By J. Ningal. Ramapo College of New Jersey.

It has to The Virus 25 • enter the human body and replicate there purchase ceftin 250 mg with visa, • cause illness in humans order ceftin 500mg line, and • be easily transmittable between humans buy generic ceftin 500 mg line. In the current situation, the potential pandemic virus would have to compete with the al- ready circulating H3N2 and H1N1 strains. The prerequisite for success is good adaptation: adaptation to human cells; the ca- pability to take over the production machinery of the host cell to produce new off- spring; as well as making the individual cough and sneeze to spread the offspring viruses. The clue to success is virulence (Noah 2005, Obenauer 2006, Salomon 2006) – and novelty: if the virus is a true newcomer, most living human beings will have little or no protection at all. The new virus will have unlimited access to virtu- ally every human being and will find a feeding ground of > 6. The passing of powers from one reigning influenza subtype to a new one is called “antigenic shift” because the antigenic characteristics of the new virus need to shift dramatically to elude the immune system of virtually the entire mankind. Antigenic shift is a major change in the influenza A viruses resulting in new haemagglutinin and/or new neuraminidase proteins. This change may occur by: 1) reassortment of the segmented genome of two parent viruses, or 2) gradual mutation of an animal virus. For reassortment to take place, both the new pandemic candidate virus, nor- mally of avian origin, and an already circulating human virus, i. Inside the cell, genes from both viruses are reassembled in an entirely new virus (they don’t actually have sex, but for didactic purposes, this image might work quite nicely). Recent evi- dence with recombinant viruses containing genes from the 1918 pandemic virus shows that viruses expressing one or more 1918 virus genes were less virulent than the constellation of all eight genes together (Tumpey 2005). The 1918 virus was particular indeed: it appears that it was not the result of a reassortment of two ex- isting viruses, but an entirely avian-like virus that gradually adapted to humans in stepwise mutations (Taubenberger 2005). It is obviously tempting to speculate that the emergence of a completely new human-adapted avian influenza virus in 1918 (n=1) could be deadlier than the introduction of reassortant viruses in 1957 and 1968 (n=2), but such speculation is not scientific. Interestingly – and worryingly –, some amino acid changes in the 1918 virus that distinguish it from standard avian sequences are also seen in the highly pathogenic avian influenza virus strains of H5N1, suggesting that these changes may facilitate virus replication in human cells and increase pathogenicity (Taubenberger 2005). They are spherical or filamentous in structure, ranging from 80 to 120 nm in diameter (Figure 4 and 5). When sliced transversely, influenza virions resemble a symmetrical pepperoni pizza, with a circular slice of pepperoni in the 26 Influenza 2006 middle and seven other slices evenly distributed around it (Noda 2006). The domestic duck in Southeast Asia is the principal host of influenza A viruses and also has a central role in the generation and maintenance of the H5N1 virus (Li 2004). In Thailand, there was a strong association between the H5N1 virus and the abundance of free-grazing ducks and, to a lesser extent, native chickens and cocks, as well as wetlands, and humans. The virus is killed by heat (56°C for 3 hours or 60°C for 30 minutes) and common disinfectants, such as formalin and iodine compounds. Transmission Influenza is primarily transmitted from person to person via droplets (> 5 µm in diameter) from the nose and throat of an infected person who is coughing and sneezing (Figure 6). Particles do not remain suspended in the air, and close contact (up to 3–6 feet) is required for transmission. Transmission may also occur through direct skin-to-skin contact or indirect contact with respiratory secretions (touching contaminated surfaces then touching the eyes, nose or mouth). Individuals may spread influenza virus from up to two days before to approximately 5 days after onset of symptoms. Avian influenza viruses bind to cell-surface glycoproteins containing sialyl-galactosyl residues linked by a 2-3-linkage, whereas human viruses bind to receptors that contain terminal 2-6-linked sialyl-galactosyl moieties. For an avian virus to be easily transmitted between humans, it is fundamental that it acquires the ability to bind cells that display the 2-6 receptors so that it can enter the cell and replicate in them. While single amino acid substitutions can significantly alter re- ceptor specificity of avian H5N1 viruses (Gambaryan 2006), it is presently un- known which specific mutations are needed to make the H5N1 virus easily and sustainably transmissible among humans, but potential routes whereby H5N1 might mutate and acquire human specificity do exist (Stevens 2006). Apart from H5N1, human infection generally resulted in mild symptoms and rarely in severe illness (Du Ry van Beest Holle 2003, Koopmans 2004). H5N1: Making Progress At the moment, H5N1 infection in humans is relatively rare, although there must have been widespread exposure to the virus through infected poultry. This in an indicator that the species barrier to the acquisition of this avian virus is still quite high for H5N1 – despite having been in circulation for nearly 10 years. However, over the past years, H5N1 strains seem to have become more pathogenic and to have expanded their range of action: Individual Management 29 • The H5N1 influenza strain continues to evolve (Li 2004), and some clones have broader binding properties which may reflect a certain degree of adapta- tion in human hosts (Le 2005). H5N1 has expanded its host range not only in avian species (Perkins 2002), but also in mammals, naturally infecting humans, tigers, leopards, domestic cats and a stone marten (Keawcharoen 2004, Thanawongnuwech 2005, Amonsin 2006).

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The management of ischaemic heart disease among diabetics differs little from that generally employed buy ceftin 500 mg otc. It is common in people older than 40yrs and results from variable combinations of insulin resistance and defects in insulin secretion discount ceftin 500mg on line. In the hypothetical case already mentioned the health officer requested the following laboratory investigations with the results shown below discount ceftin 250 mg with mastercard. Clinical features The presentation of patients depends on the type of diabetes and the stage of pathologic process. The disease is often present for many years before the diagnosis and chronic hyperglycemia may be responsible for susceptibility to infections (eg. Short term – immediate treatment to relieve the symptoms such as polydipsia, polyuria, or acute infection. Long term – to prevent the development or delay progression of complications of diabetes The treatment of diabetes can be categorized as non-drug therapy and drug therapy. Regular Physical exercise This results in improvements in the sense of well being, cardiovascular fitness, blood pressure, insulin sensitivity, weight reduction and glycemic control. Dietary Control A general dietary recommendation includes consumption of a balanced health diet composed of: - 10 – 20% protein - 30% fat - 50-60% carbohydrate Patients should be advised to avoid dimple sugars like table sugar, honey etc and low saturated fat and cholesterol white high fiber diet is recommended. Insulin is also used in type 2 diabetics when a combination of oral agents fails to achieve glucose targets and temporarily in patients with serious infection or surgery. Standard insulin therapy consists of one to two injections per day using intermediate or long acting insulin with or without regular insulin. Adults of normal weight may be started with 20-25 u/d of intermediate acting insulin and increased to maintain a blood sugar level of 80-120 mg/dl. If this regimen does not lead to adequate blood glucose control, oral antihyperglycemic agents with or without insulin are indicated. On examination, signs include tachycardia, orthostatic hypotension, poor skin turgor, warm or dry skin and mucous membranes, deep and fast breathing (Kussmaul’s respiration), hypothermia or normothermia, acetone breath, and altered mental status or coma. Relate the clinical manifestation of diabetic mellitus to the associated pathophysiologic alteration 5. Learn on the pharmacological calculation of insulin to reach on accurate dose (units to milliliter from a vial containing 40,80 or100 units) 12. Describe the major macrovascular, microvascular and neuropathic complication of diabetic and self care behavior important in the prevention 14. Use the Nursing process as a frame work for care of the patient with diabetes 43 Diabetes Mellitus Definition: - is a chronic multifactorial, systemic metabolic disorder characterized by hyperglycemia and abnormal insulin production and /or action. There are five components of management for diabetes: - - Diet - Exercise - Monitoring blood glucose - Medication (as needed) - Education 45 I. The general recommendation include consumption of a balanced healthy diet composed of the following • 50% to 60% of calories to be derived from carbohydrates • Less than 30% obtained from fat and • The remaining 10% to 20% from protein *Food which diabetic should avoid (rapidly absorbed carbohydrate/simple sugar) 1) Sugar, honey, jam, marmalade and candy 2) Cakes and sweet biscuits 3) Soft drink (Fanta, coca cola, etc) 4) Alcohol (Cognac, tej, araki, whisky) There are types of alcohols which are allowed in moderation, that is less sweat drinks i. Exercise - Is extremely important in the management of diabetes because of its effect on lowering blood glucose and reducing cardiovascular risk factors - Lowers blood glucose level by increasing the uptake of glucose by body muscles and by improving insulin utilization - Pre or post exercise snack may be required to prevent hypoglycemia after exercise - Patients should be taught to do regular, moderate exercise at the same time and in the same amount for at least 30 minutes each day. Exercise recommendations must be altered as necessary for patients with diabetic complications - Blood glucose level should be measured before any exercise activity is initiated. Medications Insulin therapy • In type 1 diabetes, the body loses the ability to produce insulin, thus, exogenous insulin must be administered indefinitely. A standard insulin treatment consists of one or two injection/day, using intermediate or long acting insulin with or with out regular insulin. In addition, some patients whose type 2 diabetes is usually controlled by diet alone or diet and an oral agent may require insulin temporarily during illness, infection, pregnancy, surgery or some other stressful events. Actually there is no significant difference in the biologic activity between insulin put in the refrigerator and in the temperature (25- 34oc). It would seem safe to conclude that unless insulin in Africa is stored for a long period at very high temperature, there is no potential problem (5). Rotation - Rotation of injection site is required to prevent lipodystrophy, localized changes in fatty tissue, The patient is instructed as: 1. Systemic allergic reaction-are rare - Can be life threatening - Local skin reaction that gradually spreads in to generalized urticaria which can include laryngeal edema with respiratory distress 51 Treatment involves: - desensitization, gradually increasing the amount of insulin under cautious observation. Insulin lipodystrophy - Refers to a localized disturbance of fat metabolism in the form of lipoatrophy (loss of subcutaneous fat and appears as slight dimpling or more serious pitting of subcutaneous fat) or lipohyperthrophy (is the development of fibro fatty masses at the injection site and is caused by the repeated use of injection site) - If insulin is injected in to scarred areas the absorption may be delayed Treatment: Patient should avoid injection on the areas and prevent by rotating injection sites 3. Metformin Dosage, 500 – 2000 mg Po daily in divided doses Side effects: anorexia, nausea, vomiting, abdominal discomfort and diarrhea. This bolus is followed by the continuous infusion of 5 to 10 % of glucose at a rate sufficient to keep the plasma glucose level> 100mg/dl Patient education: - prevented by following a regular pattern for eating, administering insulin, and exercising - Because unexpected hypoglycemia may occur all patients treated with insulin should wear an identification bracelet or tag indicating that they have diabetes and should keep sugar or candy in their pocket - Patient and family members should be aware of signs of hypoglycemia 2. Paradoxically potassium appear elevated as a response to acidosis, though this is a temporary shift of potassium from intra to extra cellular space Sign and symptoms: - anorexia, nausea, and vomiting & abdominal pain - Acetone breathe - Kussmaul respiration (very deep& and fast respiration) -Lab.

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Finally quality ceftin 500 mg, the half-life of crystalloid agement redistribution is only 15-30 minutes buy ceftin 250mg mastercard, so it must be given at a rate that accounts for its extravasation from the in- travascular space ceftin 500mg lowest price. These patients should be transfused to relatively blood volume needs to be replaced or when the conse- higher Hb levels (80-100 g/L). General indi- Transfusion of plasma, platelets or cryoprecipitate is in- cations for the transfusion of blood products are out- dicated only for the correction of defective clotting and lined in Table 5. Impaired clot- A patient with Class 3 or 4 hemorrhagic shock (Table 3) ting may be observed or anticipated in a given clinical should be transfused immediately. Prolonged clot- Healthy patients can tolerate Hb levels that are ap- ting times or thrombocytopenia alone, without clinical proximately ½ of normal (60-70 g/L). Compensations evidence of bleeding, are insufficient indications for may be inadequate in patients with pulmonary, cardiac transfusion. Compensation may be Risks and benefits of transfusion should be explained harmful in patients with certain types of heart disease to patients undergoing procedures likely to result in sig- such as severe coronary artery disease or aortic steno- 26 nificant blood loss. Table 5 Indications for blood product administration Complications of transfusion are numerous and are gen- erally categorized by acuity: early and late. The most common cause of transfusion reaction is clerical error, underscoring the need for careful adherence to fresh frozen plasma clotting factor deficits safety procedures by all members of the healthcare team. A more complete discussion of the indications and complications of the various blood products is be- yond the scope of this manual. Many excellent reviews cryoprecipitate fibrinogen on the subject can be found in the current anesthesia lit- erature. As well, you will be introduced to the equipment required for the safe delivery of anesthesia: the anesthetic machine and monitors. Premedication • To review the medical and psychological status of The patient’s and their relative’s previous anes- the patient. Re- factors where possible, and to delay surgery if neces- cording baseline vital signs is important, as is de- sary. If the patient’s medical condition cannot tecting any unstable, potentially reversible condi- be altered, then one can take other measures to tions such as congestive heart failure or broncho- attempt to reduce risk: substitute a lower-risk spasm. Studies are rarely ordered to establish a “base- On history, the anesthesiologist attempts to elicit line” but rather to detect abnormalities that re- symptoms of cardiac or respiratory disease as quire correction prior to surgery. As 2 disease; examples include controlled the patient’s underlying health is the most important hypertension, mild asthma. A patient with severe systemic disease; Though it does not lend itself to inter-rater reliability, it 3 examples include complicated diabetes, is an accepted method of communicating the overall uncontrolled hypertension, stable angina. A moribund patient who is not expected to survive 24 hours with or without the 5 operation; examples include a patient with a ruptured abdominal aortic aneurysm in profound hypovolemic shock. Due to gastric, biliary and pancreatic given to increase gastric motility (metoclopromide) or secretions (which are present even during fasting), a to decrease gastric acidity (ranitidine or sodium cit- stomach is never “empty”. Risk can also be reduced through careful airway the restriction of oral intake for a period of time prior management that may include the use of the Sellick Ma- to surgery, minimizing the volume, acidity and solidity neuver on its own or as part of a rapid sequence induc- of stomach contents. Table 7 Risk factors for aspiration For elective surgery, patients should not have solid food for 8 hours prior to anesthesia. However, more re- cent studies have shown that the time of the last (clear) • Gastroesophageal reflux fluid intake bears little relation to the volume of gastric • Pregnancy contents present at the induction of anesthesia. Thus, most institutions are allowing unrestricted intake of • Trauma clear fluids until 2-4 hours prior to scheduled surgery. For example, infants may be allowed • Bowel obstruction breast milk up to 4 hours pre-operatively and formula • Intra-abdominal pathology up to 6 hours pre-operatively. Gener- Some medications are ordered specifically for the pre- ally speaking, patients should be given their usual operative period. Examples include anxiolytics, antibi- medication on the morning of surgery with a sip of wa- otics, bronchodilators, anti-anginal medication and ter. Beta blockers have been used to reduce their usual cardiac and antihypertensive medications the incidence of cardiac morbidity and mortality in pre-operatively. Discontinuation of beta-blockers, cal- high-risk patients undergoing high-risk procedures, al- cium channel blockers, nitrates or alpha-2 agonists (clo- though the impact of this intervention is not yet fully nidine) can lead to rebound hypertension or angina. Similarly, most medications taken for chronic disease Currently, pre-operative sedation is used less fre- should be continued on the morning of surgery as well quently than it has been in the past as it can delay as throughout the peri-operative period. A delayed recovery larly important for most antidepressants, thyroid re- is particularly undesirable in the outpatient surgical placement and anticonvulsants. Examples in- operative visit has been shown to be at least as effective clude monoamine oxidase inhibitors and anticoagu- as pharmacologic means in allaying anxiety in surgical lants.

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