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Elder may have age related decreased kidney function so may be at risk of increased toxicity. Patients should repeatedly be told to drink enough fluids so they pass urine at least 4 times a day. Minor side effects: Symptoms: nausea, anorexia, arthralgias, myalagias, injection site pain, fatigue, and abdominal pain. Laboratory toxicity: elevated amylase (biochemical pancreatitis), elevated liver enzymes (biochemical hepatitis), leukopenia / anaemia / thrombocytopenia. Nausea and anorexia are substantial problems where patients are already malnourished and dehydrated. Before or during treatment some patients have ataxia and severe tremors with or without headache. Renal toxicity: Renal toxicity is increased in patients who are dehydrated, hypokalemic [= low serum potassium. Patients should be told to drink until they have passed urine at 60 Guidelines for diagnosis, treatment and prevention of visceral leishmaniasis in Somalia least 4 times a day; babies should pass urine about each hour. The dose of meglumine antimoniate is based on the amount of pentavalent antimony the presentation contains and is 20mg/kg/day. Weight Meglumine Weight in Meglumine Weight in Meglumine in kg antimoniate dose in kg antimoniate dose in kg antimoniate dose in ml ml ml < 10 2 34 8. Consider also the big volume that should be injected (if the volume of injection exceeds 10 ml, it should be divided in 2 doses: one in each buttock or thigh). It should be given slowly = over 5-10 minutes or longer, using a small butterfly style needles. Other possibility is to dilute the drug in 5% glucose solution 500 ml in adults and give it slowly (30min-1hour). In addition, children with a significant infection also lose appetite, especially in the acute phase. The appetite is tested upon admission and is repeated at each follow-up visit to the health facility. Points to consider when conducting an appetite test: fi Conduct the appetite test in a quiet separate area. Overview of treatment for concurrent illnesses in kala-azar this is a short listing of diseases common for kala-azar patients. This is a bit different than what is used in general health facilities because kala-azar patients are immune compromised. Disease First line therapy Second line therapy Comments Pneumonia Amoxicillin for mild to Chlorampenicol: Many kala-azar patients especially < 5 years old have aspirated because of moderate pneumonia For serious pneumonia or treatment failure vomiting or a febrile seizure. Make sure older children do not give this can be a side effect A combination of all the medicines may be their tablets to babies. These are likely to be standard care with only a few comments specific to kalaazar patients Disease First line therapy Second line therapy Comments Malaria Artemisinin plus Fansidar Quinine All kala-azar patients are treated for Malaria on or within 1 week of for blood film positive malaria within 2 weeks of admission. The first week of kala-azar treatment the patient has treatment with Artemisinine plus Fansidar fever from kala-azar so diagnosis is difficult. Gentian violet if blisters open Ibuprophen should not be used early in treatment because of risk of bleeding. Ibuprophen may also increase the risk of bleeding, it may sometimes be used at the end of treatment 74 Guidelines for diagnosis, treatment and prevention of visceral leishmaniasis in Somalia Annex 16. Drug guidelines for kala-azar this table is to help with these uncommon medicines you may not be familiar with. If you are not comfortable please use other medicines that you know or ask for help. Then there would be no Sometimes the tablets are 250 25-adult 1-2 tab x 2 aches, sun sensitivity medicine for dysentery epidemics. Kala-azar weekly reporting forms Government of Somalia, Ministry of Health and Human Services Weekly reporting form Centre Year. Of the four states namely Bihar, Jharkhand, West Bengal and Uttar Pradesh, Bihar alone contributes more than 60% of the cases.

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The Government is seeking ways to increase competition in international shipping to Kiribati, thus it appears that the increase in international shipping services is anticipated in the future. In addition a proposal on the concept of Tarawa operating as a transhipment port for Nauru, Tuvalu, and Wallis and Futuna is being studied. This would increase the risk of global spread of infectious diseases to Kiribati if this project comes through. Transmission aboard and to countries via Cruise lines 27 Cruise ship tourism is essential for development. Passenger ships regularly visited one of the Line Islands (Tabuaeran or Fanning Island) once every 2 weeks during the months from September to March to put ashore passengers for a few hours before departing. The development strategy for the island envisages continuation of the present pattern of visits, with progressively more of the goods and services consumed by visitors while ashore provided by island residents. The chances of global transmission on Kiritimati and Tabuaeran is a threat since there is no hospital in Tabuaeran except for a small clinic and is remotely located that urgent medical assistance may take a while to get through. The hospital on Kiritimati is inadequately equipped and if there is a chance of an outbreak on this island, it may be difficult to respond urgently. With regards to maritime quarantine if a case is suspected, no port infrastructure exist on Taebuaran while the port on Kiritimati lacks required facilities at the site for medical procedures except to report and transfer all cases to the hospital. International Seafarers Seafarers and cruise ship employment is and established and essential area of employment for I-Kiribati. More than a thousand I-Kiribati seamen and women are employed on overseas merchant ships, fishing vessels and recently on cruise ships. There are prospects of increasing the number of seafarers over the next few years particularly for their high demand from the South Pacific Maritime Services and agreements by the Government and the Norwegian Cruise Line 96 Ships. Their potential role as transmission pathway to the general 98 population is critical especially in the least developed countries which Kiribati is one. The endemicity of Chlamydia is a concern because most seafarers have regular female partners in Kiribati with whom they do not use condoms. Aggravating health risk factors in Kiribati A number of environmental factors are increasing the risk of communicable diseases in Kiribati. High-density housing and overcrowding in urban areas, such as South Tarawa, is facilitating the transmission of infectious disease. For instance, tuberculosis incidence in Kiribati has now surpassed that of other Pacific island countries, and most reported cases 102 (70%) in 2005) are found in the urban settlement of Betio in South Tarawa. Inadequate water supplies, unsafe drinking water, variable standards of personal hygiene, poor food handling and storage, and poor sanitation are all contributing to the number of cases 103 of diarrhoeal, respiratory, eye and skin infections. Diarrhoeal diseases and respiratory 104 infections are major causes of mortality among children. The pandemic will inhibit growth of the service and industrial sectors and significantly increase the costs of human capacity-building and retraining. It is small and remote, experience high cost of transport and communication, isolated from market centres, with a low or narrow resource base and depend on few commodities for foreign exchange earnings, limited internal markets, and vulnerable to natural and environmental disasters. In this situation it is difficult to scale up resources, and capacity to respond to any incidence of a pandemic. Vaccines are costly, health capacity, resources and infrastructure at hospitals and port of entry is weak, it is surmountable to respond to pandemics adequately. In an incidence of a pandemic in Kiribati especially on the capital South Tarawa will adversely affect the health of the Kiribati community, the national economy and most importantly sustainable development. There is only one international seaport in Kiribati on South Tarawa, but the population residing on Tarawa is 43. The impacts will be devastating, if not from the embargoes and travel advisories to Kiribati, it will have adverse effects on human death and suffering and on the already weak economy from loss of human resources and the restitution of a skilled community. There is a need to develop, maintain, and strengthen domestic responses against pandemic incidents from all relevant sectors, particularly in this scenario, the public health and maritime sectors.

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An integrated model of environmental factors in adult asthma lung function and disease severity: a cross-sectional study. The annual socio-economic costs of Asthma allergic diseases the annual economic cost of asthma is $19. It accounts for an annual loss of more than 14 million school days per year (approximately 8 days for each student with asthma) and more hospitalizations than any other childhood disease. It is estimated that children with asthma spend an nearly 8 million days per year restricted to bed. Economic burden in direct costs of concomitant chronic obstructive pulmonary disease and asthma in a Medicare Advantage population. The socio-economic impact of atopic dermatitis in the United States: a systematic review. Copyright 2011 World Allergy Organization 224 Pawankar, Canonica, Holgate and Lockey Allergy Care: Treatment & Training Recognition of the specialty of allergy or Allergy and Clinical Immunology is recognized as a separate medical specialty. The length of fellowship is two years (with optional a third year for research) (academic) leading to a certifcation examination by a conjoint board of pediatrics and internal medicine. Regional differences in allergy/clinical Rural patients have increased diffculty obtaining health care in general, and limited data suggesting they immunology service provision between receive inferior care for asthma. There is limited data that there may be a higher burden of asthma hospitalizations, though further study in this area needs to be done. Rural Americans also travel greater distances to obtain care, and greater distance to care is a risk for poor health outcomes and increased morbidity and mortality. Patient care would be enhanced by the implementation of electronic medical records utilizing the special knowledge of Allergists. Most undergraduate programs include basic skills for diagnosing/treating asthma, but have several diagnosis and treatment limitations regarding allergic rhinitis, drug allergy, food allergy, etc. Regional differences in allergy/clinical There are no Allergy/Clinical Immunology services in the rural areas in Venezuela. Enhancements required for improved Our country has very limited access to specialized services in Allergology. We have too few specialists patient care and most of those are distributed within big cities. Government services are scarce, and there are no drug distribution programs; this means that most patients have to buy their medication without reimbursement, making it diffcult for the physician to prescribe the correct therapy, and causing problems with patient compliance. Except for a few isolated research efforts, the state provides very limited and confusing epidemiologic information. No offcial information is available regarding morbidity for almost any disease (including asthma and allergies) in the last 10 years. For any National-based allergy and asthma control program we must begin by gathering reliable epidemiological data, providing a strong academic background to our medical students, and designing diagnosis and treatment protocols that are suitable for General Practitioners, and that include a medication supply for patients. Percentage of population with one or more Estimated fgure: allergic diseases 10% of adult population 15% of childhood population 12% of total population Major allergen triggers that are implicated House dust mites Grass pollens Mold spores in the development or exacerbation of Animal danders allergic disease Food allergens Data source: Published material and clinical observations. Major (indoor/outdoor) environmental No data available pollutants that are implicated in the development or exacerbation of allergic disease the annual socio-economic costs of No data available allergic diseases Allergy Care: Treatment & Training Recognition of the specialty of allergy or A separate medical specialty. Regional differences in allergy/clinical There are no specialist allergy or clinical immunology services outside the capital city, Harare. Registered immunology service provision between specialists are resident and operate from the capital. Factors impacting on this situation include poor patient awareness of the existence of allergic diseases, limited government emphasis on the growing allergy epidemic, and limited funding for allergy service delivery, with limited preparedness of health workers to adequately diagnose and appropriately treat allergic conditions. Patients with asthma face challenges of delayed diagnosis and so tend to present with more severe disease. The subsequent challenge is a mismatch between disease severity and treatment regimens. Severe asthma and anaphylaxis patients are faced with the general challenges of shortages in the numbers of allergy and emergency physicians, limited access to intensive care units and limited access to emergency medication.

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Much more serious long-term consequences of opioids have only been identified from observational and epidemiological investigations; these include higher risk for poor 6 functional status, inhibition of endogenous sex hormone production with resulting hypogonadism 214 21 22 and infertility, immunosuppression, falls and fractures in older adults, neonatal abstinence 23 24 25 syndrome, cardiac arrhythmia related to methadone, central sleep apnea, opioid-induced 60 27 28 hyperalgesia, nonfatal overdose hospitalizations, emergency department visits, and death from 29 unintentional poisoning. There may be apprehension about worsening of pain and withdrawal symptoms or, if there is opioid use disorder, about reduced access to the drug. This, in turn, strengthens the therapeutic relationship and supports future strategies. Consider tapering patients in an outpatient setting if they are not on high dose opioids or do not have comorbid substance use disorder or an active mental health disorder, as this can be done safely and they are at low risk for failing to complete the taper. Interagency Guideline on Prescribing Opioids for Pain [06-2015] 36 How to Discontinue Opioids Selecting the optimal timing and approach to tapering depends on multiple factors. The rate of opioid taper should be based primarily on safety considerations, and special attention is needed for patients on high dose opioids, as too rapid a taper may precipitate withdrawal symptoms or drug-seeking behavior. In addition, behavioral issues or physical withdrawal symptoms can be a major obstacle during an opioid taper. Patients who feel overwhelmed or desperate may try to convince the provider to abandon the taper. Consider sequential tapers for patients who are on chronic benzodiazepines and opioids. Do not use ultra-rapid detoxification or antagonist-induced withdrawal under heavy sedation or anesthesia. Rapid taper (over a 2 to 3 week period) if the patient has had a severe adverse outcome such as overdose or substance use disorder, or c. Use validated tools to assess conditions (Appendix B: Validated Tools for Screening and Assessment). Consider the following factors when making a decision to continue, pause or discontinue the taper plan: a. Assess the patient behaviors that may be suggestive of a substance use disorder b. The rate may be slowed or paused while monitoring for and managing withdrawal symptoms. Use non-benzodiazepine adjunctive agents to treat opioid abstinence syndrome (withdrawal) if needed. Unlike benzodiazepine withdrawal, opioid withdrawal symptoms are rarely medically serious, although they may be extremely unpleasant. Symptoms of mild opioid withdrawal may persist for six months after opioids have been discontinued (Table 10). Refer to a crisis intervention system if a patient expresses serious suicidal ideation with plan or intent, or transfer to an emergency room where the patient can be closely monitored. Do not start or resume opioids or benzodiazepines once they have been discontinued, as they may trigger drug cravings and a return to use. Symptoms and Treatment of Opioid Abstinence Syndrome (withdrawal) Restlessness, sweating or Clonidine 0. Dose reduction, discontinuation of opioids, or transition to medication-assisted treatment 218 for opioid use disorder frequently improves function, quality of life, and even pain control. Because the experience of pain and the symptoms of withdrawal that accompany an opioid taper vary from one person to the next, there is not a one size fits all approach. Many pharmacologic therapies have been studied for use as adjunctive agents during opioid taper to 219-224 palliate opioid abstinence syndrome (withdrawal) as well as emergent insomnia and anxiety. A multidisciplinary approach to pain, including psychotherapy (behavioral activation, problem solving therapy, etc.