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Dengue fever (UK: / d

e /, US: / d

i /), also known as breakbone fever, is an infectious tropical disease caused

by the dengue virus. Symptoms include fever, headache, muscle and joint pains, and a characteristic skin rash that is similar to measles. In a small proportion of cases the disease develops into the life-threatening dengue hemorrhagic fever, resulting in bleeding, low levels of blood platelets and blood plasma leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs. Dengue is transmitted by several species of mosquito within the genus Aedes, principally A. aegypti. The virus has four different types; infection with one type usually gives lifelong immunity to that type, but only short-term immunity to the others. Subsequent infection with a different type increases the risk of severe complications. As there is no vaccine, prevention is sought by reducing the habitat and the number of mosquitoes and limiting exposure to bites. Diagnosis The diagnosis of dengue is typically made clinically, on the basis of reported symptoms and physical examination; this applies especially in endemic areas.[1]However, early disease can be difficult to differentiate from other viral infections.[5] A probable diagnosis is based on the findings of fever plus two of the following:nausea and vomiting, rash, generalized pains, low white blood cell count, positive tourniquet test, or any warning sign (see table) in someone who lives in anendemic area.[23] Warning signs typically occur before the onset of severe dengue.[8] The tourniquet test, which is particularly useful in settings where no laboratory investigations are readily available, involves the application of a blood pressure cuff for five minutes, followed by the counting of any petechialhemorrhages; a higher number makes a diagnosis of dengue more likely.[8] It can be difficult to distinguish dengue fever and chikungunya, a similar viral infection that shares many symptoms and occurs in similar parts of the world to dengue.[7] Often, investigations are performed to exclude other conditions that cause similar symptoms, such as malaria, leptospirosis, typhoid fever, and meningococcal disease.[5] Management There are no specific treatments for dengue fever.[1] Treatment depends on the symptoms, varying from oral rehydration therapy at home with close follow-up, to hospital admission with administration of intravenous fluids and/or blood transfusion.[28] A decision for hospital admission is typically based on the presence of the "warning signs" listed in the table above, especially in those with preexisting health conditions.[5]

Typhoid fever, also known as typhoid,[1] is a common worldwide illness, transmitted by the ingestion of food or water contaminated with the feces of an infected person, which contain the bacterium Salmonella enterica, serovar Typhi. [2][3] The bacteria then perforate through the intestinal wall and are phagocytosed by macrophages. The organism is a Gramnegative short bacillus that is motile due to its peritrichous flagella. The bacterium grows best at 37C / 98.6F human body temperature. Signs and symptoms Typhoid fever is characterized by a slowly progressive fever as high as 40 C (104 F), profuse sweating and gastroenteritis. Less commonly, arash of flat, rose-colored spots may appear.[5]Classically, the course of untreated typhoid fever is divided

into four individual stages, each lasting approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache, and cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in the number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a positive reaction and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal test is negative in the first week. Diagnosis of typhoid Diagnosis is made by any blood, bone marrow or stool cultures and with the Widal test (demonstration of salmonella antibodies againstantigens O-somatic and H-flagellar). In epidemics and less wealthy countries, after excluding malaria, dysentery or pneumonia, a therapeutic trial time with chloramphenicol is generally undertaken while awaiting the results of Widal test and cultures of the blood and stool.[9] Treatment The rediscovery of oral rehydration therapy in the 1960s provided a simple way to prevent many of the deaths of diarrheal diseases in general. Where resistance is uncommon, the treatment of choice is a fluoroquinolone such asciprofloxacin[10][12] otherwise, a third-generation cephalosporin such as ceftriaxone or cefotaxime is the first choice.[13][14][15] Cefixime is a suitable oral alternative.[16][17] Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol,trimethoprimsulfamethoxazole, Amoxicillin and ciprofloxacin, have been commonly used to treat typhoid fever in developed countries. Prompt treatment of the disease with antibiotics reduces the case-fatality rate to approximately 1%. Prevention Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid does not affect animals and therefore transmission is only from human to human. Typhoid can only spread in environments where human feces or urine are able to come into contact with food or drinking water. Careful food preparation and washing of hands are crucial to preventing typhoid.

Mode of action Betahistine has a very strong affinity as an antagonist for histamine H3 receptors and a weak affinity as an agonist for histamine H1 receptors. Betahistine seems to dilate the blood vessels within the middle ear which can relieve pressure from excess fluid and act on the smooth muscle. Betahistine has two modes of action. Primarily, it has a direct stimulating (agonistic) effect on H1 receptors located on blood vessels in the inner ear. This gives rise to local vasodilation and increased permeability, which helps to reverse the underlying problem of endolymphatic hydrops. In addition, betahistine has a powerful antagonistic effects at H3 receptors, and increases the levels of neurotransmitters released from the nerve endings. This is thought to have two consequences;

The increased amounts of histamine released from histaminergic nerve endings can stimulate H1 receptors, thus augmenting the direct agonistic effects of betahistine on these receptors. This explains the potent vasodilatory effects of betahistine in the inner ear, which are well documented.

It is postulated that betahistine increases the levels of neurotransmitters such as serotonin in the brainstem, which inhibits the activity of vestibular nuclei.

Side effects

  

Headache. Low level of gastric side effects. Nausea can be a side effect, but the patient is generally already experiencing nausea due to the vertigo so it goes largely unnoticed.

Decreased appetite, leading to weight loss

Contraindications Betahistine is contraindicated for people with peptic ulcers or tumours of the adrenal gland, such as pheochromocytoma. People with bronchial asthma should be closely monitored. USES: This medication is used to treat dizziness (vertigo) in those who have Meniere's disease. HOW TO USE: Take as directed, usually three times a day. Dosage is adjusted to each person's response. PRECAUTIONS: Before taking this drug, tell your doctor your medical history, especially of: allergies, ulcers (active or past), asthma,pheochromocytoma. This medication should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor. It is unknown if this drug is excreted into human milk. Consult your doctor before breastfeeding. This drug is not recommended for use in children. DRUG INTERACTIONS: Tell your doctor of all nonprescription and prescription medication you may use, especially of: antihistamines (e.g., diphenhydramine, meclizine), histamine-2 (H2) blockers (e.g., cimetidine). Do not start or stop any medicine without doctor or pharmacist approval. OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly. NOTES: Do not share this medication with anyone else. MISSED DOSE: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not "double-up" the dose to catch up. STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom.

Dosage

It comes in doses of 8, 16 and 24 mg.The usual dose is 16 mg 3-4 times per day although greater effect is obtained for doses as high as 48 mg at a time (Strupp,et al. 2008). Most people that report a positive effect can decide this with a few days -- it doesn't seem to take 1 month to figure out whether betahistine is helping or not.

Ceftriaxone: Indications

Ceftriaxone has been compared to many other antibiotics in relation to a great number of infectious diseases. In many cases it proved to be equally effective as therapies that were more expensive or potentially more dangerous. Amongst the multitude of possible indications the following should be mentioned in particular:

y y y y y

Meningitis in neonates, children, and adults (except pseudomonas infections). Multiresistant Gram-negative infections, in particular caused by enterobacters. Gonorrhoea caused by -lactamase producing gonococci (single dose of 250 mg i.m.). Osteomyelitis caused by Staphylococcus aureus. Disseminated and persisting forms of Lyme disease.

Ceftriaxone is also effective against urinary tract infections, lower respiratory tract infections, infections of the skin and soft tissue, adnexitis, typhus, as well as in the prevention of infections in neutropenia and perioperative infections (single dose). It can be used for endocarditis or septicemia if there are sensitive germs. Ceftriaxone is not always effective against syphilis and chancroid (Haemophilus ducreyi). It is only insufficiently active in pseudonomas infections. Dose Indication Administration Initial loading dose Dose dangerous and advanced infections* i.v (i.m.) 1-2 g Interval Maintenance dose Dose Interval 12 to 24 hours

12 to 24 hours 1-2 g

DOSAGE AND ADMINISTRATION Rocephin (ceftriaxone) may be administered intravenously or intramuscularly. Do not use diluents containing calcium, such as Ringer's solution or Hartmann's solution, to reconstitute Rocephin (ceftriaxone) vials or to further dilute a reconstituted vial for IV administration because a precipitate can form. Precipitation of ceftriaxone-calcium can also occur when Rocephin (ceftriaxone) is mixed with calcium-containing solutions in the same IV administration line. HOW SUPPLIED Rocephin (ceftriaxone) is supplied as a sterile crystalline powder in glass vials. The following packages are available: Vials containing 500 mg equivalent of ceftriaxone. Box of 1 (NDC 0004-1963-02) and box of 10 (NDC 0004-1963-01). Vials containing 1 gm equivalent of ceftriaxone. Box of 1 (NDC 0004-1964-04) and box of 10 (NDC 0004-1964-01). NOTE: Rocephin (ceftriaxone) sterile powder should be stored at room temperature, 77F (25C) or below, and protected from light. SIDE EFFECTS Rocephin (ceftriaxone) is generally well tolerated. In clinical trials, the following adverse reactions, which were considered to be related to Rocephin (ceftriaxone) therapy or of uncertain etiology, were observed:

LOCAL REACTIONS - pain, induration and tenderness was 1% overall. Phlebitis was reported in < 1% after IV administration. The incidence of warmth, tightness or induration was 17% (3/17) after IM administration of 350 mg/mL and 5% (1/20) after IM administration of 250 mg/mL. HYPERSENSITIVITY - rash (1.7%). Less frequently reported ( < 1%) werepruritus, fever or chills. CONTRAINDICATIONS Rocephin (ceftriaxone) is contraindicated in patients with known allergy to the cephalosporin class of antibiotics. Neonates ( 28 days) Hyperbilirubinemic neonates, especially prematures, should not be treated with Rocephin. In vitro studies have shown that ceftriaxone can displace bilirubin from its binding to serum albumin, leading to a possible risk of bilirubin encephalopathy in these patients. Rocephin (ceftriaxone) is contraindicated in neonates if they require (or are expected to require) treatment with calcium-containing IV solutions, including continuous calcium-containing infusions such as parenteral nutrition because of the risk of precipitation of ceftriaxone calcium (seeCLINICAL PHARMACOLOGY, WARNINGS and DOSAGE AND ADMINISTRATION). Brand Name: PLASIL CLASSIFICATIONS Therapeutic: Antiemetics ACTIONS Physiologic Mechanism Decreased nausea and vomiting. Decreased symptoms of gastric stasis. Pharmacologic Mechanism Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of the upper GI tract and accelerates gastric emptying. INDICATION Management of esophageal reflux Treatment and prevention of postoperative nausea and vomiting NURSING CONSIDERATIONS Assess patient for nausea, vomiting, abdominal distention, and bowel sounds before and after administration. May cause drowsiness. Advise patient to avoid concurrent use of alcohol and other CNS depressant while taking this medication. Advise patient to notify health care professional immediately if involuntary movement of eyes, face or limbs occurs. Generic Name: Ceftriaxone Dosage: 250mg/ 500mg/ 1 g powder for injection (I.M./ I.V.) Category: Antibacterial

Mechanism of Action: Ceftriaxone like other cephalosphorin and penicillins, kills bacteria by inhibiting mucopepide synthesis and hence interfere with the synthesis of the bacterial cell wall. Ceftriaxone binds with high affinity to penicillin binding proteins in the bacterial cell wall, thus interfering with peptidolycan synthesis. Peptidoglycan is a hetropolymeric structure that provides a cell with mechanical stability. The final stage in the synthesis of peptidoclycan involves a completion of the cross linking and the terminal glycine residue of the pentaglycine bridge is linked to the fourth residue of the penta-petide. (D-alanine Indications: Lower respiratory tract infections Acute bacterial otitis media Skin and skin structure infections Urinary tract infections Uncomplicated gonorrhea Pelvic inflammatory disease Bacterial septicemia Bone and joint infections Intra-abdominal infections Meningitis Surgical prophylaxis Dosage and method of administration: Ceftriaxone is administered as a sodium salt by intravenous infusion or as deep intramuscular injections in the treatment of various susceptible infections that include chancroid, gastro-enteritis (invasive salmonellosis, shigellosis) gonorrhea, lyme disease, meningitis, septicaemia, surgical infection (prophylaxis), syphilis, typhoid fever and Whipples disease among others. Adults: the usual adult daily dose is 1 to 2 grams given once a day (or in equally divided doses twice a day) depending on the type and severity of infection. The total daily dose should not exceed 4 grams. For preoperative use (surgical prophylaxis), a single dose of 1 gram administered intravenously to 2 hours before surgery is recommended.

Contraindications: Ceftriaxone is contraindicated in patients with known allergy to cephalosporin class of antibiotics. Availability: Vial of 250mg with ampoule of (solvent) sterile water for injection (5mL) in box Vial of 500mg with ampoule of (solvent) sterile water for injection (5mL) in box Vial of 1 g with ampoule of (solvent) sterile water for injection (10mL) in box

Paracetamol Adverse effects

In recommended doses, the side effects of paracetamol are mild to non-existent.[22] In contrast to aspirin, it is not a blood thinner (and thus may be used in patients where coagulation is a worry), and it does not cause gastric irritation. [23] Prolonged daily use increases the risk of upper gastrointestinal complications such as stomach bleeding,[24] and may cause kidney or liver damage.[25][23]Paracetamol is metabolized by the liver and is hepatotoxic; side effects may be more likely in chronic alcoholics or patients with liver damage.[22][26] GENERIC NAME: ibuprofen BRAND NAME: Advil, Children's Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever etc. DRUG CLASS AND MECHANISM: Ibuprofen belongs to a class of drugs called non-steroidal anti-inflammatory drugs (NSAIDs). Other members of this class include aspirin, naproxen (Aleve), indomethacin (Indocin),nabumetone (Relafen) and several others. These drugs are used for the management of mild to moderate pain, fever, and inflammation. Pain, fever, and inflammation are promoted by the release in the body of chemicals called prostaglandins. Ibuprofen blocks the enzyme that makes prostaglandins (cyclooxygenase), resulting in lower levels of prostaglandins. As a consequence, inflammation, pain and fever are reduced. The FDA approved ibuprofen in 1974. PRESCRIPTION: Yes GENERIC AVAILABLE: Yes PREPARATIONS: Tablets of 200, 400, 600, and 800 mg; Chewable tablets of 50 and 100 mg; Capsules of 200 mg; Suspension of 100 mg/2.5 ml and 100 mg/5 ml; Oral drops of 40 mg/ml. STORAGE: Ibuprofen should be stored at room temperature, between 15-30C (59-86F). PRESCRIBED FOR: Ibuprofen is used for the treatment of mild to moderate pain, inflammation and fever caused by many and diverse diseases. DOSING: For minor aches, mild to moderate pain, menstrual cramps, and fever, the usual adult dose is 200 or 400 mg every 4 to 6 hours. Arthritis is treated with 300 to 800 mg 3 or 4 times daily. When under the care of a physician, the maximum dose of ibuprofen is 3.2 g daily. Otherwise, the maximum dose is 1.2 g daily. Individuals should not use ibuprofen for more than 10 days for the treatment of pain or more than 3 days for the treatment of a fever unless directed by a physician. Children 6 months to 12 years of age usually are given 5-10 mg/kg of ibuprofen every 6-8 hours for the treatment of fever and pain. The maximum dose is 40 mg/kg daily. Juvenile arthritis is treated with 20 to 40 mg/kg/day in 3-4 divided doses. Ibuprofen should be taken with meals to prevent stomach upset. DRUG INTERACTIONS: Ibuprofen is associated with several suspected or probable interactions that can affect the action of other drugs. Ibuprofen may increase the blood levels of lithium (Eskalith) by reducing the excretion of lithium by the kidneys. Increased levels of lithium may lead to lithium toxicity. Ibuprofen may reduce the blood pressure-lowering effects of drugs

that are given to reduce blood pressure. This may occur because prostaglandins play a role in the regulation of blood pressure. When ibuprofen is used in combination with aminoglycosides [for example,gentamicin (Garamycin)] the blood levels of the aminoglycoside may increase, presumably because the elimination of aminoglycosides from the body is reduced. This may lead to aminoglycoside-related side effects. Individuals taking oral blood thinners or anticoagulants [for example, warfarin(Coumadin)] should avoid ibuprofen because ibuprofen also thins the blood, and excessive blood thinning may lead to bleeding. PREGNANCY: There are no adequate studies of ibuprofen in pregnant women. Therefore, ibuprofen is not recommended during pregnancy. Ibuprofen should be avoided in late pregnancy due to the risk of premature closure of the ductus arteriosus in the fetal heart..

The main mechanism of action of paracetamol is considered to be the inhibition of cyclooxygenase (COX), and recent findings suggest that it is highly selective for COX-2.[54] While it has analgesic and antipyretic properties comparable to those of aspirin or other NSAIDs, its peripheral anti-inflammatory activity is usually limited by several factors, one of which is high level of peroxides present in inflammatory lesions. However, in some circumstances, even peripheral anti-inflammatory activity comparable to other NSAIDs can be observed. Because of its selectivity for COX-2 it does not significantly inhibit the production of the pro-clotting thromboxanes.[54] The COX family of enzymes are responsible for the metabolism of arachidonic acid to prostaglandin H2, an unstable molecule that is, in turn, converted to numerous other pro-inflammatory compounds. Classical anti-inflammatories such as the NSAIDs block this step. Only when appropriately oxidized is the COX enzyme highly active. [55][56] Paracetamol reduces the oxidized form of the COX enzyme, preventing it from forming pro-inflammatory chemicals. [57][58] This leads to a reduced amount ofProstaglandin E2 in the CNS, thus lowering the hypothalamic set-point in the thermoregulatory centre. SIDE EFFECTS: The most common side effects from ibuprofen are rash,ringing in the ears, headaches, dizziness, drowsiness, abdominal pain,nausea, diarrhea, constipation and heartburn. NSAIDs reduce the ability of blood to clot and therefore increase bleeding after an injury. Ibuprofen may cause ulceration of the stomach or intestine, and the ulcers may bleed. Sometimes, ulceration can occur without abdominal pain, and black, tarry stools, weakness, and dizziness upon standing (orthostatic hypotension) due to bleeding may be the only signs of an ulcer. NSAIDs reduce the flow of blood to the kidneys and impair function of the kidneys. The impairment is most likely to occur in patients who already have impaired function of the kidney or congestive heart failure, and use of NSAIDs in these patients should be cautious. People who are allergic to other NSAIDs, includingaspirin, should not use ibuprofen. Individuals with asthma are more likely to experience allergic reactions to ibuprofen and other NSAIDs. Fluid retention (edema), blood clots, heart attacks, hypertension and heart failure have also been associated with the use of NSAIDs. USES: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID), which relieves pain and swelling (inflammation). It is used to treat headaches, muscle aches, backaches, dental pain, menstrual cramps, arthritis, or athletic injuries. This medication is also used to reduce fever and to relieve minor aches and pains due to the common cold or flu.This drug works by blocking the enzyme in your body that makes prostaglandins. Decreasing prostaglandins helps to reduce pain, swelling, and fever. USES: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID), which relieves pain and swelling (inflammation). It is used to treat headaches, muscle aches, backaches, dental pain, menstrual cramps, arthritis, or athletic injuries. This medication is also used to reduce fever and to relieve minor aches and pains due to the common cold or flu.This drug works by blocking the enzyme in your body that makes prostaglandins. Decreasing prostaglandins helps to reduce pain, swelling, and fever.