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However order levitra extra dosage 40mg erectile dysfunction vascular causes, at least 12 hours before reconstitution of the vaccine purchase levitra extra dosage 40 mg with mastercard erectile dysfunction sample pills, the diluent must be refrigerated between 2°C and 8°C so that the diluent and lyophilised powder are at the same temperature: a temperature difference during reconstitution may reduce 4 vaccine efficacy order 40 mg levitra extra dosage visa erectile dysfunction doctor in mumbai. Dosage and vaccination schedule – Child over 1 year and adult: 2 doses administered at least 2 weeks apart – Shake the vial cheap 60 mg levitra extra dosage with amex erectile dysfunction drugs patents, squirt the suspension into the mouth (1. For young children, the contents of the vial can be drawn up in a syringe and squirted into the mouth. Contra-indications, adverse effects, precautions – Do not administer to children less than one year. If the patient vomits the dose of vaccine, wait for 10 minutes, re-administer the same dose and follow with a larger volume of water. Dosage and vaccination schedule – The 1st dose of vaccine should be administered as soon as possible after exposure, even if the patient seeks medical attention long after exposure (rabies incubation period may last several months). The schedule will depend on the patient’s vaccination status prior to exposure and the route of administration used (follow manufacturer’s instructions). Booster doses are recommended for persons exposed to permanent or frequent contact with the virus. However, at least 12 hours before reconstitution of the vaccine, the diluent must be refrigerated between 2°C and 8°C so that the diluent and lyophilised powder are at the same temperature: a temperature difference during reconstitution may reduce vaccine efficacy. Contra-indications, adverse effects, precautions – No contra-indication (including during pregnancy and breast-feeding). Remarks – Immunocompetent patients are considered as correctly vaccinated against rabies if they present a document confirming pre-exposure vaccination with 3 doses of cell culture rabies vaccine. After delivery, continue vaccination as described in the table above until the required five doses have been administered. Do not freeze – 4 tetAnus AntItoxIn (equIne) ⚠⚠ equine tetanus antitoxin should no longer be used, as there is a risk of hypersensitivity and serum sickness. Tetanus antiserum provides temporary passive immunity against tetanus for 2 weeks. Dosage and duration – Prevention of tetanus Tetanus antiserum is administered in the event of tetanus-prone wounds, e. Child and adult: 1500 Iu as a single dose; 3000 Iu if more than 24 hours has elapsed It is administered as soon as possible after injury, along with the tetanus vaccine, in a separate syringe and injection site. In children between 6 and 9 months, vaccination is only recommended in epidemics, as the risk of virus transmission may be very high. Contra-indications, adverse effects, precautions – Do not administer to patients with history of an allergic reaction to a previous injection of yellow fever vaccine, true allergy to egg, immunodeficiency (e. However, given the severity of yellow fever, the vaccine is administered 4 when the risk of contamination is very high (epidemics, unavoidable travel to regions of high endemicity). However, at least 12 hours before reconstitution of the vaccine, the diluent must be refrigerated between 2°C and 8°C so that the diluent and lyophilised powder are at the same temperature: a temperature difference during reconstitution may reduce vaccine efficacy. There must be no residual powder on hands (use powder-free gloves) and hands must be dry. Rub hands for 20-30 seconds, palm to palm, palm over dorsum, between fingers (fingers interlaced), around the thumbs and nails, until hands are completely dry. Contra-indications, adverse effects, precautions – Do not use if: • hands are visibly dirty or soiled with organic matter (wash hands); • there is residual powder on hands (wash hands); • hands are wet (water dilutes alcohol and impedes drying). Remarks – Dose required and duration of handrubbing may vary depending on the product used. Remarks – Buttocks should be held together for at least 1 minute to ensure retention. If capsules are expelled from the rectum within 30 minutes of insertion, re-administer the treatment. When it is absolutely impossible to transfer a patient to a facility where parenteral antimalarial treatment can be administered, artesunate rectal capsules should be administered once daily until the patient is able to take a 3-day course of an artemisinin-based combination. Child > 12 years Child < 2 years Child 2-12 years and adult 1 part of 25% lotion 1 part of 25% lotion Undiluted Preparation + + 25% lotion 3 parts of water 1 part of water 12 hours (6 hours Contact time 24 hours 24 hours in children < 6 months) – Apply the lotion to the whole body, including scalp, postauricular areas, palms and soles. Contra-indications, adverse effects, precautions – Do not apply to broken or infected skin. In the event of secondary bacterial infection, administer an appropriate local (antiseptic) and/or systemic (antibiotic) treatment 24 to 48 hours before applying benzyl benzoate. In case of ingestion: do not induce vomiting, do not perform gastric lavage; administer activated charcoal. Remarks – Close contacts should be treated at the same time regardless of whether they have symptoms or not. The treatment may be repeated if specific scabies lesions (scabious burrows) are still present after 3 weeks. Remarks – Storage: below 25°C – Once diluted, the solution must be used immediately; do not store the diluted solution (risk of contamination). Therapeutic action – Antiseptic Indications – Antisepsis of umbilical cord in maternity units Presentation – 7. Remarks – Storage: below 25°C – Once open, the mouthwash solution keeps for 4 weeks maximum. Clean medical surfaces, beds, surfaces, equipment Corpses, excreta, devices, equipment, ustensils contaminated with boots surfaces and linen in case of cholera blood and other body in case of cholera (after cleaning) (after cleaning) fluids spills (before cleaning) Concentration 0. Duration – 2 to 4 weeks Contra-indications, adverse effects, precautions – May cause: headache, local skin eruption or pruritus. Dosage and duration – 500 mg vaginal tablet Adult: one vaginal tablet as a single dose, at bedtime – 100 mg vaginal tablet Adult: one vaginal tablet/day for 6 days, at bedtime Contra-indications, adverse effects, precautions – May cause: local irritation; allergic reactions. At least 6 hours must have elapsed since the last administration of dinoprostone before oxytocin can be given. The % w/w is not equal to the % v/v because the mixture of water and alcohol produces a reduction in volume. For example: 40% v/v = 70° proof (British system) = 80° proof (American system) = 40° in French speaking countries. Preparation – Use 70% v/v ethanol, which is more effective than higher concentrations. To obtain 1 litre of 70% v/v ethanol: • take 785 ml of 90% v/v ethanol, or 730 ml of 95% v/v ethanol, or 707 ml of 99% v/v ethanol; • add distilled or filtered water to make up a volume of 1 litre; • leave to cool and top up with water again to bring the volume back to 1 litre (mixing water and ethanol together produces a reaction whereby volume is reduced). Precautions – Do not apply to mucous membranes, wounds or burns: it is painful, irritating and slows the healing process. Remarks – Ethanol can be used for disinfection of non-critical medical items (items that are in contact with intact skin only) that are not soiled by blood or other body fluids. Contra-indications, adverse effects, precautions – May cause: local allergic reaction (rare). However, preferably use the cream on moist lesions and the ointment on dry and scaly lesions. Contra-indications, adverse effects, precautions – Use with caution and under medical supervision in children under 2 years. The first signs of poisoning after accidental ingestion are gastrointestinal disturbances (vomiting, diarrhoea). Preventive treatment of non- infected persons is ineffective and increases the risk of resistance. As a precaution, this product should not be used in humans if an alternative is available. Therapeutic action – Antifungal, weak antiseptic, drying agent Indications – Oropharyngeal candidiasis, mammary candidiasis in nursing mothers – Certain wet skin lesions (impetigo, dermatophytosis oozing lesions) Presentation – Powder to be dissolved Preparation – Dissolve 2. Use – 2 applications/day for a few days Contra-indications, adverse effects, precautions – Do not apply to wounds or ulcerations. In the event of mammary candidiasis, clean the breast before nursing and apply cream after nursing.

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Their edi- torial work over the past several years has helped me refine the ideas in this book cheap levitra extra dosage 60 mg on-line herbal erectile dysfunction pills review. I would also like to thank Chase Echausier cheap levitra extra dosage 60 mg with visa impotence treatment, Rachael Levet cheap levitra extra dosage 40mg without prescription erectile dysfunction family doctor, and Brian Leneghan for their persistence in putting up with my foibles in the production of the manuscript order 40 mg levitra extra dosage lovastatin causes erectile dysfunction, and my assistant, Line Callahan, for her Herculean effort in typing the manuscript. I owe a great debt to the staff at the Cambridge University Press for having the faith to publish this book. Specifi- cally, I want to thank Senior Commissioning Editor for Medicine, Peter Silver, for starting the process, and Richard Marley and Katie James for continuing with the Second Edition. Of course, I am very thankful to my original copy-editor, Hugh Brazier, whose expertise and talent made the process of editing the book actually pleasant. Finally, the First Edition of the book was dedicated to my children: Memphis, Gilah, and Noah. To that list, I want to add my grandchildren: Meira, Chaim, Eliana, Ayelet, Rina, and Talia. George Santayana (1863–1952) Learning objectives In this chapter, you will learn: r a brief history of medicine and statistics r the background to the development of modern evidence-based medicine r how to put evidence-based medicine into perspective Introduction The American health-care system is among the best in the world. Are our citizens who have adequate access to health care getting the best possible care? These questions can be answered by the medical research that is published in the medical literature. When you become an effective and efficient reader of the medical literature, you will be able to answer these questions. This chapter will give you a historical perspective for learning how to find and use the best evidence in the practice of medicine. This is the beginning of a process designed to make you a more effective reader of the medical research literature. The ill person was seen as having a spiritual failing or being possessed by demons. Medicine practiced during this period and for centuries onward focused on removing these demons and cleansing the body and spirit of the ill person. Trephination, a practice in which holes were made in the skull to vent evil spirits or vapors, and religious rituals were the means to heal. With advances in civilization, healers focused on “treatments” that seemed to work. About 4000 years ago, the Code of Hammurabi listed penalties for bad out- comes in surgery. The prevailing medical theories of this era and the next few millennia involved manipulation of various forms of energy passing through the body. It was qi in China, chakras in India, humors in Europe, and natural spirits among Native Americans. Each civilization devel- oped a healing method predicated on restoring the correct balance of these ener- gies in the patient, as described in Table 1. The ancient Chinese system of medicine was based upon the duality of the universe. Yin and yang represented the fundamental forces in a dualistic cosmic theory that bound the universe together. According to the Nei Ching, medical diagnosis was done by means of “pulse diagnosis” that measured the balance of qi (or energy flow) in the body. In addition to pulse diagnosis, traditional Chinese medicine incorporated the five elements, five planets, con- ditions of the weather, colors, and tones. Acupuncture as a healing art balanced yin and yang by insertion of needles into the energy channels at different points to manipulate the qi. For the A brief history of medicine and statistics 3 Chinese, the first systematic study of human anatomy didn’t occur until the mid eighteenth century and consisted of the inspection of children who had died of plague and had been torn apart by dogs. Medical theory included seven substances: blood, flesh, fat, bone, marrow, chyle, and semen. Diet and hygiene were crucial to curing in Indian medicine, and clin- ical diagnosis was highly developed, depending as much on the nature of the life of the patient as on his symptoms. Other remedies included herbal medications, surgery, and the “five procedures”: emetics, purgatives, water enemas, oil ene- mas, and sneezing powders. Anatomy was learned from bodies that were soaked in the river for a week and then pulled apart. Indian physicians knew a lot about bones, mus- cles, ligaments, and joints, but not much about nerves, blood vessels, or internal organs. The Greeks began to systematize medicine about the same time as the Nei Ching appeared in China. Although Hippocratic medical principles are now con- sidered archaic, his principles of the doctor–patient relationship are still followed today. The Greek medical environment consisted of the conflicting schools of the dogmatists, who believed in medical practice based on the theories of health and medicine, and the empiricists, who based their medical therapies on the obser- vation of the effects of their medicines. The dogmatists prevailed and provided the basis for future development of medical theory. In Rome, Galen created pop- ular, albeit incorrect, anatomical descriptions of the human body based primar- ily on the dissection of animals. Most people turned to folk medicine that was usually performed by village elders who healed using their experiences with local herbs. Other changes in the Middle Ages included the introduction of chemical medications, the study of chemistry, and more extensive surgery by those involved with Arabic medicine. Renaissance and industrial revolution The first medical school was started in Salerno, Italy, in the thirteenth century. In the fifteenth century, Vesalius repudiated Galen’s incorrect anatomical theories and Paracelsus advocated the use of chemical instead of herbal medicines. In the six- teenth century, the microscope was developed by Janssen and Galileo and pop- ularized by Leeuwenhoek and Hooke. In the seventeenth century, the theory of 4 Essential Evidence-Based Medicine the circulation of blood was proposed by Harvey and scientists learned about the actual functioning of the human body. The eighteenth century saw the devel- opment of modern medicines with the isolation of foxglove to make digitalis by Withering, the use of inoculation against smallpox by Jenner, and the postulation of the existence of vitamin C and antiscorbutic factor by Lind. During the eighteenth century, medical theories were undergoing rapid and chaotic change. In Scotland, Brown theorized that health represented the con- flict between strong and weak forces in the body. Cullen preached a strict following of the medical ortho- doxy of the time and recommended complex prescriptions to treat illness. Hah- nemann was disturbed by the use of strong chemicals to cure, and developed the theory of homeopathy. Based upon the theory that like cures like, he prescribed medications in doses that were so minute that current atomic analysis cannot find even one molecule of the original substance in the solution. Benjamin Rush, the foremost physician of the century, was a strong proponent of bloodletting, a popular therapy of the time. He has the distinction of being the first physician in America who was involved in a malpractice suit, which is a whole other story. This alluded to the probability of two events being the product of the probability of each, but without explic- itly using mathematical calculations. Among the ancients, the Greeks believed that the gods decided all life and, therefore, that probability did not enter into issues of daily life. The Greek creation myth involved a game of dice between Zeus, Poseidon, and Hades, but the Greeks themselves turned to oracles and the stars instead.

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It is predisposed to by immobility and dation (such as dullness to percussion discount 40 mg levitra extra dosage erectile dysfunction natural supplements, increased vocal viral infections which lead to retention of secretions resonance discount 60 mg levitra extra dosage amex how to avoid erectile dysfunction causes, bronchial breathing) but even if frank con- especially in the lower lobes cheap 60 mg levitra extra dosage fast delivery erectile dysfunction treatment south africa. The infection is centred solidation is not present buy 40 mg levitra extra dosage free shipping prostaglandin injections erectile dysfunction, most patients have tachypnoea on the bronchi and bronchioles and spreads to involve (>20 breaths/minute) and crackles. In atypical pneu- adjacent alveoli, which become consolidated with an monia the signs of consolidation in the lung are often acute inflammatory exudate. Red hepatisation Organisation of the fluid into a fibrin mesh containing red cells, neutrophils and bacteria. Grey hepatisation Clearance of the red blood cells and neutrophils and predomination of macrophages in an attempt to clear the remaining bacteria. Resolution The fibrin meshwork is broken down, neutrophil debris is ingested by macrophages which are cleared through the lymphatics. The air spaces are filled with an acute 6weeks to ensure resolution, and to exclude any un- inflammatory exudate causing the lung to be firm and derlyinglesionsuchascarcinomacausingobstruction. Several identifiable secretions,analgesiaforpleuriticpainwherenecessary stages are seen in a pneumococcal lobar pneumonia andoxygenifthereishypoxia(guidedbyarterialblood (see Table 3. Outcome depends greatly on the age of the patient and r The white cell count will normally demonstrate a neu- concurrent disease (including diabetes mellitus, chronic trophilia. If patients require admission, sputum and renal failure, congestive heart failure and underlying res- blood cultures should be taken and specific serologi- piratory disease such as chronic obstructive pulmonary cal tests are available for Legionella and other atypical disease). If severe sepsis or in a neutropenic patient combination Pseudomonas, Proteus) 60% piperacillin/ tazobactam and gentamicin may be used Strep. Intermediate coexisting chronic disease, hypoxia (PaO2 < 8kPaor ratesoftuberculosisoccurinCentralandSouthAmerica, oxygen saturation < 92%), bilateral or multilobe in- Eastern Europe and Northern Africa. Ascoreof2ormorecorefeaturessuggestaseverepneu- Aetiology monia with indication for initial combined antibiotic M. It is spread by coughing up of live bacilli after invasion of the disease into a main bronchus (open tu- berculosis), which are then inhaled. Approximately 7000 new cases a year in the United r Theemergenceofmultipledrugresistanceduetonon- Kingdom and rising throughout Europe and the United States. Groups particularly at risk include the elderly, the very Age young, alcoholics, immunosuppressed, e. The macrophages Asian sub-continent have a 40 times greater incidence of can phagocytose the organisms, but mycobacterial cell Chapter 3: Respiratory infections 103 wall components interfere with the fusion of the lyso- Secondary tuberculosis somes with the phagocytic vacuole, so that the bacteria r Secondary tuberculosis is a reactivation of infection can survive intracellularly. It may occur at any time from weeks just below the pleura in the apex of the upper lobe or up to years after the original infection. It matory process forms the ‘Ghon focus’ usually just differs from primary infection in its immunopathol- beneath the pleura. The lymph nodes are rarely involved, and there is lymph nodes at the lung hilum, and excite an immune reactivation of the immune response in the tissues. This pattern forms the primary r Inthelung,thebacteriahaveapreferencefortheapices complex with infection at the periphery of the lung (higher pO2), and form an apical lung lesion known and enlarged peribronchial lymph nodes. It begins as a small caseating r The outcome of the primary infection depends on the tuberculous granuloma, histologically similar to the balance between the virulence of the organism and Ghon focus, with destruction of lung tissue and cavi- the strength of the host response (see Table 3. T cells are re-induced by the secondary infec- the host can mount an active cell mediated immune tion, with activation of macrophages, and exactly as response the infection may be completely cleared. Collagen is healing of the apical region with collagen de- is deposited around these, often becoming calcified. This is called a ‘progres- tissue, thinning of the collagen wall and increasing sive primary infection’. Coughing disperses these bacilli into the at- Poor immune system eg Good immune response, e. Without malnutrition, extremes of healthy immunised treatment, extensive caseating lesions develop rapidly, age, intercurrent disease individual leading to a high mortality. This disease is sometimes Use of appropriate antibiotics called ‘galloping consumption’. By that time there may be no evidence of tu- comesinfectedbymiliarydisseminationwithmultiple berculosis elsewhere. If a lesion erodes a pulmonary vein, there may be systemic miliary dissemination, for ex- Clinical features ample to the meninges, spleen, liver, the choroid and 1 Primary tuberculosis is usually asymptomatic, occa- the bone marrow. The hypersensitivity reaction may produce patient mounts a good immune response, organisms atransient pleural effusion or erythema nodosum. The outstanding Chapter 3: Respiratory infections 105 features are fever (drenching night sweats are rare) be normal, as tubercles are not visible until they are and cough productive of mucoid, purulent or blood 1–2 mm. Microscopy Formal culture of material is the only way of accu- The characteristic lesion, the tubercle (granuloma) con- rately determining virulence and antibiotic sensitivity sists of a central area of caseous tissue necrosis within and should be attempted in every case, results may which are viable mycobacteria. It relies on the hypersensitivity reaction, usually heals spontaneously but occasionally may per- and is rarely helpful in the diagnosis of tuberculosis: sist giving rise to bronchiectasis particularly of the i The Tine test and Heaf test are for screening: 4/6 middle lobe (Brock’s Syndrome). If the spots are confluent, logicalfractures,particularlyofthespinetogetherwith the test is positive, indicating exposure. The reaction is read at Investigations 48–72 hours and is said to be positive if the indura- r An abnormal chest X-ray is often found incidentally tion is 10 mm or more in diameter, negative if less in the absence of symptoms, but it is very rare for a than 5 mm. The X-ray shows purified protein derivative this can indicate active patchy or nodular shadowing in the upper zone with infection requiring treatment. In an immunocom- fibrosis and loss of volume; calcification and cavita- promised host (such as chronic renal failure, lym- tion may also be present. Human immunity depends largely on the haemag- niazid, ethambutol and pyrazinamide, and a further glutinin (H) antigen and the neuraminidase (N) antigen 4months of rifampicin and isoniazid alone. Major shifts in these antigenic re- taken 30 minutes before breakfast to aid absorption. Thesecancauseapandemic,whereasantigenicdrift organism is sensitive for a full 6 months to avoid de- causes the milder annual epidemics. Other upper and lower respiratory symptoms to6weeks after birth (without prior skin testing) in ar- may develop. Individuals are infective for 1 day prior to eas with a high incidence of tuberculosis. Less commonly, secondary Five per cent of patients do not respond to therapy, only Staph. Influenza A causes worldwide annual epidemics and is Retrospective diagnosis can be made by a rise in spe- infamous for the much rarer pandemics, the most seri- cificcomplement-fixingantibodyorhaemagglutininan- ous of which occurred in 1918 when ∼40 million people tibody measured 2 weeks apart, but this is usually un- died worldwide. Spread is by respiratory r Bed rest, antipyretics such as paracetamol for symp- droplets. Chapter 3: Respiratory infections 107 r The neuraminidase inhibitors zanamivir and os- emboli, e. Clinical features They are particularly indicated in the elderly, those Patients present with worsening features of pneumonia, with underlying respiratory disease such as chronic usually with a swinging pyrexia, and can be severely ill. Some are manufactured in strates one or more round opacities often with a fluid chickembryosandtheseshouldnotbegiventoanyone level. Routine vaccination is reserved for bronchoscopy may be necessary to exclude obstruction, susceptible people with chronic heart, lung or renal to look for underlying carcinoma, and to obtain biopsies disease,diabetes,immunosuppressionandtheelderly. Echocardiogram should be considered to look for infec- These predications depend on global surveillance or- tive endocarditis. This surveillance depends on viruses being cultured Complication and therefore on nose/throat swabs being taken and Breach of the pleura results in an empyema. Management Lung abscess Posturaldrainage,physiotherapyandaprolongedcourse of appropriate antibiotics to cover both aerobic and Definition anaerobic organisms will resolve most smaller ab- Localisedinfectionanddestructionoflungtissueleading scesses. Largerabscessesmayrequirerepeatedaspiration, to acollection of pus within the lung. Organismswhichcausecav- Definition itation and hence lung abscess include Staphylococcus Thereareessentiallythreepatternsof lungdiseasecaused and Klebsiella. Pathophysiology Aetiology The abscess may form during the course of an acute It is a filamentous fungus, the spores (5 µmindiame- pneumonia, or chronically in partially treated pneu- ter) are ubiquitously present in the atmosphere.

By M. Gunnar. Bethany Bible College.

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