Guy Valiquette, MD

• Department of Medicine
• Division of Endocrinology
• New York Medical College
• Westchester Medical Center
• Valhalla, NY

When online cheap pregabalin 75 mg overnight delivery, people tend to disclose more intimate details about themselves more quickly pregabalin 75mg for sale. A shy person can open up without worrying about whether or not the partner is frowning or looking away buy pregabalin 75 mg line. One can find a virtual partner who is warm discount pregabalin 75 mg without prescription, accepting purchase 75mg pregabalin mastercard, and undemanding (Gwinnell generic 75mg pregabalin amex, 1998) pregabalin 75mg with visa, and exchanges can be focused more on emotional attraction than physical appearance buy discount pregabalin 150mg on line. To evaluate what individuals are looking for online, Menkin, Robles, Wiley and Gonzaga (2015) reviewed data from an eHarmony. Their results indicated that users consistently valued communication and characteristics, such as personality and kindness over sexual attraction. Females valued communication over sexual attraction, even more when compared to males, and older users rated sexual attraction as less important than younger users. Alterovitz and Mendelsohn (2011) analyzed 600 Internet personal ads across the lifespan and found that men sought physical attractiveness and offered status related information more than women, while women were more selective than men and sought status more than men. These findings were consistent with previous research on gender differences regarding the importance of physical/sexual attraction. Catfishing and other forms of scamming is an increasing concern for those who use dating and social media sites and apps. Catfishing refers to "a deceptive activity involving the creation of a fake online profile for deceptive purposes" (Smith, Smith, & Blazka, 2017, p. The young woman "Kekua" who he had struck up an online relationship with was a hoax, and he was not the first person to have been scammed by this fictitious woman. Cohabitation: In American society, as well as in a number of other cultures, cohabitation has become increasingly commonplace (Gurrentz, 2018). For many emerging adults, cohabitation has become more commonplace than marriage, as can be seen in Figures 7. While marriage is still a more common living arrangement for those 25-34, cohabitation has increased, while marriage has declined, as can be seen in Figure 7. Those who are married tend to have higher levels of education, and thus higher earnings, or earning potential. In 1995 the median length of the cohabitation relationship was 13 months, whereas it was 22 months by 2010. Cohabitation for all racial/ethnic groups, except for Asian women increased between 1995 and 2010 (see Table 7. Forty percent of the cohabitations transitioned into marriage within three years, 32% were still cohabitating, and 27% of cohabitating relationships had dissolved within the three years. Three explanations have been given for the rise of cohabitation in Western cultures. The first notes that the increase in individualism and secularism, and the resulting decline in religious observance, has led to greater acceptance and adoption of cohabitation (Lesthaeghe & Surkyn, 1988). Moreover, the more people view cohabitating couples, the more normal this relationship becomes, and the more couples who will then cohabitate. A final explanation suggests that the change in employment requirements, with many jobs now requiring more advanced education, has led to a competition between marriage and pursuing post-secondary education (Yu & Xie, 2015). Taken together, the greater acceptance of premarital sex, and the economic and educational changes would lead to a transition in relationships. Overall, cohabitation may become a step in the courtship process or may, for some, replace marriage altogether. Similar increases in cohabitation have also occurred in other industrialized countries. For example, rates are high in Great Britain, Australia, Sweden, Denmark, and Finland. In fact, more children in Sweden are born to cohabiting couples than to married couples. The lowest rates of cohabitation in industrialized countries are in Ireland, Italy, and Japan (Benokraitis, 2005). Cohabitation in Non-Western Cultures, the Philippines and China: Similar to other nations, young people in the Philippines are more likely to delay marriage, to cohabitate, and to engage in premarital sex as compared to previous generations (Williams, Kabamalan, & Ogena, 2007). Despite these changes, many young people are still not in favor of these practices. Moreover, there is still a persistence of traditional gender norms as there are stark differences in the acceptance of sexual behavior out of wedlock for men and women in Philippine society. In China, young adults are cohabitating in higher numbers than in the past (Yu & Xie, 2015). Unlike many Western cultures, in China adults with higher, rather than lower, levels of education are more likely to cohabitate. Yu and Xie suggest this may be due to seeing cohabitation as being a more "innovative" behavior and that those who are more highly educated may have had more exposure to Western culture. This decline has occurred in both poor and rich countries, however, the countries with the biggest drops in marriage were mostly rich: France, Italy, Germany, Japan and the U. Cohen states that the decline is not only due to individuals delaying marriage, but also because of high rates of nonmarital cohabitation. Delayed or reduced marriage is associated with higher income and lower fertility rates that are reflected worldwide. Marriage in the United States: In 1960, 72% of adults age 18 or older were married, in 2010 this had dropped to barely half (Wang & Taylor, 2011). At the same time, the age of first marriage has been increasing for both men and women. Many of the explanations for increases in singlehood and cohabitation previously given can also account for the drop and delay in marriage. Same-Sex Marriage: In June 26, 2015, the United States Supreme Court ruled that the Constitution guarantees same-sex marriage. This ruling occurred 11 years after same-sex marriage was first made legal in Massachusetts, and at the time of the high court decision, 36 states and the District of Columbia had legalized same sex marriage. Worldwide, 29 countries currently have national laws allowing gays and lesbians Photo Courtesy Salvor Gissurardottir to marry (Pew Research Center, 2019). Rules of endogamy indicate the groups we should marry within and those we should not marry in (Witt, 2009). For example, many cultures specify that people marry within their own race, social class, age group, or religion. Additionally, these rules encourage homogamy or marriage between people who share social characteristics. In Western Europe, starting in the 18th century the notion of personal choice in a marital partner slowly became the norm. Arranged marriages were seen as "traditional" and marriages based on love "modern". Around the world, more and more young couples are choosing their partners, even in nations where arranged marriages are still the norm, such as India and Pakistan. Desai and Andrist (2010) found that only 5% of the women they surveyed, aged 25-49, had a primary role in choosing their partner. However, the younger cohort of women was more likely to have been consulted by their families before their partner was chosen than were the older cohort, suggesting that family views are changing about personal choice. Marital Arrangements in India: As the number of arranged marriages in India is declining, elopement is increasing. After a few days, a member of his family will inform her family of her whereabouts and gain consent for the marriage. In other cases, where the couple anticipate some degree of opposition to the union, the couple may run away without the knowledge of either family, often going to a relative of the male. After a few days, the couple comes back to the home of his parents, where at that point consent is sought from both families. Although, in some cases families may sever all ties with their child or encourage him or her to abandon the relationship, typically, they agree to the union as the couple have spent time together overnight. Once consent has been given, the couple lives with his family and are considered married. Arranged marriages are less common in the more urban regions of India than they are outside of the cities. As a result, they are often less economically dependent on their families, and may feel freer to make their own choices. Thornton (2005) suggests these changes are also being driven by mass media, international 290 travel, and general Westernization of ideas. Gottman (1999) differs from many marriage counselors in his belief that having a good marriage does not depend on compatibility. At the University of Washington in Seattle, Gottman has measured the physiological responses of thousands of couples as they discuss issues of disagreement. Gottman believes he can accurately predict whether or not a couple will stay together by analyzing their communication. In marriages destined to fail, partners engage in the "marriage killers": Contempt, criticism, defensiveness, and stonewalling. Each of these undermines the politeness and respect that healthy marriages require. Stonewalling, or shutting someone out, is the strongest sign that a relationship is destined to fail. Gottman, Carrere, Buehlman, Coan, and Ruckstuhl (2000) researched the perceptions newlyweds had about their partner and marriage. The Oral History Interview used in the study, which looks at eight variables in marriage including: Fondness/affection, we-ness, expansiveness/ expressiveness, negativity, disappointment, and three aspects of conflict resolution (chaos, volatility, glorifying the struggle), was able to predict the stability of the marriage with 87% accuracy at the four to six year-point and 81% accuracy at the seven to nine year-point. Gottman (1999) developed workshops for couples to strengthen their marriages based on the results of the Oral History Interview. Interventions include increasing the positive regard for each other, strengthening their friendship, and improving communication and conflict resolution patterns. Accumulated Positive Deposits: When there is a positive balance of relationship deposits this can help the overall relationship in times of conflict. Also, Gottman and Levenson (1992) found that couples rated as having more pleasant interactions, compared with couples with less pleasant interactions, reported marital problems as less severe, higher marital satisfaction, better physical health, and less risk for divorce. Finally, Janicki, Kamarck, Shiffman, and Gwaltney (2006) showed that the intensity of conflict with a spouse predicted marital satisfaction, unless there was a record of positive partner interactions, in which case the conflict did not matter as much. Again, it seems as though having a positive balance through prior positive deposits helps to keep relationships strong even in the midst of conflict. Intimate Partner Abuse Violence in romantic relationships is a significant concern for women in early adulthood as females aged 18 to 34 generally experience the highest rates of intimate partner violence. The study found that nationwide, 93% of women killed by men were murdered by someone they knew, and guns were the most common weapon used. The national rate of women murdered by men in single victim/single offender incidents dropped 24%, from 1. Intimate partner violence is often divided into situational couple violence, which is the violence that results when heated conflict escalates, and intimate terrorism, in which one partner consistently uses fear and violence to dominate the other (Bosson, et al. Men and women equally use and experience situational couple violence, while men are more likely to use intimate terrorism than are women. Consistent with this, a national survey described below, found that female victims of intimate partner violence experience different patterns of violence, such as rape, severe physical violence, and stalking than male victims, who most often experienced more slapping, shoving, and pushing. Based on the results, women are disproportionately affected by intimate partner violence, sexual violence, and stalking. Almost 1 in 5 women have been the victim of severe physical violence by an intimate partner, while 1 in 7 men have experienced the same. More than 1 in 4 women and more than 1 in 10 men have experienced contact sexual violence, physical violence, or stalking by an intimate partner and reported significant short- or long-term impacts, such as post-traumatic stress disorder symptoms and injury. An estimated 1 in 3 women experienced at least one act of psychological aggression by an intimate partner during their lifetime. Men and women who experienced these forms of violence were more likely to report frequent headaches, chronic pain, difficulty with sleeping, activity limitations, poor physical health, and poor mental health than men and women who did not experience these forms of violence. Children are less likely to be living with both parents, and women in the United States have fewer children than they did previously. The average fertility rate of women in the United States was about seven children in the early 1900s and has remained relatively stable at 2. Not only are parents having fewer children, the context of parenthood has also changed. Parenting outside of marriage has increased dramatically among most socioeconomic, racial, and ethnic groups, although college-educated women are substantially more likely to be married at the birth of a child than are mothers with less education (Dye, 2010). This is not surprising given that many of the age markers for adulthood have been delayed, including marriage, completing education, establishing oneself at work, and gaining financial independence. The birth rate for women in their early 20s has declined in recent years, while the birth rate for women in their late 30s has risen. For Canadian women, birth rates are even higher for women in their late 30s than in their early 20s. In 2011, 52% of births were to women ages 30 and older, and the average first-time Canadian mother was 28. Despite the fact that young people are more often delaying Source childbearing, most 18- to 29-year-olds want to have children and say that being a good parent is one of the most important things in life (Wang & Taylor, 2011). Proposed influences on parenting include: Parent characteristics, child characteristics, and contextual can sociocultural characteristics. Parent Characteristics: Parents bring unique traits and qualities to the parenting relationship that affect their decisions as parents. These characteristics include the age of the parent, gender, beliefs, personality, developmental history, knowledge about parenting and child development, and mental and physical health. Mothers and fathers who are more agreeable, conscientious, and outgoing are warmer and provide more structure to their children. Parents who have these personality traits appear to be better able to respond to their children positively and provide a more consistent, structured environment for their children. Fathers whose own parents provided monitoring, consistent and age-appropriate discipline, and warmth were more likely to provide this constructive parenting to their own children (Kerr, Capaldi, Pears, & Owen, 2009). Patterns of negative parenting and ineffective discipline also appear from one generation to the next. Child characteristics, such as gender, birth order, temperament, and health status, affect parenting behaviors and roles. On the other hand, a cranky or fussy infant elicits fewer positive reactions from his or her parents and may result in parents feeling less effective in the parenting role (Eisenberg et al. Over time, parents of more difficult children may become more punitive and less patient with their children (Clark, Kochanska, & Ready, 2000; Eisenberg et al. Thus, child temperament, as previously discussed in chapter 3, is one of the child characteristics that influences how parents behave with their children. Girls are more often responsible for caring for younger siblings and household chores, whereas boys are more likely to be asked to perform chores outside the home, such as mowing the lawn (Grusec, goodnow, & Cohen, 1996). Parents also talk differently with their sons and daughters, providing more scientific explanations to their sons and using more emotion words with their daughters (Crowley, Callanan, Tenenbaum, & Allen, 2001). Sociocultural characteristics, including economic hardship, religion, politics, neighborhoods, schools, and social support, also influence parenting. Parents who experience economic hardship are more easily frustrated, depressed, and sad, and these emotional characteristics affect their parenting skills (Conger & Conger, 2002). Thus, parents have different goals for their 294 children that partially depend on their culture (Tamis-LeMonda et al. Parents vary in how much they emphasize goals for independence and individual achievements, maintaining harmonious relationships, and being embedded in a strong network of social relationships. Other important contextual characteristics, such as the neighborhood, school, and social networks, also affect parenting, even though these settings do not always include both the child and the parent (Brofenbrenner, 1989). Culture is also a contributing contextual factor, as discussed previously in chapter four. For example, Latina mothers who perceived their neighborhood as more dangerous showed less warmth with their children, perhaps because of the greater stress associated with living a threatening environment (Gonzales et al. Conceptions of the transitions to adulthood: Perspectives from adolescence to midlife. Conceptions of the transition to adulthood among emerging adults in American ethnic groups. Saying no to being uprooted: the impact of family and gender on willingness to relocate. Proceedings of the National Academy of Sciences of the United States of America, 115(2), 234-236. Relationship trajectories and psychological well-being among sexual minority youth. Anxiety and depression across gender and sexual minorities: Implications for transgender, gender nonconforming, pansexual, demisexual, asexual, queer and questioning individuals. The glass cliff: Examining why women occupy leadership positions in precarious circumstances. Cyber dating in the age of mobile apps: Understanding motives, attitudes, and characteristics of users. Adult attachment, sexual satisfaction, and relationship satisfaction: A study of married couples. Perceptions of conflict and support in romantic relationships: the role of attachment anxiety. Proceedings of the National Academy of Science of the United States of America, 108(8), 3157-3162. Attachment, partner choice, and perception of romantic partners: An experimental test of the attachment-security hypothesis. From the cradle to the grave: Age differences in attachment from early adulthood to old age. Prenatal sex hormone effects on child and adult sex-typed behavior: Methods and findings. Resilience in Midwestern families: Selected findings from the first decade of a prospective longitudinal study. Parents explain more often to boys than to girls during shared scientific thinking.

If reinfection is suspected discount 75mg pregabalin, a second course of the same drug should be effective discount 75 mg pregabalin otc. Treatment or exclusion of asymptomatic carriers is not effective for outbreak control and is not recommended; testing of asymptomatic individuals is not recommended generic pregabalin 75 mg free shipping. Chemical disinfection with iodine is an alternative method of water treatment using either tincture of iodine or tetraglycine hydroperiodide tablets 75mg pregabalin fast delivery. Other possible manifestations of neonatal gonococcal infection include scalp abscess (which can be associated with fetal scalp monitoring) and disseminated disease with bacteremia order pregabalin 150 mg overnight delivery, arthritis buy 75 mg pregabalin amex, or In children beyond the newborn period pregabalin 150mg amex, including prepubertal children trusted pregabalin 75mg, gonococcal infection may occur in the genital tract and almost always is transmitted sexually. Anorectal and tonsillopharyngeal infection also can occur in prepubertal children and often is asymptomatic. In sexually active adolescent and young adult females, gonococcal infection of the genital tract often is asymptomatic. Infection involving other mucous membranes can produce involve skin and joints (arthritis-dermatitis syndrome; disseminated gonococcal infection) and occurs in up to 3% of untreated people with mucosal gonorrhea. Considering all racial/ethnic and age categories, gonorrhea rates times the rate among white females in the same age group, and black males 15 through the same age group. Neisseria organisms, because N gonorrhoeae can be confused with other Neisseria species that colonize different biochemical principles should be performed by the laboratory. This mandate does not require that the provider is certain that abuse has occurred but only that there is "reasonable cause to suspect abuse. Culture remains the preferred method for urethral specimens from boys and extragenital specimens (pharynx and rectum) in boys and girls. The evaluation of children in the primary care setting when sexual abuse is suspected. Although other parenteral extended-spectrum cephalosporins, such as cefotaxime, may be acceptonly be considered for treatment of an anogenital infection if parenteral treatment with N gonorrhoeae, potentially delay emergence and spread of resistance to cephalosporins, and ensure treatment of cooccurring pathogens (eg, chlamydia). In addition, azithromycin provides therapy for Chlamydia trachomatis on the presumption that the patient has concomitant infection. Because patients may be reinfected by a new or untreated partner within a few months after diagnosis and treatment, providers should advise all adolescents and adults diagnosed with gonorrhea to be retested approximately 3 months after treatment. Patients who do not receive a test-of-reinfection at 3 months should be tested whenever they are C trachomatis infections. Topical antimicrobial treatment alone is inadequate and unnecessary when recommended systemic antimicrobial treatment is given. Infants with gonococcal ophthalmia should be hospitalized and evaluated for disseminated infection (sepsis, arthritis, meningitis). Treatment of ophthalmia neonatorum may need to be continued beyond the single treatment dose until systemic infection has been ruled out; in terial cultures of normally sterile sites are negative. Complicated Gonococcal Infection: Treatment of Children Beyond the Newborn Period and Adolescents,a continued Prepubertal Children Who Weigh Less Than 100 lb (45 kg) Diseaseb disease Patients Who Weigh 100 lb (45 kg) or More and Who Are 8 Years of Age or Older Diseaseb Conjunctivitis,e continued a Concomitant therapy for Chlamydia trachomatis is recommended in addition to the recommended treatment for gonococcal infection. Pending antimicrobial susceptibility results, patients should be initiated and continued on the recommended regimen to complete at least a 7-day course of therapy. Pharyngeal infection Patients with uncomplicated pharyngeal gonococcal infection should be treated with cefN gonorrhoeae in the pharynx and should not be used. When prophylaxis is administered correctly, infants born to mothers with gonococcal infection rarely develop gonococcal ophthalmia. Children and Adolescents With Sexual Exposure to a Patient Known to Have Gonorrhea. N gonorrhoeae is high, in the third trimester is recommended for females at continued risk of gonococcal infecpatients found to be infected are as described previously for gonococcal infection, except that doxycycline should not be used in pregnant females because of the potential toxic effects on the fetus. For pregnant females who are severely allergic to cephalosporins, a consultation with an infectious diseases expert is indicated. All cases of gonorrhea must be reported use condoms is essential for community control, prevention of reinfection, and prevenof symptoms in the index case should be evaluated for N gonorrhoeae infection and treated symptom onset or patient diagnosis, the most recent sex partner should be evaluated and available. Cases in prepubertal children must be investigated to determine the source of infection. Among females or heterosexual male patients, if concerns exist that sex partners who are referred to evaluation and treatment will not seek care, expedited partner therapy mydia or gonorrhea by providing prescriptions or medications to the patient to take to is not possible if treatment involves an injection. The incidence of infection seems to correlate with sustained high temperatures and high relative humidity. The period of communicability extends throughout the duration of active lesions or rectal colonization. The microorganism also can be detected by histologic examination of biopsy specimens. Gentamicin can be added if no improvement is evident after several days of therapy. Partial healing usually is crobial agent is stopped before the primary lesion has healed completely. Pregnant and lactating females should be treated with erythromycin base, 500 mg orally, 4 times/day for at least 3 weeks and until all lesions have completely healed, and consideration should be given to adding a parenteral aminoglycoside (eg, gentamicin). Azithromycin might prove useful for treating granuloma inguinale during pregnancy, but published data are lacking. Completion of the series of vaccines for hepatitis B and human papillomavirus should be determined, then offered if not completed and if appropriate for the age group. Pharyngeal colonization by is relatively common, especially with nontypable and non-type b capsular type strains. The rate of nontypable infections in boys is twice that in girls and peaks in the late fall. The incidence was highest in southwestern Alaska Native children also been caused by other encapsulated non-b strains. Otitis media attributable to is diagnosed by culture of tympanocentesis drainage) may not be the same as those from middle-ear culture. In households with an immunocompromised child, even if the child is older than 48 months and fully immunized, all members of the household should receive rifampin because of the possibility that immunization may not have vaccine product, all household members should receive rifampin prophylaxis. Indications and Guidelines for Rifampin Chemoprophylaxis for Contacts of Index Cases of Invasive Haemophilus influenzae Type b (Hib) Disease Chemoprophylaxis Recommended For all household contactsa in the following circumstances: pletely immunizedb immunization status or age contact and treated with a regimen other than cefotaxime or ceftriaxone, chemoprophylaxis at the end of therapy for invasive infection Chemoprophylaxis Not Recommended For occupants of households with no children younger than 4 years of age other than the index patient For occupants of households when all household contacts are immunocompetent, all household immunizations For preschool and child care contacts of 1 index case For pregnant women a 5 of the 7 days preceding the day of hospital admission of the index case. Because some secondary cases occur later, initiation of prophylaxis 7 Child care and preschool. For American Indian/Alaska Native children, optimal immune provaccine (see American Indian/Alaska Native Children, Combination Vaccines. Recommended Regimens for Routine Haemophilus influenzae Type b (Hib) Conjugate Immunization for Children Immunized at 2 Months Through 4 Years of Agea Vaccine Product Primary Series Booster Dose Catch-up Dosesb Not licensed c,d Combination vaccines c,d Not licensed Not licensed e Neisseria meningitidis. Recommendations for Immunization: Indications and Schedule follows: For routine immunization of children younger than 7 months, the following guidelines are recommended: Primary series. For children who have completed a primary series, an additional dose of conjugate vaccine is recommended at zation schedule (see http:/ /aapredbook. These children should be immunized according to the age-appropriate schedule for unimmunized children as if they had received no should be initiated 1 month after onset of disease or as soon as possible thereafter. Children with decreased or absent splenic funcprimary series and a booster dose and are undergoing scheduled splenectomy (eg, for be provided at least 14 days before the procedure. Poor prognostic indicators include persistent hypotension, and milder forms of disease are rare. Limited information suggests that clinical manifestations and prognosis are similar in adults and children. Sin Nombre virus Bayou virus, Black Creek Canal virus, Monongahela virus, and New York virus are responsible for sporadic cases in Louisiana, Texas, Florida, New York, and other areas South and Central America include Andes virus, Oran virus, Laguna Negra virus, and Choclo virus. Peromyscus maniculatus; Black Creek Canal virus is transmitted by the cotton rat, Sigmodon hispidus; Bayou virus is transmitted by the rice rat, Oryzomys palustris; and New York virus is transmitted by the white-footed mouse, Peromyscus leucopus. Finally, immunohistochemistry in tissues (staining of capillary endothelial cells of the lungs and almost every organ in the body) obtained from autopsy can also establish the diagnosis retrospectively. Brooms and vacuum cleaners should not be used to clean rubber gloves before handling trapped or dead rodents is recommended. The cleanup of areas potentially infested with hantavirusinfected rodents should be carried out by knowledgeable professionals using appropriate personal protective equipment. Potentially infected material should be handled according to local regulations for infectious waste. In children, H pylori infection can result in gastroduoand guaiac-positive stools. Moreover, there is no clear association between infection and recurrent abdominal pain, in the absence of peptic ulcer disease. Infection rates are low in children in resource-rich, industrialized countries, except in children from lower socioecolence rates of up to 80% in resource-limited countries. Presence of H pylori Because of production of urease by organisms, urease testing of a gastric specimen can and biopsy. H pylori consists of at least 7 to 14 days of treatment; eradication rates are higher for regimens of 14 days. A number of treatment regimens have been pediatric patients have not been established. These regimens are effective in eliminating the organism, healing the ulcer, and preventing recurrence. Alternate therapies in people 8 years and older include: sium plus metronidazole plus tetracycline plus omeprazole. Tetracycline-based antimicrobial agents, including doxycycline, may cause permanent tooth discoloration for children younger ily to calcium compared with older tetracyclines, and in some studies, doxycycline was not associated with visible teeth staining in younger children (see Tetracyclines, p 873). Thrombocytopenia, leukopenia, axillary petechiae, generalized lymphadenopathy, and encephalopathy usually are present in in Lassa fever. Mucosal bleeding occurs in severe cases as a consequence of vascular damage, thrombocytopenia, and platelet dysfunction. The Old World complex of arenaviruses includes Lassa virus, which causes Lassa fever in West Africa, as well as Lujo virus, which was described in southern Africa during an outbreak characterized by fatal human-to-human transmission. Ingestion of food contaminated by rodent excrement also may cause disease transmission. Before a annually in agricultural workers and inhabitants of the Argentine pampas. Intravenous ribavirin has been used with success to abort a Sabia laboratory toms. A negative pressure room should be used when aerosolgenerating procedures are conducted, such as intubation or airway suctioning. Acute renal dysfunction also occurs, but hypotensive shock or 1 National Center for Infectious Diseases. A hypotensive crisis often occurs after the appearance of frank hemorrhage from the gastrointestinal tract, nose, mouth, or uterus. All genera except hantaviruses are associated with arthropod vectors, and hantavirus infections are associated with airborne exposure to infected wild rodents, primarily via inhalation of virus-contaminated urine, droppings, or nesting materials. The virus also can be transmitted by aerosol and by direct contact with infected aborted tissues or freshly slaughtered infected animal carcasses. Person-to-person transmission has not been reported, but laboratory-acquired cases are well documented. If a viral hemorrhagic fever is suspected, the state/local health department or and control measures. Airborne isolation may be required in certain circumstances when patients undergo procedures that stimulate coughing and promote generation of aerosols. Arachnicides for tick control generally have limited tick removal and protective clothing with permethrin sprays) may be effective for people at-risk (farmers, veterinarians, abattoir workers). Personal protective clothing (with permethrin sprays) and insect repellants may be effective for people at risk (farmers, veterinarians, abattoir workers). Central nervous system manifestations and renal failure are frequent in end-stage disease. In fatal cases, death typically occurs around virus disease present with spontaneous abortion and vaginal bleeding. Nonhuman primates, especially gorillas and chimpanzees, and other wild animals also may become outbreaks tend to occur after prolonged dry seasons. Although experience suggests that standard universal and contact protections usually are protective, viral hemorrhagic fever precautions consisting of at least gown, face shield, protective apron, and shoe covers or rubber boots are recommended a patient. Asymptomatic people at high, some, or low risk should have active monitoring consisting of, at a minimum, daily reporting of measured temperatures and symptoms consistent ing, abdominal pain, or unexplained hemorrhage) by the individual to the public health authority. Avoiding contact with bats, primarily by avoiding entry into caves and cially nonhuman primates but also bats, porcupines, duikers (a type of antelope), and Public Health Reporting. Because of the risk of health care-associated transmission, state/ hemorrhagic fevers are reportable by guidelines of the Council of State and Territorial to assist with case investigation, diagnosis, management, and control measures. Among older children and adults, infection usually is symptomatic and typically lasts several weeks, with jaundice occurring in 70% or more. Fecaloral spread from people with asymptomatic infections, particularly young children, likely accounts for many of these cases with an unknown source. In child care centers, recognized symptomatic (icteric) illness occurs primarily among adult contacts of children. Most infected children younger than 6 years are asymptomatic a child care center often occurs before recognition of the index case(s). Recommended doses and schedules for these different products and formula- containing vaccines are administered intramuscularly. Dosage and schedule of hepatitis A vaccine as recommended according to age in Table 3. Only monovalent hepatitis A vaccine (Havrix or Vaqta) should be used for postexposure prophylaxis. The need for additional booster doses beyond the 2-dose primary cines has not been established. Studies among adults have found no difference in the immunogenicity of a vaccine series that mixed the 2 currently available vaccines, compared with using the same vaccine throughout the licensed schedule. The vaccine can be administered either in the thigh or the arm, because the site of injection does not affect the incidence of local reactions. The vaccine should not be administered to people with hypersensitivity to any of the vaccine components. Because HepA vaccine is inactivated, no special precautions need to be taken when vaccinating immunocompromised people. Children who are not immunized or have not completed the series by 2 years of age can be immunized at subsequent visits. One dose of single-antigen vaccine administered at any time before departure can provide adequate protection for most healthy people. Older adults, immunocompromised people, and people with chronic liver disease or other chronic medical conditions who are traveling to an area with endemic infection in 2 weeks or less should receive the initial dose of vaccine and simultaneously should be completed according to the licensed schedule. Travelers who elect not to receive vaccine, are younger than 12 months, or are aller- which provides effective protection for up to 3 months. Therefore, HepA vaccine should be administered to all previously unvaccinated people who anticipate close personal contact (eg, household contact or regular babysitting) with an international adoptee from a country with high or soon as adoption is planned, ideally 2 or more weeks before the arrival of the adoptee. Periodic outbreaks among injection and noninjection drug users have been reported in many parts of the United States and in Europe. Recommendations for administering hepatitis A vaccine to contacts of international adoptees. These infected primates were born in the wild and were not primates that had been born and raised in captivity. Because people with chronic liver disease are at increased risk of fulminant hepatitis A, susceptible patients with chronic liver disease should be immunized. Susceptible people who are awaiting or have received liver transplants should be immunized. No data are available for people older than 40 years or people with underlying medical conditions. For healthy people 12 months through 40 years of age, HepA vaccine at the ageterm protection and ease of administration. However, HepA vaccine can be used if people, people with chronic liver disease, and people for whom HepA vaccine is contraindicated. HepA vacstaff members and attendees of child care centers or homes if (1) one or more cases of hepatitis A are recognized in children or staff members; or (2) cases are recognized in 2 or more households of center attendees. In centers that provide care only to children have children (center attendees) in diapers. Children and adults with hepatitis A should be excluded from the center until 1 week after onset of illness, until the postexposure prophylaxis program has been completed in the center, or until directed by the health department. Transmission by transfusion screening of blood donors and viral inactivation of certain blood products before adminsures during labor and delivery. Investigations have indicated an increased risk of settings, including assisted-living facilities and nursing homes, highlight the increased risk among people with diabetes mellitus undergoing assisted blood glucose monitoring. The incubation period for acute infection is 45 to 160 days, with an average of 90 days. Although the peak incidence in children as young as 6 years who become infected perinatally or in early childhood. An important consideration in the choice of treatment is to avoid selection of antiviral-resistant mutations. All 3 of these factors are associated with lower response rates to interferon-alfa, which is less effective for chronic infections acquired during early childhood, especially if serum aminotransferase concentrations are normal. The optimal duration of lamivudine therapy is not known, but a minimum of 1 year is required. Highly effective and safe HepB vaccines produced by recombinant as components of combination vaccines. In general, the various brands of age-appropriate HepB vacor 2 doses of a vaccine produced by one manufacturer followed by 1 or more subsequent a single product. Alternately, a 4-dose schedule at days 0, 7, and 21 to 30 followed by a booster dose at 12 months may be used. For children and adults with normal immune status, routine booster doses of HepB vaccine are not recommended. No adverse effect on the developing fetus has may result in severe disease in the mother and chronic infection in the newborn infant, Serologic Testing. Fewer than 5% of immunocompetent infants, children, and young adults receiving 6 doses of HepB vaccine administered by the appropriate schedule in the deltoid muscle fail to develop detectable antibody.

Blindness secondary to exten- 1 Compendium of Measures to Control Chlamydophila psittaci Infection Among Humans (Psittacosis) and Pet Birds (Avian Chlamydiosis) purchase pregabalin 150 mg visa, 2008 cheap 150mg pregabalin. The possibility of sexual abuse always should be considered in prepubertal children beyond infancy who have vaginal 75 mg pregabalin with visa, urethral discount pregabalin 150 mg with visa, or rectal chlamydial infection generic pregabalin 75mg fast delivery. Sexual abuse is not limited to prepubertal children pregabalin 75mg visa, and chlamydial infections can result from sexual abuse/assault in postpubertal adolescents as well pregabalin 75 mg amex. Asymptomatic infection of the nasopharynx cheap pregabalin 150mg without prescription, conjunctivae, vagina, and rectum can be acquired at birth. Nasopharyngeal cultures have been observed to remain positive for infection acquired at birth. C trachomatis testing of pharyngeal specimens from asymptomatic postoropharyngeal C trachomatis infection is unclear. A diagnosis of C trachomatis infection in an infant should prompt treatment of the mother and her sexual partner(s). An association between orally administered erythromycin and infantile hypertrophic investigation and because alternative therapies are not as well studied, the American Academy of Pediatrics continues to recommend use of erythromycin for treatment of diseases caused by C trachomatis. Infants born to mothers known to have untreated chlamydial infection are at high risk of infection; however, prophylactic antimicrobial treatment is not indicated, because the appropriate treatment if infection develops. Alternatives include oral erythromycin base (500 mg, 4 times/day) for 7 days, erythromycin ethylsuccinate (800 mg, 4 times/day) for 7 days, For children who weigh <45 kg, the recommended regimen is oral erythromycin base or ethylsuccinate, 50 mg/kg/day, divided into 4 doses daily for 14 days. For children 8 years and older, the recommended regimen is azithromycin, 1 g, orally, in a single dose, or doxycycline, 100 mg, orally, twice a day for 7 days. For pregnant females, the recommended treatment is azithromycin (1 g, orally, as a single dose). Test-of cure is not recommended for nonpregnant adult or adolescent patients treated for uncomplicated chlamydial infection unless compliance is in question, symptoms persist, or reinfection is suspected. Treatment of trachoma people diagnosed with trachoma as well as for all of their household contacts. C trachomatis genital tract infection during pregnancy can prevent disease in the infant. Four naturally occurring forms of human botulism exist: infant, foodborne, wound, and adult intestinal colonization. Some reports suggest that sudden infant death could result from rapidly progressing infant botulism. C botulinum contaminates traumatized tissue, germinates, multiplies, and produces toxin. During the last decade, self-injection of contaminated black tar heroin has been associated with most cases. The usual incubation period for foodborne botulism is incubation period is estimated at 3 to 30 days from the time of ingestion of spores. For wound botulism, the incubation period is 4 to 14 days from time of injury until onset of symptoms. The diagnosis of infant botulism is made by demonstrating botulinum toxin or botulinum toxin-producing organisms ing organisms in the wound or tissue or toxin in the serum. To increase the likelihood of diagnosis in foodborne botulism, all suspect foods should be collected, and serum and stool or enema specimens should be obtained from all people with suspected illness. Although toxin can be demonstrated in serum in some infants with botulism sterile, nonbacteriostatic water should be given promptly. Because results of laboratory bioassay testing may require several days, treatment with antitoxin should be initiated urgently for all forms of botulism on the basis of clinical suspicion. The most prominent small-amplitude, overly abundant motor action potentials may be seen after stimulation of muscle, but its absence does not exclude the diagnosis; this test is infrequently needed for diagnosis. Meticulous supportive care, in particular respiratory and nutri- tional support, constitutes a fundamental aspect of therapy in all forms of botulism. Immediate administration of antitoxin is the key to successful therapy, because antitoxin treatment ends the toxemia and stops further uptake ing, administration of antitoxin does not reverse paralysis. Aminoglycoside agents can potentiate the paralytic effects of the toxin and should be avoided. The role of antimicrobial therapy in the adult intestinal colonization form of botulism, if any, has not been established. Immediate reporting of suspect cases is particularly important, because a single case could be the harbinger of many more cases, as with foodborne botulism, and because of possible use of botulinum toxin as a bioterrorism weapon. Food containers that appear to bulge may contain gas produced by C botulinum and should be discarded. Other foods that appear to have spoiled should not be eaten or tasted (http:/ /nchfp. Other Clostridium species (eg, Clostridium sordellii, Clostridium septicum, Clostridium novyi) also have been associated with myonecrosis. Because Clostridium species are ubiquitous, their recovery from a wound is not diagnostic unless typical clinical manifestations are present. A Gram-stained smear of wound discharge demonstrating characteristic gram-positive bacilli and few, if any, polymorphonuclear leukocytes suggests clostridial infection. Mild to moderate illness is characterized by watery diarrhea, low-grade fever, and mild abdominal pain. Pseudomembranous colitis is characterized by diarrhea with mucus in feces, abdominal cramps and pain, fever, and systemic toxicity. Disease often begins while the child is hospitalized receiving antimicrobial therapy but can occur up to 10 weeks after therapy cessation. The illness usually, but not always, is associated with antimicrobial therapy or prior hospitalization. The incubation period is unknown; colitis usually develops 5 to 10 days after initherapy cessation. The predictive value of a positive test result in a child younger than 5 years is unknown, because asymptomatic carriage of toxigenic 1 American Academy of Pediatrics, Committee on Infectious Diseases. Oral vancomycin (40 mg/kg per day, orally, in 4 divided doses, to a maximum daily nidazole is indicated as initial therapy for patients with severe disease (hospitalized in ing intestinal tract disease) and for patients who do not respond to oral metronidazole. Therapy with either metronidazole or vancomycin or the combination should be administered for at least 10 days. No comparisons to metronidazole are available, and no pediatric data are available. Fecal transplant (intestinal microbiota transplantation) appears to be effective in adults, but there are limited data in pediatrics. Investigational therapies include other antimicrobial agents (rifaximin, tinidazole), Immune Globulin therapy, toxin binders, and probiotics. The most effective means of preventing hand contamination is the use of gloves when caring for infected patients or their environment, followed by hand hygiene after glove removal. Thorough cleaning of hospital rooms and bathrooms of patients with disease is essential. Because many common hospital disinfectants, and many hospitals have instituted the use of disinfectants with sporicidal activity (eg, hypochlorite). C perfringens type A, which produces a by C perfringens type C, which produces and toxins and enterotoxin. C perfringens type B, which produces e toxin, a neurotoxin, has been proposed as an environmental trigger for multiple sclerosis. Illness results from consumption 5 colony forming units/g) followed by enterotoxin production in the intestine. Ingestion of the organism is most commonly associated with foods prepared by restaurants or caterers or in institutional settings (eg, schools and camps) where food is prepared in large quantities, cooled slowly, and stored inappropriately for prolonged periods. Although C perfringens is an anaerobe, special transport conditions are unnecessary. Foods never should be held at room temperature to cool; they should be refrigerated after removal from warming devices or serving tables as soon as possible and with including time and temperature requirements during cooking, storage, and reheating, can be found at Acute infection may be associated only with cutaneous abnormalities, such as erythema multiforme, an erythematous maculopapular rash, or erythema nodosum. Cutaneous lesions and soft tissue infections often are accompanied by regional lymphadenitis. Infectious arthroconidia (ie, spores) produced from hyphae become airborne, infecting the host after inhalation or, rarely, inoculation. In tissues, arthroconidia enlarge to form spherules; mature spherules release hundreds to thousands of endospores that develop into new spherules and continue the tissue cycle. In areas with endemic coccidioidomycosis, clusters of cases can follow dust-generating events, such as storms, seismic events, archaeologic digging, or recreational activities. The incidence of reported coccidioidomycosis cases has increased substantially over the past decade and a half, rising from 5. Cases may occur in people who do not reside in regions with endemic infection but who previously have visited these areas. In regions without endemic infection, careful travel histories should be obtained Coccidioides species are listed by the Centers for Disease Control and Prevention as agents of bioterrorism. The incubation period typically is 1 to 4 weeks in primary infection; disseminated infection may develop years after primary infection. Culture of organisms is possible on spherules can convert to arthroconidia-bearing mycelia on culture plates. Suspect cultures should be sealed and handled using appropriate safety equipment and procedures. Cross reactions occur in patients with histoplasmosis, blastomycosis, or paracoccidioidomycosis. Although most cases will resolve without therapy, some experts believe that treatment may reduce illness duration or risk for severe complications. Most experts recommend treatment of coccidioidomycosis for people at risk of severe disease or people with severe primary infection. Amphotericin B is more frequently used in the presence of severe hypoxemia or rapid clinical deterioration. Amphotericin B is recommended as alternative therapy if lesions are progressing or are in critical locations, such as the vertebral column. These newer agents may be administered in certain clinical settings, such as therapeutic failure in severe coccidioidal disease (eg, meningitis). In general, therapy is continued until clinical and laboratory evidence indicates that active infection has patients may be extended to 1 year or longer. Care should be taken in handling, changing, and discarding dressings, casts, and similar materials in which arthroconidial contamination could occur. Immunocompromised people residing in or traveling to areas with endemic infection should be counseled to avoid exposure to activities that may aerosolize spores in contaminated soil. Less frequently, they are associated with lower respiratory tract infections, including bronchiolitis, croup, and pneumonia, primarily in infants and immunocompromised children and adults. Typical laboratory abnormalities include lymphopenia and increased lactate dehydrogenase and creatine kinase concentrations. Most have progressive uniother signs of barotrauma are common in critically ill patients receiving mechanical ventilation. Associated lymphopenia is less severe, and radiographic changes are milder and generally resolve more quickly than in adolescents and those of adult disease, presenting with fever, myalgia, headache, and chills. Patients commonly present with fever, myalgia, chills, shortness of breath, the case-fatality rate is high, estimated at nearly 50%. To date, most infections have been reported in male adults, and most cases have been reported with comorbidities, such as diabetes, chronic renal disease, hypertension, and chronic cardiac disease. Alphacoronavirus, Betacoronavirus, lineage B of the genus Betacoronavirus, Betacoronavirus. On the basis of available information from all recently affected countries, there is no evidence of sustained human-to-human transmission in the community. Given the potential for false-positive test results and the associated public health public health departments when there is a high degree of suspicion in a patient with no ( Airborne, droplet, and contact precautions are recom10 days after resolution of fever, provided respiratory symptoms are absent or improving. Airborne, droplet, and contact precautions are recommended as well for patients with precautions have not yet been established but are expected once more is learned about Illness pending formal recommendations. Pulmonary disease, when symptomatic, is characterized by cough, chest pain, and constitutional symptoms. C neoformans infects 5% to 10% of C gattii (formerly C neoformans var gattii) is associated with trees and surrounding soil and has emerged as a pathogen in Aboriginal people in Australia and in the central province of Papua New Guinea. Media containing cycloheximide, which inhibits growth of C neoformans, production of urease by Cryptococcus species, noting that virtually all other fungi are urease negative (exceptions being Trichosporon species and some Candida species). C neoformans will not grow in presence of L-canavanine, and the agar remains unchanged. In refractory or relapse cases, susceptibility testing can be helpful, although antifungal resistance is uncommon. When infection is refractory to systemic therapy, intraventricular amphotericin B can be administered. Monitoring of serum cryptococcal antigen is not useful to monitor response to therapy in patients with cryptococcal menindata on use of these drugs for children with C neoformans infection are limited. Discontinuing chronic suppressive therapy for cryptococcosis (after 1 year or longer of 3, and have an undetectable viral load for at least 3. In infected immunocompetent adults and children, diarrheal illness is self-limited, usu- rarely in the pancreas) has been reported in immunocompromised people. The incidence of cryptosporidiosis has been increasing since 1 In children, the incidence of cryptosporidiosis is greatest during summer and early fall, corresponding to the outdoor swimming season. Because oocysts are extremely chlorine tolerant, multistep treatment processes often are only partially effective in removing oocysts from contaminated water. Personto-person transmission occurs as well and can cause outbreaks in child care centers, in which up to 70% of attendees reportedly have been infected. The appropriate treatment of cryptosporidiosis in children who are solid organ transhave been recommended. Given the seriousness of this infection in immunocompromised individuals, use of nitazoxanide can be considered restoration. The recommended nitazoxanide dosing is the same as for immunocompetent people mentioned previously. When traveling in countries where the drinking water supply might be unsafe, do not consume inadequately treated water or ice. As the larvae migrate through skin, advancing several millimeters to a few centimeters a day, intensely pruritic serpiginous tracks or bullae are formed. Larval activity can continue for several weeks or months, but the infection is self-limiting. Anorexia, nausea, vomiting, substantial Low-grade fever occurs in approximately 50% of patients. Infection usually is self-limited, but untreated people may have remitting, relapsing symptoms for weeks to months. The oocysts are resistant to most disinfectants used in food and water processing and can remain viable for prolonged periods in cool, moist environments. Less commonly, patients treated with biologic response Congenital infection has a spectrum of clinical manifestations but usually is not evirestriction, jaundice, purpura, hepatosplenomegaly, microcephaly, intracerebral (typically is estimated to occur in 3% to 10% of infants with symptomatic infections, or 0. Congenital infection and associated sequelae can occur irrespective of the trimester of pregnancy when the mother is infected, but severe sequelae are associated more Damaging fetal infections following nonprimary maternal infection have been reported, and acquisition of a different viral strain during pregnancy in women with preexisting are born to women with nonprimary infection, and the contribution of nonprimary remains contentious and is an active area of research. Similarly, although disease can occur in ingestion of infected human milk do not develop clinical illness or sequelae, most likely because of the presence of passively transferred maternal antibody. If such patients are treated with parenteral ganciclovir, a clovir can be considered if symptoms and signs have not resolved. Pasteurization or freezing of donated human - antibody-negative women should be considered. Approximately 5% of patients develop severe dengue, which is more common with second or other subsequent infections. Because of the approximately 7 days of tissue; percutaneous exposure to blood; and exposure in utero or at parturition. It is most likely to cause severe disease in young children and women, especially pregnant women, and in patients with chronic diseases (asthma, sickle cell anemia, and diabetes mellitus). In humans, the incubation period is 3 to 14 days before symptom onset (intrinsic incubation). Infected people, both symptoms develop and throughout the approximately 7-day viremic period. No chemoprophylaxis or antiviral medication is available to treat patients with dengue. Travelers should select accommodations that are air conditioned and/or have screened windows and doors. Membranous pharyngitis associated with a bloody nasal discharge should suggest diphtheria. Cutaneous diphswelling with cervical lymphadenitis (bull neck) is a sign of severe disease. In industrialized countries, toxigenic strains of Corynebacterium ulcerans are emerging as an important cause of a diphtheria-like illness. C diphtheriae is an irregularly staining, gram-positive, nonspore-forming, nonmotile, pleomorphic bacillus with 4 biotypes (mitis, intermedius, gravis, and belfanti). Toxigenic strains express an exotoxin that consists of an enzymatically active A domain and a binding B domain, which promotes the entry of A into the cell. Organisms are spread by respiratory tract droplets and by contact with discharges from skin lesions.

Comparing methods of determining insertion length for placing gastric tubes in children 1 month to 17 years of age purchase pregabalin 150mg free shipping. Potential risk of malposition of nasogastric tube using nose-ear-xiphoid measurement purchase 75 mg pregabalin with mastercard. Head-of-bed elevation and early outcomes of gastric reflux buy pregabalin 75mg, aspiration and pressure ulcers: a feasibility study cheap pregabalin 75 mg free shipping. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials generic 150 mg pregabalin overnight delivery. Nutrition support protocols and their influence on the delivery of enteral nutrition: a systematic review pregabalin 75mg line. Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study generic pregabalin 75 mg free shipping. Care of the patient with enteral tube feeding: an evidence based practice protocol pregabalin 150 mg overnight delivery. Analysis of non-invasive ventilation effects on gastric inflation using a non-linear mathematical model. Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients. Compensatory increased enteral feeding goal rates: a way to achieve optimal nutrition. What you think is not what they get: significant discrepancies between prescribed and administered doses of tube feeding. Enteral nutrition in critical patients: should the administration be continuous or intermittent? Hazard report: incorrect key presses may cause Nutricia Flocare Infinity Series enteral feeding pumps to appear to be infusing even though and occlusion exists. Bacterial safety of commercial and handmade enteral feeds in an Iranian teaching hospital. Bacterial contamination of hospital-prepared enteral tube feeding formulas in Isfahan, Iran. Application of hazard analysis critical points system to enteral tube feeding in hospital. Neonatal enteral feeding tubes as loci for colonization by members of the Enterobacteriaceae. Biofilm formation on enteral feeding tubes by Cronobacter sakazakii, Salmonella serovars and other Enterobacteriaceae. Biofilm growth on the Lopez enteral feeding valve cultured in enteral nutrition: potential implications for medical-surgical patients, nursing care and research. Effect of an infection control program on bacterial contamination of enteral feed in nursing homes. Microbial contamination of syringes during preparation: the direct influence of environmental cleanliness and risk manipulations on end-product quality. Comparison of microbial contamination of enteral feeding solution between repeated use of administration sets after washing with water and after washing followed by disinfection. The relationship between enteral formula contamination and length of enteral delivery set usage. Preventing diarrhea in enteral nutrition: the impact of the delivery set hang time. Diarrhea risk factors in enterally tube fed critically ill patients: a retrospective audit. Stress prophylaxis in intensive care unit patients and the role of enteral nutrition. Infection Control: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Intrahospital transport of critically ill ventilated patients: a risk factor for ventilator-associated pneumonia-a matched cohort study. Practice guideline recommendations on perioperative fasting: a systematic review [published online January 9, 2015]. Feasibility of implementing a reduced fasting protocol for critically ill trauma patients undergoing operative and nonoperative procedures. Nutritional adequacy in patients receiving mechanical ventilation who are fed enterally. Clinically relevant differences in accuracy of enteral nutrition feeding pump systems. Use the largest diameter feeding tube feasible without sacrificing patient comfort. Flush feeding tubes immediately before and after feeding with intermittent feedings. Flush feeding tubes before and after medication administration and follow appropriate medication administration practices (see Section 8). Limit gastric residual checks as acidic gastric contents may cause protein in enteral formulas to precipitate within the lumen of the tube. Use aseptic technique when handling enteral formula, administration sets, and feeding tubes. Use an administration pump when slow rates of enteral formula are required, such as in the neonatal population, and respond promptly to pump alarms. Use purified water for tube flushes in immunocompromised or critically ill patients, especially when the safety of tap water cannot be reasonably assumed. Consider use of an automatic flush pump to prevent tube clogging and provide additional hydration. A clogged feeding tube can result in decreased nutrient delivery or delay administration of medication, and, if not corrected, the patient may require additional intervention to replace the tube. Replacement costs are higher for jejunal feeding tubes, as they must be replaced in radiology and require fluoroscopic confirmation of tube placement. Prompt restoration of tube patency reduces the clinical impact and may save healthcare resources devoted to tube replacement. The use of cranberry juice and carbonated beverages may worsen occlusions because of the acidic pH of these fluids. Acid can cause proteins in enteral formula to precipitate within the tube, making the clog worse or leading to more clogging later on. Rationale Small internal diameter and longer feeding tubes, such as nasogastric and nasojejunal tubes, have a higher risk of clogging compared to shorter and large diameter tubes such as gastrostomy tubes. Larger bore tubes are less likely to be occluded by either medication or highly viscous formulas. Polyurethane tubes are preferable to silicone because polyurethane better sustains patency. Clogging may also be caused by interactions of the coagulated formula with feeding tube surfaces, especially during slow feeding infusion rates. To reduce risk of formula contamination, administer water as separate flushes instead of adding it directly to the tube-feeding formula; also, wipe down enteral formula containers with isopropyl alcohol and allow them to air dry prior to use. Prevention is the preferred way to minimize the risk of enteral feeding tube clogs. Consistent and scheduled flushing of all types of tubes during feeding and medication administration is the best way to decrease the incidence of tube occlusion. No solution has been found to be superior to water for its effectiveness, accessibility, and cost. In a survey of 823 nurses, 26% always use sterile water to flush tubes before or after medication administration and 70% always use tap water. In neonatal nutrition, flushes are used sparingly because the nutrient needs of neonates are so high and there is little room for fluids that do not contain nutrients. When necessary, flushes 75 are used at a minimal volume (2 or 3 mL) to maintain the patency of the feeding tube. In pediatrics, depending on the size of the child, flushes are more commonly used to maintain tube patency and to give more water volume. In the adult patients, flush feeding tubes with a minimum volume of 30 mL of water every 4 hours during continuous feedings or before and after intermittent feedings. In neonatal and pediatric patients, flush feeding tubes with the lowest volume necessary to clear the tube. Rationale There are variations in clinical practice with regards to volume, timing, and frequency of water flushes. However, consistent flushing before and after medication administration, bolus feedings, and periodically with continuous or cyclic feedings is very important to prevent tube occlusion. Routine water flushes are not recommended after each bolus feeding or interrupting continuous feeding for any tubes other than nasojejunal tubes. Provide proper training, credentialing, and privileging at the healthcare organizational level to staff responsible for unclogging tubes according to local practice acts and institutional privileging. If water flush does not resolve the clog, use an uncoated pancreatic enzyme solution by crushing one uncoated pancreatic enzyme tablet and one 325-mg sodium bicarbonate tablet mixed in 5 mL of water. The solution should be introduced to the clog and clamp the feeding tube for at least 30 minutes. If the clog is not cleared within 30 minutes, the solution should be removed from the tube and replaced with a fresh mixture. If water flush does not resolve the clog, use an enzyme containing declogging kit or mechanical declogging device. Journal of Parenteral and Enteral Nutrition 41(1) water or cola in dissolving an enteral formula clog that would occur in feeding tubes. Commercially available enzyme declogging kits contains a syringe preloaded with a powder of food-grade papain, cellulose, and amylase enzymes, which can break down protein, fiber, and starch clogs. If the tube is still clogged, the declogging process may be repeated with the remaining solution in the syringe. In one study, 15 of 17 tubes were successfully declogged on the first attempt, and the remaining 2 were declogged on the second try, preventing the need for any tube reinsertions. An approved institutional policy on declogging enteral feeding tubes will expedite the process. The success of the method has much to do with the cause of obstruction and the knowledge and skill of the provider. The declogging process may begin when resistance is met when attempting a flush or when an occlusion alarm sounds on an enteral feeding pump and the tube is not kinked. However, it may be prudent to begin the declogging process as soon as the tube becomes sluggish. A 30- or 60-mL syringe is attached initially to the tube and the plunger pulled back to help dislodge the clog. The flush syringe is then filled with warm water and reattached to the tube to attempt a flush. If resistance is met, the plunger of the syringe may be moved using a gentle back-and-forth motion to help loosen the clog, then clamp the tube and soak for up to 20 minutes to allow the warm water to penetrate the clog. Pancreatic enzymes have been documented as effective agents in clearing feeding obstructions caused by enteral formulas. The findings show that pancreatic enzymes in enteric-coated products can be released and that these pancreatic enzymes can disrupt clogs. If the clog is of considerable size, warm water is still the first choice to allow for the passage of fluid. The protocol was administered to 83 patients, and tube patency was restored to approximately half (48. Efficacy of a Creon delayed-release pancreatic enzyme protocol for clearing occluded enteral feeding tubes. Viscosity and flow rate of three high energy, high fiber enteral nutrition formulas. Comparison of complication rates, types, and average tube patency between jejunostomy tubes and percutaneous gastrostomy tubes in a regional home enteral nutrition support program. A systematic review of nursing administration of medication via enteral tubes in adults. The role of water in the transmission of healthcare-associated infections: opportunities for intervention through the environment. It is essential that a necessary medication is appropriately prepared and administered through a feeding tube without increasing the risk for complications in the patient. Complications include impairing the patency of the feeding tube, reducing therapeutic effect of the medication, or increasing drug toxicity. Safety must be the focus of both the preparation of the medication and administration of the medication. Preparation refers to the retrieval of a medication and any alteration to a dosage form to make it suitable for delivery through a feeding tube. The alteration may be as simple as diluting a liquid medication or as complex as compounding a new formulation from multiple components, including the active pharmaceutical ingredient. Practice recommendations have been available to practitioners for a number of years. What factors should be evaluated to safely prepare and administer medication through an enteral access device? Identify whether the patient can take medication by mouth or requires enteral medication administration. Describe the device by its entry point and distal end (ie, nasogastric, percutaneous jejunostomy) and its diameter (eg, 12 French), rather than by the brand name or color of the feeding tube. The vast majority of medications are not formulated to be administered through a feeding tube. Careful consideration must be given to each individual medication prescribed and the goals of therapy. Administration of many oral medications via enteral feeding tube can be an effective method of medication administration, but a number of medications carry complex drug-nutrient or drug-drug interactions that can impact drug efficacy and drug toxicity. When institutions create policies regarding medication administration via enteral 78 flushing regimen being administered through the feeding tube. Identify the route (oral vs enteral) and the distal site of drug administration as ordered (drug administration should match current enteral status). Develop real-time communications to inform the pharmacy of any changes to the route or distal site of medications being prepared and dispensed. Confirm the following aspects of enteral medication orders and resolve any inappropriate orders with the prescriber and nurse. The drug dosage form is appropriate for enteral feeding tube administration (ie, immediate release). Avoid any solid dosage form medications that would result in a significant change in the absorption of the active ingredient(s) if opened (capsule) or crushed (tablet). If crushing the medication alters its delivery (eg, enteric coated, extended release, or novel excipients for alternative delivery systems), consider an alternative dosage form, drug, or route of administration. The drug and the formulation are both appropriate based on the distal end of the feeding tube. Any medication order that will require a preparation step (eg, crushing, diluting, mixing) prior to administration is identified. Journal of Parenteral and Enteral Nutrition 41(1) to prevent related medication errors than those that lack protocols. Although not widely recognized or reported, medication errors related to the enteral route of administration happen. These potential adverse outcomes are not always captured in medication error rates. Routine reporting of all enteral medication errors to the medication safety committee or other appropriate institutional committee is important so that systems improvements can be made to address them. The responsibility for preventing enteral medication errors should be shared by the prescriber, pharmacist, and nurse. The nurse is in a difficult position if a prescriber enters an inappropriate medication order and the pharmacist does not clarify it. An interdisciplinary group of healthcare providers, including knowledgeable prescribers, pharmacists, and nurses, can work together to develop protocols for administering medications through enteral tubes within their organization. During his 30-day hospitalization, this patient improperly received all of his scheduled oral medications via feeding tube, including multiple sustained-release and extended-release drugs, crushed and combined with each other in 40 mL of tap water. A multidisciplinary team with a pharmacist reviewing medications to be administered via enteral feeding tube could have prevented these errors and intervened with proper recommendations for medication administration. Caregivers are typically confident that they prepare and/or administer drugs appropriately, although surveys have suggested otherwise. Of those, many orders were not corrected by the pharmacist reviewing the orders, which therefore placed the nurse in the precarious position of committing a wrong route medication error. In this same study of drug administration in enterally fed hospitalized patients, less than 20% of drugs administered directly into the small bowel were considered appropriate. A number of medications, including modified-release dosage forms (eg, delayed release, sustained release), are inappropriate for the enteral route. Rationale the enteral route of drug administration is unique and differs from the oral administration in several ways.