Professor John Feehally
Randomized trial of novel tetracaine patch to provide local anaesthesia in neonates undergoing venepuncture pain treatment in lexington ky generic elavil 75 mg online. Arrhythmia associated with tetracaine in an extremely low birth weight premature infant treatment for elbow pain from weightlifting cheap elavil 10 mg with amex. Intravenous morphine and topical tetracaine for treatment of pain in preterm neonates undergoing central line placement pain solutions treatment center atlanta buy elavil paypal. Preterm babies with a low cortisol level despite stress in the first few days of life who require ventilation seem to be at greater risk of developing chronic lung damage pain treatment center of illinois new lenox generic elavil 25mg with mastercard. Tetracosactide can be used to test the adequacy of the adrenocortical response to stress (colloquially known as a with Synacthen test because that is the trade name of the product). Both hormones are rapidly metabolised to a range of inactive oligopeptides within an hour or two of administration. While it is difficult to see how administration could cause any harm, these hormones should only be given to a pregnant or lactating mother for good reason. Adverse reactions Anaphylactic and hypersensitivity reactions can occur, so tetracosactide should only be admin istered under the direct supervision of an experienced hospital specialist. Some advise the collection of a second specimen 60 minutes after the test injection. Tetracosactide administration normally causes a 70 micrograms/l (200nmol/l) rise in the plasma cortisol concentration unless there is primary adrenal failure, but equivocal results are sometimes obtained, especially in the first month of life. The help and advice of a paediatric endocrinologist should always be sought before undertaking any such test in the neonatal period. Low-dose tests: the procedure described for the standard test involves a supramaximal test dose. Very much smaller doses have been used to assess the response of the adrenal gland to a more physiological stimulus (doses as low as 500 nanograms have sometimes been used in adults). What constitutes a with normal response to such a low stimulus in the preterm baby is not yet clear. The initial control of with infantile spasms the simplest way to stop infantile spasms is to give 10 mg of prednisolone four times a day for 2 weeks and then tail treatment off over the next 2 weeks. Maturity of the adrenal cortex in very preterm infants is related to gestational age. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. The United Kingdom Infantile Spasms Study comparing vigabatrin with prednisolone or tetracosactide at 14 days: a multicentre, randomized controlled trial. Treatment of infantile spasms: emerging insights from clinical and basic science perspectives. Pharmacology Tetracycline is a naturally occurring antibiotic produced by a Streptomyces fungus. Tetracycline is bacteriostatic, inhibiting bacterial protein synthesis and cell growth. It is only partially absorbed from the gastrointestinal tract, absorption being further affected by the formation of insoluble complexes in milk. Oral administration can also cause adverse gastro intestinal symptoms, probably as a result of mucosal irritation. Most of the drug is excreted in the urine, but substantial amounts appear in bile and faeces. Tetracycline was once widely used in the management of many Gram-positive and Gram-negative infections, but the emergence of drug-resistant strains, and the development of alternative agents, has led to a decline in the use of this once popular antibiotic. Doxycycline (a semi-synthetic derivative) is sometimes used along with quinine (q. Systemic tetracycline should normally be avoided during childhood because sustained use causes an unsightly green discolouration of the permanent teeth. It remains of value, however, in the treatment of malaria and brucellosis and of chlamydial, rickettsial, mycoplasma and pro tozoal infection, and there are situations where efficacy, availability and low cost still make short-term treatment a logical option. Tetracycline is also active against most spirochetes including Borrelia, the cause of Lyme disease. Tetracycline crosses the placenta and may cause a yellow-grey/brown tooth discolouration after fetal or early childhood exposure. The related drug, oxytetracycline, is associated with increased risk of neural tube defects, cleft palate and cardiovascular abnormalities. More seriously, use in pregnancy has occasionally been associated with fatal maternal hepatotoxicity. Treatment during lactation probably carries little risk: the amount ingested by the baby in breast milk represents <5% of the usual therapeutic dose, and absorption seems to be limited by chelation to calcium. Tetracycline has been shown to retard bone growth in the preterm baby, probably because of its absorption by the epiphyseal plate. Topical treatment: Topical chlortetracycline ointment has been used to prevent, or (with oral erythromycin) to treat, Chlamydia conjunctivitis, as discussed in the monograph on eye drops, but is not available in the United Kingdom. The only preparation containing chlortetracycline available in the United Kingdom, and used in treatment of severe inflammatory skin disorders, is Aureocort, a mix of chlortetracycline hydrochloride 3% with triamcinolone acetonide 0. The latter is an extremely potent topical steroid and best avoided in young children and infants. Reconstitute the powder with 25ml of water for injection to obtain a solution containing 20mg/ml. A 25mg/ml suspension is available in the United States (but not in the United Kingdom). Pneumonia due to Chlamydia pneumonia in children: epidemiology, diagnosis and treatment. Antibiotic chemotherapy during pregnancy and lactation period: aspects for consideration. Treatment of human brucellosis: systematic review and meta-analysis of randomised controlled trials. Infection with Ureaplasma urealyticum: is there a specific clinical and radiological course in the preterm infant Congenital and opportunistic infections: Ureaplasma species and Mycoplasma hominis. Pharmacology First used in 1934, thiopental sodium is a hypnotic and anticonvulsant barbiturate, but it does not relieve pain. Because it causes marked respiratory depression, it should only be used in sit uations where immediate respiratory support can be provided. Large doses also cause a fall in peripheral vascular resistance and cardiac output. It quickly reaches the central nervous system and is then redistributed away from the brain into body fat stores. Thiopental crosses the placenta rapidly, but the effect of a single maternal injec tion is small because the drug only remains briefly in the bloodstream. Only a trace appears in breast milk after use during routine operative anaesthesia. Most babies whose immediate post-delivery seizures are only controlled by thiopental anaesthesia die before being discharged home or become severely disabled in later infancy. Thiopental can also be used to provide sedation during brief but painful neonatal procedures and has been shown to halve the time it takes to intubate the trachea. Tissue extravasation Extravasation can cause severe tissue necrosis because the undiluted product has a very high pH (11. A strategy for the immediate management of suspected tissue damage is outlined in the monograph on hyaluronidase (q. Overarching the processes and products it brings forth pain treatment alternative cheap elavil line, biotechnology is also a conceptual and ethi cal outlook pain medication for cancer in dogs discount elavil 50mg without a prescription, informed by progressive aspirations pain in jaw treatment buy elavil 50 mg fast delivery. In this sense pain treatment in lexington ky cheap elavil generic, it appears as a most recent and vibrant expression of the technological spirit, a desire and disposition rationally to understand, order, predict, and (ultimately) control the events and workings of nature, all pursued for the sake of human benefit. Thus understood, biotechnology is bigger than its proc esses and products; it is a form of human empowerment. If we are to understand what biotechnology is for, we shall need to keep our eye more on the new abilities it provides than on the technical instruments and products that make the abilities available * to us. The report recommended (and illustrated by example) that assessment of biomedical technologies concern itself with implications of both the techniques and the perfected powers they pro vide. As with all techniques and the powers they place in human hands, the techniques and powers of biotechnology enjoy considerable independence from ties to narrow or specific goals. Like any other technology, the goals it serves are supplied neither by the techniques themselves nor by the powers they make available, but by their human users. Like any other means, a given biotechnology once developed to serve one purpose is frequently available to serve multiple purposes, including some that were not imagined or even imaginable by those who brought the means into being. Second, there are several questions regarding the overall goal of biotechnology: improving the lot of humankind. Should we think only of specific, as yet-untreatable diseases that compromise our well-being, such ailments as juvenile diabetes, cancer, or Alzheimer disease Should we not also include mental illnesses and infirmities, from retardation to major depression, from mem ory loss to melancholy, from sexual incontinence to self contempt And should we consider in addition those more deep-rooted limitations built into our nature, whether of body or mind, including the harsh facts of decline, decay, and death Just sickness and suffering, or also such things as nastiness, folly, and despair As we use it, power is to be understood as neutral or better, certainly when compared to its opposite, impotence. Efforts to moderate human aggression might wind up sapping am bition; interventions aimed at quieting discontent might flatten aspiration. And, unintended consequences aside, it is not easy to say just how much less aggression or discon tent would be good for us. Once we go beyond the treat ment of disease and the pursuit of health, there seem to be no ready-made or reliable standards of better and worse available to guide our choices. We now have techniques to test early human embryos for the presence or absence of many genes: shall we use these techniques only to prevent disease or also to try to get us better children We are acquiring techniques for boosting muscle strength and performance: shall we use them only to treat muscular dystrophy and the weak mus cles of the elderly or also to enable athletes to attain supe rior performance We are gradually learning how to control the biological processes of aging: should we seek only to diminish the bodily and mental infirmities of old age or also to engineer large increases in the maximum human life span We are gaining new techniques for altering mental life, including memory and mood: should we use them only to prevent or treat mental illness or also to blunt painful memories of shameful behavior, transform a melancholic temperament, or ease the sorrows of mourning Increas ingly, these are exactly the kinds of questions that we shall be forced to face as a consequence of new biotechnical powers now and soon to be at our disposal. Ingenious nanotechnological devices, implantable into the human body and brain, raise hopes for overcoming blindness and deafness, and, more generally, of enhancing native human capacities of aware ness and action. Research on the biology of aging and se nescence suggests the possibility of slowing down age related declines in bodies and minds, and perhaps even ex panding the maximum human lifespan. In myriad ways, the discoveries of biologists and the inventions of biotechnolo gists are steadily increasing our power ever more precisely to intervene into the workings of our bodies and minds and to alter them by rational design. For the most part, there is great excitement over and en thusiasm for these developments. Even before coming to the practical benefits, we look forward to greatly enriched knowledge of how our minds and bodies work. Vast numbers of people and their families ardently await cures for many devastating diseases and eagerly an ticipate relief from much human misery. We will surely wel come, as we have in the past, new technological measures that can bring us healthier bodies, decreased pain and suf fering, peace of mind, and longer life. At the same time, however, the advent of new biotechni cal powers is for many people a cause for concern. First, the scientific findings themselves raise challenges to human self-understanding: people wonder, for example, what new knowledge of brain function and behavior will do to our no tions of free will and personal moral responsibility, formed before the advent of such knowledge. Second, the prospect of genetic engineering, though welcomed for treatment of inherited genetic diseases, raises for some people fears of eugenics or worries about designer babies. Precisely because the new knowledge and the new powers impinge directly upon the human person, and in ways that may affect our very humanity, a certain vague disquiet hov ers over the entire enterprise. While its leading benefits and blessings are readily iden tified, the ethical and social concerns raised by the march of biotechnology are not easily articulated. They go beyond the familiar issues of bioethics, such as informed consent for human subjects of research, equitable access to the fruits of medical research, or, as with embryo research, the morality of the means used to pursue worthy ends. Indeed, they seem to be more directly connected to the ends themselves, to the uses to which biotechnological powers will be put. Generally speaking, these broader concerns attach espe cially to those uses of biotechnology that go beyond ther apy, beyond the usual domain of medicine and the goals of healing, uses that range from the advantageous to the frivo lous to the pernicious. Biotechnologies are already available as instruments of bioterrorism (for example, genetically en gineered super-pathogens or drugs that can destroy the immune system or erase memory), as agents of social con trol (for example, tranquilizers for the unruly or fertility blockers for the impoverished), and as means to improve or perfect our bodies and minds and those of our children (steroids for body-building or stimulants for taking exams). In the first two cases, there are concerns about what others might do to us, or what some people, including govern ments, might do to other people. In the last case, there are concerns about what we might voluntarily do to ourselves or to our society. People worry both that our society might be harmed and that we ourselves might be diminished in ways that could undermine the highest and richest possi bilities for human life. On the contrary, some celebrate the perfection-seeking direction in which biotechnology may be taking us. Indeed, some scientists and biotechnologists have not been shy about prophesying a better-than currently-human world to come, available with the aid of genetic engineering, nanotechnologies, and psychotropic drugs. Given its poten tial importance, it is arguably the most neglected topic in public bioethics. No previous national bioethics commission has considered the subject, and for understandable reasons. The realm of biotechnology beyond therapy is hard to de fine, a gray zone where judgment is, to say the least, diffi cult. Compared with more immediate topics in bioethics, the questions raised by efforts to improve on human na ture seem abstract, remote, and overly philosophical, unfit for public policy; indeed, many bioethicists and intellectuals believe either that there is no such thing as human nature or that altering it is not ethically problematic. Analysis often requires distinguishing the primary and immediate uses of a technology (say, mood elevating drugs to treat depression or memory-blunting drugs to prevent post-traumatic stress disorder) from de rivative and longer-term uses and implications (the same drugs used as general mood-brighteners or to sanitize memories of shameful or guilty conduct). Speculation about those possible implications, never to be confused with ac curate prediction, is further complicated by the fact that the meaning of any future uses of biotechnology beyond ther apy will be determined at least as much by the goals and practices of an ever-changing society as by the technologies themselves. Finally, taking up these semi-futuristic pros pects may seem a waste of public attention, especially given the more immediate ethical issues that clamor for at tention. Yet despite these genuine difficulties and objections, we believe that it is important to open up this subject for public discussion. It touches on the ends and goals to be served by the acquisition of biotechnical power, not just on the safety, efficacy, or morality of the means. It faces squarely the alleged threat of dehumanization as well as the alleged promise of super-humanization. Given the burgeon ing research in neuroscience and the ever-expanding bio * the already widely accepted beyond therapy uses of biomedical technologies include: pills for sleep and wakefulness, weight loss, hair growth, and birth con trol; surgery to remove fat and wrinkles, to shrink thighs, and to enlarge breasts; and procedures to straighten teeth and select the sex of offspring. In 2002 Americans spent roughly one billion dollars on drugs used to treat baldness, about ten times the amount spent on scientific re search to find a cure for malaria, a disease that afflicts hundreds of millions of peo ple worldwide. Order elavil 10mg with visa. Ayurvedic Treatment For Back Pain..! Kativasti Treatment | Myra Jeevan.
An interesting finding is an abnormal hair whorl over the spine treatment guidelines for knee pain buy discount elavil on line, called the Riccardi sign pain treatment machine purchase elavil 10mg with mastercard, which represents a congenital paraspinal plexiform neurofibroma back pain treatment kerala purchase elavil 75mg with mastercard, which can lead to dysplastic scoliosis later in life (8 pain management utica ny elavil 25 mg for sale,10). Cafe au lait spots are spots with the color of coffee with milk, being tan colored. They can vary in size from smaller than 10 mm to as big as covering a body part on one side, although the typical lesions are 1-3 cm ovoid spots, which are uniform in color. They can occur anywhere on the body except for the scalp, eyebrows, palms, and soles. Axillary freckling is akin to cafe au lait spots except they are smaller, about 1 to 3 mm in size, and occur in clusters. They usually appear in intertriginous areas like the axillae, inguinal area, upper eyelids, the base of the neck, breast folds in women, and skin folds in obese patients. In those who are 5 years old, the frequency is 25%, at age 10 years it is 50%, and by age 20 years it is more than 95%. They are pigmented hamartomas appearing as translucent masses with a gray-tan hue due to the melanin-containing cells that are on the iris. Optic gliomas are benign tumors which can form anywhere along the optic tract from the globe all the way to the optic radiations out of the occipital lobe. These symptoms include decreased visual acuity, visual field deficits, proptosis, strabismus, optic atrophy, headache, nausea, anorexia, hypothalamic dysfunction, and precocious puberty. However, if it becomes progressive or symptomatic, then surgery, medical, or radiation therapy should be considered. Neurofibromatosis should be considered a multiorgan disease in that tumors can occur in any part of the body. Other manifestations are hypertension from renal artery stenosis, seizures, scoliosis, long bone dysplasia, sphenoid bone dysplasia, short stature, macrocephaly, and peripheral nerve sheath malignant tumors. Mental retardation is not common (about 5%), while learning disabilities are more common (30-60%). Although this tumor arises from the vestibular branch, the patient usually notices hearing problems before vestibular problems. The average age of onset is 18 to 22 years, although it ranges from 10 years to over 35 years of age. The patient may first present with hearing problems, such as when using the telephone. Besides tinnitus and deafness, other signs and symptoms include facial weakness, visual problems, and painful peripheral nerve tumors. These include spinal cord compression by gliomas or meningiomas, and ophthalmologic problems such as cataracts, strabismus, and amblyopia (7). Cafe au lait spots can be a sign of neurofibromatosis or a part of other neurocutaneous syndromes. Bannayan-Riley-Ruvalcaba syndrome Solitary cafe au lait spots are commonly seen in the healthy population, although three or more spots can be seen in 0. McCune Albright syndrome includes precocious puberty and multiple endocrine problems. These spots can be seen in 25% of patients with Fanconi anemia, which presents with aplastic anemia, mental retardation, generalized hyperpigmentation, radial ray defects, eye anomalies, and other multiorgan problems. Bloom syndrome is an autosomal recessive disorder that features areas of hypo and hyperpigmentation, prenatal and postnatal growth retardation, thin triangular facies, telangiectatic rash in sun exposed areas, and malignancies (leukemia, breast, and gastrointestinal). Ataxia telangiectasia can also have cafe au lait spots, but probably only in a minority of patients. This disease includes progressive neurodegeneration, bulbar conjunctival telangiectasia, immunodeficiency, and increased risk for malignancies. Russell Silver dwarfism can also have cafe au lait spots but some studies report that it might not be different in frequency to the normal population. This disorder includes prenatal growth retardation, small triangular facies, and short and curved fifth fingers. The management of a patient with neurofibromatosis should focus on genetic counseling and evaluating for the development of new tumors. The patient should be referred to a neurofibromatosis clinic if one is available, because of the multidisciplinary assistance that can be received. Blood pressure should be obtained at every visit because of the higher risk for hypertension. Learning disabilities can occur and the patient should be evaluated for this annually in terms of his or her academic performance. Annual eye examinations should be performed annually for the first six years of life, with less frequent examinations thereafter. Because of the risk for deafness, learning sign language and wearing hearing aids should be considered (7). Throughout life, these individuals develop more lesions, with new types of tumors such as Lisch nodules, neurofibromas, and optic gliomas appearing. A feature of neurofibromatosis is its clinical variability, so it is difficult to determine who will be having severe, debilitating, and disfiguring disease. Deaths in childhood are usually caused by an intracranial tumor, however, a malignant peripheral nerve sheath tumor, leukemia, or an embryonal tumor can be the cause as well. Sometimes, death can also be due to the growth of a plexiform neurofibroma in the cervical to upper mediastinum region. Deaths in middle adulthood are due to a malignant peripheral nerve sheath tumor or sarcoma from another type of tissue. Other causes are acute hydrocephalus, severe seizures, gastrointestinal hemorrhage, intracranial hemorrhage due to vasculopathy, progressive spinal cord encroachment by plexiform neurofibromas or unstable dysplastic scoliosis, and complications of hypertension due to arterial dysplasia or pheochromocytoma. The average life expectancy is 36 years with death being due to surgically inoperable tumors. These patients also suffer from vision and hearing deterioration, chronic pain from tumors, and loss of ambulation. With new discoveries and technologies, gene therapy may be used to treat and prevent this disease in individuals at risk in the near future. Discrete cutaneous and subcutaneous neurofibromas, axillary freckling in the older patient. This baby girl is a product of a normal pregnancy and was delivered full-term by normal spontaneous vaginal delivery. There were no postnatal complications and this infant was discharged from the hospital at 48 hours of life. Her history is significant for jerking movements (onset at 5 months of age) described as sudden flexion of the neck, arms, and legs onto the trunk preceded by a cry. Her parents were not too worried about this behavior since the child would return back to normal and they attributed it to colic or "gas". Her family history is also unremarkable in that there is no history of seizures, mental retardation, or consanguinity. She has multiple small 1-2 cm oval, irregular hypopigmented macules on her trunk and extremities. An echocardiogram and a renal ultrasound are also done showing tumors in both the heart and kidneys. Tuberous sclerosis was probably first described by Friedrich Daniel von Recklinghausen in 1862, when he presented a baby who died "after taking a few breaths". Recklinghausen named "myomata" and described in few words, the brain having "a great number of scleroses. Therefore, it is in the same family of disorders, which includes neurofibromatosis, Sturge-Weber disease, von Hippel-Lindau disease, ataxia telangiectasia, linear nevus syndrome, hypomelanosis of Ito, and incontinentia pigmenti (2). It was also thought to be similar to neurofibromatosis and von Hippel-Lindau disease as being one of the phakomatoses, which is derived from the Greek word phakos, meaning "spot. The estimated frequency is 1 in 6000, and there is no racial predilection; therefore, we have seen several of these patients in Hawaii. Therefore, one patient could be asymptomatic while another patient could have seizures and severe mental retardation. Also, because of the variable expression of this disease, it is imperative that in obtaining a family history, one asks if there is a history of mental retardation; seizures; obstructive hydrocephalus; brain or cardiac tumors; cardiac dysrhythmias at an early age; stillbirths (especially with hydrops); kidney, lung, or bone cysts; pulmonary failure; spontaneous pneumothorax; renal angiomyolipomas or failure; fibromatous growths around or under the nails or on gums; enamel pits; retinal phakomas; skin lesions such as hypopigmented macules, facial angiofibroma and shagreen patches; poliosis (premature white hair) or canities (white hairs) of the scalp, lashes, or brows; and iris depigmentation, in addition to recognizing that these signs can be mistaken for vitiligo, refractory acne, or autosomal dominant polycystic kidney disease. Because Page 587 of the possibility for other tumors, ophthalmologic examination, renal radiographic studies, chest radiography, and echocardiogram are often ordered. Tuberous sclerosis is a multiorgan disease and does not only include the brain pathology; therefore, "tuberous sclerosis complex" may be a better term for this disease (4).
In instances where care directives are not obtained pain treatment for trigeminal neuralgia 10mg elavil amex, children are more likely to expire in the hospital pain treatment center nashville tn buy elavil 10 mg amex. The intent of these discussions should not be interpreted as the health care team giving up xiphisternum pain treatment purchase elavil 25 mg with visa. In clinical research studies pain management shingles head elavil 25mg without a prescription, the assent of younger children is routinely sought. The community of pediatric care providers will continue to benefit from a standardized approach to planning for end-of-life care. A longitudinal, randomized, controlled trial of advance care planning for teens with cancer: anxiety, depression, quality of life, advance directives, spirituality. The baby was born at term, by normal spontaneous vaginal delivery, after spontaneous rupture of membranes with clear amniotic fluid. The newborn took 20 mL of formula within 1 hour of birth, but has taken less with each subsequent feed. Her lungs are clear to auscultation bilaterally and her heart has a regular rate and rhythm. This is most likely caused by an inborn error of metabolism, and the test most likely to reveal the diagnosis is urine organic acids. The many causes of coma in neonates can be divided by organ system, and the differential diagnosis for each case can be narrowed based on the clinical presentation. Infectious causes are common, and can include bacterial, viral, and parasitic etiologies. There is often an antecedent history of prolonged rupture of membranes, maternal fever, or a positive screen for group B Streptococcus. Pathogens of neonatal sepsis that are not routinely screened for include Escherichia coli, Listeria monocytogenes, and herpes simplex virus. Congenital heart disease is another important cause of poor feeding and lethargy in neonates. Fetal tachycardia and cardiomyopathy can also cause progressive poor feeding and lethargy. Maternal intoxication, perinatal asphyxia, hypoglycemia, and birth trauma are causes of neonatal coma that can be identified through maternal or perinatal history; however, none of these would present with hyperammonemia. The other main category of causes of neonatal coma is inborn errors of metabolism. For these infants the time of onset of signs and symptoms of a metabolic crisis will vary, but in severe cases can occur within hours or days. Poor feeding, lethargy, respiratory depression, and hypotonia are common initial signs. Acute encephalopathy presenting in an infant with an unremarkable history and unremarkable results of routine blood tests, cultures, and chest radiography should alert the clinician to consider an inborn error of metabolism. Acidosis, hyperammonemia, and hypoglycemia can cause coma, intracranial hypertension, and hemodynamic compromise. Suspected metabolic disease should prompt urgent evaluation of pH, lactate level, electrolytes, liver function tests, ammonia, and glucose level. More common metabolic disorders (Item C264) include organic acidemias, urea cycle defects, glycogen storage diseases, galactosemia, and fatty acid oxidation defects. Brain magnetic resonance imaging can detect brain malformations that can cause encephalopathy, but those infants generally have an abnormal neurologic status immediately after birth. Echocardiography would be important if congenital heart disease were suspected, but such infants generally do not have hyperammonemia. She was seen by her primary care physician 8 days ago with upper respiratory tract symptoms and a cough. Immunization status does not play a role in the decision to provide chemoprophylaxis. Another qualifying exposure includes air travel; a passenger seated directly next to an index case on a flight lasting at least 8 hours should receive chemoprophylaxis. Chemoprophylaxis is not recommended for contacts of patients with N meningitidis isolated from nonsterile sites (eg, conjunctival or oropharyngeal swab cultures) who do not have invasive disease. Additionally, persons with contact with a high risk contact and not with the index case do not require chemoprophylaxis. Family members that do not reside within the same household, such as the aunt that lives next door, also do not need chemoprophylaxis. While a childcare center contact is considered a close contact, exposure 10 days prior to symptom onset precludes concern for infection in this patient. The incubation period for N meningitides is 1 to 10 days and symptomatic infection usually occurs in less than 4 days. The resident who took the history in the emergency department does not require chemoprophylaxis. Obtaining a nasal wash, as in response choice E, would be considered direct exposure to respiratory secretions. However, this sample was obtained more than 7 days before the symptom onset, so the nurse does not require chemoprophylaxis. Agents used for chemoprophylaxis include rifampin, ceftriaxone, and ciprofloxacin. Index cases that are treated with an agent other than ceftriaxone need to be decolonized with 1 of the recommended chemoprophylactic drugs after their course of treatment for invasive disease to eliminate nasopharyngeal colonization. When an outbreak caused by a serogroup covered by licensed vaccines occurs, immunization is an adjunctive prophylaxis measure. According to his mother, the patient attained bladder and bowel control by 4 years of age. The patient has also been complaining of headaches on waking up in the morning, which have been increasing in severity for the last week. He has also had vomiting associated with headaches on waking up for the last 2 days. They moved to a new home and the patient is attending a new school for the last year. The 10-year-old boy in the vignette has recent onset of increased micturition and associated secondary nocturnal enuresis, which needs further evaluation. Polyuria is characterized by an increased total urine volume resulting from an underlying defect in water balance. This presents with the excretion of large volumes of dilute urine, as seen in diabetes mellitus (osmotic diuresis), diabetes insipidus (anti-diuretic hormone disorders), and psychogenic polydipsia. It is important to note that children with polyuria may have nocturia or nocturnal enuresis; however, the more frequently reported symptoms of frequency, nocturia, or enuresis may not be associated with increased urinary volume (or polyuria). Recent onset of increased thirst, micturition, and nocturnal enuresis (and nocturia) is indicative of increased urine volume in the patient. Absence of glucose in the urine rules out diabetes mellitus as the cause of his polyuria. A detailed neurologic examination, including examination of the spine, is vital in any patient presenting with recent onset abnormal voiding patterns. The history of headaches more prominent on waking up in the morning and association with vomiting is indicative of intracranial pathology, as noted for the patient in this vignette. It could be idiopathic (most common) or secondary to central nervous system tumors, infiltrative lesions (histiocytosis), and trauma (surgical or nonsurgical). Vasopression can be administered intravenously (1 g in infants and 2 g in older children) and the response is assessed by evaluating serum electrolytes and urine osmolality in 1 to 2 hours. Urine osmolality and serum electrolytes can be rechecked in 3 to 4 hours, as the response can take time in some cases. Intranasal desmopressin acetate (10 g for infants, 20 g for older children) can also be used for evaluating response to vasopression. |
