The purpose of using barriers is to reduce the spread of germs to staff and children from known/unknown sources of infections and prevent a person with open cuts buy depakote 250mg line symptoms juvenile rheumatoid arthritis, sores generic depakote 500 mg without a prescription medicine 027, or cracked skin (non-intact skin) and their eyes buy generic depakote 250mg online treatment alternatives, nose, or mouth (mucous membranes) from having contact with another person’s blood or body fluids. Examples of barriers that might be used for childcare and school settings include: - Gloves (preferably non-latex) when hands are likely to be soiled with blood or body fluids. This prevents the escape of bodily fluids rather than protecting from fluids that have escaped. Other examples that most likely would not be needed in the childcare or school setting are: - Eye protection and face mask when the face is likely to be splattered with another’s blood or body fluid. Proper use of safety needle/sharp devices and proper disposal of used needles and sharps are also part of standard precautions. Possible blood exposure Participation in sports may result in injuries in which bleeding occurs. The following recommendations have been made for sports in which direct body contact occurs or in which an athlete’s blood or other body fluids visibly tinged with blood may contaminate the skin or mucous membranes of other participants or staff: Have athletes cover existing cuts, abrasions, wounds, or other areas of broken skin with an occlusive dressing (one that covers the wound and contains drainage) before and during practice and/or competition. Caregivers should cover their own non-intact skin to prevent spread of infection to or from an injured athlete. Hands should be thoroughly cleaned with soap and water or an alcohol-based hand rub as soon as possible after gloves are removed. Wounds must be covered with an occlusive dressing that remains intact during further play before athletes return to competition. The disinfected area should be in contact with the bleach solution for at least 1 minute. If the caregiver does not have the appropriate protective equipment, a towel may be used to cover the wound until an off-the-field location is reached where gloves can be used during the medical examination and treatment. Everyone (childcare staff, teachers, school nurses, parents/guardians, healthcare providers, and the community) has a role in preventing antibiotic misuse. Viruses and bacteria are two kinds of germs that can cause infections and make people sick. Antibiotics are powerful medicines that are mostly used to treat infections caused by bacteria. These drugs cannot fight viruses; there is a special class of medicines called antivirals that specifically fight infections caused by viruses. There are many classes of antibiotics, each designed to be effective against specific types of bacteria. When an antibiotic is needed to fight a bacterial infection, the correct antibiotic is needed to kill the disease- producing bacteria. Anti-bacterial drugs are needed when your child has an infection caused by bacteria. The symptoms of viral infections are often the same as those caused by bacterial infections. Sometimes diagnostic tests are needed, but it is important that your doctor or healthcare provider decide if a virus or bacteria is causing the infection. You need lots of extra rest, plenty of fluids (water and juice), and healthy foods. Some over-the- counter medications, like acetaminophen (follow package directions or your healthcare providers’ instructions for dosage) or saline nose drops may help while your body is fighting the virus. Viral infections (like chest colds, acute bronchitis, and most sore throats) resolve on their own but symptoms can last several days or as long as a couple weeks. When Antibiotics Are Needed Are antibiotics needed to treat a runny nose with green or yellow drainage? Color changes in nasal mucous are a good sign that your body is fighting the virus. If a runny nose is not getting better after 10 to 14 days or if other symptoms develop, call your healthcare provider. Most cases of acute bronchitis (another name for a chest cold) are caused by viruses, and antibiotics will not help. Children with chronic lung disease are more susceptible to bacterial infections and sometimes they need antibiotics. Antibiotics are needed for sinus infections caused by bacteria; antibiotics are not needed for sinus infections caused by viruses. Check with your healthcare provider if cold symptoms last longer than 10 to 14 days without getting better or pain develops in your sinus area. Ear infections can be caused by bacteria or viruses, so not all ear infections need antibiotics. Your healthcare provider will need to assess your symptoms and determine whether antibiotics are needed. Antibiotic resistant bacteria are germs that are not killed by commonly used antibiotics. These bacteria are very difficult to cure and sometimes very powerful antibiotics are needed to treat infections caused by these bacteria. Each time we take antibiotics, sensitive bacteria are killed but resistant ones are left to grow and multiply. When antibiotics are used excessively, used for infections not caused by bacteria (for instance, those caused by viruses), or are not are not taken as prescribed (such as not finishing the whole prescription or saving part of a prescription for a future infection), resistant bacteria grow. Antibiotic resistance is a growing problem throughout the United States – including Missouri. The Missouri Department of Health and Senior Services has seen an increase in antibiotic resistance among bacteria that commonly cause disease in children. An increasing number of these bacteria are resistant to more than one type of antibiotic, making these infections harder to treat. There are three different ways that bacteria become resistant to antibiotics: - Taking antibiotics can increase your chance of developing antibiotic-resistant bacteria. Antibiotics kill the disease-causing bacteria, but they also kill some good bacteria. Some bacteria that have been exposed to the antibiotic have developed ways to fight them and survive. These resistant bacteria not only can cause you to be ill, but you can spread these resistant bacteria to others and they too may become ill. These bacteria can enter your body when you touch these objects and then touch your mouth or nose or eat food with your hands. This happens when the bacteria inside your body share, exchange, or copy genes that allow them to survive the antibiotic. At home and in childcare and school settings, antibacterial (or antimicrobial) products are no better that ordinary soap for preventing infections. Improper use of antibiotics can cause more frequent and possibly more severe illness for you and your family.
Magnetic resonance imaging uses the magnetic proper- ties of protons to generate images of tissues purchase depakote once a day medications known to cause pancreatitis. It has the advantage of not exposing the patient to ion- Incidence ising radiation (particularly important in young infants depakote 500mg free shipping medicine glossary, Third commonest cause of death in Western World (1–2 childrenandpregnantmothers) discount depakote 250mg line symptoms 14 days after iui. Geography Posterior circulation (the vertebral, basilar arteries and Black community, Japanese more common. Risk factors ipsilateral ataxia (loss of co-ordination), contralateral for stroke can be divided into loss of pain and temperature sensation and there may r Intra- or extra-cranial atherosclerosis: In particular be nystagmus, diplopia and an ipsilateral Horner’s syn- hypertension, smoking, hyperlipidaemia, family his- drome. They are predisposed to by hypertension and diabetes, are often asymptomatic but may cause focal neurologi- Pathophysiology cal defects such as weakness of a single limb, or limited Haemorrhagic strokes are discussed elsewhere. The ﬁnal picture may affected, and whether there is temporary or permanent include dementia and a shufﬂing gait which resembles ischaemia and hence infarction. In clinical situations a full neurological examination Clinical features should be performed and a careful cardiovascular ex- Anterior circulation (carotid territory) strokes are the amination in order to reveal any source of embolus or most common, in particular those involving a branch of other predisposing disease. This causes infarction of the motor pathways (at the level of the motor cortex or the Macroscopy/microscopy internal capsule) and usually results in a contralateral r In the ﬁrst 24 hours, there is little macroscopic change. The arm tends to be affected more brain following a stroke is liquifactive necrosis. Struc- than the leg (the motor cortex for the leg is supplied by tural breakdown takes place, the infarcted tissue be- the anterior cerebral artery). Chapter 7: Cerebrovascular disease 297 Macrophages enter the infarct and remove the dead beenshowntohaveimprovedfunctionaloutcomeand tissue, whilst around the edges astrocytes proliferate reduced mortality. Large r Prevention of recurrence: Any risk factors present infarcts cannot be completely replaced and heal as should be treated. Cholesterol-lowering agents (statins) and anti-hypertensive agents have also Investigations r been shown to reduce recurrence. There is a 1–5% risk of stroke or death due to Urinalysis and blood glucose for diabetes mellitus. The artery is clamped with cerebral blood Cardiac investigation: Blood pressure measurement, ﬂowmaintainedbycollateralsupplyorbyashunt. Further investigation such as carotid Prognosis and vertebral angiography may be indicated. Overall, 40% of patients die as the result of their stroke (mainly in the ﬁrst month), 40% are left signiﬁcantly Management disabled and 30% have reasonable recovery. Deﬁnition r Acutely, treat any exacerbating factors such as hy- Non-traumatic focal neurological deﬁcit due to cerebral potension, hypoglycaemia, hyperglycaemia, or severe ischaemia lasting less than 24 hours with a complete hypertension (with caution, to prevent sudden loss clinical recovery. Aetiology/pathophysiology Prevent and treat any complications such as deep vein 90% of transient ischaemic attacks are caused by ex- thrombosis due to immobility, aspiration pneumonia tracranial thromboembolic disease within the great ves- due to disordered swallow, pressure sores and limb sels, the carotid or vertebral arteries, or mural thrombi contractures. The site of the lesion is often tients who are admitted to a dedicated stroke unit have suggested by the clinical pattern. Common symptoms 298 Chapter 7: Nervous system include weakness, numbness, and transient monocular of the perfusion pressure; however, a low oxygen concen- loss of vision (amaurosis fugax) or other visual distur- tration or a blood pressure outside the range will result bance. Shorter periods or less severe episodes lar heart disease, and other risk factors such as hyper- lead to ‘watershed infarction’ of the junctional areas be- tension, arrhythmias, hypercholestrolaemia or diabetes tween the cerebral arteries, in particular the visual cortex mellitus should be sought. The hippocampus is also at risk of dam- clude hypoglycaemia, focal epilepsy (usually with a pre- age as it has a high metabolic demand. Mild cases tend to have an impaired intellect with mem- ory loss and cortical blindness. Severe cases have a pro- Investigations longed comatose state with variable outcome including Theseareasforstroke. Macroscopy There is loss of cortical mass mainly from the white mat- Management ter leading to an atrophic brain. Neurones are replaced All patients should be on an antiplatelet agent such as as- with gliosis by astrocytes. Other treatments include antihypertensives, statin cholestrol lowering agents, and management of cardiac arrhythmias, heart disease or diabetes mellitus. Prognosis Five years after a transient ischaemic attack r Intracerebral haemorrhage 1in6patients will have had a stoke. Spontaneoushaemorrhagemayoccurwithininthebasal ganglia, internal capsule, cerebellum or pons presenting as a stroke. Hypoxic ischaemic brain injury Deﬁnition Incidence Theglobalbraindamageresultingfromafailureoftissue Accounts for 15% of strokes. Aetiology Age Generalised failure of blood ﬂow or oxygenation may Occurs most commonly in the elderly. Aetiology/pathophysiology r Prolonged uncontrolled hypertension is the most Pathophysiology commoncause. Pseudoaneurysmsformonﬁneperfo- The generalised loss of perfusion results in diffuse death rating arteries, these have a tendency to rupture lead- of neurones. Within the range of 80–170 mmHg r Arteriovenous malformations may haemorrhage es- systolic pressure the cerebral blood ﬂow is independent pecially in younger patients. Chapter 7: Cerebrovascular disease 299 r Cerebral hemisphere haemorrhages may be caused Pathophysiology by cerebral amyloid (accounting for 10% of haem- r Extradural bleeds may result from a skull fracture orrhages in people over 70 years of age). Bloodaccumulatesoverdaysorweeks coma are more common in intracerebral haemorrhage. Theremaybefur- ther accumulation of ﬂuid due to the osmotic pressure Macroscopy of the degenerating blood, or further acute bleeds. If the patient survives the haematoma is removed Clinical features by phagocytosis, and replaced by gliosis. Classically the patient has a brief loss of consciousness Management at the time of injury, then a lucid interval followed r Resuscitate as necessary with management of the air- by development of headache, progressive hemipare- way, breathing and circulation. Headache, drowsiness, and confusion in cerebellar bleeds which may cause obstructive hy- (dementia if chronic) are common. Anyrisk factors present, particularly hypertension, should be managed to help prevent recurrence. Subarachnoid haemorrhage Aetiology Deﬁnition Tearingofbloodvesselswhichmaybetraumaticorspon- Spontaneous intracranial arterial bleeds into the sub- taneous. Risk Incidence factors include a tendency to fall and clotting abnormal- 15 per 100,000 per year. Saccular or berry aneurysms arise due to defects in the 2 Oral nimodipine (a calcium-channel blocker) has internal elastic lamina of arteries and occur in 2% of the been shown to reduce mortality. Severe hypertension may junctionsofarteriesonthecircleofWillisorwithitsadja- needtobecontrolledbuthypotensionmustbeavoided cent branches. Common sites include the anterior com- to prevent further loss of perfusion pressure, so pa- municating artery, the posterior communicating artery tients are kept well hydrated with intravenous saline. Most are idiopathic, but 3 In suitable patients surgical or radiological interven- theyareassociatedwithdiseasessuchasarteritis,coarcta- tion for aneurysms takes place a few days later in a tionoftheaorta,Marfan’ssyndromeandadultpolycystic neurosurgical centre: kidney disease. Neurolog- ical signs, papilloedema and retinal haemorrhages may Prognosis be present.
Discussion The discussion includes an interpretation of the data and a discussion of the clinical importance of the results buy generic depakote 250 mg on line treatment interstitial cystitis. It should ﬂow logically from the data shown and incorporate other research about the topic depakote 500 mg lowest price medications interactions, explaining why this study did or did not corroborate the results of those studies purchase depakote 500mg visa medications known to cause pill-induced esophagitis. Unfortunately, this section is often used to spin the results of a study in a particular direction and will over- or under-emphasize certain results. The discussion section should include a discussion of the statis- tical and clinical signiﬁcance of the results, the non-signiﬁcant results, and the potential biases in the study. As the sample size increases, the power of the study will increase, and a smaller effect size will become statistically signiﬁcant. Also, a study with enough subjects may ﬁnd sta- tistical signiﬁcance if even a tiny difference in outcomes of the groups is found. In these cases, the study result may make no clinical difference for your patient. What is important is a change in disease status that matters to the patient sitting in your ofﬁce. A study result that is not statistically signiﬁcant does not conclusively mean that no relationship or association exists. It is possible that the study may not have had adequate power to ﬁnd those results to be statistically signiﬁcant. On the whole, absence of evidence of an effect is not the same thing as evidence of absence of an effect. Conclusion The study results should be accurately reﬂected in the conclusion section, a one-paragraph summary of the ﬁnal outcome. The reader should be aware that pitfalls in the inter- pretations of study conclusions include the use of biased language and incorrect interpretation of results not supported by the data. Studies sponsored by drug companies or written by authors with other conﬂicts of interest may be more prone to these biases and should be regarded with caution. All sources of con- ﬂict of interest should be listed either at the start or at the end of the article. Bibliography The references/bibliography section demonstrates how much work from other writers the author has acknowledged. This includes a comprehensive reference list including all important studies of the same or similar problem. You will be better at interpreting the completeness of the bibliography when you have immersed yourself in a specialty area for some time and are able to evaluate this author’s use of the literature. Be wary if there are multiple citations of works by just one or two authors, especially if by the author(s) of the current study. The New England Journal of Medicine is a great place for medical students to start. It publishes important and high quality studies and includes a lot of correlation with basic sciences. There are also excellent case discussions, review articles, and basic-science articles. Remember, that what you read in the abstract should not be used to apply the results of the study to a clinical scenario. Initially, we will focus on learning how to criti- cally evaluate the most common clinical studies. These skills will help you to grade the quality of the studies using a schema outlined in Appendix 1. Later the book will focus on studies of diagnostic tests, clinical decision making, cost analyses, prognosis, and meta-analyses or systematic reviews. But as for certain truth, no man has known it, for all is but a woven web of guesses. This requires one to develop an effective search strategy for a clinical question. By the end of this chapter you will understand how to write a clinical question and formulate a search of the literature. Once an answerable clinical question is written and the best study design that could answer the ques- tion is decided upon, the next task is to search the literature to ﬁnd the best avail- able evidence. This might appear an easy task, but, unless one is sure of which database to use and has good searching skills, it can be time-consuming, frus- trating, and wholly unproductive. This chapter will go through some common databases and provide the information to make the search for evidence both efﬁ- cient and rewarding. Introduction Finding all relevant studies that have addressed a single question is not an easy task. The exponential growth of medical literature necessitates a systematic 33 34 Essential Evidence-Based Medicine searching approach in order to identify the best evidence available to answer a clinical question. While many people have a favorite database or website, it is important to consult more than one resource to ensure that all relevant informa- tion is retrieved. Developed by the National Library of Medicine at the National Institutes of Health in the United States, it is the world’s largest gen- eral biomedical database and indexes approximately one-third of all biomedi- cal articles. Since it was the ﬁrst medical literature database available for elec- tronic searching, most clinicians are familiar with its use. Due to its size and breadth, it is sometimes a challenge to get exactly what one wants from it. This will be the ﬁrst database discussed, after a discussion of some basic principles of searching. The database selected depends on the content area and the type of question being asked. If search- ing for the answer to a question of therapy or intervention, then the Cochrane Library might be a particularly useful resource. It provides systematic reviews of trials of health-care interventions and a registry of controlled clinical trials. For information at the point of care, DynaMed Essential Evidence Plus and Ganfyd at www. Many would consider these to be essentially on-line text- books and only provide background information. They may have explicit lev- els of evidence and the most current evidence, but are works in progress. To broaden your search to the life sciences as well as conference information and cited articles, the search engines Scopus or ebofScienceshould be consulted. It is easy to surmise that not only is the medical literature growing exponen- tially, but that the available databases and websites to retrieve this literature are also increasing. In addition to the resources covered in this chapter, an addi- tional list of relevant databases and other online resources is provided in the Bibliography. Mortality Intervention Screening Colorectal neoplasms Population Developing effective information retrieval strategies Having selected the most appropriate database one must develop an effective search strategy to retrieve the best available evidence on the topic of interest. This section will give a general searching framework that can be applied to any database.
Fleas on rodents also transmit plague zoonotically – keep the rat population under control and there will be fewer rats to spread the fleas buy discount depakote 250mg on line treatment viral pneumonia. Botulism Symptoms: Blurry vision depakote 250mg with visa medications ok to take while breastfeeding, difficulty speaking and swallowing buy generic depakote 250mg line treatment 3 degree heart block, sore/dry throat, dizziness, and paralysis. Smallpox Symptoms: Fever, rigors (uncontrolled shaking), malaise, headache, and vomiting. As a rule in primitive conditions assume all suspected cases are highly contagious. Brucellosis (Brucella melitensis) Symptoms: Fever, headache, sweating, chills, back pain Primitive treatment: Doxycycline + rifampicin Usually nonfatal. Second line biological agent due to low kill potential but has the potential to overwhelm medical services due to epidemic outbreaks. Encephalomyelitis Symptoms: Fever, headache, severe photophobia (aversion to light). Meliodosis and Glanders (Burkholderia pseudomalleri) Symptoms: Pneumonia with associated septicaemia. Primitive treatment: Ceftazidime for acute infection, doxycycline to prevent recurrence. Psittacosis (Chlamydia psittaci) Symptoms: Atypical pneumonia with fever and cough. Primitive treatment: Doxycycline or Chloramphenicol Human transmission usually from inhaled dust infected with placental tissue or secretions from infected sheep, cows, or goats. Typhus fever (Rickettsia prowazekii) Symptoms: Fever, headaches, chills, generalised pain and rash. Second line bio agent Ricin (technically a chemical agent) Symptoms: Block protein synthesis within the body. This is the support of the body’s organ systems (heart, brain, liver, kidneys) to help them continue to function following damage but is not specifically aimed at treating the underlying injury or disease. It is usually delivered in an intensive care unit and consists of treatments such as oxygen, ventilation, dialysis, fluid therapy, nutrition, and using medications to maintain blood pressure. In an austere situation your ability to deliver supportive care will be minimal and potentially a massive drain on limited resources. Since it is likely any exposure would be the result of a terrorist attack it may be difficult to avoid. If dealing with a patient of suspected chemical agent poisoning ensure you are protected and that the patient is decontaminated. Where - 123 - Survival and Austere Medicine: An Introduction formal decontamination is not possible – remove and dispose of their clothes and wash them down with soap and water. If you suspect a chemical attack try and stay up wind from the location and on the high ground. Chemical agents will be carried by the wind and as most are heavier than air the chemicals will settle in low lying areas. Inside try and find a room with minimal windows (ideally an interior room with no windows), tape cracks around doors and windows and place a wet towel around the base of the door Equipment The single most important piece of equipment is a protective facemask and appropriate filters for all the members of your family. Ensure your filters meet the standard for both biologicals, and organic chemicals, and that you have spares. The following is the Australian commercial standard for mask filters which is the most appropriate for this application: A2B2E2K2 Hg P3. A protective over-suit protects you from liquid and dense vapour contamination on your skin. Usually liquid does not spread over a wide area while vapour can disperse over wide distances. Vapour is poorly absorbed from the skin but it can be if the vapour is dense enough but this is only likely close to the release point. For most people the priority is the purchase of appropriate gasmasks before considering over-suits. If you are unable to afford commercial chemical protective suits consider purchasing those recommended for spraying agricultural chemicals; they do offer the same level of protection but are cheaper, and many nerve agents are based around organophosphate agricultural sprays. Medical preparations In an austere situation Tincture of green soap (or another mild soap) is still the recommended low-tech decontamination agent for suits and bodies. They cause their effects by blocking the breakdown of acetylcholine – a communication chemical between nerves and muscles. When the enzyme, which breaks it down, is blocked, it accumulates, and causes the symptoms of nerve agent poisoning. Treatment: Pre-treatment: This consists of the administration of medication prior to exposure to a nerve agent to minimise the effect of the agent. This binds reversibly to the same receptors to which the nerve agents bind irreversibly helping to reduce their effects. This was tolerated for prolonged periods by troops during Gulf War 1 with minimal minor side effects. If exposure occurs then pre-treatment combined with post-exposure treatment significantly reduces the death rate. Post-exposure treatment: This should be administered immediately upon suspicion of exposure to nerve agents (i. Large amounts of atropine may be required, but the indications and administration are beyond the scope of this book. The dose is titrated against signs of atropinization: dry mouth, dry skin, and tachycardia > 90 min. In the complete absence of medical care and confirmed nerve agent exposure atropine can be continued to maintain atropinization for 24 hours (usually 1-2 mg Atropine 1-4 hourly). Atropine effects are essentially peripheral and it has only a limited effect in the central nervous system 2. Oxime treatment: While atropine minimises the symptoms it does not reverse the enzyme inhibition caused by the nerve agent. By administering oximes this encourages the reactivation of the enzymes required to breakdown the acetylcholine. Different oximes work better with different nerve agents usually a mix of Pralidoxime and Obidoxime is given. Anticonvulsants: In severe exposures there is the risk of seizures leading to serious brain injury. Patients with severe exposures may also require assisted ventilation and suctioning of their airways. If you are able to get access to military autoinjectors then this is ideal first aid/initial therapy. If the patient survives the initial contact then it is likely that the patient will survive.