By O. Hatlod. Georgetown College.

Nigerian groups likely Africans – particularly West African networks – are dominate the African drug trade and are active in many increasingly transporting Afghan heroin from Pakistan countries around the world discount bentyl 10mg overnight delivery gastritis with erosion, including destination coun- into East Africa for onward shipment to Europe and tries in Europe 10 mg bentyl with mastercard gastritis in children. The emergence of Africa as a heroin traffick- involves both African networks, including Nigerians and ing hub is likely due to corruption, limited law enforce- Tanzanians, as well as foreign networks, including Chi- ment capacity and increased pressure on ‘traditional’ nese and Pakistanis. East Africa’s minimal law The United States of America dominated regional enforcement at ports of entry has encouraged drug traf- demand for heroin, with a heroin market worth an esti- fickers to transit heroin through that region. North America-based flows of heroin to Africa have also led to increases in organized crime groups (such as Mexican drug cartels) drug use across the continent. Anecdotal information points to and alter trafficking routes to exploit international paths a shortage in some countries, but not in all, suggesting of least resistance. Numerous global vulnerabilities that increased law enforcement efforts and decreased remain and some new areas are emerging. Global seizures of Most indicators and research suggest that cocaine is – cocaine have been generally stable over the period 2006- after heroin – the second most problematic drug world- 2009. Since 2006, seizures have shifted towards the wide in terms of negative health consequences and source areas in South America and away from the con- probably the most problematic drug in terms of traffick- sumer markets in North America and West and Central ing-related violence. Some secondary distribution countries in South America seem to have acquired increasing importance as The overall prevalence and number of cocaine users cocaine trafficking transit countries. There are regional differ- West Africa continues to be significant, in spite of a ences in recent trends, however, with significant decreases reduction of seizures since 2007 (from 25% of European reported in North America, stable trends in West and cocaine seizures that transited countries of West and Central Europe and increases in Africa and Asia. The area estimated consumption of cocaine in terms of the quan- remains vulnerable to a resurgence. Some countries in tities consumed appears to have declined, mainly due to the Asia-Pacific - with large potential consumer markets a decrease in the United States and low levels of per - have registered increasing cocaine seizures in 2008 and capita use in the emerging markets. While demand in the and, more recently, in South America and beyond, high- United States was more than four times as high as in lights the need to treat cocaine as a global problem, and Europe in 1998, just over a decade later, the volume and to develop strategies on the scale of the threat. Member Member Percent Percent Percent States States Use Use Use use use use Region providing perception problem problem problem problem problem problem perception response increased* stable decreased* increased stable decreased data rate Africa 8 15% 4 50% 2 25% 2 25% Americas 15 43% 5 33% 7 47% 3 20% Asia 13 29% 7 54% 3 23% 3 23% Europe 27 60% 14 52% 13 48% 0 0% Oceania 1 7% 0 Global 64 33% 30 47% 26 41% 8 13% * Identifies increases/ decreases ranging from either some to strong, unweighted by population. The information on the extent of cocaine use in South or main difference from previous years is the widening of Central Asia. In 2009, a substantial decrease in the esti- the ranges, arising from a lack of recent or reliable infor- mates of cocaine users was recorded for North America, mation in Africa - particularly West and Central Africa2 while cocaine use in Europe appeared to have stabilized. In geographical terms, however, cocaine use appears to 1 In 2008, the estimated annual prevalence number of cocaine users have spread. Source: Substance Abuse and Mental Health Services Adminis- tration, Results from the 2009 National Survey on Drug Use 3. This was particularly noticeable in Africa and Asia, where increasing seizures of cocaine, though still at low levels, users worldwide. Household surveys in the countries of have also been reported in countries that had never North America reveal a prevalence rate of annual cocaine reported any in the past. The main stabilization or decrease in cocaine use trends is perceived to be taking Since 2006, among the population aged 12 years and place in the Americas. As in the United States, use from the previous year, whereas the treatment cocaine use has also been decreasing considerably in demand for cocaine as the primary substance of concern Canada since 2004, when it was reported as 2. Cocaine use in the annual prevalence of cocaine use is much lower, at South and Central America remains at levels higher than 0. Experts in Mexico perceived an increase in cocaine 7 Health Canada, Canadian Alcohol and Drug Use Monitoring Survey, 8 This decline in treatment demand may stem from a change in treat- 2009.

Important adverse effects are dry cough discount bentyl 10 mg with visa gastritis chronic nausea, hypotension safe 10mg bentyl gastritis university of maryland, renal insufficiency, hyperkaelamia, and angioedema. Monitor digoxin level - trough blood levels (before the morning dose) should be maintained between 0. Drug Management Adjunctive therapy Control cardiac pain C: Glyceryl trinitrate sub-lingual/ spray 0. But Pain not responsive to this dose may suggest ongoing unresolved ischaemia; appropriate measure should be taken to reverse the ischaemia. Thrombolytic Therapy: Thrombolytic agents have shown significant reduction in mortality and should be used in all eligible patients, most beneficial if given first 6 hours but can be given up to 12 hours after onset of chest pain. Check for contraindications before you administer thrombolytics S: Streptokinase, I. Unstable Angina: Angina that is increasing in frequency and or severity, or occurring at rest. Pharmacological therapy C: Aspirin oral, 75 -150 mg (O) daily Plus A: Atenolol 12. Pharmacological therapy C: Aspirin 150 mg (O) daily Plus C: Simvastatin 10 mg (O) day. Sinus tachycardia most common, acute right ventricular strain – ie right axis shift, S1Q3T3 occurs in small percentage of cases, may develop acute bundle branch block – right or left, may simulate right ventricular infarction, may develop arrhythmias – eg atrial fibrillation  Arterial blood gases; not diagnostic, the pO2 decreased <60mmHg due ventilation/perfusion mismatch. The presence of a perfusion defect with normal ventilation not corresponding to an x-ray abnormality is characteristics  Pulmonary Angiography: Still gold standard investigation may necessary establish diagnosis and catheter based embolectomy in the catheterization lab. General  Administer O2 – maintain pO2 > 60mmHg,  Treat shock  Correct electrolyte & acid base abnormalities and arrhythmias  Ventilate if patient in respiratory failure I. Anticoagulation with oral warfarin 2mg – 5mg orally ounce a day for at least a month, then perform elective cardioversion at specialized hospital. A: Atenolol, oral, 50–100 mg daily (contraindicated in asthmatics; caution in Heart failure). Long – term  Continue Warfarin anticoagulation long-term, unless contra-indicated: Warfarin, oral, 5 mg daily. A: Atenolol (O) 50–100 mg daily Prevention of recurrent paroxysmal atrial fibrillation Only in patients with severe symptoms despite the above measures: D: Amiodarone 200 mg (O) 8 hourly for 1 week, followed 200 mg twice daily for one week and thereafter 200 mg daily. Do not use verapamil as it will not convert flutter to sinus rhythm and may cause serious hypotension. The patient should be supine and as relaxed as possible, to avoid competing sympathetic reflexes. If the drug reaches the central circulation before it is broken down the patient will experience flushing, sometimes chest pain and anxiety. If the tachycardia fails to terminate without these symptoms, the drug did not reach the heart. Long – term Treatment Teach the patient to perform vagal manoeuvres, Valsalva is the most effective. Lidocaine will only terminate ± 30% of sustained ventricular tachycardias, and may cause hypotension, heart block or convulsions. Do not treat with drugs Verapamil and digoxin may precipitate ventricular fibrillation by increasing the ventricular rate. In acute myocardial infarction, only treat non-sustained ventricular tachycardia if it causes significant haemodynamic compromise.

Correct severe thrombocytopenia with packed platelet concentrates 10mg bentyl with amex gastritis xarelto, while overt coagulopathy should be corrected with fresh frozen plasma discount 10mg bentyl overnight delivery mild gastritis diet, and Vitamin K S. Non Pharmacological - Endoscopy done within 24 hours could confirm diagnosis and provide sustained hemostasis control. Therapeutic modalities include variceal band ligation, Hemocliping, sclerotherapy, injectional tamponade therapy, thermocoagulation and angiographic embolization. Crohn disease can involve any segment of the gastrointestinal tract from the mouth to the anus 2. Note Diagnosis relies upon the patient’s history; clinical symptoms; negative stool examination for bacteria, C. Single contrast barium enema alternative to sigmoidoscopy but is limited by biopsy access. Note 55 | P a g e  Correction of fluid deficit and/or blood is important in acute severe forms which may necessitates hospitalization  Nutritional therapy should target to replenish specific nutrient deficits  Life long surveillance is required due to risk of bowel cancer  Use steroids only when the disease is confirmed, to avoid exacerbation of existing illness. Diagnosis  Mainly abdominal pain and diarrhea; weight loss, anorexia, and fever may be seen  Growth retardation in children  Gross rectal bleeding or acute hemorrhage is uncommon  Anemia is a common complication due to illeal disease involvement  Small bowel obstruction, due to stricturing  Perianal disease associated with fistulization  Gastroduodenal involvement may be mistaken for H. Treatment  Refer suspected cases to specialized centers for expertise management  Baseline management as for Ulcerative Colitis above 2. Increasingly implicated as a significant cause of morbidity and mortality among hospitalized patients, C difficile colitis should also be recognized 56 | P a g e among outpatient populations. Prior antibiotic exposure remains the most significant risk factor for development of disease. Antibiotics first seen with clindamycin, but amoxylin and the cephalosporin’s are now most frequently implicated. Diagnosis  Diarrhea and abdominal cramps occurs during first week, but can be delayed up to six weeks  Nausea, fever, dehydration can accompany severe colitis  Abdominal examination may reveal distension and tenderness. Note  Stool examination is sensitive on anaerobic culture facilities which reveals toxigenic and non toxigenic strains  Enzyme immunoassays are available for toxins A and B in stool  Sigmoidoscopy is highly specific if lesion is seen but insensitive compared to the above. Diagnosis  Abdominal discomfort of at least 3 months duration  Bloating or feeling of distension  Altered bowel habits (constipation and/or diarrhea)  Exacerbations triggered by life events. Diagnostic Considerations  Hematology and biochemistry studies  Stool microscopy  Colonoscopy with biopsy 57 | P a g e Treatment  Refer patients to specialized centers for proper evaluation and management. Although presenting symptoms, such as diarrhea and weight loss may be common, the specific causes of malabsorption are usually established based on physiologic evaluations. The treatment often depends on the establishment of a definitive etiology for malabsorption. Etiologic examples include pancreatic insufficiency, bacterial overgrowth, celiac disease, tropical sprue, lactase deficiency, diabetic enteropathy, thyroid disease, radiation enteritis, gastrectomy and extensive small bowel resection. Diagnosis Depending on etiology, presentation may collectively include:  Diarrhoea a commonest symptom which is frequently watery  Steatorrhea due to fat malabsorption; characterized, by the passage of pale, bulky, and malodorous stools. Stools often float on top of the toilet water and are difficult to flush  Weight loss and fatigue  Flatulence and abdominal distention  Edema due to hypoalbuminemia, and with severe protein depletion ascites may develop  Anemias which can either be microcytic iron deficiency (celiac disease) or macrocytic vitamin B-12 deficiency (chrohn’s disease or illeal resection). Vitamin malabsorption can cause generalized motor weakness (pantothenic acid, vitamin D) or peripheral neuropathy (thiamine), a sense of loss for vibration and position (cobalamin), night blindness (vitamin A), and seizures (biotin). Treatment  Patients should be referred to specialized centers for proper evaluation and definitive management  Two basic principles underlie the management of patients with malabsorption, as follows: o The correction of nutritional deficiencies o When possible, the treatment of causative diseases  Nutritional support o Supplementing various minerals, such as calcium, magnesium, iron, and vitamins, which may be deficient in malabsorption, is important o Caloric and protein replacement also is essential o Medium-chain triglycerides can be used as fat substitutes because they do not require micelle formation for absorption and their route of transport is portal rather than lymphatic o In severe intestinal disease, such as massive resection and extensive regional enteritis, parenteral nutrition may become necessary. It may present as acute pancreatitis, in which the pancreas can sometimes heal without any impairment of function or any morphologic changes, or as chronic pancreatitis, in which individuals suffer recurrent, intermittent attacks that contribute to the functional and morphologic loss of the gland.

Where emergency disinfection has taken place it is essential that an increased operational monitoring programme is undertaken to verify the effectiveness of the emergency disinfection buy bentyl 10 mg online gastritis bad eating habits. The purpose of this is to verify that the levels of chlorine in distribution network are adequate and that the emergency disinfection has dealt with the cause of the absence of or low levels of disinfectant previously in the distribution system bentyl 10mg overnight delivery gastritis upper right back pain. In all other instances, where new literature was available to support the existing recommendations or qualifcation statement for an existing recommendation, the new literature was cited. If there was no new literature on the topic, and the recom- mendation was still valid based on the existing practice and previous literature, no literature was cited. Return to Table of Contents Introduction Stroke is the ffth leading cause of death in the United States and a leading cause of serious long-term disability (Mozzafarian, 2015; Kochanek, 2014). Annually, approximately 800,000 people in the United States have a stroke, and 130,000 die (Centers for Disease Control and Prevention, 2016). In the United States, one person dies from stroke every four minutes, on average (Mozaffarian, 2015). Therefore, time is of the essence in getting appropriate early care for persons with an onset of stroke symp- toms. The recommendations in this guideline are for early management of stroke due to ischemic brain ischemia/infarction. For detailed explanation and evidence supporting the recommendations, see the original documents. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. For information on the types of studies searched and the literature search terms, please see Appendix A, "Literature Search Terms by Topic. However, it was brought to the attention by work group members to include in the review two studies published in 2016 on this topic. Scientifc rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/ American Stroke Association. The formation of a clinical process improvement team and the establishment of a stroke care data bank are helpful for such quality of care assurances. The data repository can be used to identify the gaps or disparities in quality stroke care. Once the gaps have been identified, specific interventions can be initiated to address these gaps or disparities. Designation of an acute stroke team that includes physicians, nurses, and laboratory/radiology personnel is encouraged. Patients with stroke should have a careful clinical assessment, including neurological examination. Please also see recommendation 3 in Imaging section of Endovascular Interventions recommendations table pertaining to selection for endovascular thrombectomy beyond recommended window of 6 hours from onset. Supplemental oxygen should be Class I: Agree Bennett, 2014 provided to maintain oxygen saturation > Benefit>>>Risk 94% (Class I; Level of Evidence C). Hypertension in Acute interventions to recanalize occluded Ischemic Stroke Patients Who vessels, including intra-arterial are Candidates for Acute fibrinolysis (Class I; Level of Evidence C). Hypoglycemia (blood glucose < 60 Class I: Agree mg/dL) should be treated in patients with Benefit>>>Risk acute ischemic stroke (Class I; Level of Procedure/Treatment Evidence C).