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Calcium channel blockers, captopril, carvedilol, amiodarone, quinidine, cyclosporine, itraconazole, tetracycline, and macrolide antibiotics may increase digoxin levels. In situations of cardiac arrest, DigiFab can be administered as a bolus injection but has an increased risk for infusion-related reactions. Dizziness, headache, edema, nausea, vomiting, heart block, and arrhythmias may occur. May increase levels and effects/toxicity of buspirone, cyclosporine, carbamazepine, fentanyl, digoxin, quinidine, tacrolimus, benzodiazepines, and -blockers. Cardizem immediate-release tablets should be swallowed whole because crushing or chewing may alter its pharmacokinetics. A few drops of the 10 mg/mL oral liquid may be used in the ear as a cerumenolytic. Tachyarrhythmias, ectopic beats, hypertension, vasoconstriction, and vomiting may occur. Children aged <2 yr clear dopamine faster and exhibit high variability in neonates. Safety and efficacy has not been demonstrated in patients >1 yr of continuous use. The following nebulizer compressor systems have been recommended for use: Pulmo-Aide, Pari-Proneb, Mobilaire, Porta-Neb, or PariBaby. Use of the "Sidestream" nebulizer cup can significantly reduce the medication administration time. Do not use with general anesthetic agents that can sensitize the heart to catecholamines. Do not initiate doxapram until the general anesthetic agent has been completely excreted. May also cause tachycardia, arrhythmia, seizure, hyperreflexia, hyperpyrexia, abdominal distension, bloody stools, and sweating. Generally not recommended for use in children aged <8 yr because of risk for tooth enamel hypoplasia and discoloration. Side effects: euphoria, dizziness, difficulty concentrating, anxiety, mood change, sedation, hallucinations, ataxia, paresthesia, hypotension, excessively increased appetite, and habit-forming potential. Side effects include hypotension, tachycardia, extrapyramidal side effects such as dystonia, feeling of motor restlessness, laryngospasm, and bronchospasm. Hypersensitivity to test dose (fasciculations or intestinal cramping) is an indication to stop giving drug. Antagonism of nondepolarizing neuromuscular blocking drugs is more rapid in children than in adults. Avoid use in dialysis with high-flux membranes because anaphylactoid reactions have been reported. Side effects: nausea, diarrhea, headache, dizziness, hyperkalemia, hypoglycemia, hypotension, and hypersensitivity. If oliguria or hypotension occurs in a neonate with in utero exposure to enalapril/enalaprilat, exchange transfusions or dialysis may be needed to reverse hypotension and/or support renal function. May cause fever, confusion, edema, nausea, hemorrhage, thrombocytopenia, hypochromic anemia, and pain/erythema at injection site. If removing catheter, hold anticoagulation for 12 hr and restart dosing no sooner than 2 hr after catheter removal. Alternate administration between the left and right anterolateral and left and right posterolateral abdominal wall. High-dose epinephrine after the failure of standard dose has not been shown to be effective (see remarks). High-dose rescue therapy for in-hospital cardiac arrest in children after the failure of an initial standard dose has been reported to be of no benefit compared to standard dose (N Engl J Med 2004;350:1722­1730). May produce arrhythmias, tachycardia, hypertension, headaches, nervousness, nausea, and vomiting. See EpiPen product information for proper use of the device and to prevent injury and/or inadvertent dose administration to the individual administering the dose. Accidental injection into the digits, hands, or feet may result in the loss of blood flow to the affected area. Injection (multidose vials): 10,000 U/mL (2 mL), 20,000 U/mL (1 mL); contains 1% benzyl alcohol. Reported dosage range for children (3 mo­20 yr) not requiring dialysis, 50­250 U/kg/dose 3 times per week.

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The center record shows performance in the third session with the naloxone infusion pump disconnected. Instead of terminating a shock presented every five minutes, the monkey self-administers a shock of 1 ma every five minutes, If a response did not produce shock within five seconds after elapse of the five minute fixed interval, a 7 ma shock was presented automatically. It is obvious that the rate of responding was higher when responses produce shock than when responses terminate shock. In the cumulative record shown at the top of Figure 4, a monkey with a particular behavioral history received 5 ma shocks every two minutes, independent of his response behavior, Each shock was followed by a brief timeout period. These findings that an animal will work to selfadminister a seemingly noxious electric shock, indeed the same electric shock he previously worked to avoid, or to escape from is eloquent testimony to the capacity of "aversive" events to control behavior leading to their self-administration. Morse, McKearney, and Kelleher (1977) have reviewed data on the control of behavior by noxious stimuli and discussed the generality of this phenomenon. A: Short diagonal strokes in the event record (bottom) indicate successive electric shock presentations (7 ma); diagonal strokes on the cumulative record (top) indicate the termination of shock. If a response did not produce shock within 5 seconds after 5 minutes had elapsed, a 7 ma shock was presented automatically. Although the control of drug selfadministration by aversive consequences has not been shown unequivocally in man with the degree of precision that it has been shown in primate models, the inference that aversive consequences are one part of the reinforcement complex that maintains human drug self-administration behavior is compelling. The notion of "reward" has a compelling face validity that does not invite critical examination. One advantage of the term reinforcement is that it does not imply anything about the nature of the reinforcing events, but rather describes a functional relationship between events and behavior. The defining characteristics of reinforcements and punishers are how they change behavior. The same stimulus may have either reinforcing or punishing effects, depending upon the condition under which it is presented. Electric shock and antagonist self-administration data indicate that it is not the inherent properties of the event, per se, but the way in which the event is scheduled that determines the subsequent effect on behavior (Morse, McKearney and Kelleher 1977). Clearly, it is impossible to assume an invariant effect of any particular Stimulus event. Traditional concepts 303 that drug abuse is maintained primarily as a function of rewarding or euphorigenic consequences are not consistent with the clinical data. Beyond the issue that both seemingly "aversive" and "positive" consequences contribute to the maintenance of drug self-administration, there are many other apparent paradoxes which remain unaccounted for. One example is polydrug use which often involves the simultaneous and sequential use of several drugs with different pharmacological properties and presumably different effects. The nature of the positive effects of drugs described by addicts varies considerably in different types of drug addiction (Wikler and Rasor 1953). An extreme example is the repeated intravenous injection of phencyclidine to the point of unconsciousness (Fauman and Fauman 1978). Central to the idea that stimulus self-administration is important in the maintenance of drug self-administration is the notion that the stimulus properties of drugs, rather than the specific qualities of the stimuli, may be important determinants of this behavior. State change may be the subjective response to the drug induced stimulus, whatever that stimulus may be. Mood changes in alcoholic subjects with programmed and free-choice experimental drinking. The effect of timeout on performance on a variable-interval schedule of electric shock presentation. Negative reinforcing properties of morphine antagonists in naive rhesus monkeys, Psychopharmacologia (Berl. Comparative psychosocial studies of alcoholic and non-alcoholic subjects undergoing experimentally induced ethanol intoxication. Maintenance and suppression of responding under schedules of electric shock presentation. Stimulus self-administration: Some implications for the prediction of drug abuse liability.

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The clinical presentation is variable and depends on the type, location, and extent of the hemorrhage. For infants with signs of increased intracranial pressure (full fontanel, hypertension, bradycardia, and irregular breathing) close observation for signs of herniation is warranted, and a neurosurgical consult obtained if decompression is needed. Anencephaly is characterized by the absence of the cranial vault, as well as part or most of the cerebral hemispheres. An encephalocele is a hernia of part of the brain and the meninges through a skull defect, usually in the occipital area. Spina bifida is a defect in the vertebral column through which the spinal cord and the meninges might herniate creating a meningomyelocele. Meningomyelocele Spinal Cord Injury Spinal cord injury can be caused by excessive traction or torsion during delivery. Infants with spinal cord injury usually are delivered by breech extraction or require mid-forceps application. Rarely, spinal cord injury can result from vascular occlusion of the spinal cord after umbilical catheterization or from venous air embolism. The Eastern and Southern regions have higher incidences than the West and females are more affected than males. Nerve damage can continue postnatally, if the lesion is not managed appropriately. The greatest benefit was seen in neonates with ventricle size <10mm at the time of fetal repair. Prenatal Surgery Later findings include the development of spasticity and hyperreflexia. Treatment is primarily supportive and includes mechanical ventilation, maintenance of body temperature, bowel and 128 Guidelines for Acute Care of the Neonate, Edition 26, 2018­19 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Section 9-Neurology Immediate Management · · · · · · Evaluation Avoid latex gloves at all times. Place the infant in the prone position immediately after delivery to avoid traumatic injury to the defect and spinal cord. Infants who require resuscitation at delivery and need to be supine should be placed on a doughnut shaped cushion to support the defect. This shift in the focus on pain management has led to more liberal use of prescribed opiates in pregnant women for complaints such as back pain. There has also been an increase in illicit use of opioids (both oxycontin and heroin) and opioid substitution programs. Opioid abuse has also shifted from a primarily inner city or low socioeconomic population to include all demographic and socioeconomic groups. Infants born to mothers with a history of chronic opioid use during pregnancy are at risk for withdrawal after birth. In addition, other substances including antidepressants and anxiolytics may produce withdrawal symptoms. Pathophysiology the infant should be examined thoroughly with emphasis on the neurologic examination (spontaneous movement, muscle strength, sensory level, deep tendon reflexes, and anocutaneous reflex). Imaging studies are needed to ascertain the level of the defect and any associated anomalies (hydrocephalus, Chiari malformation, tethered cord). Based on the clinical course and physical examination further diagnostic tests may be needed. Opiates also have a prolonged half-life in the fetus as compared to adults or older children. A physician from the clinic should be contacted before discharge to meet with the family. Excoriation of extensor surfaces or nasal tip results from excessive movement creating friction against bedding. The large feeding volumes can exacerbate the loose stools and lead to excoriation in the diaper and perianal area. Other symptoms include sneezing, nasal stuffiness, fever, sweating and tachycardia. Maternal Drug and Alcohol History Outcomes Occipital encephalocele ­ mortality is 40­50%, and only about 15% of survivors will have a normal outcome. A thorough history of maternal drug and alcohol use during pregnancy is essential to management of the drug-exposed newborn. Treatment (involvement in drug treatment or voluntary detoxification during pregnancy). Infants with intrauterine exposure only to marijuana or cocaine are admitted to the Level 1 nursery but should be treated the same as all other drug-exposed babies.

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Metabolomics have been used to successfully discern disease activity in a number of autoimmune diseases. Results: the mean age in this cohort was 61 years, with 6 patients each being male and Caucasian. Intensities of urinary citrate and iso-citrate are significantly higher in the remission group compared to the active group (Fig 1A). Similar trend of higher citrate and iso-citrate intensities present in serum of patients in remission versus active disease (Fig 1B). Department of Nephrology, Xiangya Hospital, Central South University, China, Changsha, China. Results: Patients with low sC3 (790 ml/L) and low sC4 (100 ml/L) at diagnosis showed poorer renal survival compared to patients with normal value (p=0. Furthermore, among patients of low sC3 at diagnosis, the cases with persistent low sC3 showed an obviously worse renal survival than those whose sC3 recovered to normal after treatment (p<0. We also found IgG deposits related to worse renal outcome than the negtative cases (p=0. Conclusions: Patients with a persistent low sC3 showed poorer renal prognosis than the patients whose sC3 level return to normal after a period of treatment, which was confirmed that both initial and continuously low sC3 can act as predictive indicators for renal outcome. Of these, 786 were included in the analysis: 622 (65%) were Caucasian, 73 (8%) were African American, and 91 (9%) were Hispanic. The need for mechanical ventilation, non-invasive ventilation support, and renal replacement therapy in African Americans and Hispanics were comparable to Caucasians. There was no significant difference in organ failure, sepsis, and in-hospital mortality between African Americans and Caucasians. In contrast, Hispanics had higher in-hospital mortality than Caucasians but similar risk of organ failure and sepsis. Additional reduction in conventional immunosuppressants was also observed in 3 patients. Well tolerated, it demonstrated considerable clinical benefit, with 12 patients [92. There was a 50% reduction in steroid dosage in this study, with preserved renal function. The coexistent of both diseases present the possibility of a new overlap syndrome which leads to different treatment and outcome. The treatment response and outcome of the case were followed up for the next 15 months. Results: Mild hematuria with rapid progressive renal failure of the patient was observed while renal biopsy revealed pauci-immune crescentic glomerulonephritis, especially with IgG4-related tubulointerstitial nephritis. First, atypical clinical and laboratory manifestations were characteristics of this entity. Third, tissue samples showed overlapping histological patterns when kidneys were involved. Fourth, the combination of glucocorticoids and immunosuppressive therapy was often required and led to a remission within 3 months. Four common clinicopathologic characteristics could be used as specific clues to the diagnosis of overlap syndrome. Case Description: A 35 year old female presented with pedal edema, reduced urine output & yellowish discoloration of eyes since 20 days. She had similar episodes in 2011 and 2013 & was given blood transfusion and oral steroids. On examination she had pallor, icterus and generalized edema, blood pressure of 170/80mmHg. Renal biopsy showed necrotising crescentic glomerulonephritis with no endocapillary proliferation. After 2 months, kidney function returned to baseline, with resolution of proteinuria and hematuria. Case Description: A 17 year old male with a history of vaping presented with acute respiratory failure requiring mechanical ventilation.

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Place the ultrasound probe transverse to the artery on the radial, posterior tibial, or dorsalis pedis pulse. On the right image, pressure has been applied and the veins are collapsed while the artery remains patent. Insert the needle into the skin at a 45-degree angle at the midline of the probe near where it contacts the skin. Dorsalis pedis artery: Puncture the artery at dorsal midfoot between first and second toes while holding the foot in plantar flexion. Ultrasound guidance: Has become standard practice to facilitate placement of internal jugular vein central venous catheters. Subclavian vein: Risks include pleural injury, pneumothorax, hemothorax, or pleural infusion causing hydrothorax as well as subclavian artery injury. Internal jugular vein: Avoid in the case of contralateral internal jugular occlusion and ipsilateral internalized cerebral ventriculostomy shunt. It is technically very difficult in patients with cervical collars and tracheostomies and discouraged in these cases if another route is readily available. Slip a catheter that has already been flushed with sterile saline over the wire into the vein. For internal jugular and subclavian vessels, obtain a chest radiograph to confirm placement and rule out pneumothorax. Introducer needle enters at the point where external jugular vein crosses posterior margin of sternocleidomastoid and is directed under its head toward sternal notch. After the sterile field has been prepped, apply gel to the probe and place within a sterile cover. The ultrasound can be placed parallel to the vessel to view the guidewire, if desired. The guidewire can be seen as a bright, hyperechoic line (G) crossing the wall of the vein and then remaining in the lumen of the jugular vein. The needle should enter the skin 2­3 cm distal to the inguinal ligament at a 30- to 45-degree angle. With the probe visualizing the vessel transversely, slowly advance the needle and follow the tip of the needle by sliding the probe away from you. Anteromedial surface of the proximal tibia, 2 cm below and 1­2 cm medial to the tibial tuberosity on the flat part of the bone (see. Medial surface of the distal tibia 1­2 cm above the medial malleolus (may be a more effective site in older children). Proximal humerus, 2 cm below the acromion process into the greater tubercle with the arm held in adduction and internal rotation. If the child is conscious, anesthetize the puncture site down to the periosteum with 1% lidocaine (optional in emergency situations). With a boring rotary motion, penetrate through the cortex until there is a decrease in resistance, indicating that you have reached the marrow. Apply easy pressure while gently depressing the drill trigger until you feel a "pop" or a sudden decrease in resistance. Remove the drill while holding the needle steady to ensure stability prior to securing the needle. It is contraindicated in the presence of possible necrotizing enterocolitis or intestinal hypoperfusion. This avoids renal and mesenteric arteries near L1, possibly decreasing the incidence of thrombosis or ischemia. Use both points of closed forceps, and dilate artery by allowing forceps to open gently. Grasp the catheter 1 cm from its tip with toothless forceps and insert the catheter into the lumen of the artery. If resistance is encountered, try loosening umbilical tape, applying steady and gentle pressure, or manipulating the angle of the umbilical cord to the skin. The catheter may be pulled back but not advanced once the sterile field is broken.

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Each study produced additional interesting findings that might prove to be important as more data appear. The reader is referred to the original papers for further details of these studies. Camp et al (2005) Genetic Linkage Studies An alternative to the study of mechanism-based candidate genes is the positional cloning strategy­the systematic study of the genome, either with genetic linkage studies of informative pedigrees followed by association studies of candidate regions. The sample sizes and phenotype definitions of these studies are summarized in Table 2. Fullerton et al (2003) studied pairs in which each sib was in the top or bottom 2. Male subjects and female subjects were analyzed separately in a secondary analysis. Note that Camp et al (2005) grouped all anxiety disorders together, regardless of the weight of evidence for genetic relatedness to depressive disorders; however, most of the anxiety diagnoses were categories (panic disorder, agoraphobia, social phobia) that have shown such a relationship (Mineka et al 1998). Each phenotype was also analyzed with two covariates (sex and positive or negative family lod score on distal chromosome 2q). Empirical genome-wide lod score thresholds were computed for each analysis, without correction for multiple tests. This reviewer encountered several difficulties in interpreting the results: 1) unusually low simulation-based lod score thresholds (1. All of the trait-based scans used quantitative multipoint analyses to study linkage to factor scores derived from personality questionnaires and then computed empirical genome-wide statistical thresholds. Neale et al (2005) analyzed neuroticism scores in a smaller sample recruited to study nicotine dependence. Initial positive linkage reports tend to overestimate the true genetic effects, particularly with smaller samples (Goring et al 2001). Thus, the full impact of genetic linkage findings on the search for depression susceptibility genes might come from combined analyses of multiple datasets. At the very least, it should become possible to study most or all sequence variation within specific candidate genes, although relevant statistical methods are still under development (Marchini et al 2005; Neale and Sham 2004). With the advent of more powerful molecular and statistical methods, sequence variation in these genes will be intensively studied in large samples of families or of cases and control subjects for depression and related phenotypes. Because these measures are generally expensive and intrusive, they present a challenge for large-scale studies, but technological innovations could increase their feasibility. Genetic studies of animal models of depression, anxiety, and antidepressant response may be important in providing initial clues or convergent evidence to augment results of human studies. Most previous genetic studies of de- Future Directions Depression is a complex and multifactorial trait with important genetic and nongenetic contributory factors. Many methods and strategies will be applied, some of them not yet feasible or even imagined. However, a number of directions can be anticipated which are likely to be fruitful, including (at least) the following. Scanning has usually involved genetic linkage studies of multiply affected families, like those described above. Linkage analysis is less powerful than analysis of association to specific sequence variants (Risch and Merikangas 1996), but only whole-genome linkage studies have been feasible until recently. Whole-genome association studies are now becoming feasible (Craig and Stephan 2005), but many questions remain about their design and power. These studies search across the genome for single nucleotide changes or polymorphisms which influence Current and near-term technology liberates us from this limitation, permitting us to query the genome in ways that could produce entirely new hypotheses and mechanisms about this complex susceptibility. Fullerton J, Cubin M, Tiwari H, Wang C, Bomhra A, Davidson S, et al (2003): Linkage analysis of extremely discordant and concordant sibling pairs identifies quantitative-trait loci that influence variation in the human personality trait neuroticism. Anguelova M, Benkelfat C, Turecki G (2003a): A systematic review of association studies investigating genes coding for serotonin receptors and the serotonin transporter: I.

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Introduction: Rhabdomyolysis has infectious etiology including Mycoplasma pneumoniae infection, Legionella, and Influenza. We report a case where acute kidney injury and rhabdomyolysis was the initial presentation. He was started on hemodialysis on day 3 of admission for anuria and worsening of renal function. He was maintained on hemodialysis with minimal ultrafiltration three times a week, intravenous fluid resuscitation along with intermittent doses of bumex. He received total of five hemodialysis treatments until he became non-oliguric and started showing signs of recovery. He was taken off dialysis approximately three weeks after his initial presentation. It is also known that once the disease activities are controlled by aggressive treatment, its recurrence is rare. Case Description: A 30-year-old man was admitted to our hospital because of general malaise, fever, oliguria and renal dysfunction. Electron microscopy of the renal biopsy that returned later showed significant foot process effacement on podocytes in the apparently normal glomeruli without electron dense deposits. Introduction: the purpose of this case study is to illustrate the sonographic findings seen in kidney infiltration by lymphoma. Case Description: A 56-year-old man with a history of hypertension, diabetes mellitus type 2 and follicular lymphoma with transformation to diffuse large B-cell lymphoma presented with worsening fatigue, headache and diplopia. The relationships with several medications have been described, but the two conditions coexisting are rare. Case Description: 28-year-old man with no significant past medical history presented with bilateral lower extremity edema, excoriations, discharge, and weakness for one week. Haptoglobin and lactate dehydrogenase were elevated, and schistocytes were identified on peripheral smear consistent with microangiopathic hemolytic anemia. Work-up for autoimmune, infectious, and connective tissue diseases was ordered and results were unrevealing. The patient started hemodialysis and a kidney biopsy was performed with findings of acute tubular necrosis, thrombotic microangiopathy, and acute interstitial nephritis. His renal function improved, and he was discharged home without need for further dialysis. Venous congestion also causes an inflammatory response within the renal parenchyma. Portales Castillo,2 Bassem Mikhael,2 Nicholas Chedid,1 Ebrahim Barkoudah,1 Alice M. Direct viral injury to tubular epithelial cells and podocytes has also been described. Case Description: A 51 year-old male with hypertension and diabetes, presented with 2 days of diffuse myalgia and mild dry cough without shortness of breath. He denied trauma, new medications, changes in diet, strenuous exercise or illicit drug use. Initial serum creatinine kinase was 340,000 U/L and peaked at 464,000 U/L on day 4. Serum and urine myoglobin levels were elevated at 15,175 mg/L and >5000 mcg/L respectively on day 5. Renal clearance and urine output then slowly improved, and dialysis was discontinued by day 15. Thus diagnosis of rhabdomyolysis and myoglobinuria requires a high index of suspicion. Case Description: A 27 year old obese male who presented with 3 month history of vomiting, diarrhea, epigastric pain, left lower extremity edema and severe fatigue. On admission patient appeared toxic, tachycardic and hypertensive with left leg elephantiasis nostras verrucosa. Blood antibody screening showed IgG4 warm antibodies and elevated serum IgG4 229 mg/dl (2.

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G Use and indications Ginger is thought to possess carminative, anti-emetic, antiinflammatory, antispasmodic and antiplatelet properties. Both fresh and dried ginger are mainly used to settle the stomach, to alleviate the symptoms of motion sickness and to relieve morning sickness. The brand of ginger used was Blackmores Travel Calm Ginger, each capsule containing an extract equivalent to 400 mg of ginger rhizome powder. Note that the number of patients taking ginger was not reported, except to say it was less than 5% of 171 ­ so it was less than 8 patients. Also, the ginger products used were not mentioned and some patients were taking more than one potentially interacting supplement. Mechanism Ginger (Zingiber officinale) has sometimes been listed as a herb that interacts with warfarin5,6 on the basis that in vitro it inhibits platelet aggregation. Nifedipine alone also had antiplatelet effects, but these were not as great as aspirin 75 mg 206 Ginger alone. Calcium-channel blockers are not generally viewed as antiplatelet drugs, and the finding of synergistic antiplatelet effects between nifedipine and aspirin in this report and its clinical relevance needs further study. Furthermore, this study suggests that ginger alone may have similar antiplatelet effects to low-dose aspirin alone; however, this antiplatelet effect has generally not been demonstrated in other controlled clinical studies of ginger (three of which have been reviewed2). Ginger + Ofloxacin For mention that sairei-to and sho-saiko-to (of which ginger is one of a number of constituents) do not affect the pharmacokinetics of ofloxacin, see Bupleurum + Ofloxacin, page 90. Terpene lactones are the other major component, and these include ginkgolides A, B and C, and bilobalide, Ginkgo extracts may be standardised to contain between 22 and 27% flavonoids (flavone glycosides) and between 5 and 12% terpene lactones, both on the dried basis. The leaves contain only minor amounts of ginkgolic acids, and some pharmacopoeias specify a limit for these. Ginkgo is unlikely to affect the activity of P-glycoprotein to a clinically relevant extent (see digoxin, page 213). Ginkgo seeds contain some toxic constituents; nevertheless, they are used in China and Japan, including as a food. Isolated case reports also suggest that ginkgo may cause seizures in patients taking phenytoin and/or valproate and one case had decreased phenytoin and valproate levels. There are some animal data suggesting that ciclosporin levels might be reduced by ginkgo, and it has been suggested that the extrapyramidal adverse effects of haloperidol and the ototoxic effects of amikacin may be enhanced by ginkgo. For information on the pharmacokinetics of individual flavonoids present in ginkgo, see under flavonoids, page 186. In contrast to the flavonoids, the bioavailability of ginkgolide A and B (but not C) and bilobalide is relatively high and a large proportion of the dose is excreted unchanged in the urine. It appears that the flavonoid fraction of ginkgo has more of an effect on the cytochrome P450 isoenzymes than the terpene lactones,2,3 and the effect on these enzymes can be halted relatively quickly when ginkgo is stopped. Induction and recovery of hepatic drug metabolizing enzymes in rats treated with Ginkgo biloba extract. G Ginkgo 209 Ginkgo + Aminoglycosides the interaction between ginkgo and amikacin is based on experimental evidence only. Importance and management Ginkgo appears to accelerate the appearance of amikacin-induced ototoxicity and to increase its ototoxic effects in rats. Because the development of ototoxicity is cumulative, if ginkgo accelerates this process, there is potential for ototoxicity to develop at a lower cumulative dose. The available evidence is weak, but until more is known it may be prudent to carefully consider the risks and benefits of continuing ginkgo during treatment with drugs such as the aminoglycosides. Importance and management Evidence for an interaction between ginkgo and valproate and phenytoin appears to be limited to case reports. The only case that measured serum levels of these antiepileptics is complicated by the use of numerous other supplements. Nevertheless, it may be prudent to consider the possibility of reduced effects if a patient taking phenytoin and/or valproate wishes also to take ginkgo. Ginkgo + Antiepileptics Case reports describe seizures in three patients taking valproate, or valproate and phenytoin, when ginkgo was also taken. Clinical evidence A 55-year-old man taking valproate and phenytoin for a seizure disorder that developed following coronary artery bypass surgery suffered a fatal breakthrough seizure while swimming a year later. The ginkgo was stopped and the patient was reportedly seizure free 8 months later. After taking a ginkgo extract 120 mg daily for 12 days prescribed by her psychiatrist, she suffered a cluster of seizures, which were treated with intravenous diazepam in the accident and emergency department.

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After the initial washing and before and after handling patients or their equipment, hands should be washed for 15 seconds with soap and water, or a golf ball-sized spray of alcoholbased foam, or an appropriate amount of alcohol-based gel. Requests for consults on infants who do not meet these criteria, but are considered high risk for neurodevelopmental problems by the attending physician, are done on an ad hoc basis. The request for consultation should be initiated at least two weeks prior to discharge, if feasible. If you hear this phrase please notify your next in line supervisor right away to join the discussion. However, gowns are to be worn by anyone who will be holding an infant against their clothing or by anyone who requests a gown while in the nursery. Masks, head covers, beard bags, and sterile gowns should be worn when placing umbilical catheters and percutaneous lines. Guidelines for Acute Care of the Neonate, Edition 26, 2018­19 Gowns Triage of Admissions Newborn Nursery Transition Area the normal newborn transition is with mother in L & D. This pager will also serve as a notice to respond to a code situation in other areas of the 3rd floor such as 3A (311 *1), 3B (311 *2), 3C (311 *3), Level 2 (311 *4) and 5555 for the first floor Emergency Room. In room stabilization is our practice with criteria in place for dealing with low risk and high-risk delivery situations (This will be included as part of your unit orientation). Ensure you have access to the scrub Pyxis located in L & D on your first day of the rotation. When entering the room, identify yourself and the team to the family and the delivering physician/midwife. After the delivery, please take the time to speak to the parents and the delivering physician/midwife regarding the status of their baby and the disposition of their baby after stabilization. The order must be placed by 1 pm to be processed by the pharmacy to be started at 9 pm. Guidelines for Acute Care of the Neonate, Edition 26, 2018­19 222 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Section 16-Overview of Nursery Routines See Pediatric Resident Reference Binder for necessary forms and complete process. A book is kept once referral faxed with date of anticipated first exam, which are generally performed on Tuesdays. Mom will receive up to 45 minutes with the nurse to ask questions at initial visit. Ben Taub is now baby friendly and all mothers could really benefit from a post discharge lactation follow up at the breastfeeding clinic. The two week appointment can also be scheduled here, unless their medical home is Legacy, or mom has a two week appointment herself at one of the Harris Health clinics; then mom and baby will be seen together. Residents who want to perform procedures or attend deliveries under the supervision of a member of the Neonatology Section are encouraged to do so during the afternoon and evening hours. All procedures, including transfusions, should be accompanied by a note that includes indications and outcome. Transfer and Off-Service Notes Every infant must have an off-service note or transfer note completed by the house officer at the appropriate times. Preferentially, routine care, elective care, and patient transfers are done during daytime hours. The timing of a clinic appointment is determined by the Developmental Care team and is based on risk factors for poor neurodevelopmental outcome. Morning report is M-W-F at 8 am in the second floor conference center and is hospital-wide. Sign out between Neonatologists generally occurs immediately before or immediately afterward of the morning report. All Medical Center campus neonatology conferences and meetings are broadcast either by video or phone. A consult should be ordered prior to discharge to facilitate an initial developmental exam and introduction to the clinic. Guidelines for Acute Care of the Neonate, Edition 26, 2018­19 225 Section 16-Overview of Nursery Routines Section of Neonatology, Department of Pediatrics, Baylor College of Medicine 226 Guidelines for Acute Care of the Neonate, Edition 26, 2018­19 Section 17: Medications Editors: Caraciolo Fernandes and Mohan Pammi 17. Hypertonic solutions, dopamine and calcium solutions, and blood may be especially caustic. If indicated in extravasation guidelines under the individual agent that has infiltrated, apply dry, cold or warm compresses.

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If untreated, xerophthalmia results in corneal ulceration and, ultimately, in blindness because of the formation of opaque scar tissue. Over 500,000 children worldwide are blinded each year by xerophthalmia caused by insufficient vitamin A in the diet. Acne and psoriasis: Dermatologic problems such as acne and psoriasis are effectively treated with retinoic acid or its derivatives (see Figure 28. Vitamin A: Excessive intake of vitamin A produces a toxic syndrome called hypervitaminosis A. Pregnant women particularly should not ingest excessive quantities of vitamin A because of its potential for teratogenesis (causing congenital malformations in the developing fetus). In excess, however, it is associated with decreased bone mineral density and increased risk of fractures. Isotretinoin: the drug, an isomer of retinoic acid, is teratogenic and absolutely contraindicated in women with childbearing potential unless they have severe, disfiguring cystic acne that is unresponsive to standard therapies. Endogenous vitamin precursor: 7-Dehydrocholesterol, an intermediate in cholesterol synthesis, is converted to cholecalciferol in the dermis and epidermis of humans exposed to sunlight and transported to liver bound to vitamin D­binding protein. Diet: Ergocalciferol (vitamin D2), found in plants, and cholecalciferol (vitamin D3), found in animal tissues, are sources of preformed vitamin D activity (Figure 28. Ergocalciferol and cholecalciferol differ chemically only in the presence of an additional double bond and methyl group in the plant sterol. Formation of 1,25-dihydroxycholecalciferol: Vitamins D2 and D3 are not biologically active but are converted in vivo to the active form of the D vitamin by two sequential hydroxylation reactions (Figure 28. The first hydroxylation occurs at the 25 position and is catalyzed by a specific 25-hydroxylase in the liver. Its formation is tightly regulated by the level of plasma phosphate and calcium ions (Figure 28. It performs this function by: 1) increasing uptake of calcium by the intestine, 2) minimizing loss of calcium by the kidney by increasing reabsorption, and 3) stimulating resorption (demineralization) of bone when blood calcium is low (see Figure 28. As a result, calcium uptake is enhanced by an increased synthesis of a specific calcium-binding protein, calbindin. Therefore, bone is an important reservoir of calcium that can be mobilized to maintain plasma levels. Distribution and requirement of vitamin D Vitamin D occurs naturally in fatty fish, liver, and egg yolk. Experts disagree, however, on the optimal level of vitamin D needed to maintain health. Nutritional rickets: Vitamin D deficiency causes a net demineralization of bone, resulting in rickets in children and osteomalacia in adults (Figure 28. Rickets is characterized by the continued formation of the collagen matrix of bone, but incomplete mineralization results in soft, pliable bones. In osteomalacia, demineralization of pre-existing bones increases their susceptibility to fracture. Insufficient exposure to daylight and/or deficiencies in vitamin D consumption occur predominantly in infants and the elderly. Renal osteodystrophy: Chronic kidney disease causes decreased ability to form active vitamin D as well as increased retention of phosphate, resulting in hyperphosphatemia and hypocalcemia. However, supplementation must be accompanied by phosphate reduction therapy to prevent further bone loss and precipitation of calcium phosphate crystals. Enhanced calcium absorption and bone resorption results in hypercalcemia, which can lead to deposition of calcium in many organs, particularly the arteries and kidneys. Vitamin K exists in several forms, for example, in plants as phylloquinone (or vitamin K1), and in intestinal bacterial flora as menaquinone (or vitamin K2). Interaction of prothrombin with membranes: the Gla residues are good chelators of positively charged calcium ions, because of their two adjacent, negatively charged carboxylate groups. With prothrombin, for example, the prothrombin­calcium complex is able to bind to negatively charged membrane phospholipids on the surface of damaged endothelium and platelets. Attachment to membrane increases the rate at which the proteolytic conversion of prothrombin to thrombin can occur (Figure 28. For example, osteocalcin of bone and proteins C and S (involved in limiting the formation of blood clots) also undergo -carboxylation. Distribution and requirement of vitamin K Vitamin K is found in cabbage, kale, spinach, egg yolk, and liver.

References:

  • https://www.jstor.org/stable/pdf/41639405.pdf
  • https://www.researchsquare.com/article/rs-16016/v1.pdf
  • https://clsi.org/media/1450/m45ed3_sample.pdf
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