#Zigzag Blanking Line

[pigswithwings]

Inspired by old clipart styles!! Trying to fiddle around with brushes and such, I think this one looks pretty cool :]

[ID: An art piece of an old computer. The background is half purple on the left side and half black on the right side, divided by a line that zigzags and curls. The computer is outlined in white and is connected to a large cord and a mouse. The cord is surrounded by various black swirls and white triangles to emulate old Microsoft styles. The plug of the large cord has purple lightning bolts shooting out of it. The mouse cord is decorated with a nearby arrow that follow the shape of the cord, as well as a purple star on the body of the mouse. The computer screen itself reads LOGIN in an analog font with a small blank input bar below it. A large, cartoonish cursor rests on the top of computer, and its right side is decorated with a line of purple dots. End ID]

[beansprean]

tfw u try to connect to your mans and turns out he's got a direct line to your soul

My Familiar's Ghost part 57

Masterpost

New pages on Patreon!

(ID in alt and under cut)

ID: 1. Black screen. A single speech bubble that says "...Nandor?"

2a. Waist up of Guillermo, dressed the same but no longer appearing in ghost form, as he blinks his eyes open to a vast void of black. A single orb of light floats behind his head. Far behind him, light rippling out like water beneath his feet, is another Guillermo mirrored, back to the viewer. A larger orb of light floats by him. 2b. Shot over Guillermo's shoulder as he turns his head to look. 2c. Repeat, mirrored. The other Guillermo copies his movement and turns his head, a small smile on his face the only difference along with the blank whiteness of his eyes.

3a. Full body of the two Guillermo's facing each other in profile, light rippling out like water beneath their feet on the black void. They stare at each other for a moment, mirror Guillermo still smiling. A small orb of light sits low behind Guillermo; a large orb of light sits high behind the other. Between them, a swirling wall of ghostly light keeps them separated. 3b. Close up of Guillermo furrowing his brow and tilting his head with confusion, cautiously reaching his hand up, small orb of light rising behind him. 3c. Repeat, mirrored. Mirror Guillermo continues to follow his movements with a smile, large orb of light rising behind him.

4a. Shot of mirror Guillermo from Guillermo's point of view as he thrusts his hand out, palm up, in a welcoming gesture. Offering the hand with an encouraging smile, large orb bright behind his shoulder. 4b. Repeat, mirrored. Guillermo's hand also thrusts itself forward as if guided by something other than his will. He stares at his mirror, confused and curious, but not frightened. The small orb settles behind his elbow.

5a. Close up of the wall of light in profile as each Guillermo reaches toward the other with mirrored hands, strands of light blooming and curling around them as their fingers make contact. 5b. Repeat. Their hands press closer, palm to palm, but mirror Guillermo's hand has changed. It is now Nandor's.

6a. Zoom out, Guillermo whips his head up in surprise to see Nandor now standing on the other side of the wall, smiling calmly down at him and wearing the clothes from when they first met. Their hands press palm to palm at the barrier; the small orb floats behind Guillermo, and the large orb floats behind what now looks like Nandor. The light barrier zigzags downward, dividing the following panel. 6b. Close up of Nandor smiling warmly down at Guillermo, a deep affection shining in his eyes. He says, "Come home, Guillermo." 6c. Reverse shot, close up. On the other side of the wall of light, Guillermo stares back, silent and hopeful.

7a. The wall of light zigzags downward again to continue to separate them. Close up on their hands on either side again as their fingers curl and lace together; a decision made. The light barrier breaks around the contact. 7b. The black void, now with three glowing orbs of light, one large, two small. Glowing ribbons of lightning snap from one to the other to the next, connecting them all together.

8a. Back in the house; wide shot of Nadja sitting on one side of a low wood table, Nadja doll in her lap and Beaverdor placed on the table inside a ring of candles. On the other side, where ghost Guillermo had been sitting, a wailing swirl of ghostly light forms and shoots upward towards the ceiling. The candles blow out. Both Nadjas stare in surprise, thrown into deep contrast by the burst of light. 8b. Zoom out. Guillermo is gone along with the light, and the candles smoke gently. Nadja looks down at her doll, lip curled up nervously, and asks, "Was that supposed to happen?" Dolly grimaces and squints to the side, replying, "Erm... let's just say yes and call it a win." /end ID

[hellofeanor]

*bows* May I ask you something about your Annatar cosplay? It looks so amazing and I would love to know how you crafted that belt. What material did you use? What mechanism did you choose to close it? Velcro, or hooks? I looks so neatly done.

Thank you! I actually do have a post somewhere about the construction, but tumblr's abysmal search function is being abysmal and/or I didn't correctly tag it as Annatar, so lord knows where it is now. Anyway. Let's go over it again in more depth!

The primary materials used are heavy duty craft interfacing for the base and high quality leather-look gold vinyl for all visible parts. Then yarn inside the cording, pants hooks for closure, covered buttons for the circles, and gold shantung backing.

I started by making a rough pattern in Microsoft Paint, since why not. I printed it off at a few different sizes to get one that looked correct for scale.

Next, I spent about eight hundred years making cord out of yarn and strips of gold vinyl. I zigzag stitched the yarn to one side of the vinyl strip, then wrapped and hand stitched into a tube. Each tube was 1.5m long to adequately cover the pattern. It took 20 tubes.

I pinned the tube cording down over the full-scale pattern printout and hand stitched it together into the appropriate wave shape.

Then wove all the wave pieces together into the correct pattern and stitched them down to a base shape of the craft interfacing covered in more gold vinyl.

To finish, I wrapped all edges in gold vinyl strips, covered some button blanks in gold vinyl and attached those, and covered the back in some gold shantung I had on hand. Added pants hooks for closures: two on the end and one on the top.

An important note is that I started making this in as May 2024 based on the first teaser and promo images. Without any clear reference pics, I had to make some guesses and construction choices, so the finished result is not in line with what we see on screen. But I like how it turned out anyway and have no current plans to remake a new and more accurate version. My version is much bulkier, but this works in my favor since I have a very feminine waist to hip ratio and this helps fill in the hourglass shape and give a boxier, more masculine silhouette.

Anyway this piece took THE LONGEST out of everything on this costume. Which is impressive considering the robe is all hand painted and I redid every single weft in the wig. BUT. It's all hand sewn except for a small bit of machine work, but even that I went over by hand because my machine hates vinyl and it looked like ass.

Thank you for your ask!

[conchiferrous]

sai file cleaning day

[IMAGE ID, IMAGE 1: Digitally drawn doodle page of various One Piece characters in a more cartoony art style where everyone has big heads and noodley limbs. Drawing 1: The first drawing is of Sanji and Bartolomeo. They're drawn waist up and Bartolomeo is grabbing Sanji by the torso and biting his arm with a wall eyed expression. Sanji appears to be only mildly surprised by this. Drawing 2: Waist up drawing of Carrot arc welding with her right arm. She's wearing a standard welding mask, a fire proof jacket, and a leather gauntlet glove on her left hand that she's using to hold her right arm steady as she makes a tee weld in the flat position with small metal plates. Drawing 3: Full body doodle of Luffy wearing a creeper t shirt, a jacket, basketball shorts, a bracelet mostly obscured by the long sleeves, and a chew necklace. He still has the straw hat and flip flops as well. He's looking off to the right with a blank neutral expression. Drawing 4: Franky doing surgery on himself, drawn from the thighs up. He is in the earlier stages of the cyborgification. He's laying on his back, holding himself open with his left hand that's a simple metal clamp, and his arms are bare metal pipes. His right hand is some kind of soldering iron that he's using to install a metal cylinder with a pipe coming out from the bottom in a zigzag pattern, replacing his stomach and intestines. His rib cage is visible as well, though there are no blood or organs shown. He has wheels installed on the sides of his hips. His head is still entirely organic and unchanged, and is looking down at himself, he looks very tense and stressed out. The only color in the drawing is Franky's blue hair and the line art on his torso is a gradient of blue to yellow to magenta. Also there's a little drawing of Sanji in the corner that looks like in was drawn in 20 seconds, he's dumbed down to a lanky black shape with long legs and huge feet, one big eye on a square head, and a long cigarette.

IMAGE 2: Unfinished sketch of Sanji and Luffy from One Piece, drawn digitally. The drawing is a spoof of the scene in the Whole Cake Island arc where Luffy tries to get Sanji to come back with him (the second time) and Sanji refuses. Sanji is turning away from Luffy and towards the viewer dramatically, arms crossed and hands holding his own shoulders, cape flapping in the wind, and a single sparkling tear rolls down his cheek. He is saying: "Get out of here and leave me alone, Luffy! You'll never understand me and my tragic past. Just leave me to die here!" in a cursive font where each capital letter has a little illustration of Cinderella over it like a fairy tale book. Luffy is staring at Sanji, in a much more simplistic style, contrasting against the relatively realistically proportioned Sanji. Luffy's staring at him with big eyes and giant pupils, with a completely blank expression. A couple of swords can be seen in the background, halfway driven into the ground. END ID]

[power-chords]

Zig-zags... switchbacks... what could it mean! Many possible culprits (and maybe all):

There is also Italo Calvino (from Invisible Cities, 1972):

In Esmeralda, city of water, a network of canals and a network of streets span and intersect each other. To go from one place to another you have always the choice between land and boat: and since the shortest distance between two points in Esmeralda is not a straight line but a zigzag that ramifies in tortuous optional routes, the ways that open to each passerby are never two, but many, and they increase further for those who alternate a stretch by boat with one on dry land.

And again:

“Happy the man who has Phyllis before his eyes each day and who never ceases seeing the things it contains,” you cry, with regret at having to leave the city when you can barely graze it with your glance. But it so happens that, instead, you must stay in Phyllis and spend the rest of your days there. Soon the city fades before your eyes, the rose windows are expunged, the statues on the corbels, the domes. Like all of Phyllis’ inhabitants, you follow zigzag lines from one street to another, you distinguish the patches of sunlight from the patches of shade, a door here, a stairway there, a bench where you can put down your basket, a hole where your foot stumbles if you are not careful. All the rest of the city is invisible. Phyllis is a space in which routes are drawn between points suspended in the void: the shortest way to reach that certain merchant’s tent, avoiding that certain creditor’s window. Your footsteps follow not what is outside the eyes, but what is within, buried, erased. If, of two arcades, one continues to seem more joyous, it is because thirty years ago a girl went by there, with broad, embroidered sleeves, or else it is only because that arcade catches the light at a certain hour like that other arcade, you cannot recall where. Millions of eyes look up at windows, bridges, capers, and they might be scanning a blank page. Many are the cities like Phyllis, which elude the gaze of all, except the man who catches them by surprise.

And, last but almost certainly not least, there is the shalshelet, the cantillation mark, the "mark of ambivalence":

Let us investigate but one of the notes of accentuation – the shalshelet – which appears only a mere four times in the entire Torah. Adding to the significance implied by the rarity of its occurrence, is the unusual demand that the shalshelet places upon the reader of the Torah – forcing a threefold extension of the vocalization of the letter it marks. As such, this cantillation draws particular attention from the listening audience; what wisdom is it trying to impart?

[elv-arts]

Silly little thing I made the other week when I was stuck in hospital while I was feeling up to making things. It's litterally just me complaining cuz I was feeling pretty fed up lol. I have been almost entirely in hospital for over a month now with a only few days off. Back home after round 2 of chemo though and hoping not to have a repeat of The Infection I made this about! lol

[ID: A series of images of a small handmade zine held together with washi tape.

Image 1 - The cover, titled "THE HOSPITAL" in big blue all caps. There's some bright pink lines shooting out for emphasis, and little doodles of plasters, pills and a syringe coloured in bright orange.

Image 2 - Page 1 and 2. "I have been in hospital for 5 1/2 days and it has thoroughly SUCKED. I only just got out from 2 1/2 weeks unplanned hospital time and was supposed to have to weeks mostly at home but nope!" In big yellow all caps is written "2 DAYS" with spikey emphasis lines. "I have been in a wonderful variety of pains, experienced many lovely symptoms, and have been bombarded with people and occurences." Written with hearts and pink flowers around it is "Thank You Neutropenia!" Followed by a doodle of a simple person giving a big thumbs up from a hospital bed with a smile and bags under their eyes.

Image 3 - Page 3 and 4. "I'm doing chemo for lymphoma, and the plan was to cut and dye my hair with my siblings like this" an arrow points to a drawing of a bright green mullet haircut with bright pink buzzed sides. There's a bright yellow zigzag shape around it. "Or this" another arrow points to a drawing of a longer bright green mullet with dark green roots. There's a bright yellow zigzag shape behind it. "asap BEFORE my hair started falling out, then when it did I'd buzz it, look like-"

Image 4 - Page 5 and 6. "-a mouldy potato for a bit, then be bald until it grows back after treatment." There's a doodle of a potato with green mould and a little smiley face, and one of a shiney orange egg with wide eyes. Then in big purple caps is written "BUT INFECTION STRUCK" "after my first pass at a haircut. I went to bed, ready to finish it the next day, then BAM! Hospitaled." The word bam has a green spikey shape around it and there's a doodle of an ambulance. "Didn't even get to wash it, so it's been GREASY until today. And now it's falling out." There's another doodle of a hand holding a clump of hair.

Image 5 - Page 7 and 8. "But that brings me to today. The other day, they switched me to a new antibiotic, and last night and today I've been feeling almost normal apart from some little side effects. I'm doing really well compared to how I was. They're saying I might get home tomorrow and I" in big yelloW all caps taking up the next page "REALLY FUCKING HOPE SO!" With lots of green zigzags.

Image 6 - Page 9 and 10. A doodle of a simple figure backed by shadow, with wide, blank, shadowed eyes hunched over the word "UPDATE" written in big purple caps with a shadow underneath. "I did escape. For long enough to have my dinner, then STRAIGHT back into hospital with a high temp. Not neutropenic this time though. Been in about a day 1/2. Hoping to go home later today." a pink squiggle between the pages, then yellow caps saying "UPDATE 2" "I AM HOME!! I have lit candles. I am chilling. I got mcdonalds on the way home :) There's stuff I need to do, but that's for later. Just gonna enjoy the peace while it lasts. AND THUS ENDS THE HOSPITAL ZINE!" There's a little doodle of a couple of green candles and one of a burger and fries.

Image 7 - The back cover. There's a little orange plaster doodle in the corner, and at the bottom it says "Made in Hospital* *mostly" End ID]

[sharmapress]

Use of Zigzag Blanking Machine

Zigzag blanking machines are highly relevant in industries. Their ability to optimize material usage enhances production efficiency. The automated feeding and control systems not only increase throughput but also minimize manual labor, reducing operational errors and safety risks. This makes zigzag blanking machines an essential asset for industries focused on maximizing productivity while reducing material costs and labor intensity.

Significance of Zigzag Blanking Machines

Zigzag blanking machines are transforming the industrial landscape by significantly enhancing efficiency, sustainability, and precision in metal processing. Their innovative zigzag stamping method optimizes material usage by minimizing scrap, which is crucial in industries like automotive, aerospace, and appliance manufacturing where raw material costs are high. This reduction in waste leads to lower production costs, making these machines an environmentally friendly option that aligns with sustainability goals.

Moreover, the automation features of zigzag blanking machines, such as automated feeding and real-time material control, have revolutionized production lines by reducing reliance on manual labor. This not only increases production speed but also minimizes operational errors and safety risks, creating safer and more reliable working environments. The machines are also capable of handling high-volume, complex designs with precision, making them indispensable in industries that demand both speed and accuracy.

By delivering greater material efficiency, reducing labor intensity, and improving precision, zigzag blanking machines are reshaping manufacturing processes and driving innovation in industrial sectors, allowing businesses to remain competitive in an increasingly cost-conscious and sustainability-driven market.

As we are clear about the relevance of ZigZag blanking machines, let’s understand their use cases closely.

Use Cases of Zigzag Blanking Machsines

Zigzag blanking machines have diverse applications across various industries due to their efficiency and material-saving capabilities. Here are some common use cases:

Automotive Industry:

Used for manufacturing parts like metal panels, brackets, and components where material utilization is crucial to minimize waste.

Ideal for stamping sheet metal parts for car bodies, chassis, and interior parts.

Appliance Manufacturing:

Applied in the production of large metal components for home appliances, such as washing machine drums, refrigerator panels, and oven casings.

Helps optimize material use in high-volume production environments.

Construction and Building Materials:

Utilized in the production of structural components like steel frames, support beams, and roofing materials.

Suitable for cutting metal sheets used in prefabricated structures or modular construction.

Electronics and Electrical Industry:

Used for stamping out metal components for electrical enclosures, circuit boards, and heat sinks.

Applicable in precision parts manufacturing for electronic devices and appliances.

Aerospace Industry:

Employed in producing lightweight yet durable components for aircraft, such as brackets, frames, and engine components, where minimizing material waste is vital.

Suitable for working with specialized alloys used in aerospace manufacturing.

Packaging Industry:

Zigzag blanking machines can be used to produce metal packaging components, such as lids, cans, or metal closures for food, beverages, or chemicals.

Furniture Manufacturing:

Applied in making metal parts for furniture frames, supports, and hardware.

Ideal for stamping steel or aluminum components used in modern furniture designs.

By optimizing the stamping process and reducing waste, zigzag blanking machines provide industries with a cost-effective and environmentally friendly solution for high-volume metal component production.

Ready to Transform Your Industrial Plant?

With expert service support from India’s best Zigzag Blanking manufacturers, you too can be a part of this industrial transformation. Contact Zigzag Blanking Line manufacturers today, and book a demo today itself.

[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.

[leftlad]

Soap Dispenser Guy

The story with this guy is strange. He never existed until last week.

Prior to this drawing, I was out for a week in Singapore with my family. (And caught the funny in the last day. Shit was fucked.) After a long night, I went to bed and had this dream that starred this dude.

The dream went like this: It was a normal morning, just minding my own business. All of a sudden, I was approached by some guy who wanted to get a gift for his grandma. The request was odd, he basically asked if I could find any soap dispenser, perfacing that it had to come from some business, like a fast food place or convinence store.

There's a blank in my dream, but I did go through the request and personally gave the soap dispenser to his grandma, wrapped and everything. I called him afterwards to tell him that I completed the task, which surprised him. So much so that he came over so we could check out the soap dispenser like any ordinary group of dudes would do, as if we were inspecting the engine of a car.

Obviously since it was a dream, I don't remember the exact design he had, all I remember is his small eyes and his clothing beinf casual. My memory is filling in that he had a cross face and zigzag mouth, but only one survived the final design.

I didn't bring my sketchpad with me to quickly draw him, so I just did it on my phone's photo app. His design stuck in my head after that dream, so it was sort of easy to sketch it.

That's not what he looks like without the mask. I designed something less basic during the piece.

He doesn't have a name yet, he just goes by Soap for the time being until I think of a name (or someone from my circle suggests a name). I just know he becomes the protagonist's new friend somewhere down the line.

I might make him a wrestling mark, thats the only thing that comes to mind when it comes to branching him from his soapy obsession.

By the way. Yes, those are ears, took me long enough to add those in my drawings. They'll be a mainstay from this point on.

[titoist]

When you have arrived at Phyllis, you rejoice in observing all the bridges over the canals, each different from the others: cambered, covered, on pillars, on barges, suspended, with tracery balustrades. And what a variety of windows looks down on the streets: mullioned, Moorish, lancet, pointed, surmounted by lunettes or stained-glass roses; how many kinds of pavement cover the ground: cobbles, slabs, gravel, blue and white tiles. At every point the city offers surprises to your view: a caper bush jutting from the fortress' walls, the statues of three queens on corbels, an onion dome with three smaller onions threaded on the spire. "Happy the man who has Phyllis before his eyes each day and who never ceases seeing the things it contains!" you cry, with regret at having to leave the city when you can barely graze it with your glance. But it so happens that, instead, you must stay in Phyllis and spend the rest of your days there. Soon the city fades before your eyes, the rose windows are expunged, the statues on the corbels, the domes. Like all of Phyllis's inhabitants, you follow zigzag lines from one street to another, you distinguish the patches of sunlight from the patches of shade, a door here, a stairway there, a bench where you can put down your basket, a hole where your foot stumbles if you are not careful. All the rest of the city is invisible. Phyllis is a space in which routes are drawn between points suspended in the void: the shortest way to reach that certain merchant's tent, avoiding that certain creditor's window. Your footsteps follow not what is outside the eyes, but what is within, buried, erased. If, of two arcades, one continues to seem more joyous, it is because thirty years ago a girl went by there, with broad, embroidered sleeves, or else it is only because that arcade catches the light at a certain hour like that other arcade, you cannot recall where. Millions of eyes look up at windows, bridges, capers, and they might be scanning a blank page. Many are the cities like Phyllis, which elude the gaze of all, except the man who catches them by surprise

[totaleclipse573]

Okay FINE my brain did the Starline au thing it likes to do (not that great, but I had to do something once the idea came to mind)

———————————

Well this was…strange. To say the least. 

When Eclipse found that little notebook hidden underneath his own mattress, he expected it to be blank. For some reason. The idea of messing around and checking to see if anything was in there seemed sort of wrong to him. In a sense that it held something he really wouldn’t like.

Something compelled him anyway. Maybe it was just the fact that it was from before.

He was still curious about what he was like. If he was that much different now. It certainly felt like it, what with the way everyone was acting lately.

After looking around for any sign of others nearby at the moment, he opened it to a random page, closer to the middle of the entire notebook. Everything was written in big, messy letters, seemingly with a red marker. He wasn’t all that good at writing and spelling…could barely read his own nonsense for a second.

The top of the page simply had “VENGANCE PLAN” with zigzag lines around it, and was very messily underlined. The points written down? The first one was to “EAT ROUGES MAKEUP” (with eat being underlined.) The second, “EAT SHADOWS COFE BEANS” (eat was, yet again, underlined.) And the third…”EAT SOMETHING OF OMEGAS.” (Same as the first two.) How creative.

What caught his attention the most was all of the little drawings around the page. The ones of each person beside their point, others seemingly depicting parts of this ‘master plan,’ and some just being. Entirely unrelated, as far as he knew. What was that blue hedgehog even on here for?

The worst part was, they were all poorly drawn stick figures. What an artist he was. 

…No, that wasn’t the worst part. Why was there so much…SHADOW in this thing?

He started flipping back pages, and almost every one had at least one mention of Shadow in it. Something he did that day that made Eclipse mad at him, or think too much about him, or even just laugh at him. Something Eclipse was planning to do to him. Something he learned about Shadow that he would most definitely use to his advantage later and needed to be taken note of. Something about how he wished he knew how they could be brothers, like Sonic and Tails are. He had so much to say just. About. Shadow.

He wanted to scribble all over it. Tear it out. Crumple it up and pretend he was never there.

He didn’t even care!

He never cared!

Shadow never cared about me….

Eclipse closed it and shoved it away. It made him feel frustrated and angry and upset and hurt and betrayed and overwhelmed and afraid and…

…This was what it was like, wasn’t it.

He used to like having Shadow around. 

Before someone got into his head and changed everything about him.

He wasn’t scared of Shadow, nor did he hate him. Not entirely, anyway. He couldn’t. Not before all this happened. 

Supposedly, they had somewhat of a bond. It’s why he came to…rescue him. Even if that bond was complex then, and shattered now, it was there. That’s why there was so much of him. But he didn’t know if he could get that back.

He couldn’t get his old self back. Not ever. Did that mean everything else was gone too? The only thing Eclipse could ever feel now when he even caught sight of Shadow was a fear greater than anything else he had ever felt in his life. It didn’t feel like there was any way out of that. This was just…him now.

He didn’t do anything for a while. Just sat there, lost in his own thoughts, as he usually did nowadays.

He grabbed the notebook back with his tail. 

A few pages after the one he had originally landed on, there was something about him going to train with Shadow again. And how it would probably be fun, if Shadow wasn’t such a party pooper this time, with the smaller extra note of “he ALWAYS is” and a little doodle of himself, tongue sticking out.

Everything else was blank after that. 

Things would never be like that again. No matter how hard he tried. He had already messed everything up. It was all his fault and now he couldn’t reverse anything.

Shadow hates me.

I hate Shadow the Hedgehog.

If everything seemed to point to those things not being true…

Then why wouldn’t they stop replaying in his head anyway…?

Eclipse has a little notebook where he just writes random things in huge letters + silly doodles sometimes. I refuse to believe this isn't true. You can't make me. Grabs a marker and just does that in his free time. He writes his vengeance plans in there and right next to them there's stick figure doodles of that person please listen.

[henlimachine2]

About Decoiler Straightener Feeder Machine Manufacturer - Henli-machine

HENLI MACHINERY FACTORY

Dongguan Henli Machinery Equipment Co., Ltd. established in 2005, is a professional manufacturer focusing on research, design, production, sales and service in the integrated of auto equipments of punching machines, coil automation solution, factory automation solution and steel coil processing production line. Henli Machinery is a Chinese enterprise company with Tainwan technology to design and make the machines. It locates in Dongguan City Guangdong China, which is an international manufacturing city between Shenzhen and Guangzhou City. Our machines are widely used in hardware, home appliance, aotomobile, electronic components and steel coil cutting slitting areas. Products of our company: Slitting line, cut to length line, 3 in 1 NC straightening roll feeder, NC servo roll feeder, high speed roll feeder, uncoiler, starightener, 2 in 1 uncoiler and starightener, double head decoiler, air feeder, precision leveler and robotic arms, etc. We own a subsidiary named Dongguan SYDA Idustrial Robot Co., Ltd. This factory also locates in Dongguan City, established in 2015, possessing a big and beautiful plant. Products of SYDA Robot: N95 type and 3 plys flat type full automatic disposable mask making machines with ultrasonic technology , 6 axis robot (including pick and place robot, welding robot, stacking robot, spraying robot, polishing robot, etc), 4 aixs stamping robotic arm, 4 axis stacking robot , translation manipulator, 2 axis/3 axis transfer manipulator, multi-machine connection transfer manipulator, single machine multistation transfer manipulator, double material feeding machine and sheet feeder, etc. Due to more than 13 years experience in stamping area, we have more advantages in providing automation solution with our

SYDA INDUSTRIAL ROBOT FACTORY

robotic arms. We are not only a robot manufacturer, but also an integrator devoted to offering solving cases according to customer’s requirement and their scene. Both Henli Machinery and SYDA Robot can offer ODM or OEM service. Even our customers want us to help them look for some accessories or materials, it is our pleasure to help customers with these. You believe us, you made us.

Our machines and production line mostly conclude uncoiling, straightening, feeding, cutting and slitting function. They are widely used for different kinds of coil materials, for example hot rolled, cold rollerd, galvanised steel, stainless steel, aluminum, manganese sheet and high strength steel, etc. The Henli products used in the steel industry include all kinds of metal strip shearing equipment, the operating line thickness is 25 mm, and the width is 2500 mm. Henli products are mainly for steel products distribution center, press users and end users, such as automobile and home appliance industries.

Sticking to the guideline for management of “seeking survival with quality, pursuing development with efficiency, expanding market with credibility”, we guarantee to supply good quality products with reasonable prices and satisfactory service. Henli is your reliable partner, please just feel free to contact us for further cooperation based on mutual benefits!

Facebook

Pinterest

YouTube

admin@henli-machine.com Address: No.165, Liyatang Industrial district, Lincun Village, Tangxia Town, Dongguan City, Guangdong Province, China(Mainland) Zip: 523721

Website:https://www.henli-machine.com/

[shelbeanie]

I let myself go wild while remaking my Collector cosplay! Thank you so much @DanaTerrace and your team, I had so much fun over analyzing all the little details in the show to try and incorporate into this!

I’m also going go to do a breakdown the 60 hours of work over 2 weeks that went into it because I had to speed up everything! My initial design. I ended up changing the design in one side to mimic the grain pattern on the other side, but all of the little details and the color shift are high key my favorites parts

I was dead set on the fabric shifting between Navy/Plum and Silver/lilac. I’m fairly certain I willed these fabrics into existence because they were almost impossible to find. I had a back up plan of navy and silver velvet if it didn’t work out, which I will likely still make

I wanted to add texture to the costume. Little details you wouldn’t notice at a distance but up close you could see all of the tiny hidden intricate details. My initial design was a quilted pattern but it priced very hard to digitize. I wanted to maximize the space I could cover while mimimizing the time spent so I created a second design. That one was further simplified down to save time. Each pattern piece has 15 panels, 25 min each

The alternate side was originally supposed to have diamonds on it, but those proved difficult to digitize and difficult to line up, they just didn’t look as good as I had hoped. I redesigned it so that the lines imitates the grain of the dark purple/crossed the grain. Much better

I also has to trim all of the strings to clean it up and trim the backing. Next time I do something like this I will use water soluble backing. This side had 15-20 panels (I lost count) at 25 min each with 3 bridging patches to help make the pattern look natural.

The sleeves have 6 designs per sleeve and the zigzag design. I wanted the zig zags to be interlocking titan skulls, each one took 7 min (11 per sleeve). There are 3 different moons with a collector hidden in each. The suns are the sign of the huntsman. Each sun/moon took 30 min. I also added the titans from the title card boarder to my collar

The hat dot/constellations are in the opening. I had to add a couple more by hand to fill in blank spaces. The hat is lined and the lining/boarder are attached via a satin stitch. I finished most edges with a satin stitch.

I have hit my limit on pictures but I’m not finished, so I am going to have to do a follow up post with the rest of the details, check the reposts for it!

[dukemeropide]

This floor hasn’t seen power for centuries, so it would seem, and yet it still groans and sighs like the belly of some great, iron beast. Far above and far below, one can make out the signs of life from the rest of the sunken Fortress - steam from hissing valves, the rhythmic hammering of a plate press, and the rattle of water through knots of pipes - but carried here through the echoing chambers of abandoned tunnels and rusted air vents, the ordinary becomes otherworldly. The long-dried and defunct metal veins snaking the corridor overhead sing softly as if with the voices of some very far away, ghostly choir.

The Duke has explored this floor once or twice on his own before. He has plumbed the Fortress’ secrets so doggedly that investigation might as well be his true job and administration simply something he does on the side, and so he has a rough idea of where they are and where to go. Concentrating on an imperfect map he’s stitched together in his mind from his previous visits, he doesn’t immediately notice when the quick, resolute heels clicking alongside the steady thump of his rubber soles die away until he’s already gone nearly to the end of the hall. He stops there and turns with a curiosity deliberate enough to stamp out the undercurrent of panic. If he lost the former Archon here, he knows the only thing the court could do to him at this point is stand him across the ring from one legendary duelist. It was a fate as good as death.

But Furina has merely stopped by the wall some feet back, examining something high above her.

Ousia nodes, she says, and Wriothesley crosses his arms.

”A few things, I’d imagine,” he says as he makes his way back to her to see what’s so special about them. They couldn’t look nearly as out of place here as she does, all but shining in the gloom in her clean white and bright blue, and in fact he’s impressed by her eye when he comes up alongside her. Three dim bulbs in a line, hardly unusual in a place like this except for the faint glow of residual energy around them. Wriothesley stares up at them with a hand stroking his chin. Had someone been here recently…?

“Looks like one of them might lead to—“ He starts to look around, following the narrow piping zigzagging away from the leftmost bulb. There’s a filthy rag draped over some irregular shape hidden in the shadows against the wall and his eyes light up. “—Aha, there’s a console under here.”

He pulls it off to reveal a rusty old machine with rows of dust-caked keys along its front. A large gear sits inert behind it, connecting to the piping from the Ousia node. Wriothesley runs his fingers along the letters, then wipes his thumb across the little square screen at the top - lifeless and blank now.

”This probably operates a few cameras on the floor. Too bad I don’t have the means to make it run. I doubt there are any Pneuma blocks sitting around down here either. Those things are too valuable to be locked up and abandoned.”

　PARADE OF THE LADY ｡

[uwuwriting]

Yandere ex w/ Midoriya and Bakugou

Request: Can I request some headcanons about Deku, Bakugou annnddd whoever else you'd like with reader and they are currently dating

Reaction to reaching you from your crazy ex boyfriend who is...very powerful and has managed to corner you, alone. You're scared, you're a civilian.

" oh shh. Don't cry baby, i'm here. Now that I'm here, you're all mine, now that you're done being silly. You and me forever"

( thought that'd get the creepy factor)

I'm just a sucker for rescue missions. I'm just so interested in how they'd approach that situation, how they'd comfort reader afterwards

Thank you. For reading this if you don't do this

Which is totally fine! - anonymous

Bruh rescue missions are just *chef’s kiss*. I’ve been having a mini Deku and Bakugou infatuation and I just wanna see more fics with these cuties and their civilian s/os. Like legit there aren’t enough fics with quirkless/civilian readers out there and I’m sad. Love ya.💖💖💖

masterlist II rules

warnings: stalking, attempted kidnapping, mentions of toxic past relationships, being chased, eventual fluff in the form of comfort, TW BEWARE. 

Midoriya Izuku/ Pro hero! Deku

-Izuku believed you were an angel walking on earth. 

-He met you in the brink of death *literally* when you stitched him up and stabbed an IV into his arm. 

-It was love at first sight for him tbh and he is proud to admit it too. 

-Soon enough -and after many many more visits to the hospital so he can be treated by dr. L/N- he asked you out and now you’re living together. 

-He knows about your ex and he hates him for what he did to you. 

-He has coaxed you into relaxing many nights after you’ve had terrible nightmares about your ex finding you again and this time not only putting your freedom on the line but also Izuku’s safety. 

-You know he is a pro hero and all but you can’t stop seeing him on your apartment floor, unmoving with your ex looming over him. 

-He is always there to chase that horrible darkness away and replace it with the warmth of his love. 

-So as time passed, thoughts of your ex became less and less frequent until they stopped popping up throughout the day all together and you were happy with that. 

-Then the universe decided that it should serve you with a good old traumatizing experience to spice things up. 

-You were walking home after your shift at the hospital was over, exhausted out of your mind when you felt the hairs at the back of your neck rise.

-It was like a sixth sense, knowing that something was up. 

- “Y/n-chan~”

-Your blood ran cold at the familiar voice, your mind going blank as you quickly fished out your phone dialing Izuku’s number while speeding up. 

- “Hey angel w-”

- “Izu he is here. H-he is f-following me.” 

-You heard his feet hitting the pavement on the other line as he ran down the busy street, completely forgetting about the patrol he was on. 

- “Where are you angel?”

-Sharing your location with him you took a sharp turn and into a convenience store, walking to the very back and hiding behind a few shelves, your eyes glazing over as you heard the sliding doors ding as your ex stepped inside not even a minute after you. 

-When did he get so close?

- “Izu please.” 

- “I’m almost there Y/N, I’ll protect you I promise.” 

-You held your breath as footsteps got closer, Izuku’s breathing keeping you grounded as they echoed through the other line. 

-Dipping behind another shelf you zigzagged through the aisles hoping to lose him as you slowly and quietly made your way to the entrance, your plan being to run outside and find Izuku. 

-Your plan though was cute short when an arm wrapped tightly around your waist bringing you flush with a sturdy chest, your ex’s head dipping into your hair and breathing in your scent in an exaggerated sniff. 

- “You like the chase Y/N-chan~? I’ve got you now.” 

-Izuku’s panicked voice could be heard coming from your phone as he listened to your ex talking to you. 

-A whimper of your actual boyfriend’s name left your lips in an attempt to get away from him but his grip on you tightened making a sob escape you as tears cascaded down your cheeks, too many awful memories of your past relationship flooding your mind. 

-You wanted your Izuku. 

- “Aww baby don’t cry. And my name isn’t Izuku so don’t make that silly little mistake again because it doesn’t make me happy when you call out other men’s names. I got you now and everything will be back to normal in no time. Just you and me my sweet Y/N.” 

-You thrashed around, your hands clawing at the arm wrapped around your waist and the other one that was holding your chin. 

-In your panic you didn’t even hear the ding of the store’s doors as your boyfriend stepped in, eyes immediately locking on your crying features and the outer fear in your eyes as you ex tried kissing your neck.  

-It took him mere seconds to untangle you from your ex’s grasp and pull you safely into his chest, a punch flying right into your attackers jaw as he fell to the floor with a loud thud. 

-His hands went immediately to cradle your head near his chest, rubbing soothing circles on your back as you sobs wracked through your body. 

- “Shh angel, it’s me I’m right here shh. He can’t hurt you Y/N.” 

-Police sirens echoed outside as a few officers poured through the double doors, Izuku scooping you up and taking you outside trudging the familiar road to your shared apartment. 

-You wouldn’t let go of his hero costume as he calmly set you on your shared bed, whispering to you that he was only going to the closet to help you both change. 

-It took him a lot of time to actually calm you down and when he managed it he called his agency to inform them that he would be taking the day off. 

-The only thing he could do after that was hold you as close to his chest as he possibly could, reassuring you that he wouldn’t be coming anywhere close to you from now on that he was officially gone. 

Bakugou Katsuki/ Pro Hero! Dynamight

-It was a stupid argument that escalated and now he found himself crashing at Kirishima’s. 

-You two hadn’t talked for about a week now and Bakugou feared that you had had enough of him and you would break up if he called. 

-He felt awful.

-He just wanted to go back home to you, kiss you, hug you, be back in his normal routine with the love of his life but no he had to be stubborn and push you to your limits with a silly argument that he doesn’t even remember what the fuck it was about. 

-It was the third sleepless night for him and he couldn’t stop his brain from drifting to you and what you might be doing. 

-You on the other hand were terrified out of your mind. 

-Not long after Katsuki stormed out of your apartment you had started getting texts from an unknown number saying things like “He is finally gone” and “Now we can be together again dolly.” 

-The nickname had sent shivers down your spine, memories of your toxic/yandere ex flooding your mind. 

-Katsuki had helped you run away from him and heal after those dark days. 

-Walking to the kindergarten you worked at became a constant threat.

-You were always looking behind your shoulder for anyone who might be following you, coming very close to calling Katsuki more than once when you thought that you had caught a whiff of your ex. 

-You began asking your coworkers to walk home with you using the excuse that it felt kinda lonely walking alone.

-Things reached a tipping point when the photos started coming in. 

-Photos of you in your class helping the kids, on your way to the station to catch your train every morning and even from inside your own house. 

-Photos of you putting on one of Katsuki’s hoodies was filled with manic scribbles of the word stop as a big red circle was drawn around your boyfriend’s sweatshirt. 

-It terrified you and you wanted nothing else than to call Katsuki and beg him to come back. 

-But despite it all your worthless pride and ego got in the way convincing you that you would fight your ex with your own two hands. 

-All those thoughts were tossed out the window when you heard your ex’s voice outside your apartment’s door on a late Friday night. 

- “Dolly open the door~” 

-In less than a second you had pushed the kitchen table in front of the door, your fingers hastily dialing Katsuki’s number, tears already streaming down your cheeks as your ex pounded at the front door, his voice and pleas becoming more and more aggressive as the seconds ticked by. 

-Two agonizing minutes passed before Bakugou answered, his gruff voice reaching your ears from the other line as he answered with a short “What”

- “Katsu please h-he is trying to get in. H-he is at the d-door. I-I don’t know what to do.” 

- “Baby lock yourself in our room and try to barricade the door. After that hide I’ll be there before you know it.”

-You could hear a door slamming shut and his hasty steps coming through the other line. 

-Doing as you were told you locked your bedroom door, pushing your dresser in front of it as more bangs came from the front door the legs of the kitchen table scraping the floor as the door almost rattled off its hinges. 

-Ducking underneath your bed you let out a few whines to which Katsuki answered with reassuring words. 

- “I’m almost there baby, I’ll save you. Fuck, I’m sorry, I’m so sorry baby. I should be home with you right now keeping you safe from that lunatic. I’m sorry I love you so much.” 

- “Katsu please hurry please. I-I’m so scared. Please.” 

- “I can see our building don’t worry-” 

-A loud thud came from the kitchen and only a few seconds later something rammed into the bedroom door ripping another whimper from your throat. 

- “Oh my god Katsu he’s in our house!!” 

- “Y/N, dolly, why are you making this so difficult my love? I just want” *thud* “to love you” *thud* “the way you” *thud* “DESERVE!”

-In one finally push your dresser was finally knocked over as the door creaked slightly open, your ex squeezing through the crack a laugh and a breathy moan of your name escaping his lips as he stepped inside.  

- “Katsuki I lo-” 

-The only thing that Katsuki could hear was your scream as he barreled up the stairs to your apartment. 

-He was gonna skin that bastard alive for hurting you and then he would skin himself alive for allowing this to happen. 

-He will never forget the look of pure terror in your eyes as you ex was pining you on the floor, your eyes darting through the room desperately searching for a way to escape this. 

-Katsuki tackled your assailant, straddling his waist as he let punch after punch connect with the bastard's face as you cowered to the far corner of the room. 

-After a few minutes of relentless punching your ex was knocked out cold while Katsuki was cradling you to his chest, rubbing circles onto your scalp as you sobbed in his chest. 

-You don’t remember much of what happened later, too exhausted to process anything and too comfortable in Katsuki’s arms as he led you to Kirishima’s house to spend the night. 

-He refused to take you to a hotel, he thought you would feel safer in a familiar environment. 

-Kiri left you two alone as Katsuki prepared a bath and a change of clothes. 

- “Katsu…” 

-His name left your lips as a mere whisper and it broke his heart. 

- “I can’t go back to our house...He had been in there….he had taken pictures I-I” 

- “Shh it’s alright. It was getting kinda small for us anyways. Shh Don’t worry about it.” 

- “I’m sorry Katsu, I’m so sorry.” 

-It would take a lot of hard work to build up your sense of safety and he knew it but he was ready to give it his all for you. 

- “No need to apologize baby. You know I would do anything for you and your safety and I’ll be here next to you now matter what. I love you and I will never stop. You kinda have my wrapped around your finger, woman.” 

-You let out a weak giggle followed by an “I love you” of your own and a little peck on the lips, as you snuggled close to him, his arms bringing you safely to his chest in a way to calm your nerves. 

-You really did have wrapped around your finger.

TAG TEAM AY:

@the-arcana-fan-fic​ @angelwritings​ @axerrri​ @reinyrei​ @dnarez​ @storage11037​ @wolfkid22​ @letscheereachotheron​ @ezoyscorner​ @luluwiie​ @threeamwriting​ @dark-thoughts-and-red-roses

[justonemorechapternicercy]

Apercy and 13? :)

13. “I can’t believe I just missed my flight.”

Percy was late. He was so, so, so late. He was going to fly to New York from San Francisco for the holidays, to visit his family, but with the traffic jam, he got to the airport late. Too late. The plane might not have been gone yet, but he was stuck in the line for the security and ticket controll, and the departure of his flight was scheduled-

Soon. Really, fucking soon.

He cursed himself for believing Annabeth that he doesn't need to be at the airport two hours before the gate opening, because the first time he tries to be not an anxious mess before flying, he was late.

Late! From his flight! Before Christmas!

There was no way he was going to get another ticket to New York for that day. He might be able to get a ticket after Christmas, before New Year's Eve, but that would mean he would miss Estelle's Christmas, and that was unacceptable.

So, as soon as he was in the terminal, he started to run, zigzagging between the chattering crowd, his lone backpack - full of thankfully not fragile gifts - flapping behind him. He threw sorry after sorry as he ran as fast as he could towards the gate, but just as he reached it, the flight attendant closed it after the last passenger.

He was too late.

"Fuck!" He shouted, angry at himself, almost yanking out his hair as he grabbed a fistful of it. He needed to call his mother to tell her the bad news. "I can't believe I just missed my flight," he lamented in despair. He took out his phone, to call his mother, not feeling up to it.

"Excuse me," said somebody tentatively, and Percy stepped away to give space to the person, still staring at the black, blank screen of his phone. He was going to call her, in a minute. Just... He needed some time.

"Hey, excuse me," said somebody again. Percy looked up with furrowed brows, not wanting to deal with anybody, but not wanting to be rude either.

Looking at the person talking to him, he felt like he was looking at the personified Sun. Golden blonde hair, sky blue eyes, sparkling white toothpaste ad smile, tanned skin... The guy was hot. And Percy didn't understand why would the guy talk to him when he clearly wanted to be left alone.

"Yes?" He asked bewildered.

"Are you okay?" At Percy's unimpressed stare, he gave an embarrassed smile and clarified, "I mean, you looked distressed and I was wondering if there's anything I can help you with."

"Thank you, but I doubt it," Percy said, maybe a bit more dismissively than he wanted, not wanting to get into his problems. He was not somebody who enjoyed pouring his plights onto strangers.

"Oh, okay. Um... Maybe- Can I get you a drink?" Asked the guy, still smiling, but less self-confidently.

A weird thought came into Percy's mind: was he flirting with me?

He squinted his eyes at the guy, considering. He was hot, there was no question about it. He looked like a model, somebody who could get anybody he wanted, so why was he trying to pick up somebody at the airport?

The longer the silence stretched, the guy's smile got more strained, disappointed. But he didn't bolt.

Suddenly, Percy smiled, "I'm Percy."

"I'm Apollo. Nice to meet you," the guy said, eyes lighting up with happiness. They shook hands, and if it took longer than it was normal, nobody could blame Percy for wanting to have something nice after a day like that.

And if in the end Percy could spend Christmas with his family and his new boyfriend, because said boyfriend had a spare ticket to New York, because his sister had to cancel her trip at the last minute, well...

That must have been a Christmas miracle.

Give me a ship and a number!