#Community Acquired Pneumonia

[flyonthewallmedstudent]

Psittacosis

Let's open with a case report, like we're on an episode of house.

Case Report

35 yo otherwise well, suddenly presents with 2/52 of high fevers and a headache (usually this means > 39)

a/w chills and rigours, responsive to medication/presumably panadol and intermittent (would resolve then come back)

no respiratory symptoms

She had neutrophilia and intrestingly, a CRP of merely 30.

CXR revealed nonspecific consolidation in 2 lobes, they followed this up with a CT revealing pretty impressive ground glass opacities (or GGOs)

She was empirically treated on IV tazocin only (I'm used to atypical coverage empirically started if there's even a whiff of resp, which she may not have had symptoms but her CXR confirms this)

eventually she was on referred to the authors, who felt her CT findings with consistent with psittacosis and treated her with doxycycline which resolved her symptoms in 48 hrs

on further history, it was revealed that she had parrots at home, one had died 2 days preceding her symptoms and she was sleeping next to its body at night (crazy)

What is it:

psittacosis is a zoonoses (transmitted by animals, animals = reservoirs), in this case, transmitted by birds. Orthinoses if birds in general, but psittacosis if referred to macaws, parrots etc. YOu can also catch it from chickens and turkeys.

Some what related is Bird fancier's lungs. Which just sounds fancy.. I'm sure it's just an old term.

Bird fancier's lung refers to a hypersensitivty pneumonitis (ILD) caused by bird exposure. DIfferent disease process, but birds is the come denominator. INhaled bird particles

Psittacosis specifically refers to the infective disease process caused by a bacteria. It was 'identified" or reported in the 1870s, when a cluster of 7 swiss patients developed the same symptoms and found to have possessed tropical birds.

Similarly, in the 1930s there was an outbreak in the US with a mortality of up to 20% (80% in pregnant women), also attributed to parrots from South America.

Eventually, with further scientific development, the causative pathogen was identified as chlamydia psittaci, an atypical intracellular organism.

Psittacosis is a significant differential to consider in community acquired pneumonia as it has a high mortality if left untreated. But it is rare, and causes about 1% of cases in the US. Part of this is due to improved hygiene practices and strict importation guidelines of tropical birds.

It's spread through the inhalation of dust with either dried faeces or respiratory secretions from infected birds.

Clinical features

Variable! but the key thing on history is birds

incubation time can be anywhere from 2 days to 20

Flu-like (fevers/chills/myalgias/arthralgias/malaise/headache)

high fevers is key

respiratory symptoms - does not always present as per the case report, and can be mild on spectrum (dry cough) to more severe

if systemic, can also get photophobia, deafness and epistaxis

Rare (particularly where doxycycline or azith are prescribed at a low threshold): hepatosplenomegaly (look out for LFTs), GI symptoms (remember CAP can present with diarrhoea, nausea/vomiting --> always do a CXR)

even rarer: endocarditis or myocarditis, encephalitis or hepatitis (usually the complications of untreated disease)

Increased risk groups:

pet shop owners

bird owners

farmers

zoo, lab workers where birds are kept, vets, avian quarantine station workers

poultry handlers/workers

So ask if they live or work with birds, or had recent exposure.

INvestigations

serology is gold standard - so looking for antibodies in blood tests

it's intracellular - so hard to culture if even possible on standard blood cultures

elevated ESR/CRP may see LFT derangement and creatinine rise in systemic illness

CXR- usually lower lobe changes, if CT is done, you can get pulmonary infiltrates with GGOs

Treatment:

usual culprits for atypical coverage: azithromycin 3 days or doxycycline 100 mg BD for 14/7

Differentials

always broad if systemic features only (also consider IE and other causes of sepsis)

with resp symptoms - legionella, Q fever, mycoplasma, tularaemia (except for tularaemia, the rest are also covered by doxycycline)

In clinical practice, I'm so used to just having atypicals on board for any cases of atypical pneumonia. I really take it for granted. But will consider this differential more myself in cases of PUO - but I feel like there should be at least CXR findings regardless.

Anyway, prognosis is very good so long as it is treated.

Sources:

CDC guidelines

Case Report: Importance of Clinical history in Psittacosis

StatPearls

Wiki

[philphys-survivalguide]

CAP

According to the Philippine Clinical Practice Guidelines for CAP in ADULTS (2020):

Unstable Co Morbids include: -> Uncontrolled DM -> Active malignancies -> Neurologic disease in evolution -> CHF FC II-IV -> Unstable CAD -> Renal Failure on dialysis -> Uncompensated COPD -> Decompensated Liver disease

Legionella urine antigen test and Influenza test are conditional recommendation for CAP HR: -> Influenza test may be done during periods of high influenza activity (July - January) if CAP HR is preceded by inluenza-like illness symptoms such as body malaise, rhinorrhea, arthralgia, sorethroat plus risk factors such as >60y/o, pregnant, asthmatic.

DRUGS: PENICILLINS: amoxicillin MACROLIDES: clarithromycin, azithromycin BETALACTAMS: co-amoxiclav, cefuroxime TETRACYCLINES: doxycycline NON PSEUDOMONAL BETALACTAMS: ampisul, cefotaxime, ceftriaxone FLUOROQUINOLONES: levofloxacin, moxifloxacin

Atypical coverage for Aspiration Pneumonia is only recommended if with suspicion of lung abscess or empyema.

Antiviral treatment is recommended with antibiotic therapy in CAP HR with risk factors mentioned under influenza testing.

Treatment should be initiated within 4 hours regardless of risk.

Duration of treatment: -> CAP LR , CAP MR: 5 days if stable -> May extend duration if pneumonia is not resolving, complicated by sepsis, infected with less common pathogens or infected with drug-resistant pathogens.

CXR post-treatment is recommended after a minimum of 6-08 weeks to establish a baseline and exclude other conditions but it is not recommended for routine testing in stable improving patients.

Inadequate Response after 72 hours of Empiric treatment: -> Reassess for possible resistance -> Reassess for the presence of other pathogens such as M. tuberculosis, viruses, parasites, or fungi.

Philippine CPG for CAP (Adults) 2020 Downloadable Link: https://www.psmid.org/cpg-management-and-prevention-of-adult-community-acquired-pneumonia-2020/

[nelyastudies]

4 oct 2023 - 12/100 days of productivity

started the day at the wards and i get to review some endocrinology (DKA, HHS) between doctor’s visits. reviewed some basic examination for dehydration and dubowitz postnatal age determination as well.

i have night shift so at 4 pm i tried to sleep at the mess, but i cant, so i read giovanni’s room. it was a bad idea. my heart is brittle paper and there was a shame that belongs to someone else in me, or i dont know, maybe it was mine! james baldwin is one of kind.

my night shift went peacefully. there is only one paediatric patient with community acquired pneumonia (the wheezing is so apparent). i spent the rest of the time reviewing respirology on my desk. i intend to study cardiology as well, but it was 3 am and after trying and starting over twice, i decided that studying something as hard as cardiology was futile. i went back to endocrinology but later when i look back at my notes, it became clear to me the connection between my hand and my brain is just isnt there anymore XD.

i went back to mess at 5 am to sleep and went to the wards at 6 to do rounds. i went back to mess at 8 am to steal some sleepytime and to write this haha.

song of the day - eat your young by hozier ughhhhh it soooooooo good SOOOO GOODDDDD

[covid-safer-hotties]

The Risks of Killing a COVID Early Warning System - Published August 1, 2024

In Ontario, the government is rolling back its detection program. Doctors are speaking out about what’s at stake.

COVID-19 is surging in parts of North America and Europe, and even played a role in ending the presidential campaign of 81-year-old Joe Biden, who was infected for the third time last month.

Nevertheless, on Wednesday the Ontario government shut down its early warning system to detect COVID and other emerging diseases.

Doctors, citizens and researchers are calling the decision to kill the province’s wastewater disease surveillance program both wrong-headed and dangerous. Ending the program will make it harder to track and thwart viral outbreaks, they say, and thereby increase the burden on Ontario’s understaffed hospitals, which experienced more than 1,000 emergency room closures last year.

“Pandemics do not end because science has been muzzled,” Dr. Iris Gorfinkel, a well-known Toronto physician and clinical researcher, told the CBC.

In emails to politicians, more than 5,000 citizens have demanded restoration of the program, with little effect.

The Tyee is supported by readers like you Join us and grow independent media in Canada In 2020, at the height of the pandemic, Ontario launched one of the world’s most comprehensive disease surveillance systems by sampling wastewater.

For five days a week since then, sewage water has been monitored for signs of COVID and its variants.

The viral particles can be detected in wastewater seven days before people experience symptoms, giving an invaluable head start on public health measures and allowing advance warning of surges in illness. The system was expanded to include wastewater testing for monkeypox, influenza and respiratory syncytial virus, or RSV, and even drug-resistant bacteria, at more than 56 locations in the province. The system covered all 34 public health districts.

Unlike other forms of testing, wastewater surveillance is relatively cheap and can be done in a small university lab. It also provides reliable updates that decision-makers and the public could easily follow in real time.

The monitoring helped millions at high risk from COVID infections, including the elderly and citizens with cancer and other immune suppressive disorders, to determine the incidence of the virus in their communities. It gave them information about when to make medical appointments, where to mask up and when to avoid crowded indoor events.

For many Indigenous communities with substandard and crowded housing, the program also served as an early warning system for waves of respiratory diseases.

The program also provided timely warnings to parents on the risk of infants acquiring RSV, which can cause pneumonia. Hospitals, too, regularly used the results to prepare for staffing and resource challenges in the wake of infectious viral waves including COVID and RSV.

Read more at either link!

[elipheleh]

David Wojnarowicz - Photo

Continuing my series of learning about things referenced in the book, I'm looking at things Alex references when he talks about engaging with queer history. These are all tagged #a series of learning about things that are referenced in the book, if you want to block the tag.

This post will cover the AIDS pandemic, which means there will be discussion of an incredibly large number of deaths, as well as government neglect of AIDS patients due to homophobia. There will be talk of the grief from the queer community & the ways it was weaponised to protest in an attempt for fundamental change. This is not a light topic, please take appropriate care when reading. As this post is going to have a few different topics in, so I decided to actually start with a read more, rather than arbitrarily place it partway down, I'd do a list of what is covered in this post & then have it all behind the cut.

So, in order, this post covers: David Wojnarowicz; AIDS; ACT-UP. In the additional reading section is a section subtitled "NAMES AIDS Memorial Quilt". This is worth looking into if you aren't already aware.

David Wojnarowicz is the man in the photo shown above, and referenced by Alex in the book. He was an AIDS activist, artist, writer, and filmmaker - among other things. He drew on his personal experiences with AIDS for his art & his political activism. In 1988, Wojnarowicz wore the leather jacket pictured above, with a pink triangle underneath text reading "if i die of aids - forget burial - just drop my body on the steps of the f.d.a." This jacket, and his similar sentiment from his book Close to the Knives, inspired David Robinson who - in 1991 - dumped the ashes of his deceased partner on the grounds of the White House in protest. These protests came to be known as "Ashes Action". Wojnarowicz died in his Manhattan home on July 22, 1992, aged 37, from what his boyfriend, Tom Rauffenbart, confirmed was AIDS. His ashes were scattered on the White House lawn in 1996.

-----

The AIDS epidemic in the US dates back to around 1970, but it wasn't until 1981 that cases started to come to light. The CDC (Centers for Disease Control and Prevention) published a report about 5 gay men becoming infected with a type of pneumonia only seen in people with compromised immune systems. As these men were healthy, this was unexpected. A year after, the New York Times published an article about a new immune system disorder, affecting over 300 people and killing over 100. Officials coined it GRID, gay-related immune deficiency, as it appeared to only be affecting gay men. It became officially known as AIDS (Acquired Immune Deficiency Syndrome) by August 1982, but was referred to as "gay plague" and many other derogatory terms for many years. Ninety-five and a half per cent of those diagnosed with AIDS between 1981 and 1987 died.

At the time, Ronald Reagan was president. He has been widely criticised for his reaction to the epidemic, for good reason. He didn't mention the word "AIDS" in public until 1985, by which time there had been 5636 deaths due to AIDS in the US. His first speech about the disease was delivered to the College of Physicians in Philadelphia in 1987, by which point there were more than 36,000 Americans living with AIDS & more than 20,000 had died. In the documentary When AIDS Was Funny (linked at the bottom), audios from press conferences in the early 1980s show how little the Reagan administration cared. Not only do they refer to AIDS as "gay plague", but joke around about it. It shows just how much the epidemic was derided - the people in charge of the country were so flippant about something so devastating, reflecting the general opinion of AIDS. Reagan's public support came overwhelmingly from the 'religious right', with Rev. Jerry Falwell using his political action group (the Moral Majority) to encourage homophobia aimed at gay men, especially those diagnosed with AIDS. Pat Buchanan, the White House Communications Director from 1985 to 1987, described the crisis as nature “exacting an awful retribution against gay men” in 1983.

Larry Kramer, when recalling the attempts to get help from public officials said:

You learn very fast that you’re a faggot, and it doesn’t make any difference that you went to Yale and were assistant to presidents of a couple of film companies, and that you had money. [source]

-----

On the 13th August, 1998, the Bay Area Reporter paper published a headline "No obits". For the first time in 17 years, there was finally a week without any deaths due to AIDS in the area covered by the paper - they are clear that there were deaths elsewhere, and they may have belated obituaries the following week, but for now this was a positive change. They had previously had up to 30 obituaries at points. Derek Gordon was quoted in the article as saying:

"I remember my grandfather said he knew he was getting near death because he used to scan the obits," he told the B.A.R. "I used to think how tragic because I was doing the same thing at 30."

-----

Wojnarowicz's jacket features a pink triangle on it. This was being used as a signal, as the pink triangle had been reclaimed by gay activists - originally in early 1970s Germany - to be used as a memorial to past victims & to protest continuing discrimination following its use by the Nazi Party to identify queer men in concentration camps. ACT-UP (AIDS Coalition To Unleash Power) adopted this icon, and turned it the other way up (so the point was at the top) and continue to use it to this day.

ACT-UP was formed in 1987, in New York City, and is now an international political group. It is working to end the AIDS pandemic using direct action, medical research & treatment, and trying to influence legislation. They debuted in October 1987, at the second National March on Washington for Lesbian and Gay Rights, not only by participating in the march but also with civil disobedience the day after. In the following October, ACT-UP shut down the F.D.A. (Food & Drug Administration) for a day in a demonstration against their drug approval process. The image of Wojnarowicz was taken that day, by William Dobbs. Activists shut down the F.D.A. by blocking the doors & walkways that would allow staff to get into the building. Some lay on the floor with faux-headstones, reading “DEAD FROM LACK OF DRUGS” and “VICTIM OF F.D.A. RED TAPE”. They attached a banner to the front of the building with ACT-UP's slogan - SILENCE = DEATH, bracketed by two pink triangles.

ACT-UP utilised different tactics from other groups - not only did they carry out (entirely non-violent) civil disobedience actions, but they also had the knowledge to be able to argue their demands successfully. The demonstration at the F.D.A. and their precise demands led to the F.D.A. listening to them and including them in decision making - and a year later their demands had started to come to fruition, with easier access to experimental drugs for those living with AIDS.

One 'Action' ACT-UP coordinated, was coined 'Ashes Action', as mentioned above. In 1992, ACT-UP marched to the White House fence to scatter the ashes of loved ones who had died due to AIDS onto the lawn of the White House. Inspired by Wojnarowicz's memoir, ashes were poured over the fence, demonstrating to the government explicitly the physical result of the AIDS policies. 'They had drums play a funeral cadence. They chanted—Bringing our dead to your door / We won't take it anymore and Out of the quilt and into the streets / Join us, join us. Unlike other protests, the Ashes Actions were not only meant to shock an uninterested public into empathy—they were meant as releases of grief for the activists themselves. "There was lots of room to scream and yell," Butler said, "but it wasn't always conducive to the work of mourning. I knew none of the people whose ashes we were carrying, but I remember when the ashes went over the fence of the White House. I just don't remember convulsive grief like the grief I felt in that moment."' [source]

sixteen, ashes of your forerunners rest on the lawn of the White House because SIXTEEN, THEY HAVE ALWAYS WATCHED US DIE. -SpondeeSoliloquy - Seventeen things (alternate link)

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I had to cut down a lot of the information here, so I would really appreciate it if you took the time to have a look through the additional reading below, there was a lot of things I would have added if I had the space.

-----

Sources: Wikipedia - David Wojnarowicz Guardian - David Wojnarowicz: still fighting prejudice 24 years after his death NY Times AIDS Timeline 1980-1987 History.com - History of AIDS Wikipedia - History of HIV/AIDS vox.com - The Reagan administration's unbelievable response to the HIV/AIDS epidemic US Studies Online The AIDS Crisis and the US Presidency SFGate - Reagan's AIDS Legacy / Silence equals death Washington Post - Pat Buchanan's Greatest Hits Wikipedia - Moral Majority Bay Area Reporter - No Obits Wikipedia - Pink Triangle Wikipedia - ACT UP New Yorker - How ACT UP Changed America Vice - Why the Ashes of People With AIDS on the White House Lawn Matter Pioneer Works - The Jacket

Additional Reading: When AIDS Was Funny - Documentary Film (cw for images of very unwell aids patients) LA Times - Police Arrest AIDS Protesters Blocking Access to FDA Offices Youtube - ACT UP Ashes Action 1992 Washington Post - AIDS ACTIVISTS THROW ASHES AT WHITE HOUSE Wikipedia - How to Survive a Plague Wikipedia - The Normal Heart (originally a play), 2014 film BBC - The drama that raged against Reagan’s America Wikipedia - Silence=Death Project Brooklyn Museum - Silence = Death Wikipedia - And The Band Played On - Randy Shilts NPR - How To Demand A Medical Breakthrough: Lessons From The AIDS Fight ACT-UP oral histories ClassicFM - Sobering black-and-white image of a gay men’s choir reminds of loss of life during AIDS epidemic Snopes - Does a Poignant Photo of Gay Men's Choir Show Devastating Impact of HIV/AIDS? Why We Fight - Vito Russo NAMES AIDS Memorial Quilt Wikipedia - NAMES Project AIDS Memorial Quilt national aids memorial - quilt history Cleve Jones interview (specifically: How he came up with the idea for the AIDS Quilt) View the NAMES AIDS memorial quilt online

[mariacallous]

Chinese Hospitals Are Housing Another Deadly Outbreak

In Beijing and other megacities in China, hospitals are overflowing with children suffering pneumonia or similar severe ailments. However, the Chinese government claims that no new pathogen has been found and that the surge in chest infections is due simply to the usual winter coughs and colds, aggravated by the lifting of stringent COVID-19 restrictions in December 2022. The World Health Organization (WHO) has dutifully repeated this reassurance, as if it learned nothing from Beijing’s disastrous cover-up of the COVID-19 outbreak.

There is an element of truth in Beijing’s assertion, but it is only part of the story. The general acceptance that China is not covering up a novel pathogen this time appears reassuring. In fact, however, China could be incubating an even greater threat: the cultivation of antibiotic-resistant strains of a common, and potentially deadly, bacteria.

Fears of another novel respiratory pathogen emerging from China are understandable after the SARS and COVID-19 pandemics, both of which Beijing covered up. Concerns are amplified by Beijing’s ongoing obstruction of any independent investigation into the origins of SARS-CoV-2, the virus that causes COVID-19—whether it accidentally leaked from the Wuhan lab performing dangerous gain-of-function research or derived from the illegal trade in racoon dogs and other wildlife at the now-infamous Wuhan wet-market.

Four years ago, during the early weeks of the COVID-19 outbreak, Beijing failed to report the new virus and then denied airborne spread. At pains to maintain their fiction, Chinese authorities punished doctors who raised concerns and prohibited doctors from speaking even to Chinese colleagues, let alone international counterparts. Chinese medical statistics remain deeply unreliable; the country still claims that total COVID-19 deaths sit at just over 120,000, whereas independent estimates suggest the number may have been over 2 million in just the initial outbreak alone. Now, Chinese doctors are once again being silenced and not communicating with their counterparts abroad, which suggests another potentially dangerous cover-up may be underway.

We don’t know exactly what is happening, but we can offer some informed guesses.

The microbe causing the surge in hospitalization of children is Mycoplasma pneumoniae, which causes M. pneumoniae pneumonia, or MPP. First discovered in 1938, the microbe was believed for decades to be a virus because of its lack of a cell membrane and tiny size, although in fact it is an atypical bacterium. These unusual characteristics makes it invulnerable to most antibiotics (which typically work by destroying the cell membrane). The few attempts to make a vaccine in the 1970s failed, and low mortality has provided little incentive for renewed efforts. Although MPP surges are seen every few years around the world, the combination of low mortality and difficult diagnostics has meant there is no routine surveillance.

Although MPP is the most common cause of community-acquired pneumonia in school children and teenagers, pediatricians such as myself refer to it as “walking pneumonia” because symptoms are relatively mild. Respiratory Syncytial Virus (RSV), influenza, adenoviruses, and rhinoviruses (also known as the common cold) all cause severe inflammation of the lungs and are far more common causes of emergency-room visits, hospitalization, and death in infants and young children. Why should MPP be acting differently now?

One contributing factor to the severity of this outbreak may be “immunity debt.” Around the globe, COVID-19 lockdowns and other non-pharmaceutical measures meant that children were less exposed to the usual range of pathogens, including MPP, for several years. Many countries have since seen rebound surges in RSV. Several experts agree with Beijing’s explanation that the combination of winter’s arrival, the end of COVID-19 restrictions, and a lack of prior immunity in children are likely behind the surging infections. Some even speculate that that substantial lockdown may have particularly compromised young children’s immunity, because exposure to germs in infancy is essential for immune systems to develop.

In China, MPP infections began in early summer and accelerated. By mid-October, the National Health Commission had taken the unusual step of adding MPP to its surveillance system. That was just after Golden Week, the biggest tourism week in China.

Infection by two diseases at the same time can make things worse. The usual candidates for coinfection in children—RSV and flu—have not previously caused comparable surges in pneumonia. One difference this time is COVID-19. It is possible that the combination of COVID-19 and MPP is particularly dangerous. Although adults are less susceptible to MPP due to years of exposure, adults hospitalized for COVID-19 who were simultaneously or recently coinfected by MPP had a significantly higher mortality rate, according to a 2020 study.

Infants and toddlers are immunologically naive to MPP, and unlike COVID-19, RSV, and influenza, there is no vaccine against MPP. It seems implausible that no child (or adult) has died from MPP, yet China has not released any data on mortality, or on extrapulmonary complications such as meningitis.

Most disturbing, and a fact being downplayed by Beijing, is that M. pneumoniae in China has mutated to a strain resistant to macrolides, the only class of antibiotics that are safe for children less than eight years of age. Beyond discouraging parents to start ad hoc treatment with azithromycin, the most common macrolide and the usual first-line antibiotic for MPP, Beijing has barely mentioned this fact. Even more worrying is that WHO has assessed the risk of the current outbreak as low on the basis that MPP is readily treated with antibiotics. Broader azithromycin resistance in MPP is common across the world, and China’s resistant strain rates in particular are exceptionally high. Beijing’s Centers for Disease Control and Prevention reported macrolide resistance rates for MPP in the Beijing population between 90 and 98.4 percent from 2009 to 2012. This means there is no treatment for MPP in children under age eight.

Fears over a novel pathogen are already abating. After all, MPP is rarely lethal. But antimicrobial resistance (AMR) is. Responsible for 1.3 million deaths a year, AMR kills more people than COVID-19. No country is immune to this growing threat. Since China, where antibiotics are regularly available over the counter, leads the world in AMR, it is inconceivable that this issue hasn’t yet come up, particularly during WHO’s World AMR Awareness week, from Nov. 18 to Nov. 24.

Any infectious disease physician would want to know: Did WHO asked China the obvious question—what is the level of azithromycin resistance of M. pneumonia in the current outbreak—and include the answer in its risk assessment? Or did it ask about resistance to doxycycline and quinolones, antibiotics that can be used to treat MPP in adults? Even if WHO did ask, China isn’t telling, and WHO isn’t talking.

China’s silence isn’t surprising. Its antibiotic consumption per person is ten times that of the United States, and policies for AMR stewardship are predominantly cosmetic. While surveillance is China’s strong point, reporting is not.

Despite Spring Festival, the Chinese celebration of the Lunar New Year and another peak travel period, approaching in February 2024, WHO hasn’t advised any travel restrictions. It should have learned the danger of accepting Beijing’s statements at face value. Four years ago, Beijing’s delay enabled more than 200 million people to travel from and through Wuhan for Spring Festival. That helped COVID-19 go global. Since China’s AMR rates are already so high, importing AMR from other countries isn’t a major concern for China. Export is the issue, and China’s track record in protecting other countries is abysmal.

Rather than repeating the self-serving whitewashing coming from Beijing, WHO should be publicly pressing China about the threat of mutant microbes. Halting AMR is essential. Before antisepsis and antibiotics, surgery was a treatment of last resort. Without antibiotics, we lose 150 years of clinical and surgical advances. Within ten years, we are at risk of few antibiotics being effective. It may not be the novel virus that people were expecting, but the next pandemic is already here.

[hamutxt]

bro is going community-acquired pneumonia mode

[teachingrounds]

Q. How long should a young child take antibiotics for pneumonia?

Since many lower respiratory tract infections are caused by viruses, shorter antibiotic courses (3-5 days) for uncomplicated community acquired pneumonia in young children 2m-5y may be noninferior to longer courses (7-10 days). Treatment failure happens ~12% of cases.

[mcatmemoranda]

CURB-65 can be used as a tool for determining disposition for patients diagnosed with community-acquired pneumonia. It is a scoring system based on a patient's confusion, BUN value, respirations, blood pressure, and age. Those with a score of 0 and sometimes 1 can generally be managed on an outpatient basis.

[tubetrading]

The Role of Ertapenem 100 mg in Modern Antibiotic Therapy

In recent years, the growing challenge of antibiotic resistance has prompted healthcare professionals to explore newer therapeutic options.  Among these, Ertapenem 100 mg has emerged as a significant player in modern antibiotic therapy.  This broad-spectrum antibiotic belongs to the carbapenem class and is renowned for its effectiveness against a variety of infections, particularly those caused by Gram-negative bacteria.  In this blog, we will delve into the importance of Ertapenem, its applications, and its availability through Ertapenem 100 mg injection manufacturers in India, exporters, suppliers, and distributors.

Understanding Ertapenem

Ertapenem is a synthetic beta-lactam antibiotic that offers potent activity against a wide range of bacterial pathogens.  Its unique structure allows it to penetrate bacterial cell walls effectively, making it suitable for treating complex infections, including those originating from intra-abdominal sources, skin and soft tissue infections, and pneumonia.  Given the rising rates of resistance to commonly used antibiotics, Ertapenem provides a vital alternative for clinicians seeking reliable treatment options.

The Need for Effective Antibiotics

The World Health Organization (WHO) has recognized antibiotic resistance as one of the most significant global health threats.  With an increasing number of bacterial strains becoming resistant to traditional therapies, the role of advanced antibiotics like Ertapenem has become crucial.  The ability of Ertapenem to maintain its efficacy against resistant strains makes it an essential component of modern treatment regimens.

Applications of Ertapenem 100 mg

Ertapenem is indicated for various infections, including:

Intra-abdominal Infections:  It is often used to treat complicated intra-abdominal infections due to its broad spectrum of activity.

Skin and Soft Tissue Infections:  Ertapenem is effective against multiple pathogens commonly responsible for skin infections.

Pneumonia:  This antibiotic is also a go-to treatment for community-acquired pneumonia.

Complicated Urinary Tract Infections:  Ertapenem can be a critical option when dealing with complicated cases.

The versatility of Ertapenem makes it a valuable asset in a clinician's toolkit, particularly for patients who have not responded to other antibiotic therapies.

Availability in India

Ertapenem 100 mg Injection Manufacturers in India

India has a robust pharmaceutical industry, recognized for producing high-quality medications at competitive prices.  Numerous Ertapenem 100 mg injection manufacturers in India are dedicated to maintaining stringent quality standards while ensuring that their products meet international guidelines.  These manufacturers play a vital role in making Ertapenem accessible to healthcare facilities across the country and abroad.

Ertapenem 100 mg Injection Exporters in India

The global demand for effective antibiotics has led to an increase in Ertapenem 100 mg injection exporters in India.  These exporters are crucial in supplying this essential medication to international markets, contributing to India's reputation as a leader in the global pharmaceutical landscape.  The adherence to quality and regulatory standards has helped these exporters establish strong relationships with healthcare providers worldwide.

Ertapenem 100 mg Injection Suppliers in India

A reliable supply chain is fundamental for the availability of Ertapenem in hospitals and clinics.  Numerous Ertapenem 100 mg injection suppliers in India ensure that healthcare institutions receive timely deliveries of this critical antibiotic.  These suppliers work closely with manufacturers to maintain a steady stock, facilitating uninterrupted access to essential medications.

Ertapenem 100 mg Injection Distributors in India

The role of Ertapenem 100 mg injection distributors in India is equally important.  They bridge the gap between manufacturers and healthcare providers, ensuring that the product reaches the end-users efficiently.  Distributors are vital in managing logistics, handling regulatory compliance, and addressing the needs of various healthcare institutions.  Their efforts ensure that doctors have immediate access to this antibiotic, particularly in emergency situations.

Best Indian Pharma Industry 2024

The best Indian pharma industry 2024 is characterized by innovation, quality, and a commitment to addressing public health challenges.  With a focus on research and development, Indian pharmaceutical companies are continually improving their product offerings.  The introduction of advanced antibiotics like Ertapenem is a testament to the industry’s efforts to combat antibiotic resistance.  The commitment to maintaining high manufacturing standards and complying with international regulations has solidified India’s position as a trusted source for pharmaceuticals worldwide.

Conclusion

The role of Ertapenem 100 mg in modern antibiotic therapy cannot be overstated.  As antibiotic resistance continues to pose significant challenges to healthcare, the importance of effective and reliable treatments like Ertapenem becomes even more critical.  The collaboration among Ertapenem 100 mg injection manufacturers, exporters, suppliers, and distributors in India has made this essential antibiotic readily available to healthcare providers, ensuring that patients receive the best possible care.

In 2024, as the best Indian pharma industry continues to evolve, the ongoing development and distribution of innovative antibiotics will remain pivotal in the fight against infectious diseases.  By prioritizing access to effective medications, we can work towards a healthier future and combat the ever-growing threat of antibiotic resistance.

[drambikachestclinic]

What are the main types of pneumonia?

Pneumonia is a lung infection that can be caused by various organisms, including bacteria, viruses, fungi, and parasites. The main types of pneumonia are generally classified based on where and how the infection was acquired. Here are the primary types:

Community-Acquired Pneumonia (CAP):

This type of pneumonia is acquired outside of healthcare settings, such as hospitals or nursing homes.

It is often caused by bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, and atypical bacteria like Mycoplasma pneumoniae.

Viruses, including influenza, respiratory syncytial virus (RSV), and coronaviruses, can also cause CAP.

Hospital-Acquired Pneumonia (HAP):

HAP occurs in patients during their stay in a hospital, typically 48 hours or more after admission.

It is often caused by more resistant bacteria such as Staphylococcus aureus (including MRSA) and Pseudomonas aeruginosa.

Patients with weakened immune systems or those who are on ventilators are at higher risk.

Ventilator-Associated Pneumonia (VAP):

A subtype of HAP, VAP occurs in people who are on mechanical ventilation for at least 48 hours.

The causative agents are often similar to those of HAP, with a higher likelihood of being multi-drug resistant organisms.

Healthcare-Associated Pneumonia (HCAP):

This type includes pneumonia in patients who are in regular contact with healthcare settings, such as nursing homes, dialysis centers, or outpatient clinics.

Like HAP, HCAP can be caused by antibiotic-resistant bacteria.

Aspiration Pneumonia:

Occurs when food, liquid, saliva, or vomit is inhaled into the lungs, leading to an infection.

It is more common in individuals with swallowing difficulties or those who are unconscious or have impaired gag reflexes.

Atypical Pneumonia:

Often referred to as "walking pneumonia," it is typically less severe and has a different clinical presentation.

Caused by atypical bacteria such as Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophila.

Symptoms are usually milder compared to typical bacterial pneumonia.

Fungal Pneumonia:

Caused by fungi, more common in people with weakened immune systems.

Examples include Histoplasmosis, Coccidioidomycosis, and Cryptococcosis.

Viral Pneumonia:

Common in children and older adults, often caused by viruses such as influenza, respiratory syncytial virus (RSV), and coronaviruses (including SARS-CoV-2).

Each type of pneumonia has different risk factors, causative organisms, and treatments, making accurate diagnosis and appropriate management crucial.

[swasli]

Why Choose Camp X-Ray for Your Diagnostic Needs

Clear Perspective: How Camp X-Ray Enhances Diagnostic 

Accuracy

In the realm of medical diagnostics, the choice of imaging services plays a pivotal role in accurate diagnosis and treatment planning. Camp X-Ray services stand out as a cornerstone in this domain, offering advanced technology, skilled professionals, and a commitment to precision. This blog explores the reasons why Camp X-Ray should be your preferred choice for diagnostic needs, highlighting its benefits, technological advancements, and impact on patient care.

Medical diagnostics have undergone significant advancements over the years, revolutionizing how healthcare providers detect, diagnose, and treat various medical conditions. Among these advancements, Camp X-Ray services have emerged as a critical component in the diagnostic toolkit, providing healthcare professionals with essential insights through advanced imaging technology.

Precision and Accuracy

Camp X-Ray services are renowned for their precision and accuracy in diagnostic imaging. Unlike traditional methods, such as film-based X-rays, Camp X-Ray facilities employ digital radiography (DR) and computed radiography (CR) systems. These technologies offer several advantages:

High-Resolution Imaging: Digital X-ray systems produce detailed, high-resolution images that allow healthcare providers to visualize anatomical structures with exceptional clarity.

Enhanced Diagnostic Capabilities: The clarity of digital images enables healthcare professionals to detect subtle abnormalities, leading to earlier detection and more accurate diagnoses of medical conditions.

Reduced Radiation Exposure: Digital X-ray systems typically require lower radiation doses compared to conventional film-based X-rays, ensuring patient safety without compromising image quality.

Optimizing Medical Care: Efficiency and Improved Outcomes

Camp X-ray services offer significant advantages for medical  professionals and healthcare facilities:

Faster Diagnosis:  The speed and convenience of Camp X-ray's mobile X-ray services enable physicians to acquire X-ray results quickly.  This can expedite the diagnostic process and potentially lead to faster and more effective treatment plans for patients.

Improved Workflow:  For clinics and medical facilities, the availability of on-site  X-ray services can significantly improve their workflow.  Eliminating the need for referrals to external imaging centers and streamlining the diagnostic process allows clinics to serve patients more efficiently and effectively.

Enhanced Patient Care:  By prioritizing patient comfort and reducing wait times, Camp X-ray services contribute to a more positive overall healthcare experience for patients.  This can translate into improved patient satisfaction and higher adherence to treatment plans.

Camp X-Ray Services: More Than Just Convenience

While convenience is a significant advantage of Camp X-ray services, their offerings extend beyond simply bringing X-ray imaging to your doorstep. Here's a deeper dive into some of the additional benefits they provide:

Specialized Services:  Camp X-ray caters to a wide range of diagnostic needs. They offer specialized X-ray services for various body parts, including bones, chest (for pneumonia or other respiratory issues), and extremities (for fractures or sprains). Additionally, they can perform portable X-rays for patients in critical care situations.

Improved Communication:  Camp X-ray prioritizes clear communication with both patients and healthcare providers. Their technicians explain the X-ray procedure clearly to patients, addressing any questions or concerns.  Additionally, they ensure the timely delivery of high-quality digital X-ray images to physicians for rapid diagnosis.

Flexibility and Scalability:  Camp X-ray services are highly adaptable to meet diverse scheduling needs. They offer flexible scheduling options to accommodate patient availability and clinic workflows. Furthermore, their mobile units can be scaled to handle various patient volumes, ensuring efficient service for both large medical facilities and smaller clinics.

Reduced Costs:  While the exact cost structure of Camp X-ray services may vary depending on location and specific requirements, their services can potentially lead to cost savings for healthcare providers. Reduced transportation costs and streamlined workflows can contribute to overall cost optimization within healthcare facilities.

Safety and Quality: Maintaining High Standards

Camp X-ray services are built on a foundation of safety and quality:

Experienced Technicians:  Camp X-ray employs highly trained and certified technicians who adhere to strict protocols to ensure proper X-ray procedures and patient safety during on-site imaging.

Advanced Technology:  Their mobile X-ray units utilize state-of-the-art equipment that delivers high-quality digital X-ray images.  These digital images facilitate accurate diagnosis by physicians.

Safety Protocols:  Camp X-ray adheres to industry-standard radiation safety protocols.  They utilize techniques and equipment that minimize patient exposure to radiation during X-ray imaging.

Camp X-ray services are not just about convenience; they represent a paradigm shift in diagnostic imaging.  Their commitment to patient comfort,  efficiency, and safety is transforming the way X-rays are performed.  By bringing imaging directly to patients, Camp X-ray service are creating a more positive and streamlined diagnostic experience for everyone involved in the healthcare journey.  As the demand for convenient and efficient diagnostic solutions grows, Camp X-ray service are poised to play a pivotal role in shaping the future of medical care.

[kaydoespharmacy]

Cold

Symptoms – sore throat, sneezing, runny/blocked nose, cough, mild fever, pressure in ears, headache, myalgia (pain in muscles)

Duration – 1-2 weeks, symptoms peak 2-3 days, incubation period 10-12 hrs

Referral criteria – suspected flu, earache not responding to analgesia, sinus pain not responding to decongestants, no improvement after 10-14 days self-medication

Complications - immunocompromised, who smoke, and with comorbidities such as diabetes mellitus, congestive heart failure, asthma, chronic obstructive pulmonary disease, cystic fibrosis, and sickle-cell disease

Sinusitis – prolonged nasal congestion and facial pain

LRTI - acute bronchitis, acute exacerbation of asthma or chronic obstructive pulmonary disease (COPD), and community-acquired pneumonia

Acute otitis media – common in younger patients

Differential diagnosis

Meningitis – high fever, drowsiness, blank expression, vomiting, loss of appetite, high pitched screaming, non-blanching rash, photophobia, severe headache, malaise

Upper airway obstruction – noisy breathing, drooling, inability to swallow.

Nasal foreign body – persistent discharge from 1 nose with no other symptoms

Management – paracetamol or ibuprofen for headache, muscle pain or fever – only continue use if distressed, change to other agent if not alleviated, don’t give both together

Paracetamol contraindicated in – liver/kidney problems, epileptic

Ibuprofen contraindicated in – pregnancy, perforated stomach, increased bleeding, severe HF, kidney or liver problems, high BP, asthma, hay fever

Intranasal decongestants – improve breathing and promote sleep and has fewer S/E than oral decongestants. Ephedrine HCL 0.5% nasal drops for 12 and older p 1-2 drops 4x daily for 1 week – contraindicated – diabetes, hypertension, hyper thyroidism, CVD, high BP, MAOI in last 2 weeks

Oral decongestants – relieve nasal congestion (phenylephrine) – max 1 week

Antitussive (cough) – dextromethorphan

Expectorants (guaifenesin)

Chlorphenamine or Beecham’s (contains phenylephrine and paracetamol) (Sedating antihistamine – dries up secretions)

Counselling points

Go to GP if

fever for more than 3 days

symptoms worsening after 5 days

symptoms not better after 10 days

follow up meeting

risk and complicated patients within the week

young children – 1 week

Headaches

Types of headaches

Primary – not associated with other conditions – migraines, tension types, cluster

Secondary – associated with other conditions – trauma/injury, vascular disorders, hyper-tension, withdrawal such as opioids, analgesics, or alcohol. Bacterial or viral infection.

Features of serious headache – referral

New severe or unexpected headache – sudden onset reaching max intensity 5 mins and new onset in over 50s

Progressive or persistent headaches that changed dramatically

Associated features – fever, impaired consciousness, seizure, stiffness, photophobia, neurological deficit, cognitive dysfunction, atypical aura (greater than 1 hour) or aura 1st time in patients using combined oral contraceptives.

Dizziness, visual disturbance, vomiting. Head trauma up to 3 months prior, triggered by coughing, sneeze, or physical exertion. Worsened by standing or lying down.

Compromised immunity

Diagnosis

Migraine without aura – at least 5 attacks lasting 4-72 hrs with unilateral location (half the face), pulsating, moderate to severe pain and aggravated by or causing avoidance of routine physical activity. Attack comes with nausea and/or vomiting, photophobia and phonophobia

Migraine with aura – 2 attacks with visual aura (zigzag lines or blind spots), pins and needles, speech/language symptoms, motor weakness, vertigo.

One aura spreading gradually for 5 mins and 2 or more occurring after

Each aura lasts for 5-60mins which is unilateral

Management – stop combined oral anticontraception – contraindicated

Ibuprofen 400mg, paracetamol 1g, advise med to be taken at start of attack – follow up 2 weeks

Tension type – recurrent episodes lasting 30 mins – 7 days with NO nausea or vomiting. May have phot/phono phobia

Bilateral (across head landscape), pressing or tight (not pulsating), mild to moderate pain, not aggravated by physical activity

Management – simple analgesia – paracetamol or NSAID

Identify comorbidities such as stress, mood disorders, chronic pain, sleep disorders to manage

Cluster headache – 5 attacks of severe/very severe unilateral orbital (around ONE eye), forehead or temporal pain lasting 15 mins to 3 hrs with nasal congestion, runny nose, eyelid oedema, sweating, facial slushing, fullness in ear or restlessness

Attacks occur between one every other day and 8 per day for more than half the time the disorder is active

Management – REFER

Advise to avoid triggers and risk of medication overuse, identify and manage comorbidities – insomnia, depression, and anxiety

Medication – occurs 15 days per month and have a pre-existing headache disorder. Regular overuse of drugs for 3 months

Management – withdrawal from medication and advice around this

Sinusitis

Sinusitis usually follows a cold and lasts less than 12 weeks

If over 12 weeks becomes chronic – risk groups are allergic rhinitis, asthma, immunosuppression

Symptoms

Adults

Nasal blockage (obstruction/congestion), nasal discharge, facial pain/pressure, frontal headache, loss, or reduction of smell, altered speech indicating nose blocked. Tenderness, swelling. Redness over cheekbone, cough, headache worse when bending or lying down. Toothache.

Children

Nose block, discoloured nasal discharge, facial pain, pressure and or cough at day or night-time

Bacterial sinusitis

More than 10 days, discoloured, pussy discharge (from 1 nose), severe local pain (1 side), fever over 38 degrees, deterioration after milder sickness

Refer to hospital immediately

If they have symptoms of acute sinusitis and;

Severe systemic infection

Intraorbital or periorbital complications, including periorbital oedema or cellulitis, displaced eyeball, double vision, or new reduced vision

Intracranial complications, including swelling over frontal bone, symptoms or signs of meningitis, severe frontal headache, or focal neurological signs

Refer to GP

Severe symptoms, painkillers don’t work, symptoms worsen, symptoms don’t improve after 1-week, recurrent infection, sudden worsening, antibiotic failure, unusual or resistant bacteria, recurrent episodes, immunocompromised, allergic cause

Treatment

Acute with symptoms less than 10 days

DON’T OFFER ANTIBIOTIC, assure that it usually self resolves without bacterial complications. Symptoms managed

Paracetamol or ibuprofen for pain, headache, and fever

Use nasal saline spray or decongestants spray

Clean nose with saltwater solution (boil 1 pint of water and add 1 teaspoon of salt and bicarbonate soda. Wash hands, stand over sink, cup the palm of 1 hand and pour small amount of solution into it. Sniff water into 1 nostril at a time, breath through mouth and allow water to pour into sink, don’t let it go into your throat. Do 3x daily)

Acute for 10 days or more with no improvement

High dose nasal corticosteroid for 2 weeks for over 12s (mometasone 200mcg 2x daily)

Counsel that It may improve symptoms but won’t make the infection any shorter, could have systemic effects, may be difficult to use correctly.

Symptoms should get better 3-5 days of treatment – REFER if not

1st line antibiotic for adult

If not life threatening - phenoxymethylpenicillin 500 mg four times a day for 5 days.

Is systemically unwell, symptoms of more serious illness or high risk of complications - co-amoxiclav 500/125 mg three times a day for 5 days.

Allergic or intolerant to penicillin - clarithromycin 500 mg twice a day for 5 days.

Pregnant or intolerant to penicillin - erythromycin 250 mg to 500 mg four times a day or

Children 1st line

Phenoxymethylpenicillin

1 to 11 months, 62.5 mg four times a day for 5 days. 

1 to 5 years, 125 mg four times a day for 5 days. 

6 to 11 years, 250 mg four times a day for 5 days. 

12 to 17 years, 500 mg four times a day for 5 days.

If very unwell - co-amoxiclav

1 to 11 months, 0.25 mL/kg of 125/31 suspension three times a day for 5 days. 

1 to 5 years, 5 mL of 125/31 suspension three times a day or 0.25 mL/ kg of 125/31 suspension three times a day for 5 days

6 to 11 years, 5 mL of 250/62 suspension three times a day or 0.15 mL/kg of 250/62 suspension three times a day for 5 days. 

12 to 17 years, 250/125 mg three times a day or 500/125 mg three times a day for 5 days.

If allergic or intolerant to penicillin – clarithromycin

Under 8 kg, 7.5 mg/kg twice a day for 5 days. 

8 to 11 kg, 62.5 mg twice a day for 5 days. 

12 to 19 kg, 125 mg twice a day for 5 days. 

20 to 29 kg, 187.5 mg twice a day for 5 days. 

30 to 40 kg, 250 mg twice a day for 5 days. 

12 to 17 years, 250 mg twice a day or 500 mg twice a day for 5 days.

2nd line – if symptoms are still worsening after 1st line treatment for 2-3 days

Adults – co-amoxiclav 500/125mg TD x 5 days

Children – specialist advice

ANTIHISTAMINES can be prescribed for allergic triggered sinusitis

Diabetes type 1

Body stops making insulin and the blood sugar (glucose) level goes extremely high - persistent hyperglycaemia (random plasma glucose of 11mmol/l or more). We must control glucose level with insulin injections, healthy diet and reduce the risk of other health complications. Typically occurs in children and young adults.

Symptoms of T1D- Frequently thirsty, pass a lot of urine, tiredness, weight loss and feeling generally unwell. Develops quite quickly, over days or weeks, as the pancreas stops making insulin.

Pathophysiology of T1D- Autoimmune disease (environmental & genetic factors). Antibodies attach to the beta cells in the pancreas destroying the cells that make insulin (pancreatic islet cells).

Diagnosing T1D- Simple dipstick test to detect glucose in a sample of urine BUT only way to confirm the diagnosis is to have a blood test to look at the level of glucose in your blood (level of 11.1 mmol/L or more in the blood sample indicates that you have diabetes) PLUS a fasting blood glucose level is taken (level of 7.0 mmol/L or more indicates that you have diabetes).

Management- Should be offered multiple daily injection basal-bolus insulin regimens as the first-line choice. Twice-daily insulin detemir should be offered as the long-acting basal insulin therapy. Once-daily insulin glargine may be prescribed if insulin detemir is not tolerated, or if a twice-daily regimen is not acceptable to the patient. Insulin detemir may also be offered as an alternative once-daily regimen. There are multiple types of insulin…

Rapid Acting- Insulin Aspart (Novorapid®), Lispro (Humalog®) and Glulisine (Apidra®)

Short Acting- Soluble insulin (Actrapid®)

Intermediate Acting- Isophane (Insulatard® or Humulin I®) & NPH - neutral protamine Hagedorn

Long Acting- Insulin glargine (Lantus®), detemir (Levemir®)

Combination insulins (biphasic)- e.g., Novomix 30®, Humalog Mix 25®, Humalog Mix 50®, Humulin M3® and Insuman Comb 50®

Diet & Lifestyle- Diet low in fat, salt, and sugar and high in fibre and with plenty of fruit and vegetables. If you are overweight try to lose weight, increase your physical activity even if it’s only going for a walk (community groups)

Other Health Complications- Get regular checks with your GP, podiatrist, and optometrist. Also get the flu jab every year.

Complications – microvascular, macrovascular (MI, stroke), metabolic (diabetic ketoacidosis) and hypoglycaemia (blood glucose less than 3.5mmol/l)

Psychological complications – anxiety, depression, and eating disorders and those at increased risk of developing autoimmune diseases

Suspect DKA in diabetics – greater than 11mmol/L

Increased thirst and urine frequency, inability to tolerate fluids, persistent vomiting, diarrhoea, visual disturbance, lethargy, fruity smell on breath, deep sighing when breathing and dehydrated

Management

HbA1c levels target of 48mmol/mol or lower - Measure 3-6 months but more often if not controlled

Self-monitoring – need glucose monitor, lancet, finger pricking device and testing strips

Taught at diagnosis and review technique 1 yearly.

Before breakfast, 2 hours after meals, during illness, before driving, if they feel hypo – at least 4 times a day including before and after meals and before bed.

More frequency required (up to 10x daily) if

Target HbA1c not achieved, frequency of hypo increases, during illness, before, during and after sports, planning, during and while breastfeeding.

Target glucose readings

Fasting plasma glucose level of 5–7 mmol/L on waking.

Plasma glucose level of 4–7 mmol/L before meals at other times of the day.

For adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating.

Agree bedtime target plasma glucose levels with the person. This should:

Consider the timing of the last meal and its related insulin dose.

Be consistent with the recommended fasting level on waking.

Provide information of effects of food and drinks – carbohydrate training (match carb quantities to insulin doses)

Educate to be careful of body weight and diets, feasting and fasting, fibre and protein intake, diabetic foods and sweeteners, alcohol intake, matching carbs with insulin and physical activity

Advice on alcohol – avoid drinking on empty stomach, eat carb snack before and after drinking (extra insulin not required). Measure glucose more regularly and maintain it with carb intake. Alcohol can exacerbate or prolong hypoglycaemic effect.

Exercise – lower glucose levels and reduces CVD risk and can help weight

Sick day rules – never stop or skip insulin – dose may need altering seek advice. Check blood more frequently – 1-2 hours including in the night. Check blood or urine ketone levels – 3-4 hours including night and if 2+ or 3mmol/l or higher then contact GP immediately.

Maintain normal meal pattern where possible if not then replace meals with carb rich drinks, milk, fruit juices and sugary drinks. Aim to drink at least 3L of fluid to prevent dehydration.

Offer multiple daily injection basal-bolus insulin regimens as the first-line choice to all adults with type 1 diabetes.

Offer twice-daily insulin detemir as the long-acting basal insulin therapy

Offer a rapid-acting insulin analogue injected before meals for mealtime insulin replacement

If a multiple daily injection basal–bolus insulin regimen is not possible and a twice-daily mixed insulin regimen is preferred

Insulin pump therapy is recommended as a treatment option for adults with type 1 diabetes mellitus if condition isn’t controlled by treatment

Diabetes type 2

The body still makes insulin however, you do not make enough insulin for your body's needs OR the cells in your body do not use insulin properly (insulin resistance means you need more insulin than normal make to keep glucose levels down. Occurs mainly in people aged > 40 but inc diagnosed in younger people, commonly associated with obesity, physical inactivity, raised blood pressure, dyslipidaemia, and a tendency to develop thrombosis (CV risk).

Symptoms of T2D- Gradual (weeks-months) and can be quite vague at first. Frequent thirst, passing large amounts of urine, tiredness, which may be worse after meals. Some people also develop blurred vision and frequent infections, such as recurring thrush.

Management- Metformin HCl 1st choice for treatment of all patients (à weight loss, red risk of hypoglycaemic events and long-term CV benefits). Has an anti-hyperglycaemic effect, lowering both basal and postprandial blood-glucose conc. It does not stimulate insulin secretion and therefore, when given alone, does not cause hypoglycaemia. If metformin contra-indicated/not tolerated trial MR formulation or initial treatment should be a sulfonylurea e.g. gliclazide OR a dipeptidyl peptidase-4 inhibitor e.g. linagliptin OR Pioglitazone.

Insulin- can be added if intensification of treatment needed. If needed, bedtime basal insulin should be initiated, and the dose titrated against morning (fasting) glucose.

Diet & Lifestyle- Avoid foods heavy in saturated/trans fats, beef and processed meats, sugary drinks, high-fat dairy products and salty/fried foods & have fibrous fruits and vegetables, high omega-3 fatty acid food and poly/monosaturated fats. Lose weight and inc physical activity (min 5 x 30 min brisk walk / week) and smoking cessation.  Also see optician regularly in case of damage to retina, GP and podiatrist.

EXTRA INFO FOR BOTH

Holiday- Pack about x3 the amount of insulin needed, test strips, lancets, needles or glucose tablets you would use, in case you need it (take cool bag to avoid insulin getting too hot). Carry your medicine in your hand luggage just in case checked-in bags go missing or get damaged (insulin can freeze and render it unusable). If injecting (i.e. will have needles/sharps) get a letter from your GP that says you need it to treat diabetes. If you use a pump or CGM, check with your airline before you travel about taking it on board as may require paperwork for medical equipment. If you use a pump, pack insulin pens in case it stops working. Take plenty of snacks in case there are any delays. Do not put your pump through the hand luggage scanner – let airport security know so they can check it another way.

<18 & Diabetic- Paediatric diabetes care team until 18 will help w injecting insulin, testing blood glucose levels, and diet. They can give advice on school or nursery and talk to your child's teachers and carers. Initially, every 1 - 2 weeks but will eventually be every 3 months.

Check Ups Needed- Annually get feet checked by podiatrist to check for loss of feeling in your feet, and for ulcers and infections. Get your eyes checked to check for any damage to blood vessels in the eyes, and checks for high blood pressure, heart, and kidney disease by your GP, also ensure to book in annually for a flu jab. Every 3 months have a blood sugar test (HbA1C test) checks your average blood sugar levels and how close they are to normal when newly diagnosed, then every 6 months once you're stable (~48-53 mmol/mol recommended).

Education- free education courses to help you learn more about and manage your diabetes, your GP will need to refer you. Diabetes UK run local charities for extra support, their website plus the NHS website offers a lot of diabetes information and advice. Maybe invest in a medical ID to carry w you.

Extra Lifestyle Advice- Eat a meal w carbs (e.g. pasta) before you drink alcohol and make sure people around you can recognise a hypo, choose diet soft drink mixers where possible, check your blood glucose regularly/before bed/the next day, drink plenty of water the next day. Avoid hypos by eating the right amount of carbs before, during and after exercise, adjust your insulin and check your blood glucose regularly, drink plenty of water. Recommended to have HbA1c <48mmol/mol when pregnant as high blood glucose levels can harm your baby, especially in the first 8 weeks of pregnancy, also a risk of having a large baby, which can cause complications during labour. Speak to your diabetes team If you're planning to get pregnant or if you get pregnant unexpectedly.

Item for disposal

Method of disposal

Needles

Sharps bin

Lancets

Sharps bin

Used blood test strips

Sharps bin

Leftover/expired insulin

Sharps bin/return to pharmacy

DVLA- tell the DVLA you’re diabetic or you could get fined due to hypoglycaemia/low sugar levels crisis. Check your blood glucose no longer than 2 hours before driving, check your blood glucose every 2 hours if you're on a long journey, travel with sugary snacks and snacks with long-lasting carbs, like a cereal bar or banana. If you feel your levels are low: stop the car when it's safe, remove the keys from the ignition, get out of the driver's seat, check your blood glucose, and treat your hypo, don't drive for 45 minutes from when you feel normal again.

Sharps Removal- Patients issued a sharps bin from the diabetes clinic/hospital on first diagnosis. Some pharmacies offer this sharps disposal service, or the diabetes clinic do too. Can arrange w GP/LHB for sharps collection (Cardiff Council does NOT offer kerbside sharps disposal)

Other Technologies- Insulin Pump (attached to skin via tiny tube which is replaced every 2-3 days & pump moved to diff part of body) will deliver a set background amount of insulin into blood day and night, can add your extra mealtime insulin using the pump. Continuous glucose monitoring (CGMs) means you can check your sugar levels at any time (see patterns in your levels, sends an alert if glucose too high/low) but as interstitial fluid sugar readings are a few mins behind your blood sugar levels you'll still need to do finger-prick checks every now and then. It’s a sensor you attach to your abdomen which needs replacing every 7 days, but some models can be worn for months. Free Style Libre is a flash glucose monitoring system measures your glucose levels continuously throughout the day via interstitial fluid (few mins behind). Attach sensor to your arm and a reader will scan to see your sugar levels (can also use a smartphone app to scan the sensor), sensors usually last for 14 days.

Testing blood glucose

Glucose monitor, specific in-date test strips, primed lancing device and cotton wool pad.

PRIMING LANCET

Twist cap off lancing device

Place fresh lancet into device so grooves line up and twist off the cover, so the needle is visible – change lancet every time so you don't get skin infections

Replace device cap - it should click and then adjust the depth metre – how far the needle will puncture – this is personal preference

Pull sliding barrel at bottom of device back to prime the lancet

CALIBRATING MONITOR

Turn on monitor – put new in-date test strip inside it and test it with in-date control solution – to make sure readings are correct

Do this every time you open a new pack of test strips, if you damage your monitor and if you think the readings are wrong.

TESTING process

Wash hands with warm water and soap and dry. Then rub hands for 10 seconds – warms hands to improve blood flow to fingers

Turn on monitor and place strip inside and wait for it say it’s ready for blood

Place device firmly on side of the finger (less nerves so less painful) and press release button then remove device from site. - change fingers regularly to stop hardening of skin.

Wipe first drop of blood away with cotton pad, use second one to test make sure by touching the blood onto the test strip

If successful wipe blood with cotton pad and apply plaster

Note readings

Remove cap of device exposing lancet. Place lancet cover on table and press lancet hard into this blue plastic cover – this will cover the needle and make it easy to remove

Place lancet and cotton pad in bin

Injecting insulin

Inject in stomach, thighs, or buttocks. Inject an inch away from previous site. Prevents lumps – this reduces absorption of insulin.

check that its correct insulin and is in date. Always check manufacturer’s instructions.

Wash hands with soap and warm water

Attach needle to pen – peel back cover, screw cap onto pen, remove white outer cover and the green cover to expose needle – change needle every time

Dial to 2 units and push plunger so you can see insulin coming out – to make sure no air stuck in there – can take multiple goes in new pens

Set correct dose

Press directly into skin and inject slowly – count to 10 

Remove needle straight without bending it

Use the white outer cap to remove the needle and dispose in yellow sharps bin

Asthma

Symptoms – episodic, worse at night/early morning, triggered by exercise, infection and exposure to cold air or allergens. Triggered by emotion and laughter in children. In adults by NSAIDS and BB use.

Common with atopic eczema, dermatitis and allergic rhinitis and family history

ACUTE EXACERBATION OF ASTHMA IN ADULTS

First-line treatment for acute asthma is a high-dose inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible. For patients with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer can be used. For patients with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended, if available. If the response to an initial dose of nebulised short-acting beta2 agonist is poor, consider continuous nebulisation with an appropriate nebuliser. Intravenous beta2 agonists are reserved for those patients in whom inhaled therapy cannot be used reliably.

In all cases of acute asthma, patients should be prescribed an adequate dose of oral prednisolone. Continue usual inhaled corticosteroid use during oral corticosteroid treatment. Parenteral hydrocortisone or intramuscular methylprednisolone are alternatives in patients who are unable to take oral prednisolone.

IN CHILDREN OVER 2

First-line treatment for acute asthma is an inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible. For children with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer device is the preferred option. The dose given should be individualised according to severity and adjusted based on response. For children with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended, if available. Parents/carers of children with acute asthma at home, should seek urgent medical attention if initial symptoms are not controlled with up to 10 puffs of salbutamol via a spacer; if symptoms are severe, additional bronchodilator doses should be given as needed whilst awaiting medical attention. Urgent medical attention should also be sought if a child's symptoms return within 3-4 hours; if symptoms return within this time, a further or larger dose (maximum of 10 puffs of salbutamol via a spacer) should be given whilst awaiting medical attention.

COPD

Symptoms - persistent respiratory symptoms and airflow obstruction, which is usually progressive and not fully reversible, exertional breathlessness, chronic/recurrent cough, or regular sputum production, wheeze

Treatment – education on condition and risk factors, smoking cessation, pneumococcal and flu vaccination yearly, treatment of associated comorbidities

1st line – SABA or SAMA to relieve breathlessness and improve exercise tolerance – reviewing medication, adherence, and inhaler technique regularly

THEN IF they have NO asthmatic features or no features of steroid responsiveness – offer LABA AND LAMA

If they continue to have day-to-day symptoms, consider 3-month trial of LABA+LAMA+ICS

If NO improvement go back to LAMA+LABA only but if it works continue and review annually

If they have asthmatic or steroid responsiveness features offer LABA+ICS if they have day to day symptoms of 1 severe or 2 moderate exacerbations a year, then offer LABA+LAMA+ICS

WITH ICS DISCUSS RISK OF USING ICS including pneumonia

Acute exacerbation of COPD – triggered by infections, smoking and environmental pollutants

Severe breathlessness, increased cough, increased sputum production and change in colour, increased wheeze, and chest tightness, cold or sore throat, reduced exercise tolerance, ankle swelling, increased fatigue, and acute confusion

FOR SEVERE exacerbation – ADMISSION

FOR non-severe – increase dose or freq of SABA and maybe change to nebuliser for ease of admission

If no contraindications with significant increase in breathlessness – offer 30mg oral prednisolone OD x 5 days or if caused by infection then amoxicillin 500mg TD x 5 days, doxycycline 200mg day 1, 100mg OD x 5 days, or clarithromycin 500mg BD X 5 days

Epilepsy

Cause – abnormal excessive or synchronous brain activity

Symptoms

Short-lived (less than 1 minute), abrupt, generalised muscle stiffening with rapid recovery — suggestive of tonic seizure.

Generalised stiffening and subsequent rhythmic jerking of the limbs, urinary incontinence, tongue biting —suggestive of a generalised tonic-clonic seizure.

Behavioural arrest — indicative of absence seizure.

Sudden onset of loss of muscle tone — suggestive of atonic seizure.

Brief, 'shock-like' involuntary single or multiple jerks —suggestive of myoclonic seizure.

Management

During seizure – protect from injury by placing in recovery position. If tonic-clonic seizure is prolonged (more than 5 mins) or recurrent – emergency buccal midazolam or emergency admission

Annually reviewed – assess seizure control, how it’s affecting QOL, adverse effects and compliance with drug

Women of childbearing age – 13 to 60

Epileptic women not treated with drugs or on non-enzyme inducing antiepileptic (except lamotrigine) – contraceptive options are same as general population

Woman on exyzme-inducing drugs – drug can reduce effectiveness of combined hormonal contraception, progestogen-only pills, transdermal patches, the vaginal ring, and progestogen-only implants. OFFER medroxyprogesterone acetate injections or an intrauterine method (copper intrauterine device or the levonorgestrel-releasing intrauterine system)

Woman on lamotrigine – oestrogen containing contraceptive reduces efficacy of lamotrigine

USE progesterone only instead but educate them to report signs of lamotrigine toxicity

Category 1 (ensure the person is maintained on a specific manufacturer's product) — phenytoin, carbamazepine, phenobarbital, primidone.

S/E – common and usually mild, advise to report and can usually be fixed with dose adjustment or change of drug

Sedation and dizziness, suicidal thoughts and behaviour, acute psychotic reactions, weight gain and loss, skin rashes.

Safe in pregnancies – lamotrigine (Lamictal) and levetiracetam (Keppra) are safest options

Anxiety

Uncontrollable widespread worry and range of cognitive and behavioural symptoms

Slow onset and symptoms don’t usually improve but are better controlled with intervention

Diagnosis – worry associated with restlessness, insomnia and muscle tension, fatigue, poor concentration, irritable. ALWAYS ask about alcohol and drug use including OTC

Treatment

Establish diagnosis and severity of anxiety and any other comorbidities (usually insomnia and depression and whichever is the most pressing is treated first) – explaining the disorder and treatment opportunities and starting them with active monitoring of symptoms either self or through regular meetings

Offer CBT – non-facilitated self-help for 6 weeks, individual guided self-help, educational groups

High intensity CBT, applied relaxation or drug therapy

Drug therapy – 1st line is SSRI (sertraline, paroxetine, or escitalopram) 2nd line SNRI (duloxetine or venlafaxine). If both contraindicated or intolerable then Pregabalin.

Review effectiveness and ADR every 2-4 weeks during first 3 months then every 3 months.

Counsel on common effects during treatment initiation (suicidal thoughts and worsening of anxiety) but importance of reporting this instead of withdrawing from drug

SSRI – don’t take NSAIDS or if prescribed take with PPI

For pregnant women step 3

DO NOT give benzo or antipsychotics in primary care

Benzodiazepines (SCH 3 and 4)

Most commonly used anxiolytics and hypnotics

Short rem relief (2-4 weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress

use to treat short-term ‘mild’ anxiety is inappropriate

Sch 4 CDs, apart from temazepam

Sch 3 (CD no register) and midazolam

Pharmacological effects of benzodiazepines

Sedation, sleep induction

sleep, but can still cause arousal

decreased anxiety, amnesia at higher doses

muscle relaxation (both midbrain and spinal effects)

anticonvulsant activity

Reduced aggression

Depression

Persistent low mood and/or loss of pleasure in most activities and range of emotional, cognitive, physical, and behavioural symptoms

Diagnosis

Low mood

Loss of interest/pleasure from normally pleasurable activities (anhedonia)

Reduced energy (fatigue)

Low self-esteem; feelings of guilt

Inability to think/concentrate

Altered psychomotor activity

Sleep disturbance; early morning wakening

Altered appetite

Suicidal thoughts

Diagnosis requires 2 core symptoms plus 2 or more others present for most of the day on most days for the last 2 weeks

Differential diagnosis

Ensure symptoms are not caused by physical illness, alcohol, medication, or illicit drug use

The symptoms aren’t caused by normal grief (death of family) – maybe consider very long grief

Never been a manic (severe levels of high mood) or hypomanic (to a reduced level) episode

Treatment

Dependant on accurate assessment and diagnosis of depression

Psychological

CBT, behavioural activation, interpersonal psychotherapy, problem solving therapy

Social

Identify stressors and work on strategies/signposting to other supporting organisations

Biological – moderate to severe

Antidepressant therapy or antidepressant and antipsychotic combination therapy in psychotic depression

Drug classes

Tricyclic antidepressants (TCAs) e.g., amitriptyline

Selective serotonin reuptake inhibitors (SSRIs) e.g., fluoxetine

Serotonin and NA uptake inhibitors (SNRIs) e.g., venlafaxine

Monoamine oxidase inhibitors (MAOIs)

Irreversible e.g., phenelzine (MAO-A and B)

Reversible e.g., Moclobemide

Atypical antidepressants e.g., Mirtazapine

Noradrenaline reuptake inhibitors (NRIs) e.g., Atomoxetine

TCA - S/E – Short lasting (days) sedation, confusion, and Incoordination in both normal and depressed patients, antimuscarinic effects, dry mouth, blurred vision, decreased mucus production. Dangerous CV effects in OD 

Severe depressive at risk of suicide shouldn’t be given TCA

Interactions – potentiation of the effects of alcohol – alcohol is a depressant and will only compound the depressive effects

SSRI’s - S/E – nausea, anorexia, insomnia, and loss of sexual function

Less anticholinergic side-effects and less dangerous in OD than TCAs. Prolonged QTc – cardiovascular complications risk with citalopram  interactions – NSAIDs, Anticoagulants, triptans

SNRI’s - S/E – significant withdrawal effects – have short half-lives so need to be taken regularly to avoid these effects. Complex nature of TCAs makes them difficult to prescribe to complex patients unlike SNRIs

Interactions – NSAIDs and anticoagulants

MAOIs - S/E – antimuscarinic effects, restlessness as a result of CNS excitation

Interactions – serious food and drug reactions e.g., cheese (tyramine from food such as cheese is broken down by MAO. The lack of breakdown from MAOIs can lead to tyramine actively displacing neurotransmitters such as 5HT, DA, NA – causing hypertensive crisis

VERY IMPORTANT COUNSELLING POINTS

No other drugs or illicit drugs with this

Side effects

Drug and food interactions are unacceptable.

“Cheese reaction”: this occurs when amines that are generated during fermentation, like tyramine, are ingested and absorbed from the gut. (The main danger is ripe cheese, yeast products - Marmite).

Large rise in systemic tyramine indirectly results in a large release

    of catecholamines

Hypertensive crisis characterised by throbbing

            headache, tachycardia & cardiac arrhythmias.

Same can occur with drugs (Pseudoephedrine)

Atypical antidepressants - S/E- sedation, weight gain, increased appetite – good in patients with anorexia or depression causing loss of appetite or weight

Blood disorders – counselling

Withdrawal issues

Can be used with other antidepressants that cause sleep issues

Interactions – alcohol

FDA black box warning – suicide

Treatment

Mild symptoms – psychological therapy

Persistent mild symptoms or moderate to severe symptoms – combination of psychological and drug therapy

1st line treatment usually SSRIs

2nd line switch to alternate SSRI

3rd line switch to different class (normally an SNRI)

Practical issues

Initiating an antidepressant can cause feelings of anxiety consider co-prescribing short course of benzodiazepines to counteract the anxiety

During the first few weeks of antidepressant treatment can have worsening suicidal thoughts with improved motivation so ensure counselling and regular reviews

Consider prescribing limited supply of meds to reduce chance of OD

Side effects often transient and improve with time

Caution when switching antidepressants – table of different half-lives and how to taper them

Treatment approach

If no response to 3 antidepressants, then check concordance, review diagnosis, and consider if social problems are maintaining depression

Consider augmentation – addition of drug to the current therapy

Mirtazapine – sleep

Quetiapine – mood

Aripiprazole

Lithium – mood stabiliser

Lamotrigine – mood stabiliser

Electroconvulsive therapy

Response

2-4 weeks usually for response to be seen (longer in elderly)

Improvement greatest during weeks 1-2

If no response during 2–4-week period, consider first increase in dosage then if again limited efficacy, then switch to alternative

Extended duration if treatment trial will lead to additional benefit in some

Differences between drugs

Mirtazapine, escitalopram, venlafaxine, and sertraline

more efficacious than

duloxetine, fluoxetine, fluvoxamine, paroxetine and reboxetine

Reboxetine less effective overall

Escitalopram and sertraline

better tolerated than

duloxetine, venlafaxine, fluvoxamine, paroxetine and reboxetine

Preventing relapse

Relapse rate 3-6 months post remission is 50% with no drug treatment

A/D treatment reduces absolute risk of relapse by about 50%

After 1st episode continue for 6-9 months

After 2nd episode continue for 12 months

After 3rd episode continue for 2 years

Insomnia – difficulty in getting to sleep or staying asleep long enough to feel refreshed the next morning

Causes

Recreational drugs

caffeine, nicotine, alcohol, cannabis)

Medicinal drugs

anticonvulsants, antipsychotics, b-blockers, SSRIs, MAOIs, steroids, decongestants, Alpha agonists and antagonists, narcotic analgesics

Drug withdrawal

from CNS depressants (eg alcohol, anxiolytics/hypnotics)

Physiological

Diet, late night exercise, shift work (night and evening work)

Environmental

Noise, bright lights, extremes of temperature

Medical conditions

Psychological - anxiety, depression, grief, stress

Non-psychological eg chronic pain, gastric reflux, asthma, sleep apnoea

Types of insomnia

Primary insomnia - insomnia not attributable to a medical psychiatric or environmental cause

Secondary insomnia- insomnia secondary to another condition

Transient (2-3 days) – caused by changes in routine (for eg. change in time zone, alteration of shift work)

Short term (<3 weeks) – may result from temporary environmental stress

Chronic insomnia (>3 weeks) –usually secondary to other conditions

Treatment

FIRST LINE IS ALWAYS NON-DRUG treatments e.g., lifestyle changes and CBT

Drug therapy – Hypnotics

Benzodiazepines

Benzodiazepine-like drugs (Z-class)

melatonin

BEFORE hypnotic is prescribed the cause of insomnia must be established and where possible, underlying factors should be treated

NICE recommends

if hypnotic medicine is the appropriate way to treat one for only short periods of time and strictly according to the licence for the drug. (Usually, 1-2 weeks and max 4 weeks) and should be prescribed on a weekly basis

Benzodiazepines

 Most benzodiazepines

decrease time taken to get to sleep

in individuals who habitually sleep <6hr, the drug increases duration of sleep

Few short-acting BDZs recommended for insomnia (short-term treatment – max 2-4 weeks)

Should only be used when SEVERE, DISABLING or causing EXTREME DISTRESS

Benzodiazepine – like drugs

Z -Hypnotics – Zaleplon, zopiclone, zolpidem (Short acting – t1/2 < 8 hr)

Short term use only (2-4 weeks)

Lack of anxiolytic effects –drowsiness or dizziness - just induce sleep

Melatonin treatment

Prolonged release melatonin available for primary insomnia in over 55yr olds (can be used up to 3 weeks)

Antihistamine gen 1 – can cause drowsiness

Anxiolytics

Kalms, Kalms day, Karma, Karmamood, Potters Newrelax, Relaxherb, Stressless

Hops, valerian, passionflower, passiflora, vervain, St John’s Wort

Sedatives

Kalms night, Kalms sleep, Dormesean, Niteherb, Nytol herbal, Potters Nodoff, sominex herbal

Hops, valerian, vervain, skullcap, wild lettuce, passiflora

Some herbal remedies do contain active ingredients so be careful of interactions

Lifestyle changes – promote sleep hygiene

establishing fixed times for going to bed and waking up

trying to relax before going to bed

maintaining a comfortable sleeping environment avoiding napping during the day

avoiding caffeine, nicotine, and alcohol late at night 

avoiding exercise within four hours of bedtime 

avoiding eating a heavy meal late at night

avoiding watching or checking the clock throughout the night

using the bedroom mainly for sleep if possible

avoid going on phone, looking at screens immediately before bed or whilst in bed

ADHD

Persistent developmentally with inappropriate levels of over reactivity, inattention and/or impulsivity

Diagnosis – based on observation there are no biomed tests

Symptoms – 9 symptoms across 2 domains

Hyperactivity/impulsivity

Inattention

Can be combined type or dominant in one

ADHD – Predominantly inattentive type

Fails to give close attention to details or makes careless mistakes.

Has difficulty sustaining attention.

Does not appear to listen.

ADHD – predominantly Hyperactive/impulsive type

Fidgets with hands or feet or squirms in chair.

Acts as if driven by a motor.

Blurts out answers before questions have been completed.

Difficulty waiting or taking turns.

Interrupts or intrudes upon others.

ADHD – Combined type

Patient meets both sets of inattention and hyperactive/impulsive criteria

ADHD – Differential diagnosis

Sensory impairment – leading to under or over-sensitivity to triggers

Epilepsy and related states – could present as inattention

Effects of head injury

Acute or chronic medical illness

Poor nutrition – linked to poor behavior – not directly linked to ADHD

Sleep disorders – linked to poor behavior – not directly linked to ADHD

Side effects of medication

School or classroom difficulties – bullying or other factors

Large links to exposure to smoking and drinking during pregnancy, childhood illness such as meningitis or other viral infection, low birthweight/prematurity. HIGH heritability

Treatment

Mild-moderate –1st line - parent-training/education programmes with parent and child, group based or individual sessions. Teachers receive ADHD training and offer intervention in schools.

2nd line – CBT or social skills training

3rd line – DRUG THERAPY ONLY FOR SEVERE and should be offered along with psychological, behavioural, and educational interventions

Drug therapy

Methylphenidate – generally first choice

Atomoxetine - if other tics, Tourette's syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present

D-amphetamine – ONLY if other drugs ineffective at raised doses – CD2 high risk in addiction and dependence and misuse so used as last resort

Decide which drug treatment to use based on:

their different adverse effects

potential problems with compliance (for example, if a mid-day dose is needed at school)

potential for drug diversion (taken by others) and misuse

preferences of the child or young person and their parent or carer

When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider: –

methylphenidate for ADHD without significant comorbidity

methylphenidate for ADHD with comorbid conduct disorder

methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present

atomoxetine if methylphenidate has been tried and has been ineffective at the max dose, or the child intolerant to low or moderate doses of methylphenidate.

Atomoxetine

Closely observe children or young people taking atomoxetine for agitation, irritability, suicidal thinking, and self-harming behavior, particularly during the initial months of treatment, or after a dose change.

Liver damage in rare cases (usually presenting as abdominal pain, unexplained nausea, malaise, darkening of the urine or jaundice).

Treatment of adults

In adults, methylphenidate normally first line treatment

Consider atomoxetine or dexamphetamine if symptoms do not respond to methylphenidate or the person is intolerant to it ~6 weeks.

Selection of appropriate medication

Immediate-release preparations if more flexible dosing is required or during initial titration to using methylphenidate, consider determine correct dosing levels

If there is a choice of more than one drug, use the drug of lowest overall cost

modified-release preparations for convenience…

their pharmacokinetic profile,

improving adherence,

reducing stigma (because the drug does not need to be taken at school)

reducing problems of storing and administering controlled drugs in schools

abuse liability

AUTISM

Symptoms

Socialization

Impaired use of non-verbal behaviors to regulate interactions

Delayed peer interactions, few or no friendships, and little interaction

Absence of seeking to share enjoyment and interests

Delayed initiation of interactions

Little or no social reciprocity and absence of social judgment

 Communication

Delay in verbal language without non-verbal compensation (gestures)

Impairment in expressive language and conversation, and disturbance in pragmatic language use

Treatments

NEED early diagnosis and defined biomarkers

Currently intervention is through family and educational support

Only some specific programs have an evidence base

Aim is to ‘improve the functional status…through skill acquisition in core areas’

Eg developing relationships

Achieving social and environmental milestones through play

Positive reinforcement of social communication

Pharmacological treatments for co-morbidities

Developmental

Hyperactivity/impulsivity (see ADHD)

Psychiatric

SSRIs, other antidepressants for depression

atypical antipsychotics for OCD

SSRI or a2 agonists for anxiety

Behavioural

Atypical antipsychotics (irritability, aggression)

Sensory

Neurological

anticonvulsants and fits, a2 agonists for tics

Gastrointestinal

Sleep disruption

melatonin and clonidine

Dementia

Symptoms –

Higher cognitive function affected

Memory, thinking, comprehension, learning capacity, language (speaking and understanding it)

Daily living activities/emotional behaviour (non-cognitive symptoms)

Behavioural and psychological symptoms of dementia (BPSD) – include agitation, apathy, depression, anxiety, delusions, hallucinations, irritability, and wandering

Treatment -

Acetylcholinesterase (AChE) inhibitors (donepezil, galantamine, and rivastigmine) — as monotherapies for managing mild to moderate Alzheimer's disease.

Memantine (a N-methyl-D-aspartic acid receptor antagonist):

As monotherapy for managing Alzheimer's disease for people with moderate Alzheimer's disease who are intolerant of, or have a contraindication to, AChE inhibitors, or for people with severe Alzheimer's disease.

In addition to an AChE for people with established moderate or severe Alzheimer's disease who are already taking an AChE

For people with non-Alzheimer's dementia the use of AChE inhibitors or memantine is unlicensed, but they may be prescribed by a specialist for people with:

Mild to moderate dementia with Lewy bodies:

Donepezil or rivastigmine are recommended first line.

Galantamine is an option if donepezil and rivastigmine are not tolerated.

Severe dementia with Lewy bodies:

Donepezil or rivastigmine are recommended.

Vascular dementia:

AChE inhibitors or memantine are options if the person has suspected comorbid Alzheimer's disease, Parkinson's disease dementia, or dementia with Lewy bodies.

Risperidone and haloperidol are the only antipsychotics licensed for treating non-cognitive symptoms of dementia, although other antipsychotics are often prescribed off-label for this purpose.

Acetylcholinesterase inhibitors

NMDA receptor antagonist

Cholinesterase inhibitors for mild to moderate AD (eventually stop working)

NMDA receptor antagonist for severe AD and moderate AD in some cases

Treatment must be started only by a specialist clinician

Rheumatoid arthritis

Inflammatory disease causing persistent symmetric joint synovitis

Presents as pain and joint stiffness with heat and swelling progressing at rest and after periods of inactivity with malaise, fatigue, fever, and weight loss

Risk factors – smoking, eating large amounts of red meat, drinks excessive coffee

Symptoms

Joints

Pain

Swelling

Stiffness

Systemic

Fatigue, depression, irritability

Anaemia

Flu-like symptoms, such as feeling generally ill, hot, and sweating

Pain worse in morning

Treatment

Drugs, mild exercise (enhance flexibility of joint and muscle strength), lifestyle changes (rich antioxidant diet, no smoking)

Main types of RA meds

NSAIDs (short term symptomatic relief) – reduce inflammation. OTC (ibuprofen, naproxen). POM (celecoxib, etoricoxib)

S/E – GI irritation, ulcers (use at lowest dose and take with food, use PPI to lessen effects)

Caution – asthmatics and renal impairment and patients with increased CV risk

Disease-modifying anti-rheumatic drugs (DMARDs) – 1ST LINE for active RA (methotrexate, sulfasalazine)

S/E – Nausea, diarrhoea, oral ulceration, alopecia, cough, SOB, bone marrow suppression – CAN BE REDUCED by co-prescribing FOLIC acid 1mg daily

Biological therapies (type of DMARD) – used when DMARDS don’t control RA

Glucocorticoids – short term treatment when starting new DMARD for rapid symprom control  - also used in flares

Analgesics (painkillers)

Drug Treatment Schedule

Start two DMARD regime once diagnosed, using titration regimens

Use anti-inflammatories (NSAIDs), paracetamol with or without corticosteroids until effective

Review after 6 months: increase dose or switch as clinical condition determines.

Patient counselling in RA

Place of drugs in therapy

Onset of action

Side effects

Immunosuppression

Regular painkillers

Regular monitoring including blood tests

Dexterity aids, prescription services

Osteoarthritis

Predominantly non-inflammatory and caused by cartilage loss from synovial joints and bone remodelling due to excessive and repeated overloading on weight bearing joints or stress of a joint over tome and specific injuries

Risk factors – genetic, age, gender, obesity, damage, occupational, and stress

Symptoms

Pain – tends to be worse when using the joint and at end of the day (Worsens on use, resolves at rest)

Stiffness – feel stiff after rest, usually wears off as you get moving

Grating or grinding sensation (crepitus) – joints creak or crunch as you move

Swelling – may be caused by osteophytes (bone outgrowth) or caused by synovial thickening and extra fluid

Muscles around joint look thin/wasted

Unable to use joint normally – doesn’t move as freely or far as normal

Joints give way – muscles have weakened, and joint is less stable

Management

Provide information on sources of advice and support

Advice on self-care strategies such as;

Weight loss, local muscle strengthening exercises and aerobic fitness training

Appropriate footwear, local heat, or cold packs

Odder psychosocial support – career and occupational health assessments if needed

Advice on simple analgesia

Arranging regular reviews to assess response to treatment

MANAGEMENT GOAL – pain reduction and symptomatic relief

First line:

Paracetamol regularly – 4g daily

Topical NSAIDs

Additional treatment:

Oral NSAIDs– not first line

-Start with ibuprofen

-Monitor for side effects

-Possible place for topical therapy

Topical capsaicin – adjunct and helpful in knee and hand – works by stimulating then decreasing the pain sensation

Corticosteroid injection: â pain and inflammation of flare-up

Role of pharmacist

Counselling:

dosage regimen

side effects

warnings

Monitoring for side effects

Weight loss advice

Physiotherapy advice

Compliance aids & living aids

Gout

Type of inflammatory arthritis – causes severe pain and damage to joints

Caused by abnormal high levels of uric acid in blood which deposits urate crystals in joints and tissue

3 phases

Asymptomatic hyperuricaemia – can remain in this stage for life

Acute attack of gouty arthritis – can vary from months to years before another attack

Final period of chronic tophaceous gout – nodules effecting joints

Treatment

Acute

Ice

Rest affected joint

NSAIDs – short term, 7-14 days, high dose, for pain relief and anti-inflammatory

Colchicine (Dose: 500mcg 2-4 x daily until symptomatic relief or SE (stomach cramps, diarrhoea, vomiting)), steroids (used when NSAID and colchine is contraindicated or not useful)

Choice of drug dependant on comorbidities and renal function (NSAID cause fluid retention whereas colchicine doesn’t)

Colchicine use limited as it can have sudden toxicity at higher conc

Combination treatment can be used as well if monotherapy isn’t controlling the attack

Long term treatment to reduce urate

Lifestyle modifications (reduce dietary intake)

Drug therapy: Allopurinol (1st line – offer to all, 100mg od, increased in 100mg increments every 2-3 weeks) S/E – rashes

Febuxostat (2nd line only use when allopurinol intolerant or contraindicated – 60mg OD dose)

Monitor urate level – aim for < 360 μmol/L or 6 mg/dl (critical level)

Muscoskeletal

Sprain

Commonly ankle, wrist, thumb, knees – pain, swelling, tenderness, bruising, disabled use and no weight

Strain

Common in legs and lower back – pain, swelling, bruising, red, and reduced function

BOTH

Self-limiting gets better in 4-6 weeks and full recovery in 12 weeks

Non-pharma advice

PRICE (Protect, Rest (48-72hrs), Ice immediately after, Compression bandages and Elevate to reduce swelling

Reduce HARM (Heat, alcohol, running and massaging for 72hrs.

Avoid NSAIDs for 72hrs

Exercises for sprains

Gently move joint in all directions to increase and maintain flexibility (lack of movement can delay recovery BUT severe sprains with complete lack of movement rest for 10 days first)

Treatment – topical and oral analgesics

Refer – severe pain, possible break or fracture, no alleviation with OTC meds

Lower back pain

Symptoms – pain, tension, soreness, stiffness without underlying cause

6 weeks usual recovery can be up to 12 weeks

Advice

Back exercises, improve posture, yoga, avoid lying or sitting for too long, remain active.

Sleep in different positions, pillows between legs, under knees, hot baths, hot water bottles, ice packs.

Treatment

OTC – topical analgesics or co-codamol if still painful

Refer

No improvement in 3 days, continues for more than 6 weeks, pain travels higher, pain after injury, younger than 20, older than 50, pain affects sleep, unsteady on feet, unexplained weight loss

EMERGENCY

Pins and needles in back, genital, bum, both legs, lose urine or bowel control

Conjunctivitis

Symptoms

Bacterial

Viral

Allergic

Eyes affected

1 or 2

Both

Both

Discharge

Pussy

Watery

watery

Sensation

Gritty

Gritty

Itchy

Co-presenting symptoms

None

Cough/cold

Rhinitis

If pussy, red or gritty it is contagious – allergic ISNT contagious

Advice

Don’t wear contacts, hold cold flannel on eyes for few mins to cool them, use FBC water to gently wipe lashes and clean off crust and clean with cotton wool pad. Use a different one for each eye

Control spread by – reg wash hands with hot soapy water, cover mouth and nose when sneezing, don’t share towels or pillows and don’t rub eyes

Refer

Baby less than 28 days old with red eyes, allergic reaction, or spots on eyelids. For all – symptoms not resolved after 2 weeks

111 - Severe pain, sensitive to light, sudden changes to vision

Treatment

Viral – self-limiting, use hygiene and non-pharma advice

Allergic – Opticrom eye drops (Adults and child – 1-2 drops in each eye up to 4x daily)

Bacterial – over 2, chloramphenicol drops/ointment (Optrex Bacterial Conjunctivitis 1%w/w Eye Ointment) - apply a small amount of ointment in the affected eye 3-4 times daily for 5 days

Blepharitis

Symptoms

NOT contagious, rims of eyelids are inflamed, burning, soreness or stinging in the eyes, crusty lashes that stick together, itchy eyelids

Advice

Clean eyelids at least 1x daily, clean eyes even if symptoms clear, don’t wear contacts, or eye makeup

Cleaning eyes – soak a clean flannel/cotton wool in warm water and place on eye for 10 mins, gently massage eyelids for 30 secs, clean lids using cotton wool. Baby shampoo at 10:1 ratio good.

Refer

No improvement after 2 weeks of cleaning eyes

Treatment OTC

Brolene eye drops – 1-2 drops in each eye up to 4 x daily. If not better in 2 days refer

Dry eyes

Symptoms

Dry feeling, sensation of something in eye, burning, grittiness, itching, light sensitivity, over-blinking, redness, excess tears (randomly tearing)

Causes – over 50, contacts, digital screens, AC, windy/cold/dry/ dusty environment, smoking, alcohol, meds (antidepressants/BP) medical conditions (blepharitis)

Refer

Treatment failure after 2 weeks, change in eyelid shape

111 – severe pain and red, contact wearer with red eyes (could be an infection)

999 A&E – sudden change in sight, bursts of light sensitivity, severe headache/nausea, dark red eyes, injured/pierced eye, something stuck in eye

Advice

Clean eyes daily, take breaks when using screens, use screens below eye level, use humidifier, wear glasses instead of contacts

Treatment 

Light lubricant – Optrex Double Action Drops for Dry and Tired Eyes - Apply 1-2 drops in each eye.

Hyaluronic Acid - Artelac Rebalance Drops, long lasting relief - Place 1 drop into the conjunctival sac 3-5 times daily or more frequently if required.

Hypromellose drops – 1-2 drops 3 x daily

Excessive ear wax

Symptoms – hearing loss, earache, noise/ringing, vertigo, dizziness, and nausea

Causes – narrow/damaged canals, hairy canal, skin condition affecting scalp around ear, inflammation of ear canal

Refer – not cleared in 5 days, badly blocked, severe, complete loss of hearing, likely infection

Advice – don’t use fingers or cotton buds to remove wax

Treatment

Olive oil drops – 2-3 drops in affected ear and massage around outside of ear BD x 7 days

Use dropper when lying down with head to one side to allow oil into ear, over 2 weeks then lumps should fall out, but symptoms should be better within 5 days

Otitis externa

Symptoms - pain, discharge, itch, irritation, external ear/canal appears red, swollen, eczema, deafness, skin swells, tender to touch

Refer – ear pain in children, inflamed pinna, unsuccessful treatment (after 4 days), hearing aids, excessive discharge (wax or pus), high fever, vomiting, fatigue, confusion, dizzy, stiff neck, rash, slurred speech, fits, light sensitivity

Advice – avoid under/over dressing feverish child, lower heating, offer regular fluids, avoid dummies when lying flat, give paracetamol/ibuprofen if child is unwell/distressed (not together)

Treatment

Acute localised (furunculosis) – infected hair follicles in outer-ear causing swelling and irritation

Treatment – hot flannel, oral analgesics, antibiotics if severe

Acute diffuse (over 3 months – more widespread inflammation of skin, bacterial/fungal infection or contact dermatitis due to irritant/allergens

Treatment – earwax plus or EarCalm

Otitis media

Symptoms – earache, discharge, hot, irritable, sleeplessness, ear pulling/rubbing, crying, temporary deafness

Refer – recurrent infections, no improvement in 3 days

Treatment

Self-limiting should be better in 3 days, single analgesics for pain

Hyperthyroidism

Too much thyroid hormones produced naturally

Symptoms

Tremor, warm sweaty palms, weigh loss despite increasing appetite, heat intolerance, diffused alopecia, hair thinning, tachycardia, diarrhoea

Advice

Healthy diet with foods rich in antioxidants, green leafy vegetables (broccoli, cabbage etc)

Vitamin D, omega 3 fatty acids and calcium rich foods. Smoking cessation

Treatment

Carbimazole (adjunct B blocker propylthiouracil for adrenergic symptoms) – block and replace regime

Combo of fixed high dose carbimazole and levothyroxine

Radioactive iodine destroys thyroid cells, surgery to remove some thyroid

Hypothyroidism

Thyroid gland doesn’t produce enough hormones caused by immune system attacking thyroid gland and damaging ait or by damage to thyroid that occurs during treatments for a hyperthyroidism or thyroid cancer

Symptoms

Fatigue, muscle pain, weakness, weight gain, sensitive to cold, dry skin, brittle hair, nails, depression, reduced libido

Advice

Eat antioxidant rich food, seeds and nuts, tyrosine (meat, dairy, legumes)

Avoid – soy, iodine rick food, leafy green vegs, caffeine, alcohol – quit smoking, alcohol.

Inform GP if pregnant (needs treatment and monitoring during)

Treatment

Levothyroxine 1st line – dose depends on blood test and progression – take tablet at same time every day (MORNING) If taking too much causes sweating, chest pain, headaches, diarrhoea, vomiting. Supressing thyroid supressing hormone with high doses causes atrial fibrillation, stroke, osteoporosis

Cold sores

Symptoms

Simplex - Pain, burning, itching, tingling before lesions and lasts 6-48 hrs

Crops of vesicles burst and crust over and heal, commonly on lower lip and ends of mouth

Gingivostomatitis – fever, malaise, sore throat, painful nodules in cervix or under jaw, excessive salivation. Painful vesicles on a red swollen base that rupture to form ulcers inside mouth, covered with yellow/grey membranes

Refer – immunocompromised, unable to swallow, risk of dehydration, severe infection, complication, pregnant, recurrent

Treatment

Paracetamol/ ibuprofen for symptoms

Topical acyclovir/penciclovir OTC – use from onset of symptoms before lesions until lesions heal

OTC topical anaesthetic or analgesics, mouthwashes, or lip barriers – topical analgesics aren’t licensed in children

DON’T prescribe oral antiviral for healthy people

Consider prescribing oral antiviral for healthy people with episode of primary oral herpes simplex, recurrent labialis if lesions are severe, frequent, or persistent and recurrent

And for those who are immunocompromised

Should take at onset and until lesions have healed – minimum of 5 days

Choice of aciclovir or valaciclovir based on preference, dose, regimen, and adherence

Advice

Reassure its usually self-limiting and heals without scarring

Adequate fluid intake

Offer leaflets or websites for more info

Avoid kissing, oral until lesions fully healed, don’t share pillows, makeup, or lip balms. Don’t touch lesions other than when applying treatment – dab instead of rubbing. Wash hands after touching.

Athletes foot

Interdigital — most common; affects the lateral toe web spaces first; usually caused by Trichophyton rubrum.

Moccasin or dry — diffuse chronic scaling and hyperkeratosis affecting the sole and lateral foot; usually caused by Trichophyton rubrum.

Vesicobullous — least common; multiple small vesicles and blisters mainly on the arches and soles of the feet; usually caused by Trichophyton interdigital.

Risk – hot, humid, occlusive footwear excessive sweating, contaminated surfaces, immunocompromised

Advice

Wear well fitting, open footwear that keep feet cool and dry, replace old shoes that may be contaminated. Maintain good foot hygiene – wear different pair of shoes every 2-3 days. Wear cotton, absorbent socks, don’t scratch skin, after washing feet dry then well and between toes, don’t share towels and wash towel freq.

Treatment

Topical antifungal cream in mild, non-extensive disease

Terbinafine 1% cream (12 and over – apply thinly to affected area 1 or 2 daily for 7 days) or clotrimazole 1% cream (2-3 times daily and continue for 4 weeks minimum) okay for kids – OTC for some ages

Additional mild topical corticosteroid if there’s inflammation

Hydrocortisone 1% cream (OD for max 7 days)

Adult severe or extensive – oral antifungal with confirmed fungal infection

1st choice – terbinafine (250 mg once daily for 2–6 weeks, depending on the severity of infection)

2nd – itraconazole, Griseofulvin if not tolerated or contraindicated

Refer

Treatment failure, severe pain, got, painful and red (indicative of serious infection), infection spreads, diabetic patient, immunocompromised

Warts and verrucae

Warts – small, rough growths caused by infection of skin with HPV, form anywhere on skin most commonly on hand and feet

Verruca – (plantar wart) wart on sold of feet

Spread by direct contact, occur and clear spontaneously at any time or may take years

Common warts are firm and raised with a rough surface that resembles a cauliflower (common on knuckles, knees, and fingers).

Periungual warts are common warts around the nails that can be painful and disturb nail growth — nail biting is a risk factor.

Plane warts are usually round, flat-topped, and skin coloured or greyish yellow (common on the backs of hands).

Filiform warts have a finger-like appearance and may have a stalk (more common on the face and neck).

Palmar and plantar warts grow on the palms and the soles of the feet (verrucae). They often have central dark dots (thrombosed capillaries) and may be painful.

Mosaic warts occur when palmar or plantar warts coalesce into larger plaques on the hands and feet.

Not harmful and don’t come with symptoms and resolve with treatment

Advice

Reducing transmission and limit spread, keep feet dry, wear slippers or waterproof plaster in shower and communal areas. don’t share towels, socks, shoes. Don’t scratch lesions, bite nails or suck fingers with warts

Refer

Painful, facial, uncertain diagnosis, immunocompromised, extensively infected

Treatment

Only treated if painful, cosmetically unsightly, or patient request and persistent as the treatment is long and can have side effects.

Topical salicylic acid – up to 12 weeks

Duofilm® (salicylic acid 16.7% plus lactic acid 16.7%) — licensed for plantar and mosaic warts.

Bazuka® extra strength gel (salicylic acid 26%) — licensed for warts and verrucae.

Occlusal® (salicylic acid 26%) — licensed for common and plantar warts.

Salactol® (salicylic acid 16.7% plus lactic acid 16.7%) — licensed for warts, plantar warts, and verrucae.

Apply OD at night, file and soften area by soaking in warm water for 5-10 mins, peel of remaining film before administering next dose, don’t apply on healthy skin

Cryotherapy – every 2 weeks for max 6 treatments

Liquid nitrogen – only for older children and adults

Corns and calluses

Hard or thick areas of skin that can be painful

Corns – lumps of hard skin on knuckles and joints of toes

Callouses – larger patches of rough, thick skin

Both can be tender and painful

Refer

Diabetic, heart disease, circulation issues. Bleeding or puss, treatment failure after 3 weeks, severe pain

Advice

Wear thick, cushioned socks, wear wide, comfortable shoes with low heel and soft sole, use insoles or heel pads, soak corns and calluses in warm water to soften them, use pumice stone regularly or foot file to remove hard skin. Moisturise.

Don’t try to cut them, walk, or stand for long period, wear high heels or tight pointy shoes, go barefoot

Treatment

Heel pads and insoles, OTC products, pain relief

Carnation brand caps for both – adhesive dressing

Fungal nail infection

Caused by dermatophyte and non-dermatophyte moulds and yeasts

Symptoms

Discoloured, abnormal, small flaky white patches and pits on top of nail and becomes rough and eroded. Nail lifted, wite or yellow opaque streaks on one side of nail, scaling, thickening

Refer

Diabetic, severe, treatment failure, spread to other nails

Advice

Keep nails trimmed short and filed, don’t share clippers and files. Well-fitting shoes, cotton socks, maintain good foot hygiene, weak shoes in communal places, avoid nail trauma

Treatment

Not needed if patient not troubled by appearance and infection is asymptomatic

Advise antifungal treatment if – walking uncomfortable, distress, cosmetic, co-morbid complication, or complication

If dermatophyte or candida infection conformed – topical antifungal treatment 0f 50% of nail involved, 2 nails infected, contraindication to oral antifungal

Topical – amorolfine 5% mail lacquer – OTC apply 1 or 2 weekly to affected nail after gentle nail filing – 6 months minimum for fingernails, 12 months for toenails

If dermatophyte nail infection is confirmed:

Prescribe oral terbinafine first-line.

250 mg once a day for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails

Oral itraconazole if an alternative drug is indicated.

Prescribe as pulsed therapy 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days.

If Candida or non-dermatophyte nail infection is confirmed:

Prescribe oral itraconazole first-line.

Prescribe as pulsed therapy 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days.

Prescribe oral terbinafine if an alternative drug is indicated.

Prescribe 250 mg once a day for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails.

[helthcareheven]

A New Era of Healing: Transformative Infectious Disease Therapeutics

Infectious diseases have plagued mankind since antiquity. While public health improvements over the past century have helped control many infectious illnesses, new pathogens continue to emerge and existing ones adapt in the face of globalization and antimicrobial resistance. Researchers have made tremendous progress understanding the biology of infection and developing new therapeutic agents, but more work remains. This article outlines some of the latest advances in infectious disease therapeutics across different disease categories and research areas. Antibacterial Drug Development The rise of multidrug-resistant bacteria is a major public health crisis, and the dwindling antibiotic pipeline requires novel solutions. Several new classes of antibacterial agents are under development with activity against resistant pathogens. These include novel ß-lactams that evade extended-spectrum ß-lactamases and novel protein synthesis inhibitors that avoid ribosomal protection mechanisms. Phage therapy is also being revisited, with early clinical studies of engineered phages demonstrating safety and efficacy against difficult-to-treat infections like Pseudomonas aeruginosa and Acinetobacter baumannii. Alternative antibacterial platforms like antimicrobial peptides and small molecule inhibitors of virulence factors also show promise. Antiviral Drug Discovery While antibiotics face resistance challenges, antiviral drug development continues making progress against several important viral pathogens. Hepatitis C virus (HCV) represents a major success story, with over 90% cure rates now possible using direct-acting antiviral agents. Research on HIV continues as well, with newer integrase inhibitors and second-generation protease inhibitors demonstrating increased genetic barriers to resistance. Influenza remains a serious threat, but novel cap-dependent endonuclease inhibitors could provide the first truly universal flu drug. For other viruses like herpes simplex, respiratory syncytial virus (RSV) Pneumococcal Conjugate Vaccines Streptococcus pneumoniae (pneumococcus) is a leading cause of community-acquired pneumonia as well as invasive pneumococcal disease such as bacteremia and meningitis worldwide. The development of pneumococcal conjugate vaccines (PCVs) targeting the most prevalent disease-causing serotypes has substantially reduced the global burden of pneumococcal disease. PCV7 was first introduced in 2000 and dramatically cut rates of invasive pneumococcal disease in vaccinated children.

Malaria Control Efforts Malaria remains one of the leading infectious killers globally, with drug and insecticide resistance complicating control efforts. Important infectious disease therapeutics advances include the development of artemisinin-based combination therapies (ACTs) that help delay antimalarial resistance. Novel compounds also aim to complement ACTs through new mechanisms of action. These include the spiroindolone KAE609, which acts on the ATP4 transporter essential for parasite viability, and the Oz439 compound targeting the apicoplast organelle to block isoprenoid biosynthesis. Vaccine progress includes the RTS,S/AS01 candidate demonstrating promising reduction of malaria cases in young children in African clinical trials. Combined with improvements in diagnostics, vector control through insecticide-treated bed nets continues reducing malaria morbidity and mortality worldwide. Tuberculosis Treatment Mycobacterium tuberculosis resistance continues complicating tuberculosis (TB) treatment and control globally - about 20% of MDR-TB cases are estimated to further develop extensively drug-resistant TB (XDR-TB). New and repurposed drugs aim to shorten treatment duration for drug-sensitive TB from 6 months to 4 months or less. Regimens including pretomanid, bedaquiline, and delamanid demonstrate potential to treat both drug-sensitive and resistant TB in significantly less time than current guidelines. New anti-TB therapies also target mycobacterial virulence factors and pathways specific to the pathogen. Developing rapid diagnostics to detect drug resistance and evaluating optimized dosing regimens are additionally helping curb the global TB epidemic.

Novel Antifungal Therapies Life-threatening invasive fungal infections negatively impact public health worldwide, especially in immunocompromised patients. Current antifungal drug classes include azoles, echinocandins, and polyenes, but limitations include toxicities, drug interactions, emerging resistance, and lack of oral options for many serious mycoses. Novel therapies in development aim to overcome these challenges. Novel azoles target the sterol 14α-demethylase enzyme through different binding properties than existing drugs. Echinocandin follow-ups show activity against resistant Candida as well as Aspergillus species.