Tirbod Fattahi, DMD, MD, FACS

• Associate Professor and Chief, Division of Oral and
• Maxillofacial Surgery
• University of Florida Health Science Center
• Jacksonville, Florida

Media violence exposure and executive functioning in aggressive and control adolescents klebsiella antibiotic resistance mechanism order tinidazole in india. Temperament and parenting during the first year of life predict future child conduct problems virus 88 order tinidazole 500 mg on-line. Journal of the American Academy of Child and Adolescent Psychiatry 2000; 39(12) vyrus 987 c3 2v buy tinidazole 300mg amex, 1468-1484 bacteria 1 in urinalysis order 300mg tinidazole with mastercard. Journal of Clinical Child and Adolescent Psychology: the Official Journal for the Society of Clinical Child and Adolescent Psychology antibiotic resistance of pseudomonas aeruginosa cheap 500mg tinidazole fast delivery, American Psychological Association infection lyrics buy tinidazole 500 mg free shipping, Division 2005; 53, 34(3), 477-505. Treatment of behavior problems in preschoolers: A review of parent training programs. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child and Adolescent Psychiatry 2007; 46(1), 126-141. Note: Form used in this chapter are: Dime-2-Section A, General Medical Questionnaire; Section B, Mental/Emotional; Section C, Neurological; Section D, Endocrine; Section E, Alcohol/Drugs; Section F, Cardiovascular; Section G, Physicians Recommendations. The words and phrases defined herein have the same meaning in this chapter unless a different definition is specifically provided. In this chapter: (a) Altered consciousness means a state of awareness characterized by loss or distortion of the impressions made by the senses or inability to respond to the impressions made by the senses. The department shall review the medical information using the standards specified in this chapter. A license issued to a person under this chapter may be restricted on the basis of a recommendation of a physician, a vision specialist, a review board, or on the results of a driving examination or evaluation. The review boards when making recommendations, and the department when taking licensing action, may consider the following information: (1) Any medical condition affecting the person including, but not limited to: (a) History of illness. There are no current symptoms of coronary artery disease, such as unstable angina, dyspnea, or pain at rest, which interfere with safe driving, as assessed by a physician or determined through a driving evaluation. There is no cause of cardiac syncope present, including ventricular tachvcardia or fibrillation, which is not successfully controlled. There is not congestive heart failure that limits functional ability and is assessed by a physician as interfering with safe driving. There is no automatic implantable cardioverter defibrillator, unless the device is assessed by and electrophysiologist as not interfering with safe driving. There is no valvular heart disease or malfunction of prosthetic valves that is assessed by a physician as interfering with safe driving. There is no impairment of reasoning or judgment preventing safe operation of a vehicle, as assessed by a physician. No license may be issued to , renewed by, or held by a person who does not meet the applicable medical review standards for conditions affecting endocrine functions of this subsection. There is no diabetic neuropathy or other complication with interferes with safe driving, as assessed by a physician or determined through a driving evaluation. No license may be issued to , renewed by, or held by a person who does not meet the applicable medical review standards for conditions affecting musculoskeletal function of this subsection. Extent to which loss of muscle tone, movement, or spasm affects functional ability. No license may be issued to , renewed by, or held by a person who does not meet the medical review standards for conditions affecting neurological or neuromuscular function of this subsection. There has been no episode of altered consciousness or loss of bodily control caused by a neurological condition within the 6 months preceding application. The person adequately compensates for any paralysis or sensory deficit when operating a vehicle. Fatigue, weakness, muscle spasm or tremor at rest does not impair safe driving, as assessed by a physician or determined through a driving evaluation. There are no effects or side effects of medication that interferes with safe driving. No license may be issued to , renewed by, or held by a person who fails to meet the medical review standards for peripheral-vascular function of this subsection. The person compensates adequately for any limitations in mobility or circulation in operating a motor vehicle. There is no fatigue, weakness, muscle spasm or tremor at rest sufficient to impair safe driving, as assessed by a physician or determined through a driving evaluation. No license may be issued to , renewed by, or held by a person who does not meet the medical review standards for conditions affecting psychosocial, mental and emotional function of this subsection. There is no behavior disorder with threatening or assaultive behavior at the time of application. Any delusional system does not interfere with safe driving, as assessed by a physician. There is no impairment of judgment that interferes with safe driving as assessed by a physician. There is no active psychosis that interferes with safe driving, as assessed by a physician. There are no effects or side effects of medication that interfere with safe driving. No license may be issued to , renewed by, or held by a person who does not meet the medical review standards for conditions affecting respiratory function of this subsection. There is no dyspnea that interferes with safe driving, as assessed by a physician or determined through a driving evaluation. No license may be issued to , renewed by, or held by a person who does not meet the medical review Supp. A person needing corrective lenses to meet the standards in his section shall be restricted to use of those lenses while driving. No person may use a bioptic telescopic or similar lens in order to meet the visual acuity standards in this subsection. Visual acuity of at least 20/60 or better in at least one eye, as assessed by a vision specialist. The department shall refer a person for examination by a vision specialist as specified in subds. If a person has uncorrected visual acuity of less than 20/40 in each eye, but at least 20/50 in one eye, the department shall refer the person to a vision specialist for examination and an advisory recommendation. The person shall complete a driving evaluation if recommended by the vision specialist. If a person has horizontal, temporal field of vision of less than 110 degrees from center, the person shall be referred to a vision specialist for an examination and an advisory recommendation. The department may require a person who has a progressive, recurring or debilitating condition to submit to follow-up examinations and reports by a physician or vision specialist as a condition of licensure. If a physician or vision specialist recommends that the person complete a test of driving ability, the driving evaluation or examination shall be in a vehicle representative of the highest licensing classification the person holds or for which the person is applying. In its present form, the driver license evaluation and testing process is not sufficient to adequately evaluate a person who requires a bioptic lens to enhance central visual acuity. These applicants will require a certifying exam by an ophthalmologist or optometrist, basic bioptic training, a thorough pretest evaluation to determine if any other cognitive impairment or physical disabilities exist, and then a rigorous road test evaluation. The following is an outline of the criteria pertinent to the licensing of drivers who require bioptic assistance for improvement of visual acuity. Much of what follows has been adopted from other states as well as the current published research. A bioptic will artificially limit the superior extent of the vertical visual field. This training must be performed by a qualified professional skilled in the use of bioptic lenses. Preliminary training will occur in the clinic on basic techniques prior to on-road teaching. Training may not be necessary unless the evaluation reveals skills are substandard, at which time the full training program will be required. These individuals may qualify using their previous out of state license for up to 30 days. The carrier is used for scanning and the telescope located near the top of the carrier lens is used for spotting. A trioptic has the above carrier and telescope lens components with the addition of bifocal added in the lower portion of the lens for focusing at near. Successful training of an individual in the proper use of bioptics requires the user to demonstrate an understanding to the basic tenant that the telescopic portion of the lens is used for periodic, brief spotting and the carrier portion for all other visual tasks. Bioptic training should be progressive, working from easier tasks to more difficult tasks. The user should demonstrate their skills while stationary and while moving as happens when traveling by automobile. Demonstrate good walking mobility while looking through the carrier portion of the lens. Demonstrate the ability to spot through the telescope by aligning it with the target and spotting through it. Demonstrate the ability to return gaze from the telescope to the carrier lens in a smooth and efficient fashion. Demonstrate good horizontal and vertical scanning techniques through the carrier lens. Advanced target practice scan with the carrier lens, spot and identify targets with the telescope. Scan, spot and identify the characteristics of stationary targets of varying size and distance from a stationary position. Practice should incorporate stationary targets associated with driving including traffic signals, street signs, highway markers, etc. Scan, spot, identify and track moving targets of varying size and distance from a stationary position. Practice should incorporate moving targets associated with driving including automobiles, bicycles, motorcycles, pedestrians, etc. Scan, spot and identify stationary targets of varying size and distance while moving (as a passenger in a car, bus or other vehicle, for example. Scan, spot and track moving targets of varying size and distance while moving as a passenger in a car, bus or other vehicle. The difference between monomania and passion can be very subtle and difficult to recognize. Only one diagnosis, Adjustment Reaction of Childhood/Adolescence, could be applied to children.

Increasingly implicated as a significant cause of morbidity and mortality among hospitalized patients antibiotics for uti and acne best order tinidazole, C difficile colitis should also be recognized 56 P a g e among outpatient populations virus blocking internet purchase tinidazole from india. Prior antibiotic exposure remains the most significant risk factor for development of disease bacteria acne discount tinidazole 1000 mg on line. Diagnosis Diarrhea and abdominal cramps occurs during first week antibiotic video purchase tinidazole 500mg with visa, but can be delayed up to six weeks Nausea virus 2014 respiratory virus purchase discount tinidazole online, fever antibiotic coverage order tinidazole 1000 mg on-line, dehydration can accompany severe colitis Abdominal examination may reveal distension and tenderness. Note Stool examination is sensitive on anaerobic culture facilities which reveals toxigenic and non toxigenic strains Enzyme immunoassays are available for toxins A and B in stool Sigmoidoscopy is highly specific if lesion is seen but insensitive compared to the above. Diagnosis Abdominal discomfort of at least 3 months duration Bloating or feeling of distension Altered bowel habits (constipation and/or diarrhea) Exacerbations triggered by life events. Diagnostic Considerations Hematology and biochemistry studies Stool microscopy Colonoscopy with biopsy 57 P a g e Treatment Refer patients to specialized centers for proper evaluation and management. Although presenting symptoms, such as diarrhea and weight loss may be common, the specific causes of malabsorption are usually established based on physiologic evaluations. The treatment often depends on the establishment of a definitive etiology for malabsorption. Etiologic examples include pancreatic insufficiency, bacterial overgrowth, celiac disease, tropical sprue, lactase deficiency, diabetic enteropathy, thyroid disease, radiation enteritis, gastrectomy and extensive small bowel resection. Diagnosis Depending on etiology, presentation may collectively include: Diarrhoea a commonest symptom which is frequently watery Steatorrhea due to fat malabsorption; characterized, by the passage of pale, bulky, and malodorous stools. Vitamin malabsorption can cause generalized motor weakness (pantothenic acid, vitamin D) or peripheral neuropathy (thiamine), a sense of loss for vibration and position (cobalamin), night blindness (vitamin A), and seizures (biotin). Treatment Patients should be referred to specialized centers for proper evaluation and definitive management Two basic principles underlie the management of patients with malabsorption, as follows: o the correction of nutritional deficiencies o When possible, the treatment of causative diseases Nutritional support o Supplementing various minerals, such as calcium, magnesium, iron, and vitamins, which may be deficient in malabsorption, is important o Caloric and protein replacement also is essential o Medium-chain triglycerides can be used as fat substitutes because they do not require micelle formation for absorption and their route of transport is portal rather than lymphatic o In severe intestinal disease, such as massive resection and extensive regional enteritis, parenteral nutrition may become necessary. It may present as acute pancreatitis, in which the pancreas can sometimes heal without any impairment of function or any morphologic changes, or as chronic pancreatitis, in which individuals suffer recurrent, intermittent attacks that contribute to the functional and morphologic loss of the gland. Common risk factors which trigger the acute episode are presence of gallstones and alcohol intake. Diagnosis Severe, unremitting epigastric pain, radiating to the back Nausea and vomiting 59 P a g e Signs of shock may be present Ileus is also common Local complications: inflammatory mass, obstructive jaundice, gastric outlet obstruction Systemic complication: sepsis, acute respiratory distress syndrome, acute renal failure Diagnostic considerations Serum amylase, in counts over 1000U/L, but poor correlates with disease severity. Treatment Prompt referral to specialized centers with intensive care facilities is recommended Principles of management include expertise supportive therapy: o Nil per oral regimen for few days up to weeks is indicated depending on severity. The most common cause for such a condition is long-term excessive alcohol consumption. Diagnosis the most common symptom is upper abdominal pain that may be accompanied by nausea, vomiting and loss of appetite As the disease gets worse and more of the pancreas is destroyed, pain may actually become less severe During an attack, the pain often is made worse by drinking alcohol or eating a large meal high in fats. This can lead to weight loss, vitamin deficiencies, diarrhea and greasy, foul smelling stools. Once digestive problems are treated, patient will usually gain back weight and diarrhea improves. Another way is by giving the patient pancreatic supplements containing digestive enzymes. Acute peritonitis is most often infectious usually related to a perforated viscus (secondary peritonitis); primary or spontaneous peritonitis refers to when no intraabdominal source is identified. Acute peritonitis is associated with decreased intestinal motility, resulting in distention of the intestinal lumen with gas and fluid. The accumulation of fluid in the bowel together with the lack of oral intake leads to rapid intravascular depletion with effects on cardiac, renal, and other systems. Diagnosis Acute peritonitis is usually characterized by acute abdominal pain and tenderness, dehydration, fever, hypotension, nausea and vomiting and tachycardia. Bacterial translocation, bacteraemia and impaired antimicrobial activity contribute to its development. Antimicrobial therapy is adjunctive to surgical correction of underlying lesion or process and treatment will depend on causative agent. Referral Patient needs referral to centers where surgical intervention is adequate. Contributory factors may include inactivity, low fiber diet and inadequate water intake. Diagnosis Fewer than three bowel movements per week, small, hard, dry stools that is difficult or painful to pass, need to strain excessively to have a bowel movement, frequent use of enemas, laxatives or suppositories are characteristic. Referral the following signs and symptoms, if present, are grounds for urgent evaluation or referral: Rectal bleeding Abdominal pain Inability to pass flatus Vomiting Unexplained weight loss. Diagnostic guides: An extensive work up of the constipated patient is performed on an outpatient basis and usually occurs after approximately 3-6 months of failed medical management. Imaging studies are used to rule out acute processes that may be causing colonic ileus or to evaluate causes of chronic constipation. In the acute situation with a patient at low risk who usually is not constipated, no further evaluation is necessary. Consider sigmoidoscopy, colonoscopy, or barium enema for colorectal cancer screening in patients older than 50 years. The internal hemorrhoids are graded into four groups: Bleeding with defecation Prolapses with defecation but return naturally to their normal position Prolapses any time especially with defecation and can be replaced manually Permanently prolapsed. Diagnosis the most common presentation of hemorrhoids is rectal bleeding, pain, pruritus, or prolapse. However, these symptoms are nonspecific and may be seen in a number of anorectal diseases. A thorough history is needed to help narrow the differential diagnosis and adequate physical examination to confirm the diagnosis. V internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation External hemorrhoid symptoms are generally divided into problems with acute thrombosis and hygiene/skin tag complaints. The former respond well to office excision (not enucleation), while operative resection is reserved for the latter. Drugs of choice Steroids and local anesthetics aims to reduce inflammation and provide relief during painful defication. Diagnosis the hall mark is severe sharp pain during and after defecation with/out bright red bleeding. Diagnostic consideration Perform digital rectal examination or protoscopy, which must be done with topical anesthesia. Treatment Guide Stools must be made soft and easy to pass; ensure high fluid intake, use osmotic laxatives such as Lactulose 20 mls 12 hrly (O) Topical anesthetics (Lidocaine jelly 2% applied 12 to 8 hrly anal area with frequent seat baths reduces sphincter spasm. At worst, anal itching causes intolerable discomfort that often is accompanied by burning and soreness. Causes include: Benign anorectal condition such as hemorrhoids or anal fissure Neoplasia such as anal cancer, pagets disease Dermatological disease. Hepatitis may occur with limited or no symptoms, but often leads to jaundice, anorexia and malaise. Hepatitis is acute when it lasts less than six months and chronic when it persists longer. A group of hepatotropic viruses cause most cases of hepatitis worldwide, but it can also be due to other viral infections. Diagnosis Acute infection with a hepatitis virus may result in conditions ranging from subclinical disease to self-limited symptomatic disease to fulminant hepatic failure. Collectively patients may develop fever, anorexia, malaise, jaundice, abdominal pain after specific incubation periods; and in severe forms signs of acute liver failure including altered consciousness may be present. Supportive management is all that is required during acute illness, except in fulminant cases where specific antiviral medication may be required. Note: Refer all cases of suspected Hepatitis to referral centers for expertise management. Notably disease chronicity can progress into liver cirrhosis and hepatocellular cancer in span of years if no early treatment is initiated. Diagnosis There is a wide clinical spectrum ranging from asymptomatic serum amino transaminases elevations to apparently acute and even fulminant hepatitis. C) in combination with Tabs Rebavirin 800mg/day (O) in devided dose for genotype 2&3 or 1000mg/day(O) in devided dose for genotype 1,4,5 up to 48 weeks. It is a histological diagnosis characterized by hepatic fibrosis and nodule formation. Depending on etiologic process the progression of liver injury to cirrhosis may occur over weeks to years. Clinical classification of the disease using Child Tourcotte Pugh score is used to determine a 1-year mortality and need for liver transplantation. Diagnostic features Include jaundice, hepatomegaly, ascites, features of increased estrogen levels in men, while in women there are features of increased androgen levels. Features of portal hypertension like splenomegaly, ascites, distended abdominal wall vessels and variceal bleeding are common. Treatment Guide In compensated cirrhosis: Treat the cause and associated complications. In decompensate cirrhosis: Treat specifically the manifestation of hepatic decompansation. Note It is advisable to refer patients with this condition to specialized centers for proper evaluation and treatment. Diagnosis May be asymptomatic if small amounts Abdominal distension and discomfort in increasing amounts, anorexia, nausea, early satiety, heartburn, flank pain, and respiratory distress. Note: Dose of each medication can be increased every 1 2 weeks to the maximum doses indicated. The mechanisms of cholestasis can be broadly classified into hepatocellular (Intrahepatic), where an impairment of bile formation occurs, and obstructive (extra hepatic), where impedance to bile flow occurs after it is formed. Extra hepatic causes which may be amenable to surgical correction include choledocholithiasis and carcinoma of the biliary tree. Parasitic infections such as Ascariasis may also cause cholestatic jaundice Diagnosis the prominent features include jaundice, dark urine, pale stools, and itching/pruritis. Diagnostic considerations Liver functions; for elevated serum levels of total bilirubin, direct bilirubin, alkaline phosphatase, gamma-glutamyl transferase, bile salt concetration Elevated serum cholesterol Elevated fecal fat levels. Note Refer patiets cholestatic liver disease to specialized centres, particularly if it is severe or prolonged. V infusion) 3 litres/day with 2g (26mmol) potassium chloride added to every litre bag (if renal function is satisfatory). V) 10mg Plus S: Fresh Frozen Plasma initially Add Platelets if count <20 x 10g/l and patient is still bleeding If ethanol etiology is suspected give: C: Thiamine (I. Note: Hepatic encephalopathy is a medical emergency and requires referral to specialized and equipped centers for proper evaluation and management. Pneumonia can either be primary (to the causing organism) or secondary to pathological damage in the respiratory system. The common causative organisms for pneumonia are bacterial (for example Streptococcus pneumoniae, Hemophilus influenza, and Staphylococcus aureus, and Mycoplasma pneumoiae, viral or parasitic. The important clinical features are high fever 39C, dry or productive cough, central cyanosis, respiratory distress, chest pain and tachypnea. Classification of pneumonia in children is based on respiratory rate whichis fast breathing and chest in-drawing. Fast breathing is defined as Respiratory rate>60 age less than 3 months Respiratory rate > 50 age between 3 months and 5 years Chest indrawing is when the lower part of the chest moves in when the child breaths in. Table 1: Important clinical features of pneumonia in underfives Age Signs Classification Infants less than 2 Severe chest in-drawing Severe pneumonia (all young months Or infants with pneumonia are classified as severe) 60 breaths per minute or more No severe chest in-drawing No pneumonia: Less than 60 breaths per-minute Cough or cold Children from 2 Chest in-drawing Severe pneumonia months to 1 year No chest in-drawing Pneumonia 50 breaths per minute or more No chest in-drawing No pneumonia Less than 50 breaths per minute Cough or cold Children from 1 year to Chest in-drawing Severe pneumonia 71 P a g e 5 year No chest in-drawing Pneumonia 40 breaths per minute or more No chest in-drawing No pneumonia Less than 40 breaths per minute Cough or cold General management Oxygen therapy if available Supportive care o Lower the temperature if 38. M once a day) for 5 days; If child responds well, complete treatment at home or in hospital with A: Amoxicillin (15 mg/kg three times a day) Plus A: Gentamicin 7. If there are no apparent complications, switch to 72 P a g e B: Chloramphenical (25 mg/kg every 6 hours I. Non-severe pneumonia A: Amoxicillin 25 mg/kg 12 hourly for 5 days Give the first dose at the clinic and teach the mother how to give the other doses at home. The symptoms are caused by constriction of bronchial smooth muscle (bronchospasm), oedema of bronchial mucous membrane and blockage of the smaller bronchi with plug of mucus. Infants under 18 months, however, may not respond well to bronchodilator Asthma attack/ acute asthma Acute asthma is a substantial worsening of asthma symptoms. If conventional spacer not available, take a 500ml plastic bottle, insert the mouth piece of the inhaler into a hole on the bottom of the bottle (the seal should be as tight as possible). The child breathes from the mouth of the bottle in the same way as he would with a spacer 76 P a g e Silent chest Salbutamol nebulizer 2. Nocturnal Asthma Patients who get night attacks should be advised to take their medication on going to bed. Chronic Asthma in Adults the assessment of the frequency of daytime and nighttime symptoms and limitation of physical activity determines whether asthma is intermittent or persistent. Therapy is step-wise (Step 1-4) based on the category of asthma and consists of: Preventing the inflammation leading to bronchospasm (controllers) Relieving bronchospasm (relievers) Controller medicines in asthma Inhaled corticosteroids. Acute bronchitis is one of the most common conditions associated with antibiotic misuse. Pertussis is the only indication for antibacterial agents in the treatment of acute bronchitis.

The Workgroup left it up to the discretion of the provider the Workgroup recognizes that one motivating factor for to select the appropriate safety recommendations based on providers to improve is credible data demonstrating the value patient age antibiotic resistance news article generic tinidazole 500 mg visa, activities virus facts order tinidazole overnight delivery, and home and work environment treatment uti zithromax cheap tinidazole 500mg free shipping. Unfortu though scant systematic studies exist investigating the impact nately antibiotic resistance causes discount tinidazole online, these data are lacking bacterial nomenclature cheap generic tinidazole canada. Some practices are moving of such counseling on patient quality of life virus pictures buy on line tinidazole, age-appropriate toward using benchmarking data to allow providers to com safety counseling is part of an integrative non-pharmacologi pare performance among peers or care between health care cal treatment of narcolepsy. Furthermore, providers likely the Workgroup aimed to use an evidence-based approach require proof that use of quality improvement measures ac and expert consensus to set quality improvement standards for tually improves health outcomes in their patient population. Our goal is to improve the health out To this end, there is a need for health outcomes research in comes of patients with narcolepsy. While much thought has the narcolepsy literature with use of valid and reliable in gone into development of these outcome and process measures, struments that are clinically useful as well as a patient data the Workgroup recognizes that their implementation into clini registry to study outcomes. Patients may have problems fnding a knowl sleep entities must have a quality assurance program. For these edgeable narcolepsy care provider and obtaining recom facilities, the quality assurance program must addresses inter mended studies and treatment because of transportation issues, scorer reliability and at least three other quality assurance indi long wait times, competing time demands, and fnancial and/or cators for facility accreditation. Awareness: the Workgroup recognizes that not all based on their clinical practice for maintenance of certifcation providers are aware of the clinical guidelines and practice through the American Board of Neurology and Psychiatry. The quality improvement ments regarding implementation of quality improvement in measures outlined in this paper are based on the most updated their clinical practice. A new method for measuring daytime sleepiness: the Epworth are publicly accessible and can be used in a variety of practice Sleepiness Scale. These tools can be printed, modifed, and scanned into effcacy of armodafnil in naive patients with excessive sleepiness associated the medical record for future data analysis. Secondly, the Work with obstructive sleep apnea, shift work disorder, or narcolepsy: a 12-month, group specifes alternative ways to address timeliness of care open-label, fexible-dose study with an extension period. The effcacy and safety of armodafnil For example, providers are encouraged to document a phone as treatment for adults with excessive sleepiness associated with narcolepsy. Lastly, the Workgroup acknowledges that the sodium oxybate therapy on quality of life in narcolepsy. Quality of life in patients with narcolepsy Nevertheless, the Workgroup acknowledges that practitioners with cataplexy, narcolepsy without cataplexy, and idiopathic hypersomnia without long sleep time: comparison between patients on psychostimulants, drug-naive may need additional administration staff to help with schedul patients and the general Japanese population. Complex movement disorders at disease of measures may be needed as parameters are implanted into onset in childhood narcolepsy with cataplexy. Symptomatic narcolepsy, cataplexy and hypersomnia, clinical practices in large scales. Important considerations are and their implications in the hypothalamic hypocretin/orexin system. Practice parameters for the non quality measures will facilitate communication with third respiratory indications for polysomnography and multiple sleep latency testing for children. In the future, more optimal the multiple sleep latency test and the maintenance of wakefulness test. Narcolepsy is complicated by high medical and psychiatric measures on patient health. This would inform efforts to revise comorbidities: a comparison with the general population. Impact of obesity in children with propriate treatment plans, continuing care and increased pa narcolepsy. Clinical and therapeutic glycemic control: an opportunity to identify high-risk diabetic patients. International classifcation of sleep of complex cognitive performance and subjective sleepiness. Interventions to evaluate ftness to drive treatment of narcolepsy and other hypersomnias of central origin. Comparison of driving simulator gestions to improve the relevancy and utility of these measures in their feld of performance and neuropsychological testing in narcolepsy. Functional status in patients with suggestions as were feasible in the refning of these measures. Scheduled naps in the management of daytime ance, for guidance in compiling the technical specifcations associated with these sleepiness in narcolepsy-cataplexy. A comparison of three different sleep schedules for reducing daytime sleepiness in narcolepsy. Maintenance of wakefulness test Submitted for publication January, 2015 scores and driving performance in sleep disorder patients and controls. The other authors have indicated no fnancial conficts of the American Academy of Sleep Medicine would like to thank the following interest. Tracking and periodically reviewing this performance data will help providers identify opportunities for improvement within their own practices. Measure Components All patients diagnosed with narcolepsy who received an evidence-based treatment and completed a baseline validated Denominator Statement sleepiness scale. Medical Reasons: Patient is on potent sedating medications administered during the day for comorbid conditions. Number of patients that showed improvement in their subjective sleepiness (assessed with a validated scale). Numerator Statement Scale options include, but are not limited to: Epworth Sleepiness Scale, Stanford Sleepiness Scale, Karolinska Sleepiness Scale, Cleveland Adolescent Sleepiness Questionnaire, or a Visual Analog scale. Exceptions Patient Reasons: Patient and/or caregiver declines; patient unable to complete scale; patient aged < 6 years. Number of patients whose sleepiness was assessed with a validated scale at every visit. Scale options include, but are not limited to: Epworth Sleepiness Scale, Stanford Sleepiness Scale, Karolinska Sleepiness Scale, Cleveland Adolescent Sleepiness Numerator Questionnaire, or a Visual Analog scale. Measure Components Denominator Statement All patients newly diagnosed with narcolepsy. Treatment may include 1 or more of the following behavioral and/or pharmacologic options: A. Amphetamine, Methamphetamine, Dextroamphetamine, Methylphenidate, and related preparations 2. Sodium oxybate Technical Specifcations: Administrative/Claims Data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). One of the following diagnosis codes indicating narcolepsy, assigned to the patient for the frst time (new diagnosis): 347. Number of patients with documentation that a comprehensive sleep history and physical examination was completed at the time of the diagnosis. At a minimum, this comprehensive sleep history would include assessment of sleep wake patterns, signs and symptoms suggestive of sleep disordered breathing, current medications, and other potential comorbidities which may contribute to Numerator Statement excessive daytime sleepiness. Note: If documentation is not available from the initial diagnosis or if the original sleep history is insuffcient/incomplete, a comprehensive history would be required when transferring care to another physician. If documentation is not available from the initial diagnosis or if the original sleep history is insuffcient/ incomplete, a comprehensive history and examination would be required when transferring care to another physician. Inclusion of questions regarding traumatic brain injury, secondary causes of cataplexy, and multiple sclerosis may be appropriate. Measure Components Denominator Statement All patients diagnosed with narcolepsy who were started on treatment. Patient Reasons: Patient and/or caregiver declines treatment; patient does not return for follow-up and/or transitioned to a Exceptions different provider. Number of patients started on evidence-based treatment (with physician approved medication or non-medication regimens) for whom reassessment* of symptoms and functionality is performed at least annually after treatment initiation. Process Measure #5: Treatment follow-up (continued) Technical Specifcations: Administrative/Claims Data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/ denominator criteria. Process Measure #6: Documented medication counseling Measure Description Proportion of patients diagnosed with narcolepsy with documentation that counseling was received regarding side effects of Description medications or interactions with other medications before or at the time of initial treatment prescription. Measure Components Denominator Statement All patients diagnosed with narcolepsy in whom a new narcolepsy medication is initially prescribed. Number of patients with documentation that counseling was received regarding side effects of narcolepsy medications or Numerator Statement interactions with other medications before or at the time of initial prescription. Number of patients who received documented age-appropriate safety measures counseling about potentially dangerous Numerator Statement activities related to home, work, school, and during transportation before or at the time of diagnosis. Technical Specifcations: Administrative/Claims Data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). This presentation (including any oral briefing and any question-and-answer in connection with it) is not intended to , and does not constitute, represent or form part of any offer, invitation or solicitation of any offer to purchase, otherwise acquire, subscribefor, exchange, sell or otherwise dispose of, any securities or the solicitation of any vote or approval in any jurisdiction. The companies in which Takeda directly and indirectly owns investments are separate entities. Likewise, the words we,us and our are also used to refer to subsidiaries in general or to those who work for them. These expressions are also used where no usefulpurpose is served by identifying the particular company or companies. Takeda undertakes no obligation to update any of the forward-looking statements contained in this presentation or any other forward-looking statements it may make, except as required by law or stock exchange rule. Nothing contained herein shouldbeconsidered a solicitation, promotion or advertisement for any prescription drugs including the ones under development. References to Legacy Takeda businesses are to our businesses held priorto our acquisition of Shire. This pro forma information has not been prepared in accordance with Article 11 of Regulation S-X. Moreover,this pro forma information gives effect to certain transactions and other events which are not directly attributable to the Shire acquisition and/or which happened subsequently to the Shire acquisition, such as divestitures and the effects of the purchase price allocation for the Shire acquisition, and therefore may not accurately reflect the effect on our financial condition and results of operations if the Shire acquisition had actually been completed on April 1, 2018. Actual future net sales achieved by our commercialized products and pipelines will be different,perhaps materially so, as there is a range of possible outcomes from clinical development, driven by a number of variables, including safety, efficacy and product labelling. In addition, if a product is approved, the effect of commercial factors including the patient population, the competitive environment, pricing and reimbursement is 17 also uncertain. Some Wave 2 assets could be accelerated into Wave 1 if they have breakthrough data 22 3. Projected timing of approvals depending on data read-outs; some of these Wave 1 target approval dates assume accelerated approval Estimated dates as of November 14, 2019 2. Projected timing of approvals depending on data read-outs; some of these target approval dates assume accelerated approval 4. Estimated number of patients projected to be eligible for treatment in markets where the product is anticipated to be 5. Currently in a non-pivotal Ph 2; interim stage gates may advance program into pivotal trial for 34 commercialized, subject to regulatory approval target approval by 2024 3. Projected timing of approvals depending on data read-outs; some of these Wave 1 target approval dates assume accelerated approval; 2. Projected timing of approvals depending on data read-outs; some Wave 1 target approval dates assume accelerated approval 2.

These patients have visual impairment even with treatment and or standard refractive correction and have a visual acuity of less than 6/18 to perception of light and a reduced central visual field antibiotics for acne from dermatologist tinidazole 1000 mg visa. Assessment of these patients is thorough eye examination to determine the causes of visual loss by Low vision therapist antibiotic prophylaxis for dental procedures 300mg tinidazole. Referral All children with Low Vision should be referred to a Paediatric Tertiary Eye Centre 2 antibiotics for dogs baytril cheap tinidazole 1000mg. The 4 types of ocular injuries are Perforating Injury bacterial vaginosis symptoms tinidazole 1000 mg generic, Blunt Injury treatment for dogs false pregnancy buy 500mg tinidazole overnight delivery, Foreign Bodies and Burns or chemical injuries infection lining of lungs purchase tinidazole paypal. From the history, one will be able to know the type of injury that will guide the management. Perforating eye injury: this is trauma with sharp objects like thorns, needles, iron nails, pens, knives, wire etc. Diagnosis There is a cut on the cornea and or sclera A cut behind the globe might not be seen but the eye will be soft and relatively smaller than the fellow eye. Refer the patient to eye surgeon immediately Surgery: this is done by a well trained eye specialist within 48 hours of injury. Diagnosis There may be pain and or poor vision There may be blood behind the cornea (hyphaema) Pupil may be normal or distorted There may be raised intraocular pressure Guideline on Management Complicated blunt trauma is best managed by eye specialist as surgery may be required in the management. Refer patients with blunt trauma to eye specialist as indicated below: Table 3: Management of Complicated Trauma Findings Action to be taken No hyphema, normal vision Observe Hyphema, no pain Refer No hyphema, normal vision, Paracetamol, Observe for 2 days, Refer if pain pain persist Poor vision and pain Paracetamol, refer urgently Hyphema, pain, poor vision Paracetamol, refer urgently Management by eye specialist A. Medical Treatment Steroid eye drops this treatment is given to all patients with blunt trauma and present with pain and or hyphema: C:Prednisolone 0. Surgical Treatment this is indicated in patients with hyphema and persistent high intraocular pressure despite treatment with antiglaucoma medicines (5 days), with or without corneal blood staining. Surgical procedure is washing of the blood clot from the anterior chamber and Observe intraocular pressure post operative. Foreign bodies this is a condition whereby something like piece of metal, vegetable or animal parts entering into any part of the eye. Diagnosis There may be pain, redness, excessive tearing and photophobia if the foreign body is on the corneal or eye lids If the foreign body is superficial, it can be seen There may be loss of vision Treatment For superficial foreign body Instill local anaesthetic agents like B: Amethocaine 0. For intraocular foreign body Apply antibiotic ointment and eye shield Refer to eye Specialist for surgical management. Burns and chemical injuries this is a condition that occurs when chemicals such as acid or alkali, snake spit, insect bite, traditional eye medicine, cement or lime enter the eye. Treatment can be changed depending on corneal scrapping results Give antiviral if Viral causes is suspected after the examination of the eye C: Acyclovir 3% eye ointment 4 hourly. Patient with corneal abrasion complains of pain, gritty sensation and excessive tearing. Majority of the cases are Idiopathic where by other cases are due to autoimmune diseases. Diagnosis It has 3 main clinical presentations namely acute, chronic and acute on chronic. In acute type, patients present with painful red eye, Excessive tearing and severe photophobia. Visual Acuity is usually reduced and the pupil is small or it may be irregular due to syneachia. With Slitlamp biomicroscopic examination, cells and keratic precipitates and hypopyon may be seen in the anterior chamber. Treatment Treatment of uveitis may be multidisciplinary approach as various specialists may be involved. Before starting treatment, investigations such as blood tests and X-Rays should be done to establish the cause of uveitis. Acute uveitis is a serious problem and the patient should be referred urgently for Specialist treatment. Treatment for uveitis is mainly steroids and specific treatment according to the cause. Clinical features and treatment guideline depends on the type and cause of conjunctivitis as shown in the following sections. Allergy Conjunctivitis: In this conditionpatients presents with history of itching of eyes, sand sensation, and sometimes discharge. When examined, the eyes may be white or red, there may also be other pathognomonic signs such as limbal hyperpigmentatin and papillae and papillae of the upper tarsal conjunctiva. In very advanced stages, allergic conjunctivitis patients may present with corneal complications. All patients with moderate to severe allergic conjunctivitis should be referred to eye specialist for further specialized care. Viral conjunctivitis: It presents with painless watery eye discharge, there may be photophobia if the cornea is involved. If adenovirus is the cause, it appears in epidemics so there will be history of being in contact with patients with similar eye condition. Apply antibiotic eye ointment or eye drops if there is secondary infection with other organisms 198 P a g e Note: Viral Conjunctivitis is very contagious so patients and members of the family should be alerted Bacterial conjunctivitis: Presents with acute onset of painless purulent discharge. Bacterial conjunctivitis patients who are not responding to treatment should have eye swabs for Gram stain and for culture and sensitivity to tailor down treatment. Ophthalmia Neonatorum/Neonatal Conjunctivitis; this is a special type of acute bacterial infection of the eyes that affect newborn baby during the first 28 days of life. Causative organisms are Neisseria gonorrhoea, Chlamydia trachomatis and Staphylococcus spp. Diagnosis: Patients present with massive oedema and redness of eyelids and with purulent and copious discharge from the eyes. There is usually rapid ulceration and perforation of corneal which eventually leads to blindness if treatment is delayed. There are many causes of squint but the most important and common ones in children are refractive errors, amblyopia (lazy eye), retinoblastoma, cataract and syndromic eye diseases that may be of neurologic origin or not. In additional to that, in adults squint may be complication of diabetes mellitus and orbital/head trauma. Thorough examination of the eyes by a pediatric eye specialist is needed to guide the management of the patients, so refer all children to Paediatric Eye Tertiary Centre. These affect the exposed area of conjunctiva as a response to chronic dryness and exposure to sunlight. Treatment Treatment for pterygium is surgical excision in advanced stage where the visual axis is involved. Surgery should be done by qualified eye care personnel and antibiotic steroid combination drops should be given postoperative. Diagnosis the tumour is seen as papillary or gelatinous mass associated with feeder vessels. Treatment If tumour is suspected, Excise the mass with wider margin (2 mm) Treat the margins with Mitomycin C, 5 Fluorouracil or cryotherapy Send the specimen for histological examination For advanced tumours where the globe has been infiltrated, removal of the eye is indicated (Enucleation or exenteration) Send patients with confirmed diagnosis to Oncologist for radiotherapy 4. Diagnosis 200 P a g e the most common initial sign is white pupil reflex (leokocoria), followed by squint, and rarelyvitreous haemorraghe, hyphema, ocular/periocular inflammation, glaucoma and in late stagesproptosis and hypopyon. It can be inherited so examine the child and sibs in hereditary for every 4 months until yr 4, then 6 monthly until yr 6 and yearly in over 8yrs. Management the goals of treatments are: To save the patients life To savage the patients eye and vision if possible Choice of treatment depends on Size of tumor, Location and Extent of the tumour. It is acquired through wounds contaminated with spores of the bacteria and in the case of neonates, through the umbilical stump, resulting in neaonatal tetanus. Diagnosis Generalized spasms and rigidity of skeletal muscles Patients are usually fully conscious and aware. Postnatal age >7 days: 1200-2000 g: 15 mg/kg/day in divided doses every 12 hours >2000 g: 30 mg/kg/day in divided doses every 12 hours For anaerobic infections: 204 P a g e A: Metronidazole Oral, I. The manifestations of brain abscess initially tend to be nonspecific, resulting in a delay in establishing the diagnosis. Diagnosis Headache is the most common symptom, neck stiffness, lethargy progressing to coma, vomiting, and focal neurologic deficit. Diagnosis Headache, fever, intolerance to light and sound, neck stiffness, vomiting, seizures, deafness and blindness In advanced stages it may present with confusion, altered consciousness and coma. Cryptococcal antigen test should be done as there are cases of negative Indian ink results with cryptococcal meningitis. Diagnosis Patients can present with focal paralysis or motor weakness depending on the brain area affected Neuro-psychiatric manifestations corresponding to the affected area in the brain, seizures or altered mental status. Note: Diagnosis is predominantly based on clinical findings after exclusion of other common causes of neurological deficit. After six weeks of treatment give prophylaxis therapy with Sulphadiazine tabs 500mg 6 hourly + Pyrimethamine tabs 25-50mg /day + Folinic acid tabs 10mg /day. For those allergic to sulphur replace Sulphadiazine tabs with S: Clindamycin capsules 450mg 6 hourly. Diagnosis Early or prodromal clinical features of the disease include apprehensiveness, restlessness, fever, malaise and headache the late features of the disease are excessive motor activity and agitation, confusion, hallucinations, excessive salivation, convulsions and hydrophobia Note: Death is considered as invariable outcome. In addition, patients should receive rabies immune globulin with the first dose (day 0) Tetanus toxoid vaccine see section on Tetanus 208 P a g e 1. Note: the disease is easily missed in Tanzanian settings due to lack of diagnostic facilities and should therefore be suspected in patients not responding to antibiotics/other treatment. It afflicts 5% of the population and is characteristically a disorder of young adults and affects women twice as often as men. Acute anxiety attacks are characterized by sudden onset of tension, restlessness, tremors, breathlessness, tachycardia and palpitations. Chronic anxiety state presents with persistent diffuse anxiety, motor tension, autonomic hyperactivity, unpleasant anticipation and irritability. Common symptoms include palpitations, sweating, trembling or shaking, shortness of breath, feeling of choking, chest pain, nausea, dizziness, and derealization; fear of losing control, fear of dying, parasthesias, and chills. Diagnosis Diagnosed after recurrent (several) panic attacks within a one month period. Treatment the initial aim is to control the panic symptoms and exclude an underlying medical cause. M half hourly in 2 hours to a maxmum of 20mg/24 hours till acute attack is controlled. By definition, a diagnosis of bipolar disorder requires either a current or previous episode of mania. An episode of mania is typically characterised by an elevated mood whereby a patient may experience extreme happiness which might also be associated with an underlying irritability. Such mood may be associated with increased energy/activity, talkativeness and a reduction in the need for sleep and features may be accompanied by grandiose and/or religiose delusions. Maintenance therapy Under specific circumstances such as past or family history of response and rapid cycling, i. Referral Mixed or rapid cycling biplolar disorder Depressive episodes in bipolar patients not responding to treatment Manic episodes not responding to treatment 2. These include bizarre appearance, reduced motor activity, withdrawal, flattened effect and mood disturbance, delusions and hallucinations. Adjunct treatment Antiparkinsonian drugs should only be used if extrapyramidal side effects occur or at higher doses of antipsychotics likely to cause extrapyramidal side effects. Any of the following can be used: C: Trihexyphenidyl (Benzhexol 5mg once to two times a day (O) last dose before 1400 hours S: Procyclidine 10mg two times a day last dose before 1400 hours Referral First psychotic episode Poor social support High suicidal risk or risk of harm to others Children and adolescents the elderly Pregnant and lactating women No response to treatment Intolerance to medicine treatment Concurrent medical or other psychiatric illness Epilepsy with psychosis 2. For Bradykinesia, rigidity and postural disturbance S: Carbidopa/levodopa 25/100 mg (O) 8 hourly. For Acute dystonic reaction Usually follows administration of dopamine-antagonistic drug. If seizures persist, increase phenytoin by 50 mg increment to a maximum dose of 600 mg daily If no appreciable improvement, change to carbamazepine, stopping phenytoin by reducing dose by 50 mg per week. Increase the dose to maximum If possible the combination of these drugs should be avoided 215 P a g e Patients still having seizures despite of having the above drugs should be referred to a higher level of treatment. Once the status epilepticus has been controlled the patient should be maintained on other antiepileptics. Continue with 100 mg every 6 hours, but do not exceed 15mg/kg/24 hours Note: these drugs when given together may cause serious respiratory depression Children: Protect airway, give oxygen Give dextrose 50% (I. V) 15 ml (1ml/min) as a bolus Give anticonvulsant: A: Diazepam 5 mg/minute (slow I. M)400mg (maximum 15 mg/kg/24hours), Children 5 mg/kg/24 hours as loading dose For febrile Convulsions in Children aged 1-5 years Do not give anticonvulsant except to known non-febrile convulsion cases or neurological abnormalities. For prolonged or recurrent febrile convulsions, Diazepam should be administered rectally by using a syringe. V fluids, chlorpromazine for acute confusional state Management of acute problems depends on the substance of abuse being identified.

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