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By: Daniel James George, MD

  • Professor of Medicine
  • Professor in Surgery
  • Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/daniel-james-george-md

In this final phase of therapy blood pressure medication starting with b buy generic hydrochlorothiazide on line, it is important to blood pressure medication karvea buy hydrochlorothiazide with mastercard identify the child’s concerns and encourage him/her to blood pressure zone chart order hydrochlorothiazide 12.5mg without a prescription take risks arteria auditiva cheap 12.5mg hydrochlorothiazide overnight delivery. A child can be encouraged to think about what he/she wants and make decisions about how he/she wants to accomplish that goal. A child can be encouraged to think about how he/she wants to behave and evaluate the outcome of his/her behavior and, if necessary, make changes. During the consolidation/termination phase, the child needs to practice that skill in other areas of his/her life. A child needs to identify those adults and peers who can be helpful and responsive to his/her needs. They need to know that this is perfectly normal; what matters is how they resolve their problems. A child needs to know how to define the problem, generate options, attempt solutions, and continue until the problem is solved. A child often benefits from acknowledging that he/she is “human” and that people make mistakes. The child must be able to seek out rewarding exchanges and avoid situations that he/she knows are dangerous or repetitive of abusive interactions. The child needs to feel worthy of positive interactions, believe that he/she is desirable, and that he/she deserves rewarding interactions with adults and peers. It is important to encourage the child to participate in social and community activities, develop hobbies and interests that help him/her connect with other children, and join teams and clubs that are of interest to them. The child needs to practice developing relationships with viable adults who will carry on the nurturing, interest, and attention that has been provided in therapy. In this way, the child learns to distinguish between helpful and hurtful behaviors, and he/she develops a support system and role models for relationships. In this final phase, the child transfers the knowledge and skills he/she has acquired in therapy to other areas of his/her life. For example, a child uses the therapeutic relationship as a model to evaluate his/her new teacher’s interest in his/her academic accomplishments. In a second example, an teenaged girl decides that she is not ready for a sexual relationship and is able to tell her boyfriend that she is worth “waiting for. The child may vacillate between wanting therapy to “get over with” and feeling fearful that he/she will not be able to manage without his/her therapist. The child benefits from hearing that change is often difficult, and saying goodbye to a therapist can feel somewhat like saying goodbye to a parent. The child also benefits from hearing that terminating a therapeutic relationship is a kind of loss that happens when he/she is ready to move on to another phase in his/her life. Sometimes, a child terminates his/her therapeutic relationship before he/she has integrated new thoughts, feelings, and skills that will increase his/her esteem, safety, and affiliation. The child is encouraged to contact the therapist if he/she needs help, wants to schedule a followup appointment, or continue therapy. These long-term issues include developmental milestones, such as puberty, when sexuality and relationship issues begin to be dominant themes for children; marriage with issues of trust, affiliation, and intimacy; and pregnancy and childbirth, which often trigger concerns about protection and safety for the young child, issues of loss and grief, and questions about parenting. The following factors can have an impact on the length of time necessary for resolution of the experience of child abuse and neglect: 58 fi the responses of relatives, friends, professionals, and the community; fi physical damage and/or permanent injury; fi loss of a parent from prosecution or abandonment; fi separation from the family and placement outside the home; fi parents’ inability to accept the child’s experience of abuse; fi parents’ unresolved issues from childhood; and fi investigation and participation in the criminal justice system. A thorough assessment enables the clinician to determine which method will best meet the child’s needs. Sometimes children participate in more than one modality, either in incremental steps or concurrently. They have the opportunity to work on interpersonal skills in individual therapy and reap the rewards of appropriate interaction during group. Psychoeducational groups that present information about the causes and effects of abuse and neglect and offer the opportunity to explore one’s experience can be an effective means of educating parents and introducing topics for them to explore in individual or group therapy. Primary Prevention Programs the purpose of primary prevention programs for children is to help the child become knowledgeable about his/her rights to safety and protection. Because children are known to be more seriously affected by prolonged abuse, knowing what abuse is and encouraging disclosure early in the abuse experience is a prevention goal well worth 156 the effort. In many communities, prevention programs are initiated in preschool and day care settings and in elementary school. Prevention programs give the child permission to talk about abuse and neglect and help the child understand what to do if abuse is occurring in his/her life. There is reason to believe that, in many situations, a child is not able to behave in the way that prevention 157 programs recommend. However, offenders report that a (child’s) threat to tell someone would have the greatest impact on deterring abuse. This message to children may be among the most 158 important that safety education programs can deliver. Play Therapy Play therapy is an effective modality that helps the child express feelings, act out behaviors, and gain mastery and control over memories and feelings generated by the abusive or neglectful experience. A child uses play to manage his/her fears and anxieties about the abuse, express his/her feelings about what happened to him/her, and demonstrate their knowledge and understanding about relationships. Play therapy allows the child to represent symbolically those events that generate fear and anxiety and helps the child move toward resolution and integration of the frightening experience. Play therapy is especially effective with children who do not have the verbal or cognitive skills necessary to participate in a more direct approach to discussing their feelings. A child who is developmentally or emotionally 59 unable to express him/herself verbally can benefit from an experience that allows him/her to demonstrate his/her feelings, fears, and attempts at mastery. Interventions need to be developed to help the child gain a sense of mastery and control over an overwhelming experience. It is incumbent upon the therapist to interpret this play material in a manner that adds insight and meaning to the child’s experience and facilitates resolution or closure of the traumatic event. Individual Therapy Usually, individual therapy is the child’s first introduction to treatment. It is an opportunity for the child to interact with a supportive and knowledgeable adult and develop a relationship that models appropriate adult/child relationships. Individual therapy also allows the therapist time to assess and evaluate the child’s interpersonal skills and help the child learn age-appropriate and engaging behaviors to interact with peers. The goal of individual therapy is understanding, integration, and resolution of those experiences that affect development, interaction, and safety. Individual therapy is most beneficial in helping children address developmental issues of trust, mastery and control, and identity. Individual therapy generally is helpful in supporting disclosure of abuse and neglect, helping the child identify issues related to their experience, and in resolving intrapersonal issues. A child who will testify during a criminal proceeding can benefit from individual therapy. It can help the child address his/her fear and anxiety related to confronting the perpetrator and testifying in front of strangers. Most children are also less likely to be affected by or incorporate other victims’ circumstances than are children who have participated in group therapy before having to testify. Group Therapy Group therapy is especially helpful for decreasing isolation, improving social skills, and monitoring and intervening in problematic interactional patterns of behavior. Group therapy also allows the child to identify and learn from peers and group leaders and helps the child learn new and possibly more effective ways of interacting and communicating about his/her circumstances. Group therapy can facilitate participation with a supportive and understanding peer group and allow the child to practice many of the skills that will improve his/her ability to affiliate and evaluate relationships. Additional benefits provided by group therapy include normalization of the experience by hearing similarities in victims’ feelings and responses to abuse or neglect, corrective capitulation of the primary family group, development of socializing techniques, acquisition of the sense of belonging, and 159 catharsis. Group therapy is not warranted for a child who is unable to manage his/her impulsive behavior. A child with limited social skills often needs individual therapy to prepare him/her for the social experience of group therapy. Family Therapy Family therapy is most helpful when the family is willing and able to view the abuse or neglect as an issue that needs to be addressed by all the members in the family. Family therapy is an opportunity to explore roles and relationships, help family members recognize the impact that their behavior has on each other, and increase family cohesion and belonging. Family therapy can facilitate problem solving and improve communication between 60 members. Family therapy seems most helpful after the individual family members have addressed their intrapersonal and developmental issues in individual or group therapy. Family therapy is often an effective tool to help family members address feelings related to reunification (when the child or offending parent has been removed from the family) and develop new behaviors that help each family member feel capable of contributing and benefiting from living together. Family therapy is not warranted when adults, especially if they are perpetrators of abuse, are unwilling to take responsibility for their behavior.

Diseases

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  • Induced delusional disorder
  • Spine rigid cardiomyopathy
  • Neuroaxonal dystrophy renal tubular acidosis
  • Prenatal infections
  • Aspergillosis
  • Spinal bulbar motor neuropathy
  • Morphea scleroderma

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It appears during the second much more likely than children to blood pressure buy hydrochlorothiazide australia become chronic carriers pulse blood pressure relationship buy hydrochlorothiazide with paypal. Rose spots are erythematous maculopapular Prevention lesions 2–3 mm in diameter that fade on pressure arteria recurrens ulnaris purchase 25 mg hydrochlorothiazide amex. They are Routine typhoid vaccine is not recommended in the United found principally on the trunk and chest and they generally States but should be considered for foreign travel to pulse pressure guidelines discount 12.5mg hydrochlorothiazide fast delivery endemic disappear within 3–4 days. Most patients will have negative cultures (including stool) by the end of a 6-week period. Third-generation cephalosporins such as cefotaxime (150 Serologic tests (Widal reaction) are not as useful as cultures mg/kg divided in three doses), azithromycin (10 mg/kg on because both false-positive and false-negative results occur. These include typhus, bruceland second-generation cephalosporins are clinically ineffeclosis, malaria, tularemia, miliary tuberculosis, psittacosis, tive regardless of in-vitro susceptibility results. In developed countries, where typhoid fever is febrile for 3–5 days even with appropriate therapy. General support of the patient is exceedingly important and Complications includes rest, good nutrition, and careful observation, with particular regard to evidence of intestinal bleeding or perfothe most serious complications of typhoid fever are gasration. Blood transfusions may be needed even in the trointestinal hemorrhage (2–10%) and perforation (1–3%). They occur toward the end of the second week or during the third week of the disease. The site of perforation generally is the terminal ileum A prolonged convalescent carrier stage may occur in chilor cecum. Three negative cultures after all antibiotics have been from those of acute appendicitis, with pain, tenderness, and stopped are required before contact precautions are stopped. With early antibiotic therapy, the prognosis is excellent, and Bacterial pneumonia, meningitis, septic arthritis, abscesses, the mortality rate is less than 1%. Relapse occurs 1–3 weeks and osteomyelitis are uncommon complications, particularly later in 10–20% of patients despite appropriate antibiotic if specific treatment is given promptly. Symptoms and Signs treatment of multidrug-resistant and nalidixic acid-resistant typhoid fever. Antimicrob Agents Chemother 2007;51:819 the incubation period of shigellosis is usually 2–4 days. Onset is abrupt, with abdominal cramps, urgency, tenesmus, Thaver D et al: Fluoroquinolones for treating typhoid and paratychills, fever, malaise, and diarrhea. The stool may contain gross blood and mucus, Pus and blood in diarrheal stools examined microscopand many neutrophils are seen if mucus from the stool is ically. Shigellae are nonmotile gram-negative rods of the family Enterobacteriaceae and are closely related to E coli. The Differential Diagnosis genus Shigella is divided into four major groups, A–D, Diarrhea due to rotavirus infection is a winter rather than a representing Shigella dysenteriae, Shigella flexneri, Shigella summer disease. Usually children with rotavirus infection boydii, and Shigella sonnei, respectively. Approximately 30,000 are not as febrile or toxic as those with shigellosis, and in cases of shigellosis are reported each year in the United rotavirus infection, stool does not contain gross blood or States. Grossly bloody S dysenteriae, which causes the most severe diarrhea of all stools in a patient without fever or stool leukocytes suggest E species and the greatest number of extraintestinal complicacoli O157:H7 infection. Amebic dysentery is diagnosed by tions, accounts for less than 1% of all Shigella infections in microscopic examination of fresh stools or sigmoidoscopy the United States. Intussusception is characterized by an abdominal Shigellosis may be a serious disease, particularly in young mass (so-called currant jelly stools) without leukocytes, and children, and without supportive treatment an appreciable by absence of fever. In older children and adults, the clinically from other forms of infectious diarrhea. Foodand water-borne Complications outbreaks are increasing in occurrence, but are less important overall than person-to-person transmission. The disease Dehydration, acidosis, shock, and renal failure are the major is very communicable—as few as 200 bacteria can produce complications. The secondary attack rate in families is occurs, characterized by mucoid stools and poor nutrition. Fulminating ease by invading the colonic mucosa, causing mucosal ulcerfatal dysentery and hemolytic-uremic syndrome occur rarely. Ampicillin Extreme and rapid dehydration and electrolyte loss, (100 mg/kg/d, given in four divided doses) is also efficawith rapid development of vascular collapse. Parenteral ceftriaxone and oral cefixime are both effective; experience with other Contact with a case of cholera or with shellfish, or the third-generation oral cephalosporins is limited. Ciprofloxacin (500 mg, given twice daily for 5 days) is efficacious in adults but is not approved for use in children. However, it may be General Considerations used in children who remain symptomatic and in need of Cholera is an acute diarrheal disease caused by the gramtherapy, and when multiply resistant strains limit other negative organism Vibrio cholerae. Successful treatment reduces the durataminated water or food, especially contaminated shellfish. Presumptive theryoung children may play an important role in transmission apy should be limited to children with classic shigellosis or of the infection. The age-specific attack rate is highest in children younger than age 5 years and declines B. Cholera toxin is a protein enterotoxin that is primarily In severe cases, immediate rehydration is critical. Cholera toxin binds to a regulaform of chronic malabsorption syndrome may supervene tory subunit of adenylyl cyclase in enterocytes, causing and require prolonged dietary control. Prognosis Nutritional status is an important factor determining the the prognosis is excellent if vascular collapse is treated severity of the diarrhea. The most recent pandemic, Shigella lasts 1–4 weeks in patients not receiving antimicrocaused by the El Tor biotype of V cholerae 01, began in 1961 bial therapy. Epidemic cholera spread in Central and South America, with a total of 1 million cases and 9500 deaths reported through 1994. Cases in the United States occurred Ashkenazi S: Shigella infections in children: New insights. Cholera is increasingly antimicrobial treatment options for children and challenges of associated with consumption of shellfish. Cholera is now rare in the United States with fewer Mandomando I et al: Epidemiology and clinical presentation than 10 cases per year reported. Symptoms and Signs one dose for 1–5 days) shortens the duration of the disease in Many patients infected with V cholerae have mild disease, children and prevents clinical relapse but is not as important with 1–2% developing severe diarrhea. Tetracycline resistance era, there is a sudden onset of massive, frequent, watery occurs in some regions, and ciprofloxacin may be used stools, generally light gray in color (so-called rice-water depending on local resistance patterns. Within 2–3 hours, the tremendous loss of fluids results in lifePrognosis threatening dehydration, hypochloremia, and hypokalemia, With early and rapid replacement of fluids and electrolytes, with marked weakness and collapse. If significant mia and irreversible peripheral vascular collapse will occur if symptoms appear and no treatment is given, the mortality fluid therapy is not administered. Stool Qureshi K et al: Breast milk reduces the risk of illness in children of mothers with cholera: Observations from an epidemic of sodium concentration may range from 80–120 mEq/L. Chemoprophylaxis is indicated for household and other close contacts of cholera patients. It should be initiated as soon General Considerations as possible after the onset of the disease in the index patient. Campylobacter species are small gram-negative, curved or Tetracycline (500 mg/d for 5 days) is effective in preventing spiral bacilli that are commensals or pathogens in many infection. In the 1990s, C jejuni was responsible for 3–11% Treatment of cases of acute gastroenteritis in North America and Europe. Physiologic saline or lactated Ringer solution should be In many areas, enteritis due to C jejuni is more common than administered intravenously in large amounts to restore that due to Salmonella or Shigella. Campylobacter fetus causes blood volume and urine output and prevent irreversible bacteremia and meningitis in immunocompromised patients. Sodium bicarC fetus may cause maternal fever, abortion, stillbirth, and bonate, given intravenously, also may be needed initially to severe neonatal infection. Helicobacter pylori (previously called overcome profound metabolic acidosis from bicarbonate Campylobacter pylori) causes gastritis and peptic ulcer disease loss in the stool. The optimal composition of the oral soluwith sick puppies or other animal contacts. Contaminated tion (in mEq/L) is as follows: Na+, 90; Cl–, 80; and K+, 20 food and water, improperly cooked poultry, and person-to(with glucose, 110 mmol/L).

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Case 3: (6 marks) A lady came to heart attack grill generic hydrochlorothiazide 25mg without prescription dermatology clinic suffering from acne-like lesions & comedones (black heads) wykladzina arteria 95 order hydrochlorothiazide 12.5mg with visa. On examination pre hypertension vs hypertension order 25 mg hydrochlorothiazide amex, the doctor noticed that the lesions are located around the mouth & chin as shown in the figure below: 1What is your probable diagnosisfi The following statement about schistosomiasis is true: aSchistosomulae penetrate the skin or mucous membrane bPraziquantel is effective against all Schistosoma species arrhythmia back pain order hydrochlorothiazide cheap online. The following parasite is tissue dwelling, causing cystic cavities in the lung with brownish purulent sputum and eosinophilia: aEchinococcus granulosus bParagonimus westermani cEntamoeba histolytica dAscaris lumbricoides 3. House dust mites cause allergic manifestations because: aThey are blood sucking causing itching and dermatitis bThey live in hair follicles causing erythema and scaling cTheir bodies and excreta are potent allergens dThey burrow tunnels in the horny layer of the skin 4. The following parasite is transmitted cylodevelopmentally by its vector: aLeishmania donovani bWuchereria bancrofti 114 cPlasmodium vivax dTrypanosoma cruzi 5. Serology is the usual method of diagnosis of: aTaeniasis bGiardiasis cTrichomoniasis dVisceral larva migrans 6. The following parasite infects the billiary tract aTaenia solium bEntamoeba coli cTrichuris trichiura dMicrosporidia 7. Malabsorption and atrophy of the villi may be caused by the following intracellular intestinal parasite: aGiardia lamblia bCapillaria philippinensis cCyclospora cayetanensis dStrongyloides stercoralis 8. Man can be infected with eggs of the following cestode: aTaenia saginata bHymenoleps diminuta cTaenia solium dDipylidium caninum 11. Norwegian (crusted) scabies aIs a mild form of scabies 115 bOccurs in immunodeficient patients cCrusts are formed due to treatment dAffects the interfigital spaces only 12. Leishmania donovani evades the immune system through: aCleavage of antibodies bAcceleration of decay of complement cAntigen mimicry dInibition of macrophages 13. In intestinal amboebiasis: aInvasion of the muvosa usually occurs in the caecum bthe stool is alkaline with scanty faecal matter cMalabsorption is a common complication dScraping fgrom the lesions shows the quadrinucleate cyst stage 15. Espundia is seen n patients from: aNorth Africa bSouth Africa cNorth Africa dSouth Africa 16. Isospora multiplies in: athe lumen of duodenum bthe lumen of ileum cthe lumen of the large intestine dthe epithelial lining of the small intestine 17. The infective stage for female Anopheles in malaria is the: aSporozoite bOokinete cGametocyte dMerozoite 18. Oocysts cause auto-infection with the following parasite: aCryptosporidium parvum bToxoplasma gondii cCylospora cayetanensis dEntamoeba histolytica 20. Charcot-Leyden crystals could be present in stool in: aGiardiasis bBalantidiasis cAmoebiasis dCryptosporidiosis 21. Scabies is characterized by: aPainful nodular swelling at the site of bite bMites live in tunnels in the subcutaneous tissue cPotassium hydroxide is the most effective acaricide dTransmission occurs by contact 22. High eosinophilia is one of the laboratory findings in: aCapillariasis bHymenolepiasis nana cBalantidiasis dFascioloasis 24. In acanthamoebiasis: athe invasive stage is the amoeboflagellate bTrophozoite only can be found in the brain cthe trophozoite reaches the brain through the cribriform plate dChronic inflammation of the brain is seen 27. The following disease is transmitted by lice: aEndemic relapsing fever bQ fever cEpidemic relapsing fever dPlague 28. Bilharzial cor pulmonale is due to: aDeposition of immune complex in small pulmonary blood vessels bEgg emboli in pulmonary blood vessls cReaction around schistosomules in lung dReaction around mature adult worms in lung 29. The following intestinal protozoal parasite is transmitted only through heteroinfection: aCylospora cayetanensis bEntamoeba histolytica cGiardia lamblia dCryptosporidium parvum 30. The patient gave a history of a nodule at the site of the lesion several months ago. What is the extent of acquired immunity in this condition and what is the prognosis of this infection if untreatedfi Mention 2 similar parasites present in other geographical areas and describe their clinical picture (3 marks). Recrudescence of Plasmodium falciparum infection is due to activation of hypnozoites dormant in the liver due to immunosuppression. Detection of anti-Toxoplasma IgM in maternal blood is diagnostic of congenital infection of her baby. Conjugation between Balantidium coli trophozoites results in doubling of their number. Serious and sometimes fatal effects of ascariasis can occur due to eggs trapped in the tissues. Undermined ulcer eCryptosporidium parvum fFalciparum malaria gSchistosomiasis haematobium (1. The ulcer resists treatment by known antibiotics 1What is your provisional diagnosisfi On examination the doctor found that the cause of such distension was increase in size of liver and spleen as shown in the figure below. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. 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Angioedema can be distinguished from after local cold challenge without immediate lesions arrhythmia recognition course cheap 25mg hydrochlorothiazide fast delivery. Hereditary angioedema is a rare autosomal domfollowed by morbilliform erythema and urticaria arrhythmia reentry hydrochlorothiazide 12.5mg mastercard. Lifeepisodes are triggered by stress or the ingestion of certain threatening laryngeal angioedema may occur arrhythmia from caffeine purchase hydrochlorothiazide 12.5 mg overnight delivery. In cold-induced disease blood pressure chart age 40 order hydrochlorothiazide from india, sudden cooling of the entire body as can occur with swimming can result in hypotension and collapse. Prognosis Spontaneous remission of urticaria and angioedema is freTreatment quent, but some patients have a prolonged course. General Measures ance is important, because this disorder can cause significant frustration. Periodic follow-up is indicated, particularly for the most effective treatment is identification and avoidance patients with laryngeal edema, to monitor for possible of the triggering agent. For breakthrough symptoms, the Serious allergic reaction that is rapid in onset and may dose may need to be increased. In the case of cold urticaria, cause death after exposure to allergen in a previously the best treatment appears to be cyproheptadine. The addition Generalized pruritus, anxiety, urticaria, angioedema, of H2 antihistamines may benefit some patients who fail to throat fullness, wheezing, dyspnea, hypotension, and respond to H1-receptor antagonists alone. Corticosteroids that occurs when large quantities of inflammatory mediators are rapidly released from mast cells and basophils Although corticosteroids are usually not indicated in the after exposure to an allergen in a previously sensitized treatment of acute or chronic urticaria, severe recalcitrant patient. Anaphylactoid reactions mimic anaphylaxis but cases may require alternate-day therapy in an attempt to are not mediated by IgE antibodies. They may be mediated diminish disease activity and facilitate control with antihistaby anaphylatoxins such as C3a or C5a or through nonimmines. Systemic corticosteroids may also be needed in the mune mast cell degranulating agents. Some of the comtreatment of urticaria or angioedema secondary to necrotizmon causes of anaphylaxis or anaphylactoid reactions are ing vasculitis, an uncommon occurrence in patients with listed in Table 36–12. Limited studies suggest that some patients may benefit from treatment with a leukotriene-receptor antagonist. The triClinical Findings cyclic antidepressant doxepin blocks both H1 and H2 histaA. Symptoms and Signs mine receptors and may be particularly useful in chronic urticaria, although its use may be limited by the sedating the symptoms and signs of anaphylaxis or anaphylactoid side effect. A limited number of patients—including euthyreactions depend on the organs affected. Onset typically roid patients—with chronic urticaria and antithyroid anoccurs within minutes after exposure to the offending agent tibodies have improved when given thyroid hormone. Common causes of systemic Tryptase released by mast cells can be measured in the serum allergic and pseudoallergic reactions. The blood sample should be obtained within 3 Drugs hours of onset of the reaction, although tryptase levels are Antibiotics often normal, particularly in individuals with food-induced Anesthetic agents anaphylaxis. The complete blood count may show an eleFoods vated hematocrit due to hemoconcentration. Elevation of Peanuts, tree nuts, shellfish, and others serum creatine kinase, aspartate aminotransferase, and lactic Biologicals Latex dehydrogenase may be seen with myocardial involvement. Antisera Arterial blood gases may show hypoxemia, hypercapnia, and Blood products acidosis. Enzymes Monoclonal antibodies (eg omalizumab) Insect venoms Differential Diagnosis Causes of anaphylactoid reactions Although shock may be the only sign of anaphylaxis, other Radiocontrast media Aspirin and other nonsteroidal anti-inflammatory drugs diagnoses should be considered, especially in the setting of Anesthetic agents sudden collapse without typical allergic findings. Anaphylaxis is highly likely when any one of the following Mastocytosis, hereditary angioedema, scombroid poisoning, three criteria are fulfilled: vasovagal reactions, vocal cord dysfunction, and anxiety 1. Acute onset of an illness (minutes to several hours) with attacks may cause symptoms mistaken for anaphylaxis. Respiratory compromise (eg, dyspnea, wheeze-bronreaction, complications may vary from none to aspiration chospasm, stridor, reduced peak expiratory flow, pneumonitis, acute tubular necrosis, bleeding diathesis, or hypoxemia) sloughing of the intestinal mucosa. Reduced blood pressure or associated symptoms of heart and brain damage can be terminal. Risk factors for end-organ dysfunction (eg, hypotonia [collapse], synfatal or near-fatal anaphylaxis include age (adolescents and cope, incontinence) young adults), reactions to peanut or tree nuts, associated 2. Two or more of the following that occur rapidly after asthma, strenuous exercise, and ingestion of medications exposure to a likely allergen for that patient (minutes to such as fi-blockers. Involvement of the skin-mucosal tissue (eg, generalPrevention ized urticaria, itch-flush, swollen lips-tongue-uvula) Strict avoidance of the causative agent is extremely imporb. Reduced blood pressure or associated symptoms (eg, temporal relationship between exposure and onset of symphypotonia [collapse], syncope, incontinence) toms. Persistent gastrointestinal symptoms (eg, crampy abor skin testing may be indicated. With exercise-induced dominal pain, vomiting) anaphylaxis, patients should be instructed to exercise with 3. Reduced blood pressure after exposure to a known alleranother person and to stop exercising at the first sign of gen for that patient (minutes to several hours) symptoms. Infants and children: low systolic blood pressure (age speeating within 4 hours—perhaps up to 12 hours—before cific) or greater than 30% decrease in systolic pressure exercise should be avoided. Low systolic blood pressure in children, defined as less laxis should carry epinephrine for self-administration (eg, than 70 mm Hg in those aged from 1 month to 1 year, EpiPen or Twinject in 0. Patients with idioIntravenous methylxanthines are generally not recompathic anaphylaxis may require prolonged treatment with mended because they provide little benefit over inhaled fi2oral corticosteroids. Corticosteroids Treatment Although corticosteroids do not provide immediate benefit, when given early they may prevent protracted or biphasic A. Intravenous methylprednisolone, 1–2 mg/kg, or Anaphylaxis is a medical emergency that requires rapid hydrocortisone, 5 mg/kg, can be given every 4–6 hours. Exposure to the triggering agent prednisone, 1 mg/kg up to 50 mg, might be sufficient for less should be discontinued. Oxygen Hypotension refractory to epinephrine and fluids should be should be delivered by mask or nasal cannula with pulse treated with intravenous vasopressors such as noradrenaline, oximetry monitoring. Epinephrine the patient should be monitored after the initial symptoms Epinephrine is the treatment of choice for anaphylaxis. Epihave subsided, because biphasic or protracted anaphylaxis nephrine 1:1000, 0. This dose in 1–20% of anaphylactic reactions, but no reliable clinical may be repeated at intervals of 5–15 minutes as necessary for predictors have been identified. If the be individualized based on the severity of the initial reaction, precipitating allergen has been injected intradermally or but a reasonable time for observation is 4–6 hours in most subcutaneously, absorption may be delayed by giving 0. There is no precisely established dosing regimen for intravenous epinephrine in anaphylaxis, but a 5–10-mcg Prognosis intravenous bolus for hypotension and 0. In two reports describing children, adolescents, and adults who died from foodC. Antihistamines induced anaphylaxis (eg, from peanuts, tree nuts, fish, shellfish, and milk) over the past 12 years, treatment with Diphenhydramine, an H1-blocker, 1–2 mg/kg up to 50 mg, epinephrine was delayed for more than 1 hour after onset can be given intramuscularly or intravenously. Addition of ranititoms are recognized promptly and treated aggressively, dine, an H2-blocker, 1 mg/kg up to 50 mg intravenously, may and the offending agent is subsequently avoided. Exercisebe more effective than an H1-blocker alone, especially for induced and idiopathic anaphylaxis may be recurrent. Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. In the presence of serum complement, the Most adverse drug reactions are not allergic although antibody-coated cell is either cleared or destroyed, causing patients or caregivers often report them as a drug drug-induced hemolytic anemia or thrombocytopenia. Sensitization usually occurs via cally mediated and may be due to idiosyncratic reactions, the topical route of administration. Stevens-Johnson syndrome, exfoliative dermatitis, and the Patients or caregivers often describe an adverse drug maculopapular rash associated with penicillin or ampicillin. Adverse drug reactions are any undesirHowever, patients given ampicillin during Epstein-Barr able and unintended response elicited by a drug. Allergic or virus and cytomegalovirus infections or with acute lymphohypersensitivity drug reactions are adverse reactions involvblastic anemia have a 69–100% incidence of non-IgE-mediing immune mechanisms. They may result from an inherited propensity for hepatic biotransformation of drug into toxic 1. The incidence of “allergic” Antibiotics constitute the most frequent cause of allergic cutaneous reactions to trimethoprim–sulfamethoxazole in drug reactions. The Clinical Findings penicillins and other fi-lactam antibiotics, including cephaA.

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