Blair Robinson, MD

• Associate Professor of Pediatrics
• Division of Pediatric Cardiology
• The North Carolina Children? Heart Center
• University of North Carolina School of Medicine
• Chapel Hill, North Carolina

Necropsy: Wear cut-resistant gloves antibiotics for uti in breastfeeding buy ivermectin overnight, facial protection and Notify: impermeable outerwear antibiotic yellow tablet ivermectin 3 mg with mastercard. If an animal is suspected // When bites or scratches occur antibiotics for uti or kidney infection generic ivermectin 3 mg with visa, wash the site with soap and of having a notifiable infectious or a foreign animal disease antibiotics for acne oxytetracycline purchase cheap ivermectin line, water immediately antimicrobial ointment buy 3mg ivermectin visa. Report all bites and other injuries to consult with a government veterinarian before proceeding with a necropsy antibiotics gas order ivermectin 3 mg line. Contact information for the government veterinarian or Infection control officer: Emergency disease hotline: who will also maintain the incident report log. Eating and drinking are // As required by law, bite incidents will be reported to not allowed in the laboratory. Public health agency: Telephone number: Environmental infection control Isolation of infectious animals: Animals with a contagious or zoonotic disease will be housed in isolation as soon as possible. Only equipment needed for the procedures care and treatment of the patient should be kept in the isolation room, and there should also be dedicated cleaning supplies. Intake: Avoid bringing potentially infectious animals in through Disassemble and thoroughly clean and disinfect any equipment the reception area. Clean and disinfect or discard protective Examination of animals: Wear appropriate protective outwear equipment between patients and whenever contaminated by and wash hands before and after examination of individual body fluids. Use disinfectant footbath before protection if a zoonotic respiratory tract infection is suspected. Animals suspected to be infectious will be examined in a Keep a sign-in log of all people (including owners or other non dedicated exam room and remain there until diagnostic employees) having contact with an animal in isolation. Staff responsible: Needlestick injury prevention: Do not bend needles, pass an uncapped needle to another person, or walk around with Appendix 1: Model infection control plan for veterinary practices Australian Veterinary Association 30 Guidelines for Veterinary Personal Biosecurity 2017. Wash with bat contact must be vaccinated against rabies, followed by hands afterwards. Tetanus vaccination: Tetanus immunisations must be up-to Clean and disinfect animal cages, toys, and food and water bowls date. Report and record puncture wounds and other possible between animals and whenever visibly soiled. Wash animal bedding and other laundry with standard laundry Seasonal influenza vaccination: Unless contraindicated, detergent and machine dry. Use separate storage and transport veterinary personnel are encouraged to receive the current bins for clean and dirty laundry. Check with the Australian Department of Health and Ageing for current recommendations Decontamination and spill response: Immediately spray spills or splashes of bodily fluids, vomitus, faeces or other potentially Staff training and education: Infection control training and infectious substance with disinfectant and contain it with education will be documented in the employee health record. Put on Documenting and reporting exposure incidents: Report gloves and protective outerwear (including shoe covers if the spill incidents that result in injury, illness or potential exposure to an is large and may be stepped in) before beginning the clean-up. Keep clients, patients and employees away from the spill area until disinfection is completed. The following information will be collected for each exposure Veterinary waste: Insert here your local and state regulations incident: date, time, location, person(s) injured or exposed, regarding disposal of animal waste, pathology waste, animal vaccination status of the injured person(s), other persons present, carcasses, bedding, sharps and biologics. Rodent and vector control: Seal entry portals, eliminate clutter vaccination history, clinical condition, diagnostic information), and sources of standing water, keep animal food in closed metal first aid provided and plans for follow-up. Do not keep food or drink for human consumption If you are concerned about your work responsibilities, so that in the same refrigerator as animal food, biologics, or laboratory accommodations may be made. Dishes for human use should be cleaned and stored supervising veterinarian and a health care provider may be away from animal care and animal food preparation areas. The following information is attached to this infection control plan: Employee health // List of reportable or notifiable veterinary diseases and where to report. Record keeping: Current emergency contact information will // State department of primary industries contact information be maintained for each employee. Appendix 1: Model infection control plan for veterinary practices Australian Veterinary Association Guidelines for Veterinary Personal Biosecurity 2017. C upsaliensis, goats, pigs, Causes gastroenteritis C fetus and cats, dogs and less commonly others Guillain Barre Syndrome Appendix 2: Zoonotic diseases of importance to Australian veterinarians Australian Veterinary Association 32 Guidelines for Veterinary Personal Biosecurity 2017. Contact, aerosol Yes As at November 2016 (prev Equine Henipavirus, Horses and (droplets, airborne). Ferret and birth fluids, uncertain 2 seropositive and cat have other body fluids of animal, without signs, has been infected flying foxes (*) been identified experimentally (*) Direct flying fox to human transmission has not been reported, but should be regarded as possible Hydatids, Echinococcus Definitive hosts: Contact, faecal oral Yes Human infection only echinococcosis granulosus dogs, wild canids, ingestion acquired from infected Intermediate canids and their hosts: ruminants, excrement wildlife, humans Japanese Flavivirus Pigs, horses, other Mosquito bite Yes There have been 5 encephalitis mammals, birds recorded human cases acquired in Australia Larval migrans Ancylostoma Dogs, cats Contact, Rare Regional (hookworm) spp. Penetrating injury Larval migrans: Toxocara canis, Dogs, cats Contact, ingestion Rare visceral, ocular, Toxocara cati neurological (roundworm) Leishmaniosis Leishmania spp. Macropods Biting midges Yes, but Enzootic in macropods in implicated as not from the Northern Territory. No vectors, but no this strain human cases recorded human cases to date recorded to date Leptospirosis Leptospira spp. Reptiles, Contact, ingestion Yes Common (non-typhoid), amphibians, (food, water) food-borne including strains poultry, horses, pathogen causing highly resistant to pigs, cattle, gastroenteritis. Appendix 2: Zoonotic diseases of importance to Australian veterinarians Australian Veterinary Association Guidelines for Veterinary Personal Biosecurity 2017. Coxiella now spread to a wide range of animals species, mostly in Europe can cause foetal death, which may be the reason for caesarean but increasingly in other countries. Medical advice should be sought on the advisability or otherwise of decolonisation of References colonised staff. Appendix 4: Disinfectants in Australian veterinary practice Australian Veterinary Association Guidelines for Veterinary Personal Biosecurity 2017. The the information in this section is from Infection control guidelines for biocidal (inactivation) structure and the general properties of the prevention of transmission of infectious diseases in the health the group to which it belongs (see Appendix 6). All solutions care setting (2001), Commonwealth Department of Health and Ageing, labelled as disinfectants inactivate a range of vegetative bacteria, Canberra, and is used with permission from the Australian Government. Contact time specified by the Decontamination provides information on use of chemicals manufacturer should be applied. Sterilants and higher-level disinfectants also inactivate bacterial endospores, mycobacteria, viruses (both the more sensitive lipid-coated viruses, such as human immunodeficiency virus, and relatively resistant viruses, such as polio virus) and other Key points microorganisms. However, the sporicidal activity during the usual Surface disinfectants/sterilants shorter exposure time for high-level disinfection may not be optimal. Chemical substances may be formulated for use on inanimate instrument-grade disinfectants, hospital surfaces (ie surface disinfectants) or for use on skin (ie skin grade disinfectants or household/ disinfectants, or antiseptics). Classification of a product using commercial-grade disinfectants any of these active ingredients as household grade, hospital grade, instrument grade, sterilant or antiseptic depends on the // Sterilants are chemical agents that may be formulation used. Disinfectants and sterilants membrane application to kill or prevent the should not harm instruments or equipment and the compatibility growth of microorganisms. Label claims must be the required amount of product should be decanted as required followed to avoid contamination of the stock solution. Appendix 4: Disinfectants in Australian veterinary practice Australian Veterinary Association 44 Guidelines for Veterinary Personal Biosecurity 2017. These instruments must be registered on the Australian Register of disinfectants must not be used to disinfect medical instruments. The use of hospital-grade disinfectants is not necessary in health Sterilants care establishments. However, hospital-grade disinfectants may be sterilise critical medical devices that will not withstand steam used on environmental surfaces such as walls, floors, furniture sterilisation. For products that may be classified as both a sterilant and a high-level disinfectant (multiuse), the sterilisation time is the Household/commercial-grade disinfectants longer of the two times that appear on the label. The label claims of such products are (including mycobactericidal), fungicidal against asexual important and should be followed. Skin disinfection before surgery as low-level disinfectants, which are ineffective against many should reduce the number of resident bacteria and thus the Appendix 4: Disinfectants in Australian veterinary practice Australian Veterinary Association Guidelines for Veterinary Personal Biosecurity 2017. For example, 4% w/v chlorhexidine is widely used fluid remaining in this container should be discarded at the as a bacterial skin cleaner for hygienic and surgical handwashing. Where disinfectant is used during dental formulations and concentrations chosen should be appropriate procedures, oral membranes should be dried/isolated to prevent to the tissues to which the antiseptic is applied. The National Health and Medical Research Council guidelines for the use of P2 respirators are available at Correct fit Incorrect fit // Well-made respirators made with good quality materials are No gaps Gap between skin and recommended. This respirator has a this respirator does not have adjustable straps the straps are not adjustable. The material is thinner than other left have relief valves, while the one on the relief valve and respirators. Material is thinner than this respirator has a well moulded nose bridge, other respirators. The picture on the right shows the inside of the respirator adjustable straps, relief valve and sturdy dome with padding over the nose to improve comfort and to improve facial seal. Appendix 5: Specifications and fitting instructions for respirators for Australian veterinarians Australian Veterinary Association Guidelines for Veterinary Personal Biosecurity 2017. Balanced approach to standard precautions: of State Public Health preventing infection in staff, based on understanding of zoonotic disease prevention Veterinarians Veterinary disease, facility design, hygienic practices and equipment. Comprehensive and practical approach, covers important matters in great detail, well set out, backed by references. Prevention and Control Eurosurveillance14,3 (2009) Queensland pandemic Queensland Government Detailed protocols to advise businesses on approaches to influenza preparedness and (2009) minimise risk of infection with influenza virus. Incorporates response guide for businesses regulatory, legal and medical recommendations. Detailed information on Denmark 2005 and Consumer Affairs, abattoir surveillance, little detail on prevention of infection Copenhagen, Denmark for veterinarians and staff. Airborne transmission Transmission by inhalation of infectious Fomites Inanimate objects that may be contaminated with agents from respiratory secretions. Hazard In risk assessment the entity or factor that can cause Antibody (immunoglobulin) Specialised protein produced injury, damage or disease. Antigen Substance which the body recognises as foreign binds Helminth parasites Worms that cause internal infections, often to the corresponding antibody in the body. Herd Any group of animals, including birds, fish and reptiles, Arthropod Animal of the phylum Arthropoda, and with maintained at a common location. High-level disinfectant A disinfectant that kills most microbial Arthropod vector An arthropod capable of transmitting micro pathogens (except bacterial endospores), when used as organisms between animals (hosts). Standard for composition, packaging, labelling and performance Attenuated Reduced in virulence, often used to describe of disinfectants and sterilants. High-level disinfection Minimum treatment recommended for Booster Second, or subsequent, dose of vaccine given to reprocessing instruments and devices that cannot be sterilised enhance the immune response. A reaction Cell-mediated immunity Immunity effected predominantly by of the previously immunised body in which tissue damage cells (T-lymphocytes and accessory cells) rather than by antibody. Disinfectant Substance used to kill or prevent the growth of Immune system the collection of organs, cells and molecules pathogenic microorganisms. Immunity Non-susceptibility to the invasive or pathogenic effects of foreign organisms or to the toxic effects of antigenic Efficacy Specific ability or capacity of a product to effect the substances. For a drench, it is often Immunisation (1) Administration of antigen in order to produce defined as the percentage of parasites killed by the product. Incubation period Interval between the time of infection and the onset of clinical signs or symptoms. Appendix 7: Glossary of terms Australian Veterinary Association 50 Guidelines for Veterinary Personal Biosecurity 2017. The aim is to decrease chemical usage and therefore decrease Risk In risk assessment, the likelihood that something will cause the chance of chemical resistance occurring. Lymphocytes are continuously Sterilant Chemical agent that kills or inactivates all made in the bone marrow and mature into antibody-forming microorganisms (including bacterial endospores) used to cells or T-cells.

Laboratory-acquired Salmonella typhimurium enteritis: association with erythema nodosum and reactive arthritis antibiotic zeniquin purchase ivermectin american express. Verocytotoxin-producing Escherichia coli in wild birds and rodents in close proximity to farms virus 48 horas 3mg ivermectin. Cholerae and other types of vibriosis: a story of human pandemics and oysters on the half shell antibiotics for dogs with gastroenteritis generic ivermectin 3 mg with visa. Doxycycline or ciprofoxacin prophylaxis and therapy against Yersinia pestis infection in mice antibiotic resistant strep purchase generic ivermectin from india. Occupational Infections Three groups are at greatest risk of laboratory-acquired infection: microbiologists antibiotics invented generic 3 mg ivermectin free shipping, veterinarians and pathologists bacterial nomenclature purchase ivermectin 3 mg line. Natural Modes of Infection the fungus has been reported from multiple geographically separated countries, but is best known as a fungus endemic to North America and in association with plant material in the environment. Outbreaks associated with the exposure of people to decaying wood have been reported. Parenteral (subcutaneous) inoculation of these materials may cause local skin infection and granulomas. Occupational Infections Laboratory-associated coccidioidomycosis is a documented hazard of working with sporulating cultures of Coccidioides spp. Smith reported that 28 of 31 (90%) laboratory-associated infections in his institution resulted in clinical disease, whereas more than half of infections acquired in nature were asymptomatic. Accidental percutaneous inoculation has typically resulted in local granuloma formation. The majority of ambient infections is subclinical and results in life-long protection from subsequent exposures. The incubation period is one to three weeks and manifests as a community-acquired pneumonia with immunologically mediated fatigue, skin rashes, and joint pain. A small proportion of infections is complicated by hematogenous dissemination from the lungs to other organs, most frequently skin, the skeleton, and the meninges. Laboratory Safety and Containment Recommendations Because of their size, the arthroconidia are conducive to ready dispersal in air and retention in the deep pulmonary spaces. The much larger size of the spherule considerably reduces the effectiveness of this form of the fungus as an airborne pathogen. Spherules of the fungus may be present in clinical specimens and animal tissues, and infectious arthroconidia in mold cultures and soil or other samples from natural sites. Inhalation of arthroconidia from environmental samples or cultures of the mold form is a serious laboratory hazard. Personnel should be aware that infected animal or human clinical specimens or tissues stored or shipped in such a manner as to promote germination of arthroconidia pose a theoretical laboratory hazard. Cryptococcus Neoformans Cryptococcus neoformans is a monomorphic fungal pathogen existing in nature, in laboratory cultures at room temperature and in vivo as a budding yeast. The sexual stage is grouped with the Basidiomycetes and is characterized by sparse 172 Biosafety in Microbiological and Biomedical Laboratories hyphal formation with basidiospores. Respiratory infections as a consequence of laboratory exposure have not been recorded. Natural Modes of Infection the fungus is distributed worldwide in the environment and is associated with pigeon feces. Infections are not transmissible from person-to-person, but require common exposure via the respiratory route to a point source. Laboratory Safety and Containment Recommendations Accidental parenteral inoculation of cultures or other infectious materials represents a potential hazard to laboratory personnel, particularly to those who may be immunocompromised. Bites by experimentally infected mice and manipulations of infectious environmental materials. Occupational Infections Laboratory-associated histoplasmosis is a documented hazard in facilities conducting diagnostic or investigative work. The small size of the infective conidia (less than 5 microns) is conducive to airborne dispersal and intrapulmonary retention. Work with experimental animals suggests that hyphal fragments are capable of serving as viable inocula. Histoplasmosis is naturally acquired by the inhalation of infectious particles, usually microconidia. Laboratory Safety and Containment Recommendations the infective stage of this dimorphic fungus (conidia) is present in sporulating mold form cultures and in soil from endemic areas. The yeast form in tissues or fuids from infected animals may produce local infection following parenteral inoculation or splash onto mucous membranes. Sporothrix schenckii Sporothrix schenckii is a dimorphic fungal pathogen existing in nature and in laboratory cultures at room temperature as a flamentous mold with asexual spores (conidia); these are the infectious particles that convert to small budding yeasts in the parasitic phase in vivo. Occupational Infections Most cases of sporotrichosis are reported sporadically following accidental inoculation with contaminated material. Large outbreaks have been documented in persons occupationally or recreationally exposed to soil or plant material containing the fungus. Natural Modes of Infection the fungus is distributed worldwide in the environment and is associated with sphagnum moss and gardening, often involving sphagnum moss and traumatic implantation. Infections are not transmissible from person-to-person, but require common exposure to a point source. Laboratory Safety and Containment Recommendations Although localized skin and eye infections have occurred in an occupational setting, no pulmonary infections have been reported as a result from laboratory exposure. It should be noted that serious disseminated infections have been reported in immunocompromised persons. Gloves should Agent Summary Statements: Fungal Agents 175 be worn during manipulation of S. Dermatophytes (Epidermophyton, Microsporum, and Trichophyton) the dermatophytes are biologically related species of the genera, Epidermophyton, Microsporum, and Trichophyton that exist as monomorphic pathogens in nature, in laboratory cultures at room temperature and in vivo as flamentous molds. These fungi are distributed worldwide, with particular species being endemic in particular regions. The species are grouped by natural environment habitat as being primarily associated with humans (anthrophilic), other animals (zoophilic), or soil (geophilic). Occupational Infections Although skin, hair, and nail infections by these molds are among the most prevalent of human infections, the processing of clinical material has not been associated with laboratory infections. Infections have been acquired through contacts with naturally or experimentally infected laboratory animals (mice, rabbits, guinea pigs, etc. Superfcial chronic infections occur frequently among immunocompromised individuals as well as elderly and diabetic persons. The dermatophytes cause infection (dermatophytosis) by invading the keratinized tissues of living animals and are among the most common infectious agents of humans. This fungal group encompasses members of three genera: Epidermophyton, Microsporum, and Trichophyton. The severity of infection depends on the infective species or strain, the anatomic site and other host factors. One of the most severe dermatophytoses is favus, a disfguring disease of the scalp caused by Trychophyton schoenleinii. In the clinical laboratory setting, the inappropriate handling of cultures is the most common source of infection for laboratory personnel. The most common laboratory procedure for detection of the infective dermatophyte is the direct microscopic examination of contaminated skin, hair, and nails, followed by its isolation and identifcation on appropriated culture media. Direct contact with contaminated skin, hair, and nails of humans could be another source of infection. Miscellaneous Molds Several molds have caused serious infection in immunocompetent hosts following presumed inhalation or accidental subcutaneous inoculation from environmental sources. These agents include the dimorphic mold, Penicillium marneffei, and the dematiaceous (brown-pigmented) molds, Bipolaris species, Cladophialophora bantiana, Exophiala (Wangiella) dermatitidis, Exserohilum species, Fonsecaea pedrosoi, Ochroconis gallopava (Dactylaria gallopava), Ramichloridium mackenziei (Ramichloridium obovoideum), Rhinocladiella atrovirens, and Scedosporium prolifcans. Laboratory Safety and Containment Recommendations Inhalation of conidia from sporulating mold cultures or accidental injection into the skin during infection of experimental animals are potential risks to laboratory personnel. A clinical report of a case of blastomycosis of the skin from accidental inoculation. Primary cutaneous (inoculation) blastomycosis: an occupational hazard to pathologists. Molecular and phenotypic description of Coccidioides posadasii sp nov, previously recognized as the non California population of Coccidioides immitis. An epidemic of coccidioidomycosis among archeology students in northern California. Primary cutaneous coccidioidomycosis: the criteria for diagnosis and a report of a case. Granuloma Coccidioides: report of a case responding favorably to antimony and potassium tartrate. Experimental murine cryptococcal infection results in contamination of bedding with Cryptococcus neoformans. Sporotrichosis: clinical and laboratory features and a serologic study in experimental animals and humans. Epidemiology, clinical manifestations, and therapy of infections caused by dematiaceous fungi. Microsporidia, historically considered parasites, are now recognized by most experts to be fungi; however, microsporidia are maintained in the parasitic agent section is this edition. These organisms are discussed here because a laboratory acquired case of infection has been reported,6 and most persons currently still look for microsporidia associated with discussion of parasitic agents. Blood and Tissue Protozoal Parasites Blood and tissue protozoal parasites that pose greatest occupational risk include Babesia, Leishmania, Plasmodium, Toxoplasma, and Trypanosoma. Other tissue protozoa of potential concern include free-living ameba (Acanthamoeba, Balamuthia mandrillaris, Naegleria fowleri) and some species of microsporidia including Encephalitozoon cuniculi that commonly cause extraintestinal infection. With the exception of Leishmania and Toxoplasma, these agents are classically thought of as bloodborne and have stages that circulate in the blood. Although not always recognized, both Leishmania and Toxoplasma may have stages that circulate in the blood. If clinically manifest, they may exhibit features similar to those seen in naturally acquired infections, although bypassing natural modes of infection could result in atypical signs and symptoms. Laboratory-acquired malaria infections may result in fever and chills, fatigue, and hemolytic anemia. Trypanosoma cruzi infection could manifest initially as swelling and redness at the inoculation site, fever, rash, and adenopathy. Blood and tissue protozoal infections associated with exposure to laboratory animals are not common. Potential direct sources of infection for laboratory personnel include accidental needle-stick while inoculating or bleeding animals, contact with lesion material from cutaneous leishmaniasis, and contact with blood of experimentally or naturally infected animals. In the case of rodents experimentally inoculated with Toxoplasma gondii via the intraperitoneal route, contact with peritoneal fuid could result in exposure to infectious organisms. Mosquito-transmitted malaria infections can occur under laboratory conditions as nearly half of the occupationally acquired malaria infections were reported to be vector borne, and contact with body fuids (including feces) of reduviids (triatomines) experimentally or naturally infected with T. Under natural conditions, Babesia is transmitted by the bite of an infected tick, or by blood transfusion; in the United States, hard ticks (Ixodes) are the principal vectors. Although no laboratory infections with Babesia have been Agent Summary Statements: Parasitic Agents 183 reported, they could easily result from accidental needle-stick or other cutaneous exposure of abraded skin to blood containing parasites. Persons who are asplenic, immunocompromised, or elderly have increased risk for severe illness if infected. Natural Modes of Infection Leishmaniasis is endemic in parts of the tropics, subtropics, and southern Europe, while malaria is widely distributed throughout the tropics. However, the prevalence of these diseases varies widely among endemic areas; the diseases can be very focal in nature. Only cats and other felines can serve as defnitive hosts for Toxoplasma gondii, which is distributed worldwide. Birds and mammals, including sheep, pigs, rodents, cattle, deer, and humans can be infected from ingestion of tissue cysts or fecal oocysts and subsequently develop tissue cysts throughout the body. Chagas disease occurs from Mexico southward throughout most of Central and South America, with the exception of the southern-most tip of South America. It has been characterized in some accounts as a zoonotic infection, yet the role of animals in maintaining human infection is unclear. African trypanosomiasis is endemic in sub-Saharan Africa but is extremely focal in its distribution. Leishmania, Plasmodium, and both American and African trypanosomes are all transmitted in nature by blood-sucking insects. Sandfies in the genera Phlebotomus and Lutzomyia transmit Leishmania; mosquitoes in the genus Anopheles transmit Plasmodium; reduviid (triatomine) bugs such as Triatoma, Rhodnius, and Panstrongylus transmit T. Depending on the parasite, the primary laboratory hazards are skin penetration through wounds or microabrasions, accidental parenteral inoculation, and transmission by arthropod vectors. Aerosol or droplet exposure of organisms to the mucous membranes of the eyes, nose, or mouth are potential hazards when working with cultures of 184 Biosafety in Microbiological and Biomedical Laboratories Leishmania, Toxoplasma gondii, or T. Because of the potential for grave consequences of toxoplasmosis in the developing fetus, women who are or might become pregnant and who are at risk for infection with T. Working with infectious oocysts poses the greatest risk of acquiring infection; needle-sticks with material containing tachyzoites or bradyzoites also pose a signifcant risk. Infection with tachyzoites or bradyzoites through mucous membranes or skin abrasions is also possible.

Pneum othorax In case of suddenly occurring pain and dyspnea antimicrobial humidifier buy cheap ivermectin 3 mg, pneumothorax should be considered antibiotics for uti keflex buy discount ivermectin on line, especially in patients with bronchial asthma and emphysema infection you catch in hospital purchase ivermectin visa. W orsening of dyspnea and pain is indicative of tension pneumothorax; in this case antibiotics kill probiotics buy generic ivermectin 3 mg line, emergency pleural puncture is indicated treatment for viral uti discount 3mg ivermectin amex. In case of suspected pneumothorax antibiotic for sinus infection and sore throat discount ivermectin 3mg with mastercard, pulmonology referral is indicated and emergency medical care should be provided. Pulm onary conditions Pleurodynia (pleurisy), caused by inflammation of pleura, often accompanies viral or bacterial res piratory infections. It may also occur in collagen 24 Clinical Practice Guidelines for General Practitioners Chest Pain vascular disorders. History suggesting pleurodynia includes acute onset of sharp pain associated with breathing or movement, sometimes accompanied by systemic symptoms of infection. A chest X-Ray should be obtained to exclude pneumonia, pleural effusion, or other intrathoracic processes. G astrointestinal conditions Reflux esophagitis is characterized by burning ret rosternal or epigastric pain radiating to the lower jaw. Pain occurs or worsens in recumbent position and front bend, especially after a meal; sleep is often disturbed. Post-prandial chest discomfort, especially if associated with radiation to the back or abdomen and accompanied by nausea, is suggestive of gallbladder disease. In case of suspected esophageal disease, gastroenterolo gy referral is indicated. Spinal diseases Chest pain is frequently caused by osteochondro sis (including hernias of intervertebral discs, espe cially those of cervical spine) and osteoarthrosis of cervical and thoracic spine. Pain in spinal disease Clinical Practice Guidelines for General Practitioners 25 Chest Pain is described as dull and gnawing, may be located in any area of the chest, including sternal area, and worsens during strain, movements and deep breathing. In case of suspected spinal disease, patient should be referred to neurologist and other specialists, as necessary. Psychogenic pain Psychogenic pain is typically located in the cardiac area and usually does not radiate. Chest pain caused by anxiety or emotional stress most commonly occurs in healthy young men or women, but it can occur at any age. In case of suspected psychogenic pain, patient should be referred to neurologist or psychiatrist, as necessary. Chest pain in the elderly In elderly people, chest pain is primarily caused by cardiovascular disease. In elderly patients complaining of chest pain, angina pectoris and myocardial infarction should be considered first. Pain may be also caused by 26 Clinical Practice Guidelines for General Practitioners Chest Pain herpes zoster, fractured ribs, pleurisy, malignant neoplasm, pulmonary thromboembolism, reflux esophagitis, etc. Chest pain in disorders of m uscles, bones and joints Patient history and physical examination usually provide sufficient information for identifying dis orders of muscles, bones, and joints. M uscular chest pain is the most frequent diagnosis in active young men and women (25-65 years old). The pain is the result of overuse of chest wall mus cles and a resulting strain within a muscle body or at its insertion site. The characteristic physical examination finding is tenderness to palpation of the chest wall muscles. In many cases, palpation of the affected muscle reproduces the chest pain expe rienced by the patient. When this occurs, the diag 28 Clinical Practice Guidelines for General Practitioners Chest Pain nosis is clear and no additional testing is necessary. Pain may be either sharp and sudden or pro longed and gnawing; it may be worsened by deep breathing, coughing, or sneezing. In very severe pain, injections of local anesthetics and corticosteroids into the affected area are indicated. Injections into the chest wall should be done with extreme caution to avoid injuring parietal pleura. Special elastic bandage proved to be effective (it relieves pain significantly without hampering respiration). Costochondral inflam m ation Costochondral inflammation is characterized by jabbing, unilateral, mild to moderate pain radiat ing to the back and abdomen and worsened by deep breathing and physical exertion; pain is influenced by change of posture. Costochondral inflammation occurs as a result of acute viral respiratory infection or physical overexertion and lasts up to several months. Costochondral inflammation is most often diagnosed in women (25-44 years old) the pain is thought to be due to inflammation of the 3rd or 4th left costochondral junction. Suggestive Clinical Practice Guidelines for General Practitioners 29 Chest Pain history includes pain with use of chest wall muscles. In addition, the pain may occur at rest or with deep inspiration, and there is usually no history of recent trauma or muscular exertion. The characteristic physical finding is tenderness to palpation over a costochondral junction. If the patient has tried them, anti-inflammatory agents have often provided relief. Back pain Back pain is usually caused by spinal disease; osteoarthrosis affecting costovertebral articula tions is among the most common causes. These joints may be affected, particularly during ster notomy with wound edges spread wide apart. Acute back pain is a rare occurrence and may be caused by spinal fracture or severe vascular or visceral disease. Other causes include intervertebral disc hernias and penetrating gastric or duodenal ulcer. Treatment: if no osteoporosis and acute inflamma tion are present and if the patient is not receiving anticoagulants, chiropractic may be administered. Chest Pain in Children Although chest pain is a common occurrence in teenagers, it rarely indicates severe disease. In a number of cases, pain cause remains unknown, because it is mostly psychogenic in nature. Other causes of pain include: disorders of chest wall muscles, bones and joints; hyperventilation syndrome, bronchial asthma; pain caused by bad cough; chest, back and upper arm traumatism occurring during games or sports. In children, lung disease (pneumonia, bronchial asthma, recurrent bronchitis) and heart disease should be ruled out. Pain caused by myocardial ischemia should be dif ferentiated from squeezing pain in the chest and left hypochondrium caused by contraction of splenic capsule (it is a common occurrence, espe cially in unexercised children after a long-distance race). Patient has history of hypertension over the last 10 years (varying within a range of 140/80 to 150/90 mmHg). Physical examination reveals the following: No breathing movement on the left side of the chest. Auscultation: absence of breath sounds in the upper left third of the chest; accentuated res piration on the left side. Percussion: bandbox reso nance over the upper left third of the chest; vesic ular resonance over the left side. Based on the above findings, provisional diagnosis of spontaneous pneumothorax was made. Patient was injected an analgesic and hospitalized in the department of thoracic surgery, where the provision al diagnosis was confirmed. Aside from increase in severity, the pain became constant with time and was influenced by breathing, movements and change of body position in bed. She had myocardial infarction 7 years ago, followed by 2-3 transient angina episodes. Physical examination reveals the following: Breathing movements appear to be symmetrical. Palpation reveals tenderness in 4th-5th intercostal spaces and along the scapular line. Lungs: vesicular respiration on auscultation, vesic ular resonance on percussion. Clinical Practice Guidelines for General Practitioners 35 Chest Pain Abdomen is soft and painless on palpation. He notes that similar pain associated with physical exertion and emotional stress has occurred peri odically (but not frequently) over the last 8 years. Current episode of pain was related to the fact that this day the elevator was out of order and the patient had to climb the stairs to the 8th floor. When he reached the 5th floor, he suddenly felt acute pain in sternal area, which was stinging and squeezing in nature and radiated to the left fore arm. However, the pain worsened again and did not respond to repeated nitroglycerin doses. Physical examination reveals the following: Breathing movements appear to be symmetrical (respiration rate 18 breaths per minute). Differential diagnosis was performed considering exertional angina, progressive unstable angina, and acute myocardial infarction. The patient was suggested Clinical Practice Guidelines for General Practitioners 37 Chest Pain to have his district therapeutist attend him after discharge. Had the district therapeutist administered early maintenance treatment and educated the patient on specific topics of his disease, this episode would have been avoided. Pain is constant, limited to the above-mentioned area, and not influenced by breathing (deep inspiration is trou blesome). He has history of periodic episodes of pain (every 2-3 months) with fever over the last 7 8 years. Physical examination reveals the following: Breathing movements appear to be symmetrical, but shallow; abdominal participation is seen. Pain was accompanied by anxi ety, nausea, vomiting, and diaphoresis (clammy sweat). Patient has history of chronic gastritis (over last 6-7 years); however, because the disease caused little or no discomfort, he has never been tested and treated. Before calling his physician, the patient took an analgesic (sedalgine) and nitroglycerin, which gave no relief. Physical examination reveals the following: Clinical Practice Guidelines for General Practitioners 39 Chest Pain Patient is restless; skin and visible mucosa are pale; clammy sweat is observed. She notes that during the last 3 days her right calf muscles grew swollen and became painful. He has no history of such a pain, and before this episode had believed himself to be in good health. Physical examination reveals the following: Patient is anxious, with pale skin and clammy sweat. Clinical Practice Guidelines for General Practitioners 41 Chest Pain Abdomen is soft and painless on palpation. Abdomen is 42 Clinical Practice Guidelines for General Practitioners Chest Pain soft and painless on palpation; hepatomegaly is identified. Breathing movements appear to be symmetrical; vesicular respiration is heard on auscultation. Cardiovascular system: Heart is not enlarged on percussion; apex beat is hyperdynamic. In the left intercostal space near the sternal edge, a scratch ing systolic murmur is heard, being accompanied by thrill. Care (symptomatic treatment) is provided; patient is hospitalized in cardiology department. Clearly, negligence of primary health care physician resulted in late diagnosis and complications. Education of patients and their families Education of patients and their families is aimed to provide them with easy-to-understand infor mation to ensure that they have adequate knowl edge to be able to prevent diseases that may cause chest pain. Specialty referral: Primary health care physicians should refer their patients to cardiologists, neurologists, surgeons, and endocrinologists, as outlined in this clinical practice guideline. Assessment of the Impact of the Application of Clinical Practice Guideline (pre and post-testing examples) 10. All of the following are incorporated into the concept of unstable angina except: a) exertional angina of recent occurrence (usually within last 4-8 weeks) b) progressive angina c) resting angina d) chronic stable angina 2. All of the pharmaceuticals listed below are effective in treating unstable angina and M I except: a) aspirin b) nitroglycerin c) heparin d) calcium channel blockers e) -blockers 3.

Clinical trial: efect of controlled trial of the efect of bifdobacteria-fermented milk on ulcerative colitis virus killing children order generic ivermectin. Lactobacillus acidophilus modu this with the probiotic Escherichia coli Nissle 1917 is as efective as with standard lates intestinal pain and induces opioid and cannabinoid receptors bacteria science fair projects buy discount ivermectin 3mg. Specifc probiotic therapy attenu assessing the efect of bifdobacteria-fermented milk on active ulcerative colitis virus like ebola purchase 3 mg ivermectin amex. A pilot trial of Saccharomyces boulardii in on visceral pain induced by colorectal distension in Sprague-Dawley rats antibiotic augmentin buy ivermectin 3mg otc. The D-alanine content of lipote Durable alteration of the colonic microbiota by the administration of donor fecal choic acid is crucial for Lactobacillus plantarum-mediated protection from visceral fora antibiotic resistance in hospitals purchase ivermectin 3mg fast delivery. The efcacy of probiotics in the ther irritable bowel syndrome without constipation antimicrobial wood sealer buy ivermectin 3mg cheap. Drouault-Holowacz S, Bieuvelet S, Burckel A, Cazaubiel M, Dray X, Marteau tor that regulates fat storage. The role of the gut microbiota in nonalcoholic An obesity-associated gut microbiome with increased capacity for energy harvest. Microbial ecology: human gut growth in nonalcoholic steatohepatitis: association with toll-like receptor 4 expres microbes associated with obesity. However, there is a lack of evidence-based guidelines to assist in planning the management of affected pregnancies. The purpose of this Good Practice guidance is to provide a summary of current expert opinion as an interim measure, with the hope that these opinions will be supplemented by objective evidence in due course. One-third of these deaths are a result of myocardial infarction/ischaemic heart disease and a similar number of late deaths are associated with peripartum cardiomyopathy. With the current increase in older mothers, obesity, immigration and survival of babies operated on for congenital heart disease, the need to identify women at risk of heart disease and to plan their careful management will also inevitably increase. Unfortunately, many of these risk factors are becoming increasingly common, and most women affected will be asymptomatic before pregnancy, with no history of heart disease. The key component of good management is therefore a high index of suspicion for myocardial infarction in any pregnant woman presenting with chest pain. All women with chest pain in pregnancy should have an electrocardiogram interpreted by someone who is skilled at detecting signs of cardiac ischaemia and infarction and, if the pain is severe, they should have computerd tomography or a magnetic resonance imaging scan of the chest. It usually presents in late pregnancy or early in the puerperium, but it can occur up to 6 months after delivery. Peripartum cardiomyopathy should be considered in any pregnant or puerperal woman who complains of increasing shortness of breath, especially on lying flat or at night. As 25% of affected women will be hypertensive, it can be confused with pre-eclampsia. All such women should have an electrocardiogram, a chest X-ray and an echocardiogram. Many of these women will never have undergone medical screening and some will be unaware that they have valvular heart disease. This highlights the need for a particularly careful cardiovascular assessment at the beginning of pregnancy of all women not born in a country where there is effective medical screening in childhood, including auscultation of the heart. Mitral valve stenosis (the most common lesion and the one that carries the highest risk) is a difficult clinical diagnosis and there should be a low threshold for echocardiography. Aortic dissection (diagnosed by computed tomography scan) is the most common serious complication of Marfan syndrome. Congenital heart disease is one of the most common congenital abnormalities and the majority of those affected will survive to adulthood, in large part because of the development of effective corrective/palliative surgery over the last 30 years. Preconception counselling should also be offered to older women with a new diagnosis. Because pregnancy carries substantially increased risks for women with congenital heart disease, particular efforts should be made to prevent unwanted pregnancy. Appendix A describes appropriate types of contraception for women with the different types of congenital lesion. Women should be given an outline of the issues relating to pregnancy with congenital heart disease at the first visit to the joint clinic, and then be reviewed with more detailed information once they are considering conception. Topics that should be covered at this detailed review include the increased risk of mortality, congenital heart disease in the offspring and the need for increased medical surveillance during pregnancy. A sample patient information leaflet on congenital heart disease and pregnancy is available in Appendix B. Appendix D describes the typical patient journey of a pregnant woman with heart disease. Women at significant risk of adverse events during pregnancy should be seen regularly in the antenatal clinic, whenever possible by the same consultant obstetrician, who should have appropriate competencies in this field. Blood pressure should be measured manually with a sphygmomanometer according to the recommendations of the British Hypertension Society. Measurement of pulse rate and rhythm is also mandatory as it may Good Practice No. Auscultation to assess any change in murmur or any lung changes associated with pulmonary oedema is recommended in all cases of significant cardiac compromise (which will have been identified early in pregnancy at the joint clinic). Women with cyanotic heart disease should have their oxygen saturations checked periodically (each trimester or more often if there are any clinical signs of deterioration). A template for adapting normal antenatal records for use in women with heart disease is available in Appendix E. All women with structural congenital heart disease should be offered a fetal echocardiogram during the second trimester to be carried out by an accredited paediatric/fetal cardiologist (as distinct from the standard four-chamber view offered to all women as part of routine antenatal screening and carried out by accredited ultrasonographers and fetal medicine specialists). Important features of such a plan include deciding who should be involved in supervising the labour, whether a caesarean section is appropriate, whether bearing down is advisable in the second stage and appropriate prophylaxis against postpartum haemorrhage (routinely used oxytocic regimes can have major cardiovascular adverse effects; a low-dose syntocinon infusion is probably the safest option, and at caesarean section prophylactic uterine compression sutures can be considered instead of oxytocics). The plan should also include postpartum management, including whether prophylaxis against thrombosis is appropriate, the length of postpartum stay in hospital and the timing of cardiac and obstetric review. In most cases this will be achieved by the use of early slow incremental epidural anaesthesia and assisted vaginal delivery. The decision about the optimum place for antenatal and intrapartum care should be made in conjunction with obstetricians and cardiologists at tertiary units known to specialise in the management of women with heart disease in pregnancy. Appropriate tertiary units will have high-dependency and intensive care units suitable for the care of pregnant women with significant heart disease. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. The Sixth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. Maternal congenital cardiac disease: outcomes of pregnancy in a single tertiary care center. Dr L Freeman, Consultant Cardiologist, Norfolk and Norwich University Hospital: Trustee of Grown Up Congenital Heart Patients Association and Marfan Patient Association. By planning ahead you will avoid having to deal with the crisis of an unexpected pregnancy. The first question to answer when considering what contraceptive to use is: what are the risks for me if I become pregnant Some women will be very high risk and therefore will need contraception that is very effective at preventing an accidental pregnancy. Women at lower risk may be willing to accept a contraceptive method with a higher failure rate. However, to be sure that you choose the right method, it is vital that you discuss your individual case with a heart/pregnancy specialist. Natural methods There are a variety of techniques that use our understanding of what time in the cycle conception occurs to try and prevent pregnancy. These methods are not very reliable and depend very much on how carefully they are used. Barrier methods (condoms, diaphragm) Like natural methods, barrier contraception has few adverse effects but again has a high failure (pregnancy) rate even when used with spermicidal creams. However, condoms have the additional benefit of protecting against sexually transmitted diseases. The Mirena coil has the advantage of causing less bleeding (periods often stop entirely) and less infection than copper coils, and can therefore be used more safely in women who have never had children (whose wombs are more at risk of infection). About one in 1000 women have a fainting reaction at the time the coil is inserted. This can be dangerous for women with severe heart disease if there is no expert help available. So, if a coil is to be used, it should be inserted in hospital, with cardiac anaesthetic expertise on standby in case of this rare complication (an actual anaesthetic is not usually necessary). A rare complication of all coils is pregnancy in the fallopian tube (ectopic pregnancy), which usually have to be removed surgically. However, the risk of pregnancy is extremely low with the Mirena coil (even lower than after sterilisation). Oral contraceptive pills There are two main types of oral contraceptive pills: those with both estrogen and progestogen hormones (the combined pill) and those with only a low dose of progestogen (the low-dose or mini pill). The combined pill is probably the most effective, with failure rates of less than one in 300 women per year if taken correctly. This risk (for the average woman) is still only about half that of dying from being pregnant. Certain heart conditions are associated with an increased risk of clotting and therefore you may be told that this form of contraception is not suitable for you. There is also a longer window of time for the woman to remember to take her pill, so the occasional missed pill is less likely to result in pregnancy. Cerazette is related to the drug in Implanon and can be used as a test before the implant is inserted. Progestogen-only injectable (depot) injections of hormone (Depo-Provera) these are intramuscular injections of progestogen which last for 12 weeks. Periods will often disappear, although they may be irregular or heavy for a while when you decide to stop the injections. Implant of progestogen (or Nexplanon) this is a small implant which is inserted under the skin in the upper arm by a doctor or nurse. Implanon is one of the safest and most effective forms of contraception available. Nexplanon has replaced Implanon, which was sometimes difficult to insert correctly. Caution: the drug bosentan, sometimes used for heart disease, can reduce the effectiveness of most hormonal contraception, including Cerazette and Nexplanon, so additional contraception should be used if you need to take bosentan. A mini-laparotomy (proper scar rather than a keyhole incision) under a regional anaesthetic (not asleep) may be safer for some women with heart problems (laparoscopy involves putting gas at high pressure into the abdomen so that the womb and tubes can be visualised, and this can affect the heart). The risk of getting pregnant once the clips have been applied is only about one in 500 (pregnancy can occur if the clip does not close the tube). The tubes can be cut and tied at caesarean section, but then the risk of the tubes joining up again is greater, about one in 200. A technique that has recently become available involves putting tiny implants into the fallopian tubes to block them. This is done via a hysteroscope (a small telescopic microscope which is passed through the vagina and cervix to look inside the womb). This can be done under local anaesthetic or intravenous sedation, although it should always be done in a centre fully equipped to deal with women with heart problems. Essure is not yet widely available, so your doctor should advise you where it can be done. Emergency contraception can be used up to five days after unprotected sex, a burst condom or missed pills. It can sometimes be used later than five days after sex, if it is likely to be no more than five days since you released an egg (ovulated). One contains progestogen hormone (levonorgestrel) and is available to buy or sometimes free of charge from pharmacies (Levonelle). It is not advisable if you have a rare condition called porphyria (nothing to do with heart disease). You can buy this pill from the pharmacist without a prescription (cost in 2009: 22); it is one tablet which you take as soon as possible. The other pill is a drug called ulipristal acetate (ellaOne), which can be used up to five days (120 hours) after sex and is available on prescription from your local doctor or sexual health clinic. The adverse effects of emergency oral contraceptive pills are mild (nausea, breast tenderness, disruption to periods) and there are no long-term effects. Other sources of information Family planning clinics and family doctors Grown Up Congenital Heart Patients Association:

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