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It can also help detect the presence of systemic to pulmonary arterial collaterals purchase propranolol 80mg on line, although it is not a sufficient test to completely define these tortuous vessels propranolol 40 mg discount. Additional information such as patency of the ductus arteriosus purchase propranolol 40 mg fast delivery, presence of a right aortic arch and additional lesions can also be clearly assessed buy propranolol 80 mg without a prescription. Therefore, cardiac catheterization continues to be a helpful procedure to delineate the distribution of the true pulmonary arteries and of the collaterals. In those patients with more exten- sive atresia of the outflow tract and more complex systemic to pulmonary arterial 17 Pulmonary Atresia with Ventricular Septal Defect 209 collaterals, cardiac catheterization is important in the long-term follow up of these patients to relieve stenotic areas in these vessels. This is often obtained prior to surgical repair in newly diag- nosed newborn children unless those patients will undergo an interventional cath- eterization, in which case cardiac catheterization will provide the information needed. Infants relying on the patent ductus arteriosus for adequate pulmonary blood flow, require immediate institution of prostaglan- din infusion after birth. Rare cases where pulmonary blood flow is excessive, secondary to extensive collaterals might require anticongestive heart failure therapy with diuretics. The main goal of therapy is to establish a reliable source of pulmonary blood flow by creating a communication between the right ventricle and the pulmonary arteries. These patients benefit from opening the atretic pulmonary valve in cases of membranous pulmonary valve atresia and patent main pulmonary artery with or without placement of a systemic to pulmonary arterial shunt. On the other hand, if pulmonary atresia is more extensive, affecting the pulmonary valve and main pulmonary artery, then a systemic to pulmonary arterial shunt is necessary to maintain a reliable source of pulmonary blood flow till the child is about 4 6 months of age when a right ventricle to pulmonary arterial conduit can be placed with closure of the ventricular septal defect. Children with multiple systemic to pulmonary arterial collaterals typically have poorly developed pulmonary arteries and numerous collateral vessels feeding different segments of the two lungs. Management in such cases is chal- lenging and requires multiple staging of operative repair. Repair starts by good understanding of the pulmonary arterial and collateral anatomy. The initial surgical step brings together as many collaterals and the pulmonary artery on one 210 K. This procedure is known as unifocalization since it connects all blood vessels supplying the lung to a single source of blood supply. After few weeks, the same surgical procedure is performed for the other side of the chest. A third surgical procedure is then performed to bring the two unifocalized sides together and connect to the right ventricle through a conduit (homograft). Those patients with abnormal pulmonary artery anatomy and extensive systemic to pulmo- nary arterial collaterals have poorer prognosis with less certain long-term results. Case Scenarios Case 1 A female newborn was noted to be severely cyanotic shortly after birth. The child was transferred to the neonatal intensive care unit for further evaluation. Physical Exam On physical examination, the patient was cyanotic, but did not otherwise appear sick. Heart rate was 148 bpm, respiratory rate 50, blood pressure was 62/38 mmHg, oxygen saturation 74% while breathing room air. On ausculta- tion, the first heart sound was normal and the second heart sound was single. The pulmonary vascular markings are decreased, suggesting decreased pulmonary blood flow. The differential at this juncture should include pulmonary pathology, cardiac pathology, as well as sepsis. A systolic murmur in the upper sternal border in a cyanotic new- born is suggestive of a congenital cyanotic heart defect. In this case, pulmonary blood flow depends on a patent ductus rather than numerous systemic to pulmonary arte- rial collaterals. Management The patient should be immediately initiated on prostaglandin infusion to keep the ductus arteriosus patent and maintain an adequate source of pulmonary blood flow. This can be done in the cardiac catheterization laboratory; however, if not possible, surgical reconstruction of the right ventricular outflow tract can then be performed. Case 2 A 16-month-old boy presented to the emergency department because of increased work of breathing and progressively turning blue during the prior recent months. In his first months of life, he was tachypneic and struggled with weight gain, but then improved until a few months ago when cyanosis developed. Physical Exam On physical examination, the patient was cyanotic and in respiratory distress. Cardiac auscultation revealed a single second heart sound and a blowing continuous murmur was heard over the precordium as well as over the back. Heart disease becomes more apparent once you examine this child and hear the continuous murmur over the precordium and back. The dys- morphic facial features along with cyanotic heart disease can help the practitioner with the differential diagnosis. He also has dysmorphic features common to DiGeorge/Velocardiofacial syndrome and this should prompt the suspicion for possible associated congenital heart disease commonly involving the conotruncal lesions such as tetralogy of Fallot and pulmonary atresia. As noted by the mother, this patient was not significantly cyanotic at birth, but actually had increased pul- monary blood flow causing his failure to thrive and increased work of breathing initially. As the patient grew older, he outgrew this 17 Pulmonary Atresia with Ventricular Septal Defect 213 source of pulmonary blood flow and started getting more cyanotic. In addition, the development of areas of stenoses in the systemic to pulmonary arterial collaterals caused a decrease in pulmonary blood flow. Typical of patients with DiGeorge syndrome (chromosome 22q11 deletion), the pulmonary arteries are commonly abnormal or discontinuous as in this case. Management This patient needs surgical intervention to improve his pulmonary blood flow. This patient should also be evaluated for findings associated with 22q11 deletion. Finally, the family should be coun- seled regarding importance of proper pediatric followup since this is an unusual late presentation. Children with ventricular septal defect tend to have increased pulmonary blood flow, while those with intact ventricular septal defect rely on the patency of ductus arteriosus to supply pulmonary blood flow. As the ductus arteriosus constricts, pulmonary blood flow is severely limited resulting in cyanosis. This makes it the third most common form of cyanotic congenital heart disease after tetralogy of Fallot and transposition of the great arteries. Anatomy/Pathology The absence of a tricuspid valve orifice causes blood from the right atrium to flow into the left atrium through a foramen ovale or atrial septal defect. The development of the right ventricle relies largely on blood flow during fetal life, so it is invariably hypoplastic. Atresia of the tricuspid valve prevents antegrade flow into the right ventricle, thus causing hypoplasia of the right ventricle. Type I: when the great arteries are normally related (approximately 70% of cases). Systemic and pulmonary venous blood then mixes in the left atrium and passes through the mitral valve to the left ventricle. These patients become more cyanotic over the first hours of life as the ductus arteriosus constricts resulting in drop in pulmonary blood flow. However, as systemic vascular resistance increases and pulmonary vascular resistance decreases over the first few days of life, blood will preferentially flow into the pulmonary artery causing excessive pulmonary blood flow and congestive heart failure. This situation mimics mitral atresia because although the ventricle on the left side of the heart develops normally, but it is morphologically the right ventricle, which is intended to handle pulmonary pressures and not systemic pressures. However, due to the complete mixing of blood in the left atrium, all these patients have some degree of cyanosis that is usually noticeable before the first week of life. The second heart sound is single if there is severe pulmonary valve stenosis; otherwise it splits in a normal fashion. Therefore, these patients will present with symptoms of congestive 18 Tricuspid Atresia 219 Fig. The second heart sound may be single due to pulmonary atresia sec- ondary to tricuspid atresia and hypoplastic right ventricle. Pulmonary valve may be normal if patient has a ventricular septal defect allowing for blood flow from the left ventricle and into the right ventricle and pulmonary valve heart failure. Auscultation reveals a single second heart sound and a systolic ejection murmur due to increased flow across the pulmonary valve. On examination, these patients are tachypneic, mildly cyanotic, and likely hypotensive depending on the degree of restriction of systemic flow. On auscultation, they have a single and loud S2, as the aortic valve is anterior when the great arteries are transposed. The degree of cardiomegaly is proportional to the degree of pulmonary blood flow, i. Left axis deviation is less common in those patients with transposed great arteries. There might also be right or sometimes bilateral atrial enlargement as evidenced by tall or wide P waves, respectively (Fig. Echocardiography Echocardiography readily establishes the diagnosis and is the diagnostic procedure of choice. Echocardiography is also essential to evaluate these patients following surgical palliative procedures to monitor for valve regurgitation, ventricular dysfunction, pulmonary flow obstruction and development of clots. A ventricular septal defect is noted in this patient Cardiac Catheterization Cardiac catheterization is no longer necessary during the newborn period as echocardiography provides a reliable non-invasive means to diagnose this entity. On the other hand, cardiac catheterization is essential in the older patient who has undergone previous palliative surgical interventions. This mainly helps deter- mine pulmonary vascular resistance, pulmonary pressures and size of the pulmo- nary arteries, all of which would help plan future surgical management. Newborn children with decreased pulmonary blood flow, who represent the majority of cases, will present with severe cyanosis and will require prompt prostaglandin infusion in order to maintain patency of the ductus arteriosus and improve pulmonary blood supply. Since these patients present with symptoms of congestive heart failure, they can benefit from diuretic therapy. The ultimate goal of management is to separate systemic and pulmonary flow to prevent mixing and to utilize the single functional ventricle to supply the systemic circulation. This is performed initially through a Glenn proce- dure (superior vena cava to pulmonary artery) at about 6 9 months of age and completion of the Fontan procedure (inferior vena cava to pulmonary artery at about 12 18 months of age). This usually provides adequate pulmonary blood flow for only the first few months of age since the shunt does not grow with the patient. At around 6 months of age, when the pulmonary vascular resistance is low, a bidirectional Glenn proce- dure is performed. At around 2 years of age, a Fontan operation is then performed to direct the rest of the systemic venous blood (from the inferior vena cave) to the right pulmonary artery. This is done through the use of a tunnel conduit and provides the last step in separating the pulmonary and systemic circulations. Patients with increased pulmonary blood flow might require a band to be placed across the main pulmonary artery to limit the amount of pulmonary blood flow if anti-congestive heart failure treatment is inadequate.

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These codes are categorized primarily on the has classically been used as the culture-based basis of the site and type of infection involved buy generic propranolol 80 mg on line. The increased prevalence of drug- 53 generic propranolol 40mg without a prescription,067 cases per 100 generic propranolol 80mg on-line,000 adult women cheap propranolol 80mg on-line, based on the resistant bacteria has made susceptibility testing National Health and Nutrition Examination Survey particularly important. Self-reported incidence of physician-diagnosed urinary tract infection during the previous 12 months by age and history of urinary tract infection among 2000 United States women participating in a random digit dialing survey. The average standard error for the total incidences in each of the age groups is 2. Urinary tract infections may be associated with The need for urine culture is also an area of debate. It is as frst-line therapy for patients without an allergy generally believed that asymptomatic bacteriuria in to this compound (5). Specifc fuoroquinolones were elderly patients does not need to be treated, although recommended as second-line agents. Prescribing trends from 1989 through 1998a Adjusted Odds Ratio (95% Confdence Interval) for Predictor, Antibiotic Prescribed 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 Year (per decade)b Trimethoprim-sulfamethoxazole 48 35 30 45 24 0. All trends adjusted for age younger than 45 years and history of urinary tract infection. These using more-expensive antimicrobials such as medications cost less than newer antimicrobials fuoroquinolones as initial therapy. In addition, reserving be due in part to increased rates of outpatient care fuoroquinolones and broad-spectrum antimicrobials and increased availability and marketing of these for complicated infections or cases with documented products. However, it has the potential to increase resistance to frst-line therapy may help reduce the both overall costs and antimicrobial resistance. Expenditures for female urinary tract infection (in millions of $) and share of costs, by site of service 1994 1996 1998 2000 Totala 1,885. Trends in visits by females with urinary tract infection listed as primary diagnosis, by site of service and year. While the overall indicates that there was a gradual decline in the rate of inpatient stays for women 84 years of age rate of admissions between 1994 and 2000 (Table and younger has remained relatively constant, there 10). This trend is refected across essentially all age was even higher for women over 95, increasing from strata analyzed. It likely refects increased use of oral 1,706 per 100,000 in 1992 to 2,088 in 1998. Urinary antimicrobials and home-based intravenous therapy tract infections may be more severe in frail elderly in the treatment of women with pyelonephritis. The women due to additional comorbidity, and this may decline in age-unadjusted rates of hospitalization for necessitate more aggressive treatment with inpatient women with pyelonephritis was most noticeable in hospitalization and intravenous antimicrobial African American and Caucasian women. African American women had higher rates relatively stable in Hispanic and Asian women. Rates of inpatient treatment than did other ethnic groups of hospitalization declined in all geographic areas, (1. This trend age) and has been relatively stable overall for those was seen across all age groups, although elderly aged 55 to 74 (Table 9). The most striking fnding in the data is that women 85 and older had inpatient Outpatient Care hospitalization rates 2. Nosocomial infections may also infuence The overall rate of hospital outpatient visits for the rates of hospitalization in this patient group. The most 162 163 Urologic Diseases in America Urinary Tract Infection in Women 162 163 Urologic Diseases in America Urinary Tract Infection in Women 164 165 Urologic Diseases in America Urinary Tract Infection in Women striking increases were observed in young women Table 11. Trends in mean inpatient length of stay (days) for adult females hospitalized with urinary tract infection 18 to 34 years of age. Overall rates of hospital listed as primary diagnosis outpatient visits by young women for any reason Length of Stay were 1. These increases in physician outpatient services occurred in the 35 to 64 and 65 year old age groups, but not in 18- to 34- year-old groups. National trends in visits by females for urinary tract infection by patient age and site of service. When physician outpatient services are stratifed a general increase in utilization between 1992 and by provider specialty, some interesting trends 1995, which remained relatively stable in 1998 (Table emerge. The most striking observation in this analysis consistently lower than those for visits to family is the peak in utilization among women between 75 practitioners and general practitioners. The signifcance of this is dwelling 75- to 84-year-old population who are treated unclear, but the trend may refect increased access to as outpatients. Although this trend has been observed in some of the other analyses, Emergency Room Care it is most pronounced in this comparison. Utilization ambulatory surgery centers (Table 18) revealed that rates for young women ranged from 2. When patients are stratifed or current diagnosis among female nursing home by age, little variation in utilization rates is seen over residents declined from 9,252 per 100,000 in 1995 this time period. Rate of emergency room visits by females with urinary tract infection listed as primary diagnosis, by patient race and year. Inpatient services accounted for the majority of incontinence than did women in the general nursing treatment costs, although the fraction of expenditures home population (Tables 22 and 23). The overall $100 million in 1998 among Medicare enrollees under rate of indwelling catheter use in nursing homes 65, primarily the disabled. A substantial number of inpatient costs in the South were the highest in the United hospitalizations, outpatient hospital and clinic visits, States. The associated direct and An analysis of prescribing costs refects a indirect costs are also large and include substantial propensity to prescribe expensive medications such out-of-pocket expenses for the patients. Expenditures for female Medicare benefciaries for treatment of urinary tract infection (in millions of $), by may occur incident to the use of fuoroquinolones. Productivity Management survey suggest that 24% of women with a medical claim for pyelonephritis missed some work time related to treatment of the increases in health care costs driven by prescription condition, the average being 7. These data do not refect the suggest that diabetes may be a risk factor for the success of treatment or whether prescriptions were development of infection (Table 30). Average annual spending and use of outpatient that lead to an increase in urinary retention, which prescription drugs for treatment of urinary tract infection in turn provides a nidus for infection. Drug Name Rx Claims Price ($) Expenditures ($) Assuming a prevalence of diabetes in the 40- to 70- Cipro 774,067 60. Including expenditures on these excluded medications would increase total outpatient drug spending for urinary tract infec- There appears to have been some decrease in the use tions by approximately 52%, to $146 million. There has been an overall trend Cost toward increased use of outpatient care in a variety ($ millions) of settings for acute pyelonephritis and selected cases Direct costs of complicated infections. Analysis of prescribing Medical expenses patterns reveals great reliance on fuoroquinolones Clinic charges 385 over more traditional frst-line antimicrobials. Prescriptions 89 This could have a variety of signifcant impacts in Nonmedical expenses terms of both cost and biology. Efforts to slow the Travel and childcare for visits 77 development of drug-resistant pathogens will depend Output lost due to time spent for visits 108 heavily on future prescribing patterns. Additional studies will be needed to identify the clinical effcacy and cost-utility of this approach. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U. Fluoroquinolones are both men and women, clinical studies suggest that particularly effective for this condition. Bacterial prostatitis, which may be acute or Basic concepts related to the defnition and diagnosis chronic, is an uncommon clinical problem. Even though a causal relationship has are the most common organisms in cases of chronic been diffcult to prove, chronic prostatic obstruction bacterial prostatitis. Patients may also complain or catheterization, both of which are common in the of obstructive and irritative urinary symptoms, sexual evaluation of men with obstructive voiding symptoms. The most common associated organisms 187 Urologic Diseases in America Urinary Tract Infection in Men The pathogenesis of prostatitis may be Cultures typically yield mixed fora with both aerobic multifactorial. The risk of mortality with prostatic ducts in the posterior urethra occurs in some Fournier s gangrene is high because the infection can patients, while ascending urethral infection plays a spread quickly along the layers of the abdominal wall role in others. Urethral instrumentation As described above, male anatomic structures that and chronic indwelling catheters may also increase may be involved with infectious processes include the risk. Today, however, most cases are associated with coliform organisms, Pseudomonas spp. These codes conditions caused by bacterial infection of the urethra are based primarily on the site and type of infection and epididymis, respectively. Percent contribution of males and females to types of urinary tract infections, 1999 2001. The younger group comprises primarily men and occurred across all racial/ethnic groups and those who qualifed for Medicare because of disability geographic regions. Increased use susceptibility data following the initiation of empiric of inpatient care may be associated with more severe therapy. Selection of antimicrobials is guided by the infections in older men due to increased comorbidity severity and location of the individual infection and and changes in immune response associated with by consideration of regional and local epidemiological increased age. The rate of inpatient utilization was somewhat higher in the Inpatient Care South than in other regions. In contrast, the rates of hospitalization for men in inpatient care for men 65 years of age and older are the 75- to 84-year age group have slowly declined, 190 191 Urologic Diseases in America Urinary Tract Infection in Men Table 4. The rates of inpatient care and 2000, the overall rate of inpatient care for the increase steadily with age, more than doubling with treatment of orchitis was relatively stable, ranging each decade beyond age 55. African American men had the highest rates of Inpatient utilization rates for elderly men decreased inpatient utilization. African lowest rates of inpatient care were seen in the West, American men had the highest rates of inpatient while rates were similar in other geographic regions. In those 95 years of age and older, the groups and geographic regions, and in both rural and rates of hospital outpatient visits more than doubled urban hospitals. In the years for which complete data outpatient clinics, physician offces, ambulatory regarding racial/ethnic differences in outpatient surgery centers, and emergency rooms. Each of these hospital utilization were available (1995 and 1998), settings was analyzed separately. Hispanic men had the highest rates of utilization, followed by African American men. The reason for likely refects the higher incidence and prevalence this observed difference is unclear. The reasons for the dramatic increases in 1992 and 1996 are unclear but may be Physician Offces related to coding anomalies. Rates in the most elderly more than 1,290,000 were for a primary diagnosis of cohort (95 and older) were similar to the overall mean.

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Operational aspects of Fraser ruling It is important that the healthcare worker makes a clinical judgement of the child s competence in each case order propranolol 40mg line. Certain criteria need to be met in order for a child to be deemed competent: The young person understands the potential risks and benefits of the treatment and the advice given The value of parental support is discussed buy 40 mg propranolol with visa. All healthcare workers are obliged to encourage the young person to inform their parents of the consultation purchase 80 mg propranolol free shipping. If s/he will not inform a parent buy discount propranolol 40mg on-line, the healthcare worker must explore the reasons why. It is important that the young person seeking contraceptive advice is aware that although the healthcare worker is legally obliged to discuss the value of parental support, the healthcare worker will respect their confidentiality The young person s physical or mental health may suffer if s/he is not prescribed treatment / contraception 315 The young person s best interests require the provision of medication / contraception without parental consent It is good practice for the healthcare worker to record the factors taken into account in making the assessment of the young person s capacity to give valid consent. It is strongly recommended that s/he records what information has been given to the young person, including questions asked and the responses given. This is invaluable if the young person s ability to make decisions were to be questioned or where parents disagree with the decisions made. Any patient under 16 who does not meet the Fraser guidance also needs to be discussed with the consultant. If disclosure is necessary to protect the young person or a third party from significant harm, confidentiality may be broken. It is important absolute confidentiality of information is not stated All young people may be seen with a friend if they wish, at any point throughout the consultation and/or examination. Groups of young people may be seen together where this facilitates access to information on services and health promotion advice It is important the health adviser ensures that the young person understands the possible consequences of sexual activity and is aware of the law relating to underage 316 sex. Safer sex is discussed and condom use demonstrated to all under 16s who are sexually active or potentially sexually active It is advisable the health adviser document which school the young person attends, particularly if they are under 16. This also provides useful data for targeting health promotion It is important the healthcare worker is satisfied that the patient has sufficient understanding of what is involved in any investigations and treatment proposed to give valid consent. This is ideally a multi-disciplinary decision although as the prescriber, the doctor is legally responsible It is important the age of the young person s partner is documented in the notes It is good practice to offer a screen for sexually transmitted infections to all sexually active young people. Many will initially decline, but may agree to a screen at a later date when they have developed greater confidence in the clinic staff. Where urine tests or self-taken swabs are available, they can be offered to young people who decline a genital examination It is advisable the healthcare worker discuss and document follow-up arrangements It is important that any concerns about a young person are discussed with other staff involved in their care and further concerns discussed with the senior doctor or consultant. It is recommended health advisers work in their referral area with the relevant school nurses, practice nurses, young peoples services, and contraceptive services to facilitate access. Specific flyers for the service can therefore be used and suitable health promotion leaflets/ materials made available Consider developing a designated young person s service, where young people need not see other adult attenders. There can be appropriate music/ videos, leaflets and posters for younger patients to make a more welcoming environment. If the young person is 13 or over, make an assessment as to whether sexual intercourse was consensual or not. Discuss cases of possible abuse with a consultant Assess whether the young person is Fraser competent. It is important to recognise boys tend to learn what they know about sex from male friends. Learning from their peer group may be complicated as often it is not acceptable that boys show ignorance and stories with other boys are often through real or imagined performance stories. Boys may mask their vulnerabilities by behaving in a macho way or by joking or messing about in the clinic, but it is important to be aware of this and their likely vulnerability. It is important to provide a safe environment, for example by seeing them with friends. Attendance of younger boys/ men may be encouraged by getting young girls attending the clinic to bring their boyfriends and male peers to the clinic. When young men attend there needs to be appropriate literature and resources for boys to give the message they are welcome. Specific issues on working with young gay men and lesbians are covered in the relevant chapters. Young people involved in prostitution are now considered in law to be victims of sexual abuse, even if they consent. Discuss all cases of suspected child prostitution with a consultant Vulnerability of those living away from home/ accommodated by the local authority Vulnerability of disabled young people/ or those with learning difficulties, irrespective of age Suspected child abuse It is important health advisers are aware of their local child protection policies and procedures and know how to contact the child protection team at any time. The effective management of child abuse demands a multidisciplinary and inter-agency approach. If an under 16 year old discloses abuse, or a health care professional suspects that abuse may be occurring, it needs to be made clear to the young person that this information may need to be discussed with other colleagues in the interest of their health and well being. In this first instance discuss the case with senior health adviser/ professional and consultant/ senior doctor in the department. The following are associated with an increased risk of abuse: History of physical or sexual abuse Partner more than 3 years older than patient Low self esteem Learning difficulties History of social services care Communication difficulties Early age of first intercourse If a child discloses information about abuse, it is best practice to involve a community paediatrician, preferably with the consent of the young person. If consent is given, an examination should only be carried out by a forensic medical examiner or evidence may not be admissible in court. A forensic medical examination will only be needed urgently if: There has been a recent sexual act and there may be evidence such as semen The child sustained physical injuries necessitating urgent medical assistance The perpetrator is likely to abscond and evidence secures arrest and detention The child requests immediate treatment 320 In any situation where there are concerns, staff members involved in the care of the young person need to discuss their concerns with each other and their senior team member as appropriate. Confidentiality may need to be breached if consent is not given, but this is only after careful consideration and discussion with a consultant. Advice can also be sought from the child protection team without disclosing the young person s identity. In practice it is an extremely rare occurrence that confidentiality needs to be breached, but if it is necessary then it is important the young person is informed of the decision. Other issues to consider prior to breaching confidentiality is if the young person is not willing to co-operate they may deny the disclosure to the outside agency. A breach of confidentiality might result in other young people not accessing the service in future. The Royal nd College of Physicians of London, Physical Signs of Sexual abuse in children. Inter-agency Borough Guidelines on Child Protection Wandsworth Area Child Protection Committee 1997. The sheer size and diversity of this population makes any attempt to cover all of the relevant issues in depth somewhat problematic. This section therefore aims to cover core issues relevant for sexual health advisers working with this client group. For a more detailed analysis of some of the subjects covered a reading list is provided at the end of the chapter. Much of the advice and information provided in the general sections of this handbook will also apply to gay men. Most gay men grow up in an environment where there continues to be both overt and covert hostility towards men who are sexually attracted to other men. These negative messages not only affect and influence gay men but also those working with them on sexual health issues. A reflection of the growing realisation that for safer sex and risk reduction messages to be effective other factors like self esteem, mood, general sexual health, alcohol and drug use have to be taken into account. Though the patient in front of you might be behaviourally homosexual, bisexual or heterosexual it is the patient s perception of his sexuality which should guide you in the work you do with him and the language you use. To self identify as gay in our society suggests (to varying degrees) an acceptance and awareness of shared experience and identification with other homosexual men. It also suggests a perception of difference from the experience of heterosexual males. The use of the word gay might therefore be seen as partly descriptive of a cultural and community identity as well as of sexual identity. A bisexual man is usually defined as a man who is sexually attracted to both women and men. Though a bisexual man is someone who behaviourally might have sex with both men and women his choice might be to identify his sexuality as either bisexual or gay. Sexual behaviours in this group can range from men who usually have sex with women but who occasionally have sex with men, to men who are almost exclusively behaviourally homosexual. Sometimes sex between men or certain types of sexual activity like mutual masturbation are defined as playing or not perceived to be real sex. In some cultures or in some male only environments sexual identity might be defined by role during penetrative sex mirroring attitudes around heterosexual sex. Other reasons for not identifying as gay or bisexual include internalised homophobia. There are also men who are 327 situationally homosexual in male only environments or institutions where female partners are unavailable, in prisons for example. Not all male escorts or rent boys (that is, men who sell sex to men) identify as gay or bisexual. The examples above present situations where the health adviser needs to be extremely sensitive to the personal circumstances of the patient. Men who have sex with men but who do not identify as gay or bisexual are frequently wary of disclosing their sexual activity with men to medical staff. This can also be true of gay or bisexual men who are just starting to explore their sexuality and men who are new attenders at your clinic. They might be anxious about how they will be treated by medical staff if they disclose their true sexuality. Some men might describe male partners as female or not mention male partners in a consultation. This is more likely to happen if the doctor, health adviser or nurse does not specifically ask a patient if he has or has ever had male partners ? Following the Wolfenden report gay sex was only partially decriminalised under the sexual offences act of 1967. Definitions of what constitutes private or public space continue to be open to interpretation and legal debate. In November 2000 the government invoked the Parliament Act to force through legislation to make the age of consent 16 in England, Scotland and Wales and 17 in Northern Ireland. There has been recent discussion at government level on changing the law on gross indecency to a new offence of public indecency. If this happens it will effectively end the legal discrimination against gay men inherent under the existing law. The content of your interview with your patient/client will of course depend upon his knowledge base and needs. Working with someone just beginning to explore his sexuality can be very different to working with someone who is sexually experienced. The following areas for discussion will depend upon why he has been referred to the health adviser or has requested to see the health adviser and should be tailored to the needs of the patient. The interview As with any patient, in order to establish trust and confidence it is first important to find out what he may already know, what he percieves his needs to be and to build on these. A key part of the health adviser role is to provide the patient with the information necessary for him to make informed choices about his sexual wellbeing. This means addressing gaps in the patient s knowledge and challenging any assumptions not based on fact or evidence. This will guide the patient towards developing a personal sexual risk reduction strategy that makes sense and is workable for him. When discussing sexual activity it is important to ascertain whether the patient ever has sex which is more risky than he would like it to be ? This can be a more helpful question for opening a discussion about risk reduction with a patient than do you ever have unsafe sex.

In many instances the erythromycins can be used as an alternative to peni- absorption and lower incidence of gastrointestinal toxi- cillin in the penicillin-allergic patient purchase propranolol 40 mg online. Azithromycin is not bination with other antibiotics is also recommended for metabolized buy generic propranolol 40mg on line, being excreted unchanged in the bile cheap 40 mg propranolol with mastercard. Clarithromycin levels in cobacter pylori include azithromycin or clarithromycin middle ear uid have been shown to be nearly 10 times combined with bismuth salts and either amoxicillin discount propranolol 80mg on-line, serum levels. Single high-dose exceed serum levels by a factor of 10 to 100, and its aver- azithromycin (1 g) effectively treats chancroid, as well as age half-life in tissues is 2 to 4 days. Single- azithromycin have been estimated to persist for 5 days dose therapy also cures male Ureaplasma urealyticum after the completion of a 5-day treatment course. In the penicillin-allergic patient, clindamycin is a reasonable alternative for 1. Increased use of macrolides selects for resistant Clindamycin distinguishes itself from the macrolides by strains of Streptococcus pyogenes and S. It is used effectively in combination with an aminogly- niae are often resistant to macrolides. Talithromycin is effective against multi-resistant treat fecal soilage of the peritoneum. Recommended for treatment of Legionella damycin in combination with a rst-generation pneumophilia. Clarithromycin is a primary drug for treatment mended as alternative therapy in the sulfa-allergic patient. It binds to the same 50S ribosomal bind- ing site used by the macrolides, blocking bacterial protein synthesis. Clindamycin penetrates most tissues, but it penicillin-resistant Streptococcus pneumoniae, does not enter the cerebrospinal uid. Used to treat anaerobic lung abscesses and Small percentages of clindamycin metabolites are also toxoplasmosis in the sulfa-allergic patient. This blockade primarily including doxycycline and tigecycline are cleared pri- inhibits protein synthesis in bacteria, but to a lesser marily by the liver. Therefore, tetracycline is The tetracyclines are able to inhibit the growth of a termed a bacteriostatic agent. High concentrations of tetra- Photosensitivity reactions consisting of a red rash over cycline are achieved in the urine, and this agent can be sun-exposed areas can develop (Table 1. Doxy- tivity reactions are less common than with the penicillins, cycline combined with gentamicin is the treatment of but they do occur. Tetracyclines are also recom- mation, and in children, teeth often become permanently mended for the treatment of Lyme disease (Borrelia discolored. Because the tetracyclines inhibit protein synthe- thritis, and endocervical infections). They are also often used in combina- tumor cerebri) is another rare neurologic side effect. Doxycycline is effectively inhibits the growth of many resistant nearly completely absorbed in the gastrointestinal gram-positive bacteria (Table 1. Organisms That May Be Susceptible to the Tetracyclines Tetra-,Doxy-,and Minocycline Tigecycline Vibrio spp. The reticulocyte count decreases, and ane- About the Tetracyclines mia develops in association with elevated serum iron. Toxicities include photosensitivity, interference patient receiving chloramphenicol requires twice- with dental enamel formation in children, gas- weekly monitoring of peripheral blood counts. Recommended, in combination with other oral preparations of chloramphenicol are no longer antibiotics, for pelvic inammatory disease. Oral absorption blocked by calcium- and absorbed, and therapeutic serum levels can be magnesium-containing antacids, milk, and achieved orally (Table 1. Tigecycline has improved gram-positive and and crosses the blood brain barrier in uninamed as gram-negative coverage, with the exception of well as inamed meninges. It is and serum levels should be monitored in patients with approved for complicated intra-abdominal and hepatic disease, maintaining the serum concentration soft-tissue infections. Tigecycline is approved for complicated intra- abdominal and soft-tissue infections. Binds to 50S subunit of the ribosome, blocking bacteria, and once in the cell, binds to the larger 50S protein synthesis; is bacteriostatic. It inhibits bacterial protein synthesis, making it use of chloramphenicol; dose-related bone bacteriostatic for most bacteria; however, chlorampheni- marrow suppression is another concern. Can be used as alternative therapy in the drial ribosomes, this agent has signicant bone mar- penicillin-allergic patient. Chloramphenicol also is very active against spirochetes, as well as Rickettsiae, Chlamydiae, and mycoplasmas. Because of its bone marrow toxicity, chlorampheni- col is not considered the treatment of choice for any infection. For the penicillin-allergic patient, chloramphenicol can be used for bacterial meningitis. Gatioxacin administra- tion can be associated with severe dysregulation of glucose homeostasis and can result in either severe hypo- or hyperglycemia. In combination with other agents that effect repolarization, moxioxacin has occasionally been associated with life-threatening cardiac arrhythmias. All gemifloxacin; less common with other quinolones demonstrate similar tissue penetration, quinolones). Streptococcus pneumoniae Providencia Vancomycin-sensitive Enterococcus Salmonella,including Sal. Ureaplasma urealyticum Bartonella henselae Neisseria gonorrhoeae result of an excellent gram-negative spectrum, thought to include anaerobes. The exact indications ciprooxacin is one of the primary antibiotics recom- for these agents are currently evolving. It ing for resistant pathogens has led to their use being concentrates in the prostate and is recommended for treat- restricted in some hospitals. Ciprooxacin has been used Oxazolidones (Linezolid) effectively for traveler s diarrhea most commonly caused by enterotoxigenic E. The nitrogen connects to a 6-member the recommended treatment for cat scratch disease caused ring, and each specific compound has side chains by Bartonella henselae. Levofloxacin, Moxifloxacin, Gatifloxacin, and These agents bind to the 50S ribosome at a site simi- Gemioxacin These agents all demonstrate impro- lar to that used by chloramphenicol. With the exception of gemifloxacin, these agents can also be used in soft-tissue infection in which a combination of gram-positive and gram-negative organisms is suspected. Given the worse toxicity proles of the three newer agents (moxioxacin, gati- floxacin, and gemifloxacin), levofloxacin should probably be the uoroquinolone of choice for those infections. Basic structure of the be considered for the treatment of mixed infections oxazolidones. Like chloramphenicol, binds to the 50S ribo- a) Excellent coverage of Pseudomonas. Also some subunit; inhibits the initiation of protein covers many other gram-negative organisms synthesis. Linezolid achieves excellent penetration c) Recommended for community-acquired of all tissue spaces, including the cerebrospinal uid. The drug is partly metabolized by the liver and excreted d) Levooxacin, gatioxacin, and moxioxacin in the urine. Because this tion of 30:70 quinupristin:dalfopristin has synergistic agent is a weak inhibitor of monoamine oxidase, hyper- activity and has been named Synercid. These two tension has been reported in association with ingestion agents inhibit bacterial protein synthesis by binding of large amounts of tyramine. Quinupristin inhibits selective serotonin reuptake inhibitors should be pre- peptide chain elongation, and dalfopristin interferes scribed with caution. Its ability penetrate various tissue compart- ments including the cerebrospinal uid has not been the drug (Table 1. Daptomycin is a large cyclic lipopeptide (C72H101N17O26) with a molecular weight of 1620 that was derived from 2. It binds to bacterial membranes and causes rapid associated with creatine phosphokinase leak; depolarization of the membrane potential. It also demonstrates sig- epidermidis, Streptococcus pyogenes, and nicant post-antibiotic effect. Inactivated by surfactant;should not be used to Muscle pain and weakness are reported in less than treat pneumonia. It is also effective for treating amoebic abscesses and Metronidazole is a nitroimidazole with a low molecular giardiasis. Metronidazole is cidal for most anaerobic bac- weight that allows it to readily diffuse into tissues. The resulting free rad- against aerobes, it is usually administered in combination icals are toxic to the bacterium, producing damage to with a cephalosporin for aerobic coverage. Metronidazole has is the drug of choice for treatment of pseudomembranous signicant activity against anaerobes. Metronidazole is usually well tolerated, but it can result in a disulram (Antabuse like) reaction with alcohol Sulfonamides and Trimethoprim consumption (Table 1. All sulfonamides be avoided in patients on Coumadin, because it impairs inhibit bacterial folic acid synthesis by competitively metabolism of that drug. Trime-thoprim consists of two 6-member rings, one of which has two About Metronidazole nitrogens and two amino groups, the other having three methoxybenzyl groups. This agent strongly inhibits dihydrofolate reductase and complements sulfonamide 1. Antabuse-like reaction can occur; mutagenic 100,000 times that of the agent s inhibition of the effects not proven in mammals, but the drug mammalian enzyme, minimizing toxicity to the patient. Organisms That May Be Susceptible to Trimethoprim/Sulfa Usually susceptible Some susceptible Streptococcus pyogenes Staphylococcus aureus Listeria monocytogenes (including community-acquired Bacillus anthracis methicillin-resistant strains) Shigella spp. Strepococcus pneumoniae Haemophilus inuenzae Proteus mirabilis Neisseria meningitidis Klebsiella spp. Chlamydia trachomatis Salmonella Burkholderia cepacia Neisseria gonorrhoeae Stenotrophomonas maltophilia Yersinia enterocolitica Nocardia spp. Sulfonamides are the treatment of choice for ing drug-induced lupus), serum sickness-like syndrome, Nocardia asteroides, and are useful in combination with and anaphylaxis have been reported. This combination often in the last month of pregnancy because they displace bilirubin bound to plasma albumin and increase fetal blood levels of unconjugated bilirubin. Competitively inhibit para-aminobenzoic acid Sulfamethoxazole and sulfadiazine are medium-acting. Hypersensitivity reactions (including Steven and glucuronidation, with the metabolites being excreted Johnson syndrome) are common; hemolytic in the urine. Agran- renal tubules, and very high concentrations of active drug ulocytosis and thrombocytopenia are less are found in the urine. Broad spectrum of activity for gram-positive hours matching the half-life of sulfamethoxazole. The and gram-negative organisms, but resistance is ratio of trimethoprim to sulfamethoxazole supplied is 1:5.

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