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- Ron and Nancy McFarlane Distinguished Professor and Chair, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
https://pharmacy.unc.edu/news/directory/drhoney/
To confirm the Group’s judgment acne 8th ave purchase benzac without prescription, an informal survey of industry safety experts generated a list of the same or similar topics for which consensus and guidance were requested skin care in your 40s generic benzac 20 gr visa. Another area deemed of high priority but outside the scope of this report skin care with vitamin c purchase benzac with a mastercard, namely risk communication skin care 20s buy benzac 20gr line, was also identified and selected for parallel effort by an independent sub-group. With great affection, upon celebration of his twenty-five years of achievements and of his retirement at the close of 1999, we pay tribute to him through the present work. Background Much progress has been made over the past several years in reducing unnecessary diversity in regulations and guidances among health authorities in the field of pharmacovigilance. As will become clear, these topics represent many obvious as well as subtle issues that affect different aspects of drug safety work. A few topics involved some very complex and controversial issues on which consensus could not be reached with regard to recommending solutions. This has particular relevance to health information, among the more sensitive types of data, and certainly applies to adverse event reports, which often include data that directly identify the subject and/ or the reporter with name, address, national health number, or other overt identifiers. Although current practices throughout the pharmaceutical industry and by regulatory authorities reflect a commitment to protection of personal data, new laws in many countries necessitate some changes in personal-data handling practices. The use of secondary databases, so important to pharmacoepidemiology and retrospective studies in general, may also be affected. For adverse event reporting, an identifiable patient or reporter relates to the existence of a real person that can be verified/validated in some way. Under data protection schemes, the term refers to an ability to associate a data set with a particular person (‘‘trace’’ a person from the data available). They are handled differently from reports arising from clinical trials with regard to expedited and periodic reporting procedures. For example, by international convention, spontaneous reports are always considered to have an implied causal relationship to the subject drug(s). Some argue that valid reports require ‘‘medical confirmation’’ while others regard patient-direct reports as potentially valuable. Is it necessary to translate articles in a ‘‘foreign’’ language, in part or in toto, and under what circumstancesfi In addition to the confidentiality and security of the data, the validity and integrity of the information, and ascertainment of the source of the information — common concerns for any application of the technology — several special issues arise: are companies responsible for ‘‘surfing’’ the Web for safety information on its productsfi Is there an appropriate role for the Internet in disseminating product ‘‘labels,’’ especially safety information, recognizing the usually unavoidable differences between countries’ product informationfi These and other questions are discussed along with specific recommendations for handling drug safety information with this now wellestablished new tool. However, there are many circumstances and applications for which there is a lack of regulatory guidance, which has led to considerable differences in practices among both companies and regulators. How should apparent safety-related data from quality-of-life questionnaires included in studies be handledfi What are the reporting obligations with respect to either isolated case findings or a suspected signal when conducting observational studies or in general when working with data bases. What and how should companies report on pertinent cases from disease-specific and other ‘‘registries’’. A common complication with spontaneous reports arises when there is ancillary information associated with a case report that on review suggests an adverse event other than the intended subject of the reporter’s communication. The proper interpretation and handling of such ‘‘incidental’’ events (as they have come to be known), especially with respect to regulatory reporting, pose a challenge. Insights are provided on dealing with the diversity of situations in which case reports might be regarded as medically serious within an administrative definition. Included is a proposal for the possible use of a standard list of reaction terms/diagnoses that would always be considered ‘‘serious,’’ even in the absence of an outcome or substantiating medical details. Spontaneous adverse reaction reports invariably lack complete information; companies have different philosophies and practices for attempting to obtain follow-up information. Among the ideas presented is inclusion of a specific section for the company’s (or other reviewer’s) comments on the case and its interpretation, including recommendations on what might be regarded as acceptable and unacceptable comments. One of the key provisions is that companies conduct six-monthly safety database reviews on their products, whether or not a formal report is prepared or required. Individual countries within Europe and elsewhere may have different schedules for the same product. The Working Group conducted a survey of companies and regulators on their workload and practices for handling the various types of periodic reports and the difficulties they can present. It is usually difficult to obtain accurate and timely exposure data, and their determination is more of an art than a science. However, there are considerably more sources and techniques for obtaining and appropriately using such data than is commonly realized. A guide to data sources and analytical approaches for exposure information is given. Introduction During the development and use of medicines, any communication involving a drug experience, positive or negative, can in principle form the basis of a case report on an individual patient. The exchange of information can originate with a patient, a healthcare provider or other party and it may be initially directed to a manufacturer, a health authority, or both. The traditional sources of adverse experience information are clinical trials and spontaneous reports (voluntary, unsolicited communications on marketed products), with the latter ordinarily far exceeding the former in numbers and types of reports, especially serious reports, over the lifetime of a product. However, there are many other media, places, and opportunities for accessing potentially useful drug safety intelligence, i. It is not as clear for other case sources on whether the respective cases should be considered solicited (vs. Some refer to the Internet as a ‘‘source’’ of adverse experience information, but it should be considered as yet another mechanism for conveying information. We believe that most companies would regard it as a study report, but with a presumption of attributability to the drug. However, there are many other circumstances, especially in postmarketing patient support programs, when prompting elicits adverse experience reports from patients. Spontaneous Reports from Persons Other than Healthcare Professionals Introduction Protecting the health of the patient/consumer is the purpose of any safety surveillance system. Yet the optimal way to include the consumer in the activities of this system has never been properly addressed. Thus, the value of a report lies not in who made it, but in the care and thoroughness with which it is prepared, documented, received, recorded, followed-up, clarified, and analyzed in evaluation of possible drugassociated problems. Internationally, adverse drug reaction reporting systems in the postmarketing environment depend primarily on voluntary reporting from healthcare professionals, especially physicians and dentists, and preferably the one directly associated with the care of the patient. Although there is no widely accepted definition of ‘‘healthcare professional,’’ others in addition to physicians and dentists commonly included, by convention or under regulatory guidance, are pharmacists, nurses, coroners, et al. Reports may also be received, primarily by 31 companies, directly from consumers, their representatives. Reports received from people other than healthcare professionals are not routinely accepted by some regulatory authorities. There are apparently only two regulatory authorities that explicitly require collection and reporting of consumer-direct reports. Canada, on the other hand, requires submission of reports originating only within Canada. Little is known about the extent and nature of consumer reporting and its management. No systematic surveys or reviews of actual experiences within existing national healthcare systems could be found by the Working 6 Group. Thus, they are, in general, expected to be relatively free of significant adverse reactions. Consumer associations in many nations have included adverse drug effects monitoring among their functions. This phenomenon has been increasing and has become more visible through extensive use of the Internet for global communication. Follow-up practices vary; in general consumers are requested to ask their physician to make a report if appropriate, and permission is usually sought from the consumer to allow the company to obtain confirmation directly from a treating physician, particularly if the report reflects an event that may 9 be serious or unusual/unexpected. Consumers do not use medical terminology or standard taxonomy for diseases and their complications; standard medical thesaurus sources are not equipped to handle such terms as ‘scared me to death’ or ‘in a fog for three days’ or ‘pizza head,’ which are examples derived from an informal survey. Such cases require in-house medical review and judgment, including the use of substitute terminology and description to characterize the case. A consumer case is generally considered ‘medically confirmed’ when a medically qualified person treating that patient provides confirmation on at least the usual minimal criteria for a case. On the other hand, if the professional is contacted and replies, he/she may not agree with the basic facts or their interpretation as presented to the company by the patient. In general, because the treating healthcare professionals remain vital partners in understanding and managing treatment emergent adverse events, their involvement in the confirmation process should take place whenever possible.
Third skin care magazines generic benzac 20 gr amex, it helps physicians distinguish between clinically important and contaminant microorganisms acne solutions 20gr benzac sale, since the proportion of positive blood cultures is crucial in interpreting blood culture results (7) acne xenia gel discount 20 gr benzac free shipping. Lastly acne in your 30s order benzac cheap online, since a finite percentage of blood cultures are contaminated (3 to 5%), routinely obtaining more than three blood cultures per septic episode usually does not help distinguish between clinically important and contaminant isolates (7). Furthermore, routinely drawing more than three blood cultures is expensive, needlessly increases laboratory work, and contributes to nosocomial (phlebotomy-induced) anemia. Patterns of positivity in successive blood cultures, showing evidence to 90 min, the best opportunity for recovering pathogenic miof the diagnostic importance of separate cultures. Reprinted from reference 199 croorganisms should be as soon after the fever spike as possiwith permission of the publisher. Interestingly, in the only published systematic study of which we are aware, Li et al. The clinical significance of each blood culture systems can detect microbial growth within a few isolate was made by physician-investigators based on published hours, it makes more sense to draw blood cultures simultacriteria (199) and then correlated with the number of bottles neously rather than serially. Every clinical microbiology laboratory in one bottle whereas 51% of pathogens and 32% of contamneeds policies and procedures designed to ensure that blood inants grew in both bottles. Thus, the degree of overlap is so cultures are collected in a timely manner, in such a way as to great that it is impossible to predict the clinical significance minimize contamination, and that proper blood volumes are based on the number of positive bottles. Whenever possible, Quantitative blood cultures have also been proposed as a blood should be collected by venipuncture of peripheral veins method to diagnose intravenous catheter-related sepsis. Whether blood incremental increase in the quantity of bacteria obtained cultures are collected by medical technologists, trained phlethrough the catheter with respect to that obtained from pebotomists, nurses, or other health care providers, an ongoing ripheral venipuncture should intuitively suggest the catheter as program to monitor compliance with these policies and prothe source of organisms in the blood. Although numerous cedures is necessary and should be part of the laboratory qualstudies addressing this issue have been published, the value of ity assurance program. Not addressed in these studies is the likelihood that septae on the blood culture bottles or tubes should be cleansed a catheter serves as stationary nidus for the growth of microand disinfected with alcohol swabs. Iodine should not be used organisms (and hence an increase in quantitation) indepenfor this purpose since, according to the manufacturers, it can dent of the origin of the organisms. After a likely site for veniprinciple, collection of blood for culture via indwelling cathepuncture has been selected, a tourniquet is applied to the limb ters should generally be discouraged (26). The tourniquet is then released and Finally, patterns of positivity of blood cultures obtained in the site of venipuncture is cleansed and disinfected with iodine sequence can aid in the interpretation of clinical significance. In endocarditis, bacteremia is done iodine swabs or pledgets are inexpensive and easy to use). BacBeginning over the point of anticipated venipuncture, the ioteremias not associated with endocarditis or other endovascudophore should be applied in a circular fashion outward for a lar infections are not continuous, and host defenses clear mifinal diameter of 5 to 6 cm. Thus, it is not surprising that only 70 povidone iodine is time-dependent, the easiest way to ensure to 80% of culture sets will be positive. Finally, the presence of adequate disinfection is to allow the solution to completely dry only a single positive culture set of several obtained in series (usually 1 to 3 min) before venipuncture. For adult patients, two or three blood ferred method is to use a 21-gauge needle with a syringe that cultures per septic episode should be obtained. Many phlebotomists prefer using a lysing leukocytes and thereby releasing phagocytized microor“butterfiy” needle with the syringe, although the use of collecganisms into the blood-broth mixture (77). Once commercial media are supplemented with proprietary combithe desired volume of blood has been drawn, the needle should nations of various nutrients and other growth factors. If the latter are used, have been done to determine which medium is superior for these tubes should be transported to the laboratory as soon as both microbial recovery and speed of detection. Most now believe that phlebotomists should not space atmospheres vary among bottles, it is difficult to draw change needles prior to inoculating bottles, as this practice conclusions regarding the relative performance of broth media increases the likelihood of needle-stick injuries. To prevent clotting, inoculated botwise, Columbia and other anaerobic broths are adequate for tles should be gently inverted a few times to mix the blood in recovering anaerobic bacteria. Most commercial blood culture media conis drawn, alcohol swabs should be used to clean the patient’s tain 0. The last effect has little effect in improving microbial recovery, since Volume of blood cultured. Culturing adequate volumes of phagocytes in blood culture bottles probably do not actively blood improves microbial recovery for both adult and pediatric ingest microorganisms, particularly if the complement cascade patients (8, 62, 97, 110, 129, 142, 154, 175). For adults, each additional milliliter of blood culinhibit the growth of Francisella tularensis and Moraxella catured increases microbial recovery by up to 3% (110). Although the number of promoting the recovery of gram-positive cocci, decrease the microorganisms present per milliliter of blood drawn from recovery of gram-negative bacteria. Supplementing blood culinfants and small children is larger, typically greater than 100 ture media with 1. Information collected from such citrate should never be used in broth blood culture media or to monitoring can be used as part of a laboratory quality assurcollect blood cultures (one notable exception being the Isolaance program. A variety of products have greater than 1:5 increases microbial recovery, probably by dibeen marketed for the purpose of increasing microbial recovluting antimicrobial agents and natural inhibitory factors in the ery from the blood of patients receiving systemic antimicrobial blood to subinhibitory concentrations (9, 143, 153). Although bottles containing these products have been more, diluting blood helps prevent clotting, one of the reasons shown to increase microbial recovery rates, the preponderance that overfilling of blood culture bottles is discouraged. The exact mechanism(s) by contain sufficient volumes of media to permit blood-to-broth which most of these products increase microbial recovery is not ratios of 1:5 to 1:10, these media have been supplemented with known, since they vary in their composition and bottles conmaterials that improve microbial recovery to the point where taining them differ from their standard counterparts in other suboptimal blood-to-broth ratios are overcome (195, 206). However, since most anaerobic blood culture bottles conbottles contain Ecosorb, a proprietary substance composed, in tain little or no oxygen in the bottle headspace atmosphere, part, of fuller’s earth and activated charcoal particles. Since bottles that include such products are more expensive Duration of incubation and testing. With manual blood culthan their standard counterparts and since the published data ture bottles, microbial growth is detected by macroscopic exdo not conclusively prove that use of these bottles is costamination of bottles and blind and/or terminal subcultures. The decision may be difficult to detect or may be absent, bottles processed must be based on the type of system used, the patient popuwith manual blood culture systems should be incubated for 7 lation being served, and the types of pathogenic isolates recovdays with terminal subcultures. Another issue that must be considIn general, for recovery of common pathogenic microorganered is that of contaminants, since some of these bottles may isms, automated blood culture systems yield almost as many recover more contaminants in addition to increasing the remicroorganisms after 5 days of incubation and testing as after covery of clinically important isolates (194). For automated systems, most and test period to 5 days yields fewer microorganisms ulticommercial blood culture bottles are manufactured with a mately judged as contaminants (208). Consequently, laboratocarefully controlled atmosphere in the bottle headspace (the ries may realize important savings in time and effort by using a inner part of the bottle that lies above the broth medium). This is particularly important with continuousAerobic bottles generally contain ambient atmosphere to monitoring blood culture systems, since with a 5-day test pewhich different amounts of carbon dioxide have been added. For aerobic blood culture bottles require venting to room air (to instance, since most clinically important microorganisms are increase the oxygen content) prior to inoculation or incubarecovered during the first 48 to 72 h of testing, it is unlikely that tion. Even if they sis in anaerobic bottles is less important than is maintaining were, isolation of a pathogenic microorganism 6 or 7 days adequate oxygen concentrations in aerobic bottles. Nonetheless, until such data are detectable levels in blood culture bottles containing insufficient collected and verified in controlled clinical studies and the oxygen (18, 53, 66, 87, 146). One important difference is that aerclinically important isolates recovered on days 6 and 7. Bottles with an external agar attachment do not and/or to perform extra subcultures for blood cultures drawn have to be vented. As with automated systems, anaerobic botfrom patients with suspected infective endocarditis but from tles should never be vented or recovery of strictly anaerobic whom blood cultures are negative. Several clinical studies have documented when modern blood culture systems are used. The bottles and paddles are inspected once little reason to believe that this practice increases microbial or twice daily for macroscopic evidence of growth and are recovery. For patients with culture-negative endocarditis, a inverted each time they are inspected. Anaerobic bottles do better practice is to use another blood culture method denot have paddle attachments. In manual systems, blind subcultures are perproviding early isolated colonies from which final identification formed at an arbitrary time during the incubation cycle (usuand susceptibility procedures can be performed (197). For ally at 24 to 48 h after the culture was drawn) and in the laboratories that process moderately large numbers of blood absence of macroscopic or other evidence of growth. Terminal cultures, the manual steps required to process these bottles subcultures, performed at the end of the incubation period in make their use less practical. They are also relatively expensive the absence of objective evidence of microbial growth, appear for laboratories that process large numbers of blood cultures. This manual system automated blood culture systems, neither blind nor terminal consists of an aerobic blood culture bottle only. In bottle is inoculated, a “signal” device, which consists of a long particular, blind subcultures are not necessary when a Gram needle in a plastic sleeve, is attached to the bottle. As the stain of the blood-broth mixture does not reveal any microormicroorganisms grow and liberate gases into the headspace ganisms (67).
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Lower respiratory tract infections Note: Low doses of penicillins are more likely to acne video generic benzac 20 gr on-line select for resistance skin care after 30 discount 20gr benzac. Do not use fluoroquinolones (ciprofloxacin skin care zamrudpur purchase benzac 20 gr amex, ofloxacin) first line because they may have long-term side effects and there is poor pneumococcal activity skin care clinic purchase benzac 20gr fast delivery. Reserve all fluoroquinolones (including levofloxacin) for proven resistant organisms. Consider a delayed Acute cough and higher risk of complications (at Consider a delayed prescribing strategy face-to-face examination): immediate or backup antibiotic. With Nitrofurantoinadvise patient on the risk of pulmonary and hepatic fibrosis, and the 500mg single dose symptoms to report if they develop during when exposed to a treatment. Antibiotic treatment is not routinely needed for Non-pregnant women asymptomatic bacteriuria in people with a urinary and men first choice if catheter. England Gastrointestinal tract infections Topical azoles are more effective than topical 2. Public Health If giardia is confirmed or suspected – tinidazole 2g single dose is the treatment of choice. Review within 48 hours or sooner if Ciprofloxacin 7days (Locally agreed) symptoms deteriorate. Second line, pregnant, breastfeeding, allergy, or intolerance: azithromycin is most effective. As lower cure rate in pregnancy, test for cure at least 3 weeks after end of treatment. Gonorrhoea Use Ciprofloxacin only If susceptibility is known Access Public Health prior to treatment and the isolate is sensitive to supporting evidence and England ciprofloxacin at all sites of infection. Pregnant/breastfeeding: avoid 2g single dose Pregnancy to treat 100mg pessary at night 6 nights Access metronidazole; clotrimazole for symptom relief symptoms: clotrimazole supporting Public Health (not cure) if metronidazole declined. Needs urgent treatment with antiviral and, if occurs around eye, requires urgent referral to ophthalmologist to exclude treat herpes keratitis. A topical steroid is required and Dermatologists would usually treat this on the body and limbs with a topical preparation combining a potent steroid with an antibiotic. If there is an improvement continue Consider Erythromycin if if for total 3 months then try to stop the antibiotic tetracyclines are but always continue topical treatment. The antibiotics used in acne are being used for their anti-infammatory effects on the skin, which is why they are used for long courses and repeat courses may be needed. Adding clindamycin does not improve outcomes Erysipelas: often facial and unilateral. Access Dog: give prophylaxis if: puncture wound; bite to Animal bites supporting hand, foot, face, joint, tendon, or ligament; evidence and immunocompromised; cirrhotic; asplenic; or penicillin allergy: Public Health rationales on the presence of prosthetic valve/joint. Scabies First choice permethrin: Treat whole body Permethrin 5% cream 2 applications, Access 24 Summary of antimicrobial prescribing guidance – managing common infections (June 2019) Doses Visual Key points Medicine Length Infection Adult Child summary from ear/chin downwards, and under nails. Access supporting Public Health Breastfeeding: oral antibiotics are appropriate, 10–14 days evidence and England where indicated. Women should continue rationales on the feeding, including from the affected breast. Topical nail lacquer is not as Toes: 3 courses Access England effective but available Over the Counter supporting To prevent recurrence: apply weekly 1% evidence and topical antifungal cream to entire toe area. Varicella zoster/ Pregnant/immunocompromised/ First line for chicken pox 800mg 5 times daily chickenpox neonate: seek urgent specialist advice. England Shingles treatment if not within 72 hours: consider starting antiviral drug up to 1 week after rash onset, if high risk of severe shingles or continued vesicle formation; older age; immunocompromised; or severe pain. Risk increased if high prevalence Prophylaxis: Access area and the longer tick is attached to the skin. Access eyelids) supporting Second line: topical antibiotics if hygiene evidence and Third line: measures are ineffective after 2 weeks. First-line treatment is with paracetamol and/or ibuprofen; codeine is not effective for toothache. Temporary pain and swelling relief can be Chlorhexidine attained with saline mouthwash (tsp salt in 0. Repeated antibiotics alone, without drainage, are ineffective in preventing the spread of infection. Antibiotics are only recommended if there Dental abscess are signs of severe infection, systemic symptoms, or a high risk of complications. The empirical use of cephalosporins, co-amoxiclav, clarithromycin, and clindamycin do not offer any advantage for most dental patients, and should only be used if there is no response to first-line drugs. The largest pool of Production of white blood cells neutrophils is in the marrow (reserve pool), and a small White blood cells originate from pluripotent haemopoietic number circulate in the peripheral blood (circulating stem cells. The circulating pool can be stem cells develop into haemopoietic progenitor cells of various lineages. Stress (exercise) causes a transient granulocytosis with neutrophil counts of 12–100 10 /L9 increase in the freely circulating pool. Most have9 Chronic idiopathic neutrophilia is a chronic form of a compact rounded or gently notched nucleus with scant leucocytosis that occurs in people who are otherwise agranular cytoplasm. B and T lymphocytes cannot be distinguished Hereditary neutrophilia, a syndrome of high leucocyte counts (20–70 10 /L), splenomegaly, and widened9 morphologically. These cells are called Patients have high leucocyte alkaline phosphatase natural killer cells because of their ability to destroy virusactivities and no propensity to infection. In severe reactions, even more regulating the afferent and efferent components of the immature cells, promyelocytes and myeloblasts, may immune system. Leukaemoid reactions can be distinguished from chronic numerous orange cytoplasmic granules. Eosinophils have myeloid leukaemia by a normal leucocyte alkaline substantial proinflammatory and cytotoxic activity and phosphatase activity and absence of the Philadelphia play an important part in the pathogenesis of various 4 chromosome. Some infants with Down’s syndrome have allergic, parasitic, and neoplastic disease processes. It may reflect a primary disorder of bone-marrow Panel 1: Non-malignant causes of neutrophilia production—either congenital or an acquired malignant disorder—or a secondary response to a disease process, Congenital forms Secondary causes Leucocyte adhesion deficiency Acute infection drug, or toxin. Non-infectious causes include carcinoma Drug-induced (lung, stomach, breast), Hodgkin’s disease, juvenile Serum sickness rheumatoid arthritis, and dermatitis herpetiformis. The clinical presentation of Stress neutrophilia can occur within minutes of exercise Epstein-Barr virus infection in young adults may be or emotional or physical stress, or after surgery, seizures, confused with acute lymphoblastic leukaemia; the two or epinephrine injection. Drugs—Steroids stimulate the release of neutrophils If this test is negative, but the clinical suspicion of from the bone marrow and result in a chronic infectious mononucleosis is high, the serum sample neutrophilia. Lymphocytosis is rarely seen in bacterial infections, agonists, such as theophylline, produce an acute with the exception of Bordetella pertussis infection, in which neutrophilia by releasing neutrophils from the marginated the lymphocyte count typically rises to more than pool. Chronic to engraftment and recovery from neutropenia; in bonemyelomonocytic leukaemia is a disorder of older people, marrow failure including myelodysplastic syndromes; in with features of both a myelodysplastic disorder and a patients with primary or secondary neutropenia resulting 14 chronic myeloproliferative disease. Secondary causes Recovery phase from neutropenia Chronic infections: tuberculosis; subacute bacterial endocarditis; Lymphocytosis fungal infections; brucellosis; kala-azar; trypanosomiasis the average absolute lymphocyte count during the first Autoimmune disorders: rheumatoid arthritis; systemic lupus year of life ranges from 5·0 to 7·0 10 /L. The count9 erythematosus; polyarteritis; ulcerative colitis; regional enteritis; declines gradually to adult values (2·0 10 /L). On physical examination, lower limit of normal for white people is 1·5 109/L, pallor, hepatosplenomegaly, lymphadenopathy, and a whereas black people have slightly lower counts, with a facial eczematoid rash are found. The lower9 include anaemia, thrombocytopenia, a raised leucocyte absolute neutrophil count in black people has been count (50–100 10 /L) with prominent monocytosis. The There are well-recognised inherited forms and acquired hypereosinophilic syndrome is a group of disorders of forms of neutropenia (panel 4). Some cases defy unknown cause characterised by excessive production of 17 classification. Such patients are generally followed up for eosinophils associated with organ infiltration. This long periods before the underlying cause of their syndrome results in end-organ damage, primarily neutropenia becomes apparent. Neutropenia can, of involving the heart, leading to eosinophilic course, be a manifestation of a more extensive marrow endomyocardial fibrosis and associated thromboembolic failure state such as aplastic anaemia, Fanconi’s anaemia, complications. Patients with hypereosinophilic syndrome do infections, severe neutropenia, and maturation arrest of not have asthma, and many have more profound marrow granulopoiesis at the myelocyte/promyelocyte eosinophilia than patients with Churg-Strauss syndrome, 20,21 stage. LongAn absolute basophil count greater than 0·2 10 /L may9 be observed with acute hypersensitivity reactions, chronic Panel 4: Causes of neutropenia infections, and inflammatory disorders (tuberculosis, Inherited forms Acquired forms rheumatoid arthritis, ulcerative colitis) or with viral 7 Ethnic or benign familial neutropenia Drug or toxin induced infections (influenza, varicella). The neutropenia generally a chymotryptic serine protease of neutrophils and develops within 1–2 weeks of the start of drug therapy. If neutropenia, metaphyseal dysplasia, and pancreatic the neutropenia is mild or moderate (absolute neutrophil insufficiency.
Nursing Management Instruct patient to acne 6dpo purchase 20gr benzac visa adhere to acne 2000 cheap benzac 20 gr fast delivery the following instructions for at least 4 months acne 7dpo cheap benzac 20gr on-line, until the skin appears completely healed: • Think about what may have caused the problem acne complex order cheap benzac online. C Medical Management See “Medical Management” under “Angina Pectoris” and “Myocardial Infarction” for additional information. Cushing Syndrome Cushing syndrome results from excessive, rather than deficient, adrenocortical activity. It is commonly caused by use of corticosteroid medications and is infrequently the result of excessive corticosteroid production secondary to hyperplasia of the adrenal cortex. Cushing syndrome occurs five times more often in women ages 20 to 40 years than in men. Clinical Manifestations • Arrested growth, weight gain and obesity, musculoskeletal changes, and glucose intolerance. Medical Management Treatment is usually directed at the pituitary gland because most cases are due to pituitary tumors rather than tumors of the adrenal cortex. Diagnosis Nursing Diagnoses • Risk for injury related to weakness • Risk for infection related to altered protein metabolism and infiammatory response • Self-care deficits related to weakness, fatigue, muscle wasting, and altered sleep patterns • Impaired skin integrity related to edema, impaired healing, and thin and fragile skin 246 Cushing Syndrome • Disturbed body image related to altered appearance, impaired sexual functioning, and decreased activity C level • Disturbed thought processes related to mood swings, irritability, and depression Collaborative Problems/Potential Complications • Addisonian crisis • Adverse effects of adrenocortical activity Planning and Goals Major goals include decreased risk of injury, decreased risk of infection, increased ability to carry out self-care activities, improved skin integrity, improved body image, improved mental function, and absence of complications. Nursing Interventions Decreasing Risk of Injury • Provide a protective environment to prevent falls, fractures, and other injuries to bones and soft tissues. Improving Body Image • Discuss the impact that changes have had on patient’s self-concept and relationships with others. Major physical changes will disappear in time if the cause of Cushing syndrome can be treated. Cystitis in men is secondary to some other factor (eg, infected prostate, epididymitis, or bladder stones). Reinfection of women with new bacteria is more common than persistence of the initial bacteria. Diagnosis C Nursing Diagnoses • Acute pain related to infection within the urinary tract • Deficient knowledge related to factors predisposing to infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy Collaborative Problems/Potential Complications • Sepsis • Renal failure, which may occur as the long-term result of either an extensive infective or inflammatory process Planning and Goals Goals of the patient may include relief of pain and discomfort, increased knowledge of preventive measures and treatment modalities, and absence of complications. Nursing Interventions Relieving Pain • Use antispasmodic drugs to relieve bladder irritability and pain. It may occur secondary to head trauma, brain tumor, or surgical ablation or irradiation of the pituitary gland. It may also occur with infections of the central nervous system (meningitis, encephalitis, tuberculosis) or with tumors (eg, metastatic disease, lymphoma of the breast or lung). The disease cannot be controlled by limiting fiuid intake, because the high-volume loss of urine continues even without fiuid replacement. Attempts to restrict fiuids cause the patient to experience an insatiable craving for fiuid and to develop hypernatremia and severe dehydration. Inability to 253 254 Diabetes Insipidus increase specific gravity and osmolality of the urine during test is characteristic of diabetes insipidus. Nursing Management • Instruct patient and family members about follow-up care and emergency measures. Diabetes Mellitus 255 • Advise patient to wear a medical identification bracelet and to carry medication information about this disorder at all times. Long-term hyperglycemia may contribute to chronic microvascular complications (kidney and eye disease) and neuropathic complications. It is characterized by destruction of the pancreatic beta-cells due to genetic, immunologic, and possibly environmental (eg, viral) factors. It results from a decreased sensitivity to insulin (insulin resistance) or from a decreased amount of insulin production. The complications include the following: • Macrovascular (large vessel) disease: affects coronary, peripheral vascular, and cerebral vascular circulations • Microvascular (small vessel) disease: affects the eyes (retinopathy) and kidneys (nephropathy); control blood glucose levels to delay or avoid onset of both microvascular and macrovascular complications • Neuropathic disease: affects sensory motor and autonomic nerves and contributes to such problems as impotence and foot ulcers Gerontologic Considerations Because the incidence of elevated blood glucose levels increases with advancing age, elderly adults should be advised that physical activity that is consistent and realistic is beneficial to those with diabetes. Medical Management the main goal of treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications. There are five 258 Diabetes Mellitus components of management for diabetes: nutrition, exercise, monitoring, pharmacologic therapy, and education. Nutritional Management • Goals are to achieve and maintain blood glucose and blood pressure levels in the normal range (or as close to normal as safely possible) and a lipid and lipoprotein profile that reduces the risk for vascular disease; to prevent, or at least slow, the rate of development of chronic complications; to address individual nutrition needs; and to maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence. In-depth follow-up education then focuses on management skills, such as eating at restaurants; reading food labels; and adjusting the meal plan for exercise, illness, and special occasions. Using food combinations to lower the glycemic response (glycemic index) can be useful. Nursing Management Nursing management of patients with diabetes can involve treatment of a wide variety of physiologic disorders, depending on the patient’s health status and whether the patient is newly diagnosed or seeking care for an unrelated health problem. Because all patients with diabetes must master the concepts and skills necessary for long-term management and avoidance of potential complications of diabetes, a solid educational foundation is necessary for competent self-care and is an ongoing focus of nursing care. More advanced continuing education may include alternative methods for insulin delivery, for example. Assessing Readiness to Learn • Assess the patient’s (and family’s) readiness to learn; assess the patient’s coping strategies and reassure the patient and family that feelings of depression and shock are normal. Teaching Experienced Patients • Continue to assess the skills and self-care behaviors of patients who have had diabetes for many years, including direct observation of skills, not just the patient’s self-report of self-care behaviors. Determining Teaching Methods D • Maintain fiexibility with regard to teaching approaches; a teaching method for one patient might not work for another. Teaching Patients to Self-Administer Insulin Insulin injections are self-administered into the subcutaneous tissue with the use of special insulin syringes. Basic information includes explanations of the equipment, insulins, and syringes and how to mix insulin. Also instruct patient to thoroughly mix any cloudy insulins by gently inverting the vial or rolling it between the hands before drawing the solution into a syringe or a pen and to discard any bottles of intermediate-acting insulin showing evidence of fiocculation (a frosted, whitish coating inside the bottle). Smaller syringes (marked in 1unit increments) may be easier to use for patients with visual deficits. Patients who have difficulty mixing insulins may use a premixed insulin, have prefilled syringes prepared, or take two injections. Systematic rotation of injection sites within an anatomic area is recommended; encourage the patient to use all available injection sites within one area rather than randomly rotating sites from area to area. Promoting Homeand Community-Based Care Promoting Self-Care • If problems exist with glucose control or with the development of preventable complications, assess the reasons for the patient’s ineffective management of the treatment regimen; do not assume that problems with diabetes management are related to the patient’s willful decision to ignore self-management; problem may be correctable simply through providing complete information and ensuring that the patient understands the information. Diabetic Ketoacidosis 265 Assessment and Diagnostic Findings • Blood glucose level: 300 to 800 mg/dL (may be lower or higher). This is the fiuid of choice (200 to 500 mL/h for several additional hours) after the first few hours, provided that blood pressure is stable and sodium level is not low. Cautious but timely replacement of potassium is vital for avoiding severe cardiac dysrhythmias that occur with hypokalemia. Diagnosis Nursing Diagnoses • Risk for fiuid volume deficit related to polyuria and dehydration • Fluid and electrolyte imbalance related to fiuid loss or shifts Diabetic Ketoacidosis 267 • Deficient knowledge about diabetes self-care skills/information • Anxiety related to loss of control, fear of inability to manage diabetes, misinformation related to diabetes, fear of diabetes complications D Collaborative Problems/Potential Complications • Fluid overload, pulmonary edema, and heart failure • Hypokalemia • Hyperglycemia and ketoacidosis • Hypoglycemia • Cerebral edema Planning and Goals the major goals for the patient may include maintenance of fiuid and electrolyte balance, optimal control of blood glucose levels, ability to perform diabetes survival skills and self-care activities, and absence of complications. Increasing Knowledge about Diabetes Management • Carefully asses the patient’s understanding of and adherence to the diabetes management plan. Take precautions to minimize activities that could increase intracranial pressure. Diarrhea Diarrhea is a condition defined by an increased frequency of bowel movements (more than three per day), increased amount of stool (more than 200 g per day), and altered consistency (liquid stool). Types of diarrhea include secretory, osmotic, malabsorptive, infectious, and exudative. It can be acute (self-limiting and often associated with infection) or chronic (persists for a long period and may return sporadically). It can be caused by certain medications, tube feeding formulas, metabolic and endocrine disorders, and viral and bacterial infections. Clinical Manifestations D • Increased frequency and fiuid content of stool • Abdominal cramps, distention, intestinal rumbling (borborygmus), anorexia, and thirst • Painful spasmodic contractions of the anus and ineffectual straining (tenesmus) with each defecation Other symptoms, depending on the cause and severity and related to dehydration and fiuid and electrolyte imbalances, include the following: • Watery stools, which may indicate small bowel disease • Loose, semisolid stools, which are associated with disorders of the large bowel • Voluminous greasy stools, which suggest intestinal malabsorption • Blood, mucus, and pus in the stools, which denote infiammatory enteritis or colitis • Oil droplets on the toilet water, which are diagnostic of pancreatic insufficiency • Nocturnal diarrhea, which may be a manifestation of diabetic neuropathy Complications Complications of diarrhea include cardiac dysrhythmias due to fiuid and electrolyte (potassium) imbalance, urinary output less than 30 mL/h, muscle weakness, paresthesia, hypotension, anorexia, drowsiness (report if potassium level is less than 3. Assessment and Diagnostic Findings When the cause is not obvious: complete blood cell count; serum chemistries; urinalysis; routine stool examination; and stool examinations for infectious or parasitic organisms, bacterial toxins, blood, fat, electrolytes, and white blood cells. Nursing Management • Elicit a complete health history to identify character and pattern of diarrhea, and the following: any related signs and symptoms, current medication therapy, daily dietary patterns and intake, past related medical and surgical history, and recent exposure to an acute illness or travel to another geographic area. These clots consume platelets and clotting factors, eventually causing coagulation to fail and bleeding to result.