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By R. Yokian. Wheaton College, Wheaton Illinois.

Merozoites enter red blood cells zyvox 600 mg overnight delivery, and pass through several stages of development finally resulting in multiple 4 order zyvox 600 mg online. The red blood cells rupture phase a few merozoites releasing merozoites into the circulation buy zyvox 600 mg mastercard. In the able to swallow generic zyvox 600mg on line, is vomiting or has impaired con- gametocyte stage there is genetic recombination causing sciousness intravenous quinine is used. Treatment should be considered in patients with Clinical features features of severe malaria even if the initial blood Most patients have a history of recent travel to an en- tests are negative. The classical description of paroxysmal chills vere cases intensive care may be required. Examination may reveal tachycardia, pyrexia, subsequent treatment with primaquine to eradicate hypotension, pallor and in chronic cases splenomegaly. In general where there is no chloroquine resistance Complications weeklychloroquineisused. It may also lead to severe intravascular haemol- endemic area (in order to detect establish tolerance) ysis causing dark brown/black urine (blackwater fever) and should continue for 4 weeks after leaving the en- particularly after treatment with quinine. Investigations Diagnosis is by identication of parasites on thick and thin blood lms. Although the rst specimen is positive in 95% of cases at least three negative samples are re- Myelodysplastic and quired to exclude the diagnosis. The thick lm is more myeloproliferative disorders sensitive for diagnosis and the thin lm is used to dif- ferentiate the parasites and quantify the percentage of Myelodysplastic syndromes parasite infected cells. Supportive therapy includes red blood cell and platelet transfusions and the use of antibiotics for infections. Al- Incidence logeneic stem cell transplantation is potentially curative 20 per 100,000 per year over the age of 70 years. These conditions have some common features: r Refractory cytopenia with multilineage dysplasia and r Extramedullary haemopoesis in the spleen and liver. Pathophysiology There may be transformation from one condition to an- The disorder arises from a single abnormal stem cell. Clinical features Patients with myelodysplastic syndrome typically present with symptoms of anaemia, thrombocytopenia Incidence (spontaneous bruising and petechiae or mucosal bleed- 1per 100,000 per year. Investigations Bone marrow aspirate examination shows normal or in- creased cellularity with megaloblastic cells and some- Sex times ring sideroblasts and abnormal myeloblasts. Almost all patients have the Philadelphia chromosome, a Cytogenetic remission is achieved in 70% of patients. Initiallythereisachronicindolentphase lasting3 5years,followedbyanacceleratedphaselasting Polycythaemia vera 6 to 18 months. Myeloid precursors and megakaryocytes may is often found from an incidental full blood count. Investigations Age r Full blood count and blood lm reveal a high neu- Most commonly presents over the age of 50 years. There may also be an increase in other gran- Sex ulocytes (basophils and eosinophils), thrombocytosis M>F and anaemia. In the chronic phase blast cells account for <10% of peripheral white blood cells. Idiopathicdisorder,althoughgeneticandenvironmental r Bone marrow aspirate shows a hypercellular marrow factors have been suggested. Polycythemia results in increased Management blood viscosity increasing the risk of arterial or venous r Hydroxyurea can induce a haematologic remission thrombosis. Platelet function is often disrupted risking and decrease splenomegaly but does not treat the un- bleeding. Patients may complain r Imatinib, a competitive inhibitor of the Bcr-Abl ty- of pruritus especially after a hot bath or shower. Hy- rosine kinase, is recommended for Philadelphia- perviscosity may result in headache or blurred vision. Abnormalities in platelet function can lead to epis- taxis, bruising and mucosal bleeding (including pep- tic ulcer disease) although severe bleeding is unusual. Prevalence r Increased blood cell turnover can lead to hyper- 2per 1,000,000 population. Investigations Fullbloodcountshowsanincreasedredbloodcellcount, Sex haemoglobin and packed cell volume. Polycythaemia vera can be distinguished from other Aetiology causes of polycythaemia by an increase in white cell Increased risk following exposure to benzene or radi- count, platelets and a high neutrophil alkaline phos- ation. On examina- hydroxyurea has been considered safe for long-term tion there is massive splenomegaly. Symptoms and signs maintenance it is also associated with increased risk of marrow failure (anaemia, recurrent infections and of development of leukaemia in comparison with ve- bleeding) may be present. Amyeloproliferative disorder characterised by increased platelets due to clonal proliferation of megakaryocytes Age in the bone marrow. Pathophysiology Platelets although increased in number have disrupted Sex function causing them to clump intravascularly lead- M = F ing to thrombosis, and to fail to aggregate causing bleeding. Risk factors include exposure to excessive ra- bleeding and cerebrovascular symptoms. Pathophysiology In acute leukaemias there is replacement of the normal Investigations bone marrow progenitor cells by blast cells, resulting in The blood lm shows increased numbers of platelets and marrow failure. Bone marrow aspiration demonstrates from the lymphoid side of the haemopoetic system (see increased megakaryocytes. Patients with life-threatening haem- orrhagic or thrombotic events should be treated with Clinical features thrombocytopheresis in addition to hydroxyurea. An- Often there is an insidious onset of anorexia, malaise grelide is occasionally used. There is often a history of recurrent infections and/or easy bruising and mucosal Prognosis bleeding. Other presentations include lymph node en- Essential thrombocythaemia may eventually transform largement, bone and joint pain and symptoms of raised to myelobrosis or acute leukaemia but the disease may intra cranial pressure. Phase 2 involves in- travenous chemotherapy (cyclophosphamide and cy- tosine) with oral 6-mercaptopurine. Lymphoid Stem Cell r Intensication: This involves intravenous metho- trexate and folinic acid, with intramuscular L- asparginase. Lymphoblast r Consolidation: This involves several cycles of chemotherapy at lower doses. Supportive treatment: Cytotoxic therapy and the leukaemia itself depresses normal bone marrow func- T Cell B Cell tion and causes a pancytopenia with resulting infection, anaemia and bleeding. Microscopy Prognosis The normal marrow is replaced by abnormal Prognosisisrelatedtoage,subtypeandinverselypropor- monotonous leukaemic cells of the lymphoid cell line. Over90%ofchildren The leukaemia is typed by cytochemical staining and respond to treatment, the rarer cases occurring in adults monoclonal antibodies to look for cell surface mark- carry a worse prognosis. Full Most common in the middle aged and elderly blood count shows a low haemoglobin, variable white count,lowplateletcount. Bonemarrowaspirationshows Sex increased cellularity with a high percentage of blast cells.

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During or shortly after birth cheap zyvox 600mg free shipping, babies are also at higher risk of developing pneumonia from coming into contact with infectious agents in the birth canal zyvox 600 mg without prescription, or from contaminated articles used during the delivery order zyvox 600mg on-line. These modes of transmission help to explain why certain risk factors increase the probability that children or adults will develop pneumonia cheap zyvox 600 mg with mastercard. Under-nutrition/malnutrition, which weakens the immune system and reduces resistance to infection. Inadequate breastfeeding or formula feeding of infants under six months old, which predisposes them to malnutrition and infection. Lack of immunization against vaccine-preventable diseases that affect the respiratory system. Exposure to indoor air pollution, especially smoke from cooking res burning vegetable and animal waste (e. Children who have bacterial pneumonia usually become severely ill and show the following symptoms:. This classication is very important because it determines what treatment is given to the patient (as you will see in Section 35. Presence of general danger signs (unable to drink or eat, lethargic or A child with fast breathing, chest unconscious) in-drawing or stridor should be immediately referred to hospital. You should refer all patients with severe pneumonia immediately to the nearest health centre or hospital, where appropriate drugs Infants less than two months old can be prescribed by doctors or health ofcers. Here we remind you of the oral antibiotics you can give children with non-severe pneumonia without any other danger signs. The course of treatment is for ve days with either co-trimoxazole (the preferred antibiotic drug), or if co-trimoxazole is not available, give amoxicillin. The doses of co-trimoxazole or amoxicillin depend on the age or weight of the child, and were summarised earlier in Table 35. What dose of co-trimoxazole syrup would you give this child, and for how many days? If any of your non-severe patients She is between 12 months and ve years, so you should give her 7. You need to know about them so you can teach members of your community how they can protect their children and vulnerable adults from acute otitis media, pharyngitis and pneumonia. Control measures, such as the treatment or isolation of cases, are applied after the occurrence of the disease, with the aim of reducing the transmission of the infectious agents to new susceptible people. Feeding children with adequate amounts of varied and nutritious food to keep their immune system strong. Avoiding irritation of the respiratory tract by indoor air pollution, such as smoke from cooking res; avoid the use of dried cow dung as fuel for indoor res. Haemophilus inuenzae type b (Hib) vaccine at 6, 10 and 14 weeks; The dosages, schedules and Hib is one of the ve vaccines in the pentavalent vaccine used in vaccination routes for Hib, Ethiopia. Immunization also increases control, by reducing the reservoir of infection in the community and increasing the level of herd immunity (described in Study Session 1 in Part 1 of this Module). Children with symptoms of acute otitis media should be identied as soon as possible and treated by wicking the pus from the ear, and giving antibiotics to prevent complications such as deafness, meningitis and pneumonia. Children with symptoms of pharyngitis should be referred to a higher level health facility for assessment and treatment. Children with severe pneumonia are at high risk of death, and should immediately be referred to a higher level health facility to save their lives. C Rheumatic heart disease is the result of the heart becoming infected with bacteria. Early diagnosis and treatment Adequate nutrition Immunization against respiratory tract infections Reduction of indoor smoke pollution Coughing or sneezing into a cloth, or turning away from other people 43 Study Session 36 Louse-Borne Diseases: Relapsing Fever and Typhus Study Session 36 Louse-Borne iseases: Relapsing Fever and Typhus Introduction You already learned about the most widespread vector-borne disease in Ethiopia malaria, transmitted by mosquitoes (Study Sessions 5 12 in Part 1 of this Module). Two other vector-borne diseases of public health importance in Ethiopia are the subject of this study session. They are caused by different bacteria, but are transmitted by the same vector the human body louse (plural, lice). The diseases are louse-borne relapsing fever and louse- borne typhus, which are classied as febrile illnesses because the symptoms always include high fever. In this study session, you will learn about the causes, modes of transmission, symptoms and methods of prevention of these diseases. This will help you to identify patients and quickly refer them to the nearest health centre or hospital for specialist treatment. You are also expected to report any cases of these louse-borne diseases to the District Health Ofce, so that coordinated action can be taken to prevent an epidemic from spreading in your community. Learning Outcomes for Study Session 36 When you have studied this session, you should be able to: 36. The human body louse (species name, Pediculus humanus humanus) is commonly found in the clothes, bedding and on the bodies of people living in overcrowded and insanitary conditions, where there is poor personal hygiene. When body lice are found, for example in clothes, the articles are said to be louse-infested. The bites cause an allergic reaction in the person s skin, which becomes inamed and itches, causing the person to scratch the area. Lice are transmitted from person to person during close contact and when sharing bedding in which eggs have been laid. It is one of the epidemic-prone diseases that can cause small, or large-scale epidemics anywhere in Ethiopia, with an estimated 10,000 cases annually. The bacteria multiply in the gut of the louse, but the infection is not transmitted to new hosts when the louse bites a healthy person. Instead, humans acquire the infection when they scratch their bites and accidentally crush a louse, releasing its infected body uids onto their skin. The bacteria enter through breaks in the skin, typically caused by scratching the itchy louse bites. After entering into the skin, the bacteria multiply in the person s blood and they can also be found in the liver, lymph glands, spleen and brain. The symptoms continue for three to nine days, while the immune system of the patient makes antibodies that attach to the bacteria and clear them from the blood, and the patient appears to recover. The numbers of bacteria gradually increase, and four to seven days after recovering from the rst episode of fever, the patient relapses, i. Almost all the organs are involved and there will be pain in the abdomen and an enlarged liver and spleen, in addition to the other symptoms. Without treatment with special antibiotics, 30% to 70% of cases can die from complications such as pneumonia and infection in the brain, leading to coma (a state of deep unconsciousness) and death. Precautions should be taken by you and by health workers in the hospital or health centre, to avoid close contact with a patient with relapsing fever, to prevent acquiring the infection. Louse-borne typhus (also known as epidemic typhus, jail fever or tessibo beshita in Amharic) is similar in many ways to relapsing fever. They are extremely small bacteria called Rickettsia prowazekii (named after two doctors who died of typhus when they were researching into the disease). Louse-borne typhus has caused major epidemics over many centuries, resulting in millions of deaths during war, famine and mass displacement.

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These are important issues that need careful attention but cannot be addressed in this paper generic zyvox 600mg mastercard. In short zyvox 600 mg with mastercard, Miles contends that this inter-generational dimension in medical practice reflects the moral obligation to consider one s teachers as one s parents and a way to secure the trust of patients and of public opinion cheap 600 mg zyvox with amex. The Commitments of the Physicians The Oath rehearses a set of obligations that mix together both moral con- cerns and religious interests in purity buy generic zyvox 600mg on line. Above all, however, the physician must restrain from all intentional wrong-doing and harm. Miles remarked that in W estern modern societies physicians and health care professionals played a particular role in society which assumes a special ethical contract for their conduct, which is often expressed in the adage Prim um non noc- 8 ere (Miles, 2004, pp. W hat the exact nature of this contract is and the basis for its obligatory dimension is not stipulated, nor clearly articulated by Miles. It is certainly the case that patients and society in general expect high standards of care for which the aim is the recovery and well-being of the patients. Some physicians will see abortion as moral wrong in the majority of the cases while others will consider the abortion of a fetus resulting from rape as an act of courage. In fact, Miles interprets the vow to keep the ill from injustice as a particular commitment to a specific view of the good. He does this so as to develop a critique of the health care delivery system in United States in which more than forty million Americans [who] do not have public or private health insurance for more than one year at a time, [a] fifth of these 112 F. W hile this is true that the medical profession is far from being united as to social concerns, particularly as to a universal health care system, it is worth noting that the introduction of the Medicare-Medic- aid Act (1965 1966) during the Kennedy and Johnson administrations (1961 1969) is precisely the source of the dependence of medicine on social institutions, thus rendering it quite un-Hippocratic. The inauguration of the managed care era transformed the medical profession on two levels, one of them being the dependence on those institutions that are often criti- cized for limiting health care benefits. The threat of malpractice lawsuits and the erosion of public trust in the medical profession due to the economic factors influencing health care delivery are important issues in contemporary reflections on the medical profession that damage to a certain extent the image of the medicine. Yet, the profound transformation of American medicine at the socio-economic level through which medicine became dependent on institutions (i. A cogent criticism of contem p orary m edicine m ust take into account this crucial elem ent which, as we will see, recast the idea of medicine as a profession. Among others, Miles attempts a criticism of the American approach to the provision of health care resources by arguing that the Hippocratic Oath, as well as the Hippocratic tradition, imply an obligation to establish a uni- versal health care. First, Miles argues from the Hippocratic injunc- tion to keep the ill from injustice to an obligation in social justice. The Greek term dik, as used in the Hippocratic corpus and generally in Greek thought, had no implications of a claim regarding distributive justice. Rather, as Ludwig Edelstein remarks, the physician obligation is towards his patient and not society per se. Second, from the fact of the matter that all industrialized societies except the United States provide for an all-encompassing health care system and also revere the Hippocratic tradition, it does not follow that they do so because of the Hippocratic tradition and its moral commitments. Granted this is a complicated issue, but it is not one that Miles estab- lishes convincingly, but which he is required to establish unless he wishes simply to hold that the establishment of a right to certain services without showing the actual benefit of that right is sufficient to secure his critique. Last but not least, he does not address the circumstance that all industrial- ized countries with universal health care coverage are more generally going a financial crisis and are as a result in the process of limiting their coverage and increasing the role of the private sector. This has particular relevance in that the Hippocratic Oath and Greek medicine were lodged in a market economy that eschewed governmental regulation of health care (on the concept of civic physicians in Ancient Greece see Nutton, 1992, esp. Finally, one could argue that while it is certainly regrettable ( unjust according to Miles) that some Americans do not have access to health care at a level higher that in many European countries, it must be emphasized that a universal health care system would likewise create injustice of various sorts. For instance, Canada prohibits already from buying better basic care, independently of one s ability to pay. The basis for a universal coverage and the notion of the right to health care seems then rather difficult to support. Not only does Miles fail to demonstrate how a universal coverage and the notion of the right to health care would be possible but he also did not rec- ognize the politically charged tone of this arguments for a universal health care system. Curiously Miles ignores his political assumptions but is eager to stress that Today, all economically developed nations whose healers claim descent from the Hippocratic tradition view universal access to affordable health care as a moral obligation of their health care system every developed nation except the United States. I believe that physicians could embrace a commitment to working for affordable universal health care as exemplifying the principle from what is to their harm or injustice I will keep them. His claim that the legal and ethical norms for these [medical] activi- ties and many other are governed by an implicit or explicit pact between physicians and society (Miles, 2004, p. The difficulty is that Miles does not develop the moral arguments needed to show that 114 F. Instead of a moral argument, he substitutes the dubious historical claim that the Hippocratic Oath and the professional tradition it supports requires such provision. Medicine as a Profession The Oath ends with the sanction that follows if the physician is not faithful of the covenant: If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite to all this be my lot. Oaths imply not only the requirement to keep personal promises but like- wise are a social institution which establish the rules for social interaction between individuals (i. Many scholars, Miles included, recognize that a position supporting the view that certain values and obligations are intrinsic to the practice of med- 12 icine (called the internal morality of medicine ) is problematic due the various moral visions inherent of our pluralistic society. Miles adopts a mid- dle way position arguing that the Oath reflects a blended position in which society s time-tested moral views are the proper measure of the ethics of medicine (Miles, 2004, p. Thus, Miles accepts that the moral standards The Hippocratic Oath and Contem porary Medicine 115 of medicine must be reevaluated in the light the historical development of society but likewise suggests that the Oath ought not to be regarded as an old relic relevant for past medical practitioners of Ancient Greece. The Oath, he claims, can still teach us one medical ethic among competing moral systems. It is only insofar as one is able to understand (thus, the necessity to study the Oath) how the Oath might have spoken to its own culture that one will be able to see how relevant it is for his or her own. This begs the question as to know whether everyone will recognize the moral values and obligations described in the Oath as relevant for contem- porary medicine. As I have emphasized, scholars such as Miles who regard the Hippo- cratic Oath simply as symbolic discount the full force of its power as a doc- ument to direct professional conduct. Thus although Greek medicine recognized and emphasized the idea of a guild/profession, it appears that it does not correspond to today s model of medical practice. Gone too are the simple certainties of an ethic based entirely on what the doctor thinks is good for the patient, and with it also any acquaintance with Hippocratic morality outside the Oath and a few phrases such as primum non nocere... Professors of medical history are giving way to medical ethicists as the keepers of the medical con- science, or are themselves turning to history of ethics as a way to ensure the relevance of their own discipline in a modern medical school. The reasons are multiple and they deserve a more careful examination than what I will be able to accomplish in this article. However, it is crucial to locate the development of medicine in its proper context, par- ticularly how American medicine went from the status of guild power between 1930 and 1965 to its decline in power from 1970 to 1990 (Krause, 1996). The turning point, Krause argued, is the introduction of the Medicare- Medicaid Act (1965 1966) during the Kennedy and Johnson administrations (1961 1969). These two programs forced the federal government, through Congress, to seek to control the increasing costs of health care. First, the medical profession could not maintain the independent professional and moral identity necessary to sustain a particular tradition, that is, the Hippocratic tradition.

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