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Signs and symptoms Throughout treatment * If these occur generic 2.5 ml xalatan visa, stop treatment immediately proven 2.5 ml xalatan. Action in case of There is no specific antidote and it is not removed by haemodialysis. Counselling Patients should be told how to recognise signs of liver disorder and advised to seek prompt medical attention if symptoms such as anorexia, nausea, vomiting, fatigue, abdominal pain or dark urine develop. This assessment is based on the full range of preparation and administration options described in the monograph. Adose of 4mg/kg isused for diagnostic manoeuvres and procedures not involving intense pain. Intramuscular injection Preparation and administration Check that you have selected the correct strength of vial. Ketamine | 481 Intravenous injection Preparation and administration Check that you have selected the correct strength of vial. Inspect visually for particulate matter or discoloration prior to administration and discard if present. Continuous intravenous infusion Preparation and administration Check that you have selected the correct strength of vial. Add the ketamine to the prepared infusion bag to give a solution containing 1mg/mL. Inspect visually for particulate matter or discoloration prior to administration and discard if present. Therateofinfusionisdependent on the patient’s reaction and response to anaesthesia. Fluid restriction: solutions containing up to 50mg/mL have been used (unlicensed). The drug may darken on prolonged exposure to light; this darkening does not appear to affect potency. Respiratory Post administration * May occur with over-rapid administration depression or overdosage of ketamine. Additional information Common and Immediate: Anaphylaxis has been reported rarely. Significant Barbiturates or narcotics may "ketamine levels or effect (or "side-effects) (prolonged interactions recovery time). This assessment is based on the full range of preparation and administration options described in the monograph. Technical information Incompatible with Not relevant Compatible with Not relevant pH Not relevant Sodium content Nil Excipients Contains benzyl alcohol. Additional information Common and serious Immediate: Anaphylaxis and other hypersensitivity reactions may occur. Action in case of Antidote: No known antidote; stop administration and give supportive therapy overdose as appropriate. This assessment is based on the full range of preparation and administration options described in the monograph. Pre-treatment checks * Avoid in active or previous peptic ulcer, cerebrovascular bleeding, haemorrhagic diatheses, the complete or partial syndrome of nasal polyps, angioedema or bronchospasm, hypovolaemia or dehydration, moderate or severe renal impairment (Cr >160 micromol/L) and severe heart failure. Inspect visually for particulate matter or discoloration prior to administration and discard if present. Monitoring Measure Frequency Rationale Reduction of pain Postoperative * To ensure that treatment is effective. Additional information Common and serious Immediate: Anaphylaxis and other hypersensitivity reactions may occur. This assessment is based on the full range of preparation and administration options described in the monograph. Patients for whom halothane is contraindicated usually requireahigherinitialdoseof 25--30mg. The dose may be doubled every 30 minutes until a satisfactory response or a dosage of 160mg/hour is reached. Inspect visually for particulate matter or discolor- ation prior to administration. Continuous intravenous infusion Preparation of a 1mg/mL solution (other strengths may be used) 1. Withdraw and discard 10mL from a 250-mL infusion bag containing compatible infusion fluid (usually Gluc 5%). Withdraw300mg(60mL)oflabetalolinjectionsolutionfromthreeampoulesusingasyringeandadd to the remaining 240mL of infusion fluid and mix well. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Fluid restriction: there are anecdotal reports of undiluted injection solution being given (unlicensed) via syringe pump in critical care situations. Stability after From a microbiological point of view, should be used immediately; however, preparation prepared infusions may be stored at 2--8 C and infused (at room temperature) within 24 hours.

Such outcomes may occur even at low levels of alcohol consumption – less than four drinks per day (Little generic 2.5 ml xalatan otc, 1977; Plant buy xalatan 2.5 ml on-line, 1984; Sokol et al. Some studies on the effects of alcohol use of various durations during pregnancy has shown that occasional binge drinking by moderate drinkers did not negatively affect birth outcome (Autti-Ramo et al. Continuous drinking throughout pregnancy appears to cause fetal damage in a dose-dependent manner (Halmesmaki, 1988). In 306 Substance abuse during pregnancy addition, the frequency of sexually transmitted diseases and other infections is higher among women who abuse alcohol during pregnancy. These anomalies repeatedly occurred among infants born to women who were chronic alcoholics, drinking eight or more such beverages every day (Clarren and Smith, 1978; Larroque, 1992; Sokol et al. The investigators found that at 5 years of age the children whose mothers had continued drinking during pregnancy showed more alcohol-related deficits than non-alcohol- exposed children or children whose mothers stopped drinking in the second trimester of pregnancy. Transient withdrawal symptoms, including tremors, hypertonia, and irri- tability, were reported among infants born to women who chronically drank alcohol late in pregnancy (Coles et al. In addition, there is genetic polymorphism for alcohol dehydrogenase, implying a pharma- cogenetic etiologic role in the severity of effects. Importantly, medical and psychological support for cessation of drinking should be offered. Since many of these women may also abuse other sub- stances, they should also be advised to stop using these agents. Alcohol summary Fetal alcohol syndrome is one of the three leading causes of mental retardation. In addition, this syndrome is a leading cause of poor pregnancy outcome and childhood morbidity (congenital anom- alies, including mental retardation). Approximately 6 percent of pregnant women tested positive for methamphetamines at delivery in one study (Little et al. No studies are available regarding the illicit use of amphetamines during pregnancy. Several factors complicate extrapolation of these results to illicit use or abuse: (1) dose regimens in illicit use are not controlled; (2) they likely involve amounts much greater than those used therapeutically; and (3) harmful impurities (e. Methylphenidate (Ritalin), dextroemphetamine (Dexedrine) and a cocktail of ampheta- mine salts (Adderall) are stimulants with potential for abuse that are often represented as amphetamine or methamphetamine by those who distribute illegal drugs. However, preterm delivery and 308 Substance abuse during pregnancy perinatal mortality were increased in frequency (Eriksson et al. Follow-up of these children found that 15 percent were delayed in academic achievement in school, but other adverse effects were not reported (Eriksson et al. Medically supervised use of amphetamines during pregnancy is not convincingly asso- ciated with an increased frequency of congenital anomalies among several thousand infants exposed during the first trimester (Heinonen et al. Illegal metham- phetamines are known as ‘designer drugs’ because they are synthesized by methylating novel sites along the carbon chain and ring in a one-step reduction process. Sometimes methamphetamines are used to ‘cut’ or dilute other illicit drugs (cocaine). In 2006, they are called ‘club drugs’ because they are available in night clubs, and are used in parties called ‘raves’ that may last 24 hours or longer. The stimulant effects of methamphetamines keep the party-goers awake, although some vari- eties of this drug may cause hallucinations or other altered states of consciousness. Notably, the prevalence of methamphetamine use has not decreased over the past decade (Buchi et al. We reported 52 pregnancies complicated by methamphetamines finding that symmetric fetal growth retardation was increased above controls. The frequency of congenital anom- alies was not significantly increased (Little et al. Perinatal infant abnormalities and maternal pregnancy complications were not increased in frequency. The small sample size of the metamphetamine-exposed groups limits the ability to extrapolate these findings. Methamphetamines and cocaine use in pregnancy were associated with lower birth weight but not with anomalies (Oro and Dixon, 1987; Chomchai et al. Fetal growth retardation was associated with methamphetamine use throughout pregnancy, but when drug use was discontinued after the second trimester no difference in birth weight was found (Smith et al. Cannabinoid use during pregnancy 309 Lower birth weight was associated with maternal methamphetamine use during pregnancy among 47 infants in a study from Thailand (Chomchai et al. Medically supervised use of methamphetamines among 89 infants born to women who took the drug during the first trimester reported a frequency of congenital anom- alies no different from controls. Among 320 infants born to women who used the drug after the first trimester there were no abnormalities (Heinonen et al.

Learning points:Learning points: Never compromise your respondent’s dignity and safety for research xalatan 2.5 ml for sale. Defne the scale of measurement you want to use for that variable based on the type of variable Learning points:Learning points: Identfy all variables necessary cheap 2.5 ml xalatan mastercard. Identfcaton of variables will help the investgator to: • specify the important items for study. Figure 6: Relatonship between groups of variables In most “cause” and “efect” studies, we are looking at the relatonship between independent and dependent variable. That is, the “efect/outcome” is the dependent variable, the “cause” is an independent variable. A variable that is associated with both the problem and the possible cause of a problem is a potental confounding variable. The confounding variable may either strengthen or weaken the apparent relatonship between an outcome and a possible cause. Therefore, in order to give a true picture of cause and efect, the confounding variables must be considered, either at planning stage of or during data analysis. Example: In a survey to investgate whether there is a relatonship between mothers who are cigarete smokers and weight of their newborn, the dependent variable is the newborn’s weight, the independent variable is the mother’s smoking habit. Two aspects need to be considered: defne the variables and state the scale of measurement. It should be objectve, observable and is sufciently clear and explicit to avoid ambiguity. The selecton for a scale is determined by the variable itself and the methods available for measuring it. A type of data in which the variables are divided into a number of named categories. Example: • Level of knowledge: poor, average, good; • Opinion of individual: fully agree, agree, disagree, and totally disagree. A type of variable in which there is an unlimited number of equally spaced categories; thus a contnuum of values is possible. Patent has Dengue fever confrmed by serology yes/No/Not available dengue fever (IgM positve or four-fold rise in Igg ttre) or virology. Social class Head of household’s main occupaton Detailed occupaton, as stated by respondent in answer classifed into social to a queston in a structured class I - V questonnaire. Haemoglobin Haemoglobin concentraton in g/dl capillary blood, measured by haemoglobinometer. We may not get results that refect the true picture if we use the wrong samplingWe may not get results that refect the true picture if we use the wrong sampling size and method. The frst step in sampling is to clearly defne the study populaton and its characteristcs. The study populaton should be the group with the problem or those potentally afected (at risk). These criteria are based on such factors as age, geographical locaton, disease severity or stage, previous treatment, presence of other medical conditons, etc. Include important demographic characteristcs, the inclusion/exclusion criteria and any other factors defning them. Identfy the control populaton from a group with similar characterictcs but without the disease/conditon being studied. The key factors determining the sample size are: a) the proporton/mean of the main variable of interest (outcome variable). Researchers should not be distressed with sample size calculaton but should get help. Ofen, you would need to increase the calculated size by 10-20% to ensure the minimum sample size is stll achieved afer drop-outs, non-response, missing records, etc. When you have limited resources, you may need to lower the power of the study to accept a smaller sample size. The sample is either selected by random procedure (probability sampling) or conveniently (non-probability sampling). If your objectves require you to make inferences (apply the results to the study populaton), you must select a random sample. If your objectves need: a) a simple, fast answer, or b) you do not have a list of your study populaton (sampling frame), then select a convenient sample. Learning points:Learning points: •• A representatve sample should possess all the important characteristcs of theA representatve sample should possess all the important characteristcs of the populaton from which it is drawn. These criteria are based on such factors as age, geographical locaton, disease severity or stage, previous treatment, presence of other medical conditons, etc. It is important that these criteria be clearly defned in an objectve manner, so that everyone involved in the study are consistent in selectng the sample. If it is important that the sample includes representatve sub-groups of individuals (for example, urban and rural residents; or age groups), then the sampling frame must be divided into sub-groups, or strata, for these characteristcs. Random or systematc samples of a pre-determined size will then have to be obtained from each stratum. Stratfed sampling is only possible when it is known what proporton of the study populaton belongs to each stratum.

Maternal hyperthyroidism Hyperthyroidism occurs in approximately two per 1000 pregnancies (Cheron et al generic xalatan 2.5 ml amex. Causes include Graves’ disease 2.5 ml xalatan, Plummer’s disease, trophoblastic disease, and Hashimoto’s thyroiditis. Symptoms include heat intolerance, tachycardia, tremulousness, palpitations, agitation, hyperreflexia, exophthalmos, lid lag, and weight loss, but many of these conditions are also seen during a normal pregnancy. Thyroid hormones do not cross the placenta in significant amounts, but the maternal hyperthyroid state may be dangerous to the fetus and newborn. The incidence of prema- turity, preeclampsia, and low birth weight is higher among hyperthyroid gravidas, and maternal weight loss can result in fetal undernutrition (Freedberg et al. However, neonatal syndromes have been described for the transplacen- tal passage of both blocking and stimulating antibodies (Zakarija et al. Treatment of hyperthyroidism during pregnancy involves a choice between antithy- roid drugs and subtotal thyroidectomy since maternal radioiodine treatment results in fetal thyroid ablation (Selenkow et al. Antithyroid drugs are commonly employed to control hyperthyroidism in pregnancy to avoid surgical intervention. Its antithyroid action blocks the synthesis but not the release of thy- roid hormone and prevents the peripheral conversion of T4 to T3. The drug is not associated with an increased risk of congenital anomalies (Becks and Burrow, 1991; Davis et al. Their antithyroid action blocks the synthesis, but not the release, of thyroid hormone. Fourteen cases of aplasia cutis (scalp defect) among infants exposed to methimazole in utero are described in the literature (Bachrach and Burrow, 1984; Farine et al. The scalp, skull, and underlying cerebral cortex development is complete by the 3rd month of ges- tation, suggesting that first-trimester exposure to methimazole is critical for induction of the scalp defects (Kokich et al. However, in the largest series of cases reported (243 infants) of methimazole use in pregnancy, no relationship was found between maternal methimazole therapy and scalp malformations (Momotani et al. It is possible that the association of maternal use of methimazole and carbimazole during pregnancy with congenital skin defects in children is not as strong as originally thought (Van Dijke et al. Two cases of fetal goiter development were reported in associ- ation with carbimazole use in pregnancy (Sugrue and Drury, 1980). Follow-up of chil- dren exposed to carbimazole in utero found no physical growth or development deficits (McCarroll et al. Maternal carbimazole or methimazole therapy for hyperthy- roidism is not recommended for use during pregnancy. Based on very limited information, ethionamide (thioamide) does appear to pose a high risk of congen- ital anomalies (Zierski, 1966). The two most common disorders of pregnancy for which pro- pranolol has been used are hypertension and hyperthyroidism. An extensive review of the use of propranolol in pregnancy can be found in Chapter 3. Iodides cross the pla- centa, and the fetus is particularly sensitive to the inhibitory effects of excessive iodide (Wolff, 1969). More than 400 cases of neonatal goiter have been reported in infants of mothers treated with potassium iodide during pregnancy (Ayromlooi, 1972; Carswell et al. These goiters, due to fetal thyroid inhibition with secondary compensatory hypertrophy, can be very large and in some cases lead to tracheal compression and neonatal death. Only in one scenario is potassium iodide not only useful, but is indicated during preg- nancy – the case of ‘thyroid storm. One survey of 182 pregnancies inadvertently exposed to radioiodine therapy for hyperthyroidism in the first trimester revealed six infants with hypothyroidism; of these, four were mentally retarded (Stoffer and Hamburger, 1976). A number of case reports document children who developed either congenital or late-onset hypothyroidism after their mothers were treated with 131I during various stages of pregnancy (Fisher et al. Maternal hypothyroidism Untreated hypothyroidism can impair fertility and increase the incidence of spontaneous abortion, stillbirth, and congenital anomalies (Davis et al. Possible causes of hypothyroidism include iodine deficiency, iatrogenic (thyroidectomy or 131I therapy) or thyroiditis. Symptoms include cold intolerance, irritability, difficulty with concentration, dry skin, coarse hair, and constipation. Clinical diagnosis may be difficult because many of these symptoms are commonly seen in normal pregnancy. Several reports suggest that it is not a major cause of con- cern (Kennedy and Montgomery, 1978; Montoro et al. The frequency of con- genital anomalies was not increased among 537 pregnancies exposed to exogenous thy- roxine or thyroid hormone during the first trimester, and 1605 pregnancies exposed at any time during pregnancy (Heinonen et al. Evidence indi- cates no increased risk of congenital anomalies in infants whose mothers used liothyro- nine during pregnancy (Heinonen et al. Pregnant women require three to four times the nonpregnant daily requirement for calcium, particularly during the latter half of gestation when most of the fetal bone mineral is deposited.