatmentarepossiblewhen a couple have had a previously affected child. Females require surgery to reduce clitoro megalyandavaginoplastybeforesexualintercourseis attempted. Females often experience psychosexual problems, which may relate to the high androgen levelsexperiencedinuteropriortodiagnosis. Even modest energy deprivationduringperiodsofrapidbraingrowthand differentiation is thought to lead to an increased risk of adverse neurodevelopmental outcome. The smaller the child, the less the calorie reserve and the shorter the period the child will be able to withstand starvation. Evensmallbutrecurrentdeficitsin early childhood will lead to a cumulative deficit in weightandheight. Infantsarepronetorecurrent infections, which reduce food intake and increase nutritional demands. Following surgery, after a brief anabolic phase, catecholamine secretion is increased, causingthemetabolicrateandenergyrequirementto increase. Urinarynitrogenlossesmaybecomesogreat that it is impossible to achieve a positive nitrogen balance and weight is lost. After uncomplicated surgery,thisphasemaylastforaweek,butitcanlast several weeks after extensive burns, complicated surgery or severe sepsis.
He continues to smoke 1 package of cigarettes per day and since his bronchitis has improved medications used to treat ptsd buy antivert 25 mg mastercard, he says he is smoking "a bit more treatment 99213 antivert 25 mg otc. For outpatient encounters for diagnostic tests that have been interpreted by a physician medicine used for adhd order antivert 25mg amex, and the final report is available at the time of coding medications made from plasma generic 25mg antivert mastercard, code any confirmed or definitive diagnosis(es) documented in the interpretation medications john frew cheap antivert 25 mg visa. Please note: this differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results treatment quotes images buy antivert 25mg with visa. Examples Diagnostic services only Patient encounter for blood typing prior to outpatient surgery tomorrow. Code: (Answers are located in Appendix B) Therapeutic services Report the diagnosis, condition, problem, or other reason for the encounter when a patient presents for a therapeutic service. Examples Therapeutic services only Patient had an outpatient phlebotomy performed for polycythemia vera. Patients receiving preoperative evaluations only For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01. Examples Preoperative examinations Patient is seen by cardiologist for surgical clearance for upcoming cataract surgery. The patient has a number of chronic medical conditions, including hypertension, diabetes type 2, and chronic atrial fibrillation. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive. The postoperative diagnosis is upper gastrointestinal bleeding, etiology undetermined, K92. The postoperative diagnosis is gastrointestinal bleeding due to gastric ulcer, K25. Prenatal visits There are specific rules for reporting routine prenatal visits that are provided in an outpatient setting. For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis. Examples First pregnancy without complication A 25-year-old female presents for initial prenatal visit. TrueFalse 3 Chronic diseases that are treated on an ongoing basis should be coded and reported as often as the patient receives treatment and care for the chronic conditions. TrueFalse 4 In the physician office it is acceptable to report Z codes as a firstlisted diagnosis. TrueFalse 5 In the outpatient setting it is unacceptable to have a sign or symptom as the first-listed diagnosis. TrueFalse 8 the first-listed diagnosis is defined as the diagnosis that is the most serious. TrueFalse 9 It is acceptable to report a code from Chapter 15 in conjunction with Z34. First-listed diagnosis: Code: 13 Patient is a new patient who was seen for flank pain and diagnosed with a urinary tract infection, and antibiotics were prescribed. First-listed diagnosis: Code: Other diagnosis: Code: 14 Patient was admitted as an outpatient for a left arthroscopic knee procedure to repair old anterior cruciate ligament tear. First-listed diagnosis: Code: 15 Patient is admitted to observation for syncope. First-listed diagnosis: Code: Other diagnosis: Other code: 17 Patient is seen by pulmonologist for surgical clearance for upcoming surgery. Patient has emphysema and is scheduled to have an endarterectomy for severe carotid stenosis on the right. First-listed diagnosis: Code: Other diagnosis 1: Other code 1: Other diagnosis 2: Other code 2: 18 Patient had an outpatient cystoscopy. Section I of the Guidelines includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Within your learning activities, the number that appears to the left of the guideline is the number of the guideline as listed in the Official Guidelines for Coding and Reporting. If you begin your I-10 coding using these steps, you will develop good coding habits that will last throughout your career. It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. Diagnosis: Index: Stroke, due to vertebral artery occlusion Stroke (main term) I63. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable. Examples Three-Character Code Diagnosis: Infectious colitis Index: Colitis (acute) (catarrhal) (chronic (noninfective) (hemorrhagic) - see also Enteritis K52. Integral Part of a Disease Process Example 1 Diagnosis: Index: Tabular: Code: Fever and shortness of breath due to pneumonia Pneumonia J18. Integral Part of a Disease Process Example 2 Diagnosis: Abdominal pain that is exacerbated by eating. Index: Ulcer, ulcerated, ulcerating, ulceration, ulcerative stomach (eroded) (peptic) (round) K25. Not an Integral Part of a Disease Process Example 1 Diagnosis: Index: Tabular: Code: Index: Tabular: Dehydration and pneumonia Pneumonia J18. Not an Integral Part of a Disease Process Example 2 Diagnosis: Ascites and cirrhosis of the liver Index: Cirrhosis, cirrhotic (hepatic) (liver) K74. It would be incorrect to assume that the cirrhosis of the liver was due to alcohol because this was not stated in the diagnosis statement. Multiple coding for a single condition In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. According to the Guideline for acute and chronic conditions, if the condition has separate subentries with the same indentation level for acute and chronic in the Index of I-10, code both the acute and chronic condition, with the acute listed first followed by the chronic condition. Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. Sequelae of complication of pregnancy, childbirth and the puerperium See Section I. Application of 7th characters for Chapter 19 Late effects codes are not located in a separate chapter in the Tabular. The residual is reported first and then the late effects code is assigned to indicate the cause of the residual or late effect of the burn. Only one code is necessary to report a sequela (S) of a scalp abrasion because when reporting S00. In these cases you will need to report the resulting condition with a separate code and the cause (sequela) with a separate code. It may be evident at the time of the acute illness or it may occur months after an injury. For example, a patient who has had a stroke may develop right-sided hemiparesis (paralysis of one side) and aphasia (loss of ability to communicate). If the medical documentation indicates that the patient has two different conditions that are both included in one diagnosis code, report the diagnosis code only once. The medical necessity for all services to this patient was the pneumonia diagnosis. When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate. Other body parts and organs are singular in physiology; for example, bladder, spine, and aorta. Laterality is not a component for code selection in pneumonia, but laterality is a component for code selection for neoplasms of the lung. Laterality is usually straightforward, but as you become more adept at coding, you will see that there are some complex laterality situations. In other instances, bilaterality can be reported with a single code, for example, H52. Chapter 4, learning objective review Review the Chapter Learning Objectives located at the beginning of the chapter, then answer the following questions that relate to each objective (Answers are located in Appendix E): 1 A dash (-) at the end of an Alphabetic Index entry indicates what requirement? For example, if a fourth digit is available, you cannot assign only a threedigit code, and if a fifth digit is available, you cannot assign only a four-digit code. TrueFalse 7 It is acceptable to use only the Alphabetic Index to assign I-10 codes. Because infectious and parasitic conditions can affect various parts of the body, the chapter contains a wide variety of codes and complex terminology. Remember: Combination coding is when one code fully describes the conditions and/or manifestations. Examples Combination coding Diagnosis: Candidiasis infection of the mouth Index: Candidiasis, candidal, mouth B37. To locate a causative organism, you locate the main term "Infection" in the Index and then the subterm of "bacterial" followed by the subterm "as cause of disease classified elsewhere," and then the specific organism, which in the example is Escherichia coli. Index: Infection, bacterial, as cause of disease classified elsewhere, Escherichia coli - See also Escherichia coli B96. Infections resistant to antibiotics Many bacterial infections are resistant to current antibiotics. Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance. Antibiotics are used to kill the bacteria that cause disease, but many antibiotics that were historically effective against bacteria are no longer effective. When reporting an infection that is antibiotic resistant, report the infection first followed by Z16. It will require at least three codes to report severe sepsis: a code for the underlying systemic infection, a code from subcategory R65. For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65. Any additional codes for the other acute organ dysfunctions should also be assigned. When severe sepsis develops during an encounter (it was not present on admission) the underlying systemic infection and the appropriate code from subcategory R65. Severe sepsis may be present on admission but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether severe sepsis was present on admission, the provider should be queried. In these instances, report a postprocedural infection first, followed by a code for the specific infection. Sepsis, severe sepsis, and septic shock 1) Coding of Sepsis and Severe Sepsis (a) Sepsis For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41. If sepsis or severe sepsis is documented as associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced first, followed by the code for the resulting infection. When both the associated non-infectious condition and the infection meet the definition of principal diagnosis either may be assigned as principal diagnosis. Only one code from category R65, Symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. Transmission modes are through blood from infected persons and from body fluids of infected mother to neonate. There are extensive Guidelines that must be understood and followed to correctly code neoplasms. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned. Malignant neoplasm of ectopic tissue Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned. Factors influencing health status and contact with health services, Status, for information regarding Z15. Treatment directed at the malignancy If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. Coding and sequencing of complications Coding and sequencing of complications associated with the malignancies or with the therapy thereof are subject to the following guidelines: 1) Anemia associated with malignancy When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for anemia (such as code D63. When the admission/encounter is for management of an anemia associated with an adverse effect of radiotherapy, the anemia code should be sequenced first, followed by the appropriate neoplasm code and code Y84. Primary malignancy previously excised When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. The secondary site may be the principal or firstlisted with the Z85 code used as a secondary code. Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy 1) Episode of care involves surgical removal of neoplasm When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as principal or first-listed diagnosis. If a patient receives more than one of these therapies during the same admission more than one of these codes may be assigned, in any sequence. Factors influencing health status and contact with health services, Encounter for prophylactic organ removal. Malignancy in two or more noncontiguous sites A patient may have more than one malignant tumor in the same organ. It should not be used in place of assigning codes for the primary site and all known secondary sites.
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