Zantac

By I. Berek. Worcester State College.

This necessitates the use of a fairly heavy inoculum (usually several colonies) order zantac 300 mg with amex, which in turn means that it should be used only where one is reasonably certain of being able to obtain an inoculum consisting entirely of one organism (especially since no purity check will be available when the strip is read) purchase 150 mg zantac with visa. Note particularly that Escherichia coli will give reactions of Shigella if insufficient reaction occurs. Always be suspicious of an identification (in any system) based only on a few characteristics. As long as one is alert to such rarities as Haemophilus in a urethral swab or Pasteurella in a sputum, the vast majority of isolates can be easily identified by the standard methods. The simple scheme below will allow the identification of the great majority of isolates of anaerobes, at least to the degree required. Even here, of course, the vast majority of isolates can be readily recognised by colonial appearance on the different media employed and identified in the usual simplistic manner. Note that both systems have problems with Enterobacter/Klebsiella; in doubtful cases, a motility test may settle the question. Capsular swelling (the swelling of capsule on the surface of the bacterium in the presence of specific antiserum) may also be useful in identifying Klebsiellla. Pseudomonas aeruginosa is usually recognisable by appearance (it commonly produces a green pigment) and distinctive odour. It grows on blood agar, enriched chocolate agar with bacitracin and on MacConkey agar, but not on colistin nalidixic agar. One can also learn to recognise such organisms as Flavobacterium, Burkholderia cepacia and Stenotrophomonas maltophilia by appearance and smell. Flavobacterium, Alcaligenes and Achromobacter are all oxidase positive organisms that are often resistant to aminoglycosides. A Gram stain should be the first step for organisms whose probable identity is unknown. Diagnosis and Management of Infectious Diseases Page 421 Identification of Isolates Oxidase negative rods of similar morphology are probably Acinetobacter. For other isolates, perform oxidase and catalase tests and set up O-F, motility, urea and indole tests. On the other hand, using the above few tests in Cowan and Steele’s tables, Balow’s keys and/or the Weaver-Hollis scheme will lead directly to an identification in many cases and provide a sure path to identification in most others. No Growth on MacConkey, Growth on Blood Agar The appearance and smell may well give a clue to the organism’s identity. The Gram stain will also often be very helpful, being quite characteristic for many organisms in this group. If you know the organism is an obligate aerobe, a combination of oxidase test, Gram stain and motility will soon tell you what genus you have. An oxidase negative organism will either be a Pseudomonas species or Bordetella parapertussis. An oxidase positive organism will either be Pseudomonas, Flavobacterium, Bordetella parapertussis, Bordetella bronchiseptica or Moraxella. Bordetella bronchiseptica gives a positive spot urease test in two minutes or a positive tube test in < 4 hours. If you know the organism is oxidative, the only choices are Pseudomonas and Flavobacterium. Eikenella corrodens again is usually easily recognised by colonial appearance and smell, though it can be mistaken for a streptococcus. Other organisms in this group for which Gram stain recognition is important are Gardnerella, Brucella, Campylobacter and salt-requiring Vibrio species. Gardnerella produces tiny non-hemolytic colonies resembling lactobacilli on blood agar but tiny -hemolytic colonies on special Gardnerella medium. For other organisms which do not meet the above criteria, oxidase and catalase tests should be performed, O-F, indole, urea and nitrate tests set up and the appropriate keys and tables followed. No Growth on Blood Agar, Growth on Enriched Chocolate Agar Gram negative bacilli which may not grow on either MacConkey agar or blood agar but which grow on enriched chocolate agar are Brucella, Campylobacter, Haemophilus and Streptobacillus moniliformis. These can all be readily separated on cellular morphology and identified appropriately. Water-soluble factors (X, V and X+V) are impregnated into discs or filter paper strips or rings and placed on a medium deficient in these factors (brain heart infusion or trypticase soy agar) which has been inoculated with the organism. The porphyrin test is regarded as a more reliable test for X factor requirement than the X factor disc method. All species are strict aerobes and oxidase positive and have characteristic colonial and cellular morphology. Neisseria gonorrhoeae, Neisseria meningitidis and Neisseria lactamica are the only Neisseria species that regularly grow on New York City medium, while Neisseria gonorrhoeae and Neisseria meningitidis do not grow on nutrient agar. However, note that a high inoculum density can produce a false result in these tests and that nutrient agar means a nutrient agar such as brain heart infusion agar, not an enriched nutrient agar such as Columbia agar (on which Neisseria meningitidis will grow).

Also cheap zantac 150 mg with amex, hemophilia A hereditary blood defect (in one’s choice of health resources often depends on males) that slows the clotting of blood and some- ability to pay and on the patient’s use of public times makes stopping bleeding very difficult zantac 300 mg on-line. The charity facilities or others that are covered by her hemophiliac lacks a protein necessary for blood or his individual health insurance, Medicare, or clotting; for this reason, the individual bleeds Medicaid. The specific goal in respect to sexual behavior is to increase the number of adolescents who abstain hepatitis A Hepatitis A is a virus that is infectious from sexual intercourse or use condoms if they are and contagious and produces inflammation of the sexually active. Hepatitis A, B, and C can cause acute infec- adults, the goal is to increase the use of condoms tions, but B and C can become chronic. Besides these aims, Healthy People 2010 has 28 Cause total focus areas with numerous objectives. The Typically, hepatitis A infection is person-to-person agenda can be viewed on the Web: http://www. Helms Amendment Enacted in 1987, this law One gets hepatitis A by ingestion of infected sought to prohibit people from entering the United fecal matter. Many people get hepa- Doctors often encourage their patients to take titis A by eating food that was prepared by some- advantage of the immunization for hepatitis A, one who did not wash his or her hands thoroughly especially for international travel. Many health after a bowel movement and thus had feces experts believe that children who live in high-dis- remaining on the skin. This virus is easily trans- ease-incidence areas should be immunized, along mitted via food contaminated during preparation. The virus gets into the mouth infected person, which accounts for 12 to 26 per- or on food during preparation. Other associations are 11 to 16 per- have been outbreaks of hepatitis A among gay men cent in day care centers; 4 to 6 percent in that some believe may have been caused by this international travel; 2 to 3 percent via food or kind of transmission. Native American number of sexual partners a man has, the more reservations and Alaskan Native villages have a likely he is to contract hepatitis A. Also, a woman high rate of hepatitis A: about 30 to 40 percent of who engages in the sexual practices of oral–anal or the children are infected by age five, and almost all digital–anal contact is at increased risk of contract- in the community are infected by the time they ing hepatitis A. Young children rarely have atitis A vaccinations for homosexual men at age symptoms, but adults usually do. If someone does have antibodies, these confer pro- Treatment tection against getting the infection again. A per- If someone does contract hepatitis A, a physician son who has a negative result on a blood test but usually recommends rest, fluids, and medication has good reason to suspect infection should repeat to counter nausea. In people with liver problems, hepati- interest is the fact that some individuals whose tis A can be very serious. In some cases, a person blood shows evidence of having had this disease in with hepatitis A does not recover strength com- the past were never aware that they contracted or pletely for several months. The blood test result can turn up negative if the Cause individual has recently been infected. A liver One way that hepatitis B is contracted is via sexual biopsy may be necessary to determine stage of intercourse, especially anal. A test that measures liver function can- transmitted by drug addicts’ sharing of needles, by not be used to rule out hepatitis infection. If a per- vertical transmission (mother to child), and in son proves to be a hepatitis B carrier, a blood test health care environments. The more sex partners a for hepatitis D (delta hepatitis) should be done, person has, the more likely she or he is to get hep- because this can only occur in someone who has atitis B. Also at higher risk are those who have a hepatitis B—and, together, the two can create a seri- sexually transmitted disease. A small percentage of sufferers have extensive Hepatitis B varies greatly, appearing in both mild liver damage that eventually results in death. Although it is usually symptom-free, hepatitis B Treatment can also make the infected person experience any Once a person has hepatitis B, no form of treat- one or a combination of a variety of symptoms: ment can eradicate it. Fortunately, though, some- tiredness, anorexia, nausea, vomiting, headache, times the body of a hepatitis B carrier eventually fever, jaundice, dark urine, and liver tenderness manages to clear the infection spontaneously. A person with hepatitis B may have As far as treatment goes, people with chronic yellow eyes and skin and brown urine, and symp- hepatitis B infection sometimes benefit from alpha- toms may be similar to those of very severe flu. Sometimes, oral medications appear about two to three months after contracting such as lamivudine or adefovir are used. Symptoms that do occur are often eral rule, those who have hepatitis B cannot drink severe and last about six weeks. Sometimes people who have hepatitis B feel In some people who turn out to be carriers, sick off and on for a long time, but most sufferers chronic active hepatitis, whereby the virus gradu- recover from the infection and cannot be rein- ally destroys the liver, leading to cirrhosis, or scar- fected. These are people seen much more often in those who have had hep- whose immune systems were not strong enough to atitis B than in the general population, can also rid them of the infection entirely. Of special infectious than carriers of the chronic active vari- hepatitis C 75 ety, and their disease is much less likely to proceed of sexually transmitted diseases, and a long-term to cancer or cirrhosis. Further, it is unlikely that The means of transmission of hepatitis B include casual contact or household exposure that is non- sexual contact and blood-to-blood contact. A In a long-term monogamous relationship, the risk needlestick injury and a transfusion with infected of transmitting this disease is considered less than blood or blood products are two other possibilities.

The wash wash programme to allow extra water to cloths may be disposable or changed daily and mechanically reduce the soiling cheap zantac 300mg with mastercard. Remember that sunlight aids disinfection zantac 300mg without a prescription, and then steam iron to Now carry out Learning Activity 9. Alternatively, the items could be tumble-dried and ironed at a lower Care of bedclothes, clothing, and other linen temperature. Staff and caregivers should wear disposable gloves and plastic aprons when removing any used Coughing and obtaining sputum samples bedclothes from the bed. Wash and dry handkerchiefs or other disposable paper to cover hands carefully after taking off gloves. Bed linen (sheets, towels, cotton sheets or quilts) Sputum samples should be transported in plastic should be washed in a hot temperature load, as bags and labelled High Risk. Page 186 Module 6 Any contaminated paper handkerchiefs should be at a registered disposal site. The easiest way to dispose of the waste is by burning Items such as flowers, newspapers or paper waste or incineration as clinical waste. If sputum containers are used they must be handled Care in the community with caution. Disposable-type containers can be Patents who are cared for in their own home while incinerated. Re-useable ones may be emptied into still infectious need simple infection control a sluice or toilets taking great care not to splash precautions: the surrounding environment. The used container • Adequate ventilation of the room where the may be reprocessed in a washer/disinfector machine patient is coughing. Empty the sputum into the sluice or Last offices/last rites toilet as mentioned previously. Clean container by Infection control precautions are also necessary immersing it in a bowl of detergent and warm during last offices. The deceased should be handled water, rinse with cold water and then immerse in with care to minimize the risk of exhalation of disinfectant for the required time. Funeral directors, religious elders and those cold water prior to leaving to air dry and then reuse. Training in the use of If an autopsy is required to confirm the cause of disinfectants must be given as part of the Infection death, the pathologist must be advised of the Control Induction programme for new staff. A body bag may be Waste that is not contaminated by sputum, blood or requested for transport of the deceased to the body fluids such as bronchial secretions, does not need mortuary. The body bag should be clearly labelled to be treated as clinical or High Risk Waste. Page 187 Clinical waste should be burnt or incinerated by an approved method or may be treated by steam A summary of infection control procedures can be and microwave to disinfect prior to deep landfill found in Appendix 3. If contaminated with bronchial secretions disinfection is necessary (see Disinfectant Policy) •care of linen – treat as soiled unless contaminated with bronchial secretions, when it should go into a water-soluble bag and as hot a wash as the fabric will tolerate • disposal of rubbish – treat as clinical type waste if contaminated by sputum • cleaning – routine cleaning • investigations – contact Head of Department prior to moving out of the isolation room – observe precautions en route and in other clinical areas •specimens - avoid contamination of outside of container; label sputum specimens “High Risk” and transport in plastic specimen bag • terminal cleaning – routine cleaning only required. Since there are so many important issues that need to be discussed, the Module is divided into two parts: Part I. Female genito-urinary tract Kidney Kidney Ureter Ureter Seminal vesicle Fallopian tube Bladder Ovary Rectum Uterus (womb) Anus Bladder Urethra Rectum Urethra Vagina Anus Diagram 3. Sexually transmitted infections are a Nurses and midwives need to be aware of the role major public health problem, not only because they gender plays in discussions regarding sexual health are a cause of far reaching morbidity, affecting and sexuality in general. In the European Region, This may make us embarrassed about talking about particularly in parts of Eastern Europe, there has sex, or about certain aspects about sex. Cultural sensitivity is important, including Controlling the spread of sexually transmitted awareness of any surrounding issues and language. The mucous membranes lining the vagina broader issues of importance that should be are also potentially more susceptible than those considered by anyone working in sexual health. In addition, menstruation Module 7, Part I Page 201 may increase risk of infection, due to the bleeding, providing an easier route of access for organisms. Similarly, the “passive” or “non-active” partner in a gay relationship is more likely to become infected. Medicine has been principally responsible for attaching deviancy labels to sexual practices decreed as not “normally” practiced. Sexuality and sexual health Nurses and midwives are expected to provide non- judgemental holistic care to their patients; however, sexual health is often overlooked, or only dealt with in the context of illness and disease. Gay and lesbian identity A great variety of pejorative terms have been used to describe individuals who have same-sex partners. Men who have sex with men and identify as being homosexual are usually comfortable with being called Gay. Gay men and lesbian women see their identity and the outward expression of that identity as being central to their sexuality and self-esteem. Neonatal • Urethral discharge chlamydia is most commonly demonstrated as • Mucoid or mucopurulent urethral discharge conjunctivitis and pneumonia. Untreated chlamydia can lead to the • Ectopic pregnancy – the risk increases by seven complications described. Complications in men • Approximately 1% of men with chlamydia will develop reactive arthritis.

On ausculta- tion order 150mg zantac with mastercard, the first heart sound was normal and the second heart sound was single buy zantac 150 mg free shipping. The pulmonary vascular markings are decreased, suggesting decreased pulmonary blood flow. The differential at this juncture should include pulmonary pathology, cardiac pathology, as well as sepsis. A systolic murmur in the upper sternal border in a cyanotic new- born is suggestive of a congenital cyanotic heart defect. In this case, pulmonary blood flow depends on a patent ductus rather than numerous systemic to pulmonary arte- rial collaterals. Management The patient should be immediately initiated on prostaglandin infusion to keep the ductus arteriosus patent and maintain an adequate source of pulmonary blood flow. This can be done in the cardiac catheterization laboratory; however, if not possible, surgical reconstruction of the right ventricular outflow tract can then be performed. Case 2 A 16-month-old boy presented to the emergency department because of increased work of breathing and “progressively turning blue” during the prior recent months. In his first months of life, he was tachypneic and struggled with weight gain, but then improved until a few months ago when cyanosis developed. Physical Exam On physical examination, the patient was cyanotic and in respiratory distress. Cardiac auscultation revealed a single second heart sound and a blowing continuous murmur was heard over the precordium as well as over the back. Heart disease becomes more apparent once you examine this child and hear the continuous murmur over the precordium and back. The dys- morphic facial features along with cyanotic heart disease can help the practitioner with the differential diagnosis. He also has dysmorphic features common to DiGeorge/Velocardiofacial syndrome and this should prompt the suspicion for possible associated congenital heart disease commonly involving the conotruncal lesions such as tetralogy of Fallot and pulmonary atresia. As noted by the mother, this patient was not significantly cyanotic at birth, but actually had increased pul- monary blood flow causing his failure to thrive and increased work of breathing initially. As the patient grew older, he outgrew this 17 Pulmonary Atresia with Ventricular Septal Defect 213 source of pulmonary blood flow and started getting more cyanotic. In addition, the development of areas of stenoses in the systemic to pulmonary arterial collaterals caused a decrease in pulmonary blood flow. Typical of patients with DiGeorge syndrome (chromosome 22q11 deletion), the pulmonary arteries are commonly abnormal or discontinuous as in this case. Management This patient needs surgical intervention to improve his pulmonary blood flow. This patient should also be evaluated for findings associated with 22q11 deletion. Finally, the family should be coun- seled regarding importance of proper pediatric followup since this is an unusual late presentation. Children with ventricular septal defect tend to have increased pulmonary blood flow, while those with intact ventricular septal defect rely on the patency of ductus arteriosus to supply pulmonary blood flow. As the ductus arteriosus constricts, pulmonary blood flow is severely limited resulting in cyanosis. This makes it the third most common form of cyanotic congenital heart disease after tetralogy of Fallot and transposition of the great arteries. Anatomy/Pathology The absence of a tricuspid valve orifice causes blood from the right atrium to flow into the left atrium through a foramen ovale or atrial septal defect. The development of the right ventricle relies largely on blood flow during fetal life, so it is invariably hypoplastic. Atresia of the tricuspid valve prevents antegrade flow into the right ventricle, thus causing hypoplasia of the right ventricle. Type I: when the great arteries are normally related (approximately 70% of cases). Systemic and pulmonary venous blood then mixes in the left atrium and passes through the mitral valve to the left ventricle. These patients become more cyanotic over the first hours of life as the ductus arteriosus constricts resulting in drop in pulmonary blood flow. However, as systemic vascular resistance increases and pulmonary vascular resistance decreases over the first few days of life, blood will preferentially flow into the pulmonary artery causing excessive pulmonary blood flow and congestive heart failure. This situation mimics mitral atresia because although the ventricle on the left side of the heart develops normally, but it is morphologically the right ventricle, which is intended to handle pulmonary pressures and not systemic pressures. However, due to the complete mixing of blood in the left atrium, all these patients have some degree of cyanosis that is usually noticeable before the first week of life. The second heart sound is single if there is severe pulmonary valve stenosis; otherwise it splits in a normal fashion. Therefore, these patients will present with symptoms of congestive 18 Tricuspid Atresia 219 Fig.

Body lice are prevalent among populations with poor personal hygiene generic zantac 300 mg line, especially in cold climates where heavy clothing is worn and bathing is infrequent or when people cannot change clothes (e purchase zantac 150 mg on line. Mode of transmission—For head and body lice, direct contact with an infested person and objects used by them; for body lice, indirect contact with the personal belongings of infested persons, especially shared clothing and headgear. Lice leave a febrile host; fever and overcrowding increase transfer from person to person. The average life cycle of the body or head louse extends over a period of 18 days; that of the crab louse, 15 days. Period of communicability—As long as lice or eggs remain alive on the infested person or on fomites. Susceptibility—Any person may become infested under suitable conditions of exposure. Preventive measures: 1) Educate the public on the value of destroying eggs and lice through early detection, safe and thorough treatment of the hair, laundering clothing and bedding in hot water (55°C or 131°F for 20 min), dry cleaning or dryers set at “hot cycle”. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Official report not ordi- narily justifiable; school authorities should be informed, Class 5 (see Reporting). None of these is 100 % effective; retreatment may be necessary after an interval of 7–10 days. Lindane and benzyl benzo- ate are no longer recommended or registered because of toxicity, side-effects and low efficacy. For body lice: Clothing and bedding should be washed using the hot water cycle of an automatic washing machine or dusted with pediculicides using power dusters, hand dusters or 2-ounce sifter cans. Epidemic measures: Mass treatment as recommended in 9B7 above, using insecticides clearly known to be effective against prevalent strains of lice. In typhus epidemics, individuals may protect themselves by wearing silk or plastic clothing tightly fastened around wrists, ankles and neck, and by impregnating their clothes with repellents or permethrin. Disaster implications: Diseases for which body and head lice are vectors are particularly prone to occur at times of social upheaval (see Typhus fever, section I, Epidemic louse-borne). Identification—An acute bacterial infection of the respiratory tract caused by Bordetella pertussis. The initial catarrhal stage has an insidious onset with an irritating cough that gradually becomes paroxysmal, usually within 1–2 weeks, and lasts for 1–2 months or longer. Paroxysms are characterized by repeated violent cough; each series of paroxysms has many coughs without intervening inhalation and can be followed by a characteristic crowing or high-pitched inspiratory whoop. Paroxysms frequently end with the expulsion of clear, tenacious mucus, often followed by vomiting. Infants under 6 months, vaccinated children, adolescents and adults often do not have the typical whoop or cough paroxysm. The vast majority of deaths occur in infants under 6 months, often in those too young to have completed primary immunization. In recent years, all deaths from pertussis in most industrialized countries occurred in infants under 6 months. In nonimmunized populations, especially those with underlying malnutrition and multiple enteric and respiratory infections, pertussis is among the most lethal diseases of infants and young children. Complications include pneumo- nia, atelectasia, seizures, encephalopathy, weight loss, hernias and death. Pneumonia is the most common cause of death; fatal encephalopathy, probably hypoxic, and inanition from repeated vomiting occasionally occur. Case-fatality rates in unprotected children are less than 1 per thousand in industrialized countries; in developing countries they are estimated at 3. In several industrialized countries with high rates of infant immunization for many years an increasing proportion of cases has been reported in adolescents and adults, whose symptoms varied from a mild, atypical respiratory illness to the full-blown syndrome. Many such cases occur in previously immunized persons and suggest waning immunity following immunization. Parapertussis is a similar but occasional and milder disease due to Bordetella parapertussis. Diagnosis is based on the recovery of the causal organism from nasopharyngeal specimens obtained during the catarrhal and early parox- ysmal stages on appropriate culture media. Indirect diagnosis (serology) consists of detecting specific antibodies in the serum of infected individual, collected at the beginning of cough (acute serum) and on serum collected one month later (convalescent serum). The presence of high level of antibodies in the serum of a non-vaccinated individual indicates infection. Serology cannot be used for diagnosis during the year following vaccination since it does not differen- tiate between antibodies due to the vaccine or to natural infection Differentiation between B. Occurrence—An endemic disease common to children (especially young children) everywhere, regardless of ethnicity, climate or geo- graphic location. A marked decline has occurred in incidence and mortality rates during the past 40 years, chiefly in communities with active immunization programs and where good nutrition and medical care are available. In 1999, despite a global vaccination coverage of around 80%, there were still an estimated 48. Incidence rates have increased in countries where pertussis immuni- zation rates fell in the past (e. Japan in the early 1980s, Sweden and the United Kingdom), and rose again when immunization programs were rees- tablished.