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By: Randolph E. Regal, BS, PharmD
- Clinical Associate Professor, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan
- Clinical Pharmacist, University of Michigan Health System, Ann Arbor, Michigan
https://pharmacy.umich.edu/people/reregal
New technologies for the acquisition and analysis of medical information will increase the autonomy of new systems muscle relaxant names buy voveran sr 100 mg. During long-term space missions spasms from dehydration order voveran sr with paypal, robotics spasms colon symptoms 100mg voveran sr for sale, expert systems quad spasms after squats cheap 100mg voveran sr mastercard, artificial intelligence, and achievements in the field of computer micro-miniaturization must be used to the fullest extent. Over the course of its almost 40-year history, in-flight medical monitoring has developed into a new scientific discipline, which is exerting significant influence on Earth-based applications (see Chapter 14). But the main point that merits attention is the substantial progress in understanding the problems of health and disease, in space and on 44 Earth. Space medicine and one of its main elements, in-flight medical monitoring, will have a great influence on the development of medicine of the future. Kosmicheskiye polety na korablyakh “Soyuz” [Medical Monitoring and Prognosis of Cosmonaut Health during Flight. Spaceflights on Soyuz Vehicles],” Biomeditsinskiye Issledovaniya [Biomedical Research], Nauka Publishers, Moscow, 1976, pp. Kosmicheskiye polety na korablyakh “Soyuz” [Work and Rest Scheduling for Soyuz Crew members. Spaceflights on Soyuz Vehicles],,” Biomeditsinskiye Issledovaniya, Nauka Publishers, Moscow, 1976, pp. Spaceflights on Soyuz Vehicles],” Biomeditsinskiye Issledovaniya, Nauka Publishers, Moscow, 1976, pp. The safety and success of space flights involving human crews depend not only on the reliability of hardware systems, but also on the performance capacity and general health of each crewmember. Accordingly, one of the main objectives of space medicine is to optimize crew health and performance during all stages of training. Experience with crewed space flights demonstrates clearly that aspects of the space flight environment can cause numerous functional disorders and organic diseases that adversely affect crewmembers’ performance, and 1–4 occasionally can interfere with the accomplishment of program objectives. Space medicine, being a form of preventive medicine, seeks to minimize the risk that such functional disorders, or preclinical organic conditions, will arise before, during, or after space flight. The importance of understanding the types and causes of disorders that could impair the health of crewmembers mandates the analysis of etiological factors that could be present during selection and training, or those that could lead to illness during or after flight. Useful data for such analyses can be obtained in several ways, including assessments of disease incidence during flights, disease incidence over the course of careers or lifespans, or disease incidence in groups exposed to aspects of the space flight environment on Earth. This chapter presents a brief overview of which kinds of factors could be expected to contribute to functional disorders in flight and in other analogous situations, goes on to describe actual episodes of in-flight diseases and injuries, and finally underscores the importance of a comprehensive set of countermeasures in preventing—or at least minimizing the complications of—in-flight medical problems. A Theoretical Assessment of Potential Contributors to Functional Impairment in Space Flight A. Existing Disorders Careful selection procedures, identification and remediation of minor health problems found in cosmonaut candidates before flight, and preventive training all serve to optimize the health of cosmonauts and astronauts 5,6 before, during, and after flight (see Chapters 1 and 2). Nonetheless, even the most sophisticated techniques cannot unfailingly detect every specific function of every organ and system, nor can such techniques predict every potential response to the complex space flight environment. In space, latent insufficiencies of some organs that normally would go unnoticed on Earth because of compensatory mechanisms could respond to the stresses engendered by space flight by producing acute disorders. Health problems caused by exposure to infectious agents, especially during the preflight period, also are a consideration, even for otherwise healthy individuals. All of these factors are associated with some risk of developing functional and somatic disorders during flight, whether arising from latent or undiagnosed health problems or from exposure to adverse space flight factors. Space Flight Factors the numerous, unusual factors to which crews are exposed in space (see Fig. The state of being weightless is probably the most important of the space flight factors, since true weightlessness cannot be achieved on Earth. In microgravity, the human skeleton is no longer exposed to the 7–9 accustomed mechanical stresses, and thus functional loading on body systems is reduced. Musculoskeletal unloading and changes in afferent stimulation, in combination with body-fluid redistribution, cause numerous 10 secondary responses that can interfere with physiological equilibrium and functioning in flight. Half or more of all crewmembers exhibit motor, sensory-motor, and autonomic disturbances early during adaptation 11 to space flight. These disturbances, which diminish gradually over the course of the flight, include impaired orientation; illusions of falling, somersaulting, body rotation and spatial displacement of observed objects; 4,8,12,13 emotional reactions; impaired motor coordination; and space motion sickness. These transient signs and symptoms disappear 4,12 during the first few days of flight, and do not seem to affect crew performance. Other manifestations of fluid redistribution that do affect performance are its effects on the cardiovascular system. Decreases in circulating blood volume, changes in vascular tonus, increases in heart rate, and frequently decreases in blood pressure and cardiac 7,8,14–16 stroke volume all represent a new level of circulatory functioning that is established in space. Debility, changes in immunological status, and metabolic disruptions during long space flights may lead to the development of various functional and organic disorders, particularly acute inflammatory and 1,2,11,12,17,18 allergic conditions. Changes in calcium metabolism, decreases in bone mineralization, and increased calcium excretion diminish the mechanical strength of bone structures and increase the risk of serious traumatic damage to the skeleton and teeth. In summary, long exposure of humans to microgravity is associated with the risk of developing a broad spectrum of functional and organic disturbances, the most likely of which seem to be functional disorders of the cardiovascular and nervous system, inflammatory disorders of various etiologies, and pathological states associated with disruptions in calcium metabolism. Linear acceleration during insertion into orbit and return to Earth can be accompanied by sensations of general heaviness; dyspnea; pain in the chest or abdomen; disruptions in respiration, cardiac activity, and visual 10 function; and loss of consciousness. High-impact accelerations during spacecraft launch and landing can cause serious injuries, especially to musculoskeletal system, and pose a high risk of internal injuries such as penetrating wounds of the thoracic and abdominal cavities with 21 rupture of viscera and blood vessels. Sources of noise on spacecraft include scientific equipment, ventilation systems, motors of life-support system equipment, and the periodic activation of the station’s attitude-control engines. Prolonged exposure to uncomfortable acoustic environments can lead to fatigue of the acoustic system, and at worst can produce hearing loss. Vibration generated by technological equipment, ventilators, and life-support systems seldom reaches 10 levels of physiological significance, and probably is not a cause of disease in flight. Changes in barometric pressure become clinically significant when rapid pressure loss 10 produces symptoms of dysbarism, including aerotitis media, barosinusitis, and altitude meteorism. The rapid drop in barometric pressure resulting from depressurization of emergency vehicles or spacesuits is extremely hazardous, 10 especially if the decompression is explosive. Organs that contain gas, especially the lungs and gastrointestinal tract, expand suddenly during explosive decompression, producing painful pressure on the organ walls as well as 23 vasovagal syncope. In the vacuum created by emergency depressurization of a spacecraft, explosive 10,22 decompression is accompanied by acute hypoxia, which can be lethal. Another hazard associated with sudden loss of barometric pressure is the powerful air currents generated by explosive decompression, which cause objects 22 to fly around at great speed, possibly inflicting severe mechanical injuries. Rapid drops in barometric pressure during flight also can cause decompression sickness, which in space might be expected to be more severe than usual since weightlessness reduces physiological resistance to various adverse effects. Malfunctioning life-support subsystems certainly can affect the composition of the cabin air. Insufficient oxygen produces health disturbances that range from moderate symptoms of hypoxia (irritability, headache, insomnia, and decreased performance) to life-threatening conditions and death. Malfunctions in life-support subsystems also can increase the risk of toxic hazards in the cabin atmosphere through the accumulation of various gaseous contaminants that would be released in open systems. Another issue is the 23,24 potential leakage of toxic substances from onboard engineering and technological systems. Increased levels of toxic substances in the cabin atmosphere could lead to poisoning, with corresponding clinical symptoms. The severity of the potential damage is associated with the crewmember’s initial physiological status, which probably would be weakened by exposure to weightlessness. When overall tolerance to adverse factors is eroded, even a relatively mild exposure to toxins is serious. Although poisoning episodes arising from changes in cabin atmosphere are unlikely, the effects of such hazards can be serious enough to terminate a flight unless the situation can be rectified. Malfunctions in spacecraft or spacesuit thermoregulation subsystems can expose crewmembers to excessively low or high temperatures. Moderate decreases in ambient temperature, especially if humidity is elevated, can cause chilling. Under space flight conditions, the discomfort and other symptoms associated with general or regional chilling are likely to be severe, with muscular activity restricted and regional circulation affected. Another aspect of this issue is local chilling of small areas of the skin by air currents created by the ventilation system, which can cause colds or inflammation of the muscles or peripheral nerves. On the other hand, prolonged exposure to significantly elevated ambient temperatures can lead to systemic overheating. Violations of safety regulations during repair and maintenance work or technological operations, especially those that involve fires, can cause burns of varying severity.
If bilateral spasms 2012 cheap 100mg voveran sr mastercard, neuroimaging is mandatory to muscle relaxant non prescription 100 mg voveran sr otc rule out an rapid deterioration has also been seen to muscle relaxant otc cvs 100 mg voveran sr for sale occur spasms heart buy voveran sr in india. The severity intra-cranial space-occupying lesion; pseudotumour cerebri is of optic neuropathy and the amount of proptosis are not another important differential diagnosis. Though visual feld defects tend to be irreversible, proptosis is often a natural mechanism to decompress the disc oedema usually resolves over several months. When examined at presentation, the optic nerve head may be normal, swollen or even pale. Clinical work-up for evidence of neuropathy includes recording the visual acuity, colour vision and visual felds. Additional tests include measuring the degree of proptosis and lagophthalmos, slit-lamp examination for exposure keratopathy, recording of intraocular pressure and testing of ocular motility. Treatment depends upon the extent of nerve involve ment and is tailored to the individual. In addition to the swelling there are dilated vessels on the disc sur oral steroids with careful monitoring is the norm. These vessels often resolve as the disc swelling abates or can progress tional measures such as sleeping propped up, avoiding to disc neovascularization. Round atrophic lesions in the retinal periphery smoking and eye protection are advised. Neuro-Ophthalmology: Diagnosis If visual loss is not controlled by these measures and Management. If vision Sometimes a picture resembling a central retinal artery oc does not improve within 24–48 hours, orbital decom clusion may be seen if there is damage to the intraorbital pression is required. However, in most cases, traumatic optic Surgery remains an option for patients who cannot be neuropathy affects the canalicular part of the nerve and the given systemic steroids for any reason. In those not consid fundus usually appears normal, with the disc pallor typical ered ft for surgery, or in whom other measures are only of optic atrophy developing after 3–4 weeks. Early onset of partially effective, orbital radiation (2000 rad in 10 divided pallor implies a substantial disruption of the blood supply doses over a fortnight) is an alternative. In most cases, the visual loss is maximum from the time of Radiation Optic Neuropathy impact but can also be delayed by a few hours and progress this delayed effect, which may manifest 1–5 years after over the next few days. Computed tomography helps diagnose radiation therapy, is more likely to occur following radia a fracture of the canal with a bone fragment pressing on the tion therapy to the eyes, orbit, paranasal sinuses, nasophar nerve and the presence of a haemorrhage in the nerve sheath. Visual loss, which is often If either of these conditions is present, surgical intervention is severe, can be acute or gradual. High-dose intravenous corticosteroids (dexametha thy may or may not be evident or present. There is no spe sone 3–5 mg/kg/day or methylprednisolone 20–30 mg/kg/day) cifc or effective treatment. Thermal Burns Treatment should be instituted within 24–48 hours and A rare, delayed type of optic neuropathy has been reported if improvement occurs, oral steroid therapy can be started following thermal burns of the body. If there is was proposed as a pathogenetic factor, as neither septicae no visual improvement within 1–2 days of this high dose of mia nor circulatory failure were found to play a role. Bilat steroids and particularly if there is worsening, presumably eral involvement and a delayed onset 2–3 weeks after the from oedema or haemorrhage within the nerve or canal, initial burn injury were noted. In other burn victims an early optic canal decompression through either a transethmoidal visual loss attributed to diffuse cerebral oedema and hy or transfrontal approach should be performed. Another in poxia with other signs and symptoms of encephalopathy dication for optic canal decompression in such cases is if have also been known to occur. Traumatic Optic Neuropathy When a rotational or shearing force is transmitted to the Congenital Abnormalities of the Optic Disc frontal areas in closed head injuries, damage to the optic nerve can occur. The blow is typically ipsilateral to the Coloboma of the Optic Disc frontal area and usually severe enough to produce a loss of this occurs in two forms, one of which is common and the consciousness. The common form is due to incom forces that may be induced in the relatively immobile cana plete closure of the embryonic fssure, and manifests itself licular portion of the nerve by the movement of the brain as an inferior crescent, resembling the myopic crescent but due to frontal impact. It occurs most com disruption of the nerve fbres or indirect damage by disrup monly in hypermetropic and astigmatic eyes, which often tion of the blood supply. Oedema or haemorrhage can also have slightly defective vision in spite of the correction of induce nerve damage by compressing the nerve within the any error of refraction. In addition, in a fracture of the wall of the optic In coloboma of the disc (or nerve sheath), there is canal, bone fragments can directly exert pressure on the greater failure of the embryonic fssure to close. Rarely, blunt trauma can lead to optic nerve looks large and the vessels have an abnormal distribution, damage in the orbit, producing an optic nerve head appearing only above or irregularly round the edges. An avulsed optic Rarer anomalies related to coloboma are round cavities nerve head is visible ophthalmoscopically as a defect in the (holes) on the disc known as optic disc pits, generally situ pupillary region and may be accompanied by haemorrhage. Chapter | 22 Diseases of the Optic Nerve 371 Another variant is the morning glory disc which re normal disc, also referred to as a double ring sign. It has a central excava vessels on the disc may show anomalous branching tion surrounded by an elevated rim of pink neuroglial tissue (Fig. Sometimes remnants of the sheaths of the hyaloids ves There is an important association between a hypoplastic sels form an excess of fbrous-like tissue on the disc which disc and cerebral malformations, which may include ab extends a short distance along the vessels. Occasionally the sence of the septum pellucidum, congenital hypopituitarism fbrous tissue takes the form of a delicate semi-transparent and agenesis of the corpus callosum. This condition has membrane that covers the disc and appears to be slung from been described following the maternal ingestion of the the vessels. This is sometimes referred to as Bergmeister anticonvulsant phenytoin, which has known teratogenic papilla. Hypoplasia of the Optic Nerve Head Optic Disc Pit the diagnosis of hypoplasia presents little diffculty in the this congenital anomaly appears as a round or oval, grey, extreme case. Adjacent peripapillary retinal pigment mented rim approximately corresponding to the size of a epithelial changes are often seen, and the involved disc is usually slightly larger than the normal disc in unilateral cases. Its exact pathogenesis is unknown but histologically a herniation of rudimentary neuroectodermal tissue in a pocket-like depression within the nerve substance has been demonstrated. The pit usually looks grey or black owing to shadowing of light and patches of pigment from the inclusion of retinal pigmentary epithelium. The fibres decussate at the optic chiasma and travel further along the optic tracts to ter minate in the lateral geniculate bodies. Some fibres leave the optic tracts to terminate in the Edinger-Westphal nucleus in the brain stem to form the sensory afferent limb of the pupillary light reflex. Diseases affecting the optic nerve have great impact on visual acuity and affect all visual functions including colour vision, contrast sensitivity and visual fields. Careful history, detailed examination including testing of pupillary reflexes and visual fields, fundus appearance of the optic nerve head and judicious use of ancillary investigations are important. The David G Cogan Ophthalmic Pathology Collection: A Summary study and teaching collection of clinical ophthalmic cases and their the optic nerve essentially consists of the axons of the reti pathology. Chapter 23 Intraocular Tumours Chapter Outline Tumours of the Uveal Tract 373 Secondary Carcinoma of the Choroid 377 Tumours of the Iris 373 Reticulum Cell Sarcoma 377 Malignant Melanoma of the Ciliary Body 373 Tumours of the Retina 378 Malignant Melanoma of the Choroid 374 Retinoblastoma 378 Intraocular tumours are rare, but of great importance, since Malignant melanoma is the only neoplasm of impor they are usually malignant and endanger the life of the tance met with in the iris but is rare. This is prob lomatous lesion depends on the absence of infammation ably the typical chronological order of events, but and the density of pigmentation. The occasional absence secondary glaucoma may arise sometimes acutely at of pigmentation (amelanotic melanoma) may give rise to an early stage, or be delayed until after extraocular diffculties. Malignant Melanoma of the Ciliary Body Tumours of the Iris A ciliary body melanoma may attain a considerable size It is not uncommon to see irides with dark brown spots (Fig. As a rule these are benign naevi, but occasionally ference with the ciliary muscle. Any increase of size impeded, and conspicuous dilatation of one or two anterior must be watched with suspicion. The growth may invade the the iris of prepubertal children who suffer from neurofbro angle of the anterior chamber when it has the appearance of matosis. Their presence is correlated with age but not with an iridodialysis, a dark crescent showing at the root of the the number of café-au-lait spots, the number of neurof iris; that it is not an iridodialysis is shown by the fact that bromata or the severity of the disease. They are bilateral, no red refex can be obtained through it on illuminating multiple, well defned, dome-shaped gelatinous elevations with the ophthalmoscope and from the absence of a history protruding above the iris surface and ranging from clear to of a blow. They are pathognomonic of be yellowish, but vessels will usually be visible upon the neurofbromatosis.
Social Development Canada muscle relaxant headache buy discount voveran sr 100 mg online, Applied Research Bulletin Volume 3 spasms 1983 youtube discount voveran sr 100mg amex, Number 2 (Summer-Fall 1997) muscle relaxant education cheap 100 mg voveran sr with mastercard, How Do We Know that Times Are Improving in Canada? Dissemination Document Dahlgren and Whitehead and beyond: the social determinants of health in research spasms after stent removal discount voveran sr 100mg without a prescription, policy and service delivery Joint meeting of the Society for Social Medicine and the Cardiff Institute of Society, Health & Ethics, 2005. Converging Technologies for Improving Human Performance: Nanotechnology, Biotechnology, Information Technology and Cognitive Science. Editor, Education and debate for and against direct to consumer advertising is medicalising normal human experience. Erectile dysfunction in general medicine practice: prevalence and clinical correlates. Regulation of prescription medicine advertising in the United States and New Zealand: a consumer perspective, 2005. Opening the medicine cabinet: first report on health aspects of prescription drugs report of the Standing Committee on Health, 2004. Drugs in the news: an analysis of Canadian newspaper coverage of new prescription drugs. Direct-to-consumer prescription drug advertising in Canada: permission by default? For and against: Direct to consumer advertising is medicalising normal human experience. The economics of direct-to-consumer advertising of prescription-only drugs: prescribed to improve consumer welfare? Licit psychostimulant consumption in Australia, 1984-2000: international and jurisdictional comparison. The New Genomics Agenda A Political Epilogue to the Book of Life: Update on Pharmaceutical Multinationals and the Human Genome. Arena Pharmaceuticals Announces Initiation of Phase 2b Clinical Trial of Its Novel Anti-Obesity Compound, 2005. Arena Pharmaceuticals Announces Positive Phase 2 Clinical Trial Results of Novel Anti-Obesity Compound, 2005. Medtronic Buys Transneuronix Medical technology firm buys obesity control device maker for more than $260 million, 2005. Drug Expenditure in Canada 1985 to 2004 National Health Expenditure Database, 2005, 1-55392-596-3. The Standing Senate Committee on Social Affairs, Science and Technology Chair Kirby. The Health of Canadians – the Federal Role Interim Report Volume Two: Current Trends and Future Challenges, 2002. New drug may help soldiers stay awake Doctors unsure of long term effect, 2003, the Ottawa Citizen. Cephalon Files Application for Marketing Approval of New Modafinil Formulation for the Treatment of Children and Adolescents with Attention-Deficit, 2004. The Economist and Plausible Futures Newsletter News and Analysis for Future Studies & Scenario Planning: Human Augmentation. Ritalin, Dexedrine becoming mainstream "study drugs" among college students in British Columbia, 2005. Experimental Pill Boosts Smarts Helps brain cells communicate better with tiredness, 2005. Providing advance notice of significant new and emerging health technologies to the Department of Health, England, 2005. Community Health Needs Assessment: A Guide for First Nations and Inuit Health Authorities, 2000. International Journal for Technology Assessment in Health Care 1997;13(2):186-219. Standing Senate Committee on Social Affairs, Science and Technology Interim Report on the state of the health care system in Canada: the Health of Canadians, the Federal Role Volume Two Current Trends and Future Challenges. Federal/Provincial/Territorial Advisory Committee on Information and Emerging Technologies, 2005. A Report Submitted to the Health Promotion Development Division of Health Canada by Study Team, 1996. Creating a Culture of Evidence-Based Decision Making; Section Evidence-Based Decision Making, 2005. Norwegian guidelines for pharmacoeconomic analysis in connection with applications for reimbursement, 2005. Comprehensive and integral international convention to promote and protect the rights of persons with disabilities, 2005. Ethik und Genetik:Ergebnisse der Umfrage zu Problemaspekten angewandter humangenetik 1994-1996. Quality of life following spinal cord injury: knowledge and attitudes of emergency care providers. Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago. Environmental factors and their role in participation and life satisfaction after spinal cord injury. Quantifying environmental factors: a measure of physical, attitudinal, service, productivity, and policy barriers. Determinants of beliefs about illness: a study of parents of children with diabetes, asthma, epilepsy, and no chronic illness. Patient and parental attitudes toward genetic screening and its implications at an adult cystic fibrosis centre. Which generation is believed to be intellectually superior and which generation believes itself intellectually superior. Variables related to acceptance of disability in persons with spinal cord injuries. Life satisfaction and well-being measures in ventilator assisted individuals with traumatic tetraplegia. Differences between rehabilitation disciplines in views of depression in spinal cord injury patients. Depressed mood in spinal cord injured patients: staff perceptions and patient realities. Quality of life among aging spinal cord injured persons: long term rehabilitation outcomes. Self perceived health status and health-related quality of life of extremely low-birth weight infants at adolescence. Folgen der Anwendung genetischer Diagnostik für behinderte Menschen (Consequences of the Application of Genetic Diagnostics for Disabled People), Expert Opinion for the Study Commission on the Law and Ethics of Modern Medicine of the German Bundestag, 2001. Attitudes toward the prenatal diagnosis of cystic fibrosis: factors in decision making among affected families. Medical geneticists confront ethical dilemmas: cross-cultural comparisons among 18 nations. Ethical problems in prenatal diagnosis: a cross-cultural survey of medical geneticists in 18 nations. Transformational outcomes associated with parenting children who have disabilities. Adults with autism living at home or in non-family settings: positive and negative aspects of residential status. Peer relationships and social and recreational activities among adolescents and adults with autism. Comparison groups in autism family research: Down syndrome, fragile X syndrome, and schizophrenia. Psychological well-being and coping in mothers of youths with autism, Down syndrome, or fragile X syndrome. The effect of quality of the relationship between mothers and adult children with schizophrenia, autism, or down syndrome on maternal well-being: the mediating role of optimism. Cultural context of caregiving: differences in depression between Puerto Rican and non-Latina White mothers of adults with mental retardation. Access to specialty medical care for children with mental retardation, autism, and other special health care needs. Quality of life of adults with mental retardation/developmental disabilities who live with family.
Syndromes
- Slurred speech
- Much less activity than normal (is not sitting up at all or looking around)
- Fluids by IV (to replace fluids lost from vomiting and diarrhea)
- Cough
- Naprofen
- More often for people with diabetes, high blood pressure, heart disease, stroke, or blood flow problems to the legs or feet.
- Hyperthyroidism
- Augmented betamethasone dipropionate (Deprolene)
- Trifluoperazine (Stelazine)
- Central nervous system damage
This type of interaction induces the activation of larger numbers of T cells compared to spasms after stroke discount voveran sr 100 mg otc antigens that are presented in the antigen recognition site infantile spasms 4 months generic voveran sr 100 mg on-line. Tachycardia Rapid beating of the heart infantile spasms 2 month old buy voveran sr 100mg overnight delivery, conventionally applied to muscle relaxant usage voveran sr 100 mg sale rates over 100 per minute. A-8 Toxoid A modified bacterial toxin that has been rendered nontoxic (commonly with formaldehyde) but retains the ability to stimulate the formation of antitoxins (antibodies) and thus producing an active immunity. Vaccinia An infection, primarily local and limited to the site of inoculation, induced in man by inoculation with the vaccinia (coxpox) virus in order to confer resistance to smallpox (variola). On about the third day after vaccination, papules form at the site of inoculation which become transformed into umbilicated vesicles and later pustules; they then dry up, and the scab falls off on about the 21st day, leaving a pitted scar; in some cases there are more or less marked constitutional disturbances. Varicella An acute contagious disease, usually occurring in children, caused by the varicella zoster virus, a member of the family Herpesviridae, and marked by a sparse eruption of papules, which become vesicles and then pustules, like that of smallpox although less severe and varying in stages, usually with mild constitutional symptoms; incubation period is about 14 to 17 days. Zoonosis An infection or infestation shared in nature by humans and other animals that are the normal or usual host; a disease of humans acquired from an animal source. Place the patient in a private room or cohort them with someone with the same infection. Place the patient in a private room or cohort them with someone with the same infection if possible. Fully immunized (completed 6 shot primary series and up-to-date on annual boosters, or 3 doses within past 6 mo): continue antibiotics for at least 30 days. Potential additional antibiotics include one or more of the following: clindamycin, rifampin, gentamicin, macrolides, vancomycin, imipenem, and chloramphenicol. Cutaneous anthrax acquired from natural exposure could be treated with 7-10 days of antibiotics. Ciprofloxacin is a possible alternative, but has been associated with increased relapse rates in animal treatment models. For this reason, most experts feel initial therapy of glanders should be based on proven therapy for the similar disease, melioidosis. Severe Disease: If ceftazidime or a carbapenem are not available, ampicillin/sulbactam or other intravenous beta lactam/beta-lactamase inhibitor combinations may represent viable, albeit less-proven alternatives. A minimum of 10 days of therapy is recommended (treat for at least 3-4 days after clinical recovery). Although not licensed for use in treating plague, gentamicin is the consensus choice for parenteral therapy by many authorities. Alternate therapy or prophylaxis for susceptible strains: trimethoprim-sulfamethoxazole Other fluoroquinolones or tetracyclines may represent viable alternatives to ciprofloxacin or doxycycline, respectively. Significant side effects if administered inappropriately; sterile abscesses if prior exposure/skin testing required prior to vaccination. Initiation of postexposure prophylaxis within 7 days of exposure merely delays incubation period of disease. Tetracyclines are preferred antibiotic for treatment of acute Q fever except in: 1. If evidence of continued disease at parturition, use tetracycline or quinolone for 2-3 weeks. Gentamicin, although not approved for treatment of tularemia likely represents a suitable alternative. Adjust gentamicin dose for renal failure Treatment with streptomycin, gentamicin, or ciprofloxacin should be continued for 10 days; doxycycline and chloramphenicol are associated with high relapse rates with course shorter than 14-21 days. Under special circumstances, if the evidence of exposure is clear in a group of individuals, some of whom have well defined neurological findings consistent with botulism, treatment can be contemplated in those without neurological signs. Antibody response is poor, requires 3-dose primary (one month) and 1-2 boosters (one month apart). Primary series yields antibody response in 77%; 5%-10% of non-responders after boosts. Antibody response is poor, requires 3-dose primary (one month) and 3-4 boosters (one month apart). Immune Globulins For Select Vaccine Adverse reactions (Eczema vaccinatum, vaccinia necrosum, ocular vaccinia w/o keratitis, severe generalized vaccinia): 1. Recommendations for use of smallpox vaccine in response to bioterrorism are periodically undated by the Centers for Disease Control & Prevention. Proper collection of specimens from patients is dependent on the time-frame following exposure. Sample collection is described for “Early post-exposure”, “Clinical”, and “Convalescent/ Terminal/ Postmortem” time-frames. Tiger-top tubes that have been centrifuged are preferred over red-top clot tubes with serum removed from the clot, but the latter will suffice. The first two, along with early post exposure clinical samples, can help identify the agent in time to initiate prophylactic treatment. While the information will most likely be too late for useful prophylactic treatment, this information along with other information may be used in the prosecution of war crimes or other criminal proceedings. However, the sample collection concerns are the same as for during or shortly after a bioaerosol attack and medical personnel may be the only personnel with the requisite training. As in any hazmat situation, a clean line and exit and entry strategy should be designed. If it is possible to have a clean line, then a three person team is recommended, with one clean and two dirty. Aerosol collection during an attack would be ideal, assuming you have the appropriate collection device. Otherwise anything that appears to be contaminated can be either sampled with swabs if available, or with absorbent paper or cloth. Well after the attack, samples from dead animals or human remains can be taken (refer to Appendix F for appropriate specimens). All samples should ideally be double bagged in Ziploc bags (the outside of the inner bag decontaminated with dilute bleach before placing in the second bag) labeled with time and place of collection along with any other pertinent data. National Defense University, Center for Counterproliferation Research, Fredonia Books, 2002 3. Investigation of a ricin-containing envelope at a postal facility- South Carolina, 2003. Greek Fire, Poison Arrows & Scorpion Bombs: Biological and Chemical Warfare in the Ancient World. Missed sentinel case of naturally occurring pneumonic tularemia outbreak: lessons for detection of bioterrorism. Clinical recognition and management of patients exposed to biological warfare agents. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. Increased detection of rickettsialpox in a New York City hospital following the anthrax outbreak of 2001: use of immunohistochemistry for the rapid confirmation of cases in an era of bioterrorism. Biological warfare training: infectious disease outbreak differentiation criteria. A large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars. A field-expedient algorithmic approach to the clinical management of chemical and biological casualties. Medical management of the suspected victim of bioterrorism: an algorithmic approach to the undifferentiated patient. Postal Service workers potentially exposed to Bacillus anthracis District of Columbia, 2001-2002. Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science 2003; 1:97-110. Department of Defense preliminary evaluation of the association of anthrax vaccination and congenital anomalies. Use of anthrax vaccine in response to terrorism: supplemental recommendations of the advisory committee on immunization practices. Complications associated with Brucella melitensis infection: a study of 530 cases.
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