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Q. Musan. Hamline University.

Care should be exercised in handling these eyes for they are likely to rupture with a squint after the initial sting of the fluorescein when it is first applied to the eye order 500mg sulfasalazine with mastercard treatment for elbow pain from weightlifting. Topical Anesthesia  Topical anesthesia in ophthalmology refers to the application of a anesthetic on the surface of the eye to alleviate minor discomfort from manipulations that the patient would ordinarily not tolerate otherwise 500 mg sulfasalazine for sale nerve pain treatment uk. Eversion of the eyelids including the third eyelid discount 500 mg sulfasalazine otc pain management utica mi, conjunctival scraping and biopsy, corneal scraping, nasolacrimal drainage apparatus manipulations and suture removal, would be examples of techniques that would necessitate this drug, in addition to sedation and possibly nerve block. Proparacaine is by far the most commonly used and is the least toxic of the three. Topical Anesthesia  There is a limit to the magnitude of analgesia provided by a topical agent. After the topical anesthetic has been applied three or four times, and no further increase in depth occurs; one can then expect only increased duration of effect and toxicity. If after four applications of proparacaine in two minutes there is not enough perceived analgesia for what is being done, then another form of analgesia needs to be added. The twitch only needs to be applied at the moment of the manipulation for supplementation. Eyelid Eversion  Eversion of the eyelids to evaluate the conjunctival cul de sacs can be aided with a muscle hook. Eyelid Eversion  “Muscle Hook” This is a smooth relatively atraumatic ophthalmic instrument used in rectus muscle surgery that can be slipped over the lid margin followed by gently pulling the eyelid away from the globe while the examiner observes the condition of the conjunctival surfaces with a bright light and magnification. Eyelid Eversion  Topical anesthetic after an auriculopalpebral block is usually necessary to do this. Some horses resist this instrument, yet have long and firmly fixed vibrissae that can be carefully used to draw the eyelid away from the globe, accomplishing the same goal of being able to look into the full extent of the cul-de-sac without using an instrument. For, just rolling the eyelid margin out with the thumb, for example, will allow visualization of the proximal palpebral conjunctival and at the same time compress the deeper cul de sac. Eyelid Eversion  The third eyelid can also be everted to look on the bulbar surface. Avoid grasping over the free margin because of the potential for damage to the cornea. A generous application with additional eye wash will usually result in the appearance of dye in the distal nasal cavity after a few minutes. If the animal has a clinical sign of tears or ocular discharge and especially if there is no passive flow of fluorescein to the nose, the nasolacrimal system can be flushed. Gentile irrigation with preferably warm eyewash delivered with a syringe works well. Most average sized horses will accommodate a 5 French size and larger animals such as a draft horse may need an 8 French. Do not force and watch the respective distal opening for the first flow to characterize the material exiting. Conjunctival Cytology  Occasionally it is necessary to perform a conjunctival scraping for cytology to characterize the inflammatory response and evaluate for bacterial organisms or evaluate for neoplastic cells or parasitic organisms. This can be done with a chemistry spatula, a Bard Parker Scalpel handle tip (part that accepts the blade but with out a blade attached) a Kimura spatula or the butt end (end opposite the sharp blade end) of a scalpel blade. Conjunctival Biopsy  Biopsy of the conjunctiva for histopathology and or parasite evaluation can be performed on a standing horse after xylazine, auriculopalpebral nerve block and either a topical anesthetic or a subconjunctival (sublesional) injection of 2% lidocaine (0. At the time of the subconjunctival injection and when the tissue to be biopsied is picked up with a fine rat toothed forceps, the application of a lip or ear twitch is usually necessary and advisable. Avoid aggressive large biopsies of the conjunctiva, for prolapse of orbital fat could occur or suture the wound after the biopsy. Corneal Cytology  Sampling of a corneal ulcer bed for culture usually requires a scraping with a spatula to obtain an adequate amount of material. Ideally, this should be done prior to the application of fluorescein or topical anesthesia due to the possibility of a bacteriostatic/cidal effect from these chemicals. If a sample can not be obtained with out topical anesthesia then anesthesia can be used. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. Acknowledgments The development of this lecture note for training Health Extension workers is an arduous assignment for Ato Melkie Edris at University of Gondar Essentially, it required the consolidation and merging of existing in depth training materials, examination of Health Extension Package manuals and the Curriculum. They do not grow well, they become ill, many die or they do not grow up as clever, as healthy. Causes and consequences of poor nutrition are better understood now, and so are the ways to prevent and manage it. The underlying causes are insufficient household food security, inadequate childcare and insufficient basic health services in the community. It includes poor living conditions, lack of education, heavy physical work, and frequent childbearing. And the basic causes are economic structure, political and ideological superstructure. The mortality among preschool children is extremely high in developing countries in general and in Ethiopia in particular. It is quite clear that malnutrition in combination with infection, more often than not is, the cause of high morbidity and mortality in Ethiopia. Micronutrient deficiencies such as vitamin A, iodine and iron are the most prevalent in Ethiopia and it affects mothers and children at large. The entire efforts in the preparation of this lecture note require that the elements of nutrition should be understood by Health Extension 1 Nutrition Students and their Instructors for the implementation of nutrition interventions. Those, which regulate chemical process in the body, are the vitamins and minerals. It is the means of transportation for most nutrients and is needed for all cellular activities. Nutrition: - is the sum total of the process by which living things receive and utilize the necessary materials for survival, growth and maintenance of worn out tissues.

Under a general anaesthetic 500mg sulfasalazine for sale mtus chronic pain treatment guidelines, the doctor slides his hand into the uterus quality 500 mg sulfasalazine chronic pelvic pain treatment guidelines, and uses his fingers to separate the placenta from the uterus and lift it away from the wall of the uterus purchase sulfasalazine 500mg with amex pain treatment with acupuncture, so that it can be drawn to the outside of the body through the vagina. This fluid acts to protect the foetus from bumps and jarring, recirculates waste, and acts as a fluid for the baby to drink. A volume greater than 1500 mL is considered to be diagnostic of polyhydramnios, but it may not become apparent until 2500 mL or more is present. Polyhydramnios occurs in about one in every 100 pregnancies, and it may be a sign that the foetus has a significant abnormality that prevents it from drinking or causes the excess production of urine. The condition is diagnosed by an ultrasound scan, and if proved, further investigations to determine the cause of the condition must follow. There is an increased risk to the mother of amniotic fluid embolism, a potentially fatal complication that occurs when some of the fluid enters the mother’s blood stream, but most pregnancies proceed relatively normally, although there is an increased risk of foetal abnormality. These babies have specific characteristics including dry peeling skin, abnormal folds of skin, and long finger and toenails. These babies are also at increased risk of complications including low blood sugar, low blood potassium, seizures and weight loss. In its mildest form most women have some feelings of up and down emotions with teary episodes in the first week after delivery. They may feel unnecessarily guilty, have a very poor opinion of themselves, feel life is hopeless, find it difficult to think or concentrate, worry excessively about their infant or neglect the child. Emotional and practical support from the partner, family and friends are vital in assisting an affected woman in her recovery. If necessary medications are prescribed to control the production of depressing chemicals in the brain (eg. In developed countries it is very uncommon, because most women undertake regular antenatal visits and checks. Pre-eclampsia is a condition that precedes eclampsia, and this is detected in about 10% of all pregnant women. The exact cause of pre-eclampsia is unknown, but it is thought to be due to the production of abnormal quantities of hormones by the placenta. Pre-eclampsia normally develops in the last three months of pregnancy, but may not develop until labour commences, when it may progress rapidly to eclampsia if not detected. Doctors diagnose the condition by noting high blood pressure, swollen ankles, abnormalities (excess protein) in the urine due to poor kidney function and excessive weight gain (fluid retention). Blood tests may show a low level of platelets (thrombocytopenia) that are used in blood clot formation. Not until the condition is well established does the patient develop the symptoms of headache, nausea, vomiting, abdominal pain and disturbances of vision. This causes convulsions, coma, strokes, heart attacks, death of the baby and possibly death of the mother. Pre-eclampsia is treated by strict rest (which can be very effective), drugs to lower blood pressure and remove excess fluid, sedatives, and in severe cases, early delivery of the baby. An infusion of magnesium sulphate into a vein may be used while waiting for an emergency delivery if the mother is at high risk of fitting. The correct treatment of pre-eclampsia prevents eclampsia, and the prognosis is very good if detected early and treated correctly. Unfortunately there is no regime that will prevent pre- eclampsia or a recurrence, although low dose aspirin is being used experimentally for prevention in high risk mothers. To facilitate this expansion, the ligaments that normally hold the joints of the pelvis (and other parts of the body) together become slightly softer and more elastic which makes them more susceptible to strain. The joints of the spine are particularly at risk because the expanding uterus shifts the centre of balance and changes posture. Standing for any length of time is likely to impose unusual stresses on the back, and this strains the supporting ligaments and results in backache. Slight movements of the vertebrae, one on the other, can cause nerves to be pinched and result in pain such as sciatica. This nerve pinching is further aggravated by the retention of fluid in the whole body, which causes the nerves to be slightly swollen and therefore more easily pinched. The best way to reduce the likelihood of backache is not to gain weight excessively and to avoid all heavy lifting. At antenatal classes, physiotherapists show the correct way to lift, and teach exercises to help relieve the backache. The bleeding may be due to a slight separation of the placenta from the wall of the womb as it grows, and it almost certainly does not involve the baby directly. About 30% of all pregnant women suffer from some degree of bleeding during pregnancy, and some have quite severe bleeds without losing the baby. Other causes of bleeding in pregnancy include an ectopic pregnancy, significant separation of the placenta from the wall of the uterus (placental abruption), vaginal ulcers or erosions or hormonal imbalances. For example, if the last period started on 5 January 2003, she will be due to deliver on 12 October 2003. The most common types of pain are lower abdominal pain due to expansion of the uterus and its attached ligaments, backache and heartburn. Abdominal pain early in pregnancy may also signal significant complications, such as a miscarriage or an ectopic pregnancy. At this early stage, a false negative result is possible, and the tests are more reliable if carried out a couple of days after the missed period. A negative test may mean that the pregnancy is not far enough advanced to be detected, rather than that the woman is not pregnant, while a positive test is almost invariably correct. In a test carried out in a test tube, the mix of urine and chemicals will form a characteristic deposit; but more often the urine is added to one side of a small flat plastic container and as the urine moves across this it interacts with chemicals that will change colour if the test is positive. To ensure a reliable result, the test is generally carried out 2-7 days after the first missed period (ie. A pregnancy test can be carried out at home with a kit purchased from the chemist, but more reliable tests are performed by doctors using a sample of blood. Although pregnancy actually occurs about two weeks after a woman had her last period, for convenience doctors always date a pregnancy from the first day of that last menstrual period. The size, position, maturity, age and sometimes sex of the foetus can all be seen, and some of the internal organs of the baby, particularly the heart, can be checked. Abnormalities such as spina bifida (split spinal cord), hydrocephalus (excess fluid in the brain) and certain other congenital disorders can be identified. A routine scan may be performed between the sixteenth and eighteenth week of pregnancy when the foetus can easily be seen and transformed into an image. Babies under 500g have only a 40% chance of survival, under 1000g a 65% chance, and over 1500g a nearly 100% chance of survival.

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Diloxanide Furoate Diloxanide furoate is directly amebicidal buy discount sulfasalazine 500 mg joint and pain treatment center thousand oaks, but its mechanism of action is not known order sulfasalazine 500 mg free shipping pain treatment center memphis. In the 2gut purchase sulfasalazine 500mg mastercard allied pain treatment center columbus ohio, diloxanide furoate is split into diloxanide and furoic acid; about 90% of the diloxanide is rapidly absorbed and then conjugated to form the glucuronide, which is rapidly excreted in the urine. For mild intestinal disease, and other forms of amebiasis it is used with another drug. Iodoquinol Iodoquinol is effective against organisms in the bowel lumen but not against trophozoites in the intestinal wall or extraintestinal tissues. Iodoquinol is an alternative drug for the treatment of asymptomatic or mild to moderate intestinal amebiasis. Adverse Effects: Reversible severe neurotoxicity (optic atrophy, visual loss, and peripheral neuropathy). Mild and infrequent adverse effects that can occur at the standard dosage include diarrhea, which usually stops after several days, anorexia, nausea and vomiting, gastritis, abdominal discomfort, slight enlargement of the thyroid gland, headache, skin rashes, and perianal itching. Paromomycin Sulfate Paromomycin is an alternative drug for the treatment of asymptomatic amebiasis. In mild to moderate intestinal disease, it is an alternative luminal drug used concurrently with metronidazole. Paromomycin is both directly and indirectly amebicidal; the indirect effect is caused by its inhibition of bowel bacteria. It can be used only as a luminal amebicide and has no effect in extraintestinal amebic infections. Other Antibiotics The tetracyclines (oxytetracycline) have very weak direct amebicidal action, and useful with a luminal amebicide in the eradication of mild to severe intestinal disease. Erythromycin although less effective can be used in the treatment of luminal amebiasis. Drugs used in Giardiasis and Trichomoniasis Metronidazole is a drug of choice for gardiasis and trichomoniasis, and the alternate drug is tinidazole. Treatment of Leishmaniasis Kala-azar, cutaneous, and mucocutaneous leishmaniasis are caused by the genus Leishmania. Treatment of leishmaniasis is difficult because of drug toxicity, the long courses of treatment, treatment failures, and the frequent need for hospitalization. Patients must be closely monitored in hospital, because adverse effects may be severe. Pentamidine Pentamidine is administered parenterally because it is not well absorbed from the gastrointestinal tract. The drug leaves the circulation rapidly and is bound avidly by the tissues, especially the liver, spleen, and kidneys. Trypanosomiasis: In African trypanosomiasis, pentamidine is an alternative in the hemolymphatic stage of the disease to (1) suramin in Trypanosoma brucei gambiense and T b rhodesiense infections or to (2) eflornithine in T b gambiense infection. Pneumocystosis 187 Adverse Effects: Pain at the injection site is common; infrequently, a sterile abscess develops and ulcerates. Occasional reactions include rash, gastrointestinal symptoms, neutropenia, abnormal liver function tests, serum folate depression, hyperkalemia, and hypocalcemia. Severe hypotension, hypoglycemia, hyperglycemia, hyponatremia, and delayed nephrotoxicity. Most anthelmintics are active against specific parasites; thus, parasites must be identified before treatment is started. Individual Drugs Albendazole Albendazole, a broad-spectrum oral anthelmintic, is used for pinworm infection, ascariasis, trichuriasis, strongyloidiasis, and infections with both hookworm species. The drug has larvicidal effects in necatoriasis and ovicidal effects in ascariasis, ancylostomiasis, and trichuriasis. The drug is teratogenic and embryotoxic in some animal species and contraindicated in the first trimester. Ascariasis, Trichuriasis, and Hookworm and Pinworm Infections: For pinworm infections, ancylostomiasis, and light ascariasis, necatoriasis, or trichuriasis, a single dose of 400 mg is given orally for adults and in children over two years of age. Other Infections: At a dosage of 200-400 mg twice daily, albendazole is the drug of choice in treatment of cutaneous larval migrans (give daily for 3-5 days) and in intestinal capillariasis (10-day course). In 3-month treatment courses causes jaundice, nausea, vomiting, abdominal pain, alopecia, rash or pruritus occurs. Diethylcarbamazine Citrate Diethylcarbamazine is a drug of choice in the treatment of filariasis, loiasis, and tropical eosinophilia. Anthelmintic Actions: Diethycarbamazine immobilizes microfilariae and alters their surface structure, making them more susceptible to destruction by host defense mechanisms. Wuchereria bancrofti, Loa loa: Diethycarbamazine is the drug of choice for treatment of infections with these parasites, given its high order of therapeutic efficacy and lack of serious toxicity. Microfilariae of all species are rapidly killed; adult parasites are killed more slowly, often requiring several courses of treatment. Onchocerca volvulus: Diethylcarbamazine temporarily kills microfilariae but are poorly effective against adult worms. If diethylcarbamazine is used in onchocerciasis treatment, suramin (a toxic drug) must be added to the regimen to kill the adult worms. Adverse Reactions Reactions to the drug itself are mild and transient includes: headache, malaise, anorexia, and weakness are frequent. Reactions Induced by dying Parasites: As a result of the release of foreign proteins from dying microfilariae or adult worms in sensitized patients. Vision can be permanently damaged as a result of dying microfilariae in the optic disks and retina. Reactions in W bancrofti, and L loa infections are usually mild in W bancrofti, and occasionally severe in L loa infections. Reactions include fever, malaise, papular rash, headache, gastrointestinal symptoms, cough, chest pains, and muscle or joint pains. Ivermectin Ivermectin is the drug of choice in individual and mass treatment of onchocerciasis and for strongyloidiasis. Clinical Uses: Onchocerciasis, Bancroftian Filariasis, Strongyloidiasis, scabies and cutaneous larva migrans Adverse Reactions: The adverse effects of ivermectin are the Mazotti reaction, which starts on the first day after a single oral dose and peaks on the second day.

Example:- castor oil laxative effect= 4ml Cathartic effect = 15-60ml Laxative and cathartics are arbitrarily classified depending on mode of action as: • Bulk forming laxatives: are substances that are largely unabsorbed from the intestine purchase sulfasalazine 500mg fast delivery treatment guidelines for neuropathic pain. When water is added order sulfasalazine 500 mg fast delivery sciatica pain treatment exercise, the substances swell and become gel-like which increases the bulk of the fecal mass that stimulates peristalsis and defecation sulfasalazine 500 mg line treatment for nerve pain from shingles. Osmotic laxatives such as magnesium sulfate, magnesium hydroxide, sodium phosphate, etc. These substances are not efficiently absorbed, thus creating a stronger than usual solution in the colon which causes water to be retained. Individual drugs are castor oil, bisacodyl, phenolphthalein, cascara sagrada, glycerine, etc. It lubricates the intestine and is thought to soften stool by retarding colonic absorption of fecal water. To empty the bowel in preparation for bowel surgery or diagnostic procedures (saline or stimulant) 4. To accelerate excretion of parasite after anthelmintic drugs (saline or stimulant) have been administered. Antidiarrhoeals: • Are used in the treatment of diarrhea, defined as the frequent expulsion of liquid or semi liquid stools → hinders absorption of fluids and electrolytes. Antidiarrheal drugs may be given to relive the symptom (non-specific therapy) or may be given to treat the underlying cause of the symptom (specific therapy). They decrease diarrhea by slowing propulsive movements in small and large intestine. Species can be treated by antibiotics (ampicillin, chloramphinicol, colistin, co-trimoxazole etc. Nausea is an unpleasant sensation of abdominal discomfort accompanied by a desire to vomit. Vomiting is the expulsion of stomach contents through the mouth Nausea may occur without vomiting and vomiting may occur without prior nausea, but the two symptoms most often occur together. To a certain extent, vomiting is a protective mechanism which can result from various noxious stimuli. Drugs used in nausea and vomiting belong to several different therapeutic classifications. Peripherally metoclopoamide stimulates the release of acetylcholine, which in turn, increases the rate of gastric emptying (used in esophapeal reflux) Indication as chlorpromazine • Scopolamine, an anticholinergic drug is very effective in reliving nausea & vomiting associated with motion sickness. Drugs used to induce vomiting In case of poisoning with noncorrosive agents, and assuming incomplete absorption of the poison has taken place, induction of vomiting can be carried out The drug used for this purpose is emetine, the active ingredient of ipecacuanha (syrup of ipecac). Drugs used in the treatment of haemorrhoids Haemorrhoids are varicose veins of the anal canal which can be very distressing for the sufferer. There is no pharmacological cure for this disorder, which is often self-limiting, if not, may require surgical intervention. The use of drugs may however, linder the sufferings: • Stool softeners may alleviate constipation; lessen straining which can worsen the condition. Drugs used in inflammatory bowel disease (ulcerative colitis and crohn’s disease) • Ulcerative colitis is an inflammatory condition of the rectum and colon; crohni’s disease can involve the whole intestine. In the absence of adequate iron, small erythrocytes with insufficient hemoglobin are formed resulting in microcytic hypochromic anemia. Nutritional deficiency Low intake of iron containing foods, reduced absorption as a result of mucosal damage, co- administration of drugs that chelate iron e. Pharmacokinetics of Iron Daily requirement of Iron - Male 10mg - Female 15 mg Increases in growing children, pregnant and lactating women Sources - Dietary - mostly in the organic form from meat, cereals, etc. Body composition of Iron Total content of Iron in the body is about 4000mg in an adult male, of which about 2/3 – 2500 mg is present in circulating red blood cells see table. Table: Iron distribution in normal adults Iron content (mg) Men Women Hemoglobin 3050 1700 Myoglobin 430 30 Enzymes 10 8 Transport (transferin 8 6 Storage ( ferritin and 750 300 other form) Total 4246 2314 N. The above estimations are based on the assumptions that: 96 The average male adult weighs 80 kg and has a mean Hb level of 16 g/dL and the female adult weighs 55 kg and has a mean Hb level of 14 g/dL. Iron crosses the stinal mucosal cell by active transport; then according to mucosal iron store, it can either be available to transferrin to be transported to plasma or be stored in the mucosal cell as ferritin. Storage: Iron is stored primarily as ferritin in intestinal mucosal cells and in macrophages in the liver, spleen and bone. Elimination: Very small amount are execrated in stool by exfoliation of intestinal mucosal cells and trace amounts are execrated in bile, urine and sweat with total daily excretion not more than 1mg/day. Treatment of iron deficiency anemia consists of administration of oral or parenteral iron preparation. Oral Iron Therapy: Only ferrous salts should be used because of most efficient absorption. Ferrous sulfate, ferrous gluconate, ferrous fumarate are the most commonly used oral iron preparations. About 25% of oral iron given as ferrous salt can be absorbed; therefore 200-400mg elemental irons should be given daily to correct iron deficiency most rapidly. Side effects: Oral iron therapy can cause nausea, vomiting, epigastric discomfort, abdominal cramps, constipation and diarrhea. Parenteral iron therapy: Should be reserved for patient unable to tolerate or absorb oral iron. Patients with extensive chronic blood loss who can not be maintained with oral iron alone including patients with various post gastrectomy conditions, previous small bowel resection, inflammatory bowel disease involving proximal small bowel and malabsorption syndromes need parenteral iron therapy. Intravenous administration may result in very severe allergic reactions and thus should be avoided if possible. Side effect: include local pain, tissue staining, headache, light headedness, fever, arthralgia, nausea, vomiting, urticaria, back pain, bronchospasm, and rarely anaphylaxis and death. Acute iron Toxicity Is exclusively seen in young children who ingest a number of iron tablets and rarely seen in adults as a result of suicide or repeated blood transfusions. Signs and symptoms Necrotizing gastroenteritis with vomiting, abdominal pain and bloody diarrhea, shock, metabolic acidosis, coma Treatment Whole bowel irrigation. It is mainly obtained from animal products and serves as a co factor for essential biochemical reaction in humans. Excess vitamin B12 is transported to the liver for storage and excreted in the urine. Clinical uses - Vit B12 is used to treat or prevent deficiency of vit B 12 Deficiency of Vit B 12 results in: - Megaloblastic anemia - Neurological syndrome involving spinal cord and peripheral nerves Causes: The causes for Pernicious anemia are defective secretion of intrinsic factor necessary for absorption of vitB 12, partial or total gastrectomy, diseases that affect distal ileum, malabsoption syndrome e. Almost all cases of vit B12 deficiencies are caused by malabsorption Treatment Vit B12 therapeutic preparations are cyanocoblamin and hydroxycobalamin and For intrinsic factor deficiency the vitamin should be given parenterally and patients with pernicious anemia will need life-long therapy.

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