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Sexually transmitted diseases treatment guidelines 2010 – Pelvic infammatory disease buy generic cytoxan line. Sexually transmitted diseases treatment guidelines 2010 – Pelvic infammatory disease cheap cytoxan 50 mg mastercard. On the other hand generic 50mg cytoxan free shipping, warfarin is contraindicated in pregnancy as there is an increased risk of congenital abnormalities and intracranial haemorrhage with its use. This should preferably be done before conception to reduce the risk of teratogenicity or as soon as the diagnosis of pregnancy is made. Summary of risk factors leading to the development of genital tract intraepithelial neoplasia. Its presence indicates higher risk of transmitting the disease to fetus from mother. Cervical lesions may need colposcopy if there is suspicion of dysplasia or malignancy. Tese women are generally asymptomatic and the infection clears spontaneously within 2 years. Low-grade abnormalities are also common in this age group, which would resolve spontaneously. Terefore, screening these women with cervical cytology would create greater anxiety, colposcopic examinations, treatments and its consequences. The incidence of cervical cancer in women under 25 years is low and screening these women has not been shown to reduce the incidence of cervical cancer. In view of the above reasons cervical screening is not recommend in women under the age of 25. It is associated with lichen sclerosus and is a high risk for developing into a squamous cell carcinoma. The following drugs can be used in the treatment of her condition except which one of the following? Fourth-degree tear involves injury to the anal sphincter complex, but not anal mucosa. Intact perineal skin excludes the possibility of damage to the anal sphincter complex. The degree of trauma in a right mediolateral episiotomy is equivalent to a second-degree tear. Question 5 A 22-year-old Caucasian para 0 woman attends maternal medicine clinic at 13 weeks’ gestation following her normal dating scan. She gives a history of deep venous thrombosis following a pelvic fracture afer a trip over the stairs 2 years ago. Choose the most appropriate management option for this woman with regards to thrombopropylaxis. Her medications box reveals that she has taken tranexamic acid for the whole previous month. Infundibulopelvic ligament Instructions For each clinical scenario below, choose the single most appropriate anatomical structure from the above list of options. You are assisting a total abdominal hysterectomy and bilateral salpingo- oophorectomy procedure on a 58-year-old woman with complex endometrial hyperplasia. The surgeon has to clamp and cut one of the above structures to excise ovaries from the pelvic side wall. She presents with history of 6 weeks, amenorrhoea, lower abdominal pains and a positive pregnancy test. Ultrasound confrms a right-sided ectopic pregnancy and at laparoscopy, Filshie clip was found on this ligament on the right side, instead of the fallopian tube. A 26-year-old nulliparous woman attends the gynaecology clinic with history of severe dysmenorrhoea and dyspareunia. On examination, the uterus is retroverted, fxed and tender with irregular nodules in the pouch of Douglas. At laparoscopy, you notice extensive endometriosis on these structures obliterating the pouch of Douglas. Autonomy Instructions For each clinical scenario below, choose the single most appropriate principle from the above list of options. A 36-year-old para 5 woman is a practicing Jehovah’s witness and has signed the advanced directive declining blood transfusion under any circumstances. She had fve normal deliveries in the past and had uncomplicated antenatal period during this pregnancy. A 38-year-old woman with a previous caesarean section presents in active labour at term and wishes to have vaginal birth afer caesarean section. At 8 cm dilatation, there is fetal bradycardia followed by maternal hypovolemia and loss of consciousness. Afer making the decision that this patient is not in a ft state to consent, you proceed with an emergency laparotomy. Afer an episode of unprotected intercourse a 15-year-old girl attends the family planning clinic for emergency contraception. As she has been sexually active for the last 3 months she is also requesting a reliable contraceptive method. Ureteric injury Instructions For each clinical scenario below, choose the single most likely surgical complication from the above list of options. A 26-year-old woman attends the emergency department with a history of lower abdominal pain and feeling unwell, 5 days afer an emergency caesarean section for failure to progress in the second stage afer a failed instrumental delivery. On examination, she was tender in the lower abdomen with guarding and bowel sounds were present. Tough there is some clinical improvement afer admission with intravenous antibiotics, she still has swinging temperatures. At delivery, there was an extension of the lef uterine angle with massive haemorrhage, which was controlled by placing multiple haemostatic sutures and securing uterine angles. A 28-year-old woman attends the emergency department with severe lower abdominal pain and feeling unwell, on day 2 afer a diagnostic laparoscopy for chronic pelvic pain and subfertility.

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The milk used (commercial or homemade for- mula) and the mixing process (to ensure appropriate dilution) should be reviewed (adding too much water to powdered formula results in inadequate nutrition) order discount cytoxan online. A 2-week food diary (the parent notes all foods offered and taken by the child) and any asso- ciated symptoms of sweating buy cytoxan 50 mg without prescription, choking purchase cytoxan 50 mg with visa, cyanosis, or difficulty sucking can be useful. Pregnancy and early neonatal histories may reveal maternal infection (toxoplas- mosis, cytomegalovirus, rubella, syphilis), maternal depression, drug use, intrauter- ine growth retardation, prematurity, or other chronic neonatal conditions. The child’s living arrangements, including primary and secondary caregivers, housing type, caregiver’s financial and employment status, the family’s social supports, and unusual stresses (domestic abuse or neglect) should be reviewed. While gathering the history, the clinician can observe for unusual caregiver–child interactions. During the examination (especially of younger infants), the clinician can observe a feeding, which may give clues to maternal-child interaction bonding issues or to physical problems (cerebral palsy, oral motor or swallowing difficulties, cleft palate). A child with cystic fibrosis in the family requires sweat chloride or genetic testing, especially if this testing is not included on the newborn state screen. A tuberculosis skin test and human immunodeficiency virus testing may also be indicated. Families should eat together in a nondistracting environment, with meals lasting between 20 and 30 minutes. Low-calorie drinks, juices, and water are limited; age-appropriate high- calorie foods (whole milk, cheese, dried fruits, peanut butter) are encouraged. For- mulas containing more than the standard 20 cal/oz may be necessary for infants, and high-calorie supplementation (PediaSure, Ensure) may be required for older children. Caregiver help in the form of job training, substance and physical abuse prevention, parenting classes, and psychotherapy may be available through community programs. Infants who have had neonatal herpes simplex virus infection (Case 6) often have meningitis as part of their illness; the result often is poor growth and developmental delay. The child with tra- cheoesophageal atresia (Case 7) will have recurrent episodes of aspiration, pneumonia, and failure to thrive. He is symmetrically less than the fifth percentile for height, weight, and head circumference on routine growth curves. He was a planned pregnancy, and his mother’s prenatal course was unevent- ful until an automobile accident initiated the labor. She was noted to have a small head at birth, be developmentally delayed throughout her life, and have required cataract surgery shortly after birth. Caloric intake has been deemed appropriate by history, and neither frequent emesis nor excessive stooling is reported. Her examination is remarkable for a small head and liver enlargement on abdominal palpation. The pregnancy was normal, his development is as expected, and the family reports no psychosocial prob- lems. The mother says that he is now a finicky eater (wants only macaroni and cheese at all meals), but she insists that he eat a variety of foods. Her current length is at the 10th percentile, head circumference is at the 50th percentile, and weight is less than the 5th per- centile. She was sent to the gastroenterologist about a month prior by a colleague after her weight was noted to have dropped from the 50th percentile on her 6-month-old visit to less than the 5th percentile on her 9-month-old visit. Feeding is via breast and bottle with a standard milk-based formula; the quantity of feeds reported seems sufficient and no excessive spit- up is reported. His recommendations at that time were to begin a 1-month’s trial of a 24 cal/oz formula and follow-up with you for a weight check. Similarly, growth for children with Down or Turner syndrome varies from that for other children. For the child in the question, weight gain should follow or exceed that of term infants. For this premature infant, when his parameters are plotted on a “premie growth chart,” normal growth is revealed. Counseling parents how to provide optimal nutrition, avoid “force-feeding,” and avoid providing snacks is usually effective. Of note, the infant is already on a calorie-fortified formula, in addition to breast milk. Growth hormone administration and further counseling regarding diet without close follow-up are not standard of care. Clues in history, examination, and selected screening labo- ratory tests may help identify affected organ systems. His medical and family histories are unre- markable except that his sole source of nutrition is goat’s milk. Understand the special needs of infants and toddlers fed on goat’s milk and vegan diets. Recognize the clinical syndromes resulting from vitamin excesses and deficiencies. Considerations A variety of feeding regimens exist for infants and toddlers—breast-feeding, goat’s milk, other types of nonformula milk, and commercial or handmade foods. Health care providers can educate parents about the benefits and potential dangers of various diet choices. Goat’s milk has lower sodium levels but more potassium, chloride, linoleic acid, and arachidonic acid than does cow’s milk. Goat’s milk should be boiled or pasteurized before ingestion because goats are particularly susceptible to brucellosis. Breast milk is considered the ideal human infant food because it contains opti- mal nutrition (with the exception of vitamin D and sometimes fluoride); iron levels are low but highly bioavailable and do not require supplementation until 4 to 6 months of age. In addition, it has antimicrobial and immunologic benefits, and the act of breast-feeding promotes bonding between the mother and infant. In developing countries, it is associated with lower infant morbidity and mortality, not only due to a reduction in diarrhea associated by avoidance of contaminated water used in formula preparation but also because it contains high concentrations of immunoglobulin A (IgA), which reduces bacterial adherence to the intestinal wall, and macrophages, which inhibit Escherichia coli growth. Iron levels in breast milk are low but highly bioavailable and do not require supplementation until 4 to 6 months of age. Com- mercial formula manufacturers strive to provide products similar to human milk. Infant growth rates with cow’s milk formula are similar to those in infants receiving breast milk.

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Bone marrow toxicity cheap 50 mg cytoxan with mastercard, one of the most frequent types of In the Gell and Coombs classifcation system order cytoxan 50mg line, allergic drug-induced toxicity order 50mg cytoxan with mastercard, may manifest as agranulocytosis, reactions are divided into four general types, each of which anemia, thrombocytopenia, or a combination of these (pan- can be produced by drugs. The effects are often reversible when the drug is hypersensitivity reactions that are mediated by immuno- withdrawn, but they may have serious consequences before globulin E antibodies. Chapter 4 y Drug Development and Safety 39 agranulocytosis may succumb to a fatal infection before the Other Organ Toxicities problem is recognized. Many drugs, such as chloramphenicol, are believed to Some drugs, such as opioid analgesics, cause respiratory cause hematopoietic toxicity by triggering hypersensitivity depression via their effects on the brain stem respiratory reactions directed against the stem cells in bone marrow or centers. Chloramphenicol also produces a reversible monary fbrosis, so patients who are being treated with these form of anemia by blocking the action of the enzyme fer- agents should have periodic chest radiographs and blood gas rochelatase and thereby preventing the incorporation of iron measurements to detect early signs of fbrosis. Anthracy- The most serious form of hematopoietic toxicity is aplas­ cline anticancer drugs, such as doxorubicin (Adriamycin), tic anemia, which may be associated with several types of produce adverse cardiac effects that resemble congestive blood cell defciencies and lead to pancytopenia. This can result in muscle pain and by administration of hematopoietic growth factors (see sometimes leads to rhabdomyolysis and renal failure. Skin rashes of all varieties, including macular, papular, maculopapular, and urticarial rashes, may be produced by Hepatotoxicity drug hypersensitivity reactions. A mild skin rash may dis- A large number of drugs produce liver toxicity, either via an appear with continued drug administration. Nevertheless, immunologic mechanism or via their direct effect on the because rashes may lead to more serious skin or organ toxic- hepatocytes. Liver toxicity can be classifed as cholestatic or ity, they should be monitored carefully. Cholestatic hepatotoxicity is often caused by a hypersensitivity mechanism producing infammation Idiosyncratic Reactions and stasis of the biliary system. Hepatocellular toxicity is Idiosyncratic reactions are unexpected drug reactions caused sometimes caused by a toxic drug metabolite. For example, acetaminophen and isoniazid have toxic metabolites that patients who have glucose-6-phosphate dehydrogenase may cause hepatitis. With many hepatotoxic drugs, elevated defciency may develop hemolytic anemia when they are serum transaminase levels may provide an early indication exposed to an oxidizing drug such as primaquine or to a of liver damage, and levels should be monitored during the sulfonamide. If transaminase levels exceed three times the rently with another drug or with food. Unfor- may be caused by changes in the pharmaceutical, pharma- tunately, some patients have developed acute hepatic failure codynamic, or pharmacokinetic properties of the affected even when serum transaminase levels have been monitored drug (Table 4-3). In recent years, several drugs such as trogli­ tazone, used to treat diabetes, have been removed from the Pharmaceutical Interactions market as a result of excessive cases of fatal hepatic failure. Pharmaceutical interactions are caused by a chemical reac- tion between drugs before their administration or absorp­ Nephrotoxicity tion. Pharmaceutical interactions occur most frequently Renal toxicity is caused by various drugs, including several when drug solutions are combined before they are given groups of antibiotics. For example, if a penicillin solution and an classifed according to site and mechanism and include aminoglycoside solution are mixed, they will form an inso- interstitial nephritis, renal tubular necrosis, and crystal­ luble precipitate, because penicillins are negatively charged luria (the precipitation of insoluble drug in the renal and aminoglycosides are positively charged. Nephrotoxicity often reduces drug clearance, drugs are incompatible and should not be combined before thereby elevating plasma drug concentrations and leading they are administered. With some drugs that routinely cause renal toxicity, such as the antineoplastic agent cisplatin, the Pharmacodynamic Interactions kidneys can be protected by means of forced diuresis, in Pharmacodynamic interactions occur when two drugs have which the drug is administered with large quantities of additive, synergistic, or antagonistic effects on a tissue, intravenous fuid so as to lower the drug concentration in organ system, microbe, or tumor cells. Some pharmacodynamic interactions occur example is cyclophosphamide, an antineoplastic drug when two drugs act on the same receptor, and others occur whose metabolite causes hemorrhagic cystitis. This when the drugs affect the same physiologic function through disorder can be prevented by administering mesna, a actions on different receptors. For example, epinephrine and sulfhydryl-releasing agent that conjugates the toxic meta- histamine affect the same function but have antagonistic bolite in the urine. Mechanisms and examples of phar- Pharmacodynamic Additive, synergistic, or antagonistic macokinetic interactions are provided in Tables 4-3 and 4-4. Interactions effects on a microbe or tumor cells Additive, synergistic, or antagonistic Altered Drug Absorption effects on a tissue or organ system There are several mechanisms by which a drug may affect Pharmacokinetic Interactions the absorption and bioavailability of another drug. One Altered drug absorption Altered gut motility or secretion mechanism involves binding to another drug in the gut and Binding or chelation of drugs preventing its absorption. For example, cholestyramine, a Competition for active transport bile acid sequestrant, binds to digoxin and prevents its Altered drug distribution Displacement from plasma protein– absorption. Another mechanism involves altering gastric or binding sites intestinal motility so as to affect the absorption of another Displacement from tissue-binding sites drug. Drugs tend to be absorbed more rapidly from the Altered drug Altered hepatic blood fow biotransformation intestines than from the stomach. Therefore a drug that Enzyme induction slows gastric emptying, such as atropine, often delays the Enzyme inhibition absorption of another drug. A drug that increases intestinal Altered drug excretion Altered biliary excretion or motility, such as a laxative, may reduce the time available for enterohepatic cycling the absorption of another drug, thereby causing its incom- Altered urine pH plete absorption. Carbamazepine Theophylline Monitor plasma theophylline concentration and adjust dosage as needed. Rifampin Phenytoin Monitor plasma phenytoin concentration and adjust dosage as needed. Inhibitors of Drug Absorption Aluminum, calcium, and iron Tetracycline Give tetracycline 1 hour before or 2 hours after giving the other agent. Cholestyramine Digoxin and warfarin Give digoxin or warfarin 1 hour before or 2 hours after giving cholestyramine. Inhibitors of Drug Biotransformation Cimetidine Benzodiazepines, lidocaine, Instead of giving cimetidine, substitute a histamine blocker that does not phenytoin, theophylline, inhibit drug metabolism. Erythromycin Carbamazepine and Lower the dose of the affected drug during erythromycin therapy. Inhibitors of Drug Clearance Diltiazem, quinidine, and Digoxin Give a subnormal dose of digoxin and monitor the plasma drug verapamil concentration. Probenecid Cephalosporins and penicillin Advise the patient that the combination of drugs is intended to increase the plasma concentration of the antibiotic. Thiazide diuretics Lithium Give a subnormal dose of lithium and monitor the plasma drug concentration. This does the drug’s rate of elimination, and any change in the inhibition increases plasma levels severalfold, sometimes drug’s effect on target tissues is usually short-lived.

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A fourth topical formulation—Solaraze—is used for actinic keratoses (see Chapter 85) order cytoxan 50 mg line. Topical diclofenac is more expensive than oral diclofenac buy cytoxan toronto, but also safer: with topical therapy order cytoxan overnight, blood levels are only about 5% of those achieved with oral therapy, and hence the risk for systemic toxicity is low. Whether topical diclofenac shares the drug interactions of oral diclofenac has not been determined. For joints of the lower extremity (knees, ankles, feet), the dosage is 4 g of gel applied 4 times a day. For joints of the upper extremity (elbows, wrists, hands), the dosage is 2 g of gel applied 4 times a day. For each application, 40 drops are spread around the entire knee (front, back, and sides). Among these are dry skin, erythema and induration, pruritus, and contact dermatitis with vesicles. As with Voltaren Gel, the treated area should not be exposed to sunlight, natural or artificial. Diclofenac/Misoprostol [Arthrotec] Oral diclofenac, in combination with misoprostol, is available under the trade name Arthrotec. Misoprostol can induce uterine contraction, and hence the product is contraindicated for use during pregnancy. Diclofenac/misoprostol is supplied in two strengths: 50 mg/200 mcg and 75 mg/200 mcg. For rheumatoid arthritis or osteoarthritis, the usual dosage is 50 mg/200 mcg 3 or 4 times a day. However, unlike the salicylates, diflunisal is not converted to salicylic acid in the body. The drug is indicated for mild to moderate pain, rheumatoid arthritis, and osteoarthritis. Diflunisal has a prolonged half-life (11–15 hours) and hence can be administered only 2 or 3 times a day. For treatment of arthritis and mild to moderate pain, the initial dose is 500 to 1000 mg. Etodolac Etodolac is indicated for rheumatoid arthritis, osteoarthritis, and moderate pain. The most common adverse effects are dyspepsia, nausea, vomiting, diarrhea, and abdominal pain. The drug is supplied in immediate-release tablets (400 and 500 mg), extended-release tablets (400, 500, and 600 mg), and capsules (200 and 300 mg). The recommended dosage for arthritis is 800 to 1200 mg/day of the extended-release medication or 400 to 1000 mg/day of the immediate-release medication in divided doses. Indomethacin Actions and Uses Indomethacin [Indocin, Tivorbex] is an effective antiinflammatory agent approved for arthritis, bursitis, tendinitis, and, as discussed in Chapter 58, acute gouty arthritis. Although indomethacin is able to reduce pain and fever, it is not routinely used for these effects, owing to potential toxicity. Pharmacokinetics Indomethacin is well absorbed after oral administration and distributes to all body fluids and tissues. Adverse Effects Untoward effects are seen in 35% to 50% of patients, causing about 20% to discontinue treatment. The most common adverse effect is severe frontal headache, which occurs in 25% to 50% of patients. Hematologic reactions (neutropenia, thrombocytopenia, aplastic anemia) have occurred but are rare. Precautions and Contraindications Because of its adverse effects, indomethacin is generally contraindicated for infants and children younger than 14 years, patients with peptic ulcer disease, and women who are pregnant or breastfeeding. Caution is required in patients with seizures and psychiatric disorders, in patients involved in hazardous activities, and in patients receiving anticoagulant therapy. Preparations, Dosage, and Administration Indomethacin [Indocin] is available in immediate-release capsules (25 and 50 mg), extended-release capsules (75 mg), an oral suspension (5 mg/mL), and rectal suppositories (50 mg). For treatment of rheumatoid arthritis, the initial dosage is 25 mg 2 or 3 times a day. A new form of indomethacin was recently approved and is available in 20- and 40-mg capsules sold as Tivorbex. Tivorbex is unique because the capsules contain particles that are 20 times smaller than traditional indomethacin particles. This allows for increased dissolution, thus producing an equianalgesic effect at smaller doses and therefore less toxic side effects. Ketorolac Actions and Uses Ketorolac is a powerful analgesic with minimal antiinflammatory actions. Although ketorolac lacks the serious adverse effects associated with opioids (respiratory depression, tolerance, dependence, abuse potential), it nonetheless has serious adverse effects of its own. Accordingly, use should be short term and restricted to managing acute pain of moderate to severe intensity. The usual indication is postoperative pain, for which ketorolac can be as effective as morphine. Pharmacokinetics Ketorolac is administered orally and parenterally (intramuscularly or intravenously). The half-life may be prolonged in older adults and in those with renal impairment. Owing to risks associated with prolonged use, treatment (parenteral plus oral) should not exceed 5 days. For patients with normal renal function who weigh more than 50 kg, the usual dosage is 2 sprays (one 15. Meclofenamate Meclofenamate is indicated for rheumatoid arthritis, osteoarthritis, mild to moderate pain, and dysmenorrhea. Because of this poor benefit-to-risk profile, meclofenamate is not a drug of first choice. Dosages are as follows: arthritis, 200 to 400 mg/day in three or four divided doses; moderate pain, 50 mg every 4 to 6 hours; and dysmenorrhea, 100 mg 3 times a day for up to 6 days. Mefenamic Acid Mefenamic acid [Ponstel, Ponstan ] is indicated for relief of primary dysmenorrhea and moderate pain.