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Necrotizing enterocolitis has been reported in term neonates receiving octreotide for the treatment of hyperinsulinemic hypoglycemia (6 cases) and chylothorax (2 cases). Special Considerations/Preparation Available in 1-mL single-dose ampules for injection containing 50-, 100-, or 500-mcg, and in 5-mL multiple-dose vials in concentrations of 200 and 1000 mcg/mL. Initial response should occur within 8 hours; tachyphylaxis may occur within several days. Titrate upward as necessary based on reduction in chyle production; dosage increases of 1 mcg/kg/hour every 24 hours have been used. Pharmacology 609 Micormedex NeoFax Essentials 2014 Octreotide is a long-acting analog of the natural hormone somatostatin. It is an even more potent inhibitor of growth hormone, glucagon, and insulin than somatostatin. After subcutaneous injection, octreotide is absorbed rapidly and completely from the injection site. Adverse Effects Vomiting, diarrhea, abdominal distention and steatorrhea may occur. Ampuls should be opened just prior to administration and the unused portion discarded. For subQ injection, use undiluted drug unless dose volume is not accurately measurable. Terminal Injection Site Incompatibility 610 Micormedex NeoFax Essentials 2014 Micafungin. Moreira-Pinto J, Rocha P, Osorio A, et al: Octreotide in the treatment of neonatal postoperative chylothorax: Report of three cases and literature review. Bulbul A, Okan F, Nuhoglu A: Idiopathic congenital chylothorax presented with severe hydrops and treated with octreotide in term newborn. Young S, Dalgleish S, Eccleston A, et al: Severe congenital chylothorax treated with octreotide. In some cases, hypomagnesemia was not reversed with magnesium supplementation and 611 Micormedex NeoFax Essentials 2014 discontinuation of the proton pump inhibitor was necessary. Onset of action is within one hour of administration, maximal effect is at approximately 2 hours. A 2-mg/mL concentration can be prepared by reconstituting up to a total volume of 10 mL with water. The appropriate dose can be administered through a nasogastric or orogastric tube. A suspension made from six 20-mg packets mixed to a final volume of 60 mL (final concentration, 2 mg/mL) was stable under refrigeration for at least 45 days. For nasogastric or gastric tube administration, add 5 mL of water to a catheter-tipped syringe then add contents of 2. Uses Short-term (less than 8 weeks) treatment of documented reflux esophagitis or duodenal ulcer refractory to conventional therapy.

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An additional complication of streptococcal pharyngitis is peritonsillar abscess; this may be noted by asymmetric swelling of the tonsils, shift of the uvula to one side, and palatal edema. It can progress to the point of airway obstruction and requires careful evaluation and appropriate treatment. If the rapid strep test is negative, the second swab may be sent for a throat culture. Rapid test or culture may be positive for streptococcus A (Johansson & Mannson, 2003). Promoting Airway Clearance Until fully awake, place the child in a side-lying or prone position to facilitate safe drainage of secretions. Dried blood may be present on the teeth and the nares, with old blood present in emesis. Providing Family Education Parents may be accustomed to "sore throats" being treated with antibiotics, but in the case of a viral cause antibiotics will not be necessary and the pharyngitis will resolve in a few days. Children may return to day care or school after they have been receiving antibiotics for 24 hours, as they are considered noncontagious at that point. Early bleeding may be identified by continuous swallowing of small amounts of blood while awake or sleeping. Citrus juice and brown or red fluids should be avoided: the acid in citrus juice may irritate the throat, and red or brown fluids may be confused with blood if vomiting occurs. Lymphadenopathy may progress to include the anterior cervical nodes, which may become tender. Croup is also referred to as laryngotracheobronchitis because inflammation and edema of the larynx, trachea, and bronchi occur as a result of viral infection. Inflammation in the larynx and trachea causes the characteristic barking cough of croup. Croup often presents suddenly at night, with resolution of symptoms in the morning. Complications of croup are rare but may include worsening respiratory distress, hypoxia, or bacterial superinfection (as in the case of bacterial tracheitis). Croup is usually managed on an outpatient basis, with only 1% to 2% of cases requiring hospitalization (Leung et al. Nursing Assessment Note the age of the child; children between 3 months and 3 years of age are most likely to present with viral croup (laryngotracheobronchitis). History may reveal a cough that developed during the night (most common presentation) and that sounds like barking (or a seal). Croup is usually diagnosed based on history and clinical presentation, but a lateral neck x-ray may be obtained to rule out epiglottitis. Extensive use of the Hib vaccine since the 1980s has resulted in a significant decrease in the incidence of epiglottitis.


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No significant differences in clinical outcomes using the different products have been seen. All preparations are reported to contain more than 92% IgG monomers and a normal distribution of IgG subclasses. The risk of necrotizing enterocolitis may be increased in term and late preterm infants treated for isoimmune hemolytic jaundice. The manufacturing process of these products now includes a solvent/detergent treatment to inactivate hepatitis C and other membrane-enveloped viruses. Shelf life varies, but is at least 445 Micormedex NeoFax Essentials 2014 2 years, when stored properly. Use immediately once via 5% ready-for-use 50 mg/mL D(Bio Products Infuse within 2 hours if vials are pooled for large doses. Intravenous immunoglobulin and necrotizing enterocolitis in newborns with hemolytic disease. It produces primarily large airway bronchodilation by antagonizing the action of acetylcholine at its receptor site. It is relatively bronchospecific when administered by inhalation because of limited absorption through lung tissue. Adverse Effects Temporary blurring of vision, precipitation of narrow-angle glaucoma, or eye pain may occur if solution comes into direct contact with the eyes. References 448 Micormedex NeoFax Essentials 2014 Fayon M, Tayara N, Germain C et al: Efficacy and tolerance of high-dose ipratropium bromide vs. Optimal dose in neonates has yet to be determined due to differences in aerosol drug delivery techniques, although the therapeutic margin appears to be wide. Uses Anticholinergic bronchodilator for primary treatment of chronic obstructive pulmonary diseases and adjunctive treatment of acute bronchospasm. The combination of ipratropium with a beta-agonist produces more bronchodilation than either drug individually. Each actuation delivers 21 mcg of ipratropium from the valve and 17 mcg from the mouthpiece. References Fayon M, Tayara N, Germain C et al: Efficacy and tolerance of high-dose ipratropium bromide vs. Lee H, Arnon S, Silverman M: Bronchodilator aerosol administered by metered dose inhaler and spacer in subacute neonatal respiratory distress syndrome. Fatal reactions have occurred following the test dose and have 450 Micormedex NeoFax Essentials 2014 occurred in situations where the test dose was tolerated. Pharmacology Iron dextran for intravenous use is a complex of ferric hydroxide and low molecular mass dextran. Adverse Effects No adverse effects have been observed in patients who have received low doses infused continuously. Large (50-mg) intramuscular doses administered to infants were associated with increased risk of infection.

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The specific circumstances can range from the report of a case or series of cases that do not fit the characteristics of any known disorder to a disease that has been thoroughly studied and for which highly accurate and specific diagnostic procedures are available. In the former category would fall the investigation of the condition that now bears the label chronic fatigue syndrome, where a vague collection of nonspecific symptoms was proposed to constitute a previously unrecognized disease entity, which still awaits a consensus regarding its existence. In situations such as these, a first task is formulating at least a provisional case definition in order to In the latter category would fall rabies, where a specific, highly virulent organism has been identified and produces characteristic manifestations. Bruce Fye [The delayed diagnosis of myocardial infarction: it took half a century. Even conditions with different etiologies may nevertheless have the same prognosis or the same response to treatment. Decisions about how far to subdivide categories of what appears to be a single entity depend, therefore, on the difference it may make, the level of knowledge, and our conceptual model. Should cancers be classified according to whether or not an aberrant p53 gene is present? If two cancers of the same site and histologic type have mutations at different loci of p53, should they be classified apart? These two approaches are manifestational criteria and causal criteria [see discussion in MacMahon and Pugh]. Manifestional criteria Manifestational criteria refer to symptoms, signs, behavior, laboratory findings, onset, course, prognosis, response to treatment, and other manifestations of the condition. Defining a disease in terms of manifestational criteria relies on the proposition that diseases have a characteristic set of The term "syndrome" (literally, "running together" [Feinstein, 2001]) is often applied to a group of symptoms or other manifestations that apparently represent a disease or condition whose etiology is as yet unknown. Most chronic and psychiatric diseases are defined by manifestational criteria (examples: diabetes mellitus, schizophrenia, cancers, coronary heart disease). Causal criteria Causal criteria refer to the etiology of the condition, which, of course, must have been identified in order to employ them. Causal criteria are most readily available when the condition is simply defined as the consequences of a given agent or process (e. The other group of conditions where causal criteria are available consists mostly of infectious diseases for which the pathogen is known, e.

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For guidelines related to screening for increased risk for type 2 diabetes (prediabetes), please refer to Section 2 "Classification and Diagnosis of Diabetes. E Patients with prediabetes should be referred to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program to achieve and maintain 7% loss of initial body weight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. B Screening for prediabetes and type 2 diabetes risk through an informal assessment of risk factors (Table 2. Using A1C to screen for prediabetes may be problematic in the presence of certain hemoglobinopathies or conditions that affect red blood cell turnover. See Section 2 "Classification and Diagnosis of Diabetes" and Suggested citation: American Diabetes Association. Prevention or delay of type 2 diabetes: Standards of Medical Care in Diabetesd2018. The 7% weight loss goal was selected because it was feasible to achieve and maintain and likely to lessen the risk of developing diabetes. After several weeks, the concept of calorie balance and the need to restrict calories as well as fat was introduced (6). A maximum of 75 min of strength training could be applied toward the total 150 min/week physical activity goal (6). The individual approach also allowed for tailoring of interventions to reflect the diversity of the population (6). Nutrition showed beneficial effects in those with prediabetes (1), moderate-intensity physical activity has been shown to improve insulin sensitivity and reduce abdominal fat in children and young adults (18,19). In addition to aerobic activity, an exercise regimen designed to prevent diabetes may include resistance training (6,20). Higher intakes of nuts (13), berries (14), yogurt (15), coffee, and tea (16) are associated with reduced diabetes risk. Conversely, red meats and sugar-sweetened beverages are associated with an increased risk of type 2 diabetes (8). As is the case for those with diabetes, individualized medical nutrition therapy (see Section 4 "Lifestyle Management" for more detailed information) is effective in lowering A1C in individuals diagnosed with prediabetes (17). Recent studies support content delivery through virtual small groups (29), Internet-driven social networks (30,31), cell phones, and other mobile devices. However, the strategies for supporting successful behavior change and the healthy behaviors recommended for people with prediabetes are comparable to those for diabetes. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Prevention and management of type 2 diabetes: dietary components and nutritional strategies.


  • Eptadone
  • It can help your doctor decide which treatments you need next.
  • Proctosigmoidoscopy (an examination of the lower bowel)
  • Follow a low-salt diet, which may reduce fluid buildup and swelling.
  • Bronchoscopy -- camera down the throat to see burns in the airways and lungs
  • Disorders present since birth that makes it hard for the body to breakdown bilirubin (such as Gilbert syndrome, Dubin-Johnson syndrome, Rotor syndrome, or Crigler-Najjar syndrome)
  • Norethindrone and ethinyl estradiol (Brevicon, Ortho-Novum 1/35, Modicon, Ortho-Novum 7/7/7, Ovcon)
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The spirometer records the amount and rate of air that is breathed in and out over a specified time. Bronchodilators are used to help open the airways in the lungs and decrease shortness of breath. Inhaled or oral steroids can help decrease inflammation in the airways in some people. This combination treatment resulted in less worsening of symptoms and improved health status and lung function. These activities play an important part in helping a patient maximize their ability to perform daily activities. The minimum length of an effective rehabilitation program varies with insurance coverage but is usually two months; the longer the program continues, the more effective the results. Close to one million persons living in the United States are on long-term oxygen therapy. Lung transplantation is now being done and may be a more readily available option in the future. Racial disparities in who gets transplantations are due, in part, to social determinants of health such as poverty and unequal access to health care. Use of inhaled corticosteroids was associated with a 70 percent increase in risk of hospitalization for pneumonia; those taking the largest dose (equivalent to fluticasone 1,000 micrograms per day or more) were at 2. The death rate due to all causes was not different among pneumonia patients who had or had not inhaled corticosteroids in the recent past. As a longtime leader on tobacco control, Lung Association volunteers and staff advocate for policies at the federal, state and local level that will increase access to smoking cessation programs, protect the public from secondhand smoke, and prevent children from starting to smoke. Such policies include comprehensive state and local smokefree laws, granting the U. Further, the Lung Association continues to work for regulatory changes to facilitate air travel for patients on oxygen therapy. For over 40 years, the American Lung Association has helped millions of patients through its Better Breathers Clubs. These support groups are located throughout the United States and meet regularly to provide peer support and education needed to understand and better manage the disease. These clubs are for adults with all chronic lung diseases, their families and their caregivers. By joining a support group, participants gain a sense of control over their disease and enter a positive cycle: They get out of the house, meet other people and become motivated to take action. The education patients receive in these groups may help them to avoid preventable hospitalizations and emergency room visits. Join the American Lung Association in its advocacy work by visiting lungaction.

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Example: If a procedure correctly identifies 81 of 90 persons with a disease, condition, or characteristic, then the sensitivity of the procedure is: Se = 81/90 = 0. The inverse of sensitivity and specificity are "false negatives" and "false positives". Sensitivity and specificity as defined above suffer from the same limitation that we have noted for percent agreement, that their calculation fails to take account of agreement expected on the basis of chance. Methods for dealing with this limitation have been published (Roger Marshall, "Misclassification of exposure in case-control studies", Epidemiology 1994;5:309-314), but are not yet in wide use. Impact of misclassification the impact of misclassification on estimates of rates, proportions, and measures of effect depend on the circumstances. This example illustrates the dilemma of false positives when studying a rare disease. The false positives and their characteristics will "dilute" or distort the characteristics of any "case" group we might assemble. Hence the emphasis on avoiding false positives through case verification, using such methods as pathological confirmation. Suppose that the participants in this cohort are "exposed", and another similar cohort consists of 1,000 participants who are not "exposed". Assuming that the diagnostic accuracy is not influenced by exposure status, we expect the results for the two cohorts to be as follows: Specificity is of utmost importance for studying a rare disease, since it is easy to have more false positive tests than real cases, identified or not; 6. Bias in the classification of a dichotomous disease typically masks a true association, if the misclassification is the same for exposed and unexposed groups. This will also be the case for nondifferential misclassification of a dichotomous disease variable or of both a dichotomous disease variable and a dichotomous exposure simultaneously. Also, when the misclassified variable has more than two levels, even nondifferential misclassification can produce bias in any direction (because this last point has been emphasized only in recent years and because traditionally the teaching of epidemiology has focused on dichotomous disease and exposure variables, it is not uncommon to hear the maxim "nondifferential misclassification bias is towards the null" without mention of the exceptions). In addition, measurement error for other variables involved in the analysis produces bias in a direction that depends on the relationships of the variables. For example, if we are performing age adjustment and have bias in the measurement of age, then the age adjustment will not completely remove the effect of age. A situation of this type is referred to as information bias in the measurement of a covariable and is discussed in Rothman and Greenland. Direction and extent of bias the importance of being able to discern the direction of the bias and, if possible, to assess its magnitude, is to enable interpretation of the observed data. For example, if a positive association is observed between two factors and the direction of misclassification bias can be shown to be toward the null, then such bias could not be responsible for the finding of a positive association.

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Intake should include all oral and intravenous fluids; output should include urine, stool, and emesis. Food- or waterborne pathogens may cause diarrheal infections in immunocompromised hosts at a smaller inoculum than that needed to infect healthy hosts; they may also cause opportunistic infections. Staphylococcus aureus, Bacillus cereus, and Clostridium perfringens can cause food poisoning. Other causes of diarrhea include medications, such as antiretrovirals, which may cause diarrhea as a side effect (refer to the chapter on antiretroviral treatment for a listing of specific medications associated with diarrhea). Many antibiotics also cause loose stools because of their effect on normal flora, and Clostridium difficile infection may occur in the setting of recent broad-spectrum antibiotic therapy. Inflammatory processes such as celiac sprue (malabsorption syndrome characterized by marked atrophy and loss of function of the small intestinal lining), surgical procedures, and tumors can change the anatomy and function of the intestines and result in diarrhea. Though diagnosis of the exact cause of diarrhea may be difficult, for treatment purposes one can usually divide diarrhea into four clinical types and then manage accordingly: 1. Diarrhea and severe acute malnutrition Assessment Assessment of a patient with diarrhea should include both subjective and objective information. The focus of the assessment should be twofold: to determine the degree of dehydration and to determine the type of diarrhea (acute, dysentery, persistent, or with severe acute malnutrition). Diagnosis of the cause of diarrhea is often difficult because of the many pathogens that produce infection. Whenever possible, appropriate enzyme immunoassays and bacterial, parasite, and special stool stains and cultures should be sent for definitive diagnosis. For management purposes dehydration can be classified as none, some (mild or moderate), or severe (Table 1). As dehydration develops, signs include a sunken fontanel in infants, poor skin turgor, dry mucous membranes, lack of tears, decreased urine output, changes in the level of consciousness, increased heart rate, and decreased weight. Fluid and electrolyte replacement and maintenance are the mainstays of diarrhea management, and the next section lists recommended protocols for giving hydration fluids on the basis of the assessed level of dehydration. Dietary changes may alleviate diarrhea, and high-protein, highcalorie foods that are low in fat and free of lactose and caffeine may be helpful. Support of appropriate nutrition, prevention and treatment of dehydration, and follow-up are the key components of management in all cases of diarrhea. Antimicrobial agents may be indicated for the treatment of diarrhea in some situations but should not be used routinely on an empiric basis. When prescribing antimicrobial agents, one should instruct patients on the importance of finishing all medications prescribed. With patients and caregivers, emphasize good perineal hygiene to prevent skin breakdown and frequent hand washing to prevent transmission of infection. Antidiarrheal medications, such as loperamide, have no practical benefit for children with diarrhea, do not prevent dehydration or improve nutritional status, may have dangerous and even fatal side effects, and should not be given to children younger than 5 years.

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Two types of heat stroke are typically reported-classic heat stroke and exertional heat stroke. Classic heat stroke is normally caused by environmental changes and often occurs during the summer months. Classic heat stroke most often occurs in infants, children, older adults, those with chronic medical illnesses and those who suffer from inefficient body heat-regulation mechanisms-such as those in poor socioeconomic settings with limited access to air conditioning and those on certain medications (e. Typically, classic heat stroke develops slowly, over a period of several days, with persons presenting with minimally elevated core temperatures. Exertional heat stroke is the opposite of classic heat stroke and is experienced more frequently than classic heat stroke. Exposure to factors such as high air temperature, high relative humidity and dehydration increases the risk for developing exertional heat stroke. Responding to Emergencies 343 Heat-Related Illnesses and Cold-Related Emergencies Signs and Symptoms of Heat Stroke Heat stroke is a serious medical emergency. You must recognize the signs and symptoms of heat stroke and give care immediately. The signs and symptoms include: Changes in level of consciousness, including confusion, agitation, disorientation or unresponsiveness. Therefore, if a person has other signs or symptoms of heat stroke, such as an extremely high body temperature, change in level of consciousness, rapid shallow breathing, confusion, trouble seeing, vomiting or seizures, assume heat stroke and call 9-1-1 or the designated emergency number immediately. Care for Heat Stroke Call 9-1-1 or the designated emergency number immediately for heat stroke as it is a life-threatening emergency. While waiting for help to arrive, you will need to immediately cool the person by following these steps: Remove the person from the hot environment. Rapidly cool the body by immersing the person up to the neck in cold water (preferred); douse the person with ice-water-soaked towels over the entire body, frequently rotating the cold, wet towels, spraying with cold water, fanning the person, or covering the person with ice towels or bags of ice placed over the body. Cold-Related Emergencies Frostbite and hypothermia are two types of cold-related emergencies. Hypothermia develops when the body can no longer generate sufficient heat to maintain normal temperature. Frostbite Frostbite is the freezing of body tissues, usually the nose, ears, fingers or toes. It usually occurs in exposed areas of the body, depending on the air temperature, length of exposure and the wind. In deep frostbite, Responding to Emergencies 344 Heat-Related Illnesses and Cold-Related Emergencies both the skin and underlying tissues are frozen. Signs and Symptoms of Frostbite the signs and symptoms of frostbite include: Lack of feeling in the affected area. Skin that appears waxy, is cold to the touch and is discolored (flushed, white, yellow or blue) (Figure 19-6). In more serious cases, blisters may form and the affected part may turn black and show signs and symptoms of deep tissue damage. Care for Frostbite When giving care for frostbite, the priority is to get the person out of the cold.

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Alternatively, a pacifier dipped in sucrose solution can be offered 2 minutes prior to the procedure. Pharmacology 796 Micormedex NeoFax Essentials 2014 Sucrose administration provides a calming effect and reduces acute procedural pain in both preterm and term infants. The potential mechanism of these effects includes activation of the endogenous opioid system through taste receptors on the tip of the tongue. Special Considerations/Preparation Sweet-Ease, a 24% sucrose and water solution, is aseptically packaged in an 15 ml cup with a peel off lid that is suitable for dipping a pacifier or for administration via a dropper. References Lefrak L, Burch K, Caravantes R, et al: Sucrose analgesia: Identifying potentially better practices. Gibbons S, Stevens B: Mechanisms of sucrose and non-nutritive sucking in procedural pain management in infants. Stevens B, Taddio A, Ohlsson A, Einarson T: the efficacy of sucrose for relieving procedural pain in neonates - a systematic review and meta-analysis. Bucher H-U, Moser T, Von Siebenthal K, et al: Sucrose reduces pain reaction to heel lancing in preterm infants: A placebo-controlled, randomized and masked study. Adverse Effects Administration of exogenous surfactants should be restricted to highly supervised clinical settings, with immediate availability of clinicians experienced with intubation, ventilator management, and general care of premature infants. Title Surfactant (Natural, animal-derived) Dose See specific products (beractant, calfactant, or poractant alfa) for dosing and administration information. Treatment of mature infants with respiratory failure due to meconium aspiration syndrome, pneumonia, or persistent pulmonary hypertension. Natural surfactants are more effective than synthetics in reducing pulmonary air leak. There are no significant differences between preparations in chronic lung disease or other long term outcomes. This may be due to hemorrhagic pulmonary edema caused by the rapid fall in pulmonary vascular resistance and resulting increased pulmonary blood flow. After dosing, frequent assessments of oxygenation and ventilation should be performed to prevent postdose hyperoxia, hypocarbia, and overventilation. Uses 800 Micormedex NeoFax Essentials 2014 Treatment of metabolic acidosis, primarily in mechanically ventilated patients with significant hypercarbia or hypernatremia. Monitor for respiratory depression, hypoglycemia, and hyperkalemia when using several doses. Uses Treatment of metabolic acidosis, primarily in mechanically ventilated patients with significant hypercarbia or hypernatremia. Solution Compatibility No data are currently available on solutions and additives.


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